Garden Terrace: Dementia Care Failures Harm Resident - KS
The inspection, completed December 30, 2025, found that Garden Terrace at Overland Park failed to notify the resident's physician about a significant deterioration in his mental and behavioral condition between November 22 and December 21, 2025.
The resident, identified in the report only as R1, developed the behaviors after a provider discontinued his medications. Licensed Nurse G told inspectors R1 had become physically aggressive, hitting people and attempting to bite them. He also began hitting himself and made statements that he wanted to die and kill himself.
Nobody called the doctor.
Licensed Nurse G confirmed she found no provider notification notes in R1's electronic medical record during that entire period. She said she never personally needed to notify the provider because R1 didn't display those behaviors on her shift. For suicidal statements, she said her practice was to ensure the resident's safety, notify the provider, and document the call in a progress note. She said she would place a resident on one-to-one observation depending on severity.
The consultant physician, identified as Consultant GG, told inspectors on December 29 that he received no notification of R1's increased behaviors during those 29 days. He said he expected the facility to follow its own notification policies.
Administrative Nurse D described the same protocol the nurses did: intervene, ensure safety, call the provider, document the call. The documentation, she said, would be in the physician notification notes.
There were none.
R1 was eventually hospitalized. Licensed Nurse G noted she had received report that he was not sleeping before he was sent to the hospital, and that she had notified the provider at that point. The facility had been working to find him an alternative placement.
For nearly a month, a man in their care said he wanted to kill himself, and the physician responsible for treating him had no idea.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Garden Terrace At Overland Park from 2025-12-30 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
GARDEN TERRACE AT OVERLAND PARK in OVERLAND PARK, KS was cited for violations during a health inspection on December 30, 2025.
The resident, identified in the report only as R1, developed the behaviors after a provider discontinued his medications.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.