Overland Park Post Acute: Pain Med Failures - KS
The patient, identified in inspection records only as R1, was readmitted with a palliative care team managing his medications. His hospital orders included oxycodone HCl 20 mg every eight hours and pregabalin 300 mg twice daily. Neither medication was correctly entered into the facility's system when he arrived.
The oxycodone had been entered as PRN, meaning R1 could ask for it but would not receive it on a schedule. The pregabalin wasn't available to him at all for four days.
Administrative Nurse E, one of three nursing administrators identified in the inspection report, told inspectors that within 24 hours of any admission, the clinical team was supposed to review orders and catch exactly this kind of discrepancy. She said she could not think of a reason why it didn't happen with R1.
It did get noticed, eventually. Administrative Nurse F reviewed R1's hospital orders on May 8 and discovered the oxycodone and pregabalin had not been reconciled. She did not report it.
That decision became its own problem. Administrative Nurse D told inspectors she later had to educate Administrative Nurse F that what she had found was a medication error, and that F should have notified D immediately on May 8. Instead, the failure sat unreported until inspectors arrived weeks later, on May 26.
Administrative Nurse D was direct about what had gone wrong. She told inspectors she expected R1's medications to match his hospital orders, and that if any changes were made, the nurse responsible was supposed to document why. There was no such documentation here because there was no deliberate change. The medications simply weren't reconciled.
The facility's own reconciliation policy, last revised in July 2017, directed staff to review medication lists carefully for discrepancies and, if any were found, to resolve them by contacting the referring facility, the prescribing physician, the attending physician, or the resident and family. None of that happened at R1's readmission.
The process at the time, Administrative Nurse D explained, had been for the floor nurse to enter medications and for Administrative Nurse E to complete the reconciliation. By May 8, the facility had added an admissions nurse, Administrative Nurse F, to go over medications with Administrative Nurse E. That new process was in place when R1 was readmitted. It failed anyway.
What that meant for R1 practically: he had PRN oxycodone available if he asked for it during the days his scheduled doses were missed. Whether he knew to ask, whether he asked and received it, or whether he went without is not detailed in the inspection report. The pregabalin, a medication used for nerve pain, was not available to him in any form for four days.
The inspection was conducted as a complaint investigation on May 26. The level of harm was assessed as minimal harm or potential for actual harm, and the number of residents affected was noted as few.
The facility's adverse consequences and medication error policy, revised as recently as June 2025, defined a medication error to include omission, where a drug is ordered but not administered. By the facility's own definition, what happened to R1 was a medication error. It took until a federal inspection for that to be formally acknowledged.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Overland Park Post Acute from 2026-05-26 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: August 13, 2026 · Our methodology
OVERLAND PARK POST ACUTE in OVERLAND PARK, KS was cited for violations during a health inspection on May 26, 2026.
The patient, identified in inspection records only as R1, was readmitted with a palliative care team managing 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.