Garden Terrace At Overland Park

F 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

morning of the incident with Resident R2 and Resident R3, before the incident occurred. She stated Resident R1 was immediately placed on one-to-one supervision until his eventual discharge. She stated all residents in the secured area were screened immediately after the incident occurred for potential abuse and psychosocial concerns. She stated all three residents involved were sent out for emergency medical assessment. She stated that the facility immediately began in-service training for all available staff. The facility's Abuse, Neglect, and Exploitation policy, revised 06/2024, documented that the resident has a right to be free from verbal, sexual, physical, and mental abuse and involuntary seclusion. The policy indicated it was the responsibility of the facility to treat each resident with respect, kindness, dignity, and care, to keep them free from abuse and neglect, and to take swift action to investigate and adjudicate alleged resident abuse and neglect. Mental abuse included, but was not limited to, verbal or non-verbal conduct which caused or has the potential to cause humiliation, intimidation, fear, shame, agitation, degradation, harassment, or threats of punishment or deprivation. The policy indicated that all staff were to be educated to identify, prevent, and intervene when potential abuse was identified. On 10/02/25 at 03:26 PM, Administrative Staff A was provided the IJ template and notified of the facility's failure to protect Resident R2 and Resident R3 from Resident R1's physical abuse, which placed all residents in the immediate area in immediate jeopardy. The facility identified, implemented, and completed

the following corrective actions related to the incident: 1. The facility immediately assessed Resident R1, Resident R2, and Resident R3 for physical harm. (09/30/25)2. Resident R1 was immediately placed under one-to-one supervision, and his behavioral care plan was updated. (09/30/25)3. The facility immediately notified all three resident representatives and the medical provider. (09/30/25)4. The facility sent Resident R1, Resident R2, and Resident R3 out for immediate acute medical intervention. (09/30/25)5. The facility immediately initiated in-service staff training related to abuse prevention, behavioral health services, dementia care, and unit supervision to be completed by staff

before the next available shift on 09/30/25 and completed on 10/01/25. 6. The facility screened all in-house cognitively intact residents for potential abuse or witnessed altercations. (09/30/25)7. The facility screened all residents who resided on the affected secured unit for abuse or psychosocial concerns. (09/30/25)8.

Administrative Nurse D completed EMR audits for all residents on the affected unit for potential abuse. (09/30/25)9. The facility's Quality Assurance Committee completed a meeting on 09/30/25. 10. The facility will interview five random staff members about behavioral management five times weekly for four weeks, three times weekly for four weeks, and then randomly thereafter. (09/30/25)11. The facility will review all resident-to-resident interactions for the last 30 days to validate root-cause analysis and causative factors. (09/30/25)12. The facility will monitor all residents with known periods of aggression and interventions to reduce the risks of recurring altercations and implement additional measures in the daily clinical meetings and risk meetings. (09/30/25)13. All results will be reported to the Quality Assurance Committee. This deficient practice was deemed past non-compliance due to the corrective actions completed on 10/01/25, prior to the surveyor entering the facility. The citation remains at a J scope and severity to represent Resident R2 and Resident R3's actual harm.

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