Inspection Reports for
Cedarhurst of Lawrence Operator, LLC
4450 BAUER FARM DRIVE, LAWRENCE, KS, 66049-9044
Back to Facility ProfileDeficiencies (last 2 years)
Deficiencies (over 2 years)
9.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
58% worse than Kansas average
Kansas average: 6 deficiencies/yearDeficiencies per year
16
12
8
4
0
Occupancy
Latest occupancy rate
55% occupied
Based on a March 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Follow-Up
Deficiencies: 0
Date: Apr 15, 2025
Visit Reason
This revisit inspection was conducted to verify that previously reported deficiencies have been corrected by the facility.
Findings
All previously cited deficiencies listed by regulation numbers were corrected as of the revisit date. The report confirms completion of corrective actions for each cited deficiency.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Apr 15, 2025
Visit Reason
This document is a plan of correction submitted in response to a complaint investigation conducted on 2025-04-15 at the assisted living facility.
Complaint Details
Complaint investigation 194219 was conducted and resulted in no citations.
Findings
The complaint investigation conducted on 2025-04-15 resulted in no citations.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Apr 15, 2025
Visit Reason
The inspection was conducted as a complaint investigation at the assisted living facility Cedarhurst of Lawrence on 04/15/2025.
Complaint Details
Complaint investigation 194219 was conducted and resulted in no citations.
Findings
The complaint investigation resulted in no citations or deficiencies.
Inspection Report
Complaint Investigation
Census: 60
Deficiencies: 6
Date: Mar 20, 2025
Visit Reason
The inspection was an abbreviated survey conducted from 03/18/2025 to 03/20/2025 in response to multiple complaints regarding the assisted living facility.
Complaint Details
The investigation was triggered by multiple complaints (#193130, 192978, 192903, 192698, 192303, 191652, and 190952) concerning resident neglect, elopement, medication administration, and documentation issues.
Findings
The facility failed to protect residents from neglect and elopement risks, failed to accurately document functional capacity screenings and negotiated service agreements, and failed to administer medications according to provider orders and professional standards. Additionally, the facility did not properly document incidents involving resident altercations and elopements.
Deficiencies (6)
KAR 26-41-101(f)(1)(B) Staff Treatment of Residents: The administrator failed to protect Resident 4 from neglect when he exited the building unnoticed through an inactivated alarmed door and was found 17 minutes later outside in cold weather.
KAR 26-41-201(d) Functional Capacity Screen Accurate: The administrator failed to ensure staff accurately documented the functional capacity screening for Residents 3, 4, and 5, missing key issues such as wandering and impaired vision.
KAR 26-41-202(a) Negotiated Service Agreement: The administrator failed to ensure the negotiated service agreements for Residents 2, 3, 4, and 10 fully described the services provided and identified the service providers.
KAR 26-41-204(a) Health Care Services: The administrator failed to ensure a licensed nurse provided necessary health care services for Resident 3, including safety interventions to secure a window that the resident could manipulate, resulting in elopement.
KAR 26-41-205(d) Facility Administration of Medications: The administrator failed to ensure medications were administered to Residents 1, 3, 4, and 10 according to provider orders and professional standards, with frequent late or missed doses.
KAR 26-41-105(f)(11) Resident Record Documentation of Incidents: The administrator failed to ensure licensed staff documented all incidents, including resident-to-resident altercation and elopements of Residents 2, 3, and 4, with missing details on actions taken and results.
Report Facts
Resident census: 60
Elopement risk score: 49
Medication administration delays: 16
Medication administration delays: 14
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Staff A | Provided statements and email responses regarding elopement incidents and investigations. | |
| Certified Medication Aide C | Certified Medication Aide | Provided observations on resident wandering and medication administration timing. |
| Administrative Nurse B | Administrative Nurse | Created incident reports and confirmed failures in medication administration and documentation. |
| Certified Nurse Aide G | Certified Nurse Aide | Documented observations of resident exit seeking behavior. |
| Certified Medication Aide E | Certified Medication Aide | Documented observations of resident exit seeking and involvement in investigations. |
| Certified Nurse Aide F | Certified Nurse Aide | Provided statements about door alarms and resident elopement. |
| Certified Nurse Aide J | Certified Nurse Aide | Reported on resident search efforts and family statements. |
| Licensed Nurse L | Licensed Nurse | Documented resident exit seeking behavior. |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Mar 18, 2025
Visit Reason
The document is a plan of correction responding to an abbreviated survey conducted for multiple complaints at an assisted living facility from March 18 to March 20, 2025.
Findings
The plan of correction addresses findings from an abbreviated survey related to complaints numbered 193130, 192978, 192903, 192698, 192303, 191652, and 190952 at the assisted living facility.
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Oct 9, 2024
Visit Reason
An offsite revisit survey was conducted to verify correction of all previous deficiencies cited on 2024-09-11.
Findings
All deficiencies have been corrected as of the compliance date of 2024-10-03 and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Report Facts
Previous deficiencies cited: 0
Inspection Report
Complaint Investigation
Census: 54
Deficiencies: 13
Date: Sep 11, 2024
Visit Reason
The inspection was conducted as an initial survey with complaint investigations #189908 and #190118 at Cedarhurst of Lawrence Assisted Living.
Complaint Details
The inspection included complaint investigations #189908 and #190118. Specific substantiation status is not stated.
Findings
The facility was found deficient in multiple areas including incomplete and unsigned Functional Capacity Screens, inaccurate cognitive assessments, incomplete and unsigned Negotiated Service Agreements, failure to provide necessary health care services such as bed rail assessments, improper labeling of over-the-counter medications, inadequate disaster preparedness reviews, unsafe food temperature monitoring and storage, insufficient infection control documentation, noncompliance with tuberculosis screening guidelines, and failure to monitor exit doors leading to resident elopement.
Deficiencies (13)
KAR 26-41-201(b): Functional Capacity Screens for residents R101, R102, and R103 were completed but not signed by the licensed nurse who performed the assessments.
KAR 26-41-201(d): Functional Capacity Screens for residents R101, R102, and R103 did not accurately reflect their cognitive functional capacity.
KAR 26-41-202(a)(1)(3): Negotiated Service Agreements for residents R102 and R103 lacked identification of parties responsible for payment of outside services and did not fully describe services provided.
KAR 26-41-202(d)(4): The facility failed to revise the Negotiated Service Agreement for resident R102 after a change in physical therapy providers.
KAR 26-41-202(h): Negotiated Service Agreements for residents R101, R102, and R103 were not signed by all individuals involved in their development.
KAR 26-41-204(a): The facility failed to ensure a licensed nurse completed an assessment for the use of bed rails and confirmed they were not restraints for resident R103.
KAR 26-41-205(g)(3): Over-the-counter medications in the memory care unit were not labeled with the full name of the resident as required.
KAR 26-41-104(d)(3): The facility failed to perform quarterly reviews of the emergency management plan with residents.
KAR 26-41-206(d): Food items were not served at proper temperatures as documented by missing food temperature logs for multiple dates.
KAR 26-41-206(e)(1): Food storage temperatures were not documented consistently, failing to ensure safe and sanitary conditions.
KAR 26-41-207(b)(4): The facility failed to document daily hot water temperatures and chemical sanitizer strengths to ensure sanitary food service conditions.
KAR 26-41-207(c): The facility failed to comply with tuberculosis screening guidelines for residents and newly hired employees, missing required symptom screen components.
KAR 28-39-254(a): The facility failed to monitor exit doors properly, resulting in resident R101 exiting the building unnoticed for approximately 20 minutes.
Report Facts
Census: 54
Deficiencies cited: 13
Duration of resident elopement: 20
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Nurse B | Licensed Nurse | Named in multiple findings related to Functional Capacity Screen assessments, Negotiated Service Agreements, and tuberculosis screening. |
| Certified Medication Aide E | Certified Medication Aide | Mentioned in observations related to bed rail use and resident elopement. |
| Certified Medication Aide C | Certified Medication Aide | Mentioned in observation of medication labeling deficiencies. |
| Regional Dining Services Director D | Regional Dining Services Director | Interviewed regarding food temperature monitoring expectations. |
| Administrative Staff A | Administrative Staff | Interviewed regarding emergency preparedness and resident elopement incident. |
| Certified Nurse Aide F | Certified Nurse Aide | Interviewed regarding resident R101 wandering and elopement. |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Sep 10, 2024
Visit Reason
The document is a plan of correction related to an initial survey conducted with complaints #189908 and #190118 at an assisted living facility on 09/10/24 and 09/11/24.
Complaint Details
The visit was complaint-related involving complaints #189908 and #190118.
Findings
The plan of correction addresses findings from an initial survey triggered by two complaints at the assisted living facility.
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