Deficiencies (last 2 years)
Deficiencies (over 2 years)
13 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
117% worse than Kansas average
Kansas average: 6 deficiencies/yearDeficiencies per year
16
12
8
4
0
Occupancy
Latest occupancy rate
74% occupied
Based on a February 2017 inspection.
Occupancy rate over time
Inspection Report
Complaint Investigation
Census: 64
Deficiencies: 11
Date: Feb 6, 2017
Visit Reason
Resurvey with complaint investigations at Grace Gardens of Leawood Assisted Living Inc conducted on multiple dates in January and February 2017.
Complaint Details
The visit was a resurvey with complaint investigations 109293 and 108796 conducted on multiple dates in January and February 2017.
Findings
The facility failed to report allegations of abuse or neglect timely, conduct required functional capacity screenings annually, review and revise negotiated service agreements annually, ensure all involved individuals signed service agreements, provide or coordinate necessary health care services, properly store medications, maintain medication destruction records, prepare therapeutic diets according to orders, maintain food temperature logs, and maintain facility safety for cognitively impaired residents.
Deficiencies (11)
KAR 26-41-101(f)(3)(E)(F) The administrator failed to report allegations of abuse or neglect to the department within 24 hours and submit complaint investigation reports within five working days.
KAR 26-41-201(c)(1) The administrator failed to ensure functional capacity screenings were conducted at least every 365 days for sampled residents.
KAR 26-41-202(d) The administrator failed to ensure review and revision of negotiated service agreements at least once every 365 days for sampled residents.
KAR 26-41-202(h) The administrator failed to ensure each individual involved in the development of the negotiated service agreement signed the agreement for sampled residents.
KAR 26-41-204(a) The administrator failed to ensure a licensed nurse provided or coordinated necessary health care services to meet residents' needs, including skin impairment management.
KAR 26-41-205(h) The licensed nurse failed to ensure all medications and biologicals were properly stored, including discarding Tuberculin PPD injection solution 30 days after opening.
KAR 26-41-205(i) The administrator failed to maintain records documenting receipt and disposition of all medications for accurate reconciliation.
KAR 26-41-102(d)(1) The administrator failed to ensure employee records contained evidence of licensure for licensed staff.
KAR 26-41-206(b)(2) The administrator failed to ensure therapeutic and mechanically altered diets were prepared according to medical or dietitian instructions and failed to provide supervision of dietetic services.
KAR 26-41-206(d) The administrator failed to ensure food was prepared using safe methods conserving nutritive value, flavor, appearance, and served at proper temperatures; food temperature logs were incomplete and memory care kitchen lacked logs.
KAR 28-39-254(a) The administrator failed to maintain the facility to protect the health and safety of cognitively impaired residents and the public due to unsecured hazardous chemicals and cleaning supplies accessible to residents.
Report Facts
Resident census: 64
Medication packets: 143
OTC medication bottles: 7
Prescription medications: 19
Suppository packages: 3
Dates missing food temperature logs: 30
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Staff F | Licensed Staff | Personnel file lacked evidence of licensure |
| Administrative Nurse C | Administrator/Nurse | Interviewed regarding multiple deficiencies including abuse reporting, functional capacity screening, NSA review, medication storage, and dietary services |
| Administrative Staff A | Administrator | Interviewed regarding employee records, facility safety, and medication destruction |
| Dietary Staff D | Dietary Staff | Interviewed regarding food temperature logs and diet preparation |
| Certified Staff K | Certified Staff | Observed preparing mechanically altered diets and food temperatures |
| Certified Staff L | Certified Staff | Interviewed regarding mechanically altered diets |
| Certified Staff M | Certified Staff | Interviewed regarding mechanically altered diet preparation |
| Certified Staff J | Certified Staff | Observed providing care for resident with skin impairment |
| Licensed Staff I | Licensed Staff | Interviewed regarding medication destruction and reconciliation |
Inspection Report
Follow-Up
Deficiencies: 5
Date: Feb 16, 2015
Visit Reason
This visit was conducted as a follow-up to verify that previously reported deficiencies have been corrected.
Findings
All deficiencies previously reported were corrected as of the revisit date. Corrections were completed for multiple regulatory items listed in the report.
Deficiencies (5)
Regulation 26-41-203 (d): Deficiency corrected as of 02/16/2015.
Regulation 26-41-204 (a): Deficiency corrected as of 02/16/2015.
Regulation 26-41-206 (a) (b): Deficiency corrected as of 02/16/2015.
Regulation 26-41-206 (d): Deficiency corrected as of 02/16/2015.
Regulation 26-41-206 (e) (1): Deficiency corrected as of 02/16/2015.
Inspection Report
Follow-Up
Deficiencies: 5
Date: Feb 16, 2015
Visit Reason
This visit was conducted as a follow-up to verify correction of previously reported deficiencies at Grace Gardens of Leawood Assisted Living Inc.
Findings
All previously reported deficiencies identified by regulation numbers 26-41-203(d), 26-41-204(a), 26-41-206(a)(b), 26-41-206(d), and 26-41-206(e)(1) were corrected as of the revisit date.
Deficiencies (5)
Regulation 26-41-203(d): Previously cited deficiency corrected as of 02/16/2015.
Regulation 26-41-204(a): Previously cited deficiency corrected as of 02/16/2015.
Regulation 26-41-206(a)(b): Previously cited deficiency corrected as of 02/16/2015.
Regulation 26-41-206(d): Previously cited deficiency corrected as of 02/16/2015.
Regulation 26-41-206(e)(1): Previously cited deficiency corrected as of 02/16/2015.
Inspection Report
Re-Inspection
Census: 64
Deficiencies: 5
Date: Jan 27, 2015
Visit Reason
The inspection was a resurvey conducted on 1-22-15, 1-26-15, and 1-27-15 to verify compliance with previously cited deficiencies at Grace Gardens of Leawood Assisted Living.
Findings
The facility failed to obtain a written medical order and inform the resident's legal representative in writing before admission to the special care unit. Licensed nursing failed to provide or coordinate necessary health care services according to residents' functional capacity screenings and negotiated service agreements. Dietary services did not prepare therapeutic or mechanically altered diets according to medical or dietitian instructions, and food safety practices were deficient including lack of food temperature logs and improper food storage with cleaning chemicals stored in food areas.
Deficiencies (5)
KAR 26-41-203(d)(3)(5): The facility failed to obtain a written medical care provider's order and failed to inform the resident's legal representative in writing before admission to the special care unit for resident #400.
KAR 26-41-204(a): The licensed nurse failed to provide or coordinate necessary health care services meeting residents' needs and consistent with functional capacity screenings and negotiated service agreements for residents #100 and #300.
KAR 26-41-206(b)(2): Therapeutic and mechanically altered diets were not prepared according to instructions from a medical care provider or licensed dietitian for residents including #300 and #600.
KAR 26-41-206(d): Dietary staff failed to ensure food was served at proper temperatures and lacked documentation of food temperature logs for all assisted living residents.
KAR 26-41-206(e)(1): Facility staff stored food and cleaning chemicals improperly, including storing poisonous compounds in food storage areas, risking contamination.
Report Facts
Census: 64
Residents in special care unit: 14
Sampled residents: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed staff B | Confirmed lack of physician's order for resident #400 transfer and therapeutic diet provision. | |
| Administrative staff A | Accompanied surveyor during facility tour and confirmed findings related to special care unit and food storage. | |
| Certified staff K | Provided information on toileting frequency for resident #300. | |
| Dietary staff C | Confirmed taking but not recording food temperatures. | |
| Dietary staff D | Unable to provide food temperature log records. | |
| Dietary staff E | Confirmed no written instructions for preparation of therapeutic diets. | |
| Dietary staff F | Confirmed no written instructions for preparation of therapeutic diets. | |
| Certified staff G | Confirmed lack of written instructions on how to puree food on special care unit. | |
| Administrative staff H | Confirmed resident #400 moved to memory care unit and lack of written information provided to family. |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: N046065 POC 260P12
Visit Reason
This document is a Plan of Correction related to a previously identified deficiency report for the facility with State ID N046065 and Event ID 260P12.
Findings
No deficiency details or findings are included in this document. It serves solely as a record of the Plan of Correction submission.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: N046065 POC BCOC11
Visit Reason
This document is a Plan of Correction related to a previously identified deficiency report for the facility.
Findings
No deficiency records are found in this Plan of Correction document. It serves as a corrective action response to prior inspection findings.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: N046065 POC F66Y11
Visit Reason
This document is a Plan of Correction related to a prior deficiency report for the facility Grace Gardens of Leawood.
Findings
No specific findings or deficiencies are detailed in this document. It serves as a record of the Plan of Correction submission and modification dates.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: N046065 POC NZ6H11
Visit Reason
This document is a Plan of Correction related to a prior inspection event for the facility identified as ASPEN with State ID N046065.
Findings
No deficiency details or findings are included in this document. It only references the Plan of Correction status and contact information for assistance.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: N046065 POC OPCC11
Visit Reason
This document is a plan of correction related to a prior deficiency report for the facility Grace Gardens Of Leawood.
Findings
No specific findings or deficiencies are detailed in this document. It serves as a record of the plan of correction submission.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: N046065 POC OPCC12
Visit Reason
This document is a Plan of Correction related to a prior inspection or regulatory finding for the facility identified as State ID N046065.
Findings
No deficiency details or findings are provided in this document. It serves solely as a record of the Plan of Correction submission and modification dates.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: N046065 POC 25PN11
Visit Reason
This document is a Plan of Correction related to a prior inspection or deficiency report for the facility identified as State ID N046065 ASPEN Event ID 25PN11.
Findings
No deficiency records or findings are included in this Plan of Correction document.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: N046065 POC 260P11
Visit Reason
This document is a Plan of Correction related to a previously identified deficiency report for the facility.
Findings
No deficiency details or findings are included in this document. It only references the Plan of Correction status and contact information for assistance.
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