Inspection Report Summary
The most recent inspection on February 27, 2025, found that all previously cited deficiencies had been corrected. Earlier inspections showed a pattern of deficiencies related primarily to resident protection, including exploitation and neglect, as well as issues with negotiated service agreements, medication labeling, emergency preparedness, and food safety. Complaint investigations in January 2025 substantiated concerns about resident exploitation via social media and neglect resulting in elopement, with immediate jeopardy identified at that time. Enforcement actions such as fines or license suspensions were not listed in the available reports. The facility appears to be addressing these issues, as indicated by the correction of all deficiencies noted in the latest revisit.
Deficiencies (last 8 years)
Deficiencies (over 8 years)
7.9 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
32% worse than Kansas average
Kansas average: 6 deficiencies/yearDeficiencies per year
12
9
6
3
0
Census
Latest occupancy rate
51 residents
Based on a January 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Re-Inspection
Deficiencies: 10
Date: Feb 27, 2025
Visit Reason
This revisit inspection was conducted to verify that previously reported deficiencies have been corrected and to document the dates such corrective actions were accomplished.
Findings
All previously cited deficiencies listed with their regulation numbers were corrected as of the revisit date, with completion dates documented for each.
Deficiencies (10)
Deficiency related to regulation 26-41-101 (f) (1)
Deficiency related to regulation 26-41-202 (a)
Deficiency related to regulation 26-41-202 (d)
Deficiency related to regulation 26-41-202 (j)
Deficiency related to regulation 26-41-204 (a)
Deficiency related to regulation 26-41-205 (g) (3)
Deficiency related to regulation 26-41-105 (f) (11)
Deficiency related to regulation 26-41-104 (d)
Deficiency related to regulation 26-41-206 (d)
Deficiency related to regulation 26-41-206 (e) (1)
Report Facts
Deficiencies corrected: 10
Inspection Report
Complaint Investigation
Census: 51
Deficiencies: 9
Date: Jan 30, 2025
Visit Reason
The inspection was a resurvey with complaints numbered 188813, 188995, 190314, 190488, and 190578 at an Assisted Living facility conducted on 01/28/25, 01/29/25, and 01/30/25.
Complaint Details
The visit was complaint-related involving multiple complaint numbers (188813, 188995, 190314, 190488, 190578). Immediate jeopardy was identified related to exploitation of resident R104 and neglect of resident R102 resulting in elopement.
Findings
The facility was found deficient in multiple areas including failure to protect a resident from exploitation via unauthorized social media posting of photos, incomplete negotiated service agreements, failure to monitor outside service providers, neglect resulting in resident elopement, improper labeling of over-the-counter medications, incomplete documentation of incidents, inadequate emergency preparedness reviews, improper food temperature monitoring, and unsafe food storage practices.
Deficiencies (9)
Failure to protect resident R104 from exploitation when a staff member posted photos of the resident's skin tears on social media.
Failure to ensure negotiated service agreements were fully developed and revised based on residents' functional capacity and changes in condition.
Failure to monitor services provided by outside resources for resident R102, including hospice and wound care documentation.
Failure to ensure resident R102 was not subjected to neglect, resulting in elopement through an unsecured window.
Failure to ensure over-the-counter medications were labeled with the resident's full name.
Failure to document all incidents, symptoms, and indications of illness or injury for resident R102, including pressure wounds.
Failure to ensure quarterly reviews of the emergency management plan covering all required topics with employees and residents.
Failure to ensure food items were served at the proper temperature as required.
Failure to ensure food items were stored under safe and sanitary conditions, including undated prepared foods and incomplete temperature logs.
Report Facts
Census: 51
Residents at risk for elopement: 21
Number of OTC medications not labeled: 7
Duration of resident unaccounted for: 30
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nurse D | Administrative Nurse | Reported privacy violation, acknowledged incomplete NSA and monitoring failures, and provided statements on wound care and incident documentation |
| Administrative Staff A | Administrative Staff | Interviewed regarding privacy policies, window safety audits, emergency preparedness, and elopement incident |
| Certified Medication Aide C | Certified Medication Aide | Took and posted unauthorized photos of resident's skin tears, resulting in termination |
| Maintenance Staff I | Maintenance Staff | Reported on window safety latch condition and audits |
| Dietary Manager J | Dietary Manager | Provided information on food temperature monitoring responsibilities |
| Administrative Nurse K | Administrative Nurse | Acknowledged NSA revision failures and hospice admission for resident R104 |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Jan 28, 2025
Visit Reason
The document is a Plan of Correction addressing findings from a resurvey with complaints numbered 188813, 188995, 190314, 190488, and 190578 conducted at the assisted living facility on January 28, 29, and 30, 2025.
Complaint Details
The Plan of Correction is related to a resurvey with complaints 188813, 188995, 190314, 190488, and 190578.
Findings
The Plan of Correction references multiple citations from the resurvey and complaint investigations conducted over three days in late January 2025 at the assisted living facility.
Report Facts
Complaint numbers: 5
Inspection Report
Follow-Up
Deficiencies: 0
Date: Mar 4, 2024
Visit Reason
An offsite revisit survey was conducted to verify correction of all previous deficiencies cited on 2024-02-20.
Findings
All deficiencies have been corrected as of the compliance date of 2024-02-29, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Report Facts
Previous deficiencies cited: 1
Inspection Report
Abbreviated Survey
Census: 52
Deficiencies: 1
Date: Feb 19, 2024
Visit Reason
The visit was an abbreviated survey with review of facility reports #185777 and #185734 conducted at the assisted living facility Cedar Lake Village on 02/19/24 and 02/20/24.
Findings
The administrator failed to protect Resident 2 from neglect by ensuring certified staff assisted the resident up off the floor after a witnessed, non-injury fall. Video review showed staff did not assist the resident after the fall despite training on abuse and neglect.
Deficiencies (1)
Failure to protect Resident 2 from neglect by ensuring certified staff assisted the resident up off the floor after a witnessed, non-injury fall.
Report Facts
Census: 52
Memory care residents: 16
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Staff A | Administrative Staff | Confirmed video footage revealed staff did not assist Resident 2 up from the floor |
| CMA C | Certified Medication Aide | Failed to assist Resident 2 up from the floor after fall |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Feb 19, 2024
Visit Reason
The document represents the findings of an abbreviated survey with review of facility reports #185777 and #185734 conducted at the assisted living facility on 02/19/24 and 02/20/24.
Findings
The document is a plan of correction submitted in response to an abbreviated survey conducted at the facility, addressing findings from the survey and related facility reports.
Inspection Report
Re-Inspection
Deficiencies: 1
Date: Oct 23, 2023
Visit Reason
This revisit report documents the correction of deficiencies previously reported during an earlier survey.
Findings
The report confirms that the previously identified deficiency under regulation 26-41-101 (f)(1) has been corrected as of the revisit date.
Deficiencies (1)
Deficiency under regulation 26-41-101 (f)(1) previously cited
Inspection Report
Abbreviated Survey
Census: 52
Deficiencies: 1
Date: Sep 25, 2023
Visit Reason
The inspection was an abbreviated survey with review of facility report #182985 conducted on 09/25/23 and 09/27/23 at an assisted living facility.
Findings
The administrator failed to protect a resident from exploitation when a Certified Medication Aide took and shared a photo of the resident just after his death on social media, violating privacy policies. The facility took corrective actions including staff meetings, warnings, and mandated HIPAA training.
Deficiencies (1)
Failure to protect Resident 1 from exploitation when a staff member took and shared a photo of the resident after death on social media.
Report Facts
Census: 52
Social media group size: 10
Social media group size: 12
Training completion dates: 2
Abatement Plan completion deadline: 30
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CMA C | Certified Medication Aide | Took and shared photo of resident after death, subject of deficiency |
| Administrative Nurse B | Administrative Nurse | Received report of incident from CMA C and confirmed photo was taken and posted |
| Administrative Staff A | Administrative Staff | Participated in interview and staff training discussions |
| CMA D | Certified Medication Aide | Provided interview about abuse, neglect, and exploitation training |
| CMA E | Certified Medication Aide | Provided interview about abuse, neglect, and exploitation training |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Sep 25, 2023
Visit Reason
The document represents the findings of an abbreviated survey with review of facility report #182985 conducted at the assisted living facility on 09/25/23 and 09/27/23.
Findings
The document is a plan of correction submitted in response to the findings of the abbreviated survey conducted on the specified dates.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Jul 10, 2023
Visit Reason
An offsite revisit survey was conducted to verify correction of all previous deficiencies cited on 2023-06-20.
Findings
All deficiencies have been corrected as of the compliance date of 2023-07-05, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Report Facts
Previous deficiencies cited: 1
Inspection Report
Re-Inspection
Census: 57
Deficiencies: 6
Date: Jun 20, 2023
Visit Reason
The inspection was a resurvey with attached complaints #180747, #177552, and #173837 conducted at an assisted living facility on 06/19/23 and 06/20/23.
Complaint Details
The resurvey included attached complaints #180747, #177552, and #173837 related to alleged neglect and other issues.
Findings
The facility failed to complete and submit an investigation of alleged neglect within five working days, failed to ensure negotiated service agreements reflected residents' needs, failed to document food temperatures after transport to satellite kitchens, failed to store food under safe conditions, failed to comply with tuberculosis screening guidelines for residents and staff, and failed to ensure chemicals were stored in locked areas to protect resident safety.
Deficiencies (6)
Administrator failed to complete and submit an investigation of alleged neglect within five working days.
Negotiated Service Agreement for Resident 619 did not describe services to prevent injury from falls.
Failed to provide evidence of documentation of food temperatures after transporting food to satellite kitchens.
Food items in satellite kitchens were not labeled or dated, stored under unsafe conditions.
Failed to ensure compliance with tuberculosis guidelines for residents and staff; missing TB symptom screens and tests.
Facility was not maintained to protect health and safety by ensuring all chemicals were stored within locked areas.
Report Facts
Census: 57
Residents in sample: 3
Food temperature log request times: 2
Date of initial report submission: 6
Number of uncovered food items: 8
Number of chemicals found in unlocked cabinets: 7
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Jun 19, 2023
Visit Reason
This document represents the findings of a resurvey with attached complaints #180747, #177552, and #173837 at the assisted living facility conducted on 06/19/23 and 06/20/23.
Complaint Details
The resurvey included attached complaints #180747, #177552, and #173837.
Findings
The document is a plan of correction submitted in response to deficiencies identified during the resurvey and complaint investigations conducted on 06/19/23 and 06/20/23.
Inspection Report
Re-Inspection
Deficiencies: 3
Date: Aug 3, 2022
Visit Reason
This revisit report documents the correction of deficiencies previously cited during an earlier inspection at Cedar Lake Village.
Findings
The report confirms that all previously identified deficiencies have been corrected as of the revisit date.
Deficiencies (3)
Deficiency related to regulation 26-41-101 (f) (1)
Deficiency related to regulation 26-41-205 (h)
Deficiency related to regulation 28-39-254
Inspection Report
Re-Inspection
Census: 56
Deficiencies: 4
Date: Jul 21, 2022
Visit Reason
The inspection was a licensure resurvey with complaint investigations attached, conducted over multiple days from 07/18/2022 to 07/21/2022.
Complaint Details
The inspection included complaint numbers 171588 and 169823. The complaints involved failure to prevent resident falls and failure to prevent a resident from leaving the facility unsupervised, resulting in injury and emergency room visits.
Findings
The facility was found deficient in staff treatment of residents, medication storage, and facility safety regarding unsecured chemicals. Specific failures included lack of interventions for residents with multiple falls resulting in injury, failure to prevent a cognitively impaired resident from leaving the facility unsupervised in cold weather, unsecured medications and biologicals in memory care units, and unsecured chemicals in resident bathroom cabinets.
Deficiencies (4)
Failure to ensure licensed nurse placed interventions for resident with multiple falls, resulting in dislocation of right hip and facial laceration.
Failure to acknowledge change in cognition/decision making for resident who left facility unsupervised in 18-degree Fahrenheit weather, resulting in unwitnessed fall and emergency room visit.
Failure to properly secure and store medications and biologicals in accordance with regulations in two secured memory care units.
Failure to ensure facility was equipped and maintained to protect health and safety of residents regarding unsecured chemicals found in four resident unsecured bathroom cabinets.
Report Facts
Census: 56
Memory care unit census: 11
Memory care unit census: 11
Dates of inspection: Inspection conducted 07/18/2022 through 07/21/2022
Temperature: 18
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LN E | Licensed Nurse | Confirmed lack of fall interventions and medication storage issues |
| Administrator K | Administrator | Confirmed resident elopement and medication storage failures |
| Senior Director H | Senior Director | Provided statement regarding resident elopement |
| Certified Medication Aide H | Certified Medication Aide | Stated resident was attending social during elopement |
| Licensed Nurse C | Licensed Nurse | Documented resident fall and emergency room visit |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Jul 18, 2022
Visit Reason
The document is a plan of correction submitted in response to findings from a licensure resurvey conducted with complaint numbers 171588 and 169823 during the visit on 7/18/2022 through 7/21/2022.
Complaint Details
The inspection was conducted with complaint numbers 171588 and 169823 attached.
Findings
The plan of correction addresses citations found during the licensure resurvey and complaint investigations conducted over multiple days in July 2022.
Inspection Report
Re-Inspection
Deficiencies: 1
Date: Aug 26, 2020
Visit Reason
This report documents a revisit inspection to verify that previously reported deficiencies have been corrected and to confirm the date such corrective actions were accomplished.
Findings
The revisit inspection confirmed that the previously cited deficiency related to regulation 26-41-101 (f)(1) was corrected as of 08/26/2020. No other deficiencies or uncorrected issues were noted.
Deficiencies (1)
Deficiency related to regulation 26-41-101 (f)(1)
Inspection Report
Complaint Investigation
Census: 56
Deficiencies: 1
Date: Jul 29, 2020
Visit Reason
The inspection was conducted as an abbreviated survey with complaint investigations #154517 and #154539, along with a special infection control survey for COVID-19, to investigate concerns related to resident safety and care.
Complaint Details
Complaint investigations #154517 and #154539 were part of the survey. Immediate jeopardy was identified related to neglect of a resident with wandering behavior who eloped from the facility and was unaccounted for over two hours. The jeopardy was removed after the facility implemented a corrective plan including frequent staff checks and securing doors.
Findings
The facility failed to ensure that a resident with a history of wandering and poor decision-making was protected from neglect after leaving the fenced outdoor memory care area through an unlocked gate and being unaccounted for over two hours. The resident was found and returned by police, and the facility lacked documented staff observation checks and updated care plans addressing the resident's risks.
Deficiencies (1)
The administrator failed to ensure no resident was subjected to neglect when a resident with a history of wandering left the fenced outdoor memory care area through an unlocked gate, was unaccounted for for at least 2 hours and 15 minutes, and returned by police. The resident continued to be at risk due to lack of documented staff observation checks and incomplete care plans.
Report Facts
Resident census: 56
Memory care unit census: 23
Duration resident unaccounted for: 135
Distance resident walked: 1.75
Temperature: 86
Wind speed: 15
Inspection Report
Re-Inspection
Deficiencies: 1
Date: Jun 10, 2019
Visit Reason
This is a revisit report completed by a State surveyor to show those deficiencies previously reported that have been corrected and the date such corrective action was accomplished.
Findings
The report indicates that the previously cited deficiency with regulation 26-41-204(i) was corrected as of 06/10/2019. No other deficiencies or findings are listed.
Deficiencies (1)
Deficiency related to regulation 26-41-204(i)
Inspection Report
Re-Inspection
Census: 56
Deficiencies: 1
Date: May 1, 2019
Visit Reason
This visit was a revisit for correction order 19-54 at the assisted living facility to verify compliance with previous deficiencies.
Findings
The administrator failed to ensure that all health care services, including answering call lights, were provided by qualified staff in accordance with acceptable standards of practice. Call light response times frequently exceeded the facility's stated expectations, with some alerts never responded to and the longest response time being 44 minutes.
Deficiencies (1)
Failure to ensure all health care services, including answering call lights, were provided by qualified staff in accordance with acceptable standards of practice.
Report Facts
Call light activations over 5 minutes: 453
Response time 6 to 10 minutes: 187
Response time 11 to 15 minutes: 87
Response time 16 to 20 minutes: 57
Response time 21 to 30 minutes: 48
Response time over 30 minutes: 30
Alerts never responded to but announced: 44
Longest response time (minutes): 44
Census: 56
Inspection Report
Re-Inspection
Deficiencies: 7
Date: May 1, 2019
Visit Reason
This report documents a revisit inspection to verify that previously reported deficiencies have been corrected and to record the dates when corrective actions were completed.
Findings
All previously cited deficiencies identified by regulation numbers were corrected as of 04/30/2019, with no uncorrected deficiencies noted at the time of this revisit.
Deficiencies (7)
Deficiency related to regulation 26-41-101 (f) (3)
Deficiency related to regulation 26-41-202 (a)
Deficiency related to regulation 26-41-202 (i)
Deficiency related to regulation 26-41-204 (a)
Deficiency related to regulation 26-41-205 (d) (1-2)
Deficiency related to regulation 26-41-205 (g) (3)
Deficiency related to regulation 26-41-207 (b) (5-6) (c)
Report Facts
Deficiencies corrected: 7
Inspection Report
Renewal
Census: 58
Deficiencies: 8
Date: Mar 20, 2019
Visit Reason
Licensure Resurvey conducted over multiple days including complaint investigations for complaints #132608 and #134608.
Complaint Details
Complaints #132608 and #134608 were investigated during the licensure resurvey.
Findings
The facility was found deficient in multiple areas including failure to timely report and investigate allegations of abuse, incomplete negotiated service agreements, inadequate health care services coordination for residents with falls, untimely response to call lights, medication administration discrepancies, improper labeling of over-the-counter medications, and non-compliance with tuberculosis screening guidelines for employees and residents.
Deficiencies (8)
Failure to ensure allegations of abuse, neglect, or exploitation were reported within 24 hours and thoroughly investigated for three sampled residents with multiple falls and injuries.
Negotiated service agreements lacked specific descriptions of services to be provided and identification of payment sources for outside services for three sampled residents.
Failure to ensure residents received services according to their negotiated service agreements, including housekeeping services not provided as specified.
Failure to ensure licensed nurse provided or coordinated health care services to address needs of residents with cognitive impairment and fall risks, with repeated falls and injuries documented.
Failure to ensure all medications administered were in accordance with signed physician orders and professional standards, with discrepancies found in medication orders and MARs.
Failure to ensure licensed nurse or pharmacist placed full resident names on all accepted original, unbroken manufacturer packages of over-the-counter medications for resident administration.
Failure to comply with tuberculosis screening guidelines for employees and residents, including lack of TB symptom questionnaires at time of hire or admission.
Failure to ensure timely response to resident call lights, with documented delays up to 41 minutes and lack of facility policy on call light response expectations.
Report Facts
Resident census: 58
Call light activations: 135
Call light response times: 41
Falls documented for Resident #185: 18
Falls documented for Resident #189: 11
Falls documented for Resident #187: 3
Inspection Report
Re-Inspection
Deficiencies: 1
Date: Dec 2, 2016
Visit Reason
This revisit report documents the correction of deficiencies previously reported during a prior survey, verifying that corrective actions have been completed.
Findings
The report confirms that the previously identified deficiency related to regulation 26-41-204(d) was corrected as of 12/02/2016. No other deficiencies or findings are noted.
Deficiencies (1)
Deficiency related to regulation 26-41-204(d)
Inspection Report
Re-Inspection
Census: 43
Deficiencies: 4
Date: Nov 9, 2016
Visit Reason
The inspection was a resurvey of the assisted living facility conducted on 11-7-16 through 11-9-16 to assess compliance with previously cited deficiencies.
Findings
The facility failed to conduct functional capacity reassessments following significant changes in condition, failed to provide or coordinate necessary health care services in accordance with functional capacity screenings and negotiated service agreements, and failed to include the licensed nurse responsible for health care service plans in the negotiated service agreements. Additionally, documentation of incidents, assessments, and follow-up actions by licensed nurses was incomplete or missing.
Deficiencies (4)
Failure to conduct functional capacity screening reassessment following significant change in condition for resident #118.
Failure to ensure licensed nurse provides or coordinates necessary health care services in accordance with functional capacity screening and negotiated service agreement for resident #118.
Negotiated service agreements lacked the name of the licensed nurse responsible for implementation and supervision of health care services for residents #118, #119, and #120.
Failure to document all incidents, symptoms, and indications of illness or injury including date, time, action taken, and results for resident #118.
Report Facts
Census: 43
Sample size: 3
Dates of inspection: 2016-11-07 to 2016-11-09
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Nurse B | Licensed Nurse | Interviewed regarding resident #118's care and confirmed deficiencies in functional capacity screening and negotiated service agreements. |
| Licensed Nurse C | Licensed Nurse | Signed progress note regarding resident #118's fall on 7-21-16. |
| Licensed Nurse D | Licensed Nurse | Signed progress note regarding resident #118's fall on 8-15-16. |
| Licensed Nurse E | Licensed Nurse | Signed progress note regarding resident #118's fall on 9-14-16. |
| Licensed Nurse F | Licensed Nurse | Signed progress note regarding resident #118's fall on 9-14-16 and assisted resident. |
Inspection Report
Re-Inspection
Deficiencies: 2
Date: Oct 28, 2014
Visit Reason
This revisit inspection was conducted to verify that previously reported deficiencies had been corrected and to document the dates such corrective actions were accomplished.
Findings
The report confirms that the deficiencies previously cited under regulations 26-41-201 (a) (b) and 26-41-204 (e) were corrected as of 10/28/2014.
Deficiencies (2)
Deficiency related to regulation 26-41-201 (a) (b)
Deficiency related to regulation 26-41-204 (e)
Report Facts
Deficiencies corrected: 2
Inspection Report
Re-Inspection
Census: 37
Deficiencies: 2
Date: Oct 6, 2014
Visit Reason
The inspection was a resurvey conducted on 10-1-14, 10-2-14, and 10-6-14 at an assisted living facility to assess compliance with functional capacity screening and delegation of nursing duties.
Findings
The facility failed to record residents' functional capacity findings on screening forms including all required elements and definitions. Additionally, a licensed nurse failed to appropriately delegate blood glucose monitoring procedures to certified medication aides and did not document their competency.
Deficiencies (2)
Failure to record individual's functional capacity findings on a screening form including each element and definition specified by the department.
Failure to ensure a licensed nurse delegated blood glucose monitoring procedures to certified medication aides and document their competency as required under the Kansas Nurse Practice Act.
Report Facts
Census: 37
Sample size: 3
Inspection Report
Plan of Correction
Deficiencies: 0
Date: N046059 3VJP12
Visit Reason
This document is a Plan of Correction related to a facility inspection event identified by State ID N046059 and ASPEN Event ID 3VJP12.
Findings
No specific deficiencies or findings are detailed in this document; it appears to be a placeholder or summary page indicating no records found for the Plan of Correction.
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