Inspection Reports for Cedarhurst of Lawrence Operator, LLC
4450 BAUER FARM DRIVE, LAWRENCE, KS, 66049-9044
Back to Facility ProfileInspection Report Summary
The most recent inspection on April 15, 2025, found no deficiencies and confirmed that all previously cited issues were corrected. Earlier inspections showed multiple deficiencies related mainly to resident safety, including failures to prevent elopement, incomplete functional capacity screenings, medication administration errors, and documentation gaps. Complaint investigations prior to April 15 were substantiated with findings of neglect and care deficiencies, including incidents placing residents at risk, but no fines or enforcement actions were listed in the available reports. Most complaints were substantiated, though the latest complaint investigation resulted in no citations. The facility’s record shows improvement over time, with the most recent inspection verifying correction of prior deficiencies.
Deficiencies (last 2 years)
Deficiencies (over 2 years)
12.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
108% worse than Kansas average
Kansas average: 6 deficiencies/yearDeficiencies per year
16
12
8
4
0
Census
Latest occupancy rate
60 residents
Based on a March 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Apr 15, 2025
Visit Reason
The inspection was conducted as a complaint investigation (complaint number 194219) at the assisted living facility Cedarhurst of Lawrence.
Complaint Details
Complaint investigation 194219 was conducted and found no citations.
Findings
The complaint investigation conducted on 04/15/2025 resulted in no citations or deficiencies.
Inspection Report
Re-Inspection
Deficiencies: 6
Date: Apr 15, 2025
Visit Reason
This revisit inspection was conducted to verify that previously reported deficiencies at Cedarhurst of Lawrence were corrected and to document the dates when corrective actions were accomplished.
Findings
All previously cited deficiencies identified by regulation or Life Safety Code provisions were corrected as of the revisit date, April 15, 2025.
Deficiencies (6)
Deficiency related to regulation 26-41-101 (f) (1)
Deficiency related to regulation 26-41-201 (d)
Deficiency related to regulation 26-41-202 (a)
Deficiency related to regulation 26-41-204 (a)
Deficiency related to regulation 26-41-205 (d) (1-2)
Deficiency related to regulation 26-41-105 (f) (11)
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Apr 15, 2025
Visit Reason
The document represents the findings of a complaint investigation conducted on 04/15/2025 at the assisted living facility.
Complaint Details
Complaint investigation 194219 conducted with no citations issued.
Findings
The complaint investigation conducted on 04/15/2025 resulted in no citations.
Inspection Report
Complaint Investigation
Census: 60
Deficiencies: 6
Date: Mar 20, 2025
Visit Reason
The inspection was an abbreviated survey conducted from 03/18/25 to 03/20/25 in response to multiple complaints regarding the assisted living facility Cedarhurst of Lawrence.
Complaint Details
The investigation was triggered by complaints #193130, 192978, 192903, 192698, 192303, 191652, and 190952 concerning neglect, elopement, and care deficiencies at the assisted living facility.
Findings
The facility was found to have multiple deficiencies including failure to protect residents from neglect and elopement, inaccurate functional capacity screenings, incomplete negotiated service agreements, improper medication administration, and inadequate documentation of incidents. Two residents eloped placing them in immediate jeopardy, and medication administration times were frequently outside the expected time frames.
Deficiencies (6)
Failure to protect cognitively impaired Resident 4 from neglect when he exited the building unnoticed through an inactivated alarmed door and was found 17 minutes later in the parking lot.
Failure to accurately document Functional Capacity Screen for Residents 3, 4, and 5 including wandering and impaired vision.
Failure to fully develop Negotiated Service Agreements for Residents 2, 3, 4, and 10 based on Functional Capacity Screen, service needs, and preferences.
Failure to ensure licensed nurse provided necessary health care services meeting resident needs, including failure to secure a window allowing Resident 3 to elope.
Failure to administer medications to Residents 1, 3, 4, and 10 according to medical orders and professional standards, including missed doses and administration outside expected time frames.
Failure to document all incidents, symptoms, and other indications of illness or injury including date, time, actions taken, and results for incidents involving Residents 2, 3, and 4.
Report Facts
Census: 60
Elopement Risk Score: 49
Elopement Risk Score: 26
Medication administration timing: 16
Medication administration timing: 14
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nurse B | Administrative Nurse | Named in findings related to elopement incident reports and medication administration confirmation. |
| Certified Medication Aide C | Certified Medication Aide | Provided statements regarding resident wandering and medication administration timing. |
| Certified Medication Aide E | Certified Medication Aide | Documented observations of resident exit seeking and involved in investigation statements. |
| Certified Nurse Aide G | Certified Nurse Aide | Documented observations of resident exit seeking. |
| CNA J | Certified Nursing Assistant | Reported on resident elopement search and family statements. |
| Administrative Staff A | Administrative Staff | Signed investigation reports and provided email responses regarding elopement incidents. |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Mar 18, 2025
Visit Reason
The document is a plan of correction addressing findings from an abbreviated survey conducted for multiple complaints at an assisted living facility between 03/18/2025 and 03/20/2025.
Complaint Details
The survey was conducted in response to multiple complaints as listed in the document.
Findings
The plan of correction corresponds to citations resulting from an abbreviated survey related to complaints numbered 193130, 192978, 192903, 192698, 192303, 191652, and 190952.
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.
Inspection Report
Complaint Investigation
Census: 54
Deficiencies: 13
Date: Sep 11, 2024
Visit Reason
Initial survey with complaints #189908 and #190118 conducted on 09/10/24 and 09/11/24 at Cedarhurst of Lawrence Assisted Living facility.
Complaint Details
The visit was triggered by complaints #189908 and #190118 concerning multiple regulatory violations at the assisted living facility.
Findings
The investigation found multiple deficiencies including failure to ensure functional capacity screens were signed and accurate, incomplete negotiated service agreements, lack of bed rail assessments, improper labeling of over-the-counter medications, inadequate disaster preparedness reviews, improper food temperature monitoring and storage, incomplete infection control documentation, non-compliance with tuberculosis screening guidelines, and failure to monitor exit doors leading to resident elopement.
Deficiencies (13)
Functional Capacity Screen (FCS) assessments were not signed by the licensed nurse for residents R101, R102, and R103.
FCS assessments did not accurately reflect residents' functional capacity for cognition for R101, R102, and R103.
Negotiated Service Agreements (NSA) were incomplete or not fully developed for residents R102 and R103, lacking identification of payment responsibility and service descriptions.
NSA revisions were not made timely when resident R102 changed physical therapy providers.
NSA for residents R101, R102, and R103 were not signed by all individuals involved in their development.
Failure to complete and document bed rail assessment for resident R103, despite use of bed rails and trapeze.
Over-the-counter medications were not labeled with the resident's full name as required.
Facility failed to perform quarterly reviews of the emergency management plan with residents.
Food items were not served at proper temperatures; food temperature logs were incomplete.
Food storage temperatures in refrigerators/freezers were not consistently documented.
Sanitary conditions for food service were not ensured due to missing documentation of hot water temperature and chemical sanitizer strengths.
Facility failed to comply with tuberculosis screening guidelines for residents and new employees; TB symptom screens were incomplete.
Failure to monitor exit doors properly resulted in resident R101 exiting the building with her dog and being outside the facility for approximately 20 minutes without staff knowledge.
Report Facts
Census: 54
Deficiencies cited: 12
Duration resident outside facility: 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 | Provided statements regarding resident R103's bed rail use and resident R101's wandering |
| Certified Nurse Aide F | Certified Nurse Aide | Reported observations related to resident R101's elopement |
| Administrative Staff A | Administrative Staff | Provided information about emergency preparedness and resident R101's safety checks and elopement |
| Regional Dining Services Director C | Regional Dining Services Director | Discussed expectations for food temperature monitoring and sanitizer logs |
| Dietary Staff C | Dietary Staff | Commented on missing temperature/sanitizer logs |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Sep 10, 2024
Visit Reason
The document addresses findings from an initial survey conducted on 09/10/24 and 09/11/24 at an assisted living facility, which included complaint investigations #189908 and #190118.
Complaint Details
The visit included complaint investigations for complaint numbers 189908 and 190118.
Findings
The citations represent findings from the initial survey and complaint investigations at the assisted living facility conducted on the specified dates.
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