Inspection Report Summary
The most recent inspection on September 18, 2024, found no deficiencies during a resurvey related to multiple complaints. Earlier inspections showed a mixed record with several deficiencies primarily involving resident care documentation, notification of significant changes, medication administration, and protection of residents, including an immediate jeopardy finding related to elopement in February 2023. Complaint investigations were mostly unsubstantiated in recent years, though a substantiated complaint in 2014 involved failure to report elopement incidents promptly. Enforcement actions such as fines or license suspensions were not listed in the available reports. The facility’s inspection history shows improvement over time, with all cited deficiencies corrected by the most recent inspections.
Deficiencies (last 9 years)
Deficiencies (over 9 years)
6.2 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
3% worse than Kansas average
Kansas average: 6 deficiencies/yearDeficiencies per year
8
6
4
2
0
Census
Latest occupancy rate
116 residents
Based on a February 2023 inspection.
This facility has shown a decline in demand based on occupancy rates.
Occupancy over time
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Sep 18, 2024
Visit Reason
The resurvey was conducted as a follow-up to attached complaints #188135, #187254, #182292, and #182033 at the assisted living facility.
Complaint Details
The visit was complaint-related involving complaints #188135, #187254, #182292, and #182033, with no deficiencies found.
Findings
The resurvey conducted on 09/17/24 and 09/18/24 resulted in a finding of no deficiency citations.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Sep 17, 2024
Visit Reason
The resurvey was conducted on 09/17/24 and 09/18/24 with attached complaints #188135, #187254, #182292, and #182033 at the assisted living facility.
Complaint Details
The resurvey included attached complaints #188135, #187254, #182292, and #182033.
Findings
The resurvey resulted in a finding of no deficiency citations.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Apr 11, 2023
Visit Reason
The inspection was conducted as a complaint investigation for complaint numbers #179291, #178963, #178740, and #178412 at Delaware Highlands Assisted Living.
Complaint Details
Complaint investigation for #179291, #178963, #178740, and #178412 resulted in no citations.
Findings
The complaint investigation conducted on 03/29/23, 03/30/23, 04/10/23, and 04/11/23 resulted in no citations.
Inspection Report
Re-Inspection
Deficiencies: 8
Date: Apr 11, 2023
Visit Reason
This revisit inspection was conducted to verify that previously reported deficiencies at Delaware Highlands Assisted Living have been corrected.
Findings
All previously cited deficiencies listed with their regulation numbers were corrected as of 03/30/2023.
Deficiencies (8)
Deficiency related to regulation 26-39-103 (h)
Deficiency related to regulation 26-41-101 (c)
Deficiency related to regulation 26-41-101 (f) (1)
Deficiency related to regulation 26-41-101 (f) (3)
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 26-41-105 (f) (11)
Report Facts
Deficiencies corrected: 8
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Apr 11, 2023
Visit Reason
The document represents the findings of a complaint investigation for multiple complaint numbers (#179291, #178963, #178740, and #178412) at an assisted living facility conducted on 03/29/23, 03/30/23, 04/10/23, and 04/11/23.
Complaint Details
Complaint investigation for #179291, #178963, #178740, and #178412 resulted in no citations.
Findings
The complaint investigation resulted in no citations.
Inspection Report
Complaint Investigation
Census: 116
Deficiencies: 8
Date: Feb 22, 2023
Visit Reason
The inspection was conducted based on multiple complaint investigations regarding Delaware Highlands Assisted Living.
Complaint Details
The inspection was triggered by complaint investigations #178340, #178331, #178327, #178119, #176892, #176862, #176787, and #175274.
Findings
The facility failed to notify residents' physicians and legal representatives of significant changes, failed to authorize a designee for the administrator, failed to protect a resident from elopement resulting in immediate jeopardy, failed to report abuse/neglect allegations timely, and failed to accurately document functional capacity, negotiated service agreements, health care services, and incident documentation.
Deficiencies (8)
Failure to notify residents' physicians and legal representatives or designated family members of significant changes including pressure wounds, falls with injury, and positive COVID test.
Failure to authorize in writing a designee to act on the administrator's behalf during absence.
Failure to protect a cognitively impaired resident from elopement through unsecured exit doors, resulting in immediate jeopardy.
Failure to report allegations of abuse, neglect, or exploitation to the department within 24 hours.
Failure to ensure the Functional Capacity Screen accurately reflected resident's cognitive impairments and wandering behavior.
Failure to develop negotiated service agreements reflecting services for wound care and impaired vision/hearing.
Failure to ensure licensed nurse provided necessary health care services including documentation of skin/wound assessments for pressure wounds.
Failure to document all incidents, symptoms, and indications of illness or injury including date, time, action taken, and results for pressure wounds, falls, and positive COVID test.
Report Facts
Census: 116
Complaint investigations: 8
Date of inspection: Feb 22, 2023
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Feb 21, 2023
Visit Reason
The document represents a plan of correction addressing findings from multiple complaint investigations conducted at the assisted living facility between 02/21/23 and 02/23/23.
Complaint Details
The plan of correction is related to complaint investigations #178340, #178331, #178327, #178119, #176892, #176862, #176787, and #175274.
Findings
The plan of correction corresponds to citations resulting from complaint investigations numbered #178340, #178331, #178327, #178119, #176892, #176862, #176787, and #175274.
Inspection Report
Re-Inspection
Deficiencies: 6
Date: Sep 12, 2022
Visit Reason
This is a revisit report completed by a State surveyor to verify that previously reported deficiencies have been corrected and to document the dates such corrective actions were accomplished.
Findings
All previously reported deficiencies identified by regulation or LSC provision numbers were corrected as of the revisit date, with completion dates documented for each.
Deficiencies (6)
Deficiency related to regulation 26-41-101 (f) (1)
Deficiency related to regulation 26-41-201 (c)
Deficiency related to regulation 26-41-202 (a)
Deficiency related to regulation 26-41-202 (d)
Deficiency related to regulation 26-41-205 (d) (3)
Deficiency related to regulation 26-41-105 (f) (11)
Inspection Report
Annual Inspection
Census: 102
Deficiencies: 6
Date: Aug 17, 2022
Visit Reason
Licensure resurvey with attached complaint investigations conducted on 08/16/22 and 08/17/22 at Delaware Highlands Assisted Living.
Findings
The facility failed to protect residents from neglect, failed to complete required Functional Capacity Screens (FCS) following significant changes, and failed to update Negotiated Service Agreements (NSA) accordingly. Medication administration procedures were deficient as staff did not remain with residents until medications were ingested. Nursing documentation lacked follow-up charting for incidents and symptoms.
Deficiencies (6)
Failure to protect Resident 172 from neglect related to fall interventions and follow-up on physician progress notes.
Failure to complete Functional Capacity Screen (FCS) for Residents 814 and 172 following significant change and for Resident 813 at least once every 365 days.
Failure to ensure Negotiated Service Agreements (NSA) for Residents 810 and 812 described services based on their Functional Capacity Screens.
Failure to review and revise Negotiated Service Agreements for Residents 172 and 212 after change of condition to reflect necessary healthcare services.
Failure to ensure licensed nurses or certified medication aides remained with Resident 813 until medication was ingested.
Failure to document all incidents, symptoms, and other indications of illness or injury including date, time, action taken, and results for Residents 172, 212, 814, 810, and 813.
Report Facts
Resident census: 102
Medication count: 6
Days late for FCS: 39
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Aug 16, 2022
Visit Reason
The document is a Plan of Correction addressing findings from a licensure resurvey conducted on 08/16/22 and 08/17/22, which included multiple attached complaint numbers.
Findings
The Plan of Correction references citations representing findings from the licensure resurvey and attached complaints for the facility conducted on 08/16/22 and 08/17/22.
Inspection Report
Re-Inspection
Census: 100
Deficiencies: 3
Date: Oct 27, 2020
Visit Reason
The inspection was conducted for re-licensure with attached complaints on 10/27/20, 10/28/20, and 10/29/20 at Delaware Highlands Assisted Living in Kansas City, KS.
Complaint Details
The survey was conducted with attached complaints #156316, 154588, 151356, 151260, 143199, 139072, 150645.
Findings
The facility failed to ensure proper medication storage according to manufacturer and regulatory requirements, had incomplete employee records lacking timely criminal background and nurse aide registry checks, and did not comply with tuberculosis screening guidelines for staff.
Deficiencies (3)
Failure to ensure licensed nurses and medication aides properly stored medications and biologicals according to manufacturer and pharmacy provider recommendations and federal and state laws.
Employee records lacked supporting documentation for criminal background checks and nurse aide registry checks upon hire for 3 of 5 staff.
Failure to ensure compliance with tuberculosis guidelines for adult care homes, including lack of required 2-step TB skin tests for certified staff.
Report Facts
Census: 100
Medication refrigerator temperature: 42
Medication refrigerator temperature log range: 41.2 to 50.9
Insulin pens: 47
Staff with late background checks: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed nurse #B | Licensed Nurse | Interviewed and confirmed lack of TB documentation and personnel record reviews. |
| Licensed nurse #G | Licensed Nurse | Observed medication refrigerator temperature and confirmed temperature results. |
| Environmental services director #H | Environmental Services Director | Observed medication refrigerator temperature and confirmed temperature results. |
| Certified staff #D | Personnel record reviewed showing late KBI and registry checks. | |
| Certified staff #E | Personnel record reviewed showing late KBI and registry checks. | |
| Certified staff #F | Personnel record reviewed showing late registry check. | |
| Certified staff #I | Personnel record reviewed showing lack of 2-step TB test documentation. |
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Aug 5, 2020
Visit Reason
The visit was a special infection control survey for COVID-19 conducted at the facility.
Findings
The survey resulted in findings of no deficiency citations.
Inspection Report
Follow-Up
Deficiencies: 5
Date: Dec 6, 2018
Visit Reason
This revisit inspection was conducted to verify that previously reported deficiencies at Delaware Highlands Assisted Living were corrected and to document the dates such corrective actions were accomplished.
Findings
All previously cited deficiencies related to specific regulations were corrected as of the revisit date, with completion dates documented for each.
Deficiencies (5)
Deficiency related to regulation 26-41-202 (a)
Deficiency related to regulation 26-41-204 (a)
Deficiency related to regulation 26-41-204 (e)
Deficiency related to regulation 26-41-205 (d) (1-2)
Deficiency related to regulation 26-41-205 (h)
Report Facts
Deficiencies corrected: 5
Inspection Report
Re-Inspection
Census: 117
Deficiencies: 1
Date: Dec 6, 2018
Visit Reason
The inspection was a re-visit with attached complaints conducted on 12/4/18 and 12/6/18 at Delaware Highlands Assisted Living in Kansas City, KS.
Complaint Details
The visit was triggered by complaints regarding delayed staff response times to resident call lights, with substantiation confirmed by interviews and record reviews.
Findings
The administrator failed to ensure the provision or coordination of the range of services specified in each resident's negotiated service agreement, including other services necessary to support the health and safety of each resident. Staff failed to respond to resident requests for assistance in a timely manner, with multiple documented long response times to call lights over two days.
Deficiencies (1)
Failure to ensure provision or coordination of the range of services specified in each resident's negotiated service agreement including other services necessary to support health and safety.
Report Facts
Census: 117
Call light response delays: 17
Response times: 35.93
Response times: 26.6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| administrative nurse #B | Confirmed long call light response times during interview |
Inspection Report
Renewal
Census: 115
Deficiencies: 5
Date: Oct 29, 2018
Visit Reason
The inspection was conducted as a survey for re-licensure with attached complaints at Delaware Highlands Assisted Living in Kansas City, KS.
Findings
The inspection identified multiple deficiencies including failure to complete negotiated service agreements in collaboration with residents or their representatives, failure to ensure licensed nurses provide or coordinate necessary health care services according to agreements, improper delegation of nursing duties, medication administration errors, and improper medication storage.
Deficiencies (5)
Failure to ensure the Negotiated Service Agreement (NSA) for residents requiring health care services was completed in collaboration with the resident or legal representative and contained required information about services, providers, and payment responsibilities.
Failure to ensure that a licensed nurse provides or coordinates necessary health care services that meet resident needs and are in accordance with functional capacity screening and negotiated service agreement.
Failure to delegate nursing procedures (blood sugar and insulin tracking) properly to medication aides under Kansas nurse practice act.
Failure to ensure all medications and treatments were administered in accordance with medical provider's written orders, professional standards, and manufacturer recommendations.
Failure to ensure medications and biologicals were securely and properly stored according to manufacturer recommendations, pharmacy provider instructions, and federal and state laws and regulations.
Report Facts
Facility census: 115
Sample size: 6
Residents receiving blood glucose monitoring by certified medication aides: 26
Medication administration count: 26
Medication doses administered incorrectly: 5
Expired medication storage: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed nurse #B | Administrative Nurse | Confirmed residents received outside provider services not documented in NSA and confirmed blood glucose monitoring by medication aides |
| Licensed nurse #C | Licensed Nurse | Confirmed medication administration errors and medication storage issues |
| Licensed nurse #D | Licensed Nurse | Confirmed residents had outside providers not documented in NSA and confirmed medication aides performing blood glucose monitoring without competency exams |
| Certified staff #E | Certified Staff | Performed blood glucose monitoring without documented competency |
| Certified staff #F | Certified Staff | Performed blood glucose monitoring without documented competency |
| Certified staff #G | Certified Staff | Observed performing blood glucose monitoring |
Inspection Report
Re-Inspection
Deficiencies: 1
Date: Jun 5, 2017
Visit Reason
This report documents a revisit conducted to verify that previously reported deficiencies at Delaware Highlands Assisted Living have been corrected.
Findings
The revisit confirmed that the previously cited deficiency under regulation 26-41-104(d) was corrected as of 06/05/2017. No other deficiencies or uncorrected issues were noted.
Deficiencies (1)
Deficiency under regulation 26-41-104(d) previously cited was corrected.
Inspection Report
Renewal
Census: 121
Deficiencies: 6
Date: May 23, 2017
Visit Reason
Licensure Resurvey conducted over multiple days including investigation of Complaint #110145.
Complaint Details
Complaint #110145 was investigated during the resurvey.
Findings
The facility failed to accurately complete functional capacity screens for residents, ensure health care services met acceptable standards, conduct proper medication assessments and administration, maintain accurate medication orders and documentation, and conduct required emergency evacuation drills.
Deficiencies (6)
Failure to ensure functional capacity screens accurately reflected residents' abilities.
Failure to provide health care services by qualified staff according to standards.
Failure to ensure licensed nurse assessment prior to resident self-administration of medication.
Failure to ensure medications administered according to medical orders and proper storage and labeling of insulin.
Failure to document all incidents, symptoms, and actions taken in resident records.
Failure to conduct an emergency evacuation drill at least annually with staff and residents.
Report Facts
Residents sampled: 6
Facility census: 121
Employees hired since last resurvey: 43
Residents self-administering medications: 20
Residents using insulin: 22
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing #B | Director of Nursing | Confirmed inaccuracies in functional capacity screens and medication administration issues. |
| Director of Nursing #M | Director of Nursing | Confirmed lack of follow-up monitoring for head injury and medication documentation issues. |
| Certified staff #K | Provided observations about residents' functional abilities. | |
| Licensed Practical Nurse #M | Licensed Practical Nurse | Confirmed insulin pen storage issues and medication bin errors. |
| Licensed Practical Nurse #N | Licensed Practical Nurse | Confirmed insulin pen storage issues. |
| Administrator #A | Administrator | Acknowledged lack of emergency evacuation drills. |
| Charge Nurse #O | Charge Nurse | Reported lack of awareness about resident #181's meal consumption. |
Inspection Report
Abbreviated Survey
Census: 117
Deficiencies: 3
Date: Oct 11, 2016
Visit Reason
An abbreviated survey was conducted at Delaware Highlands Assisted Living on 10-10-16 and 10-11-16 to assess compliance with regulatory standards.
Findings
The survey found multiple deficiencies including failure to notify the physician after resident falls with possible head injury, failure to report allegations of abuse to the department within 24 hours, and failure to administer medications, specifically insulin, as ordered by the physician.
Deficiencies (3)
Failure to ensure designated facility staff consulted with the resident's physician upon occurrence of an accident involving injury with potential for physician intervention.
Failure to report each allegation of abuse, neglect, or exploitation to the department within 24 hours.
Failure to ensure all medications and biologicals are administered in accordance with medical care provider's written order and professional standards of practice, specifically failure to administer insulin as ordered.
Report Facts
Census: 117
Residents sampled: 6
Dates of missed insulin administration: 11
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed staff B | Named in medication administration deficiency and fall incident documentation | |
| Licensed staff C | Named in fall incident and notification deficiency | |
| Licensed staff A | Named in abuse allegation reporting deficiency |
Inspection Report
Complaint Investigation
Census: 114
Deficiencies: 2
Date: Jan 25, 2016
Visit Reason
The inspection was a licensure resurvey combined with complaint investigations conducted on 1/19/16, 1/20/16, 1/21/16, and 1/25/16 at Delaware Highlands Assisted Living.
Complaint Details
The inspection included complaint investigations with citations resulting from complaints numbered 84621, 85018, 90373, 91048, 91435, and 94791.
Findings
The facility failed to ensure medications and biologicals were administered according to physician orders and professional standards, with discrepancies in medication administration and narcotic reconciliation. Additionally, the facility failed to maintain accurate and complete resident records, including vital signs documentation lacking signatures, dates, times, and follow-up on abnormal findings.
Deficiencies (2)
Failure to ensure all medications and biologicals were administered in accordance with medical care provider's written orders and professional standards, including discrepancies in narcotic medication administration and reconciliation.
Failure to maintain resident records in accordance with accepted professional standards and practices, including incomplete vital signs records lacking staff signatures, dates, times, and lack of follow-up on elevated blood pressure.
Report Facts
Census: 114
Residents sampled: 10
Residents reviewed for records: 6
Focus record reviews: 4
Dates of complaint investigations: Complaint investigations conducted on 1/19/16, 1/20/16, 1/21/16, and 1/25/16.
Inspection Report
Complaint Investigation
Census: 116
Deficiencies: 2
Date: Aug 11, 2014
Visit Reason
The inspection was a resurvey with complaint investigation 76567 conducted at Delaware Highlands Assisted Living on 2014-08-11 through 2014-08-13.
Complaint Details
The complaint investigation 76567 was substantiated by findings that the administrator failed to report episodes of elopement for resident #124 within 24 hours as required.
Findings
The facility failed to report an allegation of neglect involving a cognitively impaired resident found outside the facility within 24 hours, and failed to ensure food was prepared and served at proper temperatures with adequate documentation.
Deficiencies (2)
Failure to report an allegation of neglect to the department within 24 hours for resident #124 found outside the facility unsupervised on multiple occasions.
Failure to prepare and serve food using safe methods that conserve nutritive value, flavor, and appearance, and failure to document food temperatures properly.
Report Facts
Census: 116
Sample size: 6
Dates missing food temperature documentation: 14
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nurse A | Interviewed and confirmed resident elopement incidents and lack of food temperature monitoring policy | |
| Licensed Staff B | Documented resident wandering and elopement incidents | |
| Dietary Manager | Confirmed missing food temperature documentation |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Jul 2, 2012
Visit Reason
This document is a Plan of Correction related to a prior inspection event identified by ASPEN Event ID SM6U12 and State ID N105014.
Findings
No specific deficiencies or findings are detailed in this document; it serves as a record for the Plan of Correction submission and status.
Report Facts
Plan of Correction added date: Jul 13, 2012
Inspection start date: Jul 2, 2012
Inspection exit date: Jul 3, 2012
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