Inspection Report Summary
The most recent inspection on May 13, 2024, found the facility in compliance with all regulations and no deficiencies. Prior to that, the April 24, 2024 inspection identified deficiencies related to coordination of health care services for a resident’s sexual behaviors, incomplete documentation of emergency management plan reviews, and improper food temperature, with complaint investigations finding no evidence of abuse. Earlier inspections noted issues primarily with medication administration, documentation, negotiated service agreements, emergency preparedness, and tuberculosis screening compliance. A notable enforcement action occurred in 2016 involving immediate jeopardy for failure to report and investigate abuse allegations promptly, but no fines or license suspensions are listed in the available reports. The facility appears to have addressed prior deficiencies over time, showing improvement with the most recent inspection being free of citations.
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 April 2024 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Plan of Correction
Deficiencies: 0
May 13, 2024
Visit Reason
An offsite revisit survey was conducted to verify correction of all previous deficiencies cited on 2024-04-24.
Findings
All deficiencies have been corrected as of the compliance date of 2024-05-07, 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: 51
Deficiencies: 3
Apr 24, 2024
Visit Reason
The inspection was a resurvey with attached complaints #187357, #184822, and #184781 conducted on 04/23/24 and 04/24/24 at Garden Villas of Lenexa assisted living facility.
Findings
The inspection found deficiencies including failure to ensure a licensed nurse coordinated health care services to address sexual behaviors of a resident, failure to document quarterly reviews of the emergency management plan with staff, and failure to ensure food was served at the proper temperature.
Complaint Details
The visit was complaint-related, attached to complaints #187357, #184822, and #184781. The investigation concluded there was no evidence to indicate abuse regarding the sexual behavior incident involving Resident 1.
Severity Breakdown
SS=D: 1
SS=F: 2
Deficiencies (3)
| Description | Severity |
|---|---|
| Failed to ensure a licensed nurse coordinated health care services to address sexual behaviors for Resident 1. | SS=D |
| Failed to provide evidence of documentation quarterly reviews of the facility's emergency management plan were completed with staff. | SS=F |
| Failed to ensure food was served at the proper temperature. | SS=F |
Report Facts
Census: 51
Laceration length: 2
Food temperature log days: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Certified Medication Aide E | Certified Medication Aide | Witnessed Resident 1 in bed with blood and notified Administrative Nurse B. |
| Administrative Nurse B | Administrative Nurse | Notified of Resident 1's condition and confirmed lack of service coordination. |
| Certified Nurse Aide D | Certified Nurse Aide | Reported Resident 1's sexual behaviors and explained not reporting due to privacy. |
| Dietary Staff C | Dietary Staff | Confirmed food temperature logs were pre-filled before meals. |
| Administrative Staff A | Administrative Staff | Confirmed lack of documentation for quarterly emergency plan reviews. |
Inspection Report
Plan of Correction
Deficiencies: 0
Apr 23, 2024
Visit Reason
The document represents the findings of a resurvey with attached complaints #187357, #184822, and #184781 conducted at the assisted living facility on 04/23/24 and 04/24/24.
Findings
This plan of correction addresses the findings from the resurvey and attached complaints conducted on the specified dates at the assisted living facility.
Complaint Details
The visit was related to attached complaints #187357, #184822, and #184781.
Inspection Report
Re-Inspection
Deficiencies: 0
Jun 13, 2023
Visit Reason
An offsite revisit survey was conducted on 06/13/23 to verify correction of all previous deficiencies cited on 05/23/23.
Findings
All deficiencies cited in the previous inspection have been corrected as of the compliance date of 06/09/23, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Inspection Report
Re-Inspection
Census: 34
Deficiencies: 5
May 22, 2023
Visit Reason
The inspection was a resurvey conducted on 05/22/23 and 05/23/23 to assess compliance with previously cited deficiencies at Garden Villas of Lenexa.
Findings
The facility was found deficient in multiple areas including failure to ensure negotiated service agreements were signed by all parties, improper medication administration including use of expired medications and failure to administer prescribed medications, lack of competency assessments for medication aides dialing insulin pens, failure to label over-the-counter medications with residents' full names, and non-compliance with tuberculosis screening guidelines for residents and staff.
Severity Breakdown
SS=F: 3
SS=D: 1
SS=E: 1
Deficiencies (5)
| Description | Severity |
|---|---|
| Failure to ensure each individual involved in the development of the negotiated service agreement signed the agreement. | SS=F |
| Failure to ensure all medications and treatments were administered in accordance with medical orders and manufacturer recommendations, including administration of expired medication and omission of prescribed medication. | SS=D |
| Failure to ensure licensed nurse delegated nursing procedures not included in medication aide curriculum to medication aides with competency assessment, specifically for dialing insulin pens. | SS=F |
| Failure to ensure licensed nurses or pharmacists placed the full name of the resident on each package of over-the-counter medications. | SS=E |
| Failure to ensure compliance with tuberculosis guidelines, including lack of TB questionnaires upon admission and annually for residents and upon hire for staff. | SS=F |
Report Facts
Census: 34
Sample size: 3
Number of non-sampled residents observed: 11
Number of newly hired employees reviewed: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Administrator A | Named in multiple findings including failure to ensure NSA signatures, medication administration compliance, delegation of medication administration, OTC medication labeling, and TB screening compliance. | |
| Licensed Nurse B | Licensed Nurse | Involved in medication administration findings and TB screening compliance. |
| Certified Medication Aide H | Certified Medication Aide | Observed administering expired medication and involved in medication cart observations. |
| Certified Medication Aide C | Certified Medication Aide | Mentioned in delegation and competency findings related to insulin pen dialing. |
| Certified Medication Aide D | Certified Medication Aide | Mentioned in delegation and competency findings related to insulin pen dialing. |
| Certified Medication Aide G | Certified Medication Aide | Interviewed about dialing insulin pens for residents. |
| Certified Nurse Aide E | Certified Nurse Aide | Named in TB screening compliance findings. |
| Certified Nurse Aide F | Certified Nurse Aide | Named in TB screening compliance findings. |
Inspection Report
Plan of Correction
Deficiencies: 0
May 22, 2023
Visit Reason
The document is a Plan of Correction submitted in response to findings from a resurvey conducted at the facility on 05/22/23 and 05/23/23.
Findings
The Plan of Correction addresses citations identified during the resurvey of the facility conducted on 05/22/23 and 05/23/23.
Inspection Report
Renewal
Census: 45
Deficiencies: 1
Jun 30, 2021
Visit Reason
The inspection was conducted for re-licensure with attached complaints #51555, #35815, and #35613 at the assisted living facility.
Findings
The administrator failed to ensure disaster and emergency preparedness by not performing quarterly reviews of the facility's entire emergency management plan with staff and residents, as required.
Complaint Details
The survey included attached complaints #51555, #35815, and #35613.
Severity Breakdown
SS=F: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure quarterly review of the facility's emergency management plan with employees and residents. | SS=F |
Report Facts
Resident census: 45
Sample residents reviewed: 3
Resident signatures on emergency plan review: 23
Inspection Report
Abbreviated Survey
Deficiencies: 0
Aug 7, 2020
Visit Reason
The special infection control survey for COVID-19 was conducted at the facility on 08/07/2020.
Findings
The survey resulted in findings of no deficiency citations.
Inspection Report
Re-Inspection
Deficiencies: 1
Feb 11, 2019
Visit Reason
This is a revisit inspection conducted to verify that previously reported deficiencies have been corrected and to document the date such corrective actions were accomplished.
Findings
The report confirms that the previously cited deficiency under regulation 26-41-105 (f) (11) was corrected as of 02/11/2019. No other deficiencies or findings are documented.
Deficiencies (1)
| Description |
|---|
| Deficiency under regulation 26-41-105 (f) (11) previously cited |
Inspection Report
Re-Inspection
Census: 50
Deficiencies: 3
Feb 11, 2019
Visit Reason
The inspection was a revisit for notice of assessment at the assisted living facility Garden Villas of Lenexa conducted on 2019-02-11.
Findings
The administrator failed to ensure that all medications and biologicals were administered to residents in accordance with medical care provider's written orders and professional standards of practice. Specific medication administration discrepancies and documentation failures were found for three sampled residents (#2300, #2301, #2302).
Severity Breakdown
SS=E: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Failure to ensure medications were administered according to physician's orders and professional standards for Resident #2300, including lack of documentation and improper administration of Tylenol. | SS=E |
| Discrepancies between physician orders and Medication Administration Record (MAR) for Resident #2301, including failure to clarify orders with physician. | SS=E |
| Lack of documentation and failure to administer Vitamin D3 as ordered for Resident #2302, including failure to notify physician and document communication with family. | SS=E |
Report Facts
Census: 50
Sampled residents: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Staff B | Interviewed and confirmed medication administration discrepancies and failures to clarify orders | |
| Certified Staff C | Administered Tylenol on 1-10-19 not per physician's ordered parameters | |
| Certified Staff D | Administered Tylenol on 1-11-19 not per physician's ordered parameters |
Inspection Report
Re-Inspection
Deficiencies: 9
Jan 3, 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
All previously reported deficiencies listed with their regulation numbers were corrected as of the revisit date.
Deficiencies (9)
| Description |
|---|
| Deficiency related to regulation 26-41-201 (d) |
| Deficiency related to regulation 26-41-202 (a) |
| Deficiency related to regulation 26-41-202 (h) |
| Deficiency related to regulation 26-41-205 (h) |
| Deficiency related to regulation 26-41-102 (c) |
| Deficiency related to regulation 26-41-104 (a) |
| Deficiency related to regulation 26-41-104 (d) |
| Deficiency related to regulation 26-41-207 (b) (5-6) (c) |
| Deficiency related to regulation 28-39-254 |
Inspection Report
Re-Inspection
Census: 49
Deficiencies: 2
Jan 3, 2019
Visit Reason
Revisit for correction order 18-191 at an assisted living facility to verify correction of previously cited deficiencies related to medication administration and resident record documentation.
Findings
The facility failed to ensure medications and biologicals were administered according to medical orders and professional standards, including lack of licensed nurse assessment and documentation. Additionally, the facility failed to document incidents, symptoms, and actions taken for residents, including lack of nursing assessments prior to hospital transfer and during leave of absence.
Severity Breakdown
SS=E: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to ensure all medications and biologicals were administered in accordance with medical care provider's written orders and professional standards, including lack of licensed nurse assessment and follow-up. | SS=E |
| Failure to document all incidents, symptoms, and other indications of illness or injury including date, time, action taken, and results. | SS=E |
Report Facts
Census: 49
Sample size: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nurse B | Interviewed and confirmed lack of documentation and assessments related to medication administration and resident transfers | |
| Operator | Interviewed and confirmed lack of documentation and assessments related to medication administration and resident transfers |
Inspection Report
Re-Inspection
Census: 45
Deficiencies: 9
Nov 28, 2018
Visit Reason
The inspection was a resurvey with complaint investigations conducted over multiple days from 11-19-18 to 11-28-18 at an assisted living facility.
Findings
The inspection identified multiple deficiencies including inaccurate functional capacity screening documentation, incomplete negotiated service agreements lacking signatures and provider/payment details, improper medication storage, lack of registered nurse supervision for licensed practical nurses, incomplete incident documentation, insufficient staffing for emergency evacuations, inadequate emergency preparedness drills and reviews, non-compliance with tuberculosis screening guidelines, and unsecured cleaning chemicals in the facility.
Complaint Details
The inspection was a resurvey with complaint investigations numbered 135548 and 135136.
Severity Breakdown
SS=E: 4
SS=F: 4
Deficiencies (9)
| Description | Severity |
|---|---|
| Failure to ensure accurate documentation of residents' functional capacity screening forms. | SS=E |
| Negotiated service agreements lacked description of services, provider identification, payment responsibility, and signatures of involved parties. | SS=E |
| Medications and biologicals were not stored according to manufacturer recommendations; TB skin testing solution was not discarded after 30 days. | SS=F |
| Failure to ensure a registered nurse was available to supervise licensed practical nurses. | SS=F |
| Incomplete documentation of incidents, symptoms, and illness including date, time, actions taken, and results. | SS=E |
| Insufficient staff on night shift to evacuate residents requiring assistance to a secure location during emergencies. | SS=F |
| Failure to conduct quarterly emergency management plan reviews with residents and staff and to perform annual emergency drills including full evacuation to a secure location. | SS=F |
| Non-compliance with tuberculosis screening guidelines for employees and residents, including lack of TB skin testing and symptom screening documentation. | SS=E |
| Facility failed to maintain safety by leaving cleaning chemicals unsecured in an unlocked cabinet. | — |
Report Facts
Resident census: 45
Residents with impaired cognition: 3
Residents mobile per wheelchair: 13
Residents using walker or wheelchair: 4
Night shift staff: 1
Fire drill duration: 17
TB skin testing solution date filled: Feb 8, 2018
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Staff E | Licensed Staff | Named in findings related to inaccurate functional capacity screening and negotiated service agreement. |
| Licensed Staff I | Licensed Practical Nurse | Responsible nurse for functional screenings and negotiated service agreements; lacked registered nurse supervision. |
| Administrative Nurse B | Administrative Nurse | Responsible for supervision of licensed practical nurses; lacked documentation of TB screening. |
| Certified Staff G | Certified Staff | Lacked documentation of TB skin testing. |
| Certified Staff H | Certified Staff | Lacked documentation of TB skin testing. |
Inspection Report
Re-Inspection
Deficiencies: 6
Dec 8, 2016
Visit Reason
This revisit report documents the correction of deficiencies previously cited in a prior survey of the facility.
Findings
All previously reported deficiencies identified by regulation or LSC provision numbers were corrected as of the revisit date.
Deficiencies (6)
| Description |
|---|
| Deficiency related to regulation 26-41-101 (f) (3) |
| Deficiency related to regulation 26-41-201 (c) |
| Deficiency related to regulation 26-41-202 (d) |
| Deficiency related to regulation 26-41-202 (h) |
| Deficiency related to regulation 26-41-204 (a) |
| Deficiency related to regulation 26-41-102 (d) |
Inspection Report
Re-Inspection
Census: 42
Deficiencies: 9
Nov 9, 2016
Visit Reason
Licensure re-survey with attached complaint conducted over multiple days in November 2016 to assess compliance with regulations and investigate allegations of abuse and neglect.
Findings
The facility was found deficient in multiple areas including failure to authorize a responsible employee in writing during operator absence, failure to report and investigate allegations of abuse timely, incomplete functional capacity screenings, lack of signatures on negotiated service agreements, inadequate coordination of health care services, incomplete medication self-administration assessments, incomplete staff background checks prior to employment, insufficient documentation of incidents, and unsafe food storage practices.
Complaint Details
The complaint investigation revealed failure to report and investigate allegations of abuse involving certified staff #D, who was alleged to have caused bruises and skin tears to resident #111. The facility failed to take immediate measures to prevent further abuse and allowed the alleged staff to continue working during the investigation, placing residents in immediate jeopardy.
Severity Breakdown
Level E: 4
Level J: 1
Level D: 3
Level F: 1
Deficiencies (9)
| Description | Severity |
|---|---|
| Operator failed to authorize, in writing, a responsible employee to act on operator's behalf during absence. | Level E |
| Failure to report allegations of abuse within 24 hours, conduct thorough investigations, and take immediate measures to prevent further abuse, placing residents in immediate jeopardy. | Level J |
| Failure to conduct functional capacity screening at least once every 365 days for a resident. | Level D |
| Failure to ensure all individuals involved in development of negotiated service agreement signed the agreement. | Level D |
| Failure to ensure licensed nurse provides or coordinates necessary health care services in accordance with functional capacity screening and negotiated service agreement. | Level E |
| Failure to perform and annually update assessment for resident's ability to self-administer medication safely and accurately. | Level D |
| Failure to complete required licensure, registry, and criminal background checks prior to staff working with residents. | Level F |
| Failure to document all incidents, symptoms, and indications of illness or injury including date, time, action taken, and results. | Level E |
| Failure to store all food under safe and sanitary conditions; observed unlabeled containers and scoops lying in ice bins. | Level E |
Report Facts
Census: 42
Deficiency count: 9
Days delay for licensure confirmation: 17
Days delay for background check: 51
Days delay for background check: 38
Days delay for background check: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Operator #A | Facility Operator | Failed to authorize responsible employee in writing; confirmed abuse allegations were not reported; confirmed background checks done in batches |
| Licensed Nurse #B | Licensed Nurse | Named in multiple findings including failure to report abuse, incomplete documentation, failure to assess medication self-administration, and failure to document incidents |
| Certified Staff #D | Certified Medication Aide | Alleged perpetrator of abuse causing bruises and skin tears to resident #111 |
| Certified Staff #C | Certified Staff | Filed abuse report against certified staff #D |
| Certified Staff #E | Certified Staff | Filed abuse report against certified staff #D |
Inspection Report
Re-Inspection
Deficiencies: 5
Mar 11, 2015
Visit Reason
This is a revisit report to verify correction of previously cited deficiencies from an earlier survey conducted on 2015-02-11.
Findings
All previously reported deficiencies identified by regulation numbers 26-41-101 (f)(3), 26-41-202 (a), 26-41-204 (i), 26-41-205 (d)(4), and 26-41-206 (d) were corrected as of 2015-03-11.
Deficiencies (5)
| Description |
|---|
| Deficiency related to regulation 26-41-101 (f)(3) |
| Deficiency related to regulation 26-41-202 (a) |
| Deficiency related to regulation 26-41-204 (i) |
| Deficiency related to regulation 26-41-205 (d)(4) |
| Deficiency related to regulation 26-41-206 (d) |
Report Facts
Deficiencies corrected: 5
Inspection Report
Re-Inspection
Deficiencies: 5
Mar 11, 2015
Visit Reason
This is a revisit inspection 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 2015-03-11.
Deficiencies (5)
| Description |
|---|
| Deficiency related to regulation 26-41-101 (f) (3) |
| Deficiency related to regulation 26-41-202 (a) |
| Deficiency related to regulation 26-41-204 (i) |
| Deficiency related to regulation 26-41-205 (d) (4) |
| Deficiency related to regulation 26-41-206 (d) |
Report Facts
Deficiencies corrected: 5
Inspection Report
Re-Inspection
Census: 33
Deficiencies: 5
Feb 11, 2015
Visit Reason
The inspection was a resurvey of an assisted living facility conducted on 2-10-15 and 2-11-15 to verify correction of previous deficiencies related to abuse reporting, negotiated service agreements, health care services, delegation of medication administration, and food preparation.
Findings
The facility failed to report an allegation of abuse or neglect within 24 hours, ensure negotiated service agreements fully described services and providers, provide all health care services by qualified staff, properly delegate nursing tasks with documentation, and maintain complete food temperature logs to ensure safe food preparation and serving temperatures.
Severity Breakdown
SS=D: 2
SS=E: 1
SS=F: 2
Deficiencies (5)
| Description | Severity |
|---|---|
| Failed to ensure each allegation of abuse or neglect was reported to the department within 24 hours. | SS=D |
| Failed to ensure the negotiated service agreement provided a description of services and identification of the provider for diabetes management. | SS=D |
| Failed to ensure all health care services were provided by qualified staff in accordance with acceptable standards of practice. | SS=E |
| Failed to appropriately delegate nursing procedures related to blood glucose monitoring and insulin administration with proper documentation in personnel files. | SS=F |
| Failed to ensure food was prepared using safe methods conserving nutritive value, flavor, and appearance and served at proper temperatures; food temperature logs were incomplete. | SS=F |
Report Facts
Deficiencies cited: 5
Resident census: 33
Residents sampled: 3
Insulin units: 15
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| J | Certified Staff | Named in failure to report fall and not following facility policy for resident #457 |
| B | Licensed Staff | Involved in post-fall assessment and interviews regarding resident #457 and #317 |
| G | Certified Staff | Observed performing blood glucose monitoring and insulin pen preparation for resident #317 |
| A | Administrative Staff | Confirmed fall was unwitnessed and not reported; confirmed delegation and food temperature log issues |
| C | Dietary Staff | Confirmed food preparation and temperature log deficiencies |
| D | Dietary Staff | Confirmed food preparation and temperature log deficiencies |
| E | Certified Staff | Performed medication administration and blood glucose monitoring without proper delegation documentation |
| F | Certified Staff | Performed medication administration and blood glucose monitoring without proper delegation documentation |
| H | Certified Staff | Performed medication administration and blood glucose monitoring without proper delegation documentation |
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