Inspection Reports for Guest Home Estates Vii
806 W. 4TH STREET, KS, 66032-2415
Back to Facility ProfileInspection Report Summary
The most recent inspection on October 24, 2024, found no deficiencies after verifying correction of prior medication labeling and storage issues. Earlier inspections showed recurring deficiencies related mainly to medication management, including labeling, storage, and administration according to physician orders, as well as incomplete documentation and employee screening processes. Complaint investigations in 2022 and 2019 identified additional issues with medication administration, negotiated service agreements, infection control, and safety measures, but no enforcement actions or fines were listed in the available reports. Most complaints were unsubstantiated or addressed through corrective actions. The facility appears to be improving over time, with recent revisits confirming correction of previously cited deficiencies.
Deficiencies (last 7 years)
Deficiencies (over 7 years)
5.4 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
10% better than Kansas average
Kansas average: 6 deficiencies/year
Deficiencies per year
12
9
6
3
0
Census
Latest occupancy rate
12 residents
Based on a October 2024 inspection.
This facility has shown a decline in demand based on occupancy rates.
Census over time
Inspection Report
Re-Inspection
Deficiencies: 0
Oct 24, 2024
Visit Reason
An offsite revisit survey was conducted on 10/24/24 to verify correction of all previous deficiencies cited on 10/07/24.
Findings
All deficiencies cited in the previous inspection have been corrected as of the compliance date of 10/21/24, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Inspection Report
Plan of Correction
Deficiencies: 0
Oct 7, 2024
Visit Reason
The document represents the findings of a resurvey conducted for the Residential Health Care facility on 10/03/24 and 10/07/24.
Findings
This Plan of Correction document summarizes the findings from the resurvey visit and outlines corrective actions cross-referenced to deficiencies.
Inspection Report
Re-Inspection
Census: 12
Deficiencies: 3
Oct 3, 2024
Visit Reason
The inspection was a resurvey conducted on 10/03/24 and 10/07/24 to assess compliance with medication labeling, storage, and handling regulations at the Residential Health Care facility.
Findings
The facility failed to ensure that over-the-counter and prescription medications were labeled with the resident's full name by a licensed pharmacist or nurse, and medications were not stored according to manufacturer recommendations, including an expired vial of Tubersol found in the medication refrigerator.
Severity Breakdown
Level E: 2
Level F: 1
Deficiencies (3)
| Description | Severity |
|---|---|
| Failed to ensure a licensed pharmacist or nurse placed the full name of the resident on the original package of some over-the-counter medications. | Level E |
| Failed to ensure each prescription medication container had a label provided by a dispensing pharmacist affixed to the container. | Level E |
| Failed to ensure all medications and biologicals were securely and properly stored in accordance with manufacturer recommendations. | Level F |
Report Facts
Census: 12
Date of vial opening: 2024.05
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Nurse A | Acknowledged the presence of unlabeled OTC and prescription medications and the opened vial of Tubersol |
Inspection Report
Follow-Up
Deficiencies: 0
Jun 12, 2023
Visit Reason
An offsite revisit survey was conducted to verify correction of all previous deficiencies cited on 2023-06-01.
Findings
All deficiencies have been corrected as of the compliance date of 2023-06-08, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Report Facts
Previous deficiencies cited: Deficiencies cited on 2023-06-01
Inspection Report
Plan of Correction
Deficiencies: 0
Jun 1, 2023
Visit Reason
This document represents the provider's plan of correction following a resurvey inspection conducted at the Residential Health Care facility on 06/01/23.
Findings
The plan of correction addresses findings identified during the resurvey inspection conducted on 06/01/23. Specific deficiencies are not detailed in this document.
Inspection Report
Re-Inspection
Census: 13
Deficiencies: 6
Jun 1, 2023
Visit Reason
This document is a resurvey inspection conducted on 06/01/2023 for the Residential Health Care facility Guest Home Estates VII to assess compliance with regulatory requirements.
Findings
The inspection found multiple deficiencies including failure to complete Functional Capacity Screens and Negotiated Service Agreements annually for residents, improper administration of medications outside physician-ordered parameters, failure to label over-the-counter medications with resident names, incomplete employee records regarding nurse aide registry and criminal background checks, and non-compliance with tuberculosis screening guidelines for new employees.
Severity Breakdown
E: 3
F: 3
Deficiencies (6)
| Description | Severity |
|---|---|
| Failure to ensure designated staff completed Functional Capacity Screens for residents R102 and R103 at least once every 365 days. | E |
| Failure to ensure designated staff completed Negotiated Service Agreements for residents R102 and R103 at least once every 365 days. | E |
| Failure to ensure medications were administered according to physician's orders by not holding medications when blood pressures were outside specified parameters for residents R101 and R103. | E |
| Failure to ensure licensed pharmacist or nurse placed the full name of the resident on original packages of over-the-counter medications. | F |
| Failure to ensure timely verification of nurse aide registry and criminal background checks for two of five newly hired employees. | F |
| Failure to comply with tuberculosis screening guidelines for adult care homes, including incomplete TB symptom screening questionnaires and two-step TB skin tests for newly hired staff. | F |
Report Facts
Census: 13
Deficiencies cited: 6
Dates medications administered outside parameters: 15
Days late for TB symptom screening questionnaire: 179
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Nurse B | Licensed Nurse | Interviewed regarding medication administration and tuberculosis screening |
| Administrative Staff A | Interviewed regarding Functional Capacity Screens, Negotiated Service Agreements, and tuberculosis screening | |
| Certified Nurse Aide C | Certified Nurse Aide | Newly hired employee with delayed nurse aide registry verification and incomplete TB testing |
| Certified Nurse Aide D | Certified Nurse Aide | Newly hired employee with delayed criminal background check and late TB symptom screening questionnaire |
Inspection Report
Follow-Up
Deficiencies: 0
Apr 11, 2022
Visit Reason
An offsite revisit survey was conducted to verify correction of all previous deficiencies cited on 2022-03-04.
Findings
All deficiencies have been corrected as of the compliance date of 2022-03-28, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Inspection Report
Complaint Investigation
Census: 15
Deficiencies: 12
Mar 4, 2022
Visit Reason
The inspection was a resurvey with complaint investigations #160214, #165327, and #167529 for the assisted living facility Guest Home Estates VII conducted on 2/28/21 and 3/1-4/2022.
Findings
The facility was found deficient in multiple areas including failure to ensure sufficient information accompanied residents during transfers, failure to revise negotiated service agreements after significant changes, failure to provide health care services according to standards, medication administration issues, unsafe food preparation and storage, infection control noncompliance, unsecured chemicals, and improper hot water temperatures in resident areas.
Complaint Details
The inspection was complaint-related, involving investigations #160214, #165327, and #167529.
Severity Breakdown
E: 4
D: 3
F: 5
Deficiencies (12)
| Description | Severity |
|---|---|
| Failed to ensure sufficient information accompanied residents during transfer to another health care facility to ensure continuity of care. | E |
| Failed to ensure designated staff reviewed/revised negotiated service agreement following significant change in condition related to therapy services. | D |
| Failed to ensure all health care services were provided in accordance with standards of practice regarding safety of bed canes used as assistive devices. | E |
| Failed to ensure licensed nurse assessed resident to safely self-administer insulin. | D |
| Failed to ensure facility staff followed professional standards by remaining with resident until medication was ingested. | D |
| Failed to ensure licensed nurse delegated insulin pen preparation and dialing according to nurse practice act. | E |
| Failed to ensure documentation of all incidents, symptoms, and indications of illness or injury including actions taken and results. | E |
| Failed to ensure dietary staff prepared food using safe methods by thawing foods at room temperature. | F |
| Failed to ensure food was stored under safe and sanitary conditions including uncovered, undated, and unlabeled foods and improper storage of raw and cooked foods. | F |
| Failed to ensure compliance with tuberculosis guidelines for adult care homes for newly hired employees and a resident. | F |
| Failed to ensure chemicals were secured and not accessible to residents for safety. | F |
| Failed to ensure hot water temperature ranged between 96°F and 120°F at sinks and lavatories in resident use areas. | E |
Report Facts
Census: 15
Resident sample: 3
Closed record reviews: 2
Temperature readings: 137.6
Temperature readings: 134
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Operator A | Operator | Provided interviews and information regarding facility practices and deficiencies |
| Licensed Nurse B | Licensed Nurse | Interviewed regarding medication administration, resident assessments, and TB compliance |
| Certified Medication Aide C | Certified Medication Aide | Interviewed regarding EMS paperwork and housekeeping cart |
| Certified Medication Aide G | Certified Medication Aide | Interviewed regarding EMS paperwork and insulin pen delegation |
| Certified Nurse Aide F | Certified Nurse Aide | Interviewed regarding EMS paperwork |
| Dietary Staff D | Dietary Staff | Interviewed and observed regarding food thawing and storage practices |
| Dietary Staff E | Dietary Staff | Observed and interviewed regarding food storage |
Inspection Report
Plan of Correction
Deficiencies: 0
Feb 28, 2022
Visit Reason
The document represents the findings of a resurvey with complaint investigations #160214, #165327, and #167529 for the assisted living facility conducted on 2/28/21 and 3/1, 3/2, 3/3, and 3/4/2022.
Findings
This plan of correction addresses the findings from the resurvey and complaint investigations conducted at the assisted living facility during the specified dates.
Complaint Details
The visit was related to complaint investigations #160214, #165327, and #167529.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Jun 23, 2020
Visit Reason
The special infection control survey for COVID-19 was conducted at the facility on 06/23/2020.
Findings
The survey resulted in findings of no deficiency citations.
Inspection Report
Follow-Up
Deficiencies: 7
May 15, 2019
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 identified by regulation or LSC provision numbers were corrected as of the revisit date, May 15, 2019.
Deficiencies (7)
| Description |
|---|
| Deficiency identified under regulation 26-41-202 (a) |
| Deficiency identified under regulation 26-41-204 (a) |
| Deficiency identified under regulation 26-41-205 (d) (1-2) |
| Deficiency identified under regulation 26-41-205 (g) (3) |
| Deficiency identified under regulation 26-41-205 (h) |
| Deficiency identified under regulation 26-41-102 (d) |
| Deficiency identified under regulation 26-41-104 (a) |
Inspection Report
Complaint Investigation
Census: 19
Deficiencies: 7
Apr 9, 2019
Visit Reason
The inspection was conducted as a licensure resurvey and complaint investigations #136704 and #136962 for the facility.
Findings
The facility was found deficient in multiple areas including failure to include outside services in negotiated service agreements, failure to ensure licensed nurse coordination of health care services especially regarding fall investigations, improper medication administration and documentation, inadequate labeling of over-the-counter medications, medication storage beyond expiration dates, lack of nurse aide registry verification for new staff, and failure to conduct emergency evacuation drills with minimum staffing.
Complaint Details
The inspection included complaint investigations #136704 and #136962.
Severity Breakdown
Level D: 2
Level E: 4
Level F: 1
Deficiencies (7)
| Description | Severity |
|---|---|
| Failed to ensure the negotiated service agreement included services provided by an outside source and the party responsible for payment regarding Hospice services for resident #416. | Level D |
| Failed to ensure a licensed nurse provided or coordinated necessary health care services for resident #416 regarding investigations into repeated falls and interventions to reduce risk. | Level E |
| Failed to ensure licensed nurses and certified medication aides administered medications in accordance with medical orders and professional standards for resident #519 regarding missing doses of controlled substance pain medication. | Level E |
| Failed to ensure licensed nurse or pharmacist placed the full name of the resident on original manufacturer’s package of over-the-counter medications. | Level E |
| Failed to ensure licensed nurses and medication aides did not administer medication beyond the manufacturer’s or pharmacy provider’s recommended expiration date for resident #166. | Level E |
| Failed to have evidence of nurse aide registry verification for certified nurse aide E hired since last resurvey. | Level D |
| Failed to conduct an emergency evacuation drill with the least amount of staff on duty to ensure sufficient staff to assist residents requiring help to a secure location. | Level F |
Report Facts
Residents present: 19
Residents with cognitive impairment: 16
Medication doses missed: 7
Days medication shortage: 2.5
Tuberculosis testing solution days open: 59
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Licensed nurse F | Licensed Nurse | Interviewed regarding fall investigations, medication administration, and medication storage. |
| Certified medication aide C | Certified Medication Aide | Observed administering medications and handling medication storage. |
| Certified medication aide/operator A | Certified Medication Aide/Operator | Interviewed regarding medication administration and documentation. |
| Certified staff D | Certified Staff | Observed assisting resident #416 with ambulation. |
| Certified nurse aide E | Certified Nurse Aide | New hire lacking nurse aide registry verification. |
| Pharmacy staff H | Pharmacy Staff | Interviewed regarding medication deliveries and records. |
| Operator A | Operator | Provided resident roster and confirmed lack of registry verification and evacuation drill documentation. |
| Operator B | Operator | Conducted evacuation drill on 6/29/18. |
Inspection Report
Re-Inspection
Census: 21
Deficiencies: 1
Jan 30, 2018
Visit Reason
The inspection was a resurvey conducted at the Residential Health Care Facility to assess compliance with medication administration regulations.
Findings
The facility failed to ensure that certified staff administered medications according to physician orders and standards of practice, specifically for resident #121 whose medication orders for Lantus insulin and Metformin were not properly documented or communicated despite elevated blood sugar readings.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Certified staff failed to administer medications in accordance with physician's orders and standards of practice for resident #121. | SS=D |
Report Facts
Census: 21
Resident sample size: 3
Insulin dose: 41
Metformin dose: 500
Blood sugar reading: 483
Blood sugar reading: 463
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Licensed nursing staff | Reported using prior facility MAR and failing to notice missing physician orders; notified physician of blood sugar on 1/19/18 but did not document; unaware of elevated blood sugar on 1/28/18 |
| Operator B | Failed to ensure staff administered medications according to physician orders and standards of practice | |
| Operator staff C | Failed to ensure certified staff administered medications in accordance with physician's orders and standards of practice |
Inspection Report
Complaint Investigation
Census: 23
Deficiencies: 2
Apr 28, 2014
Visit Reason
The inspection was a resurvey with complaint investigations 74747, 74761, 72356, and 72373 conducted on 2014-04-24 and 2014-04-28 at Guest Home Estates VII.
Findings
The facility failed to report allegations of abuse to the department within 24 hours and failed to ensure proper documentation of incidents including date, time, action taken, and results. Additionally, the facility did not document resident consent for procedures or follow-up on effectiveness, specifically for resident #234.
Complaint Details
The complaint investigations involved allegations of abuse and neglect related to resident #234, including failure to report abuse allegations timely and inadequate documentation of incidents and resident consent.
Severity Breakdown
SS=D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to report each allegation of abuse to the department within 24 hours. | SS=D |
| Failure to document all incidents including date, time of occurrence, action taken, and results of the action. | SS=D |
Report Facts
Census: 23
Sample size: 3
Focus review residents: 1
Inspection Report
Plan of Correction
Deficiencies: 3
N002001 POC 8SZZ11
Visit Reason
This document is a Plan of Correction submitted by the provider in response to deficiencies cited in a prior inspection report.
Findings
The Plan of Correction indicates that no corrective action was required for the listed deficiencies (S0000, S3028-D, S3261-D) with completion dates in April 2014.
Deficiencies (3)
| Description |
|---|
| No POC required for deficiency S0000 |
| No POC required for deficiency S3028-D |
| No POC required for deficiency S3261-D |
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