Inspection Reports for Heritage Avonlea of Olathe LLC
625 N LINCOLN ST, OLATHE, KS, 66061-2501
Back to Facility ProfileInspection Report Summary
The most recent inspection on November 18, 2024, confirmed that a previously identified deficiency was corrected, with no outstanding deficiencies noted. Earlier inspections showed a pattern of deficiencies related primarily to resident protection and medication management, including substantiated complaints of neglect and failure to prevent resident elopement, some of which involved immediate jeopardy findings. Complaint investigations included substantiated cases of neglect resulting in resident harm, and staff actions leading to resident elopement, with corrective actions taken such as staff termination. Enforcement actions such as immediate jeopardy were noted in prior inspections, but fines or license suspensions were not listed in the available reports. The facility’s record shows improvement over time, with recent inspections confirming correction of prior deficiencies.
Deficiencies (last 8 years)
Deficiencies (over 8 years)
6.9 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
15% worse than Kansas average
Kansas average: 6 deficiencies/yearDeficiencies per year
12
9
6
3
0
Census
Latest occupancy rate
39 residents
Based on a October 2024 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Re-Inspection
Deficiencies: 1
Date: Nov 18, 2024
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
The revisit inspection confirmed that the previously identified deficiency related to regulation 26-41-101 (f)(1) was corrected as of 11/18/2024. No other deficiencies were listed as outstanding.
Deficiencies (1)
Deficiency related to regulation 26-41-101 (f)(1)
Inspection Report
Abbreviated Survey
Census: 39
Deficiencies: 1
Date: Oct 28, 2024
Visit Reason
The inspection was an abbreviated survey conducted on 10/28/2024 for complaints #191417, 191376, and 190964 regarding the facility's failure to protect a cognitively impaired resident from elopement and neglect.
Complaint Details
The visit was complaint-related involving three complaints (#191417, 191376, 190964) concerning the facility's failure to prevent elopement and neglect of resident R1. The complaint was substantiated with findings of Immediate Jeopardy for approximately 63 minutes on 10/21/2024.
Findings
The Administrator failed to protect resident R1 from abuse and neglect when a Certified Medication Aide (CMA C) assisted R1 out of the facility, silenced the door alarm, and did not return to check on her. R1 self-propelled down a steep driveway to a busy road and was found by law enforcement approximately 333 steps from the facility. CMA C was terminated following the incident.
Deficiencies (1)
Failure to protect resident R1 from abuse and neglect when CMA C assisted R1 out of the facility and did not monitor her, resulting in elopement.
Report Facts
Census: 39
Elopement duration (minutes): 63
Steps from facility: 333
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CMA C | Certified Medication Aide | Named in the finding for assisting resident R1 out of the facility and failing to monitor her |
| CNA D | Certified Nurse Aide | Involved in confirming resident R1 was missing and found |
| Administrator A | Administrator | Confirmed findings and termination of CMA C |
| LN B | Licensed Nurse | Received notification of elopement and participated in investigation |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Oct 28, 2024
Visit Reason
The document is a Plan of Correction addressing findings from an abbreviated survey conducted on 10/28/24 related to complaints #191417, 191376, and 190964 at the facility.
Complaint Details
The visit was complaint-related involving complaints #191417, 191376, and 190964.
Findings
The Plan of Correction corresponds to deficiencies identified during an abbreviated survey triggered by multiple complaints at the facility on 10/28/24.
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Oct 17, 2024
Visit Reason
An offsite revisit survey was conducted on 10/17/24 for all previous deficiencies cited on 09/26/24.
Findings
All deficiencies have been corrected as of the compliance date of 10/11/24 and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Report Facts
Previous deficiencies cited: 1
Inspection Report
Renewal
Census: 41
Deficiencies: 4
Date: Sep 26, 2024
Visit Reason
The inspection was a licensure resurvey with attached complaint investigations for the facility conducted on 09/25/24 and 09/26/24.
Complaint Details
The inspection included attached complaint investigations numbered 189213, 188618, 185651, 180937, and 178695.
Findings
The facility was found deficient in multiple areas including failure to assess and document the safe use of a bed assist device for a resident, improper medication storage and administration practices, failure to maintain confidentiality of resident records awaiting destruction, and failure to conduct quarterly reviews of the emergency management plan with staff and residents.
Deficiencies (4)
Failure to ensure an assessment for a resident's bed assist device was conducted to confirm it posed no risk for entrapment, was not a restraint, and was securely attached to the bed.
Failure to ensure all non-controlled medications were stored in a locked medication room, cabinet, or medication cart and failure to ensure insulin pens were not used beyond the manufacturer's recommended expiration date.
Failure to keep duplicate copies of resident records awaiting destruction confidential and securely stored.
Failure to ensure a quarterly review of the facility's emergency management plan with employees and residents.
Report Facts
Census: 41
Medication cards: 25
Insulin pen expiration days: 42
Insulin pen expiration days: 28
Stack height: 12
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Sep 25, 2024
Visit Reason
The document is a plan of correction submitted in response to findings from a licensure resurvey conducted on 09/25/24 and 09/26/24, which included attached complaint investigations.
Findings
The plan of correction addresses citations from the licensure resurvey and attached complaint numbers 189213, 188618, 185651, 180937, and 178695 conducted on 09/25/24 and 09/26/24.
Inspection Report
Re-Inspection
Deficiencies: 1
Date: Feb 20, 2023
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
The revisit inspection confirmed that the previously identified deficiency under regulation 26-41-101 (f)(1) was corrected as of 02/20/2023.
Deficiencies (1)
Deficiency under regulation 26-41-101 (f)(1) previously reported
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Jan 25, 2023
Visit Reason
The document represents the findings of an abbreviated survey with review of facility report #177676 and multiple complaint investigations (#177592, #175070, #174556, #173970, #173610, and #173277) conducted at the assisted living facility on 01/25/23 and 01/26/23.
Findings
This plan of correction addresses the findings from the abbreviated survey and complaint investigations conducted at the facility during the specified dates.
Inspection Report
Abbreviated Survey
Census: 37
Deficiencies: 1
Date: Jan 25, 2023
Visit Reason
The inspection was an abbreviated survey with review of facility report #177676 and multiple complaint investigations at the assisted living facility conducted on 01/25/23 and 01/26/23.
Complaint Details
The visit included review of multiple complaint investigations (#177592, #175070, #174556, #173970, #173610, and #173277) related to the incident where resident R110 exited the facility unsupervised and fell outside.
Findings
The administrator failed to protect one resident (R110) from neglect when she exited the facility unsupervised through a fire door, staff did not perform a head count to determine who was missing, resulting in the resident falling outside in cold weather and requiring hospital admission. The facility lacked evidence of staff training on head counts and did not have an elopement risk assessment for R110 prior to the incident.
Deficiencies (1)
Failure to protect resident R110 from neglect by not ensuring staff were aware of procedures if a resident left the facility unsupervised, resulting in Immediate Jeopardy.
Report Facts
Census: 37
Temperature: 27
Wind Speed: 6
Number of residents in sample: 5
Steps from door to fall location: 10
Steps from door to fall location: 12
Drop height: 3
Drop height: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nurse B | Administrative Nurse | Documented resident fall, monitored resident post-incident, provided elopement training, and communicated with hospital and owner. |
| Certified Medication Aide D | Certified Medication Aide | Notified nurse of resident fall, found resident outside, and described exit door and fall location. |
| Certified Nursing Assistant C | Certified Nursing Assistant | Was working during incident, checked residents' rooms, did not perform head count, and received training post-incident. |
| Maintenance Director E | Maintenance Director | Checked all door alarms following the incident. |
| Owner F | Owner | Instructed reporting of incident to department. |
| Environmental Services Staff G | Environmental Services Staff | Opened door and checked if anyone was outside during head count. |
| Administrative Staff A | Administrative Staff | Walked around building outside to check if anyone had exited. |
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Aug 2, 2022
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 by regulation numbers were corrected as of the revisit date, with no uncorrected deficiencies noted.
Inspection Report
Re-Inspection
Census: 38
Deficiencies: 11
Date: Jul 18, 2022
Visit Reason
The inspection was a licensure resurvey conducted from 07/13/22 to 07/18/22 to assess compliance with state regulations for an assisted living facility.
Findings
The facility was found deficient in multiple areas including failure to maintain advance medical directives in resident records, failure to protect residents from neglect due to unsecured exit doors resulting in immediate jeopardy, incomplete functional capacity screenings and negotiated service agreements, inadequate medication management documentation, lack of quarterly emergency preparedness reviews, improper food temperature monitoring and storage, inadequate dishwashing sanitization monitoring, and non-compliance with tuberculosis screening requirements for new employees.
Deficiencies (11)
Failed to ensure a copy of one resident's advance medical directive was in the resident's clinical record.
Failed to protect one resident from neglect by failing to secure all exit doors, resulting in immediate jeopardy when a cognitively impaired resident left the facility unsupervised.
Failed to record all findings of a resident's functional capacity on a screening form.
Failed to conduct functional capacity screening every 365 days or following a significant change in condition.
Failed to complete a negotiated service agreement based on the resident's functional capacity screen, service needs, and preferences every 365 days or following a significant change in condition.
Failed to ensure a resident's negotiated service agreement identified who was responsible for administration and management of select medications.
Failed to provide quarterly reviews of the facility's emergency management plan with employees and residents.
Failed to ensure food items were served at the proper temperature and lacked food temperature logs.
Failed to ensure food items were stored under safe and sanitary conditions, including lack of refrigerator/freezer temperature logs and unlabeled or undated food items.
Failed to ensure sanitary conditions for food service by not monitoring dishwashing temperatures or chemical sanitization levels.
Failed to ensure compliance with tuberculosis guidelines for adult care homes regarding newly hired employees, including lack of required two-step TB skin tests and symptom questionnaires.
Report Facts
Census: 38
Days past due: 278
Days past due: 285
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator B | Administrator | Named in findings related to unsecured exit doors and tuberculosis compliance |
| Administrative Staff C | Administrative Staff | Confirmed missing advance directive and functional capacity screening issues |
| Dietary Manager D | Dietary Manager | Mentioned regarding lack of food temperature logs |
| Maintenance Staff F | Maintenance Staff | Mentioned regarding door lock repairs and alarm disarming |
| Certified Medication Aide H | Certified Medication Aide | Witnessed resident elopement and did not report incident |
| Certified Medication Aide I | Certified Medication Aide | Mentioned resident wandering and door lock issues |
| Certified Medication Aide J | Certified Medication Aide | Provided information on resident behavior and staff training |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Jul 13, 2022
Visit Reason
The document is a Plan of Correction submitted in response to the licensure resurvey conducted at the facility from 07/13/22 to 07/18/22.
Findings
The Plan of Correction addresses the citations found during the licensure resurvey conducted between 07/13/22 and 07/18/22 at the facility.
Inspection Report
Renewal
Deficiencies: 0
Date: Sep 9, 2021
Visit Reason
A survey for re-licensure with attached complaints was conducted on 09/08/2021 and 09/09/2021 at the assisted living facility in Olathe, KS.
Findings
The survey resulted in a finding of no deficiency citations.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Jul 30, 2020
Visit Reason
The special infection control survey for COVID-19 was conducted at the facility on 7/30/2020.
Findings
The survey resulted in findings of no deficiency citations.
Inspection Report
Re-Inspection
Census: 30
Deficiencies: 4
Date: Apr 18, 2019
Visit Reason
The inspection was a Revisit and Notice of Assessment at an Assisted Living Facility in Olathe, Kansas, conducted on 4/17/19 and 4/18/19 to assess compliance with prior deficiencies.
Findings
The facility failed to report and investigate allegations of abuse or neglect within 24 hours, failed to ensure negotiated service agreements included required service descriptions for residents, and did not administer medications in accordance with physician orders and professional standards. Additionally, medication records lacked proper reconciliation and documentation of receipt and disposition of medications.
Deficiencies (4)
Failure to report and investigate allegations of abuse, neglect, or exploitation within 24 hours and maintain written records of investigations.
Failure to ensure negotiated service agreements included descriptions of services to be provided, identification of providers, and payment responsibilities.
Failure to administer medications and biologicals in accordance with medical care provider's written orders and professional standards.
Failure to maintain records of receipt and disposition of medications in sufficient detail for accurate reconciliation.
Report Facts
Census: 30
Sampled Residents: 3
Medication discrepancies: 9
Medication delivery dates: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Facility nurse #D | Provided incident report and confirmed lack of investigation and medication documentation | |
| Certified medication aide #K | Assisted with medication cart review and confirmed medication discrepancies |
Inspection Report
Follow-Up
Deficiencies: 5
Date: Apr 18, 2019
Visit Reason
This revisit report documents the correction of deficiencies previously cited during an earlier survey, verifying that corrective actions were completed.
Findings
All previously reported deficiencies were corrected as of 04/17/2019, with each deficiency fully identified by regulation number and marked as completed.
Deficiencies (5)
Deficiency related to regulation 26-41-205 (g) (3)
Deficiency related to regulation 26-41-205 (h)
Deficiency related to regulation 26-41-105 (f) (11)
Deficiency related to regulation 26-41-207 (b) (5-6) (c)
Deficiency related to regulation 28-39-256
Inspection Report
Re-Inspection
Census: 31
Deficiencies: 7
Date: Mar 12, 2019
Visit Reason
The inspection was a licensure revisit and correction order follow-up at Avonlea Cottage of Olathe, an assisted living facility, conducted on multiple dates in March 2019 to verify correction of previous deficiencies.
Findings
The facility was found deficient in multiple areas including failure to ensure negotiated service agreements included all required service descriptions, medication administration errors, improper labeling and storage of medications, lack of documentation of incidents in resident records, failure to comply with tuberculosis screening guidelines, and failure to maintain proper water temperatures in resident accessible sinks.
Deficiencies (7)
Negotiated service agreements failed to include descriptions of services to address falls prevention and blood sugar testing for sampled residents.
Facility administration of medications did not comply with medical orders and professional standards, including medication discrepancies and undocumented administration.
Over-the-counter medications lacked resident names on original packages.
Medications were stored beyond manufacturer expiration dates.
Resident records lacked documentation of incidents, symptoms, and actions taken for falls and other events.
Facility failed to comply with tuberculosis screening and documentation requirements for a newly admitted resident.
Water temperatures at resident accessible hand wash sinks were not maintained within the required range of 98°F to 120°F at all times.
Report Facts
Census: 31
Residents with facility managed medications: 30
Medication doses remaining: 14
Expired medications observed: 3
Water temperature low: 78.8
Water temperature high: 130.8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse #C | Facility Nurse | Confirmed deficiencies related to negotiated service agreements, medication administration, incident documentation, and tuberculosis screening |
| Medication Aide #G | Certified Medication Aide | Confirmed lack of resident names on OTC medications and presence of expired medications |
| Medication Aide #K | Certified Medication Aide | Confirmed medication administration discrepancies for resident #1068 |
| Operator #A | Facility Operator | Provided information on water leak and plumbing repairs affecting water temperature |
| Maintenance Staff #P | Maintenance Staff | Described water heater issues and temporary repairs related to water temperature deficiencies |
Inspection Report
Re-Inspection
Deficiencies: 2
Date: Mar 12, 2019
Visit Reason
This revisit report documents the correction of deficiencies previously reported during an earlier survey, verifying that corrective actions were completed.
Findings
The report confirms that previously identified deficiencies related to regulations 26-41-205(i) and 26-41-102(d) were corrected as of 03/07/2019.
Deficiencies (2)
Deficiency related to regulation 26-41-205(i)
Deficiency related to regulation 26-41-102(d)
Inspection Report
Annual Inspection
Census: 30
Deficiencies: 8
Date: Feb 4, 2019
Visit Reason
Licensure Resurvey of Avonlea Cottage of Olathe, an assisted living facility, conducted on 01/28/19 through 02/04/19, including investigation of complaints #135543 and #134014.
Complaint Details
Complaints #135543 and #134014 were investigated during the licensure resurvey.
Findings
The inspection identified multiple deficiencies including failure to ensure negotiated service agreements fully described resident services, medication administration errors and discrepancies, improper labeling and storage of medications, lack of accurate medication reconciliation, incomplete employee background checks, noncompliance with tuberculosis screening guidelines, and unsafe water temperatures at resident hand wash sinks.
Deficiencies (8)
Negotiated service agreements (NSA) for residents #185 and #187 lacked full descriptions of services to be provided, including skilled nursing and blood sugar monitoring.
Facility failed to ensure all medications administered to residents #185, #187, and #189 were in accordance with medical orders and professional standards, including documentation discrepancies and improper PRN medication recording.
Over-the-counter medications for residents lacked proper labeling with resident's full name on original packages.
Medications were not stored according to manufacturer recommendations; expired medications were found in use for multiple residents.
Facility failed to maintain accurate records of receipt and disposition of medications for residents #185, #187, and #189, resulting in discrepancies in medication counts.
Employee records for five recently hired staff lacked supporting documentation of criminal background checks.
Facility failed to comply with tuberculosis screening guidelines for employees #C and #F, lacking required two-step skin testing at hire.
Water temperatures at six resident accessible hand wash sinks exceeded the required range of 98°F to 120°F, with temperatures recorded up to 141.6°F.
Report Facts
Resident census: 30
Medication discrepancies: 15
Medication discrepancies: 8
Medication discrepancies: 36
Medication discrepancies: 16
Medication discrepancies: 356
Medication discrepancies: 141.6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Operator #B | Facility Operator | Interviewed regarding medication reconciliation, employee records, tuberculosis policy, and water temperature issues. |
| Nurse #C | Facility Nurse | Confirmed medication administration and documentation deficiencies, medication labeling issues, and assisted with medication reconciliation. |
| Medication Aide #J | Medication Aide | Observed medication labeling deficiencies and water temperature measurements. |
| Certified Medication Aide #N | Medication Aide | Confirmed expired medications and assisted with medication storage observations. |
| Dietary Manager #A | Dietary Manager | Verified water temperature readings. |
| Maintenance Staff #P | Maintenance Staff | Involved in adjusting water heater and plumbing repairs. |
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Feb 14, 2017
Visit Reason
The licensure re-survey was conducted at the assisted living facility in Olathe, Kansas to assess compliance with licensing requirements.
Findings
The re-survey resulted in a finding of no deficiency citations on 2/14/17.
Inspection Report
Re-Inspection
Deficiencies: 5
Date: Apr 16, 2015
Visit Reason
This is a revisit report to verify that previously reported deficiencies have been corrected and to document the dates such corrective actions were accomplished.
Findings
The report confirms that all previously cited deficiencies identified by regulation or Life Safety Code provisions have been corrected as of April 13, 2015.
Deficiencies (5)
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 26-41-105 (f) (11)
Deficiency related to regulation 26-41-104 (d)
Report Facts
Deficiencies corrected: 5
Inspection Report
Renewal
Census: 41
Deficiencies: 5
Date: Mar 17, 2015
Visit Reason
The inspection was a Licensure Resurvey conducted over multiple days in March 2015, including investigation of complaints #84781 and #78824.
Complaint Details
Complaints #84781 and #78824 were investigated as part of this resurvey.
Findings
The facility was found deficient in multiple areas including failure to thoroughly investigate incidents of injury or complaints of pain to rule out abuse or neglect, failure to develop adequate negotiated service agreements based on residents' functional needs, failure to provide health care services and assessments by qualified staff according to standards, incomplete documentation of incidents and assessments in resident records, and deficiencies in disaster and emergency preparedness including lack of quarterly emergency plan reviews and annual evacuation drills.
Deficiencies (5)
Failure to thoroughly investigate incidents with injury or complaints of pain to rule out potential abuse or neglect.
Failure to ensure development of written negotiated service agreements based on functional capacity and service needs.
Failure to ensure all health care services and assessments provided by qualified staff in accordance with acceptable standards of practice.
Failure to document all incidents, symptoms, and indications of illness or injury including date, time, action taken, and results.
Failure to ensure disaster and emergency preparedness including quarterly reviews of emergency management plan with employees and annual emergency evacuation drills with staff and residents.
Report Facts
Census: 41
Employees hired since last resurvey: 13
Emergency evacuation drill dates: Last two drills conducted on 10/28/2013 and 12/31/2014, more than a year apart
Employees mentioned
| Name | Title | Context |
|---|---|---|
| DON #F | Director of Nursing | Interviewed regarding investigation and assessment deficiencies |
| Operator #D | Interviewed regarding documentation and emergency preparedness deficiencies | |
| CMA #K | Certified Medication Aide | Interviewed regarding fall assessments and communication with DON |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: N046035 2tUC11
Visit Reason
This document is a Plan of Correction related to a previously conducted facility inspection.
Findings
No specific findings or deficiencies are detailed in this document; it serves as a placeholder or status page for the Plan of Correction with no records found.
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