Inspection Reports for
Heritage Avonlea of Olathe LLC

The report confirms that the previously cited deficiency under regulation 26-41-101 (f)(1) was corrected as of 11/18/2024. No other deficiencies or uncorrected issues are noted.

The investigation was triggered by complaints #191417, 191376, and 190964. The complaint was substantiated as the facility failed to protect R1 from elopement and neglect, confirmed by security footage, staff interviews, and official reports.

The Administrator failed to protect a cognitively impaired 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 check on her afterward. R1 self-propelled down a steep driveway to a busy road and was found by law enforcement approximately 333 steps from the facility before being returned by EMS.

The inspection included complaint investigations with complaint numbers 189213, 188618, 185651, 180937, and 178695.

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.

The report confirms that the previously cited deficiency under regulation 26-41-101 (f)(1) was corrected as of 02/20/2023. No other deficiencies or uncorrected issues were noted.

The visit included review of multiple complaint investigations (#177592, #175070, #174556, #173970, #173610, and #173277). The complaint involved neglect related to a resident exiting the facility unsupervised and suffering a fall.

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, and the resident was found outside in cold weather after a fall. The facility lacked evidence of staff training on head counts and did not complete an elopement risk assessment for R110.

All deficiencies previously cited were corrected as of the revisit date. The report lists multiple regulatory provisions with completed corrections.

All previously reported deficiencies listed by regulation number were corrected as of the revisit date.

The facility was found deficient in multiple areas including failure to maintain advance directives in resident records, failure to secure exit doors leading to resident elopement, incomplete functional capacity screenings and negotiated service agreements, inadequate medication management documentation, lack of quarterly emergency management plan reviews, improper food temperature monitoring and storage, inadequate dishwashing sanitization monitoring, and noncompliance with tuberculosis screening for new employees.

The facility failed to report and investigate allegations of abuse within 24 hours, ensure negotiated service agreements included complete service descriptions, and properly administer medications according to physician orders. Medication administration records showed discrepancies and missing documentation for medication receipt and disposition.

All previously cited deficiencies were corrected as of April 17, 2019, with no uncorrected deficiencies noted at the time of this revisit.

The facility failed to ensure negotiated service agreements included all required service descriptions and interventions, failed to administer medications according to physician orders and professional standards, failed to label over-the-counter medications with resident names, stored expired medications, lacked documentation of incidents in resident records, failed to comply with tuberculosis screening guidelines, and failed to maintain water temperatures within required ranges at resident accessible sinks.

The report confirms that the deficiencies identified in the prior survey were corrected by the facility, with corrections completed by 03/07/2019 as documented.

The report confirms that the deficiencies previously reported under regulation numbers 26-41-205(i) and 26-41-102(d) were corrected as of 03/07/2019.

Complaints #135543 and #134014 were investigated during the licensure resurvey.

The facility failed to ensure negotiated service agreements included all required service descriptions for residents. Medication administration did not consistently follow physician orders or professional standards. Over-the-counter medications lacked proper labeling. Medications were stored beyond expiration dates. Medication records were not maintained accurately for reconciliation. Employee records lacked documentation of criminal background checks. Tuberculosis testing policies and documentation were incomplete. Water temperatures at hand wash sinks were not maintained within required ranges.

The report documents that all previously cited deficiencies identified by regulation or Life Safety Code provisions were corrected by 04/13/2015.

The report documents that all previously cited deficiencies listed by regulation numbers 26-41-101 (f)(3), 26-41-202 (a), 26-41-204 (i), 26-41-105 (f)(11), and 26-41-104 (d) were corrected as of 04/13/2015.

Complaints #84781 and #78824 were investigated during the licensure resurvey.

The facility failed to thoroughly investigate incidents of injury or complaints of pain to rule out abuse or neglect, failed to develop adequate negotiated service agreements addressing residents' needs, and failed to provide health care services and assessments according to acceptable standards. Documentation of incidents and assessments was incomplete. The facility also failed to conduct quarterly emergency management plan reviews with employees and annual emergency evacuation drills with staff and residents.