Inspection Report Summary
The most recent inspection on January 16, 2025, found no deficiencies and confirmed that all previous issues had been corrected. Prior inspections showed several deficiencies related mainly to medication management, documentation of resident incidents, emergency preparedness, and compliance with tuberculosis screening guidelines. Complaint investigations were mostly unsubstantiated, though earlier reports noted substantiated complaints involving medication administration and resident care coordination. No fines, immediate jeopardy findings, or license actions were listed in the available reports. The facility’s record shows improvement, with recent inspections demonstrating correction of earlier deficiencies.
Deficiencies (last 10 years)
Deficiencies (over 10 years)
2.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
58% better than Kansas average
Kansas average: 6 deficiencies/yearDeficiencies per year
8
6
4
2
0
Census
Latest occupancy rate
29 residents
Based on a December 2024 inspection.
Census over time
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Jan 16, 2025
Visit Reason
An offsite revisit survey was conducted to verify correction of all previous deficiencies cited on 12/18/24.
Findings
All deficiencies have been corrected as of the compliance date of 01/16/25, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Report Facts
Previous deficiencies cited: Deficiencies cited on 12/18/24 prior to this revisit
Inspection Report
Re-Inspection
Census: 29
Deficiencies: 7
Date: Dec 18, 2024
Visit Reason
The inspection was a resurvey with attached complaints #189401 and #182588 conducted at an assisted living facility to assess compliance with state regulations.
Complaint Details
The resurvey included attached complaints #189401 and #182588.
Findings
The facility failed to ensure availability of policies and procedures to staff and others, lacked proper negotiated service agreements for residents, failed to conduct required medication self-administration assessments, did not provide training and competency documentation for medication aides, lacked documentation of resident incidents, failed to conduct quarterly emergency management plan reviews, and did not comply with tuberculosis screening guidelines.
Deficiencies (7)
Failed to ensure policies and procedures were always available to staff and others during normal business hours.
Failed to ensure the negotiated service agreement for Resident 1 described services provided for cognitive difficulties.
Failed to ensure a licensed nurse performed an assessment to determine if Resident 2 could self-administer insulin safely.
Failed to ensure two of three sampled Certified Medication Aides received training and completed competencies for delegated insulin pen preparation.
Failed to ensure licensed staff documented when Resident 1 returned to the facility after two hospital stays.
Failed to provide evidence that the emergency management plan was reviewed quarterly with residents and staff.
Failed to ensure compliance with tuberculosis guidelines, including administration and documentation of two-step TB skin tests for residents and staff.
Report Facts
Census: 29
Deficiencies cited: 7
Residents sampled: 3
Certified Medication Aides sampled: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Staff A | Interviewed regarding policies, emergency plan, and medication administration policy. | |
| Administrative Staff B | Confirmed lack of policies and issues with negotiated service agreements. | |
| Administrative Nurse C | Confirmed deficiencies related to negotiated service agreements, medication assessments, training, documentation, and TB screening. | |
| Administrative Nurse D | Confirmed lack of policies and procedures availability. | |
| Certified Medication Aide E | Certified Medication Aide | Lacked documented training and competency for insulin pen preparation and TB screening. |
| Certified Medication Aide F | Certified Medication Aide | Lacked documented training and competency for insulin pen preparation and TB screening. |
| Certified Medication Aide G | Certified Medication Aide | Did not know location of policies and procedures. |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Dec 17, 2024
Visit Reason
This document represents the findings of a resurvey with attached complaints #189401 and #182588 at the assisted living facility conducted on 12/17/24 and 12/18/24.
Complaint Details
The plan of correction is related to complaints #189401 and #182588 attached to the resurvey.
Findings
The document is a plan of correction submitted in response to deficiencies identified during the resurvey and complaint investigations conducted on the specified dates.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Jul 11, 2023
Visit Reason
The abbreviated survey was conducted on 07/11/23 in response to complaints numbered 181163 and 181189 at the assisted living facility.
Complaint Details
The visit was complaint-related for complaints #181163 and #181189; no deficiencies were cited.
Findings
The abbreviated survey resulted in a finding of no deficiency citations.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Jul 11, 2023
Visit Reason
The abbreviated survey was conducted on 07/11/23 in response to complaints numbered 181163 and 181189 at the assisted living facility.
Complaint Details
The survey was complaint-related for complaints #181163 and #181189 and found no deficiencies.
Findings
The survey resulted in a finding of no deficiency citations.
Report Facts
Complaint numbers: 2
Inspection Report
Re-Inspection
Deficiencies: 0
Date: May 15, 2023
Visit Reason
An offsite revisit survey was conducted on 05/15/23 for all previous deficiencies cited on 04/12/23.
Findings
All deficiencies have been corrected as of the compliance date of 05/10/23 and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Report Facts
Previous deficiencies cited: 1
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Apr 11, 2023
Visit Reason
The document is a Plan of Correction addressing findings from a resurvey with complaints conducted on April 11 and 12, 2023, at the facility.
Findings
The Plan of Correction references multiple complaints (#175929, #175759, #174877, #174115, #173560, and #164954) identified during the resurvey conducted on April 11 and 12, 2023.
Inspection Report
Re-Inspection
Census: 35
Deficiencies: 4
Date: Apr 11, 2023
Visit Reason
The inspection was a resurvey with complaints (#175929, #175759, #174877, #174115, #173560, and #164954) conducted on 04/11/23 and 04/12/23 at The Homestead of Lenexa.
Complaint Details
The visit was complaint-related, addressing multiple complaints (#175929, #175759, #174877, #174115, #173560, and #164954).
Findings
The facility failed to ensure a licensed nurse provided or coordinated necessary health care services, failed to label over-the-counter medications with residents' full names, lacked documentation of incidents upon resident return from hospitalization, and failed to comply with tuberculosis testing requirements for newly hired employees.
Deficiencies (4)
Failed to ensure a licensed nurse provided or coordinated necessary health care services for Resident 8, resulting in lithium toxicity due to missed monthly lab draws.
Failed to ensure licensed nurses or pharmacists placed the full name of residents on each package of over-the-counter medication.
Failed to document all incidents, symptoms, and indications of illness or injury including date, time, action taken, and results when Resident 8 returned to the facility after hospitalization.
Failed to comply with infection control policies, including tuberculosis testing and documentation for newly hired employees.
Report Facts
Resident census: 35
Number of sampled residents: 3
Number of closed record review residents: 1
Number of newly hired employees reviewed: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator A | Named in findings related to failure to ensure licensed nurse provision of care, medication labeling, documentation, and TB testing compliance. | |
| Licensed Nurse B | Licensed Nurse | Interviewed and confirmed missing lithium lab draw and lack of nurse's note documentation; also noted in TB testing compliance review. |
| Certified Medication Aide E | Certified Medication Aide | Observed medication carts with unlabeled over-the-counter medications. |
| Certified Medication Aide F | Certified Medication Aide | Observed medication carts with unlabeled over-the-counter medications and included in TB testing compliance review. |
| Certified Medication Aide G | Certified Medication Aide | Included in TB testing compliance review. |
| Certified Nurse Aide H | Certified Nurse Aide | Included in TB testing compliance review. |
| Dietary Staff D | Dietary Staff | Included in TB testing compliance review. |
Inspection Report
Renewal
Deficiencies: 0
Date: Jun 17, 2021
Visit Reason
A survey for re-licensure with attached complaint #138519 was conducted on 06/16/2021 and 06/17/2021 at the assisted living facility in Lenexa, KS.
Complaint Details
Complaint #138519 was attached to the re-licensure survey; no deficiencies were found.
Findings
The survey resulted in a finding of no deficiency citations.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: 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: 2
Date: Sep 17, 2018
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
The report confirms that the previously cited deficiencies identified by regulation numbers 26-41-101 (f) (1) and 26-41-102 (d) were corrected as of the revisit date.
Deficiencies (2)
Deficiency related to regulation 26-41-101 (f) (1)
Deficiency related to regulation 26-41-102 (d)
Inspection Report
Renewal
Census: 30
Deficiencies: 2
Date: Aug 29, 2018
Visit Reason
The inspection was conducted for re-licensure with attached complaints at an assisted living facility in Lenexa, KS on 8/27/18, 8/28/18, and 8/29/18.
Complaint Details
The visit was triggered by complaints attached to the re-licensure survey.
Findings
The facility was found deficient in staff treatment of residents, specifically neglect related to failure to provide necessary nursing assessments and treatments for a resident with pressure ulcers, resulting in wound progression and surgical intervention. Additionally, deficiencies were found in employee records, lacking timely documentation of nurse aide registry checks and criminal background checks prior to hire for certified staff.
Deficiencies (2)
Failure to ensure resident was not subjected to neglect when facility staff failed to provide necessary nursing assessments, physician ordered treatments, and individualized interventions for pressure ulcer care, resulting in wound progression to an unstageable ulcer requiring surgical debridement.
Failure to ensure employee records contained supporting documentation from the nurse aide registry and criminal background checks prior to hire for certified staff.
Report Facts
Census: 30
Resident sample size: 3
Closed chart review residents: 2
Days without nursing assessment or treatment: 13
Pressure ulcer size: 7.5
Pressure ulcer size: 5.5
Pressure ulcer size: 3
Certified staff with deficient records: 4
Inspection Report
Re-Inspection
Deficiencies: 2
Date: Aug 10, 2016
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 deficiencies identified by regulation numbers 26-41-104(d) and 26-41-206(a)(b) have been corrected as of 08/09/2016.
Deficiencies (2)
Deficiency related to regulation 26-41-104(d)
Deficiency related to regulation 26-41-206(a)(b)
Report Facts
Deficiencies corrected: 2
Inspection Report
Re-Inspection
Census: 28
Deficiencies: 3
Date: Jul 8, 2016
Visit Reason
The inspection was a licensure re-survey conducted over multiple days (7/5/16 to 7/8/16) at an assisted living facility to assess compliance with health care services, disaster preparedness, and dietary services regulations.
Findings
The facility failed to ensure licensed nursing coordination of necessary health care services for residents, lacked proper documentation and safety checks for fall interventions and use of bed rails, failed to ensure staff knowledge and training on emergency door codes and quarterly emergency plan reviews, and did not comply with dietary service requirements including lack of medical orders and proper preparation instructions for mechanically altered diets.
Deficiencies (3)
Failed to ensure licensed nurse provides or coordinates necessary health care services in accordance with functional capacity screening and negotiated service agreement for residents #705 and #706.
Failed to ensure disaster and emergency preparedness by not ensuring all staff knew door codes to exit through locked doors and failed quarterly review of emergency management plan with employees and residents.
Failed to ensure provision or coordination of dietary services including lack of medical care provider's order and proper preparation instructions for mechanically altered diet for resident #707.
Report Facts
Census: 28
Sample size: 3
Staff in-service attendance: 19
Employees mentioned
| Name | Title | Context |
|---|---|---|
| licensed staff #R | Interviewed regarding fall interventions and lack of documentation for residents #705 and #706 | |
| certified staff #V | Tested opening exit doors with codes and emergency door release | |
| certified staff #W | Unable to open exit door with code, lacked training | |
| certified staff #X | Unable to open exit door with code, noted code written backwards on fire pull | |
| administrative staff #S | Provided facility policy information and training plans, confirmed lack of quarterly emergency plan reviews | |
| dietary staff #T | Interviewed about preparation of pureed diet for resident #707 | |
| certified staff #U | Observed giving non-pureed ice cream sandwich to resident #707 |
Inspection Report
Complaint Investigation
Census: 30
Deficiencies: 1
Date: May 5, 2015
Visit Reason
The inspection was conducted as an abbreviated survey with a complaint investigation regarding allegations of abuse or neglect at the assisted living facility.
Complaint Details
The complaint investigation was triggered by family concerns that resident #145 was not receiving medications appropriately, with reports of pocketing and spitting out medications. The family found 18 pills in the resident's room since February, including one hydrocodone pill not prescribed to the resident. The facility failed to notify the department of these allegations within 24 hours.
Findings
The facility failed to report an allegation of neglect involving resident #145 to the department within 24 hours as required. The investigation revealed issues with medication administration and family concerns about missing pills, including an unprescribed hydrocodone pill found in the resident's room.
Deficiencies (1)
Failure to report each allegation of abuse or neglect to the department within 24 hours as required by KAR 26-42-101(f)(3).
Report Facts
Census: 30
Sample size: 3
Pills found: 18
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed staff A | Interviewed regarding family complaints and medication administration; signed clinical notes and care plan meeting notes | |
| Licensed staff D | Signed clinical notes regarding medication administration education | |
| Administrative staff B | Attended care plan meeting with resident's family |
Inspection Report
Re-Inspection
Deficiencies: 2
Date: Sep 22, 2014
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 deficiencies identified in prior inspections, specifically those referenced by regulation numbers 26-41-200 (a) and 26-41-201 (c), were corrected as of 09/22/2014.
Deficiencies (2)
Deficiency related to regulation 26-41-200 (a)
Deficiency related to regulation 26-41-201 (c)
Inspection Report
Abbreviated Survey
Census: 39
Deficiencies: 2
Date: Aug 26, 2014
Visit Reason
The inspection was an abbreviated survey combined with a complaint investigation conducted at an assisted living facility on 8-25-14 and 8-26-14.
Complaint Details
The visit was complaint-related, investigating allegations regarding the care and safety of a resident exhibiting behavioral symptoms including wandering and exit seeking, which led to an elopement and injury.
Findings
The facility failed to ensure that a resident with behavioral symptoms that exceeded manageability was not retained unless the negotiated service agreement included sufficient services, resulting in a resident eloping and sustaining injury. Additionally, the facility failed to conduct a functional capacity screening following a significant change in condition for the same resident.
Deficiencies (2)
Failure to ensure that a resident with behavioral symptoms that exceeded manageability was not retained unless the negotiated service agreement included services sufficient to meet the resident's needs, resulting in resident elopement and injury.
Failure to conduct a functional capacity screening following a significant change in condition as required.
Report Facts
Census: 39
Date of resident admission: Jun 17, 2014
Date of elopement: Jul 7, 2014
Height of embankment: 15
Temperature: 83
Heat index: 91
Employees mentioned
| Name | Title | Context |
|---|---|---|
| operator/LPN | Named in findings related to failure to revise negotiated service agreement and functional capacity screening. | |
| administrative nurse A | Provided reports and signed documentation related to resident behaviors. | |
| administrative nurse B | Provided reports and signed documentation related to resident injury and care. | |
| certified staff C | Interviewed regarding door alarm audibility prior to elopement. | |
| certified staff D | Interviewed regarding resident behaviors and notifications to operator/LPN. | |
| certified staff E | Interviewed regarding wanderguard knowledge and door monitoring. |
Inspection Report
Renewal
Deficiencies: 0
Date: Jul 2, 2014
Visit Reason
The licensure resurvey was conducted as a renewal inspection of the assisted living facility.
Findings
The inspection resulted in a finding of no deficiency citations on 7-2-14.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Jan 28, 2013
Visit Reason
This document is a Plan of Correction related to a prior inspection event identified by ASPEN Event ID 3F9411 and State ID N046043.
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 start date: Jan 28, 2013
Plan of Correction exit date: Jan 29, 2013
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