Inspection Report Summary
The most recent inspection on November 18, 2024, found no deficiencies and confirmed the facility was in compliance with all regulations. Prior inspections in late October 2024 identified several deficiencies related to documentation of Do Not Resuscitate orders, negotiated service agreements, medication administration responsibilities, tuberculosis testing, and securing hazardous chemicals. Earlier reports also noted issues with medication management, emergency preparedness, and food storage, with some complaint investigations substantiated but no enforcement actions or fines listed in the available reports. Most complaint investigations were unsubstantiated or addressed through plans of correction. The facility appears to have made improvements recently, correcting all cited deficiencies from the prior inspection cycle.
Deficiencies (last 9 years)
Deficiencies (over 9 years)
3.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
37% better than Kansas average
Kansas average: 6 deficiencies/yearDeficiencies per year
8
6
4
2
0
Census
Latest occupancy rate
54 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
Date: Nov 18, 2024
Visit Reason
An offsite revisit survey was conducted on 11/18/24 to verify correction of all previous deficiencies cited on 10/31/24.
Findings
All deficiencies have been corrected as of the compliance date of 11/15/24 and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Report Facts
Previous deficiencies cited: Deficiencies cited on 10/31/24 were all corrected by 11/15/24
Inspection Report
Re-Inspection
Census: 54
Deficiencies: 5
Date: Oct 31, 2024
Visit Reason
The inspection was a resurvey with complaints #186341, 188027, 190191, and 190729 conducted on 10/29/24, 10/30/24, and 10/31/24 at an assisted living facility.
Complaint Details
The visit was a resurvey with complaints #186341, 188027, 190191, and 190729.
Findings
The facility was found deficient in multiple areas including failure to maintain a signed Do Not Resuscitate (DNR) order in a resident's medical record, incomplete negotiated service agreements for residents, failure to identify responsible persons for medication administration, non-compliance with tuberculosis testing guidelines, and failure to secure chemicals properly for resident safety.
Deficiencies (5)
Failed to ensure a copy of resident R103's signed Do Not Resuscitate (DNR) order was maintained in her medical record.
Failed to ensure the Negotiated Service Agreement (NSA) was fully developed based on residents' functional capacity screening, service needs, preferences, and identification of payor for outside services for residents R101 and R102.
Failed to ensure the NSA identified the responsible person for administration and management of selected medications for resident R101.
Failed to ensure compliance with tuberculosis guidelines; resident R101 did not have a second step of a two-step TB skin test completed upon admission.
Failed to ensure staff secured all chemicals to maintain the safety of residents; mechanical room was found unlocked containing hazardous chemicals.
Report Facts
Census: 54
Deficiency count: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Nurse B | Licensed Nurse | Acknowledged lack of signed DNR and unlocked mechanical room. |
| Licensed Nurse C | Licensed Nurse | Stated resident R101 self-administered saline nasal spray and NSA did not reflect this. |
| Administrative Nurse B | Administrative Nurse | Provided information about wound care and incontinence services for resident R102. |
| Administrative Staff A | Administrative Staff | Could not locate second step of two-step TB skin test for resident R101. |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Oct 29, 2024
Visit Reason
The document is a Plan of Correction addressing findings from a resurvey with complaints #186341, 188027, 190191, and 190729 conducted on 10/29/24, 10/30/24, and 10/31/24 at the assisted living facility.
Complaint Details
The resurvey was conducted in response to complaints #186341, 188027, 190191, and 190729.
Findings
The Plan of Correction corresponds to deficiencies identified during the resurvey and complaint investigations conducted over three days in late October 2024.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Jun 8, 2023
Visit Reason
An offsite revisit survey was conducted on 06/08/23 to verify correction of all previous deficiencies cited on 05/17/23.
Findings
All deficiencies have been corrected as of the compliance date of 06/07/23, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Inspection Report
Re-Inspection
Census: 64
Deficiencies: 4
Date: May 16, 2023
Visit Reason
The inspection was a Re-Licensure survey combined with complaint investigations 165406, 167035, and 171857 conducted on 05/16/23 and 05/17/23 at an Assisted Living Facility.
Complaint Details
The visit included complaint investigations 165406, 167035, and 171857 as part of the Re-Licensure survey.
Findings
The inspection identified multiple deficiencies including failure to review and revise negotiated service agreements after significant changes in resident condition, failure to assess residents properly for self-administration of medication, inadequate documentation and communication regarding sample medications, and unsafe food storage practices.
Deficiencies (4)
Failure to ensure staff reviewed and revised the Negotiated Service Agreement when residents experienced significant changes related to therapy services.
Failure to ensure a licensed nurse assessed a resident prior to self-injection of insulin to confirm safe and accurate self-administration.
Failure to ensure proper policies and procedures for sample and indigent medication program medications including documentation, labeling, and informing residents or legal representatives.
Failure to store all food under safe and sanitary conditions, including unlabeled and undated food items in the freezer and refrigerator.
Report Facts
Census: 64
Days after admission for insulin self-injection assessment: 51
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Licensed Nurse A | Reported on the Functional Capacity Screen/Negotiated Service Agreement and sample medication procedures. | |
| Administrative Licensed Nurse B | Acknowledged failure to complete addendums for negotiated service agreements and self-injection assessments. | |
| Certified Medication Aide D | Observed opening medication cart and sample medication labeling. | |
| Dietary Staff D | Acknowledged food storage and labeling deficiencies during kitchen tour. |
Inspection Report
Renewal
Deficiencies: 0
Date: May 16, 2023
Visit Reason
The document is a Plan of Correction addressing findings from a Re-Licensure survey with complaint investigations conducted on 05/16/23 and 05/17/23 at the Assisted Living Facility.
Findings
The Plan of Correction references citations from a Re-Licensure survey combined with complaint investigations numbered 165406, 167035, and 171857 conducted over two days in May 2023.
Report Facts
Complaint investigation IDs: Complaint investigations 165406, 167035, and 171857 referenced in the survey
Inspection Report
Re-Inspection
Census: 49
Deficiencies: 4
Date: Aug 30, 2021
Visit Reason
The inspection was a resurvey with complaints #154548, #153642, #153153, and #151459 conducted on 08-23-21, 08-24-21, and 08-30-21.
Complaint Details
The resurvey was conducted in response to complaints #154548, #153642, #153153, and #151459.
Findings
The facility was found deficient in several areas including failure to ensure licensed nurses oriented and documented competency of certified medication aides in blood sugar testing and insulin administration, failure to maintain accurate accountability and reconciliation of controlled substances, failure to conduct quarterly reviews of the emergency management plan with staff and residents, and failure to secure hazardous chemicals to protect health and safety.
Deficiencies (4)
Failure to ensure licensed nurse oriented and instructed certified medication aides in blood sugar testing and insulin pen use, and failure to document CMA competency.
Failure to maintain system for accountability on controlled substances in sufficient detail for accurate reconciliation for residents #240 and #710.
Failure to conduct quarterly review of the facility's emergency management plan with staff and residents.
Failure to ensure the facility was equipped and maintained to protect health and safety regarding unsecured hazardous chemicals accessible to residents.
Report Facts
Census: 49
Residents on secured unit: 10
Residents with cognitive impairment: 16
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Nurse A | Reported CMAs were delegated blood sugar testing and insulin administration; confirmed discrepancies in medication accountability; confirmed unsecured chemicals should be secured. | |
| Certified Medication Aide C | Personnel record reviewed for lack of documented competency. | |
| Certified Medication Aide D | Personnel record reviewed for lack of documented competency. | |
| Certified Medication Aide E | Observed medication cart and reported CMAs only count syringes, not amounts. | |
| Maintenance Manager F | Provided documentation related to emergency management plan reviews and resident signature sheets. |
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Jul 9, 2020
Visit Reason
The special infection control survey for COVID-19 was conducted at the facility on 7-9-20.
Findings
The survey resulted in findings of no deficiency citations.
Inspection Report
Complaint Investigation
Census: 52
Deficiencies: 1
Date: Apr 11, 2019
Visit Reason
The inspection was conducted as an abbreviated survey for investigation of complaint #139806 at the assisted living facility on 4/9/19 and 4/11/19.
Complaint Details
Complaint #139806 triggered the investigation. The complaint was related to allegations of neglect involving resident #2. The facility failed to report incidents within 24 hours and did not conduct thorough investigations to rule out staff neglect.
Findings
The administrator failed to ensure that each potential allegation of neglect was reported to the department within 24 hours and failed to thoroughly investigate each incident to rule out staff neglect of resident #2. Multiple incidents involving resident #2 were documented, but investigations lacked proof of how determinations were made and did not include timely reporting to the department.
Deficiencies (1)
Failure to report allegations of abuse, neglect, or exploitation to the department within 24 hours and failure to thoroughly investigate each incident.
Report Facts
Census: 52
Sample size: 3
Incident dates: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed nurse C | Interviewed and stated incidents were not reported to the department; provided copies of investigations but did not maintain statements if incidents were not reported. | |
| Certified staff D | Interviewed and stated checking on resident every 30 minutes. | |
| Certified staff E | Interviewed and stated interventions to reduce falls including 30-minute checks and toileting every 2 to 3 hours; provided documentation of checks and toileting. |
Inspection Report
Re-Inspection
Deficiencies: 4
Date: Nov 15, 2018
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 identified by regulation or LSC provision numbers were corrected as of the revisit date 2018-11-15.
Deficiencies (4)
Deficiency related to regulation 26-41-101 (f) (3)
Deficiency related to regulation 26-41-202 (a)
Deficiency related to regulation 26-41-203 (d)
Deficiency related to regulation 26-41-204 (a)
Inspection Report
Complaint Investigation
Census: 45
Deficiencies: 2
Date: Jun 11, 2018
Visit Reason
The inspection was conducted as a resurvey and complaint investigation for citations #115328, #121118, and #125631 at Chaucer Estates LLC on 6/7/18 and 6/11/18.
Complaint Details
The inspection included complaint investigations #115328, #121118, and #125631.
Findings
The facility failed to provide 30-day written notice of monthly rate increases to three sampled residents and failed to ensure that licensed nurses or pharmacists placed the full name of residents on over-the-counter medication packages or containers in medication carts and rooms.
Deficiencies (2)
Failure to provide 30-day written notice of monthly rate increase to residents #401, #402, and #403.
Failure to ensure licensed nurse or pharmacist placed full resident name on over-the-counter medication packages or containers in 3 medication carts and 2 medication rooms.
Report Facts
Census: 45
Residents sampled: 3
Medication carts inspected: 3
Medication rooms inspected: 2
Inspection Report
Re-Inspection
Deficiencies: 1
Date: Dec 7, 2015
Visit Reason
This report documents a revisit inspection to verify correction of previously cited deficiencies at Chaucer Estates LLC.
Findings
The revisit confirmed that the previously reported deficiency identified by regulation 26-41-104 (d) with ID prefix S3280 was corrected as of 12/07/2015.
Deficiencies (1)
Deficiency previously cited under regulation 26-41-104 (d) corrected
Inspection Report
Complaint Investigation
Census: 72
Deficiencies: 1
Date: Oct 26, 2015
Visit Reason
The inspection was a resurvey with investigation of complaints #80317, #81202, #84945, and #86081 conducted on 10/21/15, 10/22/15, and 10/26/15.
Complaint Details
The visit was complaint-related involving complaints #80317, #81202, #84945, and #86081. The findings were substantiated as the administrator failed to ensure required quarterly reviews of the emergency management plan.
Findings
The administrator failed to ensure disaster and emergency preparedness by not performing a quarterly review of the facility's emergency management plan with employees and residents as required.
Deficiencies (1)
Failure to ensure quarterly review of the facility's emergency management plan with employees and residents.
Report Facts
Census: 72
Complaint numbers: 4
Inspection Report
Follow-Up
Deficiencies: 5
Date: Aug 19, 2014
Visit Reason
This revisit report documents the correction of deficiencies previously reported during a prior survey, verifying that corrective actions were accomplished.
Findings
All previously cited deficiencies identified by regulation numbers 26-41-204(d), 26-41-205(i), 26-41-102(d), 26-41-104(d), and 26-41-206(e)(1) were corrected as of the revisit date.
Deficiencies (5)
Deficiency related to regulation 26-41-204(d)
Deficiency related to regulation 26-41-205(i)
Deficiency related to regulation 26-41-102(d)
Deficiency related to regulation 26-41-104(d)
Deficiency related to regulation 26-41-206(e)(1)
Report Facts
Deficiencies corrected: 5
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Aug 19, 2014
Visit Reason
The document is a plan of correction related to a deficiency found during an inspection of an assisted living facility regarding the development of negotiated service agreements for residents.
Findings
The facility failed to meet the requirement to develop a written negotiated service agreement for each resident, including descriptions of services, service providers, and payment responsibilities.
Deficiencies (1)
Failure to develop a written negotiated service agreement for each resident based on functional capacity screening, service needs, and preferences.
Inspection Report
Complaint Investigation
Census: 60
Deficiencies: 6
Date: Jul 31, 2014
Visit Reason
Resurvey with investigation of complaint #75445 at an assisted living facility conducted over 7/28/14 to 7/31/14.
Complaint Details
The visit was a resurvey with investigation of complaint #75445 conducted from 7/28/14 to 7/31/14.
Findings
The investigation found multiple deficiencies including failure to develop adequate negotiated service agreements for residents, improper medication disposal practices, incomplete employee records, lack of disaster and emergency preparedness training and education, and unsafe food storage practices.
Deficiencies (6)
Failure to develop a negotiated service agreement for resident #650 that included a description of hospice services and the party responsible for payment.
Failure to ensure negotiated service agreements contained a description of health care services and the name of the licensed nurse responsible for implementation and supervision for residents #652, #650, #653, and #651.
Failure to maintain records documenting the destruction of discontinued non-controlled medications and failure to follow facility policy for medication disposal.
Failure to ensure employee records contained evidence of licensure and supporting documentation from the Kansas nurse aide registry that employees did not have findings of abuse, neglect, or exploitation.
Failure to ensure disaster and emergency preparedness including orientation of new employees, resident education upon admission, and quarterly review of emergency management plan with employees and residents.
Failure to store all food under safe and sanitary conditions including uncovered food items, unlabeled and undated food containers, and dusty food service equipment.
Report Facts
Residents requiring facility management of medications: 51
Residents sampled: 4
Dates of resident falls: 9
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed nurse #G | Named in medication disposal deficiency; described medication disposal process. | |
| Certified medication aide #H | Named in medication disposal deficiency; described medication disposal process and resident care. | |
| Wellness director | Named in multiple deficiencies related to negotiated service agreements and health care service plans. | |
| Administrator | Named in deficiencies related to negotiated service agreements, employee records, and emergency preparedness. | |
| Certified medication aide #D | Named in medication disposal deficiency; described medication destruction process. | |
| Certified employee #I | Named in fall risk interventions for resident #650. | |
| Certified employee #J | Named in fall risk interventions for resident #653. | |
| Certified nursing assistant #A | Named in hospice services observation for resident #650. | |
| Director of maintenance | Named in emergency preparedness deficiency; described limited review of emergency policies. | |
| Business office manager | Named in employee records and emergency preparedness deficiencies. | |
| Dietary manager | Named in food storage deficiency; described food labeling and storage requirements. |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Apr 11, 2012
Visit Reason
This document is a Plan of Correction related to a prior inspection event identified by ASPEN Event ID TJ4X12 for facility State ID N087048.
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: Apr 11, 2012
Plan of Correction exit date: Apr 12, 2012
Viewing
Loading inspection reports...
