Inspection Report Summary
The most recent inspection on October 9, 2024, found the facility in compliance with all regulations and no new deficiencies. Prior to that, the September 24, 2024 inspection identified deficiencies related to incomplete negotiated service agreements, medication storage issues, incomplete incident documentation, and failure to conduct quarterly emergency management plan reviews. Earlier complaint investigations included a substantiated case in February 2022 involving medication administration practices, and prior reports noted recurring issues with functional capacity screenings, documentation, and emergency preparedness. Enforcement actions such as fines or license suspensions were not listed in the available reports. The facility appears to have addressed recent deficiencies promptly, showing improvement in the latest follow-up inspection.
Deficiencies (last 8 years)
Deficiencies (over 8 years)
3.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
45% better than Kansas average
Kansas average: 6 deficiencies/yearDeficiencies per year
8
6
4
2
0
Census
Latest occupancy rate
39 residents
Based on a September 2024 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Follow-Up
Deficiencies: 0
Date: Oct 9, 2024
Visit Reason
An offsite revisit survey was conducted on 10/09/24 to verify correction of all previous deficiencies cited on 09/24/24.
Findings
All deficiencies have been corrected as of the compliance date of 10/04/24 and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Report Facts
Previous deficiencies cited: Deficiencies cited on 09/24/24 and corrected by 10/04/24
Inspection Report
Renewal
Census: 39
Deficiencies: 5
Date: Sep 24, 2024
Visit Reason
The inspection was a licensure resurvey conducted on 09/23/24 and 09/24/24 to assess compliance with regulatory requirements for the assisted living facility.
Findings
The facility was found deficient in multiple areas including incomplete negotiated service agreements lacking descriptions of services and payment responsibilities, failure to provide healthcare services according to professional standards, improper medication storage, incomplete documentation of resident incidents, and failure to conduct quarterly emergency management plan reviews with employees and residents.
Deficiencies (5)
Negotiated Service Agreements for residents R1 and R3 lacked descriptions of services to be received and identification of parties responsible for payment for outside services.
R1's NSA lacked description and instructions regarding a bed assist device attached to the right side of the bed.
Medications and biologicals for resident R3 were not stored in separately locked compartments within a locked medication room, cabinet, or medication cart.
Resident R3's records lacked documentation of all incidents, symptoms, and other indications of illness or injury including date, time, actions taken, and results.
Facility failed to ensure quarterly review of the emergency management plan with employees and residents.
Report Facts
Census: 39
Residents in sample: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Operator A | Interviewed regarding deficiencies in negotiated service agreements, medication storage, incident documentation, and emergency preparedness | |
| Licensed Nurse B | Licensed Nurse | Interviewed regarding deficiencies in negotiated service agreements, medication storage, and incident documentation |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Sep 23, 2024
Visit Reason
The document is a Plan of Correction submitted in response to findings from the licensure resurvey conducted on 09/23/24 and 09/24/24 at the facility.
Findings
The Plan of Correction addresses citations identified during the licensure resurvey conducted on 09/23/24 and 09/24/24. Specific deficiencies are not detailed in this document.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Jan 10, 2023
Visit Reason
The abbreviated survey was conducted on 01/10/23 at the facility to assess compliance.
Findings
The survey resulted in a finding of no non-compliance.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Jan 10, 2023
Visit Reason
The abbreviated survey with review of facility report #1777335 was conducted at the assisted living facility.
Findings
The survey resulted in a finding of no deficiency citations.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Mar 14, 2022
Visit Reason
An offsite revisit survey was conducted to verify correction of all previous deficiencies cited on 2022-02-09.
Findings
All deficiencies cited in the prior inspection have been corrected as of the compliance date 2022-02-16, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Report Facts
Previous deficiencies cited: 1
Inspection Report
Re-Inspection
Census: 32
Deficiencies: 1
Date: Feb 9, 2022
Visit Reason
The inspection was a resurvey with a complaint (#166584) at the assisted living facility conducted on 2/8 and 2/9/2022.
Complaint Details
The visit was complaint-related under complaint #166584. The complaint was substantiated as the facility failed to comply with medication administration requirements.
Findings
The facility failed to ensure that licensed nurses or medication aides remained with residents until medications were ingested, as evidenced by multiple observations and resident interviews indicating medications were left with residents to take later.
Deficiencies (1)
Failure to ensure licensed nurse or medication aides remained with the resident until the medication is ingested.
Report Facts
Census: 32
Residents with medications administered by staff: 28
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Nurse B | Licensed Nurse | Provided resident roster and reported on medication administration |
| Licensed Nurse C | Licensed Nurse | Reported on medication administration practices regarding leaving medications for residents |
| Certified Medication Aide D | Certified Medication Aide | Reported staff could not leave medications for residents to take later but must stay with them |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Feb 8, 2022
Visit Reason
The document is a plan of correction responding to findings from a resurvey conducted with a complaint #166584 at the assisted living facility on February 8 and 9, 2022.
Complaint Details
The visit was complaint-related, associated with complaint #166584.
Findings
The plan of correction addresses citations found during the resurvey related to the complaint investigation conducted at the facility.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Aug 6, 2020
Visit Reason
The special infection control survey for COVID-19 was conducted at the facility on 08/06/2020.
Findings
The survey resulted in findings of no deficiency citations.
Inspection Report
Complaint Investigation
Census: 32
Deficiencies: 3
Date: Jan 10, 2019
Visit Reason
The inspection was a resurvey with complaint investigations 136500, 121564, and 118147 conducted at the assisted living facility on 1-8-19, 1-9-19, and 1-10-19.
Complaint Details
The inspection was triggered by complaint investigations numbered 136500, 121564, and 118147.
Findings
The facility was found deficient in conducting functional capacity screenings at least annually and following significant changes in condition, ensuring negotiated service agreements included descriptions of certain services such as use of bed assist rails and blood glucose monitoring, and ensuring quarterly review of the entire emergency management plan with all residents.
Deficiencies (3)
Failed to ensure designated facility staff conducted a screening to determine each resident's functional capacity at least once every 365 days and following a significant change in condition.
Failed to ensure the Negotiated Service Agreement included a description of services including use of a bed assist transfer rail and/or blood glucose monitoring.
Failed to ensure disaster and emergency preparedness by ensuring quarterly review of the facility's entire emergency management plan with all residents.
Report Facts
Census: 32
Residents sampled: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Staff D | Interviewed regarding Resident #300's need for physical assistance with dressing, toileting, and mobility. | |
| Licensed Staff C | Performed Functional Capacity Screen assessment on Resident #300 and confirmed decline in resident's abilities. | |
| Administrative Nurse C | Confirmed lack of Functional Capacity Screen in 2017 and lack of documentation in negotiated service agreements. | |
| Operator | Provided documentation and interview regarding emergency management plan and disaster preparedness. |
Inspection Report
Abbreviated Survey
Census: 30
Deficiencies: 2
Date: Apr 17, 2017
Visit Reason
The inspection was an abbreviated survey combined with a complaint investigation at an assisted living facility.
Complaint Details
The visit included a complaint investigation (114104) related to failure to conduct functional capacity reassessments and inadequate documentation of incidents and resident transfers.
Findings
The facility failed to conduct required functional capacity screenings following significant changes in resident conditions and failed to document incidents, symptoms, and other indications of illness or injury including dates, times, actions taken, and results. Documentation was incomplete or missing for resident transfers, hospital admissions, and assessments.
Deficiencies (2)
Failed to ensure designated facility staff conducted a screening to determine the resident's functional capacity following a significant change in condition.
Failed to ensure documentation of all incidents, symptoms, and other indications of illness or injury including the date, time of occurrence, action taken, and results of the action.
Report Facts
Census: 30
Sample size: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Staff C | Mentioned in relation to documentation of resident assessments and nurse's notes. | |
| Licensed Staff D | Signed nurse's note regarding a choking incident. | |
| Operator | Interviewed regarding resident condition changes and discharge notices. |
Inspection Report
Re-Inspection
Deficiencies: 7
Date: Jan 11, 2017
Visit Reason
This revisit report documents the correction of deficiencies previously reported during an earlier survey, verifying that corrective actions were completed.
Findings
All previously cited deficiencies identified by regulation or LSC provision numbers were corrected as of the revisit date.
Deficiencies (7)
Deficiency related to regulation 26-39-102 (a)
Deficiency related to regulation 26-41-201 (a) (b)
Deficiency related to regulation 26-41-202 (f)
Deficiency related to regulation 26-41-204 (a)
Deficiency related to regulation 26-41-205 (h)
Deficiency related to regulation 26-41-105 (f) (11)
Deficiency related to regulation 28-39-254
Inspection Report
Re-Inspection
Census: 31
Deficiencies: 8
Date: Dec 7, 2016
Visit Reason
Licensure re-survey with attached complaint at the assisted living facility conducted on 12/5/16, 12/6/16 and 12/7/16.
Complaint Details
The inspection was a licensure re-survey with an attached complaint. Specific complaint details are not separately stated but deficiencies relate to admission agreements, medication administration, and resident safety.
Findings
The facility was found deficient in multiple areas including failure to execute written admission agreements, incomplete functional capacity screening forms, lack of negotiated service agreements for refused services, inadequate health care service coordination, improper medication administration and storage, incomplete incident documentation, and unsecured chemicals in resident areas.
Deficiencies (8)
Failed to execute with resident or legal representative a written admission agreement detailing services and obligations.
Facility's functional capacity screening form lacked required elements and definitions as specified by the department.
Failed to include required elements in negotiated service agreement when resident refused necessary services.
Licensed nurse failed to provide or coordinate necessary health care services in accordance with functional capacity screening and negotiated service agreement.
Failed to ensure all medications and treatments were administered according to medical orders, professional standards, and manufacturer recommendations.
Failed to securely and properly store medications and biologicals in locked medication room, cabinet, or cart.
Failed to document all incidents, symptoms, and indications of illness or injury including date, time, action taken, and results.
Facility was not maintained to protect health and safety of residents when chemicals were unsecured in a resident use area.
Report Facts
Resident census: 31
Medication administration record entries: 13
Blood glucose results: 18
Fall risk score: 9
Medication administration days: 14
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed nurse #D | Interviewed regarding functional capacity screening, medication administration, and incident documentation | |
| Facility operator #C | Interviewed regarding admission agreement and resident non-compliance | |
| Licensed nurse #E | Interviewed regarding medication application and storage |
Inspection Report
Renewal
Deficiencies: 0
Date: Oct 5, 2015
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 10-5-15.
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