Inspection Report Summary
The most recent inspection on September 18, 2024, found no deficiencies and confirmed the facility was in compliance with all regulations. Prior inspections in August 2024 identified multiple deficiencies related to medication administration, staff training on dementia care, emergency plan reviews, and documentation, among others. Earlier reports from late 2023 and 2022 cited issues with resident safety, including failures to secure exit doors that led to elopement incidents and inadequate staff training, some of which involved immediate jeopardy findings. Complaint investigations were mostly unsubstantiated except for substantiated issues in 2022 and 2015 involving failure to report abuse and inadequate staff training. The facility appears to have addressed recent deficiencies promptly, showing improvement in the most current inspection.
Deficiencies (last 8 years)
Deficiencies (over 8 years)
3.1 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
48% better than Kansas average
Kansas average: 6 deficiencies/yearDeficiencies per year
12
9
6
3
0
Census
Latest occupancy rate
32 residents
Based on a August 2024 inspection.
Census over time
Inspection Report
Follow-Up
Deficiencies: 0
Date: Sep 18, 2024
Visit Reason
An offsite revisit survey was conducted to verify correction of all previous deficiencies cited on 2024-08-22.
Findings
All deficiencies have been corrected as of the compliance date of 2024-09-17 and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Inspection Report
Renewal
Census: 32
Deficiencies: 11
Date: Aug 22, 2024
Visit Reason
The inspection was a Re-Licensure Survey with complaint investigations conducted on August 19-22, 2024, to assess compliance with regulatory requirements for the facility.
Complaint Details
The visit included complaint investigations KS00176426, KS185916, KS00188342, KS188515, and KS00189151.
Findings
The survey identified multiple deficiencies including failure to notify legal representatives of significant resident changes, incomplete signatures on service agreements, inadequate provision of health care services related to weight loss, improper delegation of nursing tasks to medication aides, medication administration errors, improper medication storage, lack of dementia training for staff, failure to conduct quarterly emergency plan reviews, and incomplete tuberculosis testing documentation.
Deficiencies (11)
Failed to notify resident's legal representative of significant changes related to behaviors and new medication orders.
Failed to ensure all involved in the development of the Negotiated Service Agreement signed the agreement.
Failed to ensure licensed nurse provided or coordinated necessary health care services for residents with unplanned weight loss.
Failed to ensure newly hired Certified Medication Aides were trained and delegated nursing procedures for blood glucose checks.
Failed to ensure administration of insulin was done by qualified staff in accordance with standards of practice; medication aides improperly held insulin pens against resident's skin.
Failed to ensure delegation of medication administration for preparing and dialing insulin pens was completed by licensed nurse for newly hired CMAs.
Failed to ensure all over-the-counter medications were labeled with the resident's full name on both the original package and medication container.
Failed to store insulin pens with dates indicating when they were first put into use to prevent use beyond manufacturer expiration.
Failed to provide staff orientation and in-service education on treatment and appropriate response to persons exhibiting behaviors associated with dementia.
Failed to perform quarterly reviews of the facility's emergency management plan with all employees and residents.
Failed to ensure compliance with tuberculosis guidelines including documentation of TB skin test reading dates and timely testing for new employees.
Report Facts
Resident census: 32
Weight loss: 10.2
Weight loss: 31.4
Insulin units remaining: 150
Insulin units remaining: 80
Insulin units remaining: 180
Insulin units remaining: 70
Insulin units remaining: 150
Insulin units remaining: 50
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Executive Director A | Executive Director | Named in multiple findings including failure to ensure staff training, delegation, emergency plan reviews, and compliance with TB guidelines. |
| Administrative Nurse B | Administrative Nurse | Interviewed regarding service agreements, health care services, and medication administration. |
| Administrative Nurse C | Administrative Nurse | Interviewed regarding notification of legal representatives, delegation, and TB skin test documentation. |
| Certified Medication Aide E | Certified Medication Aide | Interviewed and observed regarding medication administration and labeling. |
| Certified Medication Aide G | Certified Medication Aide | Observed administering insulin improperly by holding pen against resident's skin. |
Inspection Report
Renewal
Deficiencies: 0
Date: Aug 19, 2024
Visit Reason
The document represents findings from a Re-Licensure Survey with complaint investigations conducted at the facility on August 19, 20, 21, and 22, 2024.
Complaint Details
The survey included complaint investigations KS00176426, KS185916, KS00188342, KS188515, and KS00189151.
Findings
The plan of correction addresses citations found during the Re-Licensure Survey and complaint investigations conducted over four days in August 2024.
Report Facts
Complaint investigations: 5
Inspection Report
Re-Inspection
Deficiencies: 1
Date: Jan 22, 2024
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
The report indicates that previously cited deficiencies have been corrected as of the revisit date, with at least one specific regulation (26-41-101 (f)(1)) marked as completed.
Deficiencies (1)
Deficiency related to regulation 26-41-101 (f)(1)
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Dec 27, 2023
Visit Reason
The document represents the findings of an abbreviated survey with review of facility report #184740 at the assisted living facility conducted on 12/27/2023.
Findings
This is a plan of correction document related to the abbreviated survey findings; no specific deficiencies or findings details are provided in this document.
Inspection Report
Abbreviated Survey
Census: 36
Deficiencies: 1
Date: Dec 27, 2023
Visit Reason
An abbreviated survey was conducted to review facility report #184740 at the assisted living facility The Homestead of Olathe North on 12/27/23.
Findings
The administrator failed to protect ten residents at risk for elopement by not securing all exit doors, resulting in a cognitively impaired resident (R1) exiting the facility unsupervised and being found outside after approximately 5 hours, leading to immediate jeopardy. The facility implemented corrective actions including door locks, staff education, and elopement drills to remove the immediate jeopardy.
Deficiencies (1)
Failure to protect residents at risk for elopement by not securing all exit doors, resulting in a resident exiting unsupervised and being found outside after several hours.
Report Facts
Resident census: 36
Residents at risk for elopement: 10
Residents marked for wandering: 9
Resident R1 elopement time: 5
Resident R1 body temperature: 86.7
Door lock installation date: Dec 19, 2023
Elopement drills dates: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Staff A | Provided statements regarding door security and staff actions | |
| Certified Nurse Aide C | CNA | Reported resident missing and participated in search |
| Certified Medication Aide D | CMA | Assisted in rounds and searching for resident |
| Certified Medication Aide F | CMA | Checked resident every two hours during the day |
| Certified Nurse Aide E | CNA | Entered resident's apartment during rounds |
Inspection Report
Re-Inspection
Deficiencies: 1
Date: Nov 30, 2023
Visit Reason
This revisit report documents the correction of deficiencies previously reported during an earlier survey, verifying that corrective actions have been completed.
Findings
The report confirms that the previously cited deficiency under regulation 26-41-101 (f)(1) has been corrected as of 11/30/2023.
Deficiencies (1)
Deficiency under regulation 26-41-101 (f)(1) previously cited
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Nov 7, 2023
Visit Reason
The document represents the findings of an abbreviated survey with review of facility report #183800 conducted at the assisted living facility on 11/07/23.
Findings
This document is a Plan of Correction submitted in response to the findings of the abbreviated survey conducted on 11/07/23. It outlines corrective actions related to the deficiencies identified in the referenced survey report.
Inspection Report
Abbreviated Survey
Census: 34
Deficiencies: 1
Date: Nov 7, 2023
Visit Reason
An abbreviated survey was conducted to review the facility report #183800 at the assisted living facility to assess compliance with regulations related to resident safety and elopement risks.
Findings
The facility failed to protect four cognitively impaired residents at risk for elopement due to inadequate staff elopement training and failure to secure all exit doors. One resident (R1) exited the facility unsupervised through an unsecured door, resulting in immediate jeopardy. The facility lacked proper documentation and testing of door alarms and resident monitoring systems.
Deficiencies (1)
Failure to protect residents from neglect by inadequate staff elopement training and failure to secure all exit doors, resulting in resident R1 eloping unsupervised.
Report Facts
Resident census: 34
Residents in sample: 4
Elopement risk score for R1 before elopement: 35
Elopement risk score for R1 after elopement: 60
Time resident R1 was outside facility: 43
Number of exit doors: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nurse B | Administrative Nurse | Confirmed alarm audibility issues and described door alarm systems |
| Administrative Staff A | Administrative Staff | Provided information on door alarms, staff training, and elopement policy |
| Maintenance Staff C | Maintenance staff involved with door alarm system, not trained on elopement policy | |
| Maintenance Staff D | Maintenance staff involved with door alarm system, not trained on elopement policy | |
| Certified Medication Aide E | Certified Medication Aide | Observed resident's alarm bracelet after elopement |
| Licensed Nurse F | Licensed Nurse | Reported resident had cut off alarm bracelet |
Inspection Report
Follow-Up
Deficiencies: 0
Date: Nov 17, 2022
Visit Reason
An offsite revisit survey was conducted to verify correction of all previous deficiencies cited on 2022-10-26.
Findings
All deficiencies cited in the prior inspection have been corrected as of 2022-11-16, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Report Facts
Previous deficiencies cited: Deficiencies cited on 2022-10-26 (number not specified)
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Oct 27, 2022
Visit Reason
The document is a plan of correction responding to findings from a licensure resurvey with attached complaints #175622, 173164, and 165275 conducted on 10/25/22, 10/26/22, and 10/27/22.
Complaint Details
The plan of correction relates to complaints #175622, 173164, and 165275 attached to the licensure resurvey.
Findings
The plan of correction addresses citations resulting from the licensure resurvey and complaint investigations conducted over three days in late October 2022.
Inspection Report
Renewal
Census: 35
Deficiencies: 6
Date: Oct 26, 2022
Visit Reason
Licensure resurvey with attached complaints #175622, 173164, and 165275 conducted on 10/25/22, 10/26/22, and 10/27/22.
Complaint Details
The inspection included attached complaints #175622, 173164, and 165275. The complaint investigation found substantiated issues including failure to report abuse timely and inadequate staff training.
Findings
The facility was found deficient in multiple areas including failure to report an allegation of abuse within 24 hours, improper medication storage and administration, inadequate staff development and training especially for non-English speaking employees, failure to serve food at proper temperatures, non-compliance with tuberculosis testing guidelines for new employees, and unsafe storage of chemicals accessible to cognitively impaired residents.
Deficiencies (6)
Failed to report an allegation of abuse to the department within 24 hours of notification.
Failed to ensure medications were securely stored and not administered beyond expiration, including an undated insulin pen.
Failed to provide required employee education in a language the non-English speaking employee could understand, resulting in delayed abuse reporting.
Failed to ensure food was served at proper temperature and dietary staff did not document food temperatures as required.
Failed to ensure compliance with tuberculosis testing guidelines for newly hired employees.
Failed to maintain facility safety by leaving unlocked chemicals accessible to cognitively impaired residents.
Report Facts
Census: 35
Deficiencies cited: 6
Cognitively impaired residents: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Operator B | Confirmed failure to report abuse and acknowledged facility conditions and staff training issues | |
| Non-certified staff A | Housekeeper | Witnessed abuse but delayed reporting due to language barrier |
| Regional Licensed Nurse C | Licensed Nurse | Confirmed medication cart locking procedures and TB testing deficiencies |
| Certified Medication Aide E | Certified Medication Aide | Observed with undated insulin pen and medication cart unlocked |
| Dietary staff D | Assisted non-certified staff A in reporting abuse using translator app | |
| Licensed Nurse F | Licensed Nurse | New hire lacking required TB testing documentation |
| Certified Medication Aide G | Certified Medication Aide | New hire lacking proper TB test date and time documentation |
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Jul 29, 2020
Visit Reason
The special infection control survey for COVID-19 was conducted at the facility on 7.29.2020.
Findings
The survey resulted in findings of no deficiency citations.
Inspection Report
Complaint Investigation
Census: 33
Deficiencies: 2
Date: Dec 19, 2018
Visit Reason
The inspection was a resurvey with complaint investigation 126699 conducted at the assisted living facility The Homestead of Olathe North on 12-17-18, 12-18-18, and 12-19-18.
Complaint Details
The visit was a resurvey with complaint investigation number 126699.
Findings
The facility failed to ensure that each individual involved in the development of the negotiated service agreement signed the agreement, specifically for Resident #600. Additionally, the clinical record for Resident #600 lacked documentation of a medical care provider's order for each medication administered.
Deficiencies (2)
Failure to ensure each individual involved in the development of the negotiated service agreement signed the agreement.
Failure to ensure the clinical record contained a medical care provider's order for each medication administered to the resident.
Report Facts
Census: 33
Medications administered without physician order: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Staff B | Interviewed and confirmed lack of resident/legal representative signature on service agreement and lack of physician orders for medications. |
Inspection Report
Renewal
Deficiencies: 0
Date: Nov 22, 2016
Visit Reason
The licensure resurvey of the assisted living facility was conducted on 11-21-16 and 11-22-16 as part of the renewal process.
Findings
The inspection resulted in findings of no deficiency citations.
Inspection Report
Abbreviated Survey
Census: 36
Deficiencies: 2
Date: Jun 16, 2015
Visit Reason
The inspection was an abbreviated survey with a compliant investigation conducted at the assisted living facility on June 15-16, 2015.
Complaint Details
The visit included a complaint investigation (81542) related to failure to report and investigate abuse, neglect, or exploitation allegations. The complaint was substantiated based on findings for residents #2 and #4 regarding unreported falls and injuries.
Findings
The facility failed to report and investigate allegations of abuse, neglect, or exploitation within 24 hours as required. Specific deficiencies included failure to report an unwitnessed fall resulting in a fractured hip and femur, failure to document incidents and communication with residents' families, and failure to maintain proper records of investigations.
Deficiencies (2)
Failed to report and investigate allegations of abuse, neglect, or exploitation within 24 hours.
Failed to ensure documentation of all incidents, symptoms, and other indications of illness or injury including date, time, action taken, and results.
Report Facts
Census: 36
Sample size: 4
Discharged residents reviewed: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| licensed staff B | Interviewed and provided information regarding resident #2's fall and failure to report and investigate | |
| licensed staff D | Reported finding resident #2 lying on the floor with injury | |
| licensed staff E | Found resident #2 lying on the floor with injury | |
| licensed staff G | Documented clinical notes for resident #4's injuries | |
| licensed staff F | Documented clinical notes for resident #4's fall and injury | |
| licensed staff C | Documented last medical record entry for resident #3's transfer to hospital | |
| administrative staff A | Interviewed regarding unreported incidents and communication with resident #3's family |
Inspection Report
Renewal
Deficiencies: 0
Date: Oct 30, 2014
Visit Reason
The licensure resurvey of the facility was conducted on 10/29/2014 and 10/30/2014 as part of the renewal process.
Findings
The inspection resulted in a finding of no deficiency citations.
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