Inspection Report Summary
The most recent inspection on October 10, 2024, found no deficiencies and confirmed that all prior issues had been corrected. Earlier inspections showed recurring deficiencies related mainly to medication management, emergency plan reviews, and safe food and chemical storage. Complaint investigations were attached to some inspections, with deficiencies substantiated in areas such as medication labeling and storage, emergency plan documentation, and food safety, but no fines or enforcement actions were listed in the available reports. Most complaints were addressed through corrective actions, and no immediate jeopardy findings or license suspensions were noted. The facility’s record shows improvement over time, with the latest inspection demonstrating compliance after previous citations.
Deficiencies (last 8 years)
Deficiencies (over 8 years)
2.4 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
60% better than Kansas average
Kansas average: 6 deficiencies/yearDeficiencies per year
8
6
4
2
0
Census
Latest occupancy rate
38 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
Re-Inspection
Deficiencies: 0
Date: Oct 10, 2024
Visit Reason
An offsite revisit survey was conducted to verify correction of all previous deficiencies cited on 2024-09-24.
Findings
All deficiencies cited in the prior inspection have been corrected as of the compliance date 2024-09-27, 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: Sep 23, 2024
Visit Reason
This document represents the findings of a resurvey with attached complaints 189533, 188377, and 188325 at the assisted living facility conducted on 09/23/24 and 09/24/24.
Complaint Details
The resurvey was conducted with attached complaints numbered 189533, 188377, and 188325.
Findings
The plan of correction addresses the findings from the resurvey and attached complaints conducted at the facility on the specified dates.
Inspection Report
Re-Inspection
Census: 38
Deficiencies: 5
Date: Sep 23, 2024
Visit Reason
The inspection was a resurvey with attached complaints 189533, 188377, and 188325 conducted at the assisted living facility.
Complaint Details
The visit was a resurvey with attached complaints 189533, 188377, and 188325.
Findings
The facility failed to ensure proper labeling of over-the-counter medications with residents' full names, proper medication storage including expired and undated medications, lacked documentation of quarterly emergency management plan reviews, failed to store food items under safe and sanitary conditions, and did not store chemicals in locked areas to protect health and safety.
Deficiencies (5)
Failed to ensure licensed pharmacist or nurse placed full names of residents on original packages of nine over-the-counter medications.
Failed to ensure all medications and biologicals were stored according to manufacturer or pharmacy recommendations, including expired and undated insulin pens and medications.
Failed to provide evidence of quarterly reviews of the facility's emergency management plan with residents and staff for two quarters of 2023.
Failed to ensure food items were stored under safe and sanitary conditions, including unsealed, undated, and unlabeled food items in kitchen storage areas.
Failed to ensure all chemicals were stored within locked areas, with multiple unlocked cabinets containing aerosol disinfectant sprays.
Report Facts
Census: 38
Over-the-counter medications unlabeled: 9
Food items unsealed or undated: 9
Aerosol spray cans of Lysol disinfectant: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Nurse D | Confirmed observations regarding unlabeled OTC medications and expired/undated medications. | |
| Dietary Staff C | Confirmed observations regarding unsealed and undated food items. | |
| Administrative Staff A | Confirmed lack of documentation for emergency plan reviews and unlocked chemical storage. |
Inspection Report
Follow-Up
Deficiencies: 0
Date: May 18, 2023
Visit Reason
An offsite revisit survey was conducted to verify correction of all previous deficiencies cited on 2023-05-01.
Findings
All deficiencies have been corrected as of the compliance date of 2023-05-03, 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: 37
Deficiencies: 3
Date: May 1, 2023
Visit Reason
The visit was a resurvey with an attached complaint #166171 at the assisted living facility conducted on 04/27/2023 and 05/01/2023.
Complaint Details
The inspection was conducted as a resurvey with attached complaint #166171.
Findings
The facility failed to provide quarterly reviews of the emergency management plan with staff and residents, failed to ensure food was served at the proper temperature due to lack of food temperature logs, and failed to ensure food was stored under safe conditions as freezer temperature logs were missing and refrigerator logs were incomplete.
Deficiencies (3)
Failure to provide quarterly reviews of the facility's emergency management plan with staff and residents.
Failure to ensure food was served at the proper temperature; no food temperature log was maintained.
Failure to ensure food was stored under safe and sanitary conditions; freezer temperature logs were absent and refrigerator temperature logs were incomplete.
Report Facts
Census: 37
Days without refrigerator temperature logs: 19
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Staff A | Confirmed lack of documentation of quarterly reviews of the emergency management plan. | |
| Dietary Staff C | Confirmed absence of food temperature log and freezer temperature log, and incomplete refrigerator temperature logs. |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Apr 27, 2023
Visit Reason
This document represents the findings of a resurvey with an attached complaint (#166171) at the assisted living facility conducted on 04/27/23 and 05/01/23.
Complaint Details
The visit was related to a complaint investigation identified as complaint #166171.
Findings
The document is a plan of correction submitted in response to deficiencies identified during the resurvey and complaint investigation conducted on the specified dates.
Inspection Report
Re-Inspection
Census: 37
Deficiencies: 5
Date: Dec 16, 2021
Visit Reason
The inspection was a resurvey of an assisted living facility conducted on 12/14, 12/15, and 12/16/2021 to assess compliance with regulatory requirements.
Findings
The facility was found deficient in multiple areas including failure to complete functional capacity reassessments after significant changes in resident status, incomplete negotiated service agreements and health care service plans, failure to revise service agreements after changes in resident condition, incomplete documentation of medication administration responsibilities, and failure to post required electronic monitoring notices outside resident rooms.
Deficiencies (5)
Failure to complete a functional capacity screen for resident R113 after a significant change in status.
Failure to ensure negotiated service agreements included descriptions of all services received and providers for residents R213 and R413.
Failure to review and revise negotiated service agreements for residents R113 and R313 after significant changes in status.
Failure to include responsible person for administration and management of selected medications in the negotiated service agreement for resident R413.
Failure to post required notice of electronic monitoring outside each resident's room.
Report Facts
Census: 37
Sample size: 3
Focused record review: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative staff A | Confirmed deficiencies related to functional capacity screening, negotiated service agreements, and electronic monitoring notices. | |
| Certified Medication Aide C | Certified Medication Aide | Observed assisting resident R113 with transfers and cares. |
| Certified Nursing Assistant D | Certified Nursing Assistant | Reported resident R113's need for assistance after hip fracture. |
| Certified Medication Aide E | Certified Medication Aide | Reported resident R113's prior and current care needs and observed resident R213's pressure ulcer care. |
| Certified Nurse Aide F | Certified Nurse Aide | Assisted resident R213 with positioning and cares. |
| Administrative Nurse B | Administrative Nurse | Reported uncertainty about medication documentation requirements for nasal gel. |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Dec 14, 2021
Visit Reason
The document represents a plan of correction submitted in response to findings from a resurvey conducted at the assisted living facility on December 14, 15, and 16, 2021.
Findings
The plan of correction addresses citations identified during the resurvey of the assisted living facility conducted over three days in December 2021.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Jun 23, 2020
Visit Reason
The visit was a special infection control survey for COVID-19 conducted at the facility.
Findings
The survey resulted in findings of no deficiency citations.
Inspection Report
Renewal
Census: 36
Deficiencies: 2
Date: Aug 15, 2019
Visit Reason
The inspection was conducted for re-licensure with attached complaints at an assisted living facility in Topeka, KS on 8/14/19 and 8/15/19.
Complaint Details
The survey included attached complaints which triggered the re-licensure survey.
Findings
The administrator failed to ensure that a licensed nurse provided or coordinated necessary health care services in accordance with functional capacity screenings and negotiated service agreements for residents #814 and #815. Additionally, the administrator failed to ensure resident #814 could safely self-administer medication without staff assistance.
Deficiencies (2)
Failure to ensure licensed nurse provides or coordinates necessary health care services per functional capacity screening and negotiated service agreement for residents #814 and #815.
Failure to ensure resident #814 could perform medication self-administration safely and accurately without staff assistance.
Report Facts
Census: 36
Census: 1536
Sample residents: 3
Focus review residents: 1
Inspection Report
Re-Inspection
Census: 33
Deficiencies: 2
Date: Nov 20, 2017
Visit Reason
The inspection was a licensure re-survey conducted at the assisted living facility to assess compliance with regulations related to staff treatment of residents and health care services.
Complaint Details
The complaint investigation was related to allegations of abuse and neglect for resident #711, which were not reported or investigated as required.
Findings
The facility failed to report allegations of abuse and neglect within 24 hours and did not initiate timely investigations or submit complaint investigation reports. Additionally, the facility failed to ensure that licensed nurses provided or coordinated necessary health care services in accordance with residents' functional capacity screenings and negotiated service agreements, including proper catheter care and fall prevention interventions.
Deficiencies (2)
Failure to report allegations of abuse, neglect, or exploitation to the department within 24 hours and failure to initiate investigations and submit complaint reports within five working days.
Failure to ensure that a licensed nurse provides or coordinates necessary health care services that meet the needs of residents and are in accordance with functional capacity screening and negotiated service agreements.
Report Facts
Census: 33
Sampled residents: 3
Focus review residents: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator #A | Facility Administrator | Confirmed incidents were unwitnessed and not reported; confirmed lack of catheter care and missing care plan entries |
| Licensed Nurse #B | Licensed Nurse | Confirmed catheter care is not performed by staff and lack of care plan entries |
| Licensed Nurse #C | Licensed Nurse | Confirmed fall interventions and lack of catheter care |
Inspection Report
Re-Inspection
Census: 36
Deficiencies: 2
Date: Jun 6, 2016
Visit Reason
The inspection was a licensure re-survey conducted on 6/1/16, 6/2/16, and 6/6/16 to assess compliance with health care service provision and medication administration requirements at The Homestead of Topeka.
Findings
The facility failed to ensure that a licensed nurse provided or coordinated necessary health care services in accordance with residents' functional capacity screenings and negotiated service agreements, including omissions in care plans for insulin self-injection, fall interventions, and eating assistance. Additionally, the facility failed to ensure that licensed nurses or medication aides administered only medications they personally prepared, with medication boxes being pre-set by one nurse but administered by others who were unaware of the contents.
Deficiencies (2)
Failure to ensure licensed nurse provides or coordinates necessary health care services per functional capacity screening and negotiated service agreement, including lack of interventions for insulin self-injection, use of side rails, air mattress, falls, and eating assistance.
Failure to ensure licensed nurse or medication aide administered only medications personally prepared, with medication boxes pre-set by one nurse but administered by others who did not know the contents.
Report Facts
Census: 36
Residents sampled: 3
Residents sampled: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed staff #A | Confirmed resident self-injection of insulin and lack of care plan entries; pre-sets medication boxes weekly | |
| Licensed staff #B | Observed handing insulin pen to resident; interviewed regarding care plan deficiencies | |
| Licensed staff #D | Observed administering medication box to resident #605 | |
| Administrative staff #C | Confirmed use of air mattress, side rails, and blue mat; interviewed regarding care plan deficiencies | |
| Administrative staff #E | Interviewed regarding care plan deficiencies and medication administration |
Inspection Report
Renewal
Deficiencies: 0
Date: Jun 9, 2014
Visit Reason
The licensure resurvey of the assisted living facility was conducted on 6/5/14 and 6/9/14 as part of the renewal process.
Findings
The inspection resulted in no deficiency citations being found at the facility.
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