Deficiencies per Year
4
3
2
1
0
Severe
High
Moderate
Unclassified
Census Over Time
Inspection Report
Re-Inspection
Deficiencies: 0
Sep 9, 2025
Visit Reason
The visit was a resurvey at the assisted living facility conducted on 09/08/2025 and 09/09/2025.
Findings
The resurvey resulted in no citations or deficiencies.
Inspection Report
Plan of Correction
Deficiencies: 0
Sep 8, 2025
Visit Reason
This document represents the findings of a resurvey at the assisted living facility conducted on 09/08/25 and 09/09/25.
Findings
The resurvey resulted in no citations.
Inspection Report
Re-Inspection
Deficiencies: 2
Mar 19, 2024
Visit Reason
This report documents a revisit inspection to verify that previously reported deficiencies have been corrected and to confirm the dates such corrective actions were accomplished.
Findings
The revisit report indicates that the previously cited deficiencies identified by regulation numbers 26-41-101 (f)(1) and 26-41-204 (a) were corrected as of 03/18/2024.
Deficiencies (2)
| Description |
|---|
| Deficiency related to regulation 26-41-101 (f)(1) |
| Deficiency related to regulation 26-41-204 (a) |
Report Facts
Deficiencies corrected: 2
Inspection Report
Complaint Investigation
Census: 54
Deficiencies: 2
Feb 29, 2024
Visit Reason
The inspection was a resurvey with attached complaints #184586, #184539, #184561, #182482, #180042, #178386, and #177167 conducted at Lexington Park Assisted Living on 02/28/24 and 02/29/24.
Findings
The facility failed to protect Resident 1 from neglect by not ensuring two-person assist during mechanical sling lift transfers, resulting in injury. Additionally, the facility failed to ensure a licensed nurse provided necessary health care services for Resident 5 by not including a bed assist device in the negotiated service agreement for transfers.
Complaint Details
The visit was complaint-related involving multiple complaints (#184586, #184539, #184561, #182482, #180042, #178386, #177167). The findings substantiated neglect and failure to provide necessary health care services as per negotiated service agreements.
Severity Breakdown
G: 1
D: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to protect Resident 1 from neglect by not ensuring two-person assist during mechanical sling lift transfers, resulting in injury. | G |
| Failure to ensure a licensed nurse provided necessary health care services for Resident 5 by not including a bed assist device in the negotiated service agreement for transfers. | D |
Report Facts
Census: 54
Staff Inservice Attendance: 14
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| CNA C | Certified Nurse Aide | Named in the finding related to improper transfer of Resident 1 using mechanical sling lift alone. |
| APRN D | Advanced Practice Registered Nurse | Documented Resident 1's fracture of left distal tibia. |
| Administrative Staff A | Confirmed CNA C used mechanical sling lift alone and confirmed Resident 5's use of bed assist device. | |
| Administrative Nurse B | Confirmed Resident 5's negotiated service agreement lacked documentation of bed assist device use. |
Inspection Report
Plan of Correction
Deficiencies: 0
Feb 28, 2024
Visit Reason
This document represents the findings of a resurvey with attached complaints #184586, #184539, #184561, #182482, #180042, #178386, and #177167 at the assisted living facility conducted on 02/28/24 and 02/29/24.
Findings
The document is a plan of correction submitted in response to the findings from the resurvey and attached complaints at the assisted living facility.
Complaint Details
The resurvey was conducted with attached complaints #184586, #184539, #184561, #182482, #180042, #178386, and #177167.
Inspection Report
Follow-Up
Deficiencies: 0
Sep 20, 2022
Visit Reason
An offsite revisit survey was conducted to verify correction of all previous deficiencies cited on 2022-08-25.
Findings
All deficiencies cited in the prior inspection were corrected as of the compliance date of 2022-09-13, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Report Facts
Previous deficiencies cited: Deficiencies cited on 2022-08-25, corrected by 2022-09-13
Inspection Report
Complaint Investigation
Census: 55
Deficiencies: 4
Aug 25, 2022
Visit Reason
The inspection was a resurvey with complaint investigations #161997, #167190, and #167224 conducted at Lexington Park Assisted Living on 08/23/22, 08/24/22, and 08/25/22.
Findings
The facility was found deficient in multiple areas including failure to complete negotiated service agreements accurately for residents, failure to conduct quarterly emergency management plan reviews with residents, improper infection control practices by dietary staff, and failure to complete required paperwork for authorized electronic monitoring in residents' rooms.
Complaint Details
The visit was complaint-related, involving investigations #161997, #167190, and #167224. The complaints included issues with negotiated service agreements, emergency preparedness, infection control, and electronic monitoring paperwork. Substantiation status is not explicitly stated.
Severity Breakdown
SS=E: 2
SS=F: 1
Deficiencies (4)
| Description | Severity |
|---|---|
| Failure to ensure designated staff completed the Negotiated Service Agreement/Health Care Service Plan to include a description of the services the resident will receive and identification of the provider of each service. | SS=E |
| Failure to ensure disaster and emergency preparedness by ensuring quarterly review of the facility's emergency management plan with residents. | SS=F |
| Failure to ensure staff implemented procedures to prevent the spread of infections, including improper handling of glasses and coffee cups by dietary staff. | SS=E |
| Failure to ensure proper paperwork was completed for the use of video surveillance in residents' rooms as required by state regulations. | — |
Report Facts
Census: 55
Water volume: 300
Additional water volume: 60
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Staff A | Confirmed details about Functional Capacity Screen, Negotiated Service Agreement, and electronic monitoring paperwork. | |
| Administrative Staff E | Confirmed resident conditions and assisted with observations related to tube feeding. | |
| Certified Medication Aide D | Observed assisting resident R823 with medications and tube feeding. | |
| Maintenance Staff C | Reported not reviewing emergency management plan with residents. | |
| Dietary Staff F | Observed improperly handling glasses and coffee cups, contributing to infection control deficiency. | |
| Dietary Staff G | Reported proper procedures for handling cups and glasses. | |
| Activity Staff B | Reported Maintenance Staff C's activities with residents regarding emergency management plan. |
Inspection Report
Plan of Correction
Deficiencies: 1
Aug 23, 2022
Visit Reason
The document is a plan of correction addressing findings from a resurvey with complaint investigations #161997, #167190, and #167224 conducted on 08/23/22, 08/24/22, and 08/25/22 at the assisted living facility.
Findings
The plan of correction corresponds to citations resulting from a resurvey combined with complaint investigations at the facility over three days in August 2022.
Complaint Details
The visit included complaint investigations #161997, #167190, and #167224.
Deficiencies (1)
| Description |
|---|
| Findings of a resurvey with complaint investigations #161997, #167190, #167224 |
Inspection Report
Re-Inspection
Deficiencies: 3
Apr 29, 2021
Visit Reason
This revisit inspection was conducted to verify that previously reported deficiencies at Lexington Park Assisted Living have been corrected.
Findings
The report shows that all previously cited deficiencies identified by regulation numbers 26-41-202 (h), 26-41-204 (d), and 26-41-206 (a)(b) were corrected as of the revisit date.
Deficiencies (3)
| Description |
|---|
| Deficiency related to regulation 26-41-202 (h) |
| Deficiency related to regulation 26-41-204 (d) |
| Deficiency related to regulation 26-41-206 (a)(b) |
Inspection Report
Renewal
Census: 44
Deficiencies: 3
Mar 10, 2021
Visit Reason
The inspection was conducted for re-licensure with an attached complaint at Lexington Park Assisted Living in Topeka, KS on 3/8/21, 3/9/21, and 3/10/21.
Findings
The facility failed to ensure that each individual involved in the development of the negotiated service agreement (NSA) signed the agreement and failed to provide copies of the initial agreement and revisions to residents or their legal representatives. Additionally, the NSA lacked a description of health care services and the name of the licensed nurse responsible for implementation and supervision. The facility also failed to ensure a medical care provider's order was on file for a resident receiving a mechanically altered diet and/or thickened liquids, and the diet was not prepared according to instructions.
Complaint Details
The inspection included an attached complaint investigation as part of the re-licensure survey.
Severity Breakdown
F: 2
D: 1
Deficiencies (3)
| Description | Severity |
|---|---|
| Failure to ensure signatures on negotiated service agreements and provision of copies to residents or legal representatives. | F |
| Negotiated service agreements lacked description of health care services and name of licensed nurse responsible for implementation and supervision. | F |
| Failure to have medical care provider's order on file and prepare mechanically altered diet according to instructions for resident #312. | D |
Report Facts
Census: 44
Residents in sample: 5
Physician's order date: Jan 5, 2021
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Operator #A | Interviewed regarding NSA signatures and dietary recipe book. | |
| Licensed Nurse #B | Interviewed regarding NSA signatures and distribution of Functional Capacity Screen. | |
| Dietary Staff #C | Interviewed regarding preparation of mechanical soft diet. |
Inspection Report
Routine
Deficiencies: 0
Jun 22, 2020
Visit Reason
The special infection control survey for COVID-19 was conducted at the facility on 2020-06-22.
Findings
The survey resulted in findings of no deficiency citations.
Inspection Report
Renewal
Deficiencies: 0
Aug 23, 2018
Visit Reason
A survey for re-licensure was conducted on 08/23/2018 at Lexington Park Assisted Living in Topeka, KS.
Findings
The survey resulted in a finding of no deficiency citations.
Inspection Report
Complaint Investigation
Census: 51
Deficiencies: 1
Sep 23, 2016
Visit Reason
The inspection was a licensure re-survey with complaints conducted at the assisted living facility on 9/21/16, 9/22/16, and 9/23/16.
Findings
The facility failed to provide health care services to resident #923 by qualified staff in accordance with acceptable standards of practice, specifically failing to provide a physician-ordered mechanical soft diet due to lack of staff awareness and facility capability.
Complaint Details
The visit was complaint-related as it was a licensure re-survey with complaints. Specific substantiation status is not stated.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to provide health care services to resident #923 by qualified staff in accordance with acceptable standards of practice, including not providing the ordered mechanical soft diet. | SS=D |
Report Facts
Census: 51
Sampled residents: 3
Focus review residents: 1
Inspection Report
Follow-Up
Deficiencies: 1
Sep 23, 2015
Visit Reason
This revisit report documents the correction of deficiencies previously reported during an earlier survey and confirms the dates when corrective actions were completed.
Findings
The report indicates that the previously cited deficiency under regulation 26-41-101 (f) (1) was corrected as of 09/23/2015. No other deficiencies or findings are noted.
Deficiencies (1)
| Description |
|---|
| Deficiency under regulation 26-41-101 (f) (1) corrected |
Report Facts
Deficiency correction date: Sep 23, 2015
Inspection Report
Complaint Investigation
Census: 58
Deficiencies: 1
Aug 20, 2015
Visit Reason
The inspection was an abbreviated survey with complaint investigation 0558 conducted at Lexington Park Assisted Living on 8-17-15 through 8-20-15, triggered by concerns related to resident neglect and elopement risk.
Findings
The facility failed to ensure that a cognitively impaired resident at risk for elopement was properly supervised and that the sign in/out policy was enforced. Resident #1 left the facility without staff knowledge and without signing out on 8-13-15 and was found deceased on 8-20-15 in a wooded area adjacent to the facility. The licensed nurse failed to provide or coordinate necessary health care services to address the resident's elopement risk, placing the resident in immediate jeopardy.
Complaint Details
The complaint investigation found that resident #1, who had cognitive impairments and was at risk for elopement, left the facility without staff knowledge and without signing out. The resident was missing for several hours before being found deceased. The facility failed to accurately assess elopement risk and enforce policies to prevent elopement.
Severity Breakdown
SS=J: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure no resident was subjected to neglect when the licensed nurse failed to provide or coordinate health care services necessary to address the cognitively impaired resident's risk for elopement, and failure to enforce the policy for sign in and sign out when residents were leaving the building. | SS=J |
Report Facts
Census: 58
Elopement Risk Score: 14
Elopement Risk Score (adjusted): 17
Date of resident elopement: Aug 13, 2015
Date resident found deceased: Aug 20, 2015
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nurse A | Interviewed and confirmed failures in monitoring sign out register and resident supervision | |
| Licensed Nurse A | Confirmed failure to read hospital reports and assess resident's elopement risk | |
| Administrative Staff B | Participated in search and monitoring of resident sign out | |
| Sitter #1 | Provided care and supervision to resident, confirmed resident required accompaniment when outside facility | |
| Operator | Interviewed regarding facility policies and search efforts |
Inspection Report
Follow-Up
Deficiencies: 1
Jul 6, 2015
Visit Reason
This visit was conducted as a follow-up to verify that previously reported deficiencies have been corrected.
Findings
The report confirms that the deficiency identified by regulation 26-41-205 (h) with ID prefix S3215 was corrected on 07/06/2015.
Deficiencies (1)
| Description |
|---|
| Deficiency related to regulation 26-41-205 (h) |
Inspection Report
Renewal
Census: 51
Deficiencies: 1
Jun 9, 2015
Visit Reason
The inspection was a Licensure Resurvey at Lexington Park Assisted Living in Topeka, Kansas on 6/08/15 and 6/09/15, which also included investigation of Complaints #76608 and #82625.
Findings
The licensed nurses and medication aides failed to ensure insulin pens were stored according to the manufacturer's recommendations. Specifically, open and in use insulin pens were stored in the refrigerator contrary to manufacturer instructions, which require open pens to be stored at room temperature.
Complaint Details
Complaints #76608 and #82625 were investigated during this licensure resurvey.
Severity Breakdown
SS=F: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Licensed nurses and medication aides failed to ensure insulin pens were stored in accordance with manufacturer's recommendations, with open and in use pens improperly stored in the refrigerator. | SS=F |
Report Facts
Census: 51
Residents using insulin: 8
Sampled residents: 3
Residents with insulin storage deficiency: 8
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Resident Care Coordinator (RCC)/Registered Nurse (RN) | Confirmed insulin pens inside the basket were open and in use and reviewed manufacturer's storage instructions. | |
| Operator | Stated nurses administer insulin to residents. |
Inspection Report
Follow-Up
Deficiencies: 3
Jul 7, 2014
Visit Reason
This revisit report documents the correction of deficiencies previously reported during an earlier survey, verifying that corrective actions were completed as of the revisit date.
Findings
The report confirms that previously identified deficiencies under regulations 26-41-204(a), 26-41-205(d)(1-2), and 28-39-255 were corrected by 07/07/2014.
Deficiencies (3)
| Description |
|---|
| Deficiency under regulation 26-41-204(a) |
| Deficiency under regulation 26-41-205(d)(1-2) |
| Deficiency under regulation 28-39-255 |
Inspection Report
Complaint Investigation
Census: 50
Deficiencies: 3
Jun 17, 2014
Visit Reason
The inspection was a resurvey and investigation of complaints #67101 and #75530 at Lexington Park Assisted Living conducted on multiple dates in June 2014.
Findings
The facility failed to ensure a licensed nurse accurately assessed and coordinated necessary health care services for a cognitively impaired resident with wandering and exit-seeking behaviors, resulting in the resident eloping, falling, fracturing an arm, and requiring hospitalization. Additionally, medication administration errors and sanitary deficiencies in the dietary area were identified.
Complaint Details
The visit was triggered by complaints #67101 and #75530. The investigation substantiated that the facility failed to prevent elopement of a cognitively impaired resident, resulting in injury and hospitalization.
Severity Breakdown
Level J: 1
Level D: 1
Level F: 1
Deficiencies (3)
| Description | Severity |
|---|---|
| Failure to ensure licensed nurse accurately assessed and coordinated necessary health care services to prevent elopement of a cognitively impaired resident, resulting in injury and hospitalization. | Level J |
| Failure to administer medications in accordance with medical provider's orders and standards of practice, including administration of medication at incorrect times and lack of communication regarding medication availability. | Level D |
| Failure to maintain sanitary conditions in dietary areas, including dust accumulation, dead bugs, water damage, and lack of cleaning schedule. | Level F |
Report Facts
Census: 50
Deficiencies cited: 3
Distance walked by resident: 1.3
Medication dosage: 0.5
Medication dosage: 10
Medication dosage: 28
Medication dosage: 25
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Licensed nurse #A | Documented resident wandering and placed wanderguard on resident's ankle | |
| Licensed nurse #B | Failed to assess resident prior to medication administration and did not respond to door alarms | |
| Certified Medication Aide #C | Administered clonazepam at incorrect time and documented resident behavior | |
| Certified Medication Aide #E | Observed resident trying to exit building and redirected resident | |
| Certified Nursing Assistant #D | Reset door alarm without checking outside and provided care during elopement incident | |
| Resident Care Coordinator | Provided statements regarding medication administration and resident care | |
| Dietary Manager | Acknowledged lack of cleaning schedule in kitchen | |
| Office Manager | Reviewed video recordings and confirmed kitchen needed cleaning |
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