Inspection Reports for Neuvant Md Memory Care LLC
1216 BILTMORE DRIVE, KS, 66049
Back to Facility ProfileInspection Report Summary
The most recent inspection on July 31, 2024, found no deficiencies and confirmed the facility was in compliance with all regulations. Prior inspections showed multiple deficiencies related mainly to documentation issues, incomplete negotiated service agreements, failure to investigate and report unexplained bruises, and safety concerns such as an unsafe bed assist device and inadequate tuberculosis screening. A complaint investigation in September 2023 identified immediate jeopardy due to failure to prevent a resident’s elopement and incomplete care planning. Enforcement actions such as fines or license suspensions were not listed in the available reports. The facility appears to have addressed prior deficiencies promptly, as follow-up inspections consistently verified correction of earlier issues.
Deficiencies (last 6 years)
Deficiencies (over 6 years)
6.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
8% worse than Kansas average
Kansas average: 6 deficiencies/yearDeficiencies per year
8
6
4
2
0
Census
Latest occupancy rate
28 residents
Based on a July 2024 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Follow-Up
Deficiencies: 0
Jul 31, 2024
Visit Reason
An offsite revisit survey was conducted to verify correction of all previous deficiencies cited on 07/03/24.
Findings
All deficiencies have been corrected as of the compliance date of 07/26/24, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Inspection Report
Re-Inspection
Census: 28
Deficiencies: 6
Jul 3, 2024
Visit Reason
The inspection was a resurvey conducted on 07/02-07/03/2024 at an assisted living facility to assess compliance with regulatory requirements following previous findings.
Findings
The facility was found deficient in multiple areas including failure to report and investigate unexplained bruises on a resident, incomplete negotiated service agreements for residents, lack of naming licensed nurse responsible for healthcare plans, unsafe bed assist device posing entrapment risk, incomplete documentation of incidents, and failure to comply with tuberculosis screening guidelines for residents and staff.
Complaint Details
The visit was a complaint-related resurvey triggered by allegations of abuse and neglect, specifically regarding failure to report and investigate unexplained bruises on Resident 2.
Severity Breakdown
SS=D: 4
SS=E: 2
Deficiencies (6)
| Description | Severity |
|---|---|
| Failure to report to the department within 24 hours and to investigate unexplained bruises on Resident 2. | SS=D |
| Negotiated Service Agreements (NSA) for Residents 2 and 3 failed to describe services based on Functional Capacity Screens (FCS). | SS=D |
| NSA for Resident 3 lacked the name of the licensed nurse responsible for implementing and supervising healthcare service plans. | SS=D |
| Bed assist device had a gap greater than 4.5 inches without a cover, posing risk of entrapment. | SS=D |
| Licensed staff failed to document all incidents, symptoms, and indications of illness or injury including date, time, action taken, and results for Residents 1 and 2. | SS=E |
| Facility failed to comply with tuberculosis screening guidelines for one resident and two staff members. | SS=E |
Report Facts
Census: 28
Gap size: 12
Gap size: 11
Elevated blood glucose: 312
Days late: 15
Inspection Report
Plan of Correction
Deficiencies: 0
Jul 2, 2024
Visit Reason
The document represents the findings of a resurvey conducted at the assisted living facility from July 2 to July 3, 2024.
Findings
This document is a plan of correction submitted in response to the findings from the resurvey conducted on July 2-3, 2024. It outlines corrective actions related to deficiencies identified during the resurvey.
Inspection Report
Follow-Up
Deficiencies: 3
Oct 16, 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 all previously identified deficiencies, referenced by regulation numbers 26-41-101 (f)(1), 26-41-201 (c), and 26-41-202 (d), have been corrected as of the revisit date.
Deficiencies (3)
| Description |
|---|
| Deficiency related to regulation 26-41-101 (f)(1) |
| Deficiency related to regulation 26-41-201 (c) |
| Deficiency related to regulation 26-41-202 (d) |
Inspection Report
Complaint Investigation
Census: 13
Deficiencies: 3
Sep 18, 2023
Visit Reason
The inspection was conducted as a complaint investigation (182728) at an assisted living facility regarding a cognitively impaired resident who eloped from the facility without staff knowledge.
Findings
The facility failed to ensure resident safety by not implementing interventions for a resident at risk of elopement, resulting in immediate jeopardy when the resident exited through an unalarmed door and was unaccounted for approximately 90 minutes. Additionally, the facility failed to complete required annual Functional Capacity Screenings and Negotiated Service Agreements for the resident within the required timeframe.
Complaint Details
The complaint investigation was triggered by an incident where a cognitively impaired resident (R101) exited the facility through an unalarmed exit door and patio gate without staff knowledge and was missing for approximately 90 minutes before being found by neighbors and transported to an emergency room. The facility failed to identify the resident as at risk for elopement and did not implement adequate safety interventions.
Severity Breakdown
Immediate Jeopardy: 1
Level D: 2
Deficiencies (3)
| Description | Severity |
|---|---|
| Failure to ensure resident was not subjected to neglect by failing to implement interventions for resident safety, resulting in immediate jeopardy when resident eloped. | Immediate Jeopardy |
| Failure to complete a Functional Capacity Screen for resident at least once every 365 days. | Level D |
| Failure to revise a Negotiated Service Agreement/Health Care Service Plan for resident at least once every 365 days. | Level D |
Report Facts
Resident census: 13
Elopement duration: 90
Elopement risk score: 9
Functional Capacity Screen delay: 10
Negotiated Service Agreement delay: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nurse B | Documented multiple behavior and incident notes related to resident R101 and provided statements regarding resident's condition and care. | |
| Licensed Nurse C | Provided statements about resident's behavior and door locking status prior to elopement. | |
| Administrative Staff A | Informed of findings resulting in immediate jeopardy and submitted abatement plan including door locking and paging system replacement. | |
| Certified Medication Aide E | Documented incident report of resident missing and attempted to locate resident. | |
| Certified Nurse Aide F | Assisted in searching for resident after elopement. | |
| Licensed Nurse D | Coordinated search efforts and reported resident missing to 911. | |
| Director of Nursing | DON | Completed Elopement Assessment Form and care plan changes after elopement incident. |
Inspection Report
Plan of Correction
Deficiencies: 0
Sep 18, 2023
Visit Reason
The document represents the findings of a complaint investigation conducted at the assisted living facility on 09/18/23 and 09/19/23.
Findings
This document is a plan of correction submitted in response to the findings from the complaint investigation at the assisted living facility.
Complaint Details
The visit was related to complaint investigation 182728 at the assisted living facility.
Inspection Report
Follow-Up
Deficiencies: 0
Feb 16, 2023
Visit Reason
An offsite revisit survey was conducted on 02/16/2023 to verify correction of all previous deficiencies cited on 02/02/2023.
Findings
All deficiencies have been corrected as of the compliance date of 02/15/2023 and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Report Facts
Previous deficiencies cited: 1
Inspection Report
Complaint Investigation
Census: 21
Deficiencies: 1
Feb 1, 2023
Visit Reason
The inspection was a resurvey with a complaint #168330 at the assisted living facility conducted on 02/01/23 - 02/02/23.
Findings
The operator failed to ensure that the Negotiated Service Agreement (NSA) was fully developed for residents R101, R102, and R103 to include all items triggered on their Functional Capacity Screens (FCS), such as cognition, communication, falls, use of assistive devices, and other care needs.
Complaint Details
This was a resurvey with complaint #168330. The findings were related to incomplete Negotiated Service Agreements for three residents based on their Functional Capacity Screens.
Severity Breakdown
SS=F: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure the Negotiated Service Agreement was fully developed based on the Functional Capacity Screen triggers for residents R101, R102, and R103. | SS=F |
Report Facts
Resident census: 21
Residents sampled: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nurse B | Provided statements regarding the requirement that items triggered on the Functional Capacity Screen should be addressed in the Negotiated Service Agreement. |
Inspection Report
Plan of Correction
Deficiencies: 0
Feb 1, 2023
Visit Reason
The document is a Plan of Correction addressing findings from a resurvey with a complaint #168330 conducted at the assisted living facility from 02/01/23 to 02/02/23.
Findings
The Plan of Correction corresponds to citations identified during the resurvey related to the complaint investigation at the assisted living facility.
Complaint Details
The visit was triggered by complaint #168330 and was a resurvey to address the complaint findings.
Inspection Report
Renewal
Deficiencies: 0
Oct 22, 2020
Visit Reason
A survey for re-licensure with attached complaints #155762 and 155272 was conducted at the residential care facility.
Findings
The survey resulted in a finding of no deficiency citations.
Complaint Details
The survey included attached complaints #155762 and 155272; no deficiencies were found.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Jul 16, 2020
Visit Reason
The special infection control survey for COVID-19 was conducted at the facility on 07/16/2020.
Findings
The survey resulted in findings of no deficiency citations.
Inspection Report
Renewal
Census: 10
Deficiencies: 1
Jun 11, 2018
Visit Reason
The inspection was a re-visit for re-licensure conducted at the assisted living facility on 6/7/18 and 6/11/18.
Findings
The administrator failed to ensure documentation of all indications of illness or injury including date, time of occurrence, action taken, and results of the action for two sampled residents. Records lacked documentation of physician's orders, reasons for medication changes, notification of family, initiation of psychologist evaluation process, and follow-up for medication effectiveness.
Severity Breakdown
SS=E: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to document all indications of illness or injury including date, time of occurrence, action taken, and results of the action for residents #1606 and #1609. | SS=E |
Report Facts
Census: 10
Sampled residents: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| licensed nurse #C | Interviewed and confirmed record lacked documentation |
Inspection Report
Re-Inspection
Deficiencies: 3
Jun 11, 2018
Visit Reason
This revisit report documents the correction of deficiencies previously reported during an earlier survey.
Findings
All previously cited deficiencies identified by regulation numbers 26-41-202 (h), 26-41-204 (d), and 26-41-205 (a)(1) 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 26-41-205 (a)(1) |
Inspection Report
Re-Inspection
Census: 9
Deficiencies: 4
May 24, 2018
Visit Reason
The inspection was a licensure re-survey conducted at the assisted living facility on 5/23/18 and 5/24/18 in Lawrence, KS.
Findings
The facility was found deficient in multiple areas including failure to obtain signatures on negotiated service agreements, incomplete health care service plans lacking the name of the licensed nurse responsible, failure to assess residents' ability to self-administer medications safely, and inadequate documentation of incidents including resident falls and changes in physician orders.
Severity Breakdown
E: 3
D: 1
Deficiencies (4)
| Description | Severity |
|---|---|
| Failure to ensure each individual involved in the development of the negotiated service agreement signed the agreement. | E |
| Negotiated service agreement lacked a description of the health care services to be provided and the name of the licensed nurse responsible for implementation and supervision. | D |
| Failure to ensure residents could perform medication self-administration safely and accurately without staff assistance; lack of assessment for self-administration. | E |
| Failure to document all incidents, symptoms, and indications of illness or injury including date, time, action taken, and results. | E |
Report Facts
Census: 9
Sampled residents: 3
Deficiencies cited: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Nurse #C | Interviewed regarding lack of signatures on agreements, medication self-administration assessments, and documentation of incidents. | |
| Administrative Staff #B | Interviewed confirming lack of licensed nurse name on negotiated service agreement. |
Inspection Report
Re-Inspection
Deficiencies: 2
Jun 30, 2016
Visit Reason
This revisit report documents the correction of deficiencies previously cited during an earlier survey, verifying that corrective actions have been completed as of the revisit date.
Findings
The report confirms that the previously identified deficiencies, specifically those referenced by regulation numbers 26-41-202 (h) and 26-41-105 (b), have been corrected and completed by the revisit date of 06/30/2016.
Deficiencies (2)
| Description |
|---|
| Deficiency related to regulation 26-41-202 (h) |
| Deficiency related to regulation 26-41-105 (b) |
Inspection Report
Re-Inspection
Census: 8
Deficiencies: 4
May 25, 2016
Visit Reason
The inspection was a resurvey with complaint 92759 conducted on 5-23-16, 5-24-16, and 5-25-16 at Neuvant House of Lawrence East, a residential health care facility.
Findings
The facility was found deficient in multiple areas including failure to notify the resident's physician and legal representative of significant treatment changes, lack of signatures on negotiated service agreements for residents, expired medication aide certification for an employee administering medications, and failure to maintain confidentiality of resident records.
Complaint Details
The visit was complaint-related, triggered by complaint number 92759. The complaint involved issues such as failure to notify physicians of treatment changes and confidentiality breaches.
Severity Breakdown
SS=D: 2
SS=E: 1
SS=F: 1
Deficiencies (4)
| Description | Severity |
|---|---|
| Failure to ensure designated facility staff consulted with the resident's physician and notified the resident's legal representative upon occurrence of a need to alter treatment significantly. | SS=D |
| Failure to ensure that each individual involved in the development of the Negotiated Service Agreement signed the agreement. | SS=E |
| Failure to ensure employee records contained evidence of certification for each employee performing a function that requires specialized education or training. | SS=D |
| Failure to ensure that all information in each resident's record is kept confidential. | SS=F |
Report Facts
Census: 8
Employees hired since last resurvey: 24
Certified staff reviewed: 3
Licensed staff reviewed: 1
Non-certified staff reviewed: 1
Medication aide certification expiration date: 2016
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Certified staff D | Certified Staff | Administered medications without current certification; certification expired on 5-13-16 |
| Licensed staff C | Licensed Staff | Confirmed physician was not notified of medication changes and confirmed confidentiality breach of resident records |
| Administrative staff A | Administrative Staff | Confirmed certification expiration and confidentiality breach incident |
| Administrative staff B | Administrative Staff | Reviewed video surveillance footage of confidentiality breach |
| Certified staff E | Certified Staff | Confirmed work room door should be locked to protect confidentiality |
Inspection Report
Plan of Correction
Deficiencies: 2
Jul 23, 2015
Visit Reason
The document is a Statement of Deficiencies and Plan of Correction for Neuvant House of Lawrence East, detailing regulatory compliance issues identified during a survey completed on July 23, 2015.
Findings
The facility failed to meet requirements related to the development of written negotiated service agreements for residents and the provision and coordination of dietary services as specified in the regulations.
Severity Breakdown
SS=D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to develop a written negotiated service agreement for each resident based on functional capacity screening, service needs, and preferences. | SS=D |
| Failure to ensure provision or coordination of dietary services to residents as identified in each resident's negotiated service agreement, including supervisory responsibility and medical care provider orders for therapeutic diets. | SS=D |
Inspection Report
Re-Inspection
Deficiencies: 4
Jul 23, 2015
Visit Reason
This report is a revisit conducted to verify that previously reported deficiencies have been corrected and to document the dates when corrective actions were accomplished.
Findings
The revisit report confirms that all previously cited deficiencies identified by regulation or Life Safety Code provisions have been corrected as of the revisit date.
Deficiencies (4)
| Description |
|---|
| Deficiency identified under regulation 26-41-204 (c) |
| Deficiency identified under regulation 26-41-205 (d) (3) |
| Deficiency identified under regulation 26-41-205 (d) (4) |
| Deficiency identified under regulation 26-41-104 (a) |
Report Facts
Deficiencies corrected: 4
Inspection Report
Original Licensing
Census: 9
Deficiencies: 6
Jul 7, 2015
Visit Reason
Initial survey conducted at the residential health care facility to assess compliance with regulatory requirements.
Findings
The survey identified multiple deficiencies including failure to ensure negotiated service agreements adequately described services and providers, failure to ensure health care services were provided by appropriately licensed or certified staff, improper medication administration practices, inadequate delegation documentation, insufficient staffing for emergency evacuations, and failure to prepare therapeutic diets according to medical instructions.
Severity Breakdown
SS=D: 4
SS=G: 1
SS=J: 1
Deficiencies (6)
| Description | Severity |
|---|---|
| Negotiated service agreement lacked documentation of who performs blood glucose monitoring and administers insulin as ordered by the physician for resident #154. | SS=D |
| Health care services coordinated by a licensed nurse including personal care were not provided by direct care staff or certified/licensed nursing staff employed by a licensed home health agency, resulting in a fractured femur for resident #153 due to improper transfer by untrained private caregiver. | SS=G |
| Medication aides administered medication that they had not personally prepared for resident #154. | SS=D |
| Licensed nurse failed to appropriately delegate nursing procedures related to blood glucose monitoring and insulin administration, lacking documentation of delegation in personnel files for medication aides. | SS=D |
| Insufficient number of staff on night shift to assist residents requiring two-person transfers during emergency or disaster, placing residents in immediate jeopardy. | SS=J |
| Resident #152's mechanically altered therapeutic diet was not prepared according to instructions from a medical care provider or licensed dietitian. | SS=D |
Report Facts
Resident census: 9
Sampled residents: 3
Residents requiring two-person transfer: 4
Residents with impaired cognition: 7
Evacuation time: 20
Insulin dose: 85
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| licensed staff C | Interviewed regarding medication administration, resident transfers, and emergency evacuation | |
| administrative staff A | Interviewed regarding staffing, resident transfers, and delegation documentation | |
| dietary staff E | Interviewed regarding preparation of resident #152's diet | |
| certified staff F | Lacked documentation of competency checklists for insulin pen preparation and blood glucose monitoring | |
| certified staff G | Lacked documentation of competency checklists for insulin pen preparation and blood glucose monitoring | |
| certified staff H | Lacked documentation of competency checklists for insulin pen preparation and blood glucose monitoring |
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