Inspection Reports for Oak Creek Senior Living

KS, 66614

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Inspection Report Follow-Up Deficiencies: 0 Sep 18, 2024
Visit Reason
An offsite revisit survey was conducted on 09/18/24 to verify correction of all previous deficiencies cited on 08/28/24.
Findings
All deficiencies have been corrected as of the compliance date of 09/18/24, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Inspection Report Re-Inspection Census: 29 Deficiencies: 3 Aug 28, 2024
Visit Reason
The inspection was a resurvey with an attached complaint investigation (complaint 189301) conducted at Oak Creek Senior Living to assess compliance with negotiated service agreements and other regulatory requirements.
Findings
The facility failed to ensure negotiated service agreements were fully developed based on residents' functional capacity screenings for three sampled residents. Additionally, the facility did not label over-the-counter medications with residents' full names and failed to store chemicals in locked areas, compromising resident safety.
Complaint Details
The visit included a complaint investigation (complaint 189301) attached to the resurvey.
Severity Breakdown
E: 2 F: 1
Deficiencies (3)
DescriptionSeverity
Negotiated Service Agreements (NSA) were incomplete and did not fully describe services based on residents' Functional Capacity Screens for three residents.E
Over-the-counter medications were not labeled with residents' full names in multiple locations including the shower room/beauty shop cabinet and medication carts.E
Chemicals were stored in an unlocked cabinet accessible to residents and visitors, violating safety requirements.F
Report Facts
Census: 29 OTC medications not labeled: 5 Chemicals observed: 6
Employees Mentioned
NameTitleContext
Administrative Staff AConfirmed deficiencies related to negotiated service agreements for residents R1, R2, and R3.
Staff EConfirmed unlabeled OTC medication and chemicals not stored in locked areas.
Certified Medication Aide CCertified Medication AideConfirmed OTC medication in north medication cart was not labeled.
Certified Medication Aide DCertified Medication AideConfirmed three OTC medications in south medication cart were not labeled.
Inspection Report Plan of Correction Deficiencies: 0 Aug 27, 2024
Visit Reason
This document represents the findings of a resurvey with an attached complaint investigation conducted at the assisted living facility on August 27 and 28, 2024.
Findings
The document is a plan of correction submitted in response to deficiencies identified during the resurvey and complaint investigation at the facility.
Complaint Details
The visit included an attached complaint investigation identified as complaint 189301.
Inspection Report Follow-Up Deficiencies: 0 Apr 4, 2023
Visit Reason
An offsite revisit survey was conducted to verify correction of all previous deficiencies cited on 2023-03-21.
Findings
All deficiencies have been corrected as of the compliance date of 2023-04-01, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Report Facts
Previous deficiencies cited: Deficiencies cited on 2023-03-21
Inspection Report Complaint Investigation Census: 32 Deficiencies: 5 Mar 20, 2023
Visit Reason
The inspection was a resurvey with a complaint (#176146) conducted at Oak Creek Senior Living on 03/20/23 and 03/21/23.
Findings
The facility failed to ensure annual review and revision of negotiated service agreements, proper coordination of necessary health care services by licensed nurses, safe use and assessment of bed assistive devices, proper labeling of over-the-counter medications with resident names, and compliance with tuberculosis testing guidelines for new employees.
Complaint Details
The visit was a resurvey with a complaint (#176146).
Severity Breakdown
SS=D: 5
Deficiencies (5)
DescriptionSeverity
Failure to ensure the review and revision of the Negotiated Service Agreement at least once every 365 days.SS=D
Failure to ensure a licensed nurse provided and coordinated necessary health care services in accordance with the functional capacity screening and negotiated service agreement.SS=D
Failure to ensure health care services were provided by qualified staff in accordance with acceptable standards of practice, specifically regarding the use of bed assistive devices.SS=D
Failure to ensure licensed nurses or pharmacists placed the full name of the resident on each package of the resident's over-the-counter medication.SS=D
Failure to ensure compliance with tuberculosis testing guidelines for new employees, with TB testing not completed within seven days of hire for one staff member.SS=D
Report Facts
Residents present: 32 Sample size: 3 New employees reviewed: 5 Time delay for TB testing: 21
Employees Mentioned
NameTitleContext
Certified Medication Aide DCertified Medication AideInterviewed regarding resident R1's care and assistance
Licensed Nurse BLicensed NurseInterviewed regarding negotiated service agreement and health service plan for resident R1
Operator/Licensed Nurse AOperator/Licensed NurseNamed in multiple findings related to failure to ensure compliance with negotiated service agreements, health care services, medication labeling, and TB testing
Certified Medication Aide CCertified Medication AideStaff member whose TB testing was not completed within seven days of hire
Inspection Report Plan of Correction Deficiencies: 0 Mar 20, 2023
Visit Reason
The document is a plan of correction submitted in response to a resurvey with a complaint (#176146) conducted on 03/20/23 and 03/21/23 at the facility.
Findings
The citations represent findings from the resurvey and complaint investigation conducted on the specified dates.
Complaint Details
The visit was complaint-related, referencing complaint #176146.
Inspection Report Re-Inspection Census: 31 Deficiencies: 4 Oct 27, 2021
Visit Reason
The inspection was a resurvey with complaints #140801, #141374, and #141461 conducted at Oak Creek Senior Living to assess compliance with health care service standards and medication administration.
Findings
The facility failed to ensure licensed nurses provided necessary health care services, including proper treatment of a pressure ulcer, and failed to administer medications according to physician orders. Additionally, medication aides administered medications without current certification, insulin pens were not dated after opening, and documentation of incidents and follow-up care was incomplete.
Complaint Details
The resurvey was conducted with complaints #140801, #141374, and #141461.
Severity Breakdown
Level D: 1 Level E: 3
Deficiencies (4)
DescriptionSeverity
Failed to ensure licensed nurse provided or coordinated necessary health care services to meet the needs of a resident who developed a pressure ulcer.Level D
Failed to ensure medications were administered according to physician orders and medication aides had current certification.Level E
Failed to ensure medications were not administered beyond manufacturer or pharmacy recommended expiration dates due to undated insulin pens.Level E
Failed to document all incidents, symptoms, and other indications of illness or injury including date, time, action taken, and results for sampled residents.Level E
Report Facts
Census: 31 Residents with insulin pens not dated: 4 Residents sampled: 3 Medication aide certificate expiration date: Oct 18, 2021
Employees Mentioned
NameTitleContext
Licensed Nurse BLicensed NurseNamed in findings related to pressure ulcer care, medication administration, and documentation
Certified Medication Aide CCertified Medication AideAdministered medications with expired certification
Certified Medication Aide ECertified Medication AideInterviewed regarding pressure ulcer and insulin pen dating
Certified Medication Aide DCertified Medication AideInterviewed regarding insulin administration practices
Operator AFacility OperatorProvided employee information and confirmed medication aide certification expiration
Inspection Report Plan of Correction Deficiencies: 0 Oct 25, 2021
Visit Reason
The document is a plan of correction responding to a resurvey conducted on 10/25, 10/26, and 10/27/2021 related to complaints #140801, #141374, and #141461 at the facility.
Findings
The plan of correction references findings from a resurvey with complaints but does not detail specific deficiencies or findings within this document.
Complaint Details
The resurvey was conducted in response to complaints #140801, #141374, and #141461.
Inspection Report Routine Deficiencies: 0 Jun 23, 2020
Visit Reason
The special infection control survey for COVID-19 was conducted at the facility on 06/23/2020.
Findings
The survey resulted in findings of no deficiency citations.
Inspection Report Re-Inspection Deficiencies: 4 Jun 25, 2019
Visit Reason
This revisit inspection was conducted to verify that previously reported deficiencies at Oak Creek Senior Living were corrected and to document the dates such corrective actions were accomplished.
Findings
The report confirms that all previously cited deficiencies identified by regulation or Life Safety Code provisions were corrected as of the revisit date.
Deficiencies (4)
Description
Deficiency related to regulation 26-41-202 (c)
Deficiency related to regulation 26-41-204 (a)
Deficiency related to regulation 26-41-205 (d) (1-2)
Deficiency related to regulation 26-41-105 (f) (11)
Inspection Report Re-Inspection Census: 28 Deficiencies: 1 Jun 25, 2019
Visit Reason
The visit was a revisit for licensure conducted on 6/24/19 and 6/25/19 at Oak Creek Senior Living, an assisted living facility in Topeka, KS.
Findings
The facility failed to ensure that licensed nurses or medication aides stored all medications and biologicals securely and properly according to manufacturer and pharmacy provider recommendations and federal and state laws. Specifically, over-the-counter medications lacked the full name of the resident and were not accounted for regarding which resident the medication belonged to.
Severity Breakdown
SS=E: 1
Deficiencies (1)
DescriptionSeverity
Licensed nurses or medication aides failed to store all medications and biologicals securely and properly, with over-the-counter medications lacking resident full names and proper accounting for ownership.SS=E
Report Facts
Census: 28 Residents receiving medication management: 20 Sample size: 3 Medication quantities: 100 Medication quantities: 150 Medication quantities: 72 Medication quantities: 300 Medication quantities: 50 Medication quantities: 4 Medication quantities: 6
Inspection Report Renewal Census: 32 Deficiencies: 5 Nov 12, 2018
Visit Reason
The inspection was conducted as a survey for re-licensure with attached complaints at an assisted living facility in Topeka, KS on 11/7/18, 11/8/18, and 11/12/18.
Findings
The facility was found deficient in multiple areas including failure to conduct functional capacity screenings following significant changes in condition, incomplete negotiated service agreements lacking collaboration and necessary details, failure to ensure licensed nurse coordination of health care services, failure to notify medical providers of medication regimen variances, and incomplete employee records lacking timely criminal background checks.
Complaint Details
The inspection included attached complaints as part of the re-licensure survey.
Severity Breakdown
SS=D: 2 SS=E: 2 SS=F: 1
Deficiencies (5)
DescriptionSeverity
Failure to conduct a functional capacity screening following any significant change in condition for resident #117.SS=D
Failure to ensure negotiated service agreements for residents #118 and #119 contained required information and collaboration.SS=E
Failure to ensure a licensed nurse provides or coordinates necessary health care services in accordance with functional capacity screening and negotiated service agreement for resident #117.SS=D
Failure to notify medical care provider of medication regimen variances requiring immediate action and to seek response within required timeframe for residents #117 and #118.SS=E
Failure to maintain employee records with supporting documentation for criminal background checks at time of hire for certified staff #C, #D, #E, and #F.SS=F
Report Facts
Census: 32 Residents sampled: 3 Focus review residents: 1 Certified staff lacking timely criminal background checks: 4
Employees Mentioned
NameTitleContext
Administrative nurse #BInterviewed and confirmed deficiencies related to resident care and documentation.
Facility operator #AInterviewed regarding submission and recordkeeping of criminal background checks.
Inspection Report Re-Inspection Census: 35 Deficiencies: 2 Jan 9, 2018
Visit Reason
The inspection was a licensure re-survey conducted at Oak Creek Senior Living to assess compliance with admission policies and medication administration regulations.
Findings
The facility failed to execute a written admission agreement with resident #124 or their legal representative at the time of admission, and failed to ensure all medications and treatments were administered according to a medical care provider's written orders and professional standards.
Severity Breakdown
SS=D: 2
Deficiencies (2)
DescriptionSeverity
Failed to execute a written admission agreement with resident #124 or their legal representative at the time of admission.SS=D
Failed to ensure all medications and treatments for resident #124 were administered in accordance with a medical care provider's written order, professional standards, and manufacturer's recommendations.SS=D
Report Facts
Census: 35 Medications administered: 14 Medications lacking signed physician orders: 11
Employees Mentioned
NameTitleContext
operator/licensed nurse #AInterviewed regarding unsigned admission agreement for resident #124
licensed nurse #BInterviewed regarding lack of signed admission physician orders for resident #124
Inspection Report Re-Inspection Deficiencies: 2 Apr 11, 2016
Visit Reason
This is a revisit inspection conducted to verify that previously reported deficiencies have been corrected and to document the date such corrective actions were accomplished.
Findings
The report confirms that the deficiencies identified in the prior survey have been corrected as of the revisit date, with specific corrections noted for regulations 26-41-204 (a) and 26-41-204 (d).
Deficiencies (2)
Description
Deficiency related to regulation 26-41-204 (a)
Deficiency related to regulation 26-41-204 (d)
Inspection Report Re-Inspection Census: 31 Deficiencies: 1 Apr 11, 2016
Visit Reason
The inspection was a licensure revisit conducted on 2016-04-07 and 2016-04-11 to assess compliance with medication administration regulations at Oak Creek Senior Care.
Findings
The facility failed to ensure that all medications and treatments were administered according to professional standards. Certified staff administered as-needed (PRN) narcotic medications to residents without seeking instructions from a licensed nurse, and nursing notes lacked documentation of pain assessment or nurse contact prior to medication administration.
Severity Breakdown
SS=F: 1
Deficiencies (1)
DescriptionSeverity
Certified staff administered PRN narcotic medications to residents without consulting a licensed nurse, contrary to facility policy and professional standards.SS=F
Report Facts
Census: 31 Sample residents reviewed: 6
Employees Mentioned
NameTitleContext
Licensed staff KLicensed nurseInterviewed and confirmed certified staff did not contact licensed nurse prior to PRN medication administration; also confirmed no charting in nurses notes when contacted.
Certified staff JAdministered PRN medications without nurse consultation.
Certified staff LAdministered PRN medications without nurse consultation.
Certified staff MAdministered PRN medications without nurse consultation.
Certified staff NAdministered PRN medications without nurse consultation.
AdministratorConfirmed facility lacks a system for recording nurse contact prior to PRN medication administration.
Inspection Report Renewal Census: 31 Deficiencies: 3 Mar 16, 2016
Visit Reason
The inspection was a licensure resurvey conducted over three days (3/14/16, 3/15/16, and 3/16/16) at Oak Creek Senior Care, a residential health care facility in Topeka, Kansas.
Findings
The facility failed to ensure that licensed nurses provided or coordinated necessary health care services in accordance with functional capacity screenings and negotiated service agreements. Deficiencies included lack of licensed nurse identification in service agreements, failure to address resident allergies in care plans, and improper administration of PRN medications by certified staff without licensed nurse instructions.
Severity Breakdown
E: 1 F: 2
Deficiencies (3)
DescriptionSeverity
Failure to ensure licensed nurse provides or coordinates necessary health care services according to functional capacity screening and negotiated service agreement for residents #314 and #315.E
Negotiated service agreements lacked description of health care services and name of licensed nurse responsible for implementation and supervision for residents #314, #315, and #316.F
Failure to ensure all medications and treatments were administered in accordance with professional standards; PRN medications administered by certified staff without licensed nurse instructions for residents #314 and #316.F
Report Facts
Census: 31 Residents sampled: 3 PRN medication administration dates: 6
Inspection Report Plan of Correction Deficiencies: 4 Mar 19, 2014
Visit Reason
This document is a Plan of Correction submitted in response to deficiencies cited in a prior inspection report for Oak Creek Senior Care dated 03/19/2014.
Findings
The Plan of Correction indicates that no corrective action was required for the listed deficiencies (S0000, S105-E, S3085-E, S3155-D) as noted in the linked deficiency report.
Deficiencies (4)
Description
S0000 - No POC required
S105-E - No POC required
S3085-E - No POC required
S3155-D - No POC required
Inspection Report Re-Inspection Census: 29 Deficiencies: 3 Mar 19, 2014
Visit Reason
The inspection was a resurvey conducted on 3-17-14 through 3-19-14 to assess compliance with previously cited deficiencies at Oak Creek Senior Care, a residential health care facility.
Findings
The facility was found deficient in multiple areas including failure to ensure residents' rights to self-administer medications, incomplete negotiated service agreements lacking identification of services and responsible parties, and failure to provide necessary health care services such as admission skin assessments and prevention plans for residents at high risk for skin impairment.
Severity Breakdown
SS=E: 2 SS=D: 1
Deficiencies (3)
DescriptionSeverity
Failure to ensure residents were afforded the right to exercise their rights, including choice in medication self-administration methods.SS=E
Negotiated service agreements lacked descriptions of services, identification of providers, and responsible parties for payment.SS=E
Failure to ensure licensed nurse provided or coordinated necessary health care services, including admission skin assessment and prevention plan for skin impairment.SS=D
Report Facts
Census: 29 Sampled residents: 3 Medication dosage: 325 Medication dosage: 2 Wound size: 10 Wound size: 2
Employees Mentioned
NameTitleContext
Administrative nurse BAdministrative NurseNamed in findings related to medication self-administration and wound care
Administrative staff AInterviewed regarding medication administration and negotiated service agreements
Staff nurse FStaff NurseReported open areas on resident's buttocks

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