Inspection Report Summary
The most recent inspection on September 18, 2024, found no deficiencies and confirmed that all previous issues were corrected. Earlier inspections showed recurring deficiencies related primarily to incomplete negotiated service agreements, improper labeling and storage of over-the-counter medications, and lapses in licensed nurse coordination of health care services. Complaint investigations were attached to some inspections, with deficiencies substantiated in areas such as medication management and service agreement compliance; most complaints were addressed through corrective actions. Enforcement actions such as fines or license suspensions were not listed in the available reports. The facility’s record shows improvement over time, with recent follow-up inspections confirming correction of prior deficiencies.
Deficiencies (last 8 years)
Deficiencies (over 8 years)
4.6 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
23% better than Kansas average
Kansas average: 6 deficiencies/yearDeficiencies per year
8
6
4
2
0
Census
Latest occupancy rate
29 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 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
Date: 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.
Complaint Details
The visit included a complaint investigation (complaint 189301) attached to the resurvey.
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.
Deficiencies (3)
Negotiated Service Agreements (NSA) were incomplete and did not fully describe services based on residents' Functional Capacity Screens for three residents.
Over-the-counter medications were not labeled with residents' full names in multiple locations including the shower room/beauty shop cabinet and medication carts.
Chemicals were stored in an unlocked cabinet accessible to residents and visitors, violating safety requirements.
Report Facts
Census: 29
OTC medications not labeled: 5
Chemicals observed: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Staff A | Confirmed deficiencies related to negotiated service agreements for residents R1, R2, and R3. | |
| Staff E | Confirmed unlabeled OTC medication and chemicals not stored in locked areas. | |
| Certified Medication Aide C | Certified Medication Aide | Confirmed OTC medication in north medication cart was not labeled. |
| Certified Medication Aide D | Certified Medication Aide | Confirmed three OTC medications in south medication cart were not labeled. |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: 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.
Complaint Details
The visit included an attached complaint investigation identified as complaint 189301.
Findings
The document is a plan of correction submitted in response to deficiencies identified during the resurvey and complaint investigation at the facility.
Inspection Report
Follow-Up
Deficiencies: 0
Date: 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
Date: 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.
Complaint Details
The visit was a resurvey with a complaint (#176146).
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.
Deficiencies (5)
Failure to ensure the review and revision of the Negotiated Service Agreement at least once every 365 days.
Failure to ensure a licensed nurse provided and coordinated necessary health care services in accordance with the functional capacity screening and negotiated service agreement.
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.
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.
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.
Report Facts
Residents present: 32
Sample size: 3
New employees reviewed: 5
Time delay for TB testing: 21
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Medication Aide D | Certified Medication Aide | Interviewed regarding resident R1's care and assistance |
| Licensed Nurse B | Licensed Nurse | Interviewed regarding negotiated service agreement and health service plan for resident R1 |
| Operator/Licensed Nurse A | Operator/Licensed Nurse | Named in multiple findings related to failure to ensure compliance with negotiated service agreements, health care services, medication labeling, and TB testing |
| Certified Medication Aide C | Certified Medication Aide | Staff member whose TB testing was not completed within seven days of hire |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: 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.
Complaint Details
The visit was complaint-related, referencing complaint #176146.
Findings
The citations represent findings from the resurvey and complaint investigation conducted on the specified dates.
Inspection Report
Re-Inspection
Census: 31
Deficiencies: 4
Date: 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.
Complaint Details
The resurvey was conducted with complaints #140801, #141374, and #141461.
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.
Deficiencies (4)
Failed to ensure licensed nurse provided or coordinated necessary health care services to meet the needs of a resident who developed a pressure ulcer.
Failed to ensure medications were administered according to physician orders and medication aides had current certification.
Failed to ensure medications were not administered beyond manufacturer or pharmacy recommended expiration dates due to undated insulin pens.
Failed to document all incidents, symptoms, and other indications of illness or injury including date, time, action taken, and results for sampled residents.
Report Facts
Census: 31
Residents with insulin pens not dated: 4
Residents sampled: 3
Medication aide certificate expiration date: Oct 18, 2021
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Nurse B | Licensed Nurse | Named in findings related to pressure ulcer care, medication administration, and documentation |
| Certified Medication Aide C | Certified Medication Aide | Administered medications with expired certification |
| Certified Medication Aide E | Certified Medication Aide | Interviewed regarding pressure ulcer and insulin pen dating |
| Certified Medication Aide D | Certified Medication Aide | Interviewed regarding insulin administration practices |
| Operator A | Facility Operator | Provided employee information and confirmed medication aide certification expiration |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: 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.
Complaint Details
The resurvey was conducted in response to complaints #140801, #141374, and #141461.
Findings
The plan of correction references findings from a resurvey with complaints but does not detail specific deficiencies or findings within this document.
Inspection Report
Routine
Deficiencies: 0
Date: 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
Date: 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)
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
Date: 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.
Deficiencies (1)
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.
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
Date: 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.
Complaint Details
The inspection included attached complaints as part of the re-licensure survey.
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.
Deficiencies (5)
Failure to conduct a functional capacity screening following any significant change in condition for resident #117.
Failure to ensure negotiated service agreements for residents #118 and #119 contained required information and collaboration.
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.
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.
Failure to maintain employee records with supporting documentation for criminal background checks at time of hire for certified staff #C, #D, #E, and #F.
Report Facts
Census: 32
Residents sampled: 3
Focus review residents: 1
Certified staff lacking timely criminal background checks: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative nurse #B | Interviewed and confirmed deficiencies related to resident care and documentation. | |
| Facility operator #A | Interviewed regarding submission and recordkeeping of criminal background checks. |
Inspection Report
Re-Inspection
Census: 35
Deficiencies: 2
Date: 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.
Deficiencies (2)
Failed to execute a written admission agreement with resident #124 or their legal representative at the time of admission.
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.
Report Facts
Census: 35
Medications administered: 14
Medications lacking signed physician orders: 11
Employees mentioned
| Name | Title | Context |
|---|---|---|
| operator/licensed nurse #A | Interviewed regarding unsigned admission agreement for resident #124 | |
| licensed nurse #B | Interviewed regarding lack of signed admission physician orders for resident #124 |
Inspection Report
Re-Inspection
Deficiencies: 2
Date: 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)
Deficiency related to regulation 26-41-204 (a)
Deficiency related to regulation 26-41-204 (d)
Inspection Report
Re-Inspection
Census: 31
Deficiencies: 1
Date: 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.
Deficiencies (1)
Certified staff administered PRN narcotic medications to residents without consulting a licensed nurse, contrary to facility policy and professional standards.
Report Facts
Census: 31
Sample residents reviewed: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed staff K | Licensed nurse | Interviewed 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 J | Administered PRN medications without nurse consultation. | |
| Certified staff L | Administered PRN medications without nurse consultation. | |
| Certified staff M | Administered PRN medications without nurse consultation. | |
| Certified staff N | Administered PRN medications without nurse consultation. | |
| Administrator | Confirmed facility lacks a system for recording nurse contact prior to PRN medication administration. |
Inspection Report
Renewal
Census: 31
Deficiencies: 3
Date: 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.
Deficiencies (3)
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.
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.
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.
Report Facts
Census: 31
Residents sampled: 3
PRN medication administration dates: 6
Inspection Report
Plan of Correction
Deficiencies: 4
Date: 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)
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
Date: 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.
Deficiencies (3)
Failure to ensure residents were afforded the right to exercise their rights, including choice in medication self-administration methods.
Negotiated service agreements lacked descriptions of services, identification of providers, and responsible parties for payment.
Failure to ensure licensed nurse provided or coordinated necessary health care services, including admission skin assessment and prevention plan for skin impairment.
Report Facts
Census: 29
Sampled residents: 3
Medication dosage: 325
Medication dosage: 2
Wound size: 10
Wound size: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative nurse B | Administrative Nurse | Named in findings related to medication self-administration and wound care |
| Administrative staff A | Interviewed regarding medication administration and negotiated service agreements | |
| Staff nurse F | Staff Nurse | Reported open areas on resident's buttocks |
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