Deficiencies (last 8 years)
Deficiencies (over 8 years)
3.6 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
40% better than Kansas average
Kansas average: 6 deficiencies/yearDeficiencies per year
8
6
4
2
0
Occupancy
Latest occupancy rate
71% occupied
Based on a August 2024 inspection.
Occupancy rate over time
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Sep 18, 2024
Visit Reason
An offsite revisit survey was conducted to verify correction of all previous deficiencies cited on 2024-08-28.
Findings
All deficiencies cited in the prior inspection have been corrected as of the compliance date of 2024-09-18, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Inspection Report
Complaint Investigation
Census: 29
Deficiencies: 3
Date: Aug 28, 2024
Visit Reason
The inspection was a resurvey with an attached complaint investigation (complaint 189301) at an assisted living facility.
Complaint Details
The visit was a resurvey with an attached complaint (189301).
Findings
The facility failed to ensure negotiated service agreements were fully developed based on residents' functional capacity screenings and service needs. Additionally, over-the-counter medications were not properly labeled with residents' full names, and chemicals were not stored in locked areas, compromising resident safety.
Deficiencies (3)
KAR 26-41-202(a)(1) The administrator failed to ensure negotiated service agreements for three residents fully described services based on their functional capacity screenings, including continence, medication management, treatments, and sensory impairments.
KAR 26-41-205(g)(3) The administrator failed to ensure licensed staff placed residents' full names on original packages of five over-the-counter medications in multiple medication storage areas.
KAR 28-39-254(a) The operator failed to ensure all chemicals were stored within locked areas, risking health and safety of residents and visitors.
Report Facts
Census: 29
OTC medications unlabeled: 5
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.
Findings
The plan of correction addresses the findings from the resurvey and complaint investigation conducted on the specified dates. The document serves as the facility's response to the identified deficiencies.
Inspection Report
Re-Inspection
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 cited in the prior inspection have been corrected as of 2023-04-01, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Mar 20, 2023
Visit Reason
This 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 a resurvey with a complaint (#176146).
Findings
The Plan of Correction addresses citations found during the resurvey related to the complaint investigation conducted on the specified dates.
Inspection Report
Complaint Investigation
Census: 32
Deficiencies: 5
Date: Mar 20, 2023
Visit Reason
The inspection was a resurvey with a complaint (#176146) conducted on 03/20/23 and 03/21/23 at Oak Creek Senior Living.
Complaint Details
The inspection was triggered by complaint #176146 and included a resurvey of the facility.
Findings
The facility failed to ensure annual review and revision of negotiated service agreements, proper coordination of health care services by licensed nurses, safe use 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)
KAR 26-41-202 (d) (1) The facility failed to ensure the review and revision of the Negotiated Service Agreement at least once every 365 days for one resident.
KAR 26-41-204 (a) The facility failed to ensure a licensed nurse provided and coordinated necessary health care services in accordance with the functional capacity screening and negotiated service agreement for one resident.
KAR 26-41-204 (i) The facility failed to ensure a licensed nurse provided or coordinated necessary health care services meeting acceptable standards of practice for the use of bed assistive devices for one resident.
KAR 26-41-205 (g) (3) The facility failed to ensure licensed nurses or pharmacists placed the full name of the resident on each package of over-the-counter medication for multiple residents.
K.A.R 26-41-207 (c) The facility failed to ensure compliance with tuberculosis testing guidelines by not completing TB testing within seven days of hire for one staff member.
Report Facts
Resident census: 32
Sample size: 3
Newly hired employees reviewed: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Medication Aide D | Certified Medication Aide | Interviewed regarding resident assistance and medication administration. |
| Operator/Licensed Nurse A | Operator/Licensed Nurse | Named in multiple findings including failure to ensure annual NSA review, coordination of health care services, medication labeling, and TB testing compliance. |
| Licensed Nurse B | Licensed Nurse | Interviewed confirming lack of annual NSA for resident. |
| Certified Medication Aide C | Certified Medication Aide | Staff member whose TB testing was not completed within seven days of hire. |
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 to evaluate compliance with prior deficiencies and complaints.
Complaint Details
The resurvey was conducted in response to complaints #140801, #141374, and #141461.
Findings
The facility failed to ensure proper health care services for a resident with a pressure ulcer, proper medication administration according to physician orders, proper medication storage including dating insulin pens, and complete documentation of incidents and symptoms for residents. Multiple deficiencies were identified related to nursing care, medication administration, and record keeping.
Deficiencies (4)
KAR 26-41-204(i): The licensed nurse failed to provide or coordinate necessary health care services for resident #102 who developed a pressure ulcer without a documented treatment plan or pressure relief interventions.
KAR 24-41-205(d)(1): The facility failed to ensure medications were administered according to physician orders and that medication aides had current certification; a medication aide administered insulin after certification expiration and insulin was held without physician orders.
KAR 26-41-205(h)(4): The facility failed to ensure insulin pens were dated when opened, risking administration beyond manufacturer recommended expiration for 4 residents.
KAR 26-421105(f)(11): The facility failed to document all incidents, symptoms, actions taken, and results for residents #101 and #102, including fall follow-up, chest X-ray results, weight changes, and skin condition assessments.
Report Facts
Census: 31
Residents with insulin pens not dated: 4
Residents reviewed: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Nurse B | Licensed Nurse | Named in findings related to pressure ulcer care, medication administration, and documentation deficiencies |
| Certified Medication Aide C | Certified Medication Aide | Administered medications after certification expiration |
| Certified Medication Aide E | Certified Medication Aide | Interviewed regarding pressure ulcer and insulin pen dating |
| Operator A | Facility operator involved in medication aide certification and documentation issues |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Oct 25, 2021
Visit Reason
This document is a plan of correction submitted in response to a resurvey conducted with complaints #140801, #141374, and #141461 at the facility on October 25, 26, and 27, 2021.
Findings
The plan of correction addresses the findings from the resurvey related to the three complaints. The detailed citation findings are referenced in the attached deficiency report 2567.
Inspection Report
Routine
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
Re-Inspection
Deficiencies: 0
Date: Jun 25, 2019
Visit Reason
This is a revisit report completed by a State surveyor to verify that previously reported deficiencies have been corrected and to document the date such corrective actions were accomplished.
Findings
All previously reported deficiencies identified by regulation or Life Safety Code provisions have been corrected as of the revisit date.
Inspection Report
Re-Inspection
Census: 28
Deficiencies: 1
Date: Jun 25, 2019
Visit Reason
This inspection 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, pharmacy, federal, and state requirements. Specifically, over-the-counter medications lacked the full name of the resident and were not accounted for regarding which resident they belonged to.
Deficiencies (1)
K.A.R 26-41-205(h) Medication Storage: The facility failed to ensure that licensed nurses or medication aides stored all medications and biologicals securely and properly. Over-the-counter medications lacked the full name of the resident and were not accounted for which resident the medication belonged to.
Report Facts
Resident census: 28
Residents receiving medication management: 20
Sample size: 3
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 the assisted living facility.
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 after significant changes in condition, incomplete negotiated service agreements, inadequate coordination of health care services by licensed nurses, failure to notify medical providers of medication regimen variances, and lack of timely criminal background checks for certified staff.
Deficiencies (5)
KAR 26-41-201(c)(2) Functional Capacity Screen Reassessment: The facility failed to ensure designated staff conducted a screening following a significant change in condition for resident #117.
KAR 26-41-202(a) Negotiated Service Agreement: The facility failed to ensure negotiated service agreements for residents #118 and #119 included service descriptions, provider identification, and payment responsibility.
KAR 26-41-204(a) Health Care Services: The facility failed to ensure a licensed nurse provided or coordinated necessary health care services in accordance with the functional capacity screening and negotiated service agreement for resident #117.
KAR 26-41-205(l)(2) Medication Regimen Review Variance Report: The facility failed to ensure licensed pharmacist or nurse notified medical providers of medication variances requiring immediate action for residents #117 and #118.
KAR 26-41-102(d) Staff Qualifications Employee Records: The facility failed to maintain supporting documentation for criminal background checks at the time of hire for certified staff #C, #D, #E, and #F.
Report Facts
Census: 32
Residents sampled: 3
Focus review residents: 1
Inspection Report
Re-Inspection
Census: 35
Deficiencies: 2
Date: Jan 9, 2018
Visit Reason
The inspection was a licensure re-survey conducted at the residential care facility to assess compliance with admission policies and medication administration standards.
Findings
The facility failed to execute a written admission agreement with a resident or their legal representative at the time of admission. Additionally, the facility did not ensure all medications were administered according to a medical care provider's written orders and professional standards.
Deficiencies (2)
26-39-102(a)(3) Admission Policy: The operator failed to execute a written admission agreement with resident #124 or the resident's legal representative specifying services, goods, and obligations at the time of admission.
26-41-205(d) Facility Administration of Medications: The operator failed to ensure all medications and treatments for resident #124 were administered in accordance with a medical care provider's written orders and professional standards.
Report Facts
Census: 35
Medications administered: 14
Sampled residents: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| licensed nurse #A | Confirmed resident agreement and admission paperwork had not been signed. | |
| licensed nurse #B | Confirmed resident record lacked signed admission physician orders. |
Inspection Report
Re-Inspection
Deficiencies: 2
Date: Apr 11, 2016
Visit Reason
This is a revisit inspection 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 previously cited deficiencies identified by regulation numbers 26-41-204 (a) and 26-41-204 (d) have been corrected as of the revisit date.
Deficiencies (2)
Regulation 26-41-204 (a) deficiency was corrected as of 04/11/2016.
Regulation 26-41-204 (d) deficiency was corrected as of 04/11/2016.
Inspection Report
Re-Inspection
Census: 31
Deficiencies: 1
Date: Apr 11, 2016
Visit Reason
This 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 documentation was incomplete regarding pain assessment and nurse contact.
Deficiencies (1)
KAR 26-42-205(d) Facility administration of medications was not in compliance as certified staff administered PRN narcotic medications to residents without contacting a licensed nurse or documenting pain assessment and nurse communication.
Report Facts
Resident census: 31
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 licensed nurses provided or coordinated necessary health care services in accordance with functional capacity screenings and negotiated service agreements. Deficiencies included incomplete negotiated service agreements lacking the name of the responsible licensed nurse and failure to administer medications according to professional standards, specifically PRN medications given by certified staff without licensed nurse instructions.
Deficiencies (3)
KAR 26-41-204(a) The operator failed to ensure a licensed nurse provided or coordinated necessary health care services for residents #314 and #315 as per functional capacity screening and negotiated service agreements.
KAR 26-41-204(d) The negotiated service agreements for residents #314, #315, and #316 lacked the name of the licensed nurse responsible for implementation and supervision of the health care services.
KAR 26-41-205(d) The facility failed to ensure medications, including PRN medications for residents #314 and #316, were administered according to professional standards, as certified staff administered PRN medications without licensed nurse instructions.
Report Facts
Census: 31
Sample size: 3
Inspection Report
Re-Inspection
Census: 29
Deficiencies: 3
Date: Mar 19, 2014
Visit Reason
The inspection was a resurvey conducted on 3-17-14, 3-18-14, and 3-19-14 to evaluate compliance with previously cited deficiencies at Oak Creek Senior Care.
Findings
The facility failed to ensure residents' rights to self-administer medications and make choices regarding medication administration. The negotiated service agreements lacked required details including service descriptions and responsible parties. The licensed nurse failed to provide or coordinate necessary health care services, including admission skin assessments, resulting in skin impairments for a resident.
Deficiencies (3)
KAR 26-39-103(b)(1) The operator failed to ensure residents were afforded the right to exercise their rights, including choice in insulin self-administration methods.
KAR 26-41-202(a) The negotiated service agreements lacked descriptions of services, identification of providers, and responsible parties for payment.
KAR 26-41-204(a) The licensed nurse failed to provide or coordinate necessary health care services, including admission skin assessment and prevention planning, resulting in skin impairment on buttocks and coccyx.
Report Facts
Census: 29
Sample size: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nurse B | Administrative Nurse | Named in findings related to medication administration and skin care deficiencies. |
| Administrative Staff A | Interviewed regarding residents' rights and negotiated service agreements. | |
| Staff Nurse F | Staff Nurse | Reported open areas on resident's buttocks. |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Mar 19, 2014
Visit Reason
This document is a Plan of Correction submitted by Oak Creek Senior Care in response to deficiencies cited in a prior inspection report.
Findings
The Plan of Correction indicates that no corrective action was required for the listed deficiencies with tags S0000, S105-E, S3085-E, and S3155-D as of the completion date 03/19/2014.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: N089002 POC PBJH11
Visit Reason
This document is a Plan of Correction related to a prior inspection or regulatory finding for the facility identified by State ID N089002 and Event ID PBJH11.
Findings
No deficiency details or findings are included in this Plan of Correction document. It serves as a corrective action response without specific findings listed.
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