Inspection Report Summary
The most recent inspection on December 24, 2024, found that all previously cited deficiencies had been corrected. Earlier inspections showed a pattern of deficiencies related primarily to resident supervision and safety, negotiated service agreements, and tuberculosis screening compliance. Complaint investigations substantiated issues such as elopement risks, delayed responses to resident needs, and incomplete service agreements, but enforcement actions like fines or license suspensions were not listed in the available reports. Most complaints were substantiated, especially those involving resident care and safety, with some findings involving immediate jeopardy related to elopement risks. The facility appears to have addressed recent deficiencies effectively, as indicated by the correction of all cited issues in the latest revisit.
Deficiencies (last 10 years)
Deficiencies (over 10 years)
5.4 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
10% better than Kansas average
Kansas average: 6 deficiencies/yearDeficiencies per year
8
6
4
2
0
Census
Latest occupancy rate
70 residents
Based on a December 2024 inspection.
This facility has shown a decline in demand based on occupancy rates.
Census over time
Inspection Report
Re-Inspection
Deficiencies: 5
Date: Dec 24, 2024
Visit Reason
This revisit inspection was conducted to verify that previously reported deficiencies at Regent Park Assisted Living and Memory Care have been corrected.
Findings
All previously cited deficiencies were found to be corrected as of the revisit date, with corrective actions completed and documented.
Deficiencies (5)
Deficiency related to regulation 26-41-101 (f) (1)
Deficiency related to regulation 26-41-202 (a)
Deficiency related to regulation 26-41-204 (a)
Deficiency related to regulation 26-41-207 (b) (5-6) (c)
Deficiency related to regulation 28-39-254
Inspection Report
Complaint Investigation
Census: 70
Deficiencies: 5
Date: Dec 10, 2024
Visit Reason
The inspection was a resurvey with multiple complaints (#185341, 185782, 185994, 187086, 187941, and 189211) at an assisted living facility, focusing on allegations including neglect and compliance with care and safety regulations.
Complaint Details
The visit was triggered by multiple complaints alleging neglect and safety issues including elopement, inadequate care, and infection control.
Findings
The facility failed to protect a cognitively impaired resident (R104) from elopement due to unsecured exit doors and inadequate staff interventions, failed to identify hospice providers in service agreements, did not respond timely to resident call lights resulting in falls, lacked tuberculosis screening documentation for residents, and had exit door alarms that were inaudible to staff in the memory care unit, putting residents at risk.
Deficiencies (5)
Failure to protect resident R104 from neglect by not securing exit doors and inadequate staff interventions for wandering behavior resulting in elopement and immediate jeopardy.
Negotiated Service Agreement for resident R107 did not identify the hospice service provider.
Failure to provide health care services in accordance with functional capacity screening and negotiated service agreement, resulting in resident R102 falling after staff failed to respond to call light and resident R103 found on floor after prolonged time.
Failure to comply with tuberculosis screening guidelines for residents R107 and R105, lacking TB symptom screening upon admission.
Exit door alarms in the memory care unit were inaudible to staff while providing care, putting residents at risk for elopement.
Report Facts
Census: 70
Residents in memory care unit: 13
Staff education attendance: 24
Staff education completion: 22
Staff reading broadcast message: 52
Staff total: 71
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CMA C | Certified Medication Aide | Last staff to see resident R104 before elopement; left keys in door lock |
| Licensed Nurse D | Licensed Nurse | Notified of resident R104 missing and assisted in search |
| Administrative Nurse B | Administrative Nurse | Involved in investigation and provided statements about door alarms and staff training |
| Administrative Staff A | Administrative Staff | Assisted in search for resident R104 |
| CNA E | Certified Nurse Aide | Found resident R104 outside facility and assisted return |
| CNA F | Certified Nurse Aide | Found resident R104 outside facility and assisted return |
| CNA G | Certified Nurse Aide | Provided shift report and assisted resident R104 to bed |
| Licensed Nurse J | Licensed Nurse | Provided information on call light response and resident care |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Dec 4, 2024
Visit Reason
The document is a plan of correction responding to findings from a resurvey conducted with complaints #185341, 185782, 185994, 187086, 187941, and 189211 at the assisted living facility on 12/04/24, 12/09/24, and 12/10/24.
Complaint Details
The resurvey was conducted in response to complaints #185341, 185782, 185994, 187086, 187941, and 189211.
Findings
The plan of correction addresses citations resulting from a resurvey triggered by multiple complaints at the assisted living facility conducted over three days in December 2024.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Jul 30, 2023
Visit Reason
An offsite revisit survey was conducted to verify correction of all previous deficiencies cited on 07/10/23.
Findings
All deficiencies have been corrected as of the compliance date of 07/24/23, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Inspection Report
Re-Inspection
Census: 74
Deficiencies: 3
Date: Jul 10, 2023
Visit Reason
The inspection was a resurvey with complaints #180883 and #181085 at Regent Park Assisted Living and Memory Care conducted on 06/29/23, 07/05/23, 07/06/23, and 07/10/23.
Complaint Details
The inspection was triggered by complaints #180883 and #181085.
Findings
The facility failed to fully develop negotiated service agreements (NSA) for several residents, including missing service details and signatures. Additionally, the facility did not comply with tuberculosis screening guidelines for new employees, with delays in TB symptom screening and testing.
Deficiencies (3)
Failed to ensure the Negotiated Service Agreement (NSA) was fully developed based on the Functional Capacity Screen (FCS) triggers for residents R102, R104, R105, and R106, including missing identification of home health agency services and assistance details.
Failed to ensure the NSA for residents R101, R102, R103, and R106 were signed by all individuals involved in the development of the NSA, including durable power of attorney (DPOA).
Failed to comply with tuberculosis guidelines by not ensuring timely TB symptom screening questionnaires and two-step TB skin tests for newly hired employees.
Report Facts
Residents in census: 74
Residents in sample: 6
New employee records reviewed: 5
Days late for TB Symptom Screening Questionnaire: 73
Days late for TB Symptom Screening Questionnaire: 38
Days late for first step of two-step TB skin test: 3
Days late for first step of two-step TB skin test: 30
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nurse B | Acknowledged deficiencies in NSA development and signature collection | |
| Administrative Staff B | Acknowledged NSA deficiencies for resident R106 |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Jun 29, 2023
Visit Reason
The document is a plan of correction related to a resurvey conducted with complaints #180883 and #181085 at an assisted living facility on 06/29/23, 07/05/23, 07/06/23, and 07/10/23.
Complaint Details
The resurvey was conducted following complaints #180883 and #181085.
Findings
The plan of correction addresses findings from the resurvey conducted in response to the complaints mentioned, but specific deficiencies or findings are not detailed in this document.
Inspection Report
Follow-Up
Deficiencies: 1
Date: Aug 22, 2022
Visit Reason
An offsite revisit survey was conducted on 08/22/2022 to verify correction of all previous deficiencies cited on 07/27/2022.
Findings
All previously cited deficiencies have been corrected as of the compliance date of 08/22/2022, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Deficiencies (1)
Infection Control Policies not met, including prohibiting employees with communicable diseases from contact with residents or their food/equipment, providing orientation and annual in-service education on infection control, and ensuring compliance with tuberculosis guidelines.
Inspection Report
Renewal
Census: 65
Deficiencies: 1
Date: Jul 27, 2022
Visit Reason
The inspection was a licensure resurvey with attached complaint investigations for multiple complaint numbers conducted over several days in July 2022.
Complaint Details
The inspection included attached complaint numbers 172725, 172425, 171292, 170431, 169499, 167462, 168337, 168479, 168374, and 167849.
Findings
The facility failed to comply with tuberculosis (TB) guidelines for adult care homes as four of five newly hired employees lacked documentation of the required two-step TB test within seven days of employment.
Deficiencies (1)
Failure to ensure compliance with tuberculosis guidelines for adult care homes; four of five newly hired employees lacked required two-step TB test documentation within seven days of employment.
Report Facts
Census: 65
Number of newly hired employees reviewed: 5
Number of residents sampled: 6
Number of closed record reviews: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LN A | Licensed Nurse | Named in deficiency for lack of required two-step TB test documentation |
| LN B | Licensed Nurse | Named in deficiency for lack of required two-step TB test documentation |
| CMA C | Certified Medication Aide | Named in deficiency for lack of required two-step TB test documentation |
| CNA D | Certified Nurse Aide | Named in deficiency for lack of required two-step TB test documentation |
| administrator E | Interviewed and confirmed lack of required TB test documentation for newly hired employees |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Jul 25, 2022
Visit Reason
The document is a Plan of Correction responding to findings from a licensure resurvey and attached complaint investigations conducted on 07/25/22, 07/26/22, 07/27/22, and 07/28/22 at the facility.
Complaint Details
The plan references complaint numbers 172725, 172425, 171292, 170431, 169499, 167462, 168337, 168479, 168374, and 167849 associated with the licensure resurvey.
Findings
The Plan of Correction addresses citations representing findings from the licensure resurvey and multiple complaint numbers associated with the facility during the specified dates.
Report Facts
Complaint numbers referenced: 10
Inspection Report
Follow-Up
Deficiencies: 6
Date: Mar 29, 2021
Visit Reason
This revisit report documents the correction of deficiencies previously reported during an earlier survey, verifying that corrective actions have been completed.
Findings
All previously cited deficiencies identified by regulation or LSC provision numbers have been corrected as of the revisit date.
Deficiencies (6)
Deficiency related to regulation 26-41-101 (f) (1)
Deficiency related to regulation 26-41-201 (d)
Deficiency related to regulation 26-41-202 (h)
Deficiency related to regulation 26-41-205 (b)
Deficiency related to regulation 26-41-205 (d) (4)
Deficiency related to regulation 28-39-254
Report Facts
Deficiencies corrected: 6
Inspection Report
Complaint Investigation
Census: 77
Deficiencies: 6
Date: Sep 16, 2020
Visit Reason
The inspection was conducted as a resurvey and complaint investigation for complaints #155400 and #152607 at Regent Park Assisted Living and Memory Care.
Complaint Details
The visit was complaint-related, investigating complaints #155400 and #152607 regarding resident supervision and care.
Findings
The facility failed to provide adequate supervision for a resident who eloped, failed to accurately reflect residents' functional capacities and medication management in service agreements, failed to ensure signatures on negotiated service agreements, failed to properly delegate medication administration tasks to certified medication aides, and failed to secure hazardous chemicals, posing safety risks.
Deficiencies (6)
Failure to ensure staff provided adequate supervision allowing a resident to be absent from the facility without staff knowledge.
Failure to ensure functional capacity screening accurately reflected residents' wandering behavior, socially inappropriate behavior, and toileting needs.
Failure to ensure each individual involved in the development of the negotiated service agreement signed the agreement.
Failure to ensure the negotiated service agreement identified who was responsible for administration and management of selected medications.
Failure to ensure a licensed nurse oriented and instructed certified medication aides in blood sugar testing and insulin pen preparation, and to document competency.
Failure to ensure the facility was equipped and maintained to protect health and safety regarding unlocked hazardous chemicals accessible to residents.
Report Facts
Census: 77
Sample size: 6
Residents with wandering behavior: 6
Residents on memory care unit: 18
Residents on assisted living unit: 59
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed nurse L | Licensed Nurse | Named in findings related to functional capacity screening inaccuracies, medication administration delegation, and service agreement issues |
| Administrator/operator O | Administrator/Operator | Named in findings related to supervision failure, facility safety, and service agreement issues |
| Certified Medication Aide C | Certified Medication Aide | Named in findings related to supervision failure and medication administration delegation |
| Certified Medication Aide H | Certified Medication Aide | Named in findings related to supervision failure |
| Licensed nurse Q | Licensed Nurse | Interviewed regarding functional capacity screening and medication administration |
| Certified Medication Aide A | Certified Medication Aide | Named in medication administration delegation findings |
| Certified Medication Aide B | Certified Medication Aide | Named in medication administration delegation findings |
| Certified Medication Aide D | Certified Medication Aide | Named in medication administration delegation findings |
| Certified Medication Aide E | Certified Medication Aide | Named in medication administration delegation findings |
| Certified Medication Aide F | Certified Medication Aide | Named in medication administration delegation findings |
| Certified Medication Aide N | Certified Medication Aide | Interviewed regarding facility safety and unlocked chemicals |
| Maintenance employee G | Maintenance Employee | Interviewed regarding gate lock maintenance |
| Life enrichment employee F | Life Enrichment Staff | Interviewed regarding supervision during elopement incident |
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Jul 14, 2020
Visit Reason
The special infection control survey for COVID-19 was conducted at the facility on 7-14-2020.
Findings
The survey resulted in findings of no deficiency citations.
Inspection Report
Re-Inspection
Deficiencies: 6
Date: Jul 10, 2018
Visit Reason
This is a revisit inspection conducted to verify that previously reported deficiencies have been corrected and to document the dates such corrective actions were accomplished.
Findings
All previously cited deficiencies listed with their regulation numbers were corrected as of the revisit date, with completion dates documented for each.
Deficiencies (6)
Deficiency related to regulation 26-41-201 (c)
Deficiency related to regulation 26-41-202 (d)
Deficiency related to regulation 26-41-202 (h)
Deficiency related to regulation 26-41-205 (g) (3)
Deficiency related to regulation 26-41-102 (d)
Deficiency related to regulation 26-41-104 (d)
Inspection Report
Complaint Investigation
Census: 75
Deficiencies: 6
Date: Jun 7, 2018
Visit Reason
The inspection was conducted as a resurvey and complaint investigation for the facility based on complaints #116777 and #128806 on 6/5/18, 6/6/18, and 6/7/18.
Complaint Details
The inspection was triggered by complaints #116777 and #128806. The findings included substantiated deficiencies related to resident care, medication management, staff qualifications, and emergency preparedness.
Findings
The facility was found deficient in multiple areas including failure to conduct annual Functional Capacity Screenings for residents, failure to review and revise Negotiated Service Agreements annually, failure to ensure all parties signed the agreements timely, improper labeling of over-the-counter medications without full resident names, lack of verification of licenses and registry checks for staff, and failure to provide quarterly emergency preparedness training to employees and residents.
Deficiencies (6)
Failure to conduct a Functional Capacity Screening at least annually for 1 of 4 residents sampled (#402).
Failure to review/revise the Negotiated Service Agreement at least annually for 1 of 4 residents sampled (#402).
Failure to ensure the Negotiated Service Agreements and revisions were signed by all parties who participated on the day of the agreement or change for 4 of 4 residents (#401, #402, #403, #404).
Failure to ensure a licensed nurse or pharmacist placed the full name of the resident on each over-the-counter medication package or container in 3 of 3 medication carts and the central medication room.
Failure to have evidence of verifying the license for administrator G and registry verification for 3 of 3 nurse aides/CMAs hired since last resurvey.
Failure to provide quarterly review of the facility's emergency management plan with employees and residents.
Report Facts
Census: 75
Residents sampled: 4
Residents receiving medication management: 59
Nurse aides/CMAs lacking registry verification: 3
Resident council meeting attendance: 9
Resident council meeting attendance: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator G | Administrator | Failed to ensure verification of license and timely signing of Negotiated Service Agreements. |
| Nurse aide/CMA A | Certified Medication Aide | Lacked documented nurse aide registry verification and involved in medication labeling deficiencies. |
| Nurse aide/CMA H | Certified Medication Aide | Lacked documented nurse aide registry verification. |
| Nurse aide J | Nurse Aide | Lacked documented nurse aide registry verification. |
| Licensed nurse E | Licensed Nurse | Interviewed regarding Functional Capacity Screenings and Negotiated Service Agreements. |
| Maintenance staff F | Maintenance Staff | Reported last emergency preparedness training conducted on 11/10/17. |
Inspection Report
Re-Inspection
Deficiencies: 2
Date: Jul 27, 2016
Visit Reason
This revisit inspection was conducted to verify that previously reported deficiencies at Regent Park Assisted Living and Memory Care were corrected and to document the dates such corrective actions were accomplished.
Findings
The report confirms that the deficiencies previously cited under regulation numbers 26-41-101 (f) (1) and 26-41-204 (a) were corrected as of 07/26/2016. No other deficiencies or uncorrected issues are noted.
Deficiencies (2)
Deficiency under regulation 26-41-101 (f) (1) corrected
Deficiency under regulation 26-41-204 (a) corrected
Inspection Report
Complaint Investigation
Census: 82
Deficiencies: 1
Date: Jul 27, 2016
Visit Reason
The inspection was a revisit for a notice of assessment related to allegations of resident abuse at the assisted living facility.
Complaint Details
The complaint involved allegations of abuse for residents #1000 and #1200. The administrator did not report the allegations to the department within 24 hours and did not conduct thorough investigations or take preventive measures during the investigations.
Findings
The administrator failed to report allegations of resident abuse involving two residents to the department within 24 hours and failed to thoroughly investigate and take measures to prevent further potential abuse while the investigation was in progress.
Deficiencies (1)
Failure to report an allegation of resident abuse to the department within 24 hours and failure to thoroughly investigate and take measures to prevent further potential abuse during the investigation.
Report Facts
Census: 82
Sample size: 6
Skin tear size: 0.5
Skin tear size: 1.1
Skin tear size: 1.5
Skin tear size: 3
Skin tear size: 2.75
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Nurse B | Documented resident notes and reported allegations of abuse and skin tears. | |
| Licensed Nurse A | Stated the incident was investigated but not reported to the department and did not investigate the cause of bruises or skin tears. | |
| Administrator C | Stated a written investigation was not conducted because the resident changed their story and failed to report allegations to the department. |
Inspection Report
Complaint Investigation
Census: 78
Deficiencies: 2
Date: Jun 8, 2016
Visit Reason
The inspection was an abbreviated survey conducted for the investigation of complaints #93723, #95054, and #95841 at Regent Park Assisted Living and Memory Care on multiple dates from 2016-05-31 to 2016-06-08.
Complaint Details
The investigation was triggered by complaints #93723, #95054, and #95841. The complaint was substantiated as evidenced by findings of neglect and failure to provide coordinated health care services for residents.
Findings
The facility failed to ensure that cognitively impaired resident #851 was properly monitored, resulting in elopements and immediate jeopardy due to neglect when a companion was not assigned. Additionally, the facility failed to ensure licensed nurse coordination of necessary health care services for residents #851 and #854, with inadequate documentation and supervision of companion care services.
Deficiencies (2)
Failure to ensure no resident was subjected to neglect when a companion was not assigned to monitor cognitively impaired resident #851 with a known risk for elopement.
Failure to ensure that a licensed nurse provided or coordinated the provision of necessary health care services that met the needs of residents #851 and #854 and were in accordance with the functional capacity screening and negotiated service agreement.
Report Facts
Census: 78
Residents sampled: 6
Elopement risk scores: 5
Elopement risk scores: 13
Elopement risk scores: 16
Distance resident found from facility: 0.7
Temperature range: 80
Temperature range: 83
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Health care coordinator H | Documented care plans, schedules, and interviews related to resident #851's care and elopement incidents | |
| Licensed nurse A | Documented resident #851's elopement and care, interviewed regarding incidents | |
| Certified nursing assistant B | CNA | Worked floor instead of providing companion care on 5/28/16 for resident #851 |
| Certified nursing assistant C | CNA | Provided companion care to resident #851 on 5/27/16 |
| Certified medication aide D | CMA | Last staff member to see resident #851 before elopement on 5/28/16 |
| Certified medication aide G | CMA | Reported companion care for resident #854 did not start until 4:00 p.m. on 6/1/16 |
| Certified nursing assistant J | CNA | Provided companion care to resident #854 but was not instructed on care and services |
| Employee E | Event center employee who found resident #851 after elopement | |
| Receptionist I | Transported resident #851 back to facility after elopement |
Inspection Report
Follow-Up
Deficiencies: 5
Date: Dec 7, 2015
Visit Reason
This visit was conducted as a follow-up to verify correction of previously reported deficiencies at Regent Park Assisted Living and Memory Care.
Findings
All previously reported deficiencies identified by regulation or Life Safety Code provisions were corrected as of the revisit date.
Deficiencies (5)
Deficiency identified under regulation 26-41-101 (f) (3)
Deficiency identified under regulation 26-41-202 (i)
Deficiency identified under regulation 26-41-202 (j)
Deficiency identified under regulation 26-41-204 (a)
Deficiency identified under regulation 26-41-207 (a) (b)
Report Facts
Deficiencies corrected: 5
Inspection Report
Complaint Investigation
Census: 75
Deficiencies: 5
Date: Oct 28, 2015
Visit Reason
Resurvey with complaints #86860 and #91681 conducted over multiple days in October 2015 to investigate allegations of abuse/neglect and compliance with negotiated service agreements and health care services.
Complaint Details
Complaint investigation involved allegations of abuse/neglect related to falls and injuries of residents #600 and #200. The investigation found failures in timely reporting, investigation, and corrective actions. Resident #200 lacked required 24-hour companion care and monitoring of outside services was inadequate.
Findings
The facility failed to report allegations of abuse/neglect timely, conduct thorough investigations, and implement corrective actions. Resident #600 experienced multiple falls resulting in injuries including fractures and lacerations, with inadequate health care coordination and fall risk interventions. Resident #200 did not receive 24-hour companion care as required by the negotiated service agreement, and outside services were not properly monitored. The facility also failed to maintain a safe and sanitary environment in the kitchen and food service areas.
Deficiencies (5)
Failure to report allegations of abuse/neglect within 24 hours, conduct investigations, and take corrective action for residents #600 and #200.
Failure to ensure residents receive services according to negotiated service agreements, including lack of 24-hour companion care for resident #200.
Failure to monitor outside resources and advocate for resident #200 when services did not meet professional standards.
Failure to ensure licensed nurse provides or coordinates necessary health care services for resident #600, resulting in multiple falls and injuries.
Failure to maintain a safe, sanitary environment and sanitary food service conditions, including unsanitary kitchen conditions and improper food storage.
Report Facts
Resident census: 75
Falls: 9
Temperature: 144
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed staff L | Notified family and physician of resident #600 fall on 6-2-15; involved in care and reporting | |
| Licensed staff P | Notified family and medical care provider of resident #600 fall on 6-7-15 | |
| Licensed staff N | Notified family and medical care provider of multiple falls and injuries of resident #600; administered pain medication; communicated x-ray orders | |
| Licensed staff M | Spoke with family about 24-hour caretaker for resident #600 post fall | |
| Licensed staff A | Provided information on interventions for resident #600 and companion care for resident #200; interviewed regarding documentation and care | |
| Certified staff J | Reported resident #600 had several falls with injuries | |
| Certified staff G | Reported ambulating resident #600 with walker; unaware of companion sitter | |
| Licensed staff C | Reported resident #200 condition and care | |
| Home health aide I | Provided private duty sitter services for resident #200 | |
| Dietary manager | Observed unsanitary kitchen conditions and food storage |
Inspection Report
Renewal
Deficiencies: 0
Date: Jun 23, 2014
Visit Reason
The licensure resurvey of the assisted living facility was conducted on 6/19/14 and 6/23/14 as part of the renewal process.
Findings
The inspection resulted in no deficiency citations being found at the facility.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Oct 16, 2012
Visit Reason
This document is a Plan of Correction related to a prior inspection event identified by ASPEN Event ID MIDT12 and State ID N087069.
Findings
No specific deficiencies or findings are detailed in this Plan of Correction document; it serves as a record for corrective actions related to the referenced inspection.
Report Facts
Plan of Correction start date: Oct 16, 2012
Plan of Correction exit date: Oct 17, 2012
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