Inspection Reports for Shawnee Hills
6335 Maurer Rd, Shawnee, KS 66217, KS, 66217
Back to Facility ProfileDeficiencies per Year
12
9
6
3
0
Moderate
Inspection Report
Re-Inspection
Deficiencies: 0
Feb 20, 2025
Visit Reason
An offsite revisit survey was conducted on 02/20/25 for all previous deficiencies cited on 01/29/25.
Findings
All deficiencies have been corrected as of the compliance date of 02/20/25, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Inspection Report
Complaint Investigation
Census: 45
Deficiencies: 11
Jan 29, 2025
Visit Reason
Licensure survey with attached complaints #191121, 191400, and 193088 conducted on 01/28/25 and 01/29/25 to investigate allegations of abuse and compliance with regulatory requirements.
Findings
The facility was found deficient in multiple areas including failure to report abuse allegations timely, incomplete and inaccurate functional capacity screenings, incomplete negotiated service agreements, lack of medication self-administration assessments, improper labeling of medications, lack of policies for sample medications, failure to conduct quarterly emergency plan reviews with residents, and unsafe food handling and storage practices.
Complaint Details
The visit was triggered by complaints #191121, 191400, and 193088 related to abuse allegations and regulatory compliance issues.
Severity Breakdown
Level D: 3
Level E: 5
Level F: 3
Deficiencies (11)
| Description | Severity |
|---|---|
| Failure to report an allegation of abuse to the operator and to the department within 24 hours for Resident 6. | Level D |
| Failure to complete Functional Capacity Screen (FCS) after change in condition for Residents 2 and 3. | Level E |
| Failure to accurately document Functional Capacity Screen for Residents 2, 3, and 6. | Level E |
| Failure to fully develop Negotiated Service Agreements based on FCS, service needs, and preferences for Residents 1, 3, 4, and 6. | Level E |
| Failure to perform medication self-administration assessments for Residents 1 and 5. | Level E |
| Failure to label nine over-the-counter medications with residents' full names. | Level E |
| Failure to ensure prescription medication container had a pharmacist affixed label for one medication. | Level D |
| Failure to develop policies and procedures for receiving and identifying sample medications including all required conditions. | Level D |
| Failure to document quarterly reviews of the facility's emergency management plan with residents. | Level F |
| Failure to ensure food was served at the proper temperature; food temperature logs were incomplete and many recorded temperatures were below safe levels. | Level F |
| Failure to store food under safe and sanitary conditions; temperature logs for food storage units were incomplete or missing. | Level F |
Report Facts
Census: 45
Lantus medication pens: 53
OTC medications unlabeled: 9
Food temperature logs missing: 19
Lunch meals below safe temperature: 9
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Staff A | Confirmed failure to report abuse, incomplete FCS and NSA documentation, lack of medication self-administration assessments, unlabeled medications, lack of emergency plan reviews, and food safety issues. | |
| Administrative Staff B | Confirmed facility policies and procedures related to functional capacity screens and sample medications. | |
| Certified Medication Aide C | Alleged to have abused Resident 6. | |
| Certified Medication Aide G | Confirmed staff manage Resident 2's medications and Resident 5 self-administers medications. | |
| Certified Medication Aide E | Observed unlocking medication cart containing sample medications. | |
| Dietary Staff F | Confirmed incomplete food temperature logs and food storage temperature logs. | |
| Administrative Nurse A | Confirmed incomplete functional capacity screens and medication self-administration assessments. |
Inspection Report
Plan of Correction
Deficiencies: 0
Jan 28, 2025
Visit Reason
The document represents findings of a licensure survey with attached complaints #191121, 191400, and 193088 for the assisted living facility conducted on January 28 and 29, 2025.
Findings
The document is a Plan of Correction submitted in response to the licensure survey and attached complaints conducted on the specified dates.
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