Inspection Reports for Sunrise of Leawood
11661 Granada Ln, Leawood, KS 66211, United States, KS, 66211
Back to Facility ProfileInspection Report Summary
The most recent inspection on October 3, 2024, was a complaint investigation that resulted in no deficiencies. Prior inspections showed a pattern of deficiencies related mainly to resident assessments, negotiated service agreements, medication storage and labeling, food safety, and chemical storage, with some issues involving staffing and resident safety in the memory care unit. Earlier complaint investigations were generally unsubstantiated, and enforcement actions such as fines or license suspensions were not listed in the available reports. The facility corrected all previously cited deficiencies by the time of the latest revisit, indicating improvement in compliance. Recent inspections suggest the facility has addressed prior concerns, showing a positive trend toward meeting regulatory requirements.
Deficiencies (last 11 years)
Deficiencies (over 11 years)
4.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
25% better than Kansas average
Kansas average: 6 deficiencies/yearDeficiencies per year
8
6
4
2
0
Census
Latest occupancy rate
75 residents
Based on a September 2024 inspection.
This facility has shown a decline in demand based on occupancy rates.
Occupancy over time
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Oct 3, 2024
Visit Reason
The visit was conducted as a complaint investigation (#190659) at the assisted living facility.
Complaint Details
Complaint investigation #190659 was conducted and resulted in no citations.
Findings
The complaint investigation conducted on 10/03/24 resulted in no citations.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Oct 3, 2024
Visit Reason
The inspection was conducted as a complaint investigation #190659 at Sunrise Assisted Living of Leawood on 10/03/2024.
Complaint Details
Complaint investigation #190659 was conducted and found no citations.
Findings
The complaint investigation resulted in no citations.
Inspection Report
Re-Inspection
Deficiencies: 5
Date: Oct 3, 2024
Visit Reason
This revisit report documents the correction of deficiencies previously reported during an earlier survey of the facility.
Findings
All previously cited deficiencies have been corrected as of the revisit date, with each correction fully identified by regulation number and completion date.
Deficiencies (5)
Deficiency related to regulation 26-41-201 (a) (b)
Deficiency related to regulation 26-41-202 (a)
Deficiency related to regulation 26-41-202 (d)
Deficiency related to regulation 26-41-206 (e) (1)
Deficiency related to regulation 28-39-254
Inspection Report
Re-Inspection
Census: 75
Deficiencies: 4
Date: Sep 10, 2024
Visit Reason
Revisit for correction order 24-SCCC-184 conducted on 09/09/24 and 09/10/24 to verify compliance with previously cited deficiencies.
Findings
The facility failed to ensure licensed nurses completed required assessments for residents whose Functional Capacity Screens indicated health care services were needed. Negotiated Service Agreements (NSA) did not accurately describe services based on residents' needs and were not updated timely. Food storage practices were unsafe with unlabeled and improperly stored food items. Chemicals were stored in unlocked areas accessible to residents, posing safety risks.
Deficiencies (4)
Licensed nurse failed to document assessments for residents whose Functional Capacity Screens indicated health care services were required.
Negotiated Service Agreements failed to describe services based on residents' Functional Capacity Screens and were not updated at least every 365 days.
Facility staff failed to store food under safe and sanitary conditions; food items were unlabeled, lacked preparation dates, and some were stored unrefrigerated.
Chemicals were stored in unlocked areas accessible to residents in the memory care unit, posing health and safety risks.
Report Facts
Census: 75
Residents in sample: 7
Residents in memory care unit: 23
Days since last NSA for R7: 381
Days between NSA and FCS for R2: 1
Days between NSA and FCS for R7: 304
Days between NSA and FCS for R8: 287
Days between NSA and FCS for R9: 241
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nurse B | Confirmed CNA completed Functional Capacity Screens and NSA deficiencies. | |
| Certified Nurse Aide C | Stated she completed the residents' Functional Capacity Screens and confirmed unsafe food storage. | |
| Administrative Staff A | Confirmed chemicals were stored in unlocked areas accessible to residents. |
Inspection Report
Re-Inspection
Deficiencies: 5
Date: Sep 10, 2024
Visit Reason
This is a revisit report completed by a State surveyor to show those deficiencies previously reported that have been corrected and the date such corrective action was accomplished.
Findings
All previously reported deficiencies listed with their regulation numbers were corrected as of the revisit date 09/10/2024.
Deficiencies (5)
Deficiency related to regulation 26-41-101 (f) (1)
Deficiency related to regulation 26-41-205 (g) (3)
Deficiency related to regulation 26-41-205 (h)
Deficiency related to regulation 26-41-104 (a)
Deficiency related to regulation 26-41-206 (d)
Report Facts
Deficiencies corrected: 5
Inspection Report
Re-Inspection
Census: 75
Deficiencies: 8
Date: Aug 7, 2024
Visit Reason
The inspection was a resurvey with attached complaints at Sunrise Assisted Living of Leawood conducted from 08/05/24 to 08/07/24.
Complaint Details
The visit was a resurvey with attached complaints #189570, #187379, #187341, #187074.
Findings
The inspection found multiple deficiencies including failure to protect a cognitively impaired resident from elopement and neglect, inadequate negotiated service agreements for residents, improper labeling of over-the-counter medications, improper medication storage, insufficient staffing for emergency and daily needs, unsafe food preparation and storage practices, and unsecured chemical storage in the memory care unit.
Deficiencies (8)
Failure to protect cognitively impaired Resident 1 from neglect when he eloped from the secured memory care unit and was found 1.3 miles away after 43 minutes.
Negotiated Service Agreements for multiple residents failed to describe services based on functional capacity screening and failed to identify service providers.
Over-the-counter medications in medication carts were not labeled with residents' full names.
Medications, including insulin pens, were not stored according to manufacturer recommendations; some were expired.
Insufficient staffing to assist residents during emergencies and daily care, with documented delays in call light responses.
Food was not served at proper temperatures; food temperature logs were incomplete.
Food storage was unsafe with undated, unsealed, dented, and improperly stored food items.
Chemicals in the memory care kitchen were stored in an unlocked cabinet accessible to residents.
Report Facts
Census: 75
Residents at risk for wandering: 14
Call light activations: 270
Call lights answered over 30 minutes: 139
Call lights answered over one hour: 82
Residents requiring two-person assistance: 21
Evacuation drill staff: 6
Evacuation drill time: 29
OTC medications unlabeled: 35
Expired insulin pens: 3
Food temperature logs missing: 71
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nurse B | Administrative Nurse | Notified CMA to call law enforcement for missing resident; arranged hospital transfer; stated staffing and call light response goals. |
| Certified Medication Aide E | Certified Medication Aide | Last saw resident before elopement; reported door alarm and search efforts. |
| Certified Nurse Aide F | Certified Nurse Aide | Responded to door alarm and searched memory care unit. |
| Certified Medication Aide I | Certified Medication Aide | Confirmed unlabeled OTC medications in medication carts. |
| Licensed Nurse H | Licensed Nurse | Confirmed unlabeled OTC medications and expired insulin pens; reported insufficient time to complete tasks. |
| Dietary Staff L | Dietary Staff | Confirmed incomplete food temperature logs and unsafe food storage. |
| Certified Medication Aide N | Certified Medication Aide | Confirmed chemicals stored in unlocked cabinet accessible to residents. |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Aug 5, 2024
Visit Reason
This document represents the findings of a resurvey with attached complaints #189570, #187379, #187341, and #187074 at the assisted living facility conducted from 08/05/24 to 08/07/24.
Complaint Details
The resurvey included attached complaints #189570, #187379, #187341, and #187074.
Findings
The document is a Plan of Correction addressing deficiencies identified during the resurvey and complaint investigations conducted in early August 2024.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Mar 13, 2024
Visit Reason
The abbreviated survey was conducted on 03/13/24 for complaints #186421, #186281, #184116, and #182908 at the assisted living facility.
Findings
The abbreviated survey resulted in a finding of no deficiency citations.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Mar 13, 2024
Visit Reason
The abbreviated survey was conducted in response to complaints #186421, #186281, #184116, and #182908 at the assisted living facility.
Complaint Details
The survey was complaint-related for complaints #186421, #186281, #184116, and #182908 and found no deficiencies.
Findings
The survey resulted in a finding of no deficiency citations.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Sep 13, 2023
Visit Reason
The document is a plan of correction related to an abbreviated survey conducted for complaint #182775 at an assisted living facility on 09/13/23.
Complaint Details
The survey was complaint-related, specifically for complaint #182775, but no deficiencies were cited.
Findings
The abbreviated survey conducted on 09/13/23 resulted in no deficiency citations.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Sep 13, 2023
Visit Reason
The abbreviated survey was conducted in response to complaint #182775 at Sunrise Assisted Living of Leawood.
Complaint Details
Complaint #182775 was investigated and resulted in no deficiency citations.
Findings
The abbreviated survey conducted on 09/13/2023 resulted in no deficiency citations.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Sep 6, 2023
Visit Reason
An offsite revisit survey was conducted to verify correction of all previous deficiencies cited on 08/22/23.
Findings
All deficiencies have been corrected as of the compliance date of 08/31/23, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Report Facts
Previous deficiencies cited: Deficiencies cited on 08/22/23, all corrected by 08/31/23
Inspection Report
Re-Inspection
Census: 70
Deficiencies: 6
Date: Aug 22, 2023
Visit Reason
The inspection was a resurvey with an attached complaint (#180832) conducted to verify correction of previous deficiencies and compliance with licensing requirements.
Complaint Details
The visit was a resurvey with an attached complaint (#180832).
Findings
The facility failed to appoint a licensed administrator as required, failed to ensure signatures on negotiated service agreements for sampled residents, failed to label over-the-counter medications with residents' full names, failed to properly store medications according to manufacturer and regulatory requirements, failed to obtain required criminal background checks for the Executive Director, and failed to conduct required quarterly emergency management plan reviews and annual emergency drills including resident evacuation.
Deficiencies (6)
Failed to appoint an administrator or operator who held a Kansas license as an adult care home administrator or completed required training and testing.
Failed to ensure each individual involved in the development of the negotiated service agreement signed the agreement for sampled residents.
Failed to ensure licensed nurses or pharmacists placed the full name of the resident on each package of over-the-counter medication.
Failed to ensure medications and biologicals were securely and properly stored in accordance with manufacturer recommendations and regulations.
Failed to obtain evidence of supporting documentation for criminal background checks for Executive Director A as required.
Failed to ensure quarterly review of the emergency management plan with residents and staff and failed to conduct an annual emergency drill including evacuation of all residents to a secure location.
Report Facts
Census: 70
Sampled residents: 6
Non-sampled residents: 12
Days without licensed administrator: 77
Residents with impaired cognitive abilities: 48
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Executive Director A | Executive Director | Named in findings related to failure to appoint a licensed administrator and failure to obtain required criminal background checks. |
| Licensed Nurse B | Licensed Nurse | Interviewed regarding negotiated service agreements and confirmed lack of signatures. |
| Certified Medication Aide D | Certified Medication Aide | Interviewed and observed medication carts lacking resident full names on over-the-counter medications. |
| Certified Medication Aide E | Certified Medication Aide | Interviewed and observed medication carts lacking resident full names on over-the-counter medications. |
| Certified Medication Aide C | Certified Medication Aide | Interviewed and observed medication carts lacking resident full names on over-the-counter medications. |
| Maintenance Staff G | Maintenance Staff | Interviewed regarding emergency drill and confirmed no full evacuation drill was located. |
| Administrative Staff F | Administrative Staff | Interviewed regarding emergency management plan reviews and confirmed missing documentation. |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Aug 21, 2023
Visit Reason
The document is a plan of correction related to a resurvey with an attached complaint (#180832) conducted at the facility on 08/21/23 and 08/22/23.
Complaint Details
The visit was related to a complaint investigation (#180832) attached to the resurvey.
Findings
The citations represent findings from the resurvey and complaint investigation conducted on the specified dates.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Mar 2, 2021
Visit Reason
The licensure resurvey was conducted on 2/28/2021, 3/1/2021, and 3/2/2021 with complaint numbers 165854, 164359, and 164333 attached at the assisted living facility.
Findings
The inspection resulted in a finding of no deficiency citations.
Inspection Report
Renewal
Deficiencies: 0
Date: Mar 2, 2021
Visit Reason
The licensure resurvey was conducted on 2/28/2021, 3/1/2021, and 3/2/2021 with complaint numbers 165854, 164359, and 164333 attached, at the assisted living facility.
Findings
The licensure resurvey resulted in a finding of no deficiency citations.
Inspection Report
Routine
Deficiencies: 0
Date: Aug 4, 2020
Visit Reason
The special infection control survey for COVID-19 was conducted at the facility on 08/04/2020.
Findings
The survey resulted in findings of no deficiency citations.
Inspection Report
Re-Inspection
Census: 92
Deficiencies: 2
Date: Apr 23, 2019
Visit Reason
The inspection was a resurvey with complaint investigations 136887, 139972, and 139966 conducted over multiple days in April 2019 to assess compliance with regulatory requirements.
Complaint Details
The inspection included complaint investigations 136887, 139972, and 139966.
Findings
The facility failed to properly store tuberculosis skin testing solution according to manufacturer recommendations and failed to ensure food was prepared and served at proper temperatures, with multiple missing food temperature records documented.
Deficiencies (2)
Licensed nurses and medication aides failed to ensure tuberculosis skin testing solution was discarded after 30 days as recommended by the manufacturer.
The administrator failed to ensure food was prepared using safe methods that conserve nutritive value, flavor, and appearance and served at proper temperatures, with missing documentation of food temperatures on multiple dates.
Report Facts
Census: 92
Missing food temperature records: 24
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nurse C | Interviewed regarding tuberculosis skin testing solution storage | |
| Dietary Staff B | Interviewed regarding missing food temperature records |
Inspection Report
Re-Inspection
Deficiencies: 1
Date: Aug 6, 2018
Visit Reason
This report documents a revisit inspection to verify that previously reported deficiencies have been corrected and to confirm the date such corrective actions were accomplished.
Findings
The revisit report confirms that the previously cited deficiency under regulation 26-41-203(a) was corrected as of 08/06/2018. No other deficiencies or findings are noted.
Deficiencies (1)
Deficiency under regulation 26-41-203(a) previously cited
Inspection Report
Re-Inspection
Census: 92
Deficiencies: 4
Date: Jul 16, 2018
Visit Reason
The inspection was a licensure re-survey with attached complaints conducted at the assisted living facility on 7/10/18, 7/11/18, 7/12/18, and 7/16/18.
Complaint Details
The visit was complaint-related involving allegations of abuse (bruises on resident #710), neglect (failure to report and investigate), and theft (resident #713 reported theft of $400 and wallet). The facility failed to report these allegations to the department and conduct investigations within required timeframes.
Findings
The facility failed to report allegations of abuse, neglect, and exploitation within required timeframes, failed to ensure provision or coordination of services as per residents' negotiated service agreements including timely response to call lights, failed to store medications according to manufacturer recommendations, and failed to document all incidents and resident discharge information properly.
Deficiencies (4)
Failure to report allegations of abuse, neglect, and exploitation to the department within 24 hours and to conduct timely investigations and submit complaint investigation reports.
Failure to ensure provision or coordination of the range of services specified in each resident's negotiated service agreement including timely response to call lights.
Failure to store non-controlled medications according to each manufacturer's recommendations.
Failure to document all incidents, symptoms, and indications of illness or injury including date, time, action taken, and results.
Report Facts
Census: 92
Residents sampled: 6
Closed chart review residents: 3
Non-sampled residents observed: 15
Call light response times: 26
Call light response times: 15
Call light response times: 44
Medication bottles: 10
Medication fill dates: Apr 28, 2018
Medication fill dates: May 20, 2018
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Failed to ensure allegations of abuse, neglect, and exploitation were reported and investigated timely | |
| Licensed Nurse #E | Confirmed failure to report allegations and lack of investigation | |
| Certified Staff #E | Confirmed call light alert system details and resident assistance requirements | |
| Administrative Staff #C | Confirmed theft report and call alert system clearing time |
Inspection Report
Re-Inspection
Deficiencies: 1
Date: Mar 23, 2017
Visit Reason
This report documents a revisit conducted to verify that previously reported deficiencies have been corrected and to confirm the date such corrective actions were accomplished.
Findings
The revisit confirmed that the previously cited deficiency with ID Prefix S3420 and Regulation #28-39-256 was corrected as of 03/23/2017. No other deficiencies or uncorrected issues were noted.
Deficiencies (1)
Previously reported deficiency with ID Prefix S3420, Regulation #28-39-256
Inspection Report
Re-Inspection
Census: 93
Deficiencies: 1
Date: Feb 23, 2017
Visit Reason
The inspection was a licensure re-survey with attached complaints conducted at the assisted living facility in Leawood, Kansas over multiple days from 2/20/17 to 2/23/17.
Complaint Details
The visit was triggered by attached complaints as part of the licensure re-survey.
Findings
The facility failed to maintain safe hot water temperatures between 98 and 120 degrees Fahrenheit at sinks in resident use areas, with multiple sinks exceeding the maximum temperature. The mixing valve for the hot water heaters was not working properly and was scheduled for replacement.
Deficiencies (1)
Failed to ensure the facility water distribution system maintained a safe hot water temperature between 98 and 120 degrees Fahrenheit at the sinks in resident use areas.
Report Facts
Resident census: 93
Residents with impaired cognitive status: 44
Water temperature readings: 122.1
Water temperature readings: 124.3
Water temperature readings: 123
Water temperature readings: 129.2
Water temperature readings: 126.6
Water temperature readings: 126.8
Water temperature readings: 121.6
Water temperature log range: 115
Water temperature log range: 119
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Facility operator #A | Provided information during facility tour regarding water temperatures. | |
| Maintenance staff #C | Interviewed about water temperature testing procedures. | |
| Maintenance staff #B | Interviewed about malfunctioning mixing valve for hot water heaters. |
Inspection Report
Re-Inspection
Deficiencies: 1
Date: Jan 19, 2016
Visit Reason
This report documents a revisit inspection to verify that previously reported deficiencies have been corrected and to confirm the date such corrective actions were accomplished.
Findings
The revisit report indicates that the previously cited deficiency related to regulation 26-41-205 (d)(3) was corrected as of 01/19/2016. No other deficiencies or findings are noted.
Deficiencies (1)
Deficiency related to regulation 26-41-205 (d)(3)
Inspection Report
Re-Inspection
Census: 82
Deficiencies: 5
Date: Dec 22, 2015
Visit Reason
The inspection was a resurvey with complaint investigations 88832 and 94711 conducted at Sunrise Assisted Living of Leawood on 12-16-15, 12-17-15, 12-21-15, and 12-22-15.
Complaint Details
The inspection included complaint investigations 88832 and 94711.
Findings
The facility was found deficient in multiple areas including failure to notify physicians and family members of resident accidents, incomplete functional capacity screenings, lack of signatures on negotiated service agreements, failure to provide or coordinate necessary health care services addressing fall risks, and failure to document actual clock times for medication administration.
Deficiencies (5)
Failure to ensure designated facility staff consulted with the resident's physician and notified the resident's legal representative or designated family member upon occurrence of an accident involving the resident that resulted in injury or had potential for requiring physician intervention.
Failure to record individual's functional capacity findings on a screening form which included each element and definition specified by the department.
Failure to ensure that each individual involved in the development of the Negotiated Service Agreement signed the agreement.
Failure to ensure that a licensed nurse provided or coordinated the provision of necessary health care services to address the resident's risk for falls.
Failure to document the actual clock times medications were administered when the medication administration record identified only time intervals.
Report Facts
Resident census: 82
Falls: 6
Residents sampled: 6
Residents with medication management: 76
Employees mentioned
| Name | Title | Context |
|---|---|---|
| licensed nurse B | Interviewed multiple times confirming lack of documentation and signatures on NSA/HCSP and medication administration records. | |
| licensed staff B | Interviewed confirming lack of notification to physician and family, and lack of documentation of fall on 11-22-15. | |
| licensed staff C | Signed documentation entries lacking notification of physician and family. |
Inspection Report
Follow-Up
Deficiencies: 0
Date: May 12, 2014
Visit Reason
This revisit inspection was conducted to verify that previously reported deficiencies had been corrected and to document the dates such corrective actions were accomplished.
Findings
All previously cited deficiencies were corrected as of the revisit date, with corrections documented for multiple regulation numbers.
Report Facts
Correction completion dates: 6
Inspection Report
Re-Inspection
Census: 71
Deficiencies: 6
Date: Apr 23, 2014
Visit Reason
The inspection was a resurvey with complaint investigations conducted on multiple dates in April 2014 to assess compliance with regulatory requirements at Sunrise Assisted Living of Leawood.
Complaint Details
The inspection included complaint investigations numbered 73520, 72992, 72718, 72353, and 72013.
Findings
The facility was found deficient in multiple areas including failure to ensure negotiated service agreements adequately described services and providers, improper delegation of nursing duties related to blood glucose monitoring, improper medication storage, lack of quarterly emergency management plan reviews with staff and residents, and failure to ensure food was prepared and served at proper temperatures.
Deficiencies (6)
Failure to ensure the negotiated service agreement provided a description of services for diabetes management including identification of the provider.
Failure to ensure the negotiated service agreement provided a description of hospice services, identification of hospice and psychiatric service providers, and payment responsibilities.
Licensed nurse failed to appropriately delegate nursing procedures related to blood glucose monitoring to certified medication aides.
Licensed nurses and medication aides failed to ensure medications and biologicals were securely and properly stored according to manufacturer and pharmacy recommendations, specifically insulin pens and tuberculosis testing solution.
Failure to ensure disaster and emergency preparedness by not performing quarterly review of the facility's emergency management plan with employees and residents.
Failure to ensure food was prepared using safe methods that conserve nutritive value, flavor, and appearance and served at proper temperature, with missing temperature documentation on multiple dates.
Report Facts
Census: 71
Sample size: 6
Dates missing food temperature documentation: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative nurse B | Confirmed deficiencies related to negotiated service agreements and delegation of nursing duties. | |
| Certified medication aide B | Interviewed regarding insulin administration and blood glucose monitoring. | |
| Certified medication aide D | Confirmed use of insulin pens for resident #134. | |
| Licensed staff C | Signed nursing progress note and interviewed regarding tuberculosis test solution. | |
| Administrator | Confirmed lack of quarterly emergency management plan reviews and food temperature documentation. | |
| Maintenance director | Confirmed lack of quarterly emergency management plan reviews. | |
| Administrative dietary staff | Confirmed missing food temperature documentation. |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Aug 19, 2013
Visit Reason
This document is a Plan of Correction related to a prior inspection event identified by ASPEN Event ID CT1L12 and State ID N046072.
Findings
No specific findings or deficiencies are detailed in this document; it serves as a record of the Plan of Correction submission and status.
Inspection Report
Plan of Correction
Deficiencies: 6
Date: N046072 POC 2MC411
Visit Reason
This document is a Plan of Correction submitted in response to deficiencies cited in a prior inspection report for Sunrise AL of Leawood.
Findings
The Plan of Correction indicates that no corrective actions were required for the listed deficiencies, all marked as 'No POC required' with completion dates of 04/23/2014.
Deficiencies (6)
S0000 - No POC required
S3085-E - No POC required
S3166-F - No POC required
S3215-D - No POC required
S3280-F - No POC required
S3298-E - No POC required
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