Inspection Report Summary
The most recent inspection on July 10, 2024, found the facility in compliance with all regulations and no new deficiencies. Prior inspections showed some deficiencies related mainly to medication management, including improper insulin administration, and food safety practices such as thawing and storage issues. Earlier reports also noted concerns with negotiated service agreements, health care services coordination, and emergency preparedness, along with some substantiated complaints about failure to report and investigate abuse and neglect. Enforcement actions such as fines or license suspensions were not listed in the available reports. The facility appears to have addressed previous deficiencies effectively, demonstrating improvement over time.
Deficiencies (last 9 years)
Deficiencies (over 9 years)
5.2 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
13% better than Kansas average
Kansas average: 6 deficiencies/yearDeficiencies per year
12
9
6
3
0
Census
Latest occupancy rate
28 residents
Based on a June 2024 inspection.
Census over time
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Jul 10, 2024
Visit Reason
An offsite revisit survey was conducted to verify correction of all previous deficiencies cited on 2024-06-18.
Findings
All deficiencies have been corrected as of the compliance date of 2024-07-03, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Report Facts
Previous deficiencies cited: 1
Inspection Report
Re-Inspection
Census: 28
Deficiencies: 3
Date: Jun 18, 2024
Visit Reason
The inspection was a licensure resurvey with attached complaint investigations numbered 182484 and 181526 conducted on 06/18/2024.
Complaint Details
The inspection included attached complaint investigations numbered 182484 and 181526.
Findings
The facility failed to ensure proper medication storage and administration, specifically administering insulin beyond the manufacturer's recommended expiration date. Additionally, the facility did not follow safe food preparation and storage practices, including improper thawing methods and failure to date food items stored in refrigerators and freezers.
Deficiencies (3)
Failure to ensure licensed nurses or certified medication aides did not administer insulin medication beyond the manufacturer's or pharmacy's recommended expiration date for a resident.
Failure to ensure dietary staff prepared food using safe methods, including improper thawing of meat in running water without proper submersion or temperature control.
Failure to ensure all food was stored under safe and sanitary conditions, including lack of dates on refrigerated and frozen food items and opened containers.
Report Facts
Census: 28
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dietary Director B | Dietary Director | Interviewed regarding food thawing and storage practices. |
| Operator A | Interviewed regarding food thawing method and food storage practices. | |
| Licensed Nurse C | Licensed Nurse | Observed unlocking medication cart and confirmed insulin pen storage and dating procedures. |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Jun 18, 2024
Visit Reason
The document is a Plan of Correction addressing findings from a licensure resurvey conducted on 06/18/24, which included attached complaint numbers 182484 and 181526.
Complaint Details
The Plan of Correction references attached complaint numbers 182484 and 181526 related to the licensure resurvey.
Findings
The Plan of Correction corresponds to deficiencies identified during the licensure resurvey and complaint investigations conducted on 06/18/24.
Report Facts
Complaint numbers: 2
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Jun 29, 2023
Visit Reason
The abbreviated survey with review of facility report #181031 was conducted on 06/28/23 and 06/29/23 at the assisted living facility.
Findings
The survey resulted in a finding of no deficiency citations.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Jun 28, 2023
Visit Reason
The document is a plan of correction related to an abbreviated survey conducted on 06/28/23 and 06/29/23 at an assisted living facility.
Findings
The abbreviated survey resulted in a finding of no deficiency citations.
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Jan 25, 2023
Visit Reason
An offsite revisit survey was conducted to verify correction of all previous deficiencies cited on 2023-01-05.
Findings
All deficiencies have been corrected as of the compliance date of 2023-01-20, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Inspection Report
Re-Inspection
Census: 35
Deficiencies: 4
Date: Jan 5, 2023
Visit Reason
This inspection was a resurvey with attached complaints #170953, #170557, #165345, #161604, and #161601 conducted at an assisted living facility.
Complaint Details
The inspection was conducted as a resurvey with attached complaints #170953, #170557, #165345, #161604, and #161601.
Findings
The facility was found deficient in multiple areas including failure to complete assessments for residents self-administering medications, incomplete negotiated service agreements regarding medication management, improper labeling of over-the-counter medications, and non-compliance with tuberculosis screening and infection control policies.
Deficiencies (4)
Failed to ensure an assessment was completed to determine that Resident R105 could safely and accurately self-administer insulin.
Failed to ensure Residents R104 and R106's Negotiated Service Agreements identified who was responsible for administration and management of selected medications.
Failed to ensure a licensed pharmacist or nurse placed the full names of residents on the original package of eight over-the-counter medications.
Failed to ensure compliance with tuberculosis guidelines for adult care homes, including missing yearly symptom screening questionnaires for Resident R105 and incomplete TB testing documentation for three staff members.
Report Facts
Census: 35
Over-the-counter medications without resident names: 8
Days since last yearly symptom screening for Resident R105: 793
Staff sampled for TB compliance: 5
Residents sampled: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Nurse B | Administrative Nurse | Confirmed Resident R105 self-administered insulin and lack of assessment; confirmed OTC medication labeling issues; confirmed TB screening deficiencies. |
| Certified Medication Aide D | Certified Medication Aide | Employee record reviewed for TB compliance; lacked evidence of TB test results. |
| Certified Medication Aide E | Certified Medication Aide | Employee record reviewed for TB compliance; lacked evidence of symptom screening questionnaire and timely TB test. |
| Administrative Staff A | Administrative Staff | Confirmed TB test and symptom screening deficiencies in employee records. |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Jan 4, 2023
Visit Reason
This document is a Plan of Correction addressing findings from a resurvey with attached complaints #170953, #170557, #165345, #161604, and #161601 conducted at the assisted living facility on 01/04/23 and 01/05/23.
Complaint Details
The Plan of Correction is related to attached complaints #170953, #170557, #165345, #161604, and #161601.
Findings
The Plan of Correction references multiple deficiencies identified during the resurvey and complaint investigations conducted on the specified dates.
Inspection Report
Re-Inspection
Census: 29
Deficiencies: 3
Date: Apr 15, 2021
Visit Reason
The inspection was a resurvey with complaint investigations #147461 and #154875 conducted at an assisted living facility to assess compliance with negotiated service agreements, health care services, and emergency preparedness.
Complaint Details
The inspection was triggered by complaint investigations #147461 and #154875.
Findings
The executive director failed to ensure the development of negotiated service agreements for residents with specific needs, proper health care services related to pressure wound management, and disaster and emergency preparedness including quarterly review of the emergency management plan with staff. Deficiencies were found in communication assistance, assistive device assessments, wound care coordination, and emergency training specificity.
Deficiencies (3)
Failure to develop negotiated service agreements including communication aids for resident with aphasia and use of assistive devices for another resident.
Failure to provide or coordinate necessary health care services related to pressure wound management for a resident.
Failure to ensure disaster and emergency preparedness including quarterly review of the emergency management plan with employees.
Report Facts
Census: 29
Sample size: 3
Focused record reviews: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Nurse B | Licensed Nurse | Reported on wound care management and confirmed deficiencies related to wound assessment and communication aids. |
| Executive Director A | Executive Director | Failed to ensure negotiated service agreements, health care services, and emergency preparedness compliance. |
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Jul 1, 2020
Visit Reason
The special infection control survey for COVID-19 was conducted at the facility on 07-01-2020.
Findings
The survey resulted in findings of no deficiency citations.
Inspection Report
Re-Inspection
Census: 31
Deficiencies: 3
Date: Jan 9, 2019
Visit Reason
The inspection was a revisit for correction order 18-192 conducted on 1/8/19 and 1/9/19 to verify compliance with previously cited deficiencies.
Findings
The facility failed to ensure accurate functional capacity screening reflecting fall risks for resident #489, failed to develop adequate negotiated service agreements for residents #307 and #489, and failed to provide or coordinate necessary health care services for residents #307, #318, and #411 in accordance with functional capacity screening and negotiated service agreements. Deficiencies included lack of fall risk identification, incomplete service agreements, and inadequate health service plans addressing fall prevention, assistive devices, and dialysis care.
Deficiencies (3)
Failure to ensure accurate functional capacity screening reflecting resident #489's fall risk.
Failure to develop written negotiated service agreements based on functional capacity screening and service needs for residents #307 and #489.
Failure to ensure licensed nurse provided or coordinated necessary health care services meeting residents' needs in accordance with functional capacity screening and negotiated service agreements for residents #307, #318, and #411.
Report Facts
Census: 31
Fall risk score: 28
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed nurse B | Licensed Nurse | Interviewed and made nursing notes related to resident #489's fall and health status; confirmed deficiencies in functional capacity screening and health service plans. |
| Certified medication aide A | Certified Medication Aide | Interviewed regarding resident #307's care needs and fall risk. |
| Operator C | Interviewed and confirmed deficiencies in negotiated service agreements and health service plans. | |
| Licensed nurse D | Licensed Nurse | Provided nursing care and documented resident #411's condition after fall. |
| Licensed nurse E | Licensed Nurse | Applied ice pads and monitored resident #411 after fall. |
Inspection Report
Re-Inspection
Deficiencies: 10
Date: Jan 9, 2019
Visit Reason
This report is a revisit 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 by regulation numbers were corrected as of the revisit date, January 9, 2019.
Deficiencies (10)
Deficiency related to regulation 26-41-201 (c)
Deficiency related to regulation 26-41-202 (d)
Deficiency related to regulation 26-41-204 (i)
Deficiency related to regulation 26-41-205 (d) (4)
Deficiency related to regulation 26-41-205 (h)
Deficiency related to regulation 26-41-102 (d)
Deficiency related to regulation 26-41-105 (c)
Deficiency related to regulation 26-41-104 (d)
Deficiency related to regulation 26-41-207 (b) (5-6) (c)
Deficiency related to regulation 28-39-254
Inspection Report
Complaint Investigation
Census: 29
Deficiencies: 11
Date: Nov 21, 2018
Visit Reason
The inspection was a resurvey with complaints (#131932, #132140, #134968) at an assisted living facility to investigate compliance with state regulations.
Complaint Details
The inspection was conducted as a resurvey with complaints #131932, #132140, and #134968.
Findings
The facility failed to complete required functional capacity screenings and negotiated service agreements timely for several residents, improperly delegated medication administration tasks to uncertified staff, failed to store medications and chemicals securely, did not safeguard resident records adequately, and failed to comply with tuberculosis screening requirements and emergency preparedness reviews.
Deficiencies (11)
Failed to complete Functional Capacity Screen for resident #117 at least every 365 days.
Failed to develop negotiated service agreements based on functional capacity screens for 4 residents (#115, #116, #117, #118).
Failed to review and revise negotiated service agreement for resident #117 at least every 365 days.
Certified staff pierced resident #117's skin prior to resident self-injecting insulin, placing resident in immediate jeopardy.
Failed to delegate nursing procedures of blood sugar monitoring and insulin pen dialing to certified medication aides as required.
Failed to store Tubersol medication according to professional standards; vial was undated.
Failed to maintain employee records with evidence of licensure, registration, or certification for certified medication aide M.
Failed to safeguard resident records against unauthorized use; resident records were found unsecured in an unlocked maintenance room.
Failed to ensure quarterly review of the emergency management plan with employees and residents.
Failed to comply with tuberculosis screening guidelines for residents and new employees; several staff lacked required TB skin tests.
Failed to secure chemicals properly; hazardous chemicals were accessible to residents.
Report Facts
Residents sampled for review: 3
Residents with deficient negotiated service agreements: 4
Certified medication aides without delegation for blood sugar monitoring: 5
Certified medication aides without delegation for insulin pen dialing: 4
Residents' census: 29
Staff without required TB skin tests: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Certified Staff | Observed piercing resident #117's skin prior to insulin injection. |
| Staff L | Certified Staff | Reported proper insulin pen administration procedure. |
| Staff M | Certified Medication Aide | Administered medications without current certification. |
| Administrative Staff A | Administrator | Reported lack of delegation and unsecured resident records. |
| Administrative Licensed Nursing Staff E | Licensed Nurse | Reported audit findings and TB screening deficiencies. |
| Licensed Nursing Staff D | Licensed Nurse | Reported proper insulin pen administration procedure. |
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Jan 22, 2018
Visit Reason
This revisit report documents the correction of deficiencies previously reported during an earlier survey, verifying that corrective actions were completed as of the revisit date.
Findings
All previously cited deficiencies identified by regulation or LSC provision numbers were corrected and completed by the revisit date of 2018-01-22.
Report Facts
Deficiencies corrected: 7
Inspection Report
Re-Inspection
Census: 31
Deficiencies: 8
Date: Dec 14, 2017
Visit Reason
The inspection was a resurvey with multiple complaints (#117541, #120766, #121536, #121777, #122681, #123079, and #123821) conducted over several days in December 2017.
Complaint Details
The resurvey was conducted in response to multiple complaints (#117541, #120766, #121536, #121777, #122681, #123079, and #123821). The investigation found substantiated issues including failure to report and investigate abuse and exploitation allegations, including identity theft and misappropriation of resident funds.
Findings
The facility was found deficient in multiple areas including failure to notify residents of changes in charges or services, failure to report and investigate allegations of abuse, neglect, or exploitation timely, failure to monitor outside service providers, failure to provide health care services in accordance with plans, medication administration errors, failure to safeguard resident records, and inadequate staffing for emergency evacuations.
Deficiencies (8)
Failed to notify residents or their legal representatives in writing of any changes in charges or services at least 30 days before the effective date of the change.
Failed to report allegations of abuse, neglect, or exploitation to the department within 24 hours and failed to conduct timely investigations and corrective actions.
Failed to monitor services provided by outside resources and act as an advocate for the resident if services do not meet professional standards.
Failed to ensure licensed nurse provided or coordinated necessary health care services in accordance with functional capacity screening and negotiated service agreement.
Failed to ensure all medications administered in accordance with medical provider's orders, professional standards, and manufacturer's recommendations.
Failed to remain with resident until medication is ingested or applied.
Failed to safeguard resident records against theft; records were kept unsecured in an open cabinet in a copy room accessible to all staff.
Failed to ensure sufficient number of staff to assist residents requiring help during emergency evacuation and failed to document ability to safely evacuate residents with least number of staff on duty.
Report Facts
Census: 31
Complaints investigated: 7
Staff on duty during evening/night shifts: 2
Evacuation staff count: 8
Evacuation staff count: 14
Insulin dose error: 15
Residents requiring two-person transfer: 1
Residents requiring transfer assist to toilet: 5
Residents with impaired cognition: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Nurse A | Licensed Nurse | Named in findings related to failure to report abuse, medication administration errors, and failure to monitor outside services |
| Certified Staff D | Certified Staff | Involved in insulin administration error for resident #412 |
| Certified Staff L | Certified Staff | Reported resident #412 ran out of insulin and inability to locate insulin pen |
| Certified Staff M | Certified Staff | Reported residents not getting showers as scheduled |
Inspection Report
Complaint Investigation
Census: 31
Deficiencies: 5
Date: May 25, 2016
Visit Reason
The inspection was a resurvey of an assisted living facility conducted on 5/23/16, 5/24/16, and 5/25/16 to investigate allegations of abuse, neglect, and regulatory compliance related to staff treatment of residents and delegation of nursing duties.
Complaint Details
The visit was complaint-related due to allegations of abuse and neglect involving residents found on the floor, injuries, and a resident leaving the facility without staff awareness. The operator failed to report these incidents and conduct investigations as required.
Findings
The facility failed to report and investigate multiple incidents of residents found on the floor or injured, failed to delegate glucometer testing and insulin pen preparation to certified medication aides as required, failed to obtain proper nurse aide registry documentation for employees, and failed to maintain hot water temperatures within the required range in resident apartments.
Deficiencies (5)
Failed to report and investigate incidents involving residents found on the floor or injured, and when a resident left the facility without staff awareness.
Licensed nurse failed to delegate glucometer testing of residents' blood sugar levels to certified medication aides.
Licensed nurse failed to delegate preparation and dialing of an insulin pen to a certified medication aide.
Failed to obtain supporting documentation from the Kansas nurse aide registry that employees did not have findings of abuse, neglect, or exploitation prior to employment.
Failed to ensure hot water temperatures in resident apartments were maintained between 98°F and 120°F and failed to monitor hot water temperatures throughout the building.
Report Facts
Census: 31
Glucometer testing frequency: 4
Glucometer testing frequency: 2
Glucometer testing frequency: 2
Insulin dosage: 12
Insulin dosage: 50
Hot water temperature: 126.8
Hot water temperature: 124.8
Hot water temperature: 109.7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed nurse A | Licensed Nurse | Named in findings related to failure to report incidents and failure to delegate nursing procedures |
| Certified medication aide B | Certified Medication Aide | Identified residents requiring glucometer testing and insulin pen preparation |
| Certified medication aide C | Certified Medication Aide | Prepared and dialed insulin pen without documented delegation |
| Certified medication aide D | Certified Medication Aide | Lacked documentation of nurse aide registry verification |
Inspection Report
Renewal
Deficiencies: 0
Date: Apr 9, 2014
Visit Reason
The licensure resurvey of the facility Vintage Park at Waterfront LLC was conducted to assess compliance and determine if any deficiencies were present.
Findings
The licensure resurvey resulted in a finding of no deficiency citations on 4-9-14.
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