Inspection Report Summary
The most recent inspection on December 30, 2024, found the facility in compliance with all regulations and no new deficiencies. Prior inspections showed recurring issues with updating negotiated service agreements, medication management documentation, and safe storage practices for food and chemicals. Complaint investigations mostly resulted in deficiencies related to resident care coordination, medication administration, and emergency preparedness, with some substantiated complaints but no fines or enforcement actions listed in the available reports. Earlier complaints included failure to report incidents timely and unsafe water temperatures, but these were corrected in subsequent revisits. The facility appears to have addressed prior deficiencies effectively, showing improvement in recent inspections.
Deficiencies (last 9 years)
Deficiencies (over 9 years)
5.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
5% better than Kansas average
Kansas average: 6 deficiencies/yearDeficiencies per year
12
9
6
3
0
Census
Latest occupancy rate
37 residents
Based on a December 2024 inspection.
Census over time
Inspection Report
Follow-Up
Deficiencies: 0
Date: Dec 30, 2024
Visit Reason
An offsite revisit survey was conducted to verify correction of all previous deficiencies cited on 2024-12-10.
Findings
All deficiencies have been corrected as of the compliance date of 2024-12-27, 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: 37
Deficiencies: 6
Date: Dec 10, 2024
Visit Reason
The inspection was a resurvey with attached complaints 190424, 191933, 191936, 192103, and 188173 at the assisted living facility.
Complaint Details
The resurvey included attached complaints 190424, 191933, 191936, 192103, and 188173.
Findings
The facility failed to ensure accurate Functional Capacity Screens for medication management for several residents, failed to update Negotiated Service Agreements after significant changes in condition, lacked proper assessments for bed assist device safety, failed to document incidents and injuries adequately, stored food improperly without date labeling or safe storage, and failed to store chemicals in locked areas to protect resident safety.
Deficiencies (6)
Functional Capacity Screen did not accurately reflect residents' medication management abilities for Residents 1, 2, and 3.
Negotiated Service Agreements were not revised following significant changes in condition for Residents 3 and 4.
Licensed nurse failed to complete assessment for safe use of bed assist device for Resident 1; bed assist device had a gap greater than 4.75 inches without cover.
Licensed staff failed to document all incidents, symptoms, and indications of illness or injury including date, time, action taken, and results for Resident 4.
Food items in kitchen were stored without proper date labeling and some were past the seven-day consumption/discard period.
Chemicals were stored in unlocked cabinets in multiple areas including memory care kitchen, main dining area, and resident bathroom.
Report Facts
Census: 37
Gap size: 5.5
Deficiencies cited: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nurse B | Confirmed inaccuracies in Functional Capacity Screens, lack of documentation for bed assist device assessment, incident documentation, and chemical storage. | |
| Certified Medication Aide C | Administered medications to Resident 1 and provided information about medication management for Residents 1 and 2. | |
| Certified Nurse Aide D | Stated Certified Medication Aide C administered medications to Resident 1. | |
| Administrative Staff A | Confirmed food items lacked date labels and chemicals were not stored in locked areas. |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Dec 9, 2024
Visit Reason
The document represents the findings of a resurvey with attached complaints 190424, 191933, 191936, 192103, and 188173 at the assisted living facility conducted on 12/09/24 and 12/10/24.
Complaint Details
The resurvey included attached complaints numbered 190424, 191933, 191936, 192103, and 188173.
Findings
This plan of correction addresses the findings from the resurvey and attached complaints conducted at the facility on the specified dates.
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Nov 8, 2023
Visit Reason
An offsite revisit survey was conducted on 11/08/23 for all previous deficiencies cited on 10/18/23.
Findings
All deficiencies have been corrected as of the compliance date of 11/06/23, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Inspection Report
Complaint Investigation
Census: 22
Deficiencies: 9
Date: Oct 18, 2023
Visit Reason
The inspection was a resurvey with complaints numbered 174632, 175415, 177549, 177995, and 179464 at an assisted living facility.
Complaint Details
The inspection was a resurvey with complaints numbered 174632, 175415, 177549, 177995, and 179464.
Findings
The facility was found deficient in multiple areas including incomplete negotiated service agreements for residents, failure to provide specified health care and housekeeping services, lack of identification of licensed nurses responsible for health care plans, improper labeling and storage of medications, incomplete employee records, inadequate documentation of resident incidents, and unsafe water temperatures exceeding regulatory limits.
Deficiencies (9)
Negotiated Service Agreements were not fully developed to address all items triggered in the Functional Capacity Screen for residents R102 and R103.
Resident R104 did not receive health care services based on licensed nurse assessment and housekeeping services as specified in the negotiated service agreement.
Negotiated Service Agreements did not identify the licensed nurse responsible for implementation and supervision of health care plans for residents R101, R102, and R103.
Over-the-counter medications for six residents were not labeled with the resident's full name by a licensed pharmacist or nurse.
Prescription medication containers for multiple residents were not labeled with a label provided by a dispensing pharmacist.
Resident medications were not stored in accordance with manufacturer recommendations; specifically, an unsealed vial of TUBERSOL was not marked with an opened date.
Employee records for three of five newly hired employees lacked timely verification of nurse aide registry checks.
Resident R106's medical record lacked documentation of all incidents, actions taken, and results related to falls.
Water temperatures in resident use areas exceeded the regulatory maximum of 120 degrees Fahrenheit, with recorded temperatures up to 127.9 degrees Fahrenheit.
Report Facts
Census: 22
Fall Risk Evaluations: 4
Hot water temperature readings above 120 F: 72
Days after hire for nurse aide registry check: 22
Days after hire for nurse aide registry check: 35
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nurse B | Administrative Nurse | Acknowledged deficiencies in negotiated service agreements and documentation |
| Certified Medication Aide C | Certified Medication Aide | Provided information on resident care and medication labeling |
| Maintenance Staff D | Maintenance Staff | Provided information on hot water temperature monitoring |
| Administrative Staff A | Administrative Staff | Reported inability to find fall investigations for resident R106 |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Oct 17, 2023
Visit Reason
The document is a plan of correction responding to findings from a resurvey with complaints numbered 174632, 175415, 177549, 177995, and 179464 conducted at the assisted living facility on 10/17/23 and 10/18/23.
Complaint Details
The resurvey was conducted in response to multiple complaints (174632, 175415, 177549, 177995, and 179464).
Findings
The plan of correction addresses citations identified during the resurvey and complaint investigations conducted on the specified dates at the assisted living facility.
Inspection Report
Abbreviated Survey
Census: 37
Deficiencies: 1
Date: Jun 7, 2022
Visit Reason
The inspection was an abbreviated survey conducted on 6/6/2022 and 6/7/2022 for multiple complaints numbered 172267, 170473, 169834, 169841, 169332, 168577, 167868, 167874, 167498, and 166058.
Complaint Details
The survey was complaint-related, triggered by multiple complaints. The allegation of abuse involving resident R1 was investigated and found unsubstantiated, but the facility failed to report the allegation to the department within the required 24-hour timeframe.
Findings
The facility failed to report an allegation of abuse involving resident R1 to the department within 24 hours of notification, as required by state regulations. The investigation was completed with an unsubstantiated outcome, but the required timely reporting and notification to the legal representative were not met.
Deficiencies (1)
Failure to report an allegation of abuse involving resident R1 to the department within 24 hours of notification.
Report Facts
Census: 37
Complaints investigated: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Regional Licensed Nurse B | Regional Licensed Nurse | Investigated the alleged abuse incident and confirmed failure to report to the department. |
| Residence Director F | Residence Director | Confirmed via email that the allegation of abuse was not reported to the department within 24 hours. |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Jun 6, 2022
Visit Reason
The document addresses findings from an abbreviated survey conducted on 6/6/2022 and 6/7/2022 related to multiple complaints against the facility.
Complaint Details
The survey was conducted in response to complaints #172267, 170473, 169834, 169841, 169332, 168577, 167868, 167874, 167498, and 166058.
Findings
An offsite revisit survey on 06/10/2022 confirmed that all previously cited deficiencies from 06/07/2022 were corrected by 06/09/2022, with no new noncompliance found. The facility is in compliance with all surveyed regulations.
Report Facts
Complaints referenced: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Shirley Boltz | Contact person for Plan of Correction assistance |
Inspection Report
Re-Inspection
Deficiencies: 4
Date: Sep 21, 2021
Visit Reason
This revisit inspection was conducted to verify that previously reported deficiencies at The Windsor of Lawrence were corrected and to document the dates such corrective actions were accomplished.
Findings
All previously cited deficiencies identified by regulation numbers 26-41-101 (j), 26-41-204 (i), 26-41-205 (d) (1-2), and 26-41-207 (a) (b) were corrected as of 09/21/2021.
Deficiencies (4)
Deficiency related to regulation 26-41-101 (j)
Deficiency related to regulation 26-41-204 (i)
Deficiency related to regulation 26-41-205 (d) (1-2)
Deficiency related to regulation 26-41-207 (a) (b)
Inspection Report
Complaint Investigation
Census: 35
Deficiencies: 4
Date: Aug 25, 2021
Visit Reason
The inspection was an abbreviated survey conducted in response to complaint #164579 at an assisted living facility.
Complaint Details
The visit was complaint-driven based on complaint #164579. The complaint involved concerns about emergency telephone availability, resident care after a fall, medication administration, and sanitary conditions.
Findings
The facility was found deficient in multiple areas including lack of emergency telephones in cottages, failure to assess a resident after an unwitnessed fall, failure to administer medications according to physician orders, and failure to maintain sanitary conditions in resident bathrooms and food service areas.
Deficiencies (4)
Failure to ensure cottages had a working telephone for resident and staff emergency use.
Failure to ensure a licensed nurse assessed a resident after an unwitnessed fall despite complaints of back pain and increased negative behaviors.
Failure to ensure facility staff administered medications according to medical provider's written orders and professional standards of practice.
Failure to provide a safe, sanitary, and comfortable environment by not properly cleaning a resident's bathroom and not sanitizing silverware and drinking cups in the cottages.
Report Facts
Census: 35
Residents sampled: 3
Residents affected: 4
Medication tablets: 30
Medication tablets: 30
Inspection Report
Re-Inspection
Deficiencies: 2
Date: Jul 22, 2021
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
The report shows that the deficiencies identified in the prior survey have been corrected as of 07/21/2021, with corrections documented for specific regulation numbers.
Deficiencies (2)
Deficiency related to regulation 26-41-202 (d)
Deficiency related to regulation 26-41-205 (d) (1-2)
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jul 21, 2021
Visit Reason
An abbreviated survey was conducted at the assisted living facility for complaint investigation #163802 on 07-21-2021 and 07-22-2021.
Complaint Details
Complaint investigation #163802 was substantiated but resulted in no deficiency citations.
Findings
The allegation was found to be substantiated with no deficiency citations.
Inspection Report
Complaint Investigation
Census: 38
Deficiencies: 2
Date: Jun 29, 2021
Visit Reason
The inspection was an abbreviated survey conducted in response to multiple complaints (#163197, 163265, 162987, 162590, and 162463) regarding the facility.
Complaint Details
The visit was triggered by complaints #163197, 163265, 162987, 162590, and 162463. The findings substantiated issues with service agreement updates and medication administration.
Findings
The facility failed to update the negotiated service agreement for a resident to reflect changes in behavior and therapy needs after a fall. Additionally, licensed nurse and medication aides failed to administer medications as ordered and in a timely manner for multiple residents, including failure to locate medications and late administration of doses.
Deficiencies (2)
Failed to update negotiated service agreement for resident #1 to reflect changes in behaviors, unsteadiness, and therapy services after a fall.
Failed to ensure licensed nurse and medication aides administered medications according to medical orders and professional standards, including failure to locate medications and late administration for residents #1, #2, and #3.
Report Facts
Census: 38
Medication non-administration days: 3
Medication administration times: 50
Fall date: May 24, 2021
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Nurse C | Licensed Nurse | Named in medication administration and resident behavior findings |
| Certified Medication Aide A | Certified Medication Aide | Named in medication administration deficiencies |
| Certified Medication Aide D | Certified Medication Aide | Named in medication administration deficiencies |
| Operator B | Operator | Interviewed regarding medication administration and facility operations |
Inspection Report
Renewal
Census: 36
Deficiencies: 2
Date: Apr 28, 2021
Visit Reason
The inspection was a licensure resurvey with multiple complaint investigations conducted on 4/22/2021, 4/26/2021, 4/27/2021, and 4/28/2021.
Complaint Details
The licensure resurvey included complaint investigations for complaint numbers 161840, 160466, 157199, 157095, 155810, 155515, 155410, 151406, 151358, 148628, and 145432. The facility failed to report an allegation of sexual abuse for resident #113 and did not complete required assessments for resident #576.
Findings
The facility failed to report an allegation of sexual abuse for resident #113 within 5 working days of the initial report and failed to ensure a licensed nurse performed an assessment for resident #576 regarding self-administration of medication. The investigation included interviews, record reviews, and revealed deficiencies in reporting and assessment procedures.
Deficiencies (2)
Failed to report to the department an allegation of sexual abuse for resident #113 within 5 working days of the initial report.
Failed to ensure the licensed nurse performed an assessment on resident #576 to determine if resident could perform self-administration of medication safely and accurately without staff assistance.
Report Facts
Census: 36
Sample size: 3
Closed record reviews: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Operator B | Interviewed and confirmed failure to report allegation of sexual abuse and lack of assessment documentation. | |
| Licensed Nurse C | Interviewed regarding resident care and assessments; involved in investigation of abuse allegation. |
Inspection Report
Routine
Deficiencies: 0
Date: Jul 16, 2020
Visit Reason
The special infection control survey for COVID-19 was conducted at the facility on 07/16/2020.
Findings
The survey resulted in findings of no deficiency citations.
Inspection Report
Follow-Up
Deficiencies: 3
Date: Jun 10, 2019
Visit Reason
This revisit inspection was 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 identified by regulation or Life Safety Code provisions were corrected as of the revisit date.
Deficiencies (3)
Deficiency related to regulation 26-41-105 (f) (11)
Deficiency related to regulation 26-41-104 (d)
Deficiency related to regulation 26-41-207 (b) (5-6) (c)
Inspection Report
Plan of Correction
Census: 32
Deficiencies: 1
Date: Jun 10, 2019
Visit Reason
The inspection was conducted to assess compliance with nursing delegation procedures, specifically regarding the delegation of insulin administration by medication aides under the Kansas nurse practice act.
Findings
The facility failed to ensure that a licensed nurse properly delegated the procedure of insulin administration by injected pen to medication aides, as required. Certified staff dialed the insulin dose for a resident who self-injected, but lacked a competency exam for this delegated task.
Deficiencies (1)
Failure to ensure licensed nurse delegated insulin injection procedure to medication aides under Kansas nurse practice act.
Report Facts
Census: 32
Sampled residents: 3
Certified staff hire date: May 6, 2019
Insulin administration dates: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified staff #C | Certified Medication Aide | Staff who dialed insulin dose without competency exam |
| Licensed nurse #B | Licensed Nurse | Confirmed delegation and lack of competency exam for certified staff #C |
Inspection Report
Renewal
Census: 28
Deficiencies: 4
Date: Apr 30, 2019
Visit Reason
The inspection was conducted for re-licensure with attached complaints at the assisted living facility.
Complaint Details
The survey was conducted with attached complaints, indicating the visit was complaint-related.
Findings
The facility was found deficient in multiple areas including failure to ensure licensed nurse delegation of nursing procedures to medication aides, incomplete documentation of incidents and resident records, lack of disaster and emergency preparedness including failure to conduct evacuation drills and quarterly reviews, and non-compliance with tuberculosis screening guidelines for staff.
Deficiencies (4)
Failure to ensure licensed nurse delegated nursing procedures such as accuchecks and insulin injections to medication aides under the Kansas nurse practice act.
Failure to document all incidents, symptoms, and indications of illness or injury including date, time, action taken, and results.
Failure to ensure disaster and emergency preparedness including quarterly review of emergency management plan with staff and residents and failure to conduct evacuation drills.
Failure to comply with tuberculosis guidelines including lack of documentation of TB symptom screening and 2-step TB skin tests for staff.
Report Facts
Census: 28
Residents in sample: 3
Closed review residents: 2
Certified staff hire dates: Certified staff #G hired 10/3/18, #H hired 2/1/19, #E hired 1/17/19, #F hired 2/13/18.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed nurse #B | Confirmed delegation failures and lack of competency exams for medication aides. | |
| Certified medication aide #G | Lacked competency exam for accuchecks and insulin pen injections. | |
| Certified medication aide #H | Lacked competency exam for accuchecks. | |
| Certified staff #E | Lacked tuberculosis screening documentation. | |
| Certified staff #F | Lacked tuberculosis screening documentation. | |
| Certified staff #G | Lacked tuberculosis screening documentation within 7 days of hire. | |
| Facility operator #A | Confirmed lack of TB documentation and emergency preparedness deficiencies. | |
| Maintenance supervisor #D | Confirmed lack of evacuation drills and incomplete emergency preparedness. |
Inspection Report
Re-Inspection
Deficiencies: 2
Date: Jul 14, 2017
Visit Reason
This revisit report documents the correction of deficiencies previously reported during an earlier survey at The Windsor of Lawrence facility.
Findings
The report confirms that previously identified deficiencies related to regulations 26-41-204 (a) and 26-41-204 (d) have been corrected as of the revisit date.
Deficiencies (2)
Deficiency related to regulation 26-41-204 (a)
Deficiency related to regulation 26-41-204 (d)
Inspection Report
Re-Inspection
Census: 29
Deficiencies: 3
Date: May 11, 2017
Visit Reason
The inspection was a licensure re-survey with attached complaints at the assisted living facility in Lawrence, Kansas conducted on 5/9/17, 5/10/17, and 5/11/17.
Complaint Details
The inspection included attached complaints which triggered the licensure re-survey.
Findings
The facility failed to ensure that a licensed nurse provides or coordinates necessary health care services in accordance with functional capacity screenings and negotiated service agreements. The negotiated service agreements lacked the name of the licensed nurse responsible for implementation and supervision. Additionally, documentation of incidents, symptoms, and indications of illness or injury were incomplete, lacking date, time, action taken, and results of the action for some residents.
Deficiencies (3)
Failure to ensure a licensed nurse provides or coordinates necessary health care services according to functional capacity screening and negotiated service agreement for residents requiring health care services.
Negotiated service agreements lacked the name of the licensed nurse responsible for implementation and supervision of the health care service plan for residents requiring health care services.
Failure to document all incidents, symptoms, and indications of illness or injury including date, time of occurrence, action taken, and results of the action for residents.
Report Facts
Census: 29
Sampled residents: 4
Closed review residents: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| facility operator #A | Interviewed and confirmed lack of documentation in health care service plans. | |
| licensed nurse #B | Interviewed and confirmed lack of documentation in health care service plans. |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Oct 8, 2015
Visit Reason
Licensure resurvey with investigation of complaints at the assisted living facility.
Complaint Details
Investigation of complaints resulted in no deficiency citations.
Findings
The investigation resulted in a finding of no deficiency citations on 2015-10-07 and 2015-10-08.
Inspection Report
Follow-Up
Deficiencies: 4
Date: Jun 10, 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
The report confirms that all previously cited deficiencies identified by regulation or Life Safety Code provisions were corrected as of the revisit date.
Deficiencies (4)
Deficiency related to regulation 26-41-104 (d)
Deficiency related to regulation 26-41-206 (d)
Deficiency related to regulation 28-39-254
Deficiency related to regulation 28-39-256
Report Facts
Deficiencies corrected: 4
Inspection Report
Re-Inspection
Census: 37
Deficiencies: 4
Date: May 15, 2014
Visit Reason
The inspection was a resurvey with complaint investigations 75002 and 71025 conducted at the assisted living facility on 5-13-14, 5-14-14, and 5-15-14.
Complaint Details
The inspection included complaint investigations 75002 and 71025.
Findings
The facility was found deficient in disaster and emergency preparedness due to failure to perform quarterly reviews of the emergency management plan with residents. Food preparation records lacked documentation of proper food temperatures. Some resident apartments did not meet building interior requirements for sleeping areas with windows and living areas. Hot water temperatures in resident areas exceeded the allowable range, posing a safety risk.
Deficiencies (4)
Failure to ensure quarterly review of the facility's emergency management plan with residents.
Failure to ensure food is prepared using safe methods that conserve nutritive value, flavor, and appearance and served at proper temperature; food temperature logs lacked documentation for multiple dates.
Failure to provide a sleeping area with a window that opens for ventilation and conforms with minimum building code dimensions, and failure to provide a living area in some apartments.
Failure to ensure hot water temperature ranged between 98°F and 120°F at sinks in resident use areas; observed temperatures exceeded 130°F.
Report Facts
Census: 37
Food temperature missing records: 19
Residents with impaired cognition: 29
Hot water temperature: 130
Inspection Report
Plan of Correction
Deficiencies: 0
Date: N023017 5G2112
Visit Reason
This document is a Plan of Correction related to a facility inspection event identified by ASPEN Event ID 5G2112 and State ID N023017.
Findings
No specific deficiencies or findings are listed in this Plan of Correction document. It appears to be a placeholder or an empty record with no detailed content.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: N023017 IR4D11
Visit Reason
This document is a Plan of Correction related to a facility inspection event identified by State ID N023017 and ASPEN Event ID IR4D11.
Findings
No specific deficiencies or findings are listed in this Plan of Correction document; it appears to be a placeholder or an empty record with no detailed content provided.
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