Inspection Report Summary
The most recent inspection on November 19, 2025, found no deficiencies and confirmed the facility’s compliance with all regulations. Prior inspections showed recurring issues primarily with the development and updating of negotiated service agreements based on functional capacity screenings, as well as securing chemicals to ensure resident safety. Earlier reports also noted deficiencies related to medication labeling, emergency management plan reviews, tuberculosis screening compliance, and food safety practices. Complaint investigations were not listed in the available reports, and no fines, immediate jeopardy findings, or license actions were reported. The facility appears to have addressed previous deficiencies successfully, demonstrating improvement over time.
Deficiencies (last 10 years)
Deficiencies (over 10 years)
6.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
12% worse than Kansas average
Kansas average: 6 deficiencies/yearDeficiencies per year
12
9
6
3
0
Census
Latest occupancy rate
16 residents
Based on a November 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Census over time
Inspection Report
Follow-Up
Deficiencies: 0
Date: Nov 19, 2025
Visit Reason
An offsite revisit survey was conducted on 11/19/25 to verify correction of all previous deficiencies cited on 11/05/25.
Findings
All deficiencies cited in the prior inspection have been corrected as of the compliance date of 11/19/25, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Nov 19, 2025
Visit Reason
An offsite revisit survey was conducted on 11/19/25 to verify correction of all previous deficiencies cited on 11/05/25.
Findings
All deficiencies have been corrected as of the compliance date of 11/19/25, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Nov 19, 2025
Visit Reason
An offsite revisit survey was conducted on 11/19/25 to verify correction of all previous deficiencies cited on 11/05/25.
Findings
All deficiencies have been corrected as of the compliance date of 11/19/25, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Nov 19, 2025
Visit Reason
An offsite revisit survey was conducted on 11/19/25 to verify correction of all previous deficiencies cited on 11/05/25.
Findings
All deficiencies have been corrected as of the compliance date of 11/19/25, 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: 16
Deficiencies: 2
Date: Nov 5, 2025
Visit Reason
The inspection was a resurvey of Kearny County Hospital Assisted Living conducted to verify compliance with previously identified deficiencies.
Findings
The facility failed to fully develop negotiated service agreements for residents based on their functional capacity screenings and service needs, and failed to secure chemicals properly to ensure resident and visitor safety.
Deficiencies (2)
The operator failed to ensure the Negotiated Service Agreement was fully developed based on the resident's Functional Capacity Screen, service needs, and preferences for residents R101 and R103.
The operator failed to ensure staff secured all chemicals to maintain the safety of all residents and visitors, with multiple unlocked chemicals observed in the library area.
Report Facts
Census: 16
Number of residents in sample: 3
Chemical quantities: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nurse A | Provided statements regarding residents R101 and R103's behaviors and service needs | |
| Administrative Staff A | Provided statements regarding resident R101's behavior and redirection |
Inspection Report
Follow-Up
Deficiencies: 0
Date: Jun 11, 2024
Visit Reason
An offsite revisit survey was conducted to verify correction of all previous deficiencies cited on 2024-05-15.
Findings
All deficiencies have been corrected as of the compliance date of 2024-06-10, 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: 16
Deficiencies: 11
Date: May 15, 2024
Visit Reason
The inspection was a resurvey of the Kearny County Hospital Assisted Living facility conducted on 05/15/2024 and 05/16/2024 to assess compliance with previously identified deficiencies and regulatory requirements.
Findings
The facility was found deficient in multiple areas including failure to post the most recent survey report, incomplete functional capacity screenings, inadequately developed negotiated service agreements, unlabeled medications, lack of quarterly medication regimen reviews, failure to conduct quarterly emergency management plan reviews, improper food temperature documentation, and non-compliance with tuberculosis screening guidelines for residents and staff.
Deficiencies (11)
Failure to ensure a copy of the most recent survey report and plan of correction was available in a public area for residents and others.
Failure to complete Functional Capacity Screen (FCS) for residents R101 and R103 at least once every 365 days.
Failure to fully develop Negotiated Service Agreements (NSA) based on Functional Capacity Screen, service needs, and preferences for residents R101, R102, and R103.
Failure to revise Negotiated Service Agreements (NSA) for residents R101 and R102 at least once every 365 days.
Failure to identify the licensed nurse responsible for implementation and supervision of the health care services plan in the NSA for residents R101, R102, and R103.
Failure to label over-the-counter medications with the full name of the resident for four residents; nine containers not labeled.
Failure to label prescription medication containers with a label provided by a dispensing pharmacist for four residents; seven containers not labeled.
Failure to ensure quarterly medication regimen reviews by a licensed pharmacist for residents R101 and R103.
Failure to conduct quarterly review of the facility's emergency management plan with employees and residents.
Failure to ensure food items were served at the proper temperature; multiple days lacked documentation of food temperatures.
Failure to comply with tuberculosis guidelines including lack of annual TB symptom screening questionnaires for residents R101, R102, R103 and staff, and lack of two-step TB skin tests for new residents and employees.
Report Facts
Census: 16
Unlabeled OTC medication containers: 9
Unlabeled prescription medication containers: 7
Residents sampled: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Nurse A | Licensed Nurse | Interviewed regarding deficiencies in functional capacity screening, negotiated service agreements, medication labeling, medication regimen reviews, and tuberculosis screening |
| Certified Medication Aide B | Certified Medication Aide | Interviewed regarding medication administration and labeling deficiencies |
| Administrative Nurse E | Administrative Nurse | Named in negotiated service agreements as nurse responsible for care plan but no longer employed |
| Administrative Staff D | Administrative Staff | Acknowledged lack of documentation for quarterly emergency management plan reviews |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: May 15, 2024
Visit Reason
The document represents the findings of a resurvey conducted for the above named Assisted Living facility on 05/15/2024 and 05/16/2024.
Findings
This document is a Plan of Correction submitted in response to the resurvey findings for the Assisted Living facility. It outlines corrective actions cross-referenced to the identified deficiencies.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Nov 16, 2022
Visit Reason
An offsite revisit survey was conducted on 11/16/22 to verify correction of all previous deficiencies cited on 10/20/22.
Findings
All deficiencies have been corrected as of the compliance date of 11/11/22, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Inspection Report
Re-Inspection
Census: 24
Deficiencies: 11
Date: Oct 20, 2022
Visit Reason
The inspection was a resurvey of the Kearny County Hospital Assisted Living facility conducted on 10/19/22 - 10/20/22 to assess compliance with previously identified deficiencies.
Findings
The facility failed to complete and accurately document Functional Capacity Screens (FCS) prior to or upon admission for residents, failed to fully develop and timely complete Negotiated Service Agreements (NSA) including required signatures and identification of responsible licensed nurses, failed to label over-the-counter medications with resident names, lacked a comprehensive emergency management plan including missing persons and natural gas leak protocols, failed to conduct quarterly emergency plan reviews with staff and residents, and failed to comply with tuberculosis (TB) testing guidelines requiring two-step TB skin tests for residents and new employees.
Deficiencies (11)
Failure to complete Functional Capacity Screen (FCS) prior to or upon admission and failure to document all required findings for residents R101 and R102.
Failure to accurately reflect resident R102's functional capacity for vision on the FCS.
Failure to fully develop Negotiated Service Agreements (NSA) for residents R101, R102, and R103 based on FCS triggers.
Failure to develop initial NSA at admission for residents R101 and R102.
Failure to review and revise NSA for resident R103 at least once every 365 days.
Failure to obtain signatures from all individuals involved in NSA development for residents R101 and R102.
Failure to identify licensed nurse responsible for implementation and supervision of health care services in NSA for residents R102 and R103.
Failure to label over-the-counter medications with resident names; medications were stored as 'stock' without individual labeling.
Emergency management plan failed to include protocols for missing residents and natural gas leaks.
Failure to conduct quarterly reviews of the emergency management plan with employees and residents including all required topics.
Failure to comply with tuberculosis guidelines requiring two-step TB skin tests for residents and newly hired employees.
Report Facts
Census: 24
Number of residents in sample: 3
Number of unlabeled OTC medication containers: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nurse A | Administrative Nurse | Provided statements regarding FCS and NSA completion and signatures |
| Certified Medication Aide B | Certified Medication Aide | Observed handling of unlabeled over-the-counter medications |
| Administrative Staff C | Administrative Staff | Acknowledged deficiencies in emergency plan reviews and staff education |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Oct 19, 2022
Visit Reason
The document represents the findings of a resurvey conducted for the named Assisted Living facility on 10/19/22 - 10/20/22.
Findings
This document is a Plan of Correction submitted in response to the findings from the resurvey of the Assisted Living facility conducted on 10/19/22 - 10/20/22.
Inspection Report
Re-Inspection
Deficiencies: 6
Date: Mar 17, 2021
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 numbers 26-41-202(a), 26-41-204(e), 26-41-205(a)(4), 26-41-205(h), 26-41-207(b)(5-6)(c), and 28-39-254 were corrected and completed by 03/17/2021.
Deficiencies (6)
Deficiency related to regulation 26-41-202(a)
Deficiency related to regulation 26-41-204(e)
Deficiency related to regulation 26-41-205(a)(4)
Deficiency related to regulation 26-41-205(h)
Deficiency related to regulation 26-41-207(b)(5-6)(c)
Deficiency related to regulation 28-39-254
Inspection Report
Re-Inspection
Census: 31
Deficiencies: 6
Date: Feb 23, 2021
Visit Reason
The inspection was a resurvey conducted on 2-17, 2-18, and 2-22-2021 to evaluate compliance with previously cited deficiencies at Kearny County Hospital Assisted Living.
Findings
The facility was found deficient in multiple areas including failure to include all required services in negotiated service agreements, improper delegation of blood glucose monitoring, inadequate labeling of prefilled medication containers, improper medication storage, failure to comply with tuberculosis screening guidelines, and unsecured chemical storage posing safety risks to residents.
Deficiencies (6)
Negotiated service agreements did not include descriptions of all services residents would receive or identification of service providers, specifically related to blood glucose monitoring and use of assistive devices.
Failure to delegate nursing procedures of blood sugar monitoring to certified medication aides according to Kansas nurse practice act.
Prefilled medication containers used by a resident who self-administered medications lacked labels with resident's name and date container was prefilled.
Medications, specifically insulin pens, were not stored securely in locked medication rooms or cabinets and lacked proper labeling with resident's name and date initiated.
Facility failed to comply with tuberculosis screening guidelines for residents and newly hired employees, missing initial and annual TB symptom screens and second TB skin tests.
Chemicals and cleaning supplies were stored unlocked in resident areas, posing safety risks.
Report Facts
Census: 31
Deficiencies cited: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Operator A | Confirmed issues with negotiated service agreements, delegation of duties, medication storage, and chemical storage | |
| Licensed nursing staff D | Licensed Nurse | Reported on assistive device use, medication administration, and confirmed medication storage issues |
| Certified staff B | Reported blood sugar monitoring duties and lacked documented training | |
| Certified staff C | Lacked documented training for blood sugar monitoring | |
| Certified staff G | Reported medication aides checked blood sugar levels twice daily | |
| Licensed nurse D | Licensed Nurse | Reported on medication setup and TB screening status |
Inspection Report
Routine
Deficiencies: 0
Date: Jun 17, 2020
Visit Reason
The special infection control survey for COVID-19 was conducted at the facility on 2020-06-17.
Findings
The survey resulted in findings of no deficiency citations.
Inspection Report
Re-Inspection
Deficiencies: 4
Date: Sep 5, 2018
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
The report documents that previously identified deficiencies related to specific regulations were corrected as of 09/05/2018.
Deficiencies (4)
Deficiency related to regulation 26-41-201 (a) (b)
Deficiency related to regulation 26-41-202 (a)
Deficiency related to regulation 26-41-204 (d)
Deficiency related to regulation 26-41-104 (d)
Inspection Report
Re-Inspection
Census: 83
Deficiencies: 4
Date: Aug 7, 2018
Visit Reason
The inspection was a resurvey conducted on 8/6 and 8/7/2018 at Kearny County Hospital Assisted Living to assess compliance with previously cited deficiencies.
Findings
The facility failed to ensure that functional capacity screenings included all required elements, negotiated service agreements adequately described services and identified providers, and that the licensed nurse responsible for health service plans was named. Additionally, the facility did not perform quarterly reviews of the emergency management plan with employees and residents as required.
Deficiencies (4)
Functional capacity screens lacked required elements and coding for all residents reviewed.
Negotiated service agreements failed to provide descriptions of services and identify providers for all residents reviewed.
Negotiated service agreements lacked the name of the licensed nurse responsible for implementation and supervision of the health service plan for all residents reviewed.
Failure to ensure quarterly review of the emergency management plan with employees and residents.
Report Facts
Census: 83
Sample size: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative nursing staff A | Interviewed regarding functional capacity screens, negotiated service agreements, and emergency preparedness |
Inspection Report
Re-Inspection
Deficiencies: 3
Date: Jun 23, 2017
Visit Reason
This revisit inspection was conducted to verify that previously reported deficiencies at Kearny County Hospital Assisted Living have been corrected.
Findings
All previously reported deficiencies identified by regulation or LSC provision numbers were corrected as of the revisit date.
Deficiencies (3)
Deficiency with regulation 26-39-101 (h)
Deficiency with regulation 28-39-158(g)
Deficiency with regulation 26-41-102 (d)
Inspection Report
Renewal
Capacity: 30
Deficiencies: 3
Date: May 30, 2017
Visit Reason
The inspection was conducted as an Assisted Living Licensure Resurvey to assess compliance with licensing requirements and regulations.
Findings
The facility was found to have exceeded its licensed capacity by housing 32 residents while licensed for 30, failed to discard expired food and monitor refrigerator/freezer temperatures, and did not complete required nurse aide registry and criminal background checks prior to staff providing resident care.
Deficiencies (3)
Facility failed to apply for a license capacity change when census increased from 30 to 32 residents.
Facility failed to discard expired food and monitor refrigerator/freezer temperatures in the kitchen.
Facility failed to complete nurse aide registry checks and criminal background checks prior to direct care staff providing resident care.
Report Facts
Census: 32
Licensed Capacity: 30
Expired food items: 8
Missing temperature records: 12
Days staff worked prior to background check: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Direct care staff D | Named in deficiency for providing care prior to completion of nurse aide registry and background checks | |
| Dietary staff E | Confirmed presence of expired food items in kitchen | |
| Dietary staff F | Interviewed regarding food removal and temperature monitoring procedures |
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Jul 7, 2016
Visit Reason
This revisit report documents the follow-up inspection to verify that previously reported deficiencies have been corrected at Kearny County Hospital Assisted Living.
Findings
All previously cited deficiencies listed with their regulation numbers were corrected as of 10/30/2015, with no uncorrected deficiencies noted at the time of this revisit.
Report Facts
Deficiencies corrected: 8
Inspection Report
Re-Inspection
Census: 25
Deficiencies: 9
Date: Oct 2, 2015
Visit Reason
The inspection was a Health Licensure Resurvey of Kearny County Hospital Assisted Living to assess compliance with state regulations.
Findings
The facility failed to notify a resident's physician of worsening pressure ulcers, failed to provide adequate treatment and monitoring for pressure ulcers, failed to serve food in a sanitary manner, failed to maintain expired medications off the medication cart, failed to make the most recent survey report publicly available, failed to ensure medication regimen review variances were reported to medical providers, failed to make the emergency plan available to residents and visitors, failed to complete an annual functional capacity screen for a resident, and failed to ensure qualified staff developed negotiated service agreements.
Deficiencies (9)
Failed to notify physician of worsening pressure ulcers and development of new pressure ulcers for resident #3.
Failed to provide treatment and services to promote healing and prevent new pressure ulcers for resident #3.
Failed to serve foods in a sanitary manner in the 300 hall dining room.
Failed to ensure a copy of the most recent survey report and plan of correction was available in a public area.
Failed to ensure expired medications were not available for use in the 300 hall medication cart.
Failed to ensure consultant pharmacist reported medication regimen review variances to residents' medical care providers.
Failed to make the emergency management plan available to residents and visitors.
Failed to complete an annual Functional Capacity Screen for resident #2 within 365 days.
Failed to ensure qualified staff developed the negotiated service agreement in collaboration with the resident.
Report Facts
Census: 25
Pressure ulcer size: 0.4
Pressure ulcer size: 0.5
Pressure ulcer size: 1
Pressure ulcer size: 1
Pressure ulcer size: 2.5
Pressure ulcer size: 3
Expired medication dates: 2014
Expired medication dates: 2015
Functional Capacity Screen date: 2014
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse C | Licensed Nurse | Named in findings related to failure to notify physician and inadequate pressure ulcer care for resident #3 |
| Administrative Nurse A | Administrator | Interviewed regarding awareness of pressure ulcers, medication regimen reviews, emergency plan availability, and functional capacity screening |
| Staff G | Dietary Staff | Observed serving food in unsanitary manner |
| Staff H | Dietary Staff | Interviewed about proper food service procedures |
| Direct Care Staff E | Direct Care Staff | Observed medication cart and interviewed about medication expiration |
| Direct Care Staff D | Direct Care Staff | Interviewed about medication expiration and resident care |
| Administrative Staff B | Director of Assisted Living | Signed negotiated service agreement without proper certification and interviewed about survey report and emergency plan availability |
Inspection Report
Re-Inspection
Deficiencies: 3
Date: Jul 3, 2014
Visit Reason
This report documents a revisit inspection to verify that previously reported deficiencies at Kearny County Hospital Assisted Living have been corrected.
Findings
The revisit inspection confirmed that the deficiencies identified in the prior survey were corrected as of the revisit date.
Deficiencies (3)
Deficiency related to regulation 26-43-101(g) (ID Prefix S2030)
Deficiency related to regulation 26-41-204(a) (ID Prefix S3155)
Deficiency related to regulation 28-39-256 (ID Prefix S3420)
Report Facts
Deficiencies corrected: 3
Inspection Report
Plan of Correction
Deficiencies: 2
Date: Jun 23, 2014
Visit Reason
This document is a Plan of Correction submitted by Kearny Co Hospital AL in response to deficiencies identified in a prior inspection.
Findings
The Plan of Correction outlines corrective actions including posting policy notices in assisted living halls, educating staff nurses on updating resident health service plans, and implementing a QA/QI project to monitor compliance over the next 12 months.
Deficiencies (2)
Availability of Policies and Procedures - Notices posted in assisted living halls informing residents/public that policies and procedures are available for review.
Health Care Services - Education provided to full-time staff nurses regarding updating resident health service plans by specified dates.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Pamela Twilleger | RN/DON | Submitted the Plan of Correction |
Inspection Report
Renewal
Census: 30
Deficiencies: 3
Date: Jun 10, 2014
Visit Reason
The inspection was a Licensure Resurvey to assess compliance with assisted living facility regulations.
Findings
The facility failed to post a notice of availability of policies and procedures, did not ensure coordination of necessary health care services for a resident requiring assistance with a back brace, and failed to maintain hot water temperatures within the required range in resident areas.
Deficiencies (3)
Failure to post notice of availability of policies and procedures to residents and the public.
Failure to ensure coordination of necessary health care services for a resident requiring assistance with application of a back brace.
Failure to maintain hot water temperatures between 98°F and 120°F in resident areas, with temperatures observed up to 137.2°F.
Report Facts
Census: 30
Residents sampled: 3
Water temperature: 137.2
Water temperature: 136.1
Water temperature: 135
Water temperature: 130.2
Water temperature: 134.7
Water temperature: 134.5
Water temperature: 124.6
Water temperature: 107.4
Water temperature: 107.9
Hot water heater temperature range: 123
Hot water heater temperature range: 136
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Nurse E | Licensed Nurse | Verified resident #1 required assistance with back brace application and confirmed health service plan lacked revision. |
| Maintenance Staff D | Measured water temperatures and reported to supervisor; unaware of safe water temperature limits. | |
| Maintenance Staff C | Supervisor who adjusted hot water heater and called plumber; unaware of water temperature requirements. | |
| Administrative Staff A | Confirmed failure to post notice of availability of policies and procedures. |
Document
Deficiencies: 0
Date: N047002 POC 06DP11
Visit Reason
The document is an error notification stating that the inspection report page cannot be accessed due to a system error.
Findings
No inspection findings or content are available as the report page is inaccessible.
Inspection Report
Plan of Correction
Deficiencies: 4
Date: N047002 POC 4G7911
Visit Reason
This document is a Plan of Correction submitted by Kearny Co Hospital AL in response to deficiencies cited in a prior inspection report.
Findings
The Plan of Correction addresses multiple deficiencies including pressure ulcer prevention, wound assessment, functional capacity screening, and completion of negotiated service agreements, with corrective actions and monitoring plans described for each.
Deficiencies (4)
Pressure ulcer prevention and wound assessment deficiencies including use of pressure reducing mattress, removal of donut cushions, wound assessment flowchart, and education of nursing staff.
Functional Capacity Screen completion and monitoring.
Completion and review of Negotiated Service Agreements by qualified staff.
No Plan of Correction required for deficiencies with tags S3055, S3171, S3215, S3225, S3285, S3305.
Report Facts
Deficiency tags referenced: 9
Inspection Report
Plan of Correction
Capacity: 35
Deficiencies: 3
Date: N047002 POC EX7V11
Visit Reason
This document is a Plan of Correction submitted in response to deficiencies identified in a prior inspection, addressing compliance issues and corrective actions for the facility.
Findings
The plan addresses deficiencies related to licensed capacity compliance, food safety including expiration and temperature monitoring, and verification of staff credentials before employment.
Deficiencies (3)
Licensed capacity has been increased from 30 residents to 35 residents; monitoring of census to ensure compliance.
Dietary staff to be educated on First in First Out Policy for food expiration and daily checks of expiration dates and freezer/refrigerator temperatures.
Verification of certified and licensed staff credentials before employment with monthly checks of employment files.
Report Facts
Licensed capacity: 35
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Susan Stingley | CNO | Submitted the Plan of Correction |
| Shirley Boltz | Contact for Plan of Correction assistance |
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