Inspection Report Summary
The most recent inspection on December 10, 2025, found no deficiencies and confirmed the facility was in compliance with all regulations. Prior inspections showed some deficiencies related mainly to incomplete negotiated service agreements, food safety issues, and unsecured chemical storage. Earlier reports also cited concerns with resident protection, medication management, emergency preparedness, and staff background checks, often linked to complaint investigations; however, enforcement actions such as fines or license suspensions were not listed in the available reports. Most complaint investigations were substantiated, particularly those involving neglect, exploitation, and failure to report incidents timely. The facility appears to have addressed prior deficiencies effectively, showing improvement over time with recent inspections confirming correction of earlier issues.
Deficiencies (last 8 years)
Deficiencies (over 8 years)
3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
50% better than Kansas average
Kansas average: 6 deficiencies/yearDeficiencies per year
8
6
4
2
0
Census
Latest occupancy rate
34 residents
Based on a November 2025 inspection.
Census over time
Inspection Report
Follow-Up
Deficiencies: 0
Date: Dec 10, 2025
Visit Reason
An offsite revisit survey was conducted to verify correction of all previous deficiencies cited on 2025-11-18.
Findings
All deficiencies have been corrected as of the compliance date of 2025-12-02, 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: 34
Deficiencies: 4
Date: Nov 18, 2025
Visit Reason
The inspection was a resurvey with an attached complaint investigation (complaint 192939) conducted at an assisted living facility to verify correction of previous deficiencies.
Complaint Details
The visit was a resurvey with an attached complaint (192939). The complaint investigation was integrated into the resurvey findings.
Findings
The facility failed to ensure that Negotiated Service Agreements (NSA) were fully developed for residents based on their Functional Capacity Screens, specifically lacking descriptions of services for bladder incontinence, fall prevention, cognition difficulties, and impaired decision making. Additionally, food safety violations were found including use of dented canned foods and improper food storage without proper labeling or dating. The facility also failed to store chemicals in locked areas, posing health and safety risks.
Deficiencies (4)
Negotiated Service Agreements failed to describe services provided for bladder incontinence, fall prevention, cognition difficulties, and impaired decision making for multiple residents.
Food in cans with significant defects such as denting was found in storage and was not properly managed according to facility policy.
Food items in the kitchen were stored without proper labeling or dating, including cheeses and dressings, violating safe food storage requirements.
Chemicals in the salon and public bathroom were stored in unlocked cabinets, failing to protect residents and visitors from hazardous substances.
Report Facts
Census: 34
Deficiency count: 4
Food can weight: 6.375
Food can volume: 99
Chemical container volume: 32
Chemical container volume: 4
Chemical container volume: 14
Chemical container volume: 20
Chemical container quantity: 240
Chemical container volume: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Staff A | Confirmed deficiencies related to Negotiated Service Agreements and chemical storage | |
| Administrative Nurse B | Confirmed NSA deficiencies for resident R4 | |
| Dietary Staff C | Confirmed dented food cans and improper food labeling/storage |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Nov 17, 2025
Visit Reason
The document represents the findings of a resurvey with an attached complaint investigation at an assisted living facility conducted on November 17-18, 2025.
Complaint Details
The visit was related to complaint number 192939, attached to the resurvey.
Findings
This plan of correction document addresses the findings from the resurvey and complaint investigation conducted at the facility on the specified dates.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Apr 10, 2024
Visit Reason
An offsite revisit survey was conducted to verify correction of all previous deficiencies cited on 2024-03-18.
Findings
All deficiencies have been corrected as of the compliance date of 2024-04-03, 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: 34
Deficiencies: 6
Date: Mar 18, 2024
Visit Reason
The inspection was a resurvey with complaints related to the assisted living facility conducted on 03/13/24, 03/14/24, and 03/18/24.
Complaint Details
The inspection was triggered by multiple complaints (180419, 180564, 181072, 182376, 182520, 185903, and 186477) concerning neglect, exploitation, and failure to report incidents timely.
Findings
The facility was found deficient in multiple areas including failure to protect residents from neglect and exploitation, failure to report allegations of abuse, neglect, or exploitation within 24 hours, incomplete negotiated service agreements, unlabeled prescription medication containers, and failure to perform quarterly emergency management plan reviews with residents.
Deficiencies (6)
Failed to protect resident R106 from neglect when staff deposited morning medications in a sharps container instead of administering them.
Failed to protect resident R102 from exploitation when staff diverted narcotics from R102's medication supply.
Failed to report allegations of abuse, neglect, or exploitation to the department within 24 hours.
Failed to ensure the Negotiated Service Agreement for resident R101 was fully developed based on functional capacity screening, service needs, and preferences.
Failed to ensure each prescription medication container had a label provided by a dispensing pharmacist affixed to the container.
Failed to ensure disaster and emergency preparedness by failing to perform quarterly reviews of the emergency management plan with residents.
Report Facts
Census: 34
Residents in sample: 3
Closed record reviews: 4
Missing narcotics report date: Feb 13, 2024
Initial report call date: Feb 15, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Staff A | Confirmed neglect and exploitation findings, reported missing narcotics, and acknowledged failure to report incidents within 24 hours. | |
| Certified Medication Aide B | Provided observations regarding resident R101's condition. | |
| Licensed Nurse D | Was being interviewed for suspected narcotics diversion but interview was not completed. |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Mar 13, 2024
Visit Reason
The document is a Plan of Correction addressing findings from a resurvey with multiple complaints at an Assisted Living facility conducted on 03/13/24, 03/14/24, and 03/18/24.
Complaint Details
The resurvey was conducted in response to multiple complaints as listed in the document.
Findings
The Plan of Correction references citations representing findings from a resurvey triggered by complaints numbered 180419, 180564, 181072, 182376, 182520, 185903, and 186477.
Report Facts
Complaint numbers: 7
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Feb 27, 2023
Visit Reason
An offsite revisit survey was conducted to verify correction of all previous deficiencies cited on 2023-02-02.
Findings
All deficiencies cited in the prior inspection have been corrected as of the compliance date of 2023-02-16, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Report Facts
Previous deficiencies cited: Deficiencies cited on 2023-02-02
Inspection Report
Re-Inspection
Census: 31
Deficiencies: 3
Date: Feb 2, 2023
Visit Reason
The inspection was a resurvey with complaint investigations for the assisted living facility conducted on 02/01/23 and 02/02/23.
Complaint Details
The resurvey included complaint investigations numbered 163640, 164981, 165000, 165090, 165101, 165919, 1672209, 173408, 175767, and 176324.
Findings
The facility was found deficient in multiple areas including failure to complete required criminal background checks for newly hired staff, failure to conduct quarterly reviews of the emergency management plan with residents and staff, and failure to ensure all exit doors and gates were properly secured and alarmed, resulting in an elopement incident and potential risk of significant injury to residents.
Deficiencies (3)
Failure to have evidence of completed criminal background checks for one of five newly hired staff.
Failure to ensure quarterly reviews of the emergency management plan with all residents and staff.
Failure to ensure all exit doors alarmed and were functioning properly and all exit gates were secure, resulting in resident elopement and risk of injury.
Report Facts
Census: 31
Newly hired employees reviewed: 5
Residents identified as moderate risk for elopement: 2
Drop off height: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Executive Director | Failed to ensure criminal background checks and secure exit doors | |
| Administrative Staff A | Reported issues with criminal background check submission and acknowledged emergency plan review deficiencies | |
| Administrative Licensed Nurse B | Observed elopement incident and reported on door alarm system failures | |
| Certified Medication Aide D | Reported door alarms coming across walkies |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Feb 1, 2023
Visit Reason
The document is a Plan of Correction addressing findings from a resurvey with complaint investigations conducted on 02/01/23 and 02/02/23 at an Assisted Living facility.
Complaint Details
The Plan of Correction relates to complaint investigations numbered 163640, 164981, 165000, 165090, 165101, 165919, 1672209, 173408, 175767, and 176324.
Findings
The Plan of Correction references multiple complaint investigations and citations from a resurvey conducted over two days, indicating prior deficiencies requiring correction.
Report Facts
Complaint investigations referenced: 10
Inspection Report
Follow-Up
Deficiencies: 3
Date: May 17, 2021
Visit Reason
This revisit report documents the correction of deficiencies previously reported during an earlier survey, verifying that corrective actions were completed.
Findings
The report confirms that all previously identified deficiencies related to specific regulations were corrected as of the revisit date.
Deficiencies (3)
Deficiency related to regulation 26-41-204 (a)
Deficiency related to regulation 26-41-204 (i)
Deficiency related to regulation 26-41-205 (g) (3)
Inspection Report
Renewal
Census: 36
Deficiencies: 3
Date: Apr 12, 2021
Visit Reason
The inspection was conducted as a survey for re-licensure with attached complaints on multiple dates in April 2021 at an assisted living facility in Tonganoxie, KS.
Complaint Details
The survey included attached complaints numbered #131559, 133941, 134913, 135941, 138806, 146496, 154925, 154899, 156510.
Findings
The facility failed to ensure licensed nurses provided or coordinated necessary health care services in accordance with functional capacity screenings and negotiated service agreements for residents with health care needs. Additionally, nursing staff failed to document wound size and condition for some residents, and the facility failed to ensure over-the-counter medication packages had residents' full names as required.
Deficiencies (3)
Failed to ensure licensed nurse provides or coordinates necessary health care services in accordance with functional capacity screening and negotiated service agreement for residents #406, 407, 408.
Failed to ensure all health care services were provided in accordance with acceptable standards of practice when nursing staff failed to document size and condition of wounds for residents #407 and #410.
Failed to ensure a licensed nurse or pharmacist placed the full name of the resident on packages of over-the-counter medications for 34 residents.
Report Facts
Census: 36
Residents sampled: 3
Residents receiving medication management: 34
Wound size: 4
Wound size: 0.4
Medication counts: 16
Medication counts: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed nurse #B | Interviewed nurse who confirmed lack of interventions for falls and wound documentation. | |
| Certified staff #C | Interviewed staff who confirmed OTC medications lacked resident full names and only had room numbers. |
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Jul 20, 2020
Visit Reason
The special infection control survey for COVID-19 was conducted at the facility on 2020-07-20.
Findings
The survey resulted in findings of no deficiency citations.
Inspection Report
Re-Inspection
Deficiencies: 5
Date: Apr 12, 2018
Visit Reason
This revisit inspection was conducted to verify that previously reported deficiencies have been corrected and to document the dates when corrective actions were accomplished.
Findings
All previously cited deficiencies identified by regulation or Life Safety Code provisions were corrected as of April 11, 2018.
Deficiencies (5)
Deficiency related to regulation 26-39-103 (q)
Deficiency related to regulation 26-41-204 (a)
Deficiency related to regulation 26-41-205 (g) (3)
Deficiency related to regulation 26-41-105 (f) (11)
Deficiency related to regulation 26-41-104 (d)
Report Facts
Deficiencies corrected: 5
Inspection Report
Renewal
Deficiencies: 0
Date: Mar 7, 2016
Visit Reason
The licensure resurvey was conducted as a renewal inspection of the assisted living facility.
Findings
The inspection resulted in a finding of no deficiency citations on 3-7-16.
Inspection Report
Renewal
Deficiencies: 0
Date: Jun 12, 2014
Visit Reason
The licensure resurvey was conducted as a renewal inspection of the assisted living facility.
Findings
The inspection resulted in no deficiency citations on the dates of 2014-06-11 and 2014-06-12.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: N052008 POC 4K4F11
Visit Reason
This document is a Plan of Correction submitted by the facility in response to deficiencies cited in a prior inspection report.
Findings
The document contains the provider's plan of correction for deficiencies identified in a previous inspection, but does not detail the specific findings or deficiencies themselves.
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