Deficiencies (last 8 years)
Deficiencies (over 8 years)
5.6 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
7% better than Kansas average
Kansas average: 6 deficiencies/yearDeficiencies per year
12
9
6
3
0
Occupancy
Latest occupancy rate
66% occupied
Based on a February 2026 inspection.
This facility has shown a decline in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Renewal
Census: 66
Deficiencies: 9
Date: Feb 5, 2026
Visit Reason
The inspection was a Re-Licensure survey combined with multiple complaint investigations conducted over several days in February 2026 at an assisted living facility.
Complaint Details
The inspection included complaint investigations with multiple complaint numbers listed, indicating the visit was triggered by complaints and included a re-licensure survey.
Findings
The facility failed to ensure licensed nursing staff provided or coordinated necessary health care services, including wound care and medication management. Deficiencies were found in documentation of incidents, medication administration by certified aides with lapsed certification, dietary services compliance, food preparation and temperature control, and tuberculosis screening for new employees.
Deficiencies (9)
KAR 26-41-204(a) The administrator failed to ensure a licensed nurse provided or coordinated necessary health care services for residents with pressure ulcers and stasis ulcers, including proper wound care and prevention interventions.
KAR 26-41-204(g)(1)(2) The executive director failed to ensure the health care service plan included skilled nursing care details and documentation of services and outcomes for a resident receiving IV antibiotics.
KAR 26-41-205(a)(1) The administrator failed to ensure licensed nurses completed assessments for self-administration of medications for two residents prior to and annually during self-administration.
KAR 26-41-205(b) The executive director failed to ensure the negotiated service agreement identified selected medications a resident chose to self-administer.
KAR 26-41-205(d)(1) The executive director failed to ensure only licensed nurses or certified medication aides administered medications, as one aide administered medications while certification was inactive.
KAR 26-41-105(f)(11) The administrator failed to ensure resident records contained documentation of all incidents, symptoms, actions taken, and results for two residents.
KAR 26-41-206(b)(2) The operator failed to ensure dietary staff had approved instructions from a medical provider or licensed dietitian for a resident on a therapeutic soft, bite-sized diet.
KAR 26-41-206(d) The executive director failed to ensure dietary staff prepared and served foods maintaining flavor, appearance, and proper serving temperature, as a steam table was cold and food served below required temperature.
KAR 26-41-207(c) The executive director failed to ensure compliance with tuberculosis screening guidelines for two newly hired employees who received TB skin tests more than seven days after hire.
Report Facts
Resident census: 66
Medication Aide certification lapse duration: 35
Medication Aide certification lapse duration: 26
Food temperature: 99
Food temperature: 128.4
Food temperature: 128
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Feb 2, 2026
Visit Reason
The document represents findings from a Re-Licensure survey with multiple complaint investigations conducted at the assisted living facility over several days.
Findings
The report summarizes the results of a Re-Licensure survey combined with complaint investigations identified by multiple event IDs conducted from February 2 to February 5, 2026.
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Dec 16, 2024
Visit Reason
An offsite revisit survey was conducted to verify correction of all previous deficiencies cited on 2024-11-18.
Findings
All deficiencies have been corrected as of the compliance date of 2024-12-11 and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Dec 16, 2024
Visit Reason
An offsite revisit survey was conducted to verify correction of all previous deficiencies cited on 2024-11-18.
Findings
All deficiencies have been corrected as of the compliance date of 2024-12-11 and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Inspection Report
Re-Inspection
Census: 89
Deficiencies: 8
Date: Nov 18, 2024
Visit Reason
Re-Licensure Survey with complaint investigations 185986 and 190261 for an Assisted Living Facility.
Complaint Details
The inspection included complaint investigations 185986 and 190261.
Findings
The facility failed to complete required admission screenings and agreements timely, did not ensure proper labeling of over-the-counter and sample medications, failed to monitor and document food preparation and storage safety, and did not maintain sanitary conditions for food service in the Memory Care unit.
Deficiencies (8)
KAR 26-41-201(a) Functional Capacity Screen on Admission was not completed on or before admission for one resident (R5).
KAR 26-41-202(c) Admission Negotiated Service Agreement was not completed at admission for one resident (R5).
KAR 26-41-202(h) Negotiated Service Agreement signatures were incomplete; not all parties signed for one resident (R5).
KAR 26-41-205(g)(3) Over-the-counter medications lacked residents' full names on original packages and containers.
KAR 26-41-205(g)(4)(E) Sample medications were not properly labeled with required information and verification for one resident (R3).
KAR 26-41-206(d) Food preparation was not monitored for proper temperature and no logs were maintained in Memory Care units.
KAR 26-41-206(e) Food storage was unsafe; food items in walk-in cooler were not sealed, labeled, or dated properly.
KAR 26-41-207(b)(4) Sanitary conditions for food service were inadequate; hot water temperature and chemical sanitizer strength were not documented daily in Memory Care unit.
Report Facts
Census: 89
Residents sampled: 3
Memory Care residents: 13
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nurse B | Administrative Nurse | Reported on admission screening and negotiated service agreement completion and signatures. |
| Dietary Staff C | Dietary Staff | Acknowledged lack of food temperature logs and sanitary documentation. |
| Dietary Staff E | Dietary Staff | Reported on food preparation and temperature monitoring. |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Nov 14, 2024
Visit Reason
The document addresses findings from a Re-Licensure Survey with complaint investigations conducted on 11/14/24 and 11/18/24 at an Assisted Living Facility.
Findings
The citations represent findings from the Re-Licensure Survey and complaint investigations. The document is a Plan of Correction submitted in response to these findings.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Oct 16, 2023
Visit Reason
The abbreviated survey was conducted on 10/16/23 in response to complaints #183303 and #182260 at the assisted living facility.
Complaint Details
The visit was complaint-related for complaints #183303 and #182260. No deficiencies were found.
Findings
The survey resulted in a finding of no deficiency citations.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Oct 16, 2023
Visit Reason
The abbreviated survey was conducted in response to complaints #183303 and #182260 at the assisted living facility.
Complaint Details
The survey was complaint-related for complaints #183303 and #182260 and found no deficiencies.
Findings
The survey resulted in a finding of no deficiency citations.
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Jun 29, 2023
Visit Reason
An offsite revisit survey was conducted to verify correction of all previous deficiencies cited on 2023-06-07.
Findings
All deficiencies cited in the prior inspection have been corrected as of the compliance date of 2023-06-28, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Jun 29, 2023
Visit Reason
An offsite revisit survey was conducted to verify correction of all previous deficiencies cited on 2023-06-07.
Findings
All deficiencies cited in the prior inspection have been corrected as of the compliance date of 2023-06-28, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Jun 29, 2023
Visit Reason
An offsite revisit survey was conducted to verify correction of all previous deficiencies cited on 2023-06-07.
Findings
All deficiencies cited in the previous inspection have been corrected as of the compliance date of 2023-06-28, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Jun 29, 2023
Visit Reason
An offsite revisit survey was conducted to verify correction of all previous deficiencies cited on 2023-06-07.
Findings
All deficiencies cited in the prior inspection have been corrected as of the compliance date 2023-06-28, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Jun 29, 2023
Visit Reason
An offsite revisit survey was conducted to verify correction of all previous deficiencies cited on 2023-06-07.
Findings
All deficiencies cited in the prior inspection have been corrected as of the compliance date 2023-06-28, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Jun 29, 2023
Visit Reason
An offsite revisit survey was conducted to verify correction of all previous deficiencies cited on 2023-06-07.
Findings
All deficiencies cited in the previous inspection have been corrected as of the compliance date of 2023-06-28, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Inspection Report
Renewal
Census: 65
Deficiencies: 8
Date: Jun 7, 2023
Visit Reason
The inspection was a Re-Licensure survey with complaint investigations for an assisted living facility conducted on 06/07/2023 and 06/08/2023.
Complaint Details
The survey included complaint investigations numbered 177868, 177487, 175966, and 170044.
Findings
The facility was found deficient in multiple areas including failure to develop complete negotiated service agreements for residents, failure to review and revise service agreements after significant changes, failure to label over-the-counter medications with resident names, inadequate documentation and policies for sample medications, lack of electronic medical record policies, incomplete resident record documentation, and failure to conduct quarterly emergency management plan reviews with all employees and residents.
Deficiencies (8)
KAR 26-41-202 (a)(1)(2)(3) The facility failed to ensure negotiated service agreements included descriptions of services, providers, and payment responsibilities for residents' needs such as falls and podiatry.
KAR 26-41-202 (d)(2) The facility failed to review and revise negotiated service agreements following significant changes in resident condition, such as initiation of Home Health services.
KAR 26-41-204 (d) The facility failed to include the name of the licensed nurse responsible for implementation and supervision of the health care service plan in residents' negotiated service agreements.
KAR 26-41-205 (g)(3) The facility failed to ensure all over-the-counter medications were labeled with the resident's full name on both the original package and medication container.
KAR 26-41-205 (g)(4)(D)(E)(F) The facility failed to properly document receipt, labeling, and resident notification for sample medications as required.
KAR 26-41-105 (e) The facility failed to develop policies addressing protection, safeguarding, confidentiality, and preservation of electronic medical records.
KAR 26-41-105 (f)(11) The facility failed to document incidents including wound assessment and changes in resident medication administration status.
KAR 26-41-104 (d)(3)(4) The facility failed to conduct quarterly reviews of the emergency management plan with all employees and residents.
Report Facts
Census: 65
Deficiencies cited: 8
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Dec 22, 2021
Visit Reason
The licensure resurvey was conducted on 12/20/2021, 12/21/2021, and 12/22/2021 at the assisted living facility.
Findings
The resurvey resulted in a finding of no deficiency citations.
Inspection Report
Renewal
Deficiencies: 0
Date: Dec 22, 2021
Visit Reason
The licensure resurvey was conducted as a renewal inspection at the assisted living facility on 12/20/2021 through 12/22/2021.
Findings
The inspection resulted in no deficiency citations for the facility.
Inspection Report
Routine
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: 72
Deficiencies: 3
Date: Jul 2, 2019
Visit Reason
The inspection was a resurvey with complaints #141243 and #133072 conducted on multiple dates from 2019-06-19 to 2019-07-02 to evaluate compliance with regulatory requirements.
Complaint Details
The resurvey was conducted in response to complaints #141243 and #133072. The findings confirmed failures related to Functional Capacity Screening and incident documentation.
Findings
The facility failed to conduct Functional Capacity Screenings (FCS) following significant changes in condition for sampled residents. The licensed nurse did not ensure provision of necessary health care services in accordance with FCS and negotiated service agreements. Documentation of incidents, including an elopement, was incomplete and not timely.
Deficiencies (3)
KAR 26-41-201(c)(2) Functional Capacity Screening was not conducted following significant changes in condition for residents #211 and #677.
KAR 26-41-204(a) The licensed nurse failed to provide or coordinate necessary health care services for resident #456 in accordance with the Functional Capacity Screening and Negotiated Service Agreement regarding use of a bed assistive device.
KAR 26-41-105(f)(11) Resident record lacked documentation of all incidents, symptoms, and indications of illness or injury including date, time, action taken, and results for resident #852.
Report Facts
Census: 72
Sample size: 6
Closed record review: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Nurse A | Licensed Nurse | Interviewed and confirmed failures in Functional Capacity Screening and incident documentation; involved in notification and care coordination. |
| Licensed Nurse H | Licensed Nurse | Documented resident incidents and behaviors related to resident #211 and #677. |
| Licensed Nurse I | Licensed Nurse | Administered medication and attempted to redirect resident #211 during an incident. |
| Licensed Nurse J | Licensed Nurse | Reported resident found outside and safely returned to unit. |
| Licensed Nurse K | Licensed Nurse | Documented verbal abuse incident involving resident #677. |
| Licensed Nurse G | Licensed Nurse | Received call from police regarding missing resident #852. |
Inspection Report
Follow-Up
Deficiencies: 3
Date: Dec 28, 2017
Visit Reason
This revisit inspection was conducted to verify that previously cited deficiencies have been corrected by the facility.
Findings
All previously reported deficiencies identified by regulation numbers 26-41-204 (a), 26-41-104 (d), and 26-41-207 (b)(5-6)(c) were corrected as of the revisit date.
Deficiencies (3)
Regulation 26-41-204 (a) deficiency was corrected as of 12/28/2017.
Regulation 26-41-104 (d) deficiency was corrected as of 12/28/2017.
Regulation 26-41-207 (b)(5-6)(c) deficiency was corrected as of 12/28/2017.
Inspection Report
Re-Inspection
Census: 90
Deficiencies: 6
Date: Nov 30, 2017
Visit Reason
Re-survey inspection conducted over multiple days in November 2017 to assess compliance with previously cited deficiencies and regulatory requirements at Avita Senior Living at Rolling Hills.
Findings
The facility was found deficient in multiple areas including failure to conduct functional capacity screenings following significant changes in resident condition, failure to revise negotiated service agreements accordingly, inadequate provision and coordination of health care services for cognitively impaired residents with fall risks, medication administration not in accordance with provider orders, incomplete disaster preparedness reviews, and non-compliance with tuberculosis screening requirements for staff.
Deficiencies (6)
KAR 26-41-201(c)(2) Functional Capacity Screen: Facility staff failed to conduct a Functional Capacity Screen following a significant change in condition for resident #300.
KAR 26-41-202(d) Negotiated Service Agreement Revisions: Administrator failed to ensure review and revision of the Negotiated Service Agreement following significant change in condition for resident #300.
KAR 26-41-204(a) Health Care Services: Administrator failed to ensure licensed nurse provided or coordinated necessary health care services for residents #111, #100, and #500 who had cognitive impairments and experienced multiple falls.
KAR 26-41-205(d) Facility Administration of Medications: Administrator failed to ensure medications were administered according to provider orders and standards for resident #300, with delays in administration of prescribed diuretics and potassium.
KAR 26-41-104(d) Disaster and Emergency Preparedness: Administrator failed to ensure quarterly review of emergency management plan with residents and complete review with staff.
KAR 26-41-207(c) Infection Control Policies: Administrator failed to ensure compliance with tuberculosis screening guidelines; two staff lacked required two-step TB skin tests.
Report Facts
Resident falls: 19
Resident falls: 13
Resident falls: 7
Medication administration delay: 8
Facility census: 90
Inspection Report
Follow-Up
Deficiencies: 0
Date: Dec 29, 2015
Visit Reason
This visit was conducted as a follow-up to verify correction of previously cited deficiencies from the survey completed on 2015-12-02.
Findings
All previously reported deficiencies listed by regulation numbers were corrected as of 2015-12-29. The report confirms completion of corrective actions for each cited deficiency.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Dec 29, 2015
Visit Reason
This visit was conducted as a follow-up to verify correction of previously cited deficiencies from the survey completed on 2015-12-02.
Findings
All previously reported deficiencies were corrected as of the revisit date. The report lists multiple regulation citations with correction completion dates of 2015-12-29.
Inspection Report
Complaint Investigation
Census: 94
Deficiencies: 8
Date: Dec 2, 2015
Visit Reason
Resurvey with investigation of complaint #84254 regarding failure to report and investigate incidents of residents found on the floor and other regulatory compliance issues.
Complaint Details
Complaint #84254 triggered the investigation focusing on failure to report and investigate residents found on the floor and other compliance issues.
Findings
The facility failed to report and investigate incidents of cognitively impaired residents found on the floor within 24 hours, failed to conduct timely functional capacity screenings, failed to develop and properly sign negotiated service agreements, failed to provide coordinated health care services addressing residents' risks, failed to maintain resident records properly, failed to conduct quarterly emergency management plan reviews, and failed to prepare mechanically altered diets and thickened liquids according to medical orders.
Deficiencies (8)
KAR 26-41-101(f)(3)(A) The administrator failed to report and immediately investigate incidents when staff found cognitively impaired residents on the floor to rule out abuse or neglect.
KAR 26-41-201(c)(1)(2) The administrator failed to ensure functional capacity screenings were conducted at least annually and after significant changes for sampled residents.
KAR 26-41-202(a)(1)(2) The administrator failed to develop written negotiated service agreements for sampled residents that included descriptions of services and providers, especially hospice services.
KAR 26-41-202(h) The administrator failed to ensure all individuals involved in developing negotiated service agreements signed the agreements for sampled residents.
KAR 26-41-204(a) The administrator failed to ensure licensed nurses provided or coordinated necessary health care services addressing residents' needs and risks, including fall prevention.
KAR 26-41-105(a) The administrator failed to maintain resident records in accordance with accepted standards, including proper dating of health care plan interventions and documentation of resident discharges.
KAR 26-41-104(d)(3) The administrator failed to ensure quarterly review of the emergency management plan with employees and residents.
KAR 26-41-206(b)(2) The administrator failed to ensure mechanically altered diets and thickened liquids were prepared according to medical care provider or licensed dietitian instructions.
Report Facts
Resident census: 94
Residents sampled: 6
Falls recorded for resident #333: 24
Falls recorded for resident #777: 11
Inspection Report
Plan of Correction
Deficiencies: 0
Date: N087067 POC 2K8111
Visit Reason
This document is a Plan of Correction related to a prior deficiency report for Avita Senior Living at Rolling Hills.
Findings
No specific findings or deficiencies are detailed in this document. It serves as a placeholder or reference for the Plan of Correction submission.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: N087067 POC 2K8112
Visit Reason
This document is a Plan of Correction related to a previous inspection event for the facility identified as ASPEN with State ID N087067 and Event ID 2K8112.
Findings
No deficiency records or findings are included in this Plan of Correction document.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: N087067 POC HJMI11
Visit Reason
This document is a Plan of Correction related to a prior inspection or deficiency report for the facility identified as ASPEN with State ID N087067.
Findings
No deficiency details or findings are included in this document. It serves solely as a placeholder or record for the Plan of Correction submission with no substantive content.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: N087067 POC HJMI12
Visit Reason
This document serves as a plan of correction related to a prior inspection or deficiency report for the facility identified as Aspen.
Findings
No deficiency records or findings are included in this plan of correction document.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: N087067 POC QWP111
Visit Reason
This document is a Plan of Correction related to a previous deficiency report for the facility.
Findings
No specific findings or deficiencies are detailed in this document. It serves as a placeholder or administrative record for the Plan of Correction.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: N087067 POC QWP112
Visit Reason
This document is a Plan of Correction related to a prior inspection event identified as QWP112 for the facility with State ID N087067.
Findings
No deficiency details or findings are included in this document. It only references the Plan of Correction status and contact information for assistance.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: N087067 POC UP2I11
Visit Reason
This document is a plan of correction related to deficiencies found in a prior inspection at Avita Senior Living at Rolling Hills concerning COVID-19.
Findings
No specific findings or deficiencies are detailed in this document. It serves as a placeholder or reference to a prior deficiency report.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: N087067 POC XT3Q11
Visit Reason
This document is a Plan of Correction related to a prior deficiency report for the facility Avita Rolling Hills dated 7-2-19.
Findings
No specific findings or deficiencies are detailed in this document. It serves as a placeholder or reference for the Plan of Correction associated with the prior inspection.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: N087067 POC ZWXS11
Visit Reason
This document is a Plan of Correction related to a prior inspection or deficiency report for the facility identified as State ID N087067.
Findings
No specific deficiencies or findings are detailed in this document. It serves as a record of the Plan of Correction submission and related contact information.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: N087067 POC ZWXS12
Visit Reason
This document is a Plan of Correction related to a prior inspection event identified as ZWXS12 for facility State ID N087067 ASPEN.
Findings
No deficiency details or findings are included in this Plan of Correction document. It only references the related deficiency report with no records found.
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