Deficiencies (last 8 years)
Deficiencies (over 8 years)
1.6 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
73% better than Kansas average
Kansas average: 6 deficiencies/yearDeficiencies per year
8
6
4
2
0
Occupancy
Latest occupancy rate
80% occupied
Based on a August 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Aug 28, 2025
Visit Reason
An offsite revisit survey was conducted to verify correction of all previous deficiencies cited on 2025-08-12.
Findings
All deficiencies have been corrected as of the compliance date of 2025-08-25, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Aug 12, 2025
Visit Reason
The document represents the findings of a resurvey with attached complaints #195254 and #190591 at the assisted living facility conducted on 08/12/25.
Findings
This is a plan of correction document related to a resurvey and complaints at the assisted living facility. The document does not provide specific findings or deficiencies but references the linked deficiency report.
Inspection Report
Re-Inspection
Census: 32
Deficiencies: 8
Date: Aug 12, 2025
Visit Reason
This is a resurvey with attached complaints #195254 and #190591 conducted at an assisted living facility to verify correction of previous deficiencies and investigate complaints.
Complaint Details
This resurvey included attached complaints #195254 and #190591. The complaints involved failure to notify legal representatives of resident condition changes and other care deficiencies.
Findings
The inspection found multiple deficiencies including failure to notify legal representatives of resident condition changes, untimely staple removal, lack of medication self-administration assessments, incomplete medication management agreements, inadequate documentation of incidents, failure to conduct quarterly emergency plan reviews, unsafe food storage practices, and poor sanitary conditions in the kitchen.
Deficiencies (8)
KAR 26-39-103(h)(1)(B) Resident Right Notification of Changes: The administrator failed to ensure licensed staff consulted Resident 2's physician and notified her legal representative when a red area on her leg developed into an open sore.
KAR 26-41-204(i) Health Care Services Standards of Practice: The administrator failed to ensure timely staple removal for Resident 4, with removal occurring after the seven-day recommended period.
KAR 26-41-205(a)(1) Self Administration of Medication: The administrator failed to ensure licensed nurse assessments were completed to determine if Residents 1 and 3 could safely self-administer medications.
KAR 26-41-205(b) Administration of Selected Medications: The administrator failed to ensure Resident 1's negotiated service agreement identified who was responsible for administration and management of insulin.
KAR 26-41-105(f)(11) Resident Record Documentation of Incidents: The administrator failed to ensure licensed staff documented all incidents, symptoms, and indications of illness or injury for Resident 2, including date, time, action taken, and results.
KAR 26-41-104(d) Disaster and Emergency Preparedness: The administrator failed to provide evidence of quarterly reviews of the facility's emergency management plan with residents and staff.
KAR 26-41-206(e) Facility Food Storage: The administrator failed to ensure designated staff stored food items under safe and sanitary conditions, with numerous unlabeled and expired food items observed.
KAR 26-41-207(a)(b) Infection Control: The administrator failed to ensure designated staff maintained sanitary conditions for food handling, with unclean equipment, dust, grease buildup, and blank cleaning logs observed in the kitchen.
Report Facts
Census: 32
Deficiencies cited: 8
Resident red area size: 3
Staple removal delay: 2
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Feb 19, 2024
Visit Reason
An offsite revisit survey was conducted to verify correction of all previous deficiencies cited on 2024-01-30.
Findings
All deficiencies have been corrected as of the compliance date of 2024-02-19, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Inspection Report
Re-Inspection
Census: 30
Deficiencies: 3
Date: Jan 30, 2024
Visit Reason
The inspection was a licensure resurvey with attached complaint investigations numbered 180225, 180179, and 180114 conducted at the facility.
Complaint Details
The inspection included complaint investigations numbered 180225, 180179, and 180114.
Findings
The facility failed to ensure that negotiated service agreements were signed by all participants, over-the-counter medications were properly labeled with resident names, and resident records contained complete documentation of incidents, symptoms, actions taken, and results for residents R1, R2, and R3.
Deficiencies (3)
KAR 26-41-202(h) The facility failed to ensure the negotiated service agreement for Resident R1 was signed by all participants involved in its development.
K.A.R. 26-41-205 (g)(3) The facility failed to ensure over-the-counter medications were labeled with the full name of the resident, and stock medications were improperly used.
K.A.R. 26-41-105 (f)(11) The facility failed to document all incidents, symptoms, actions taken, and results for residents R1, R2, and R3 after falls and illness indications.
Report Facts
Resident census: 30
Falls documented for Resident R3: 6
Falls documented for Resident R2: 3
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Jan 30, 2024
Visit Reason
The document is a plan of correction responding to findings from a licensure resurvey with attached complaint investigations numbered 180225, 180179, and 180114 conducted on January 30, 2024.
Findings
The plan of correction addresses citations resulting from the licensure resurvey and associated complaints at the facility.
Inspection Report
Renewal
Deficiencies: 0
Date: Jul 7, 2022
Visit Reason
The licensure resurvey with complaint number 159738 was conducted on 7/5/2022, 7/6/2022, and 7/7/2022 at the assisted living facility.
Findings
The inspection resulted in a finding of no deficiency citations.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Jul 7, 2022
Visit Reason
The licensure resurvey with complaint number 159738 was conducted on 7/5/2022, 7/6/2022, and 7/7/2022 at the assisted living facility.
Findings
The resurvey resulted in a finding of no deficiency citations.
Inspection Report
Renewal
Census: 28
Deficiencies: 1
Date: Sep 9, 2020
Visit Reason
The inspection was conducted for re-licensure with attached complaints and a special infection control/COVID survey at the assisted living facility.
Findings
The facility failed to maintain safe hot water temperatures between 98 and 120 degrees Fahrenheit at sinks and showers in resident rooms, with multiple instances of water temperatures exceeding 120 degrees. The facility lacked a policy for hot water monitoring and water temperatures fluctuated due to shared hot water heaters.
Deficiencies (1)
KAR 28-39-256 (c)(2)(B) The facility failed to ensure the water distribution system maintained hot water temperatures between 98 and 120 degrees Fahrenheit at sinks and showers in resident rooms, with observed temperatures up to 127.5F.
Report Facts
Resident census: 28
Water temperature readings: 127.5
Water temperature readings: 125.4
Water temperature readings: 127.1
Water temperature readings: 123.8
Water temperature readings: 126.3
Water temperature readings: 123.6
Water temperature readings: 124
Water temperature readings: 122.9
Water temperature readings: 123.4
Residents with impaired cognitive status: 9
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Director #D | Interviewed regarding water temperature testing and facility policy. | |
| Corporation Nurse #C | Interviewed by phone regarding facility policy on hot water monitoring. | |
| Operator #A | Participated in phone interview regarding facility policy on hot water monitoring. |
Inspection Report
Renewal
Deficiencies: 0
Date: Nov 14, 2018
Visit Reason
A survey for re-licensure was conducted on 11/13/18 and 11/14/18 at the assisted living unit in Overland Park, KS.
Findings
The survey resulted in a finding of no deficiency citations.
Inspection Report
Renewal
Deficiencies: 0
Date: Nov 15, 2016
Visit Reason
The licensure resurvey of the assisted living facility was conducted on 11-14-16 and 11-15-16 as part of the renewal process.
Findings
The inspection resulted in findings of no deficiency citations.
Inspection Report
Re-Inspection
Census: 31
Deficiencies: 1
Date: Sep 21, 2015
Visit Reason
The visit was a resurvey of the assisted living facility conducted on 9-16-15, 9-17-15, and 9-21-15 to evaluate compliance with regulatory requirements following prior findings.
Findings
The operator failed to ensure that allegations of abuse, neglect, or exploitation were reported to the department within 24 hours and investigated promptly. Specifically, for resident #233, multiple falls were not reported or investigated as required.
Deficiencies (1)
KAR 26-41-101 (f)(3)(A) requires reporting and investigation of abuse allegations within 24 hours. The operator failed to report and investigate multiple falls involving resident #233, who was cognitively impaired and unable to explain the incidents.
Report Facts
Resident census: 31
Sample size: 3
Inspection Report
Plan of Correction
Deficiencies: 0
Date: May 7, 2012
Visit Reason
This document is a plan of correction submitted in response to deficiencies identified in a prior inspection.
Findings
No specific deficiencies or findings are detailed in this document. It only indicates the existence of a plan of correction with no records found.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: N046070 POC 4WWE11
Visit Reason
This document is a Plan of Correction related to a prior inspection or regulatory event for the facility identified as ASPEN with State ID N046070 and Event ID 4WWE11.
Findings
No deficiency details or findings are included in this document. It serves as a record of the Plan of Correction submission and modification dates.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: N046070 POC BRAH11
Visit Reason
This document is a Plan of Correction related to a prior deficiency report for the facility.
Findings
No specific findings or deficiencies are detailed in this document. It serves as a record of the Plan of Correction submission and modification dates.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: N046070 POC DO3R11
Visit Reason
This document is a Plan of Correction related to a prior deficiency report for the facility Silvercrest at Deer Creek dated 9.9.2020.
Findings
No specific findings are detailed in this document. It serves as a Plan of Correction submission referencing a prior deficiency report.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: N046070 POC IWJ311
Visit Reason
This document is a Plan of Correction related to a prior deficiency report for the facility Silvercrest at Deer Creek.
Findings
No specific findings or deficiencies are detailed in this document. It serves as a record of the Plan of Correction submission and modification dates.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: N046070 POC WJEO11
Visit Reason
This document is a Plan of Correction related to a prior deficiency report for the facility Silvercrest at Deer Creek.
Findings
No specific findings or deficiencies are detailed in this document. It serves as a record of the Plan of Correction submission and modification dates.
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