Deficiencies (last 7 years)
Deficiencies (over 7 years)
5.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
12% better than Kansas average
Kansas average: 6 deficiencies/yearDeficiencies per year
16
12
8
4
0
Occupancy
Latest occupancy rate
69% occupied
Based on a March 2026 inspection.
This facility has shown a decline in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Mar 17, 2026
Visit Reason
This document is a plan of correction submitted in response to findings from a licensure resurvey with an attached complaint conducted on March 17, 2026.
Complaint Details
The inspection was conducted with an attached complaint (198005).
Findings
The plan of correction addresses citations found during the licensure resurvey and complaint investigation conducted on March 17, 2026. Specific deficiencies are referenced in the linked deficiency report.
Inspection Report
Complaint Investigation
Census: 29
Deficiencies: 1
Date: Mar 17, 2026
Visit Reason
The inspection was a licensure resurvey combined with a complaint investigation for the facility.
Complaint Details
The inspection included a complaint investigation identified as complaint number 198005.
Findings
The facility failed to ensure disaster and emergency preparedness by not performing quarterly reviews of the entire Emergency Management Plan with residents and staff as required. Documentation was missing for emergency management plan reviews with residents for the third and fourth quarters of 2025 and with staff for the third quarter of 2025.
Deficiencies (1)
26-41-104 (d) Disaster and Emergency Preparedness: The facility failed to perform quarterly reviews of the entire Emergency Management Plan with residents and staff as required. Documentation was missing for reviews with residents for the third and fourth quarters of 2025 and with staff for the third quarter of 2025.
Report Facts
Resident census: 29
Sample residents reviewed: 3
Newly hired employee records reviewed: 5
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Dec 9, 2024
Visit Reason
An offsite revisit survey was conducted to verify correction of all previous deficiencies cited on 2024-11-25.
Findings
All deficiencies have been corrected as of the compliance date of 2024-12-09 and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Dec 9, 2024
Visit Reason
An offsite revisit survey was conducted to verify correction of all previous deficiencies cited on 2024-11-25.
Findings
All deficiencies have been corrected as of the compliance date of 2024-12-09 and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Nov 25, 2024
Visit Reason
This document is a plan of correction submitted in response to a resurvey with attached complaints (#187507 and #187419) conducted at the facility on 11/25/2024.
Findings
The plan of correction addresses findings from a resurvey and complaint investigations conducted on 11/25/2024 at the facility.
Inspection Report
Re-Inspection
Census: 21
Deficiencies: 1
Date: Nov 25, 2024
Visit Reason
The visit was a resurvey with attached complaints (#187507 and #187419) conducted to assess compliance with staff development requirements related to dementia care.
Complaint Details
The inspection was conducted as a resurvey with attached complaints #187507 and #187419.
Findings
The facility failed to provide required staff orientation and in-service education on dementia care for 4 of 5 sampled employees. The deficiency has the potential to affect all residents, including those with impaired cognition.
Deficiencies (1)
KAR 26-41-103 (c) Staff Development on Dementia: The facility failed to ensure employee orientation and in-service education on treatment and appropriate response to persons exhibiting dementia-related behaviors for 4 of 5 sampled employees.
Report Facts
Resident census: 21
Employees reviewed: 5
Employees lacking dementia training: 4
Residents with impaired cognition: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Operator LN A | Operator / Licensed Nurse | Named in failure to ensure provision of dementia training for employees. |
| CMA B | Certified Medication Aide | Employee lacking documented dementia training upon hire. |
| CMA C | Certified Medication Aide | Employee lacking documented dementia training upon hire. |
| CNA D | Certified Nurse Aide | Employee lacking documented dementia training upon hire. |
| CNA E | Certified Nurse Aide | Employee lacking documented dementia training upon hire. |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Aug 15, 2023
Visit Reason
An abbreviated survey was conducted at the assisted living facility on 08/15/23.
Findings
The abbreviated survey resulted in no deficiency citations.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Aug 15, 2023
Visit Reason
An abbreviated survey was conducted at the assisted living facility to assess compliance.
Findings
The abbreviated survey conducted on 08/15/23 resulted in no deficiency citations.
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Jun 5, 2023
Visit Reason
An offsite revisit survey was conducted to verify correction of all previous deficiencies cited on 2023-05-10.
Findings
All deficiencies have been corrected as of the compliance date of 2023-05-25, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Jun 5, 2023
Visit Reason
An offsite revisit survey was conducted to verify correction of all previous deficiencies cited on 2023-05-10.
Findings
All deficiencies have been corrected as of the compliance date of 2023-05-25, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: May 10, 2023
Visit Reason
The document is a plan of correction submitted in response to a resurvey with complaints (#179908, #166708, and #166641) conducted at the facility on 2023-05-10.
Findings
The plan of correction addresses citations found during the resurvey with complaints at the facility on 2023-05-10. Specific deficiencies are not detailed in this document.
Inspection Report
Re-Inspection
Census: 19
Deficiencies: 6
Date: May 10, 2023
Visit Reason
The inspection was a resurvey with complaints (#179908, #166708, and #166641) conducted at Marquis Place on 05/10/2023.
Complaint Details
The inspection was a resurvey with complaints #179908, #166708, and #166641.
Findings
The facility was found deficient in multiple areas including failure to properly delegate nursing procedures to medication aides, incomplete criminal background checks for staff, inadequate disaster and emergency preparedness reviews, failure to serve food at proper temperatures, and failure to post required electronic monitoring notices.
Deficiencies (6)
KAR 26-41-204 (e) Delegation of Duties: Licensed nurse failed to delegate nursing procedures such as blood sugar monitoring to medication aides as required by Kansas nurse practice act.
KAR 26-41-205 (d) (4) Delegation of Medication Administration: Licensed nurse failed to ensure delegation of insulin pen dialing to medication aides with competency assessment.
KAR 26-41-102 (d) Staff Qualifications Employee Records: Facility failed to obtain evidence of criminal background checks through the Kansas Department for Aging and Disability Services for newly hired staff.
KAR 26-41-104 (d) Disaster and Emergency Preparedness: Facility failed to perform quarterly reviews of the emergency management plan with staff and residents as required.
KAR 26-41-206 (d) Food Preparation: Facility staff failed to serve food at the proper temperature, with missing supper food temperature logs on multiple dates.
Kansas Statute 39-981 Authorized Electronic Monitoring: Facility failed to post conspicuous notices at the entrance and resident rooms regarding electronic monitoring.
Report Facts
Deficiencies cited: 6
Census: 19
Missing supper food temperature log dates: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Operator/LN A | Operator/Licensed Nurse | Named in multiple findings related to delegation failures, background check deficiencies, emergency preparedness, food temperature monitoring, and electronic monitoring signage. |
| CMA C | Certified Medication Aide | Mentioned in relation to missing competency checkoffs for accuchecks and insulin pen dialing. |
| CMA D | Certified Medication Aide | Mentioned in relation to missing competency checkoffs for accuchecks and insulin pen dialing. |
| Dietary Staff B | Dietary Staff | Interviewed regarding food temperature monitoring logs. |
Inspection Report
Routine
Deficiencies: 0
Date: Jul 30, 2020
Visit Reason
The special infection control survey for COVID-19 was conducted at the facility on 07/30/2020.
Findings
The survey resulted in findings of no deficiency citations.
Inspection Report
Follow-Up
Deficiencies: 8
Date: May 13, 2019
Visit Reason
This visit was conducted as a follow-up to verify correction of previously cited deficiencies at the facility.
Findings
All previously reported deficiencies were corrected as of the revisit date. The report documents completion of corrective actions for multiple cited regulations.
Deficiencies (8)
26-41-201 (a) (b): Previously cited deficiency corrected as of 05/13/2019.
26-41-202 (a): Previously cited deficiency corrected as of 05/13/2019.
26-41-204 (d): Previously cited deficiency corrected as of 05/13/2019.
26-41-205 (l) (3): Previously cited deficiency corrected as of 05/13/2019.
26-41-102 (d): Previously cited deficiency corrected as of 05/13/2019.
26-41-104 (b): Previously cited deficiency corrected as of 05/13/2019.
26-41-104 (d): Previously cited deficiency corrected as of 05/13/2019.
26-41-104 (e): Previously cited deficiency corrected as of 05/13/2019.
Inspection Report
Renewal
Census: 23
Deficiencies: 8
Date: Apr 9, 2019
Visit Reason
Licensure Resurvey of an assisted living facility conducted on 4/03/19, 4/04/19, 4/08/19, and 4/09/19 to assess compliance with state regulations.
Findings
The facility failed to complete required functional capacity screens and negotiated service agreements for sampled residents, lacked medication regimen reviews in clinical records, had incomplete employee criminal background check documentation, and had deficiencies in emergency management planning and preparedness.
Deficiencies (8)
KAR 26-41-201(a): Facility staff failed to complete functional capacity screens for two of three sampled residents that included all required elements and definitions.
KAR 26-41-202(a): Negotiated service agreements for two of three sampled residents lacked descriptions of services the residents would receive.
KAR 26-41-204(d): Negotiated service agreements for three sampled residents lacked the name of the licensed nurse responsible for implementation and supervision of the health service plan.
KAR 26-41-205(l)(3): Medication regimen reviews were not kept in each resident's clinical record for three sampled residents, missing reviews for multiple months.
KAR 26-41-102(d): Employee records for four of five new hires lacked supporting documentation for criminal background checks as required by state law.
KAR 26-41-104(b): Emergency management plan lacked procedures for water outage and missing residents, failing to include all required topics.
KAR 26-41-104(d): Facility failed to conduct evacuation drills at least annually and did not conduct quarterly reviews of the emergency management plan with employees and residents.
KAR 26-41-104(e): Emergency management plan was not made available to staff not authorized to pass medications, residents, and visitors.
Report Facts
Resident census: 23
Employees hired since last resurvey: 14
Residents sampled: 3
Residents receiving medication and treatment management: 22
Residents self-administering medications: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Operator/LPN #G | Licensed Practical Nurse | Named in relation to confirming deficiencies in functional capacity screens, negotiated service agreements, medication reviews, employee records, and emergency plan availability |
| Administrator/RN #F | Registered Nurse | Named in relation to confirming deficiencies in functional capacity screens, negotiated service agreements, medication reviews, and emergency plan availability |
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Jul 11, 2017
Visit Reason
This is a revisit inspection to verify that previously reported deficiencies have been corrected and to document the dates such corrective actions were accomplished.
Findings
All previously cited deficiencies listed by regulation numbers were corrected as of the revisit date.
Inspection Report
Follow-Up
Deficiencies: 6
Date: Jul 11, 2017
Visit Reason
This visit was conducted as a follow-up to verify that previously reported deficiencies have been corrected and to confirm the date such corrective actions were accomplished.
Findings
All deficiencies previously reported were corrected as of the revisit date. Each deficiency was identified by regulation number and marked as completed.
Deficiencies (6)
26-39-103 (i): Previously cited deficiency corrected as of 07/11/2017.
26-41-202 (j): Previously cited deficiency corrected as of 07/11/2017.
26-41-204 (a): Previously cited deficiency corrected as of 07/11/2017.
26-41-205 (e) (f): Previously cited deficiency corrected as of 07/11/2017.
26-41-102 (c): Previously cited deficiency corrected as of 07/11/2017.
28-39-255: Previously cited deficiency corrected as of 07/11/2017.
Inspection Report
Renewal
Census: 26
Deficiencies: 6
Date: Jun 22, 2017
Visit Reason
Licensure Resurvey at an Assisted Living Facility in Concordia, Kansas conducted on 6/19/17 through 6/22/17 to assess compliance with state regulations and licensing requirements.
Findings
The facility was found deficient in multiple areas including failure to protect resident privacy and confidentiality, inadequate monitoring of outside service providers, failure to provide necessary health care services as per resident plans, incomplete documentation of verbal medication orders, lack of RN supervision for licensed practical nurses, and unsecured chemical storage in the laundry room.
Deficiencies (6)
KAR 26-39-103(i) Resident Right Privacy and Confidentiality. The Administrator failed to develop and implement policies to ensure personal and clinical records were maintained confidentially, including improper posting of resident resuscitation preferences in public areas.
KAR 26-41-202(j) Negotiated Service Agreement Outside Resource. The Operator failed to ensure designated staff monitored services provided by outside resources for residents #185, #187, and #189, lacking documentation of therapy visits and progress.
KAR 26-41-204(a) Health Care Services. The Administrator failed to ensure a licensed nurse provided or coordinated necessary health care services for resident #189, including interventions for open area treatment and fall prevention.
KAR 26-41-205(e) Medication Verbal Orders and Standing Orders. Licensed nurse failed to ensure verbal orders for residents #185 and #187 were signed by the medical care provider within seven working days.
KAR 26-41-102(c) Staff Qualifications RN available. The Administrator failed to ensure a Registered Nurse was available to supervise licensed practical nurses as required by state law.
KAR 28-39-255 Laundry. The facility failed to provide locked cabinets for storage of chemicals and supplies in the laundry room, leaving hazardous materials accessible.
Report Facts
Residents with outside provider services: 10
Residents with facility managed medications: 23
Residents with impaired cognitive status: 14
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Facility Nurse #B | Licensed Practical Nurse | Interviewed regarding monitoring of outside services, verbal orders, and care coordination. |
| Administrator #C | Administrator | Interviewed regarding privacy policies, RN supervision, and chemical storage. |
| Facility Nurse #E | Licensed Nurse | Interviewed regarding care needs and interventions for resident #189. |
| Housekeeping staff #D | Housekeeping Staff | Interviewed regarding chemical cabinet locking in laundry room. |
Inspection Report
Renewal
Census: 31
Deficiencies: 1
Date: Jan 22, 2016
Visit Reason
The inspection was a Licensure Resurvey at the assisted living facility to assess compliance with licensure requirements.
Findings
The facility failed to ensure proper documentation of medication administration for one resident. Specifically, medication was documented as given despite being discontinued and unavailable.
Deficiencies (1)
KAR 26-41-205(d)(3) Facility Administration of Medication: The administrator failed to ensure documentation of each resident's medication immediately before or following completion of the task for resident #187. Medication was documented as given despite being discontinued and not available.
Report Facts
Facility census: 31
Residents with facility managed medications: 28
Sampled residents: 3
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Jan 22, 2016
Visit Reason
This document is a Plan of Correction related to deficiencies identified in a prior inspection at the facility.
Findings
No specific deficiencies or findings 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: N015008 POC MUQP11
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 N015008.
Findings
No specific deficiencies or findings are detailed in this document. It serves as a placeholder or record for the Plan of Correction with no records found.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: N015008 POC CCOH12
Visit Reason
This document is a Plan of Correction related to a prior inspection event identified as CCOH12 for the facility with State ID N015008.
Findings
No deficiency records or findings are included in this Plan of Correction document.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: N015008 POC 1GG911
Visit Reason
This document is a Plan of Correction related to a previously identified deficiency report for the facility.
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: N015008 POC FNQE11
Visit Reason
This document is a Plan of Correction related to a prior deficiency report for a facility identified as Aspen, linked to a COVID-related inspection event dated 07/30/2020.
Findings
No specific findings or deficiencies are detailed in this document. It serves solely as a Plan of Correction submission with no records found in the content provided.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: N015008 POC 1GG912
Visit Reason
This document is a Plan of Correction related to a previous inspection event for the facility identified as ASPEN with State ID N015008 and Event ID 1GG912.
Findings
No deficiency details or findings are provided in this Plan of Correction document. It only references the related deficiency report but states no records found.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: N015008 POC HPS411
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: N015008 POC HPS412
Visit Reason
This document is a Plan of Correction related to a prior inspection event identified as HPS412 for the facility with State ID N015008.
Findings
No deficiency details or findings are provided in this document. It serves solely as a record of the Plan of Correction submission.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: N015008 POC CCOH11
Visit Reason
This document is a Plan of Correction related to a previously identified deficiency report for the facility.
Findings
No specific findings are detailed in this document; it serves as a plan of correction linked to a prior deficiency report.
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