Inspection Reports for Antioch Valley Senior Living
12700 Antioch Rd, Overland Park, KS 66213, KS, 66213
Back to Facility ProfileInspection Report Summary
The most recent inspection on March 3, 2025, found the facility in compliance with all regulations and no new deficiencies. Prior inspections showed multiple deficiencies related mainly to documentation issues such as incomplete functional capacity screens and negotiated service agreements, medication administration errors, and safety concerns including unsecured chemical storage and incomplete emergency preparedness activities. Complaint investigations were frequent, with most complaints unsubstantiated, though some inspections noted substantiated issues particularly around resident assessments and medication management. Enforcement actions such as fines or license suspensions were not listed in the available reports. The facility has demonstrated improvement over time by correcting all cited deficiencies from previous inspections before the most recent survey.
Deficiencies (last 8 years)
Deficiencies (over 8 years)
4 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
33% better than Kansas average
Kansas average: 6 deficiencies/yearDeficiencies per year
16
12
8
4
0
Census
Latest occupancy rate
75 residents
Based on a January 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Census over time
Inspection Report
Follow-Up
Deficiencies: 0
Date: Mar 3, 2025
Visit Reason
An offsite revisit survey was conducted to verify correction of all previous deficiencies cited on 2025-01-29.
Findings
All deficiencies have been corrected as of the compliance date of 2025-02-27, 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: 75
Deficiencies: 16
Date: Jan 29, 2025
Visit Reason
The inspection was a resurvey with attached complaints at an assisted living facility to evaluate compliance with regulatory requirements.
Complaint Details
The inspection was a resurvey with attached complaints #192790, #192091, #192092, #192042, and #190127.
Findings
The facility was found deficient in multiple areas including failure to complete functional capacity screens and negotiated service agreements following significant changes, lack of signatures on service agreements, failure to name licensed nurses responsible for healthcare service plans, inadequate assessment of bed assist devices, failure to assess resident ability to self-administer medications, improper delegation and administration of medications, lack of criminal background checks and tuberculosis screening documentation for staff and residents, failure to conduct emergency preparedness drills and reviews, and improper storage of chemicals.
Deficiencies (16)
Failure to complete Functional Capacity Screen for Resident 5 following significant change.
Negotiated Service Agreements for Residents 2, 4, 5, and 6 failed to describe services provided and identify providers.
Failure to complete significant change Negotiated Service Agreement for Residents 4 and 5.
Negotiated Service Agreements lacked signatures for all residents.
Negotiated Service Agreements failed to name licensed nurse responsible for implementation and supervision of Healthcare Service Plans for all residents.
Licensed nurse failed to assess Resident 5's bed assist device for restraint status, purpose, safety, and entrapment risk.
Failure to perform assessment for Resident 6 to determine ability to self-administer insulin safely.
Resident 6's Negotiated Service Agreement failed to identify who was responsible for administration and management of select medications.
Certified Nurse Aide administered medications, which is not permitted; licensed nurse delegated medication administration improperly.
Certified Medication Aides lacked documented training and competencies for delegated insulin pen preparation.
Over-the-counter medications lacked residents' full names on original manufacturer packages.
Licensed nurse failed to notify medical care provider of medication regimen review variances and seek response for Resident 3.
Employee records lacked evidence of criminal background checks for five sampled staff.
Facility failed to provide evidence of quarterly emergency management plan reviews and annual evacuation drills with residents and staff.
Facility failed to comply with tuberculosis screening guidelines for all sampled residents and staff.
Facility failed to maintain building safety by storing chemicals in unlocked areas accessible to residents and visitors.
Report Facts
Census: 75
Residents in sample: 6
Deficiency count: 16
Medication carts: 3
OTC medications without resident names: 5
Residents marked for insulin injection: 11
Sampled Certified Medication Aides: 3
Sampled staff lacking criminal background checks: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA J | Certified Nurse Aide | Named in medication administration violation where CNA administered medications without proper authorization. |
| Licensed Nurse D | Licensed Nurse | Named in medication administration violation for delegating medication administration to CNA. |
| Administrative Nurse B | Administrative Nurse | Confirmed multiple policy and documentation deficiencies including lack of FCS, NSA policies, and staff records. |
| Administrative Nurse C | Administrative Nurse | Confirmed multiple deficiencies and provided statements regarding resident care and staff training. |
| Administrative Staff A | Administrative Staff | Provided information on staff records and investigation status. |
| Certified Medication Aide F | Certified Medication Aide | Witnessed CNA administering medications and confirmed OTC medications lacked resident names. |
| Certified Medication Aide G | Certified Medication Aide | Confirmed insulin preparation by CMAs and lack of competency documentation. |
Inspection Report
Follow-Up
Deficiencies: 0
Date: May 28, 2024
Visit Reason
An offsite revisit survey was conducted to verify correction of all previous deficiencies cited on 2024-05-07.
Findings
All previously cited deficiencies have been corrected as of the compliance date of 2024-05-23, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Report Facts
Previous deficiencies cited: 1
Inspection Report
Abbreviated Survey
Census: 83
Deficiencies: 2
Date: May 7, 2024
Visit Reason
The inspection was an abbreviated survey conducted in response to multiple complaints (#187358, #187289, #187291, #187292, #187923, #187189, and #186222) at the facility.
Complaint Details
The survey was complaint-related, triggered by multiple complaints (#187358, #187289, #187291, #187292, #187923, #187189, and #186222).
Findings
The facility failed to ensure that the Functional Capacity Screen (FCS) and the Negotiated Service Agreement (NSA) for Resident 1 accurately reflected her impaired vision and the services she received. Staff did not identify or document the resident's impaired vision, resulting in inadequate service descriptions and support.
Deficiencies (2)
Failure to ensure the Functional Capacity Screen accurately reflected Resident 1's impaired vision.
Failure to ensure the Negotiated Service Agreement described the services Resident 1 received based on her functional capacity and service needs for impaired vision.
Report Facts
Census: 83
Residents in sample: 6
Closed record reviews: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nurse B | Confirmed that Resident 1's Functional Capacity Screen and Negotiated Service Agreement failed to identify impaired vision and services. | |
| Licensed Nurse C | Reported Resident 1 had difficulty seeing and was confused, often asking directions to her apartment. |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: May 6, 2024
Visit Reason
The document is a plan of correction responding to findings from an abbreviated survey conducted on 05/06/24 and 05/07/24 related to multiple complaints at the facility.
Complaint Details
The survey was conducted in response to multiple complaints as listed in the document.
Findings
The plan of correction addresses citations resulting from an abbreviated survey triggered by complaints numbered #187358, #187289, #187291, #187292, #187923, #187189, and #186222.
Report Facts
Complaint numbers: 7
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Jan 16, 2024
Visit Reason
The document is a plan of correction related to an abbreviated survey conducted for multiple complaints at an assisted living facility on 01/16/24 and 01/17/24.
Complaint Details
The visit was complaint-related for multiple complaints, but no deficiencies were found.
Findings
The abbreviated survey for complaints #184937, #184455, #184396, #184218, #180557, #180122, and #179684 resulted in a finding of no deficiency citations.
Report Facts
Complaint numbers: 7
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Jan 16, 2024
Visit Reason
The abbreviated survey was conducted in response to multiple complaints (#184937, #184455, #184396, #184218, #180557, #180122, #179684) at the assisted living facility.
Complaint Details
The survey was complaint-related, covering multiple complaint numbers, and resulted in no deficiencies.
Findings
The survey resulted in a finding of no deficiency citations at the facility.
Inspection Report
Follow-Up
Deficiencies: 0
Date: May 15, 2023
Visit Reason
An offsite revisit survey was conducted to verify correction of all previous deficiencies cited on 2023-04-25.
Findings
All deficiencies have been corrected as of the compliance date of 2023-05-10, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Report Facts
Previous deficiencies cited: 1
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Apr 24, 2023
Visit Reason
This document represents the findings of a resurvey with multiple complaints (#179109, #177613, #170940, #169564, #169538, #169371, #169000, #168560, #168507, #167541, #165948, #166047, and #165901) for the assisted living facility conducted on 04/24/23 and 04/25/23.
Findings
The document is a plan of correction submitted in response to the findings from the resurvey and complaints listed, indicating corrective actions to address the deficiencies identified during the inspection.
Inspection Report
Re-Inspection
Census: 83
Deficiencies: 6
Date: Apr 24, 2023
Visit Reason
The inspection was a resurvey with multiple complaints for Rose Estates Assisted Living Community conducted on 04/24/23 and 04/25/23.
Complaint Details
The resurvey was conducted with complaints #179109, #177613, #170940, #169564, #169538, #169371, #169000, #168560, #168507, #167541, #165948, #166047, and #165901.
Findings
The facility was found deficient in multiple areas including failure to complete negotiated service agreements annually, lack of signatures on service agreements, verbal medication orders not signed within seven days, over-the-counter medications not labeled with resident names, non-compliance with tuberculosis screening guidelines for staff, and unsecured storage of cleaning chemicals posing safety hazards.
Deficiencies (6)
Failure to ensure facility staff completed a Negotiated Service Agreement (NSA) based on resident's Functional Capacity Screen every 365 days.
Failure to ensure each individual involved in the development of the NSA signed the agreement.
Failure to ensure all verbal medication orders were signed by the medical care provider within seven working days.
Failure to ensure licensed pharmacist or nurse placed full names of residents on original packages of over-the-counter medications.
Failure to comply with tuberculosis screening guidelines for adult care homes for three of five sampled staff.
Failure to keep cleaning chemicals in a locked, secured area, posing a potential safety hazard.
Report Facts
Resident census: 83
Number of residents with impaired cognitive abilities: 19
Number of verbal medication orders lacking physician signatures for Resident 1: 4
Number of verbal medication orders lacking physician signatures for Resident 2: 17
Number of verbal medication orders lacking physician signatures for Resident 4: 7
Number of verbal medication orders lacking physician signatures for Resident 5: 4
Days delayed for TB skin test for CMA C: 206
Days delayed for TB skin test for CMA D: 140
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator A | Named in multiple findings including failure to ensure NSA completion and signatures, medication order compliance, tuberculosis screening, and chemical storage. | |
| Administrative Nurse B | Interviewed and confirmed deficiencies related to NSA, medication orders, and OTC medication labeling. | |
| Certified Nurse Aide E | CNA | Employee record lacked evidence of TB test and symptom screen within seven days of hire. |
| Certified Medication Aide C | CMA | TB skin test completed 206 days after hire. |
| Certified Medication Aide D | CMA | TB skin test completed 140 days after hire. |
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Jul 30, 2020
Visit Reason
The special infection control survey for COVID-19 was conducted at Rose Estates Assisted Living Community on 7-30-2020.
Findings
The survey resulted in findings of no deficiency citations.
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Jun 5, 2018
Visit Reason
A re-survey for licensure and investigation into attached complaints was conducted at the assisted living facility in Overland Park, KS on 5/31/18, 6/4/18, and 6/5/18.
Complaint Details
The visit was complaint-related as it included an investigation into attached complaints; no deficiencies were found.
Findings
The re-survey resulted in a finding of no deficiency citations.
Inspection Report
Renewal
Deficiencies: 0
Date: Feb 28, 2017
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 2017-02-27 and 2017-02-28.
Inspection Report
Re-Inspection
Deficiencies: 2
Date: May 31, 2016
Visit Reason
This revisit report documents the correction of deficiencies previously reported during an earlier survey.
Findings
The report confirms that previously identified deficiencies, specifically those referenced by regulation numbers 26-41-206 (d) and 26-41-206 (e)(1), have been corrected as of the revisit date.
Deficiencies (2)
Deficiency related to regulation 26-41-206 (d)
Deficiency related to regulation 26-41-206 (e)(1)
Inspection Report
Follow-Up
Deficiencies: 1
Date: May 5, 2016
Visit Reason
This revisit report documents the follow-up inspection to verify that previously reported deficiencies have been corrected and the dates such corrective actions were accomplished.
Findings
The report confirms that the previously cited deficiency related to regulation 26-41-205 (l) (2) was corrected as of 05/04/2016. No other deficiencies or uncorrected issues are noted.
Deficiencies (1)
Deficiency related to regulation 26-41-205 (l) (2)
Inspection Report
Re-Inspection
Census: 87
Deficiencies: 2
Date: May 5, 2016
Visit Reason
The inspection was a special revisit conducted on 2016-05-04 and 2016-05-05 to evaluate compliance with food preparation and storage regulations at Rose Estates Assisted Living Community.
Findings
The facility failed to ensure food was prepared using safe methods that conserve nutritive value, flavor, and appearance, and served at proper temperatures, with missing documentation of cold food temperatures. Additionally, food storage practices were unsafe and unsanitary, including unlabeled and undated food containers, dirty kitchen equipment, and improper freezer conditions.
Deficiencies (2)
Failure to prepare food using safe methods that conserve nutritive value, flavor, and appearance and serve at proper temperatures, including lack of documentation for cold food temperatures.
Failure to store all food under safe and sanitary conditions, including unlabeled repackaged food, food debris on floors, spillage in cooler, uncovered food items, unclean kitchen equipment, and improper freezer conditions.
Report Facts
Census: 87
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dietary Staff A | Provided food temperature logs and confirmed observations during kitchen tour | |
| Administrator | Interviewed regarding dietary standards and facility conditions |
Inspection Report
Re-Inspection
Census: 88
Deficiencies: 3
Date: Mar 16, 2016
Visit Reason
The inspection was a resurvey with complaint investigations conducted on 3-10-16, 3-14-16, 3-15-16, and 3-16-16 at Rose Estates Assisted Living Community.
Complaint Details
The visit was a resurvey with complaint investigations numbered 89485, 92935, 93786, 93865, and 98073.
Findings
The facility was found deficient in medication regimen review variance reporting where licensed nurses failed to notify medical care providers of variances. Additionally, food preparation, storage, and temperature monitoring practices did not meet safety standards, including missing food temperature logs, unlabeled and undated food items, unsanitary kitchen conditions, and improper storage of food and cleaning supplies.
Deficiencies (3)
Licensed nurse failed to notify the medical care provider upon discovery of any variance identified in the medication regimen review for residents #420 and #430.
Food was not prepared using safe methods that conserve nutritive value, flavor, and appearance and was not served at proper temperatures; food temperature logs were incomplete or missing.
Facility staff failed to store all food under safe and sanitary conditions, including unlabeled and undated food items, broken glass and food debris on kitchen floor, lack of thermometer in coolers, greasy kitchen equipment, and lack of paper towels at hand sink.
Report Facts
Census: 88
Sample size: 6
Dates missing food temperature documentation: 50
Inspection Report
Renewal
Deficiencies: 0
Date: Jun 30, 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 6-25-14, 6-26-14, and 6-30-14.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: N046060 POC TOB811
Visit Reason
This document is a Plan of Correction related to a previously identified deficiency report for the facility.
Findings
The document indicates that a Plan of Correction is in progress for deficiencies cited in the linked deficiency report.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: N046060 CZPT11
Visit Reason
This document is a Plan of Correction related to a facility inspection event identified by State ID N046060 and ASPEN Event ID CZPT11.
Findings
No specific deficiencies or findings are detailed in this document; it appears to be a placeholder or summary page for a Plan of Correction with no records found.
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