Inspection Report Summary
The most recent inspection on September 12, 2024, found the facility in compliance with all regulations and no new deficiencies. Prior inspections showed a pattern of deficiencies related mainly to the accuracy and updating of Negotiated Service Agreements and medication management, including storage and administration issues. Complaint investigations substantiated failures to perform required functional capacity screenings and to revise service agreements after resident condition changes. Enforcement actions such as fines or license suspensions were not listed in the available reports. The facility appears to be improving, as previous deficiencies have been corrected and recent inspections have found no new issues.
Deficiencies (last 7 years)
Deficiencies (over 7 years)
3.6 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
40% better than Kansas average
Kansas average: 6 deficiencies/yearDeficiencies per year
8
6
4
2
0
Census
Latest occupancy rate
20 residents
Based on a September 2024 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Sep 12, 2024
Visit Reason
An offsite revisit survey was conducted to verify correction of all previous deficiencies cited on 2024-09-03.
Findings
All deficiencies have been corrected as of the compliance date of 2024-09-06, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Report Facts
Previous deficiencies cited: 0
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Sep 3, 2024
Visit Reason
The document is a Plan of Correction related to an abbreviated survey conducted for complaints #190122 at the facility on 09/03/2024.
Complaint Details
The visit was complaint-related for complaints #190122.
Findings
The Plan of Correction addresses findings from an abbreviated survey triggered by complaints at the facility. Specific deficiencies are not detailed in this document.
Inspection Report
Complaint Investigation
Census: 20
Deficiencies: 2
Date: Sep 3, 2024
Visit Reason
The inspection was an abbreviated survey conducted in response to complaints #190122 regarding the facility's failure to perform required functional capacity screenings and to review and revise the Negotiated Service Agreement for a resident after changes in condition.
Complaint Details
The visit was complaint-driven based on complaint #190122. The complaints involved failure to conduct required functional capacity reassessments and to update service agreements following changes in resident condition. The complaints were substantiated as evidenced by the cited deficiencies.
Findings
The facility failed to perform a functional capacity screening for Resident 1 following a significant change in condition and did not review or revise the resident's Negotiated Service Agreement after the resident was identified as a moderate elopement risk and experienced behavioral and physical decline.
Deficiencies (2)
Failure to perform a functional capacity screening for Resident 1 following a change in condition.
Failure to review and revise the Negotiated Service Agreement for Resident 1 after scoring as a moderate elopement risk and experiencing behavioral and physical decline.
Report Facts
Census: 20
Complaint Number: 190122
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Operator A | Interviewed and confirmed failure to perform functional capacity screening and review of service agreement. |
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Jul 17, 2024
Visit Reason
An offsite revisit survey was conducted to verify correction of all previous deficiencies cited on 2024-06-27.
Findings
All deficiencies have been corrected as of the compliance date of 2024-07-10, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Report Facts
Previous deficiencies cited: 1
Inspection Report
Renewal
Census: 18
Deficiencies: 3
Date: Jun 27, 2024
Visit Reason
The inspection was a licensure resurvey conducted on 06/26/24 and 06/27/24 to assess compliance with state regulations for the facility.
Findings
The facility was found deficient in multiple areas including failure to identify responsible parties for administration of selected medications in the negotiated service agreement, improper medication storage including use of expired Tubersol testing solution and unsecured over-the-counter medications, and failure to conduct quarterly reviews of the emergency preparedness management plan with staff and residents.
Deficiencies (3)
Failure to ensure the Negotiated Service Agreement identified who was responsible for administration of selected medications for resident R2.
Failure to ensure medication storage compliance including use of Tubersol testing solution beyond expiration and unsecured over-the-counter medications for resident R1.
Failure to ensure the emergency preparedness management plan was reviewed at least quarterly with all staff and residents.
Report Facts
Census: 18
Residents in sample: 3
Dates of emergency preparedness training: 06/16/23, 08/29/23, 12/19/23, 03/06/24, 04/05/24
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Jun 26, 2024
Visit Reason
The document is a Plan of Correction submitted in response to findings from the licensure resurvey conducted on June 26 and June 27, 2024.
Findings
The Plan of Correction addresses citations identified during the licensure resurvey of the facility conducted on June 26 and 27, 2024.
Report Facts
Inspection dates: 2
Inspection Report
Follow-Up
Deficiencies: 0
Date: Feb 9, 2023
Visit Reason
An offsite revisit survey was conducted to verify correction of all previous deficiencies cited on 2023-01-25.
Findings
All deficiencies have been corrected as of the compliance date of 2023-01-31, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Report Facts
Previous deficiencies cited: 0
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Jan 23, 2023
Visit Reason
The document is a plan of correction submitted in response to findings from the licensure resurvey conducted on 01/23/23, 01/24/23, and 01/25/23.
Findings
The plan of correction addresses citations identified during the licensure resurvey of the facility conducted over three days in January 2023.
Inspection Report
Renewal
Census: 21
Deficiencies: 2
Date: Jan 23, 2023
Visit Reason
The inspection was a licensure resurvey conducted over three days (01/23/23 to 01/25/23) to assess compliance with regulatory requirements for the assisted living facility.
Findings
The facility failed to ensure that the Negotiated Service Agreement (NSA) included a description of all services, the provider of services, and the payor source for physical and occupational therapy for a sampled resident. Additionally, the facility failed to ensure food served to residents was at the proper temperature after transport from a satellite kitchen due to lack of temperature checks upon arrival.
Deficiencies (2)
Negotiated Service Agreement lacked description of physical therapy and occupational therapy services, provider, and payor source for resident R2.
Food served to residents was not ensured to be at proper temperature after transport from satellite kitchen.
Report Facts
Census: 21
Deficiency count: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Operator A | Interviewed regarding kitchen remodeling and food temperature procedures |
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Jul 14, 2020
Visit Reason
The special infection control survey for COVID-19 was conducted at the facility on 07/14/2020.
Findings
The survey resulted in findings of no deficiency citations.
Inspection Report
Re-Inspection
Deficiencies: 5
Date: Apr 15, 2019
Visit Reason
This revisit report documents the correction of deficiencies previously cited during an earlier survey, verifying that corrective actions were completed as of the revisit date.
Findings
All previously reported deficiencies identified by regulation or Life Safety Code provisions were corrected and completed by the revisit date of 04/15/2019.
Deficiencies (5)
Deficiency related to regulation 26-41-202 (a)
Deficiency related to regulation 26-41-205 (d) (1-2)
Deficiency related to regulation 26-41-205 (g) (3)
Deficiency related to regulation 26-41-105 (b)
Deficiency related to regulation 26-41-105 (f) (11)
Inspection Report
Renewal
Census: 15
Deficiencies: 5
Date: Feb 27, 2019
Visit Reason
The inspection was a licensure resurvey conducted over three days (2/25/19 to 2/27/19) to assess compliance with regulatory requirements for the assisted living facility.
Findings
The facility was found deficient in multiple areas including failure to identify responsible payors in negotiated service agreements for outside services, improper administration of PRN medications by certified medication aides without nurse consultation, inadequate labeling of over-the-counter medications, breach of resident confidentiality by publicly displaying resident information, and incomplete documentation of incidents and symptoms for a resident requiring emergency medical services.
Deficiencies (5)
Negotiated service agreements failed to identify the responsible party for payment of outside services for 2 of 3 residents sampled (#281 and #311).
Medications and biologicals for resident #311 were administered by certified medication aides without required nurse consultation before PRN medication administration.
Over-the-counter medications were not labeled by a licensed nurse or pharmacist with the resident's full name on both the original package and medication container.
Resident personal and confidential information was kept in public areas accessible to the public, violating confidentiality requirements.
Documentation of incidents, symptoms, and other indications of illness or injury was incomplete for resident #281, lacking date, time, actions taken, and results related to an illness requiring EMS and hospital admission.
Report Facts
Census: 15
Residents sampled: 3
Residents receiving medication management: 13
PRN Tylenol administrations: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed nurse/operator B | Interviewed regarding negotiated service agreements, medication administration, OTC medication labeling, resident confidentiality, and incident documentation | |
| Certified medication aide A | Observed handling medication cart and OTC medication labeling | |
| Certified medication aide C | Interviewed about PRN medication administration practices |
Inspection Report
Re-Inspection
Deficiencies: 1
Date: Apr 11, 2017
Visit Reason
This report documents a revisit inspection to verify that previously reported deficiencies have been corrected and to confirm the dates such corrective actions were accomplished.
Findings
The revisit inspection confirmed that the previously cited deficiency related to regulation 26-41-104 (d) was corrected as of 04/11/2017. No other deficiencies or issues were noted in this report.
Deficiencies (1)
Deficiency related to regulation 26-41-104 (d) previously cited
Inspection Report
Re-Inspection
Census: 21
Deficiencies: 7
Date: Apr 3, 2017
Visit Reason
The inspection was a resurvey conducted on 3-29-17, 3-30-17, and 4-3-17 to assess compliance with previously cited deficiencies at Asbury Village, a residential health care facility.
Findings
The facility was found deficient in multiple areas including failure to ensure signatures on negotiated service agreements, inadequate coordination of health care services, lack of medication self-administration assessments, improper medication storage, insufficient medication disposition records, lack of quarterly emergency management plan reviews, and non-compliance with tuberculosis screening guidelines for staff and residents.
Deficiencies (7)
Failure to ensure each individual involved in the development of the negotiated service agreement signed the agreement for residents #114 and #115.
Failure to ensure a licensed nurse provided or coordinated necessary health care services in accordance with functional capacity screening and negotiated service agreement for resident #114.
Failure to complete an assessment before resident #114 initially began self-administration of medication.
Failure to store controlled medications in separately locked compartments within a locked medication room, cabinet, or medication cart for residents #203 and #207.
Failure to maintain records documenting the receipt and disposition of all medications managed by the facility in sufficient detail for accurate reconciliation for multiple residents including #114, #200-#207.
Failure to ensure quarterly review of the facility's emergency management plan with employees and residents.
Failure to ensure compliance with tuberculosis screening guidelines for adult care homes for staff (Administrative Nurse B, Certified Staff C and E) and resident #114.
Report Facts
Census: 21
Deficiencies cited: 8
Medication counts: 13
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nurse B | Administrative Nurse | Confirmed lack of signatures on negotiated service agreements and lack of TB skin testing documentation |
| Administrative Staff A | Confirmed multiple deficiencies including lack of signatures, improper medication storage, lack of emergency plan review documentation, and TB testing documentation | |
| Certified Staff F | Certified Staff | Documented resident behavior related to anxiety and wandering |
| Certified Staff G | Certified Staff | Documented resident anxiety and confusion |
| Certified Staff D | Certified Staff | Reported resident #206 moved and confirmed medication box contents |
| Certified Staff C | Certified Staff | Lacked documentation of 2-step TB skin test |
| Certified Staff E | Certified Staff | Had positive TB skin test but lacked chest x-ray documentation |
Inspection Report
Re-Inspection
Deficiencies: 0
Date: May 21, 2015
Visit Reason
This was a licenser re-survey at the residential health care facility to verify compliance and check for deficiencies.
Findings
The re-survey resulted in a finding of no deficiency citations on 5-20-15 and 5-21-15.
Inspection Report
Renewal
Deficiencies: 0
Date: Mar 11, 2014
Visit Reason
The visit was a licensure resurvey of the residential health care facility to assess compliance with licensing requirements.
Findings
The licensure resurvey resulted in no deficiency citations on the dates 2013-03-10 and 2013-03-11.
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