Deficiencies (last 8 years)
Deficiencies (over 8 years)
2.6 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
57% better than Kansas average
Kansas average: 6 deficiencies/yearDeficiencies per year
12
9
6
3
0
Occupancy
Latest occupancy rate
63% occupied
Based on a September 2024 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Renewal
Deficiencies: 0
Date: Feb 4, 2026
Visit Reason
The licensure resurvey with attached complaint number 197540 was conducted at the assisted living facility to assess compliance and licensure status.
Complaint Details
The inspection was conducted with an attached complaint number 197540; no deficiencies were found.
Findings
The inspection resulted in a finding of no deficiency citations.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Feb 4, 2026
Visit Reason
The licensure resurvey with attached complaint number 197540 was conducted at the assisted living facility.
Findings
The inspection resulted in a finding of no deficiency citations.
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.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Sep 3, 2024
Visit Reason
The document is a plan of correction responding to findings from an abbreviated survey conducted on 09/03/2024 related to complaints #190122 at the facility.
Complaint Details
The visit was complaint-related, concerning complaints #190122, but no substantiation status is provided.
Findings
The plan of correction addresses citations resulting from an abbreviated survey triggered by complaints. Specific findings or 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 complaint #190122 regarding the facility's compliance with functional capacity screening and negotiated service agreement revisions.
Complaint Details
The complaint investigation was triggered by complaint #190122. The findings substantiated that the facility failed to conduct required reassessments and service agreement revisions for Resident 1 after significant changes in condition and elopement risk.
Findings
The facility failed to perform a required functional capacity screening for Resident 1 following a significant change in condition. Additionally, the facility did not review or revise Resident 1's Negotiated Service Agreement after a moderate elopement risk was identified and following changes in behavior and physical decline.
Deficiencies (2)
K.A.R. 26-41-201 (c) (2) Functional Capacity Screen Reassessment was not performed for Resident 1 when she experienced a change in condition, despite documented cognitive and physical decline.
K.A.R. 26-41-202 (d) (2) The Negotiated Service Agreement for Resident 1 was not reviewed or revised after she was identified as a moderate elopement risk and following changes in behavior and physical decline.
Report Facts
Census: 20
Complaint Number: 190122
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.
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 failed to ensure the negotiated service agreement identified responsibility for administration of selected medications, used Tubersol testing solution beyond expiration, stored over-the-counter medications improperly, and did not review the emergency preparedness plan quarterly with staff and residents.
Deficiencies (3)
K.A.R. 26-41-205 (b) The facility failed to ensure the negotiated service agreement for resident R2 identified who was responsible for administration of selected medications.
K.A.R. 26-41-205 (h) (4) The facility nurse used Tubersol testing solution beyond its date of expiration and failed to ensure all over-the-counter medications were stored in a locked medication room for resident R1.
K.A.R. 26-41-104(d) (3) The facility failed to ensure the emergency preparedness management plan was reviewed at least quarterly with all staff and residents, including fire, flood, severe weather, tornado, explosion, natural gas leak, lack of electrical or water services, missing residents, and other emergencies.
Report Facts
Census: 18
Residents sampled: 3
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Jun 26, 2024
Visit Reason
This 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 on June 26 and 27, 2024. Specific deficiencies are not detailed in this document.
Inspection Report
Re-Inspection
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.
Inspection Report
Re-Inspection
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 cited in the prior inspection have been corrected as of 2023-01-31, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Inspection Report
Renewal
Census: 21
Deficiencies: 2
Date: Jan 23, 2023
Visit Reason
The inspection was a licensure resurvey conducted over three days to assess compliance with regulatory requirements for the assisted living facility.
Findings
The facility failed to ensure that the negotiated service agreement included all required service descriptions, providers, and payor sources for a resident's therapy services. Additionally, the facility did not ensure food was served at the proper temperature after transport from a satellite kitchen.
Deficiencies (2)
26-41-202 (a) The facility failed to ensure the negotiated service agreement included a description of all services, the provider of the services, and the payor source for physical therapy and occupational therapy for a resident.
26-41-206 (d) The facility failed to ensure food served to residents was at the proper temperature after being transported from a satellite kitchen to the assisted living facility.
Report Facts
Resident census: 21
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 a licensure resurvey conducted on January 23, 24, and 25, 2023.
Findings
The plan of correction addresses citations identified during the licensure resurvey of the facility conducted over three days in January 2023.
Inspection Report
Routine
Deficiencies: 0
Date: Jul 14, 2020
Visit Reason
The inspection was a special infection control survey for COVID-19 conducted at the facility.
Findings
The survey resulted in findings of no deficiency citations.
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Apr 15, 2019
Visit Reason
This is a revisit inspection to verify that previously reported deficiencies have been corrected and to document the date such corrective actions were accomplished.
Findings
All previously cited deficiencies listed by regulation numbers were corrected as of the revisit date. The report confirms completion of corrective actions for multiple cited regulations.
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 parties for payment in negotiated service agreements, improper administration of medications without nurse consultation, inadequate labeling of over-the-counter medications, breach of resident confidentiality by publicly displaying personal information, and incomplete documentation of incidents and illnesses for residents.
Deficiencies (5)
KAR 26-41-202 (a) (3) The facility failed to ensure negotiated service agreements identified each party responsible for payment of outside services for 2 of 3 residents sampled.
KAR 26-41-205 (d) The facility failed to ensure medications were administered according to medical orders and professional standards, lacking nurse consultation before PRN medication administration by certified medication aides for 1 resident.
KAR 26-41-205 (g) (3) The facility failed to ensure licensed staff labeled over-the-counter medications with the resident's full name on both the original package and medication container.
KAR 26-41-105 (b) The facility failed to keep all residents' personal and confidential information secure, as resident rosters with sensitive data were publicly accessible in common areas.
KAR 26-41-105 (f)(11) The facility failed to document all incidents, symptoms, and indications of illness or injury including date, time, actions taken, and results for 1 resident.
Report Facts
Census: 15
Residents receiving medication management: 13
Sampled residents: 3
PRN Tylenol administrations: 15
OTC medication labeling issues: 7
Resident names on public rosters: 19
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed nurse/operator B | Interviewed regarding medication administration, negotiated service agreements, and confidentiality breaches | |
| Certified medication aide A | Observed handling medication cart and OTC medication labeling | |
| Certified medication aide C | Interviewed about PRN medication administration practices |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Apr 18, 2017
Visit Reason
This document is a plan of correction related to a prior inspection event identified as BKHC12 for the facility with State ID N063012.
Findings
No deficiency records or findings are included in this plan of correction document.
Inspection Report
Follow-Up
Deficiencies: 1
Date: Apr 11, 2017
Visit Reason
This visit was conducted as a follow-up to verify that previously reported deficiencies have been corrected.
Findings
The report confirms that the previously cited deficiency under regulation 26-41-104(d) was corrected as of the revisit date.
Deficiencies (1)
Regulation 26-41-104(d) deficiency was corrected as of 2017-04-11.
Inspection Report
Follow-Up
Deficiencies: 1
Date: Apr 11, 2017
Visit Reason
This visit was conducted as a follow-up to verify that previously reported deficiencies have been corrected.
Findings
The report confirms that the previously cited deficiency under regulation 26-41-104(d) was corrected as of the revisit date.
Deficiencies (1)
Regulation 26-41-104(d) deficiency was corrected by the revisit date of 2017-04-11.
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 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 assessment for self-administration of medication, improper medication storage, inadequate medication disposition records, failure to conduct quarterly emergency management plan reviews, and non-compliance with tuberculosis screening guidelines.
Deficiencies (7)
KAR 26-41-202(h) NSA Signatures: The administrator failed to ensure each individual involved in the development of the negotiated service agreement signed the agreement for residents #114 and #115.
KAR 26-41-204(a) Health Care Services: The administrator failed to ensure a licensed nurse provided or coordinated necessary health care services in accordance with the functional capacity screening and negotiated service agreement for resident #114.
KAR 26-41-205(a)(1) Self Administration of Medication: The administrator failed to ensure an assessment was completed before resident #114 began self-administering medications.
KAR 26-41-205(h)(1) Medication Storage: The administrator failed to ensure controlled medications were stored in separately locked compartments within a locked medication room, cabinet, or medication cart for residents #203 and #207.
KAR 26-41-205(i) Disposition of Medication: The administrator failed to maintain records of receipt and disposition of all medications in sufficient detail for accurate reconciliation for multiple residents including #114, #200-#206, and #207.
KAR 26-41-104(d)(3) Disaster and Emergency Preparedness: The administrator failed to ensure quarterly review of the facility's emergency management plan with employees and residents.
KAR 26-41-207(c) Infection Control Policies: The administrator failed to ensure compliance with tuberculosis guidelines for adult care homes for staff (Administrative Nurse B, Certified Staff C and E) and resident #114 due to lack of required TB skin testing and chest x-ray documentation.
Report Facts
Census: 21
Deficiencies cited: 7
Controlled medications found: 3
Medications in plastic box: 15
Inspection Report
Re-Inspection
Deficiencies: 0
Date: May 21, 2015
Visit Reason
The visit was a licenser re-survey of the residential health care facility to verify compliance and deficiency status.
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 document is a licensure resurvey conducted as a renewal inspection of the residential health care facility.
Findings
The licensure resurvey resulted in no deficiency citations on the dates 2013-03-10 and 2013-03-11.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: N063012 POC 0SM111
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 placeholder or administrative record for the Plan of Correction.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: N063012 POC BKHC11
Visit Reason
This document is a plan of correction related to a prior deficiency report for the facility identified as Aspen with State ID N063012.
Findings
No specific findings or deficiencies are detailed in this document. It serves as a placeholder or reference for the plan of correction linked to a previous deficiency report.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: N063012 POC H6F311
Visit Reason
This document is a Plan of Correction related to a previous deficiency report for the facility Asbury Village.
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: N063012 POC HOM111
Visit Reason
This document serves as a Plan of Correction related to a prior inspection or deficiency report for the facility identified by State ID N063012 and Event ID HOM111.
Findings
No deficiency records 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: N063012 POC TMD611
Visit Reason
This document is a plan of correction related to a previously issued deficiency report for the facility.
Findings
No specific findings are detailed in this document; it serves as a corrective action response to prior deficiencies.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: N063012 POC TMD612
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 serves solely as a record of the Plan of Correction submission.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: N063012 POC V6N011
Visit Reason
This document is a Plan of Correction related to a prior deficiency report for the facility Asbury Village.
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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