Inspection Report Summary
The most recent inspection on June 16, 2025, found deficiencies related to previously cited issues, though corrections were underway. Earlier inspections showed a pattern of deficiencies involving resident safety, such as unsecured exit gates leading to elopement risks, and issues with medication labeling and emergency preparedness. Complaint investigations included substantiated findings about failure to secure residents and maintain safe conditions, but immediate jeopardy was removed after corrective actions. Enforcement actions such as fines or license suspensions were not listed in the available reports. The facility has shown some improvement over time by correcting prior deficiencies, though recent inspections indicate ongoing challenges with safety and regulatory compliance.
Deficiencies (last 8 years)
Deficiencies (over 8 years)
6.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
5% worse than Kansas average
Kansas average: 6 deficiencies/yearDeficiencies per year
12
9
6
3
0
Census
Latest occupancy rate
28 residents
Based on a May 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Census over time
Inspection Report
Re-Inspection
Deficiencies: 2
Date: Jun 16, 2025
Visit Reason
The visit was conducted as a re-inspection to verify correction of previously reported deficiencies at Brookdale Liberal Springs.
Findings
The report shows that corrections were completed for deficiencies with ID prefixes S3026 and S3320, including regulation numbers 26-41-101 (f)(1) and 28-39-254, with completion dates of 06/16/2025.
Deficiencies (2)
Deficiency related to regulation 26-41-101 (f)(1)
Deficiency related to regulation 28-39-254
Report Facts
Deficiencies cited: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Shanie Maxwell | RN/HFS | Surveyor who signed the report and conducted the re-inspection |
Inspection Report
Complaint Investigation
Census: 28
Deficiencies: 2
Date: May 29, 2025
Visit Reason
The inspection was a licensure resurvey combined with complaint investigations for multiple complaint numbers, conducted over three days from 05/27/25 to 05/29/25.
Complaint Details
The visit was triggered by complaints with numbers 194140, 191295, 191150, 190561, 189453, and 188897. The immediate jeopardy related to elopement was removed on 03/13/25 after corrective actions including elopement training and securing gates were implemented.
Findings
The facility failed to ensure the safety of residents by not securing exit gates, allowing a cognitively impaired resident to elope and be missing for 37 minutes. Additionally, unsecured chemicals were found in cognitively impaired residents' rooms, posing a health and safety risk.
Deficiencies (2)
Failure to ensure staff secured all 3 exit gates in the back fenced area, allowing cognitively impaired resident R1 to leave the facility unnoticed and be missing for 37 minutes.
Failure to maintain the facility to protect residents' health and safety due to unsecured chemicals found in cognitively impaired residents' rooms.
Report Facts
Census: 28
Elopement duration: 37
Distance eloped: 0.8
Date of elopement incident: Mar 12, 2025
Date of immediate jeopardy removal: Mar 13, 2025
Date of inspection: 2025-05-27 to 2025-05-29
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA B | Certified Nurse Aide | Let resident R1 into the backyard and failed to ensure gates were secured, contributing to elopement. |
| Maintence Director C | Maintenance Director | Responsible for checking gate security and reminded contractors to secure gates. |
| Administrator D | Administrator | Notified of the elopement incident and responsible for facility oversight. |
| LN F | Licensed Nurse | Confirmed that all chemicals should be stored securely. |
| CMA A | Certified Medication Assistant | Documented resident R1's behavior prior to elopement. |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: May 27, 2025
Visit Reason
The document is a plan of correction responding to findings from a licensure resurvey with attached complaint investigations conducted on 05/27/25, 05/28/25, and 05/29/25.
Complaint Details
The plan references complaint numbers 194140, 191295, 191150, 190561, 189453, and 188897 attached to the licensure resurvey.
Findings
The plan of correction addresses citations resulting from the licensure resurvey and multiple complaint numbers associated with the facility during the specified dates.
Report Facts
Complaint numbers: 6
Inspection Report
Follow-Up
Deficiencies: 0
Date: Jun 5, 2024
Visit Reason
An offsite revisit survey was conducted to verify correction of all previous deficiencies cited on 2024-05-09.
Findings
All deficiencies have been corrected as of the compliance date of 2024-05-30 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: 31
Deficiencies: 11
Date: May 9, 2024
Visit Reason
The inspection was a resurvey with complaints 184695 and 185207 conducted on 05/08/24 and 05/09/24 at Brookdale Liberal Springs, an assisted living facility.
Complaint Details
The resurvey was conducted with complaints 184695 and 185207.
Findings
The inspection identified multiple deficiencies including failure to inform residents about advance medical directives, failure to keep the most recent survey report available publicly, inaccurate functional capacity screening, outdated or missing nurse identification on negotiated service agreements, unlabeled over-the-counter and prescription medications, inadequate disaster preparedness training, improper food temperature monitoring and storage, lack of sanitary conditions in food service, and non-compliance with tuberculosis screening guidelines for residents and new employees.
Deficiencies (11)
Failed to inform resident or legal representative in writing of state statutes related to advance medical directives upon admission.
Failed to ensure the most recent survey report and plan of correction was available in a public area for residents and others.
Failed to ensure Functional Capacity Screen accurately reflected recent problems and risks for residents R102 and R103.
Failed to ensure negotiated service agreements identified the licensed nurse responsible for implementation and supervision of health care service plans for residents R101, R102, and R103.
Failed to ensure licensed pharmacist or nurse placed the full name of the resident on original packages of over-the-counter medications.
Failed to ensure prescription medication containers had labels provided by a dispensing pharmacist.
Failed to ensure disaster and emergency preparedness by not performing quarterly review of emergency management plan with employees.
Failed to ensure food items were served at proper temperatures and lacked documentation of food temperatures on multiple dates.
Failed to ensure food items were stored under safe and sanitary conditions, including unlabeled and undated refrigerated foods and missing temperature logs.
Failed to ensure sanitary conditions for food service by not documenting hot water temperatures each shift.
Failed to ensure compliance with tuberculosis guidelines by not completing required two-step TB skin tests for residents and new employees.
Report Facts
Census: 31
Deficiencies cited: 11
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nurse A | Interviewed regarding advance directives, functional capacity screens, and negotiated service agreements. | |
| Administrative Staff B | Interviewed regarding food temperature logs and dishwasher temperature logs. |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: May 8, 2024
Visit Reason
The document is a plan of correction submitted in response to findings from a resurvey with complaints 184695 and 185207 conducted on 05/08/24 and 05/09/24 at the assisted living facility.
Complaint Details
The visit was related to complaints 184695 and 185207, indicating a complaint investigation resurvey.
Findings
The plan of correction addresses citations identified during the resurvey and complaint investigations conducted on the specified dates.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Aug 15, 2023
Visit Reason
An offsite revisit survey was conducted to verify correction of all previous deficiencies cited on 07/26/23.
Findings
All deficiencies have been corrected as of the compliance date of 08/11/23, 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: 25
Deficiencies: 5
Date: Jul 26, 2023
Visit Reason
The inspection was a resurvey conducted in response to complaints #177903, 180696, and 181126 at the assisted living facility.
Complaint Details
The resurvey was conducted following complaints #177903, 180696, and 181126.
Findings
The facility failed to fully develop negotiated service agreements addressing residents' functional capacity screening triggers, failed to update agreements with current licensed nurses responsible for health care plans, did not timely verify nurse aide registry checks for new employees, lacked documentation of quarterly emergency management plan reviews and annual evacuation drills, and failed to comply with tuberculosis screening guidelines for new staff.
Deficiencies (5)
Failed to ensure negotiated service agreements fully addressed all items triggered on the Functional Capacity Screen for residents R101, R103, and R104.
Failed to update negotiated service agreements to identify the current licensed nurse responsible for implementation and supervision of health care services for residents R101 and R104.
Failed to ensure employee records included timely verification with the nurse aide registry for five newly hired employees.
Failed to ensure quarterly review of the emergency management plan with employees and residents and failed to conduct annual evacuation drills.
Failed to comply with tuberculosis guidelines by not completing required TB symptom screenings and two-step TB skin tests for newly hired staff.
Report Facts
Census: 25
Number of residents in sample: 3
Number of newly hired employees with deficient nurse aide registry verification: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Nurse B | Licensed Nurse | Acknowledged that items triggered on the Functional Capacity Screen should be addressed on the Negotiated Service Agreement and was unaware of needing to complete an addendum identifying her as the nurse responsible. |
| Administrative Staff A | Administrative Staff | Provided documentation and stated inability to locate documentation for quarterly emergency management plan reviews and annual evacuation drills; also commented on tuberculosis testing issues. |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Jul 25, 2023
Visit Reason
The document addresses findings from a resurvey conducted on 07/25/23 - 07/26/23 related to complaints #177903, 180696, and 181126 at the assisted living facility.
Complaint Details
The resurvey was conducted in response to complaints #177903, 180696, and 181126.
Findings
The plan of correction corresponds to citations identified during the resurvey linked to multiple complaints at the assisted living facility.
Inspection Report
Re-Inspection
Deficiencies: 3
Date: Dec 21, 2021
Visit Reason
This revisit report documents the correction of deficiencies previously reported during an earlier survey conducted on 11/10/2021.
Findings
The report confirms that all previously identified deficiencies have been corrected as of 12/21/2021, with specific regulatory citations listed as completed.
Deficiencies (3)
Deficiency related to regulation 26-41-202 (a)
Deficiency related to regulation 26-41-104 (d)
Deficiency related to regulation 26-41-207 (b) (5-6) (c)
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Nov 10, 2021
Visit Reason
The document addresses findings from a health resurvey and complaint investigations conducted at the assisted living facility on November 8, 9, and 10, 2021.
Findings
The plan of correction references multiple citations resulting from the health resurvey and complaint investigations at the facility during the specified dates.
Report Facts
Complaint investigations referenced: 5
Inspection Report
Complaint Investigation
Census: 27
Deficiencies: 3
Date: Nov 10, 2021
Visit Reason
The inspection was conducted as a health resurvey and complaint investigations at the assisted living facility on 11/8, 11/9, and 11/10/2021.
Complaint Details
The visit included complaint investigations #147207, #152306, #153817, #153826, and #162989.
Findings
The executive director failed to ensure the development of negotiated service agreements/health care service plans for sampled residents to accurately reflect services provided, failed to ensure quarterly reviews of the emergency management plan with employees and residents for 2021, and failed to comply with tuberculosis screening guidelines for newly hired employees.
Deficiencies (3)
Failure to develop negotiated service agreements/health care service plans for residents that accurately identify services provided, including medication management and podiatry services.
Failure to ensure quarterly review of the facility's emergency management plan with employees and residents for 2021.
Failure to comply with tuberculosis screening guidelines for newly hired employees, including lack of TB symptom screening and two-step TB skin tests.
Report Facts
Census: 27
Sampled residents: 3
Newly hired employees reviewed: 5
Non-compliant employees: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Executive Director | Named as responsible for failure to ensure development of negotiated service agreements and compliance with emergency preparedness and tuberculosis screening requirements. | |
| Administrative nursing staff G | Provided information confirming deficiencies in residents' negotiated service agreements. | |
| Administrative staff A | Reported lack of emergency management plan reviews for 2021 and confirmed lack of TB screening upon hire. | |
| Administrative staff F | Reported that new employees only had one TB skin test and no TB symptom screening. | |
| Medication Technician B | Newly hired employee with incomplete TB screening. | |
| Medication Technician C | Newly hired employee with incomplete TB screening. | |
| Certified Nursing Assistant D | Newly hired employee with incomplete TB screening. | |
| Housekeeping staff E | Newly hired employee with incomplete TB screening. |
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Jun 23, 2020
Visit Reason
The special infection control survey for COVID-19 was conducted at the facility on 2020-06-23.
Findings
The survey resulted in findings of no deficiency citations.
Inspection Report
Re-Inspection
Deficiencies: 6
Date: Apr 12, 2018
Visit Reason
This revisit report documents the correction of deficiencies previously reported during an earlier survey.
Findings
All previously cited deficiencies identified by regulation numbers 26-41-101 (f)(3), 26-41-201 (a)(b), 26-41-201 (d), 26-41-204 (e), 26-41-205 (d)(1-2), and 26-41-205 (h) were corrected as of the revisit date.
Deficiencies (6)
Deficiency related to regulation 26-41-101 (f)(3)
Deficiency related to regulation 26-41-201 (a)(b)
Deficiency related to regulation 26-41-201 (d)
Deficiency related to regulation 26-41-204 (e)
Deficiency related to regulation 26-41-205 (d)(1-2)
Deficiency related to regulation 26-41-205 (h)
Inspection Report
Complaint Investigation
Census: 42
Deficiencies: 6
Date: Mar 14, 2018
Visit Reason
The inspection was a resurvey with a complaint survey conducted on 3/12, 3/13, and 3/14/2018 at an assisted living facility following complaints #114496, #122540, and #124574.
Complaint Details
The visit was complaint-related, triggered by complaints #114496, #122540, and #124574. The report includes substantiation of deficiencies related to abuse/neglect reporting, functional capacity screening, nursing delegation, medication administration, and medication storage.
Findings
The facility was found deficient in multiple areas including failure to report allegations of abuse/neglect within 24 hours, incomplete and inaccurate functional capacity screenings, improper delegation of nursing duties to certified medication aides, lack of self-injection assessment for insulin administration, and improper medication storage including use of expired Tubersol.
Deficiencies (6)
Failure to report allegations of abuse, neglect, or exploitation to the Kansas Department for Aging and Disabilities within 24 hours for one resident (#314).
Failure to complete a functional capacity screen on or before admission for one resident (#318).
Failure to ensure functional capacity screen accurately reflected resident status for one resident (#313).
Failure to delegate nursing procedures of blood sugar monitoring and insulin pen dosage dialing to certified medication aides as required by Kansas nurse practice act.
Failure to complete a self-injection assessment for one resident (#316) receiving insulin to ensure proper self-injection.
Failure to store medications, including Tubersol (PPD), according to manufacturer recommendations and administering beyond expiration date.
Report Facts
Census: 42
Falls: 2
Certified Medication Aides without delegation: 3
Days after opening: 30
Days expired: 7
Inspection Report
Renewal
Census: 48
Deficiencies: 7
Date: Aug 30, 2016
Visit Reason
The inspection was a Licensure Resurvey conducted over multiple days in August 2016 to assess compliance with state regulations for the assisted living facility.
Findings
The inspection identified multiple deficiencies including failure to ensure negotiated service agreements (NSA) were properly signed and contained required information, inadequate monitoring of outside service providers, improper delegation of nursing duties, lack of self-administration medication assessments, improper medication storage, and failure to conduct quarterly emergency preparedness reviews with staff and residents.
Deficiencies (7)
Failure to ensure each individual involved in the development of the negotiated service agreement signed the agreement.
Failure to ensure designated facility staff monitored services provided by outside resources and acted as advocates for residents.
Failure to ensure the negotiated service agreement contained a description of health care services and the name of the licensed nurse responsible for implementation and supervision.
Failure to ensure procedures not included in nurse aide or medication aide curriculums were appropriately delegated to Certified Medication Aides by a licensed nurse.
Failure to ensure a licensed nurse performed an assessment of the resident's ability to safely and accurately self-administer medications.
Failure to ensure insulin pens were stored in accordance with manufacturer's recommendations.
Failure to ensure quarterly reviews of the facility's emergency management plan were conducted with employees and residents.
Report Facts
Census: 48
Residents sampled: 3
Residents self-administering medications: 10
Employees hired since last resurvey: 59
Insulin pens observed without date opened: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Health and Wellness Director | Interviewed multiple times regarding deficiencies and facility practices | |
| Owner/Operator | Confirmed deficiencies related to negotiated service agreements and health service plans | |
| Operator in Training/RN | Confirmed deficiencies related to negotiated service agreements and health service plans |
Inspection Report
Complaint Investigation
Census: 43
Deficiencies: 5
Date: Mar 30, 2015
Visit Reason
The inspection was a resurvey with investigation of complaints #81352 and #84932 at the assisted living facility Emeritus at Liberal Springs conducted on 3/24/15, 3/25/15, 3/26/15, and 3/30/15.
Complaint Details
The visit was complaint-related involving allegations of failure to investigate and report incidents of residents found on the floor, inadequate negotiated service agreements, insufficient health care service coordination, incomplete incident documentation, and lack of emergency plan reviews.
Findings
The operator failed to investigate and report incidents of residents found on the floor to rule out abuse or neglect, failed to ensure development of written negotiated service agreements including identification of service providers and payment responsibilities, failed to ensure health care services were properly coordinated or supervised by licensed nurses, and failed to maintain complete documentation of incidents and resident deaths. Additionally, the facility did not perform quarterly reviews of the emergency management plan with employees and residents.
Deficiencies (5)
Failed to investigate and report to the department each time staff found residents on the floor to rule out abuse or neglect.
Failed to ensure development of written negotiated service agreements for residents that included description of services, identification of providers, and payment responsibilities.
Failed to ensure health care services were provided or coordinated by a licensed nurse including supervision of personal care and nursing care.
Failed to document all incidents, symptoms, and indications of illness or injury including date, time, action taken, and results.
Failed to perform quarterly review of the facility's emergency management plan with employees and residents.
Report Facts
Census: 43
Residents sampled: 4
Closed records reviewed: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed nurse #A | Licensed Nurse | Documented hospice services and insulin administration; confirmed deficiencies in negotiated service agreements and incident documentation |
| Licensed nurse #C | Licensed Nurse | Documented multiple incidents of residents found on the floor; provided service notes related to resident care |
| Licensed nurse #D | Licensed Nurse | Documented last service notes for resident #255 prior to death |
| Certified staff member #B | Certified Staff | Stated limited care provided to resident #252 unless caregiver calls |
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