Deficiencies (last 9 years)
Deficiencies (over 9 years)
5.6 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
7% better than Kansas average
Kansas average: 6 deficiencies/yearDeficiencies per year
12
9
6
3
0
Occupancy
Latest occupancy rate
50% occupied
Based on a May 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Follow-Up
Deficiencies: 2
Date: Jun 16, 2025
Visit Reason
This visit was conducted as a follow-up to verify correction of previously reported deficiencies at Brookdale Liberal Springs.
Findings
The report shows that previously identified deficiencies with regulation numbers 26-41-101 (f)(1) and 28-39-254 have been corrected and the corrective actions were completed by the date of revisit.
Deficiencies (2)
Regulation 26-41-101 (f)(1) deficiency was corrected and the correction was completed by 06/16/2025.
Regulation 28-39-254 deficiency was corrected and the correction was completed by 06/16/2025.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Shanie Maxwell | RN/HFS | Surveyor who signed the report and conducted the follow-up inspection. |
Inspection Report
Re-Inspection
Census: 28
Deficiencies: 2
Date: May 29, 2025
Visit Reason
The inspection was a licensure resurvey with attached complaint investigations for multiple complaint numbers, conducted over three days from 05/27/2025 to 05/29/2025.
Complaint Details
The visit was triggered by multiple complaints (numbers 194140, 191295, 191150, 190561, 189453, and 188897). The immediate jeopardy related to the elopement incident was removed on 03/13/2025 after corrective actions were implemented.
Findings
The facility failed to ensure staff secured exit gates, resulting in a cognitively impaired resident eloping and being unaccounted for 37 minutes. Additionally, unsecured chemicals were found in cognitively impaired residents' rooms, posing health and safety risks.
Deficiencies (2)
K.A.R. 26-41-101 (f) (1) (B) Staff failed to secure all three exit gates in the back fenced area, allowing a cognitively impaired resident to leave the facility unnoticed for 37 minutes.
K.A.R. 28-39-254 (a) The facility failed to protect resident health and safety by leaving unsecured chemicals in cognitively impaired residents' rooms.
Report Facts
Resident census: 28
Elopement duration: 37
Distance eloped: 0.8
Temperature: 36
Number of complaints attached: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Medication Assistant | Documented resident behavior related to elopement. | |
| Certified Nurse Aide | Let resident into backyard and failed to ensure gates were locked. | |
| Maintenance Director | Confirmed gate security checks and reminded contractors to secure gates. | |
| Administrator | Notified of elopement incident and responsible for facility compliance. | |
| Licensed Nurse | Confirmed chemicals should be stored securely. |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: May 27, 2025
Visit Reason
The document is a plan of correction submitted in response to findings from a licensure resurvey with attached complaint investigations conducted on May 27, 28, and 29, 2025.
Findings
The plan of correction addresses citations resulting from the licensure resurvey and multiple complaint investigations for the facility conducted over three days in May 2025.
Inspection Report
Re-Inspection
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 cited in the prior inspection have been corrected as of the compliance date 2024-05-30. No new noncompliance was found and the facility is in compliance with all regulations surveyed.
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 an assisted living facility.
Complaint Details
The inspection was a resurvey with complaints 184695 and 185207.
Findings
The facility was found deficient in multiple areas including failure to provide advance medical directives information, failure to keep the most recent survey report available publicly, inaccurate functional capacity screens, outdated negotiated service agreements, improper labeling of over-the-counter and prescription medications, inadequate disaster preparedness training, improper food temperature monitoring and storage, failure to document hot water temperatures, and noncompliance with tuberculosis screening guidelines for residents and new employees.
Deficiencies (11)
26-39-102(b) The facility failed to ensure the resident or legal representative was informed in writing of state statutes related to advance medical directives upon admission.
26-41-101(l) The facility failed to keep the most recent survey report available in a public area for residents and others to review.
26-41-201(d) The facility failed to ensure the Functional Capacity Screen accurately reflected recent problems and risks for residents R102 and R103.
26-41-204(d) The facility failed to update negotiated service agreements to identify the current licensed nurse responsible for implementation and supervision of health care service plans for residents R101, R102, and R103.
26-41-205(g)(3) The facility failed to ensure over-the-counter medications were labeled with the full name of the resident.
26-41-205(g)(2) The facility failed to ensure prescription medication containers had labels provided by a dispensing pharmacist affixed to the container.
26-41-104(d) The facility failed to ensure quarterly review of the emergency management plan with employees was documented.
26-41-206(d) The facility failed to ensure food items were served at the proper temperature and lacked documentation of food temperatures on multiple dates.
26-41-206(e) The facility failed to store food under safe and sanitary conditions by not maintaining refrigerator temperatures at 41°F or below and failing to label and date stored foods.
26-41-207(a)(b) The facility failed to ensure sanitary conditions for food service by not documenting hot water temperatures each shift.
26-41-207(b)(5-6)(c) The facility failed to comply with tuberculosis screening guidelines by not completing the second step of the two-step TB skin test for residents and new employees.
Report Facts
Census: 31
Deficiency counts: 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 a resurvey with complaints 184695 and 185207 conducted on 05/08/24 and 05/09/24 at the assisted living facility.
Findings
The Plan of Correction addresses citations found during the resurvey related to the complaints. Specific findings are not detailed in this document.
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Aug 15, 2023
Visit Reason
An offsite revisit survey was conducted to verify correction of all previous deficiencies cited on 2023-07-26.
Findings
All deficiencies have been corrected as of the compliance date of 2023-08-11, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Inspection Report
Re-Inspection
Census: 25
Deficiencies: 5
Date: Jul 26, 2023
Visit Reason
The inspection was a resurvey conducted on 07/25/23 - 07/26/23 following 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 facility failed to fully develop negotiated service agreements to address all triggered items from functional capacity screenings for residents R101, R103, and R104. The facility also failed to update the negotiated service agreements to identify the current licensed nurse responsible for health care service plans. Additionally, employee records lacked timely nurse aide registry verifications and tuberculosis testing compliance. The facility failed to ensure disaster and emergency preparedness through quarterly emergency plan reviews and annual evacuation drills.
Deficiencies (5)
KAR 26-41-202(a)(1) The operator failed to ensure negotiated service agreements fully addressed all items triggered on the functional capacity screen for residents R101, R103, and R104.
KAR 26-41-204(d) The negotiated service agreements did not identify the current licensed nurse responsible for implementation and supervision of health care service plans for residents R101 and R104.
KAR 26-41-102(d)(1) The operator failed to ensure timely verification of nurse aide registry for five newly hired employees.
KAR 26-41-104(d)(3)(4) The operator failed to ensure quarterly reviews of the emergency management plan with employees and residents and annual evacuation drills were completed.
KAR 26-41-207(c) The operator failed to ensure compliance with tuberculosis guidelines, including completion of two-step TB skin tests and symptom screening questionnaires for newly hired staff.
Report Facts
Census: 25
Deficiencies cited: 5
Late nurse aide registry verification: 5
Days late for nurse aide registry confirmation: 6
Days late for nurse aide registry confirmation: 3
Days late for nurse aide registry confirmation: 6
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Jul 25, 2023
Visit Reason
The document is a plan of correction related to a resurvey conducted at an assisted living facility following complaints #177903, 180696, and 181126.
Findings
The plan of correction addresses findings from a resurvey conducted on 07/25/23 - 07/26/23 at the assisted living facility related to multiple complaints.
Inspection Report
Follow-Up
Deficiencies: 3
Date: Dec 21, 2021
Visit Reason
This is a follow-up visit to verify correction of previously reported deficiencies at the facility.
Findings
The report confirms that previously cited deficiencies identified by regulation numbers 26-41-202 (a), 26-41-104 (d), and 26-41-207 (b)(5-6)(c) have been corrected as of the revisit date.
Deficiencies (3)
Regulation 26-41-202 (a) deficiency was corrected by the revisit date.
Regulation 26-41-104 (d) deficiency was corrected by the revisit date.
Regulation 26-41-207 (b)(5-6)(c) deficiency was corrected by the revisit date.
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 facility failed to ensure proper development of negotiated service agreements for residents, lacked quarterly reviews of the emergency management plan for 2021, and did not comply with tuberculosis screening guidelines for newly hired employees.
Deficiencies (3)
KAR 26-42-202(a)(1)(2) The executive director failed to ensure the negotiated service agreements identified all services provided to residents, including medication setup and podiatry services.
KAR 26-41-104(d)(3) The executive director failed to ensure quarterly reviews of the facility's emergency management plan were completed with employees and residents for 2021.
K.A.R 26-41-207(c) The facility failed to comply with tuberculosis guidelines by not completing TB symptom screens or two-step TB skin tests for 4 of 5 newly hired employees.
Report Facts
Resident census: 27
Newly hired employees reviewed: 5
Employees non-compliant with TB guidelines: 4
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Nov 8, 2021
Visit Reason
The document addresses findings from a health resurvey and complaint investigations at an assisted living facility conducted on November 8, 9, and 10, 2021.
Findings
The report summarizes citations resulting from the health resurvey and multiple complaint investigations at the facility during the specified dates.
Inspection Report
Routine
Deficiencies: 0
Date: Jun 23, 2020
Visit Reason
The visit 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
Follow-Up
Deficiencies: 6
Date: Apr 12, 2018
Visit Reason
This revisit inspection was conducted to verify that previously reported deficiencies have been corrected and to confirm the dates such corrective actions were accomplished.
Findings
All previously cited deficiencies identified by regulation or Life Safety Code provisions were corrected as of the revisit date. The report documents completion of corrective actions for multiple specific deficiencies.
Deficiencies (6)
Regulation 26-41-101 (f) (3) deficiency was corrected as of 04/12/2018.
Regulation 26-41-201 (a) (b) deficiency was corrected as of 04/12/2018.
Regulation 26-41-201 (d) deficiency was corrected as of 04/12/2018.
Regulation 26-41-204 (e) deficiency was corrected as of 04/12/2018.
Regulation 26-41-205 (d) (1-2) deficiency was corrected as of 04/12/2018.
Regulation 26-41-205 (h) deficiency was corrected as of 04/12/2018.
Inspection Report
Complaint Investigation
Census: 42
Deficiencies: 6
Date: Mar 14, 2018
Visit Reason
The inspection was a resurvey with a complaint survey triggered by complaints #114496, #122540, and #124574 at the assisted living facility.
Complaint Details
The visit was complaint-related involving allegations of abuse, neglect, and regulatory compliance issues with resident care and medication management. The complaints were substantiated by findings of failure to report abuse, incomplete or inaccurate functional capacity screening, improper delegation of nursing tasks, lack of self-injection assessment, and improper medication storage.
Findings
The facility failed to report allegations of abuse and neglect timely, did not complete functional capacity screens on admission or accurately, failed to delegate nursing procedures properly to certified medication aides, did not complete a self-injection assessment for an insulin-dependent resident, and improperly stored medications including expired Tubersol.
Deficiencies (6)
KAR 26-41-101 (f)(3) The facility failed to report an allegation of abuse, neglect, or exploitation to the Kansas Department for Aging and Disabilities within 24 hours for resident #314 after multiple falls.
K.A.R.26-41-201(a) The facility failed to ensure resident #318 had a functional capacity screen completed on or before admission; it was completed 2 days after admission.
KAR 26-41-201(d) The facility failed to ensure resident #313's functional capacity screen accurately reflected the resident's status, omitting a fall that occurred within 180 days.
KAR 26-41-204(e) The facility failed to delegate nursing procedures of blood sugar monitoring and insulin pen dosage dialing to certified medication aides as required by the Kansas nurse practice act.
KAR 26-41-205(d) The facility failed to complete a self-injection assessment for resident #316 who self-injected insulin, lacking evidence the assessment was done according to standards.
KAR 26-41-205(h)(4) The facility failed to ensure medications, including a vial of Tubersol for TB testing, were stored according to manufacturer recommendations and not administered beyond expiration.
Report Facts
Resident census: 42
Complaint survey numbers: 3
Falls for resident #314: 4
Days after admission for FCS completion: 2
Days Tubersol vial was used beyond expiration: 7
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Mar 3, 2017
Visit Reason
This document is a Plan of Correction submitted in response to deficiencies identified in a prior inspection.
Findings
No specific deficiencies or findings are detailed in this document; it serves solely as a Plan of Correction record with no linked deficiency reports found.
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 at an Assisted Living Facility in Liberal, Kansas.
Findings
The inspection identified multiple deficiencies including failure to ensure negotiated service agreements 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 management plan reviews with staff and residents.
Deficiencies (7)
KAR 26-41-202(h) The Operator failed to ensure each individual involved in the development of the negotiated service agreement signed the agreement for Resident #187.
KAR 26-41-202(j) The Operator failed to ensure designated facility staff monitored services provided by outside resources and acted as advocates for Residents #185 and #189.
KAR 26-41-204(d) The Operator failed to ensure the negotiated service agreements for Residents #185 and #189 contained descriptions of health care services and named the licensed nurse responsible for implementation and supervision.
KAR 26-41-204(e) The Operator failed to ensure nursing procedures not included in nurse aide or medication aide curriculums were appropriately delegated to Certified Medication Aides by a licensed nurse for Resident #189 and others.
KAR 26-41-205(a)(1) The Operator failed to ensure a licensed nurse performed an assessment of Resident #189's ability to safely and accurately self-administer medications prior to self-administration.
KAR 26-41-205(h) Licensed nurses and medication aides failed to ensure insulin pens for Resident #189, #170, and others were stored according to manufacturer recommendations, with in-use pens improperly refrigerated and lacking date opened.
KAR 26-41-104(d) The Operator failed to ensure quarterly reviews of the facility's emergency management plan were conducted with employees and residents.
Report Facts
Deficiencies cited: 7
Facility census: 48
Employees hired since last resurvey: 59
Residents who self-administer medications: 10
Residents who used insulin: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Health and Wellness Director #F | Health and Wellness Director | Interviewed multiple times regarding deficiencies related to negotiated service agreements, monitoring of outside providers, medication administration, and insulin pen storage. |
| Owner/Operator #C | Owner/Operator | Confirmed deficiencies related to negotiated service agreements and resident care plans. |
| Operator in Training/RN #B | Registered Nurse | Confirmed deficiencies related to negotiated service agreements and resident care plans. |
| Operator #J | Operator | Provided information regarding emergency management plan reviews and staffing. |
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.
Complaint Details
The inspection was triggered by complaints #81352 and #84932 regarding failure to investigate and report resident falls and other care deficiencies.
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 complete negotiated service agreements for residents, failed to provide or coordinate health care services under licensed nurse supervision, failed to document incidents and resident deaths properly, and failed to conduct quarterly reviews of the facility's emergency management plan with employees and residents.
Deficiencies (5)
KAR 26-41-101(f)(3)(A) The operator failed to investigate and report to the department each time staff found residents on the floor to rule out abuse or neglect.
KAR 26-41-202(a)(1)(2)(3) The operator failed to ensure the development of a written negotiated service agreement for residents that included service descriptions, providers, and payment responsibilities.
KAR 26-41-204(c)(1)(2)(3) The operator failed to ensure health care services were provided or coordinated by a licensed nurse including personal care by facility staff or supervised caregivers.
KAR 26-41-105(f)(11) The operator failed to ensure resident records contained documentation of all incidents, symptoms, and indications of illness or injury including date, time, action taken, and results.
KAR 26-41-104(d)(3) The operator failed to ensure quarterly review of the facility's emergency management plan with employees and residents.
Report Facts
Resident census: 43
Residents sampled: 4
Closed records reviewed: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed nurse #A | Provided statements and documentation related to residents' care and deficiencies. | |
| Licensed nurse #C | Documented service notes and incident reports related to resident falls. | |
| Licensed nurse #D | Documented last service notes for resident #255. | |
| Certified staff member #B | Provided statements regarding care for resident #252. |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: N088003 POC 5ZGH11
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: N088003 POC 5ZGH12
Visit Reason
This document is a Plan of Correction related to a previous inspection event for the facility identified as ASPEN with State ID N088003.
Findings
No deficiency records or findings are included in this Plan of Correction document.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: N088003 POC 6VKU11
Visit Reason
This document is a Plan of Correction related to a prior deficiency report for the facility Emeritus at Liberal Springs.
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: N088003 POC 864J11
Visit Reason
This document is a Plan of Correction related to a prior 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: N088003 POC 8IRP11
Visit Reason
This document is a Plan of Correction related to a prior deficiency report for the facility.
Findings
No specific findings are detailed in this document; it serves as a placeholder for the Plan of Correction linked to a previous COVID-related deficiency report.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: N088003 POC 963P11
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: N088003 POC 963P12
Visit Reason
This document is a Plan of Correction related to a prior inspection event for the facility identified as ASPEN with State ID N088003.
Findings
No deficiency details or findings are included 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: N088003 POC G3H011
Visit Reason
This document is a plan of correction related to a prior inspection event identified as G3H011 for the facility with State ID N088003.
Findings
No deficiency details or findings are included in this document. It serves solely as a record of the plan of correction submission and modification dates.
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