Inspection Report Summary
The most recent inspection on July 29, 2025, confirmed that a previously cited deficiency had been corrected. Earlier inspections showed a pattern of deficiencies related mainly to resident care planning and supervision, including a notable Immediate Jeopardy finding in July 2025 when a resident eloped without staff knowledge, which was addressed promptly. Prior issues also involved medication labeling and employee documentation, but enforcement actions such as fines or license suspensions were not listed in the available reports. Complaint investigations were mixed, with some substantiated findings like the elopement case, while others were unsubstantiated. The facility appears to be making improvements over time, as several revisit inspections verified correction of earlier deficiencies.
Deficiencies (last 6 years)
Deficiencies (over 6 years)
1 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
83% better than Kansas average
Kansas average: 6 deficiencies/yearDeficiencies per year
4
3
2
1
0
Census
Latest occupancy rate
21 residents
Based on a July 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Census over time
Inspection Report
Re-Inspection
Deficiencies: 1
Date: Jul 29, 2025
Visit Reason
This revisit report documents the correction of deficiencies previously reported during an earlier survey, verifying that corrective actions have been completed.
Findings
The report confirms that the previously cited deficiency under regulation 26-41-101 (f)(1) has been corrected as of 07/29/2025.
Deficiencies (1)
Deficiency under regulation 26-41-101 (f)(1) previously cited
Inspection Report
Complaint Investigation
Census: 21
Deficiencies: 1
Date: Jul 9, 2025
Visit Reason
The inspection was an abbreviated survey conducted in response to complaints #195710 and #194794 at the facility.
Complaint Details
The investigation was triggered by complaints #195710 and #194794. The resident was found to have eloped from the facility, and the facility failed to follow established policies for door alarm response and resident supervision. Immediate Jeopardy was removed after the facility initiated one-on-one supervision and took corrective actions.
Findings
The facility failed to protect a resident (R1) who was a known wander risk and eloped from the facility without staff knowledge through an alarmed exit door, placing the resident in Immediate Jeopardy. The resident was found approximately 2 hours and 15 minutes later outside the facility. The facility lacked an Elopement Risk Assessment for the resident and failed to follow door alarm response protocols.
Deficiencies (1)
Failure to ensure no resident was subjected to neglect when a known wander risk resident eloped from the facility without staff knowledge.
Report Facts
Resident census: 21
Resident elopement duration: 135
Date of resident discharge: Apr 15, 2025
Date of resident admission: Feb 3, 2025
Date of Immediate Jeopardy removal: Apr 15, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA D | Certified Nurse Aide | Named in the finding for failing to notify staff after door alarm sounded; suspended and no longer employed |
| Operator/LN A | Operator / Licensed Nurse | Failed to provide or coordinate services to ensure resident safety |
| Regional Nurse B | Regional Nurse | Provided resident roster used in review |
| Certified Medication Aide E | Certified Medication Aide | Last saw resident in activity area before elopement |
| Administrative Staff C | Administrative Staff | Confirmed facility door alarm response procedures |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Jul 9, 2025
Visit Reason
The document is a plan of correction related to an abbreviated survey conducted for complaints #195710 and #194794 at the facility on 07/09/2025.
Complaint Details
The visit was complaint-related involving complaints #195710 and #194794.
Findings
The plan of correction addresses findings from an abbreviated survey triggered by two complaints at the facility.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Shirley Boltz | Contact person for Plan of Correction assistance. | |
| Mary Tegtmeier | Submitted and modified the Plan of Correction document. |
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Apr 23, 2025
Visit Reason
An offsite revisit survey was conducted to verify correction of all previous deficiencies cited on 2025-04-08.
Findings
All deficiencies cited in the previous inspection have been corrected as of the compliance date 2025-04-09, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Report Facts
Previous deficiencies cited: Deficiencies cited on 2025-04-08, all corrected by 2025-04-09
Inspection Report
Re-Inspection
Census: 25
Deficiencies: 1
Date: Apr 8, 2025
Visit Reason
The inspection was a resurvey with attached complaints (#189692 and #186458) conducted to assess compliance with regulatory requirements.
Complaint Details
The resurvey included attached complaints #189692 and #186458.
Findings
The facility failed to ensure that the Negotiated Service Agreement (NSA) was fully developed based on the resident's Functional Capacity Screen, service needs, and preferences for two sampled residents. The Personal Service Plans did not accurately reflect the residents' status for transfer and mobility, as confirmed by staff interviews and record reviews.
Deficiencies (1)
Failure to ensure the Negotiated Service Agreement was fully developed based on the resident's Functional Capacity Screen, service needs, and preferences.
Report Facts
Census: 25
Sampled residents: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Staff A | Failed to ensure the Negotiated Service Agreement was fully developed. | |
| Certified Medication Aide B | Certified Medication Aide | Provided information about residents' transfer and mobility status. |
| Regional Nurse C | Regional Nurse | Acknowledged inaccuracies in the Personal Service Plans. |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Apr 8, 2025
Visit Reason
The document is a Plan of Correction addressing findings from a resurvey with attached complaints (#189692 and #186458) conducted at the facility on 04/08/25.
Complaint Details
The visit was related to complaints #189692 and #186458 attached to the resurvey.
Findings
The Plan of Correction references citations from a resurvey and complaint investigations conducted on 04/08/25, but does not detail specific findings within this document.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Shirley Boltz | Contact person for Plan of Correction assistance | |
| Mary Tegtmeier | Submitted the Plan of Correction to KDADS |
Inspection Report
Follow-Up
Deficiencies: 0
Date: Sep 26, 2023
Visit Reason
An offsite revisit survey was conducted to verify correction of all previous deficiencies cited on 09/13/23.
Findings
All deficiencies cited in the prior inspection have been corrected as of the compliance date of 09/21/23, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Inspection Report
Re-Inspection
Census: 39
Deficiencies: 2
Date: Sep 13, 2023
Visit Reason
The inspection was a resurvey conducted in response to complaints (#175913) to verify compliance with previous deficiencies.
Complaint Details
The visit was triggered by complaints (#175913).
Findings
The facility failed to ensure licensed nurses or pharmacists placed the full name of residents on each package of over-the-counter medications. Additionally, the facility did not comply with tuberculosis (TB) guidelines by failing to complete TB questionnaires upon hire for several employees.
Deficiencies (2)
Licensed nurses or pharmacists failed to place the full name of the resident on each package of the resident's over-the-counter medication.
Facility failed to ensure compliance with tuberculosis guidelines by not completing TB questionnaires upon hire for certain employees.
Report Facts
Resident census: 39
Sample size: 3
Non-sampled residents observed: 4
Newly hired employees reviewed: 5
Employees lacking TB questionnaire: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CMA F | Certified Medication Aide | Interviewed and confirmed medications without full resident names. |
| CMA C | Certified Medication Aide | Employee record lacked evidence of TB questionnaire completion upon hire. |
| CMA D | Certified Medication Aide | Employee record lacked evidence of TB questionnaire completion upon hire. |
| CNA E | Certified Nurse Aide | Employee record lacked evidence of TB questionnaire completion upon hire. |
| LN B | Licensed Nurse | Confirmed TB questionnaires were not completed upon hire. |
| Administrator A | Failed to ensure licensed nurses or pharmacists placed full resident names on medication packages. |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Sep 13, 2023
Visit Reason
The document is a plan of correction related to a resurvey with complaints (#175913) conducted at the facility on 09/13/2023.
Complaint Details
The visit was complaint-related, referencing complaints number 175913.
Findings
The plan of correction addresses citations found during the resurvey with complaints at the facility on 09/13/2023.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Jul 29, 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 related to infection control.
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Jun 26, 2018
Visit Reason
The visit was a resurvey conducted on 6/25 and 6/26/2018 to assess compliance at the assisted living facility.
Findings
The resurvey resulted in zero citations, indicating no deficiencies were found during the inspection.
Inspection Report
Renewal
Census: 38
Deficiencies: 1
Date: Sep 29, 2016
Visit Reason
Licensure Resurvey at the Assisted Living Facility including investigation of Complaints #106046 and #104508.
Complaint Details
Complaints #106046 and #104508 were investigated during the licensure resurvey.
Findings
The facility failed to ensure employee records contained supporting documentation for criminal background checks for four certified staff members hired since the last resurvey.
Deficiencies (1)
Employee records lacked supporting documentation for criminal background checks for certified staff #A, #B, #D, and #E.
Report Facts
Facility census: 38
Employees hired since last resurvey: 27
Certified staff records reviewed: 5
Certified staff with missing documentation: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Executive Director #H | Operator | Confirmed no criminal background documentation available and described corrective actions |
Inspection Report
Renewal
Deficiencies: 0
Date: Sep 21, 2015
Visit Reason
The Licensure Resurvey at the Assisted Living Facility in Salina, Kansas on 9/16/15, 9/17/15, and 9/21/15 was conducted as a renewal inspection. Complaint #89154 was also investigated during this visit.
Complaint Details
Complaint #89154 was investigated but no deficiencies were cited.
Findings
The inspection resulted in no deficiency citations.
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