Inspection Report Summary
The most recent inspection on March 20, 2025, found the facility in compliance with all regulations and no new deficiencies. Prior inspections showed some deficiencies related mainly to food temperature control and tuberculosis testing documentation, which were addressed by the March 6, 2025 compliance date. Earlier reports also noted issues with medication labeling, employee background checks, and tuberculosis compliance, as well as a substantiated complaint in 2018 regarding staff leaving the building unattended. No fines, immediate jeopardy findings, or license actions were listed in the available reports. The facility appears to have improved over time, correcting previous deficiencies and maintaining compliance in the latest inspections.
Deficiencies (last 10 years)
Deficiencies (over 10 years)
3.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
45% better than Kansas average
Kansas average: 6 deficiencies/yearDeficiencies per year
8
6
4
2
0
Census
Latest occupancy rate
25 residents
Based on a March 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Census over time
Inspection Report
Follow-Up
Deficiencies: 0
Date: Mar 20, 2025
Visit Reason
An offsite revisit survey was conducted to verify correction of all previous deficiencies cited on 2025-03-05.
Findings
All deficiencies have been corrected as of the compliance date of 2025-03-06, 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: 2
Date: Mar 5, 2025
Visit Reason
The inspection was a resurvey with attached complaints (#191531, #184900, #183557) conducted to evaluate compliance with food preparation and infection control regulations.
Complaint Details
The inspection was triggered by complaints #191531, #184900, and #183557.
Findings
The facility failed to ensure food was served at the proper temperature as required by regulations, with incomplete food temperature logs for multiple dates. Additionally, the facility did not comply with tuberculosis guidelines for adult care homes, as documentation for a newly hired Certified Medication Aide's second step TB testing and questionnaire was missing.
Deficiencies (2)
Facility staff failed to serve food at the proper temperature, with missing food temperature records for multiple dates.
Facility failed to ensure compliance with tuberculosis guidelines; missing documentation of second step TB testing and TB questionnaire for a newly hired staff member.
Report Facts
Residents present: 25
Missing food temperature log dates: 23
Sampled staff: 5
Sampled residents: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Operator A | Named in findings related to failure to ensure proper food temperature and TB compliance | |
| Certified Medication Aide C | Certified Medication Aide | Staff member with missing second step TB testing and questionnaire documentation |
| Regional Administration Staff D | Interviewed regarding incomplete food temperature logs and TB documentation |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Mar 5, 2025
Visit Reason
The document is a plan of correction responding to a resurvey with attached complaints (#191531, #184900, #183557) conducted at the facility on 03/05/25.
Complaint Details
The visit was related to complaints #191531, #184900, and #183557 attached to the resurvey.
Findings
The plan of correction addresses citations resulting from a resurvey and complaint investigations conducted on 03/05/25 at the facility.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Sep 6, 2023
Visit Reason
An offsite revisit survey was conducted on 09/06/23 for all previous deficiencies cited on 08/16/23.
Findings
All deficiencies have been corrected as of the compliance date of 09/06/23, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Inspection Report
Re-Inspection
Census: 28
Deficiencies: 3
Date: Aug 15, 2023
Visit Reason
The inspection was a resurvey conducted on 08/15/23 and 08/16/23 to assess compliance with previously identified deficiencies at the facility.
Findings
The facility was found deficient in medication labeling where insulin injector pens for two residents were not properly labeled by a pharmacist. Additionally, staff records lacked required criminal background check documentation for one employee, and tuberculosis testing and questionnaires were incomplete for residents and staff, indicating failure to comply with state tuberculosis guidelines.
Deficiencies (3)
Prescription medication containers were not labeled with a pharmacist-provided label for two residents' insulin injector pens.
Employee records lacked evidence of criminal background checks completed through the Kansas Department for Aging and Disability Services for one staff member.
Failure to ensure compliance with tuberculosis guidelines including missing annual TB questionnaires for residents and lack of TB testing for staff.
Report Facts
Census: 28
Residents receiving medication management: 23
Sampled residents: 3
Sampled newly hired employees: 5
Insulin units for R4: 25
Insulin units for R5: 20
Hire date of Operator A: Jul 18, 2022
Admission date for R1: Nov 12, 2019
Admission date for R3: Jun 15, 2023
Hire date of LN B: May 15, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Operator A | Named in medication labeling deficiency and lack of criminal background check and TB testing | |
| Licensed Nurse B | Named in medication observation and lack of TB testing | |
| Certified Medication Aide D | Identified unlabeled insulin injector pens | |
| Administrative Staff C | Confirmed lack of criminal background check and TB testing |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Aug 15, 2023
Visit Reason
The document is a Plan of Correction submitted in response to findings from a resurvey conducted at the facility on 08/15/23 and 08/16/23.
Findings
The Plan of Correction addresses citations identified during the resurvey conducted on 08/15/23 and 08/16/23 at the facility.
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Apr 12, 2022
Visit Reason
The visit was a resurvey conducted on 04/12/22 and 04/13/22 to verify compliance following a prior inspection.
Findings
The resurvey resulted in no citations or deficiencies at the facility.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Apr 12, 2022
Visit Reason
This document represents the provider's plan of correction following a resurvey conducted on 04/12/22 and 04/13/22.
Findings
The resurvey conducted on 04/12/22 and 04/13/22 resulted in no citations.
Inspection Report
Routine
Deficiencies: 0
Date: Jul 28, 2020
Visit Reason
The special infection control survey for COVID-19 was conducted at the facility on 07/28/2020.
Findings
The survey resulted in findings of no deficiency citations.
Inspection Report
Re-Inspection
Deficiencies: 4
Date: Dec 2, 2019
Visit Reason
This revisit inspection was conducted to verify that previously reported deficiencies at Brookdale Salina Kirwin have been corrected.
Findings
All previously cited deficiencies identified by regulation or LSC provision numbers were corrected as of the revisit date.
Deficiencies (4)
Deficiency related to regulation 26-41-202 (a)
Deficiency related to regulation 26-41-202 (h)
Deficiency related to regulation 26-41-205 (d) (1-2)
Deficiency related to regulation 28-39-254
Inspection Report
Re-Inspection
Census: 27
Deficiencies: 4
Date: Nov 14, 2019
Visit Reason
The inspection was a resurvey conducted on 11/7, 11/13, and 11/14/2019 at an assisted living facility to evaluate compliance with negotiated service agreements, medication administration, and facility safety.
Findings
The facility failed to ensure negotiated service agreements included required information such as outside service providers and payment sources, and that all parties signed the agreements. Medication administration did not consistently follow professional standards, particularly regarding PRN medications, lacking documentation of nurse notification and reasons for administration. Additionally, the facility failed to secure chemicals stored under the dining room sink, posing a safety risk.
Deficiencies (4)
Failed to ensure negotiated service agreements included identification of outside service providers and payment sources.
Failed to ensure all individuals involved in the development of negotiated service agreements signed the agreements.
Failed to ensure medications and biologicals were administered in accordance with professional standards, specifically lacking nurse notification and documentation for PRN medications.
Failed to maintain the facility to protect health and safety by leaving chemicals unsecured under the dining room sink.
Report Facts
Census: 27
PRN medication administrations: 7
PRN medication administrations: 6
PRN medication administrations: 5
PRN medication administrations: 9
PRN medication administrations: 10
PRN medication administrations: 3
PRN medication administrations: 8
PRN medication administrations: 2
PRN medication administrations: 8
PRN medication administrations: 3
PRN medication administrations: 2
PRN medication administrations: 2
PRN medication administrations: 13
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed nursing staff B | Licensed Nurse | Confirmed therapy addendums needed to include service provider and payment source; reported expectations for PRN medication administration. |
| Certified staff J | Certified Staff | Reported procedures for administering PRN medications and notifying nurses. |
| Certified staff K | Certified Staff | Reported requirement to contact nurse before administering PRN medications. |
| Licensed nursing staff C | Licensed Nurse | Confirmed chemicals were not to be stored under unlocked dining room sink and removed chemicals. |
Inspection Report
Re-Inspection
Deficiencies: 1
Date: Nov 5, 2018
Visit Reason
This revisit inspection was conducted to verify that previously reported deficiencies have been corrected and to document the date such corrective actions were accomplished.
Findings
The report confirms that the previously cited deficiency related to regulation 26-41-102 (a) was corrected as of 11/05/2018. No other deficiencies or findings are documented in this report.
Deficiencies (1)
Deficiency related to regulation 26-41-102 (a) previously cited and now corrected
Inspection Report
Complaint Investigation
Census: 29
Deficiencies: 1
Date: Sep 26, 2018
Visit Reason
The inspection was a resurvey with complaints (#123692, #123891, #123893) at the assisted living facility conducted on 9/25 and 9/26/2018.
Complaint Details
The visit was complaint-related involving three complaints (#123692, #123891, #123893). The complaint was substantiated by findings that staff left the building unattended while retrieving a missing resident.
Findings
The operator failed to ensure that direct care staff or licensed nursing staff were in attendance at the facility at all times, as evidenced by an incident where two staff left the building unattended while retrieving a resident who had walked out.
Deficiencies (1)
Failed to ensure direct care staff or licensed nursing staff were in attendance at the facility at all times.
Report Facts
Census: 29
Complaints: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Certified Staff | Involved in the incident where resident #250 was found outside the facility. |
| Staff B | Certified Staff | Reported missing resident #250 and assisted in retrieving the resident. |
| Staff C | Administrative Nursing Staff | Arrived at the facility to assess resident #250 after the incident. |
| Staff D | Administrative Staff | Reported on staffing situation during the incident. |
Inspection Report
Re-Inspection
Deficiencies: 8
Date: Aug 8, 2017
Visit Reason
This revisit inspection was conducted to verify that previously reported deficiencies had been corrected and to document the dates when corrective actions were accomplished.
Findings
All previously cited deficiencies were corrected as of the revisit date, with each correction documented and completed on 08/08/2017.
Deficiencies (8)
Deficiency related to regulation 26-39-102 (b) (c)
Deficiency related to regulation 26-41-101 (f) (3)
Deficiency related to regulation 26-41-202 (j)
Deficiency related to regulation 26-41-204 (g) (h)
Deficiency related to regulation 26-41-205 (l) (2)
Deficiency related to regulation 26-41-102 (d)
Deficiency related to regulation 26-41-104 (d)
Deficiency related to regulation 28-39-256
Inspection Report
Renewal
Census: 26
Deficiencies: 8
Date: May 17, 2017
Visit Reason
Licensure Resurvey at the Assisted Living Facility conducted on 5/10/17, 5/11/17, and 5/16/17, including review of facility investigation #3207.
Findings
The facility was found deficient in multiple areas including failure to maintain copies of residents' advanced directives, incomplete investigations of abuse allegations, inadequate monitoring of outside service providers, lack of timely physician orders and documentation for skilled nursing and therapy services, failure to respond to pharmacist variance reports, incomplete employee criminal background checks, failure to conduct quarterly emergency management plan reviews with employees, and water temperature exceeding safe limits at resident accessible sinks.
Deficiencies (8)
Failure to maintain copies of residents' advanced directives in medical records for residents #187 and #189.
Failure to thoroughly investigate allegations of potential abuse or neglect for resident #180.
Failure to monitor services provided by outside resources and act as an advocate for residents #189 and #187.
Failure to ensure timely physician orders and documentation of skilled nursing and therapy services for residents #189 and #187.
Failure to seek a response from the medical care provider within five working days as a result of pharmacist variance reports for resident #187.
Failure to maintain supporting documentation for criminal background checks for certified medication aide #C.
Failure to conduct quarterly reviews of the facility's emergency management plan with employees.
Failure to maintain water temperature between 98°F and 120°F at all times in resident accessible hand wash sinks (Dining Room and Public Bathroom sinks).
Report Facts
Census: 26
Pharmacy review dates: 5
Employee records reviewed: 5
Employee hires since last resurvey: 27
Water temperature: 138.2
Water temperature: 133.3
Water temperature: 124.5
Water temperature: 107.2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Health and Wellness Director L | Health and Wellness Director | Interviewed regarding missing advanced directives, abuse investigation, therapy services, and medication variance reports |
| Executive Director M | Executive Director | Interviewed regarding missing advanced directives, abuse investigation, therapy services, medication variance reports, emergency management plan reviews, and water temperature issues |
| Certified Medication Aide C | Certified Medication Aide | Employee record reviewed; lacked supporting documentation for criminal background check |
| Maintenance Technician P | Maintenance Technician | Provided water temperature logs and information about mixing valve replacement |
| Cook K | Cook | Verified water temperature readings at Dining Room hand sink |
Inspection Report
Renewal
Census: 30
Deficiencies: 2
Date: Mar 29, 2016
Visit Reason
The inspection was a Licensure Resurvey conducted at the Assisted Living Facility to assess compliance with licensing requirements.
Findings
The facility failed to execute a written admission agreement at the time of admission for one resident and failed to notify the resident or representative in writing of rates, charges, and payment obligations. Additionally, medication administration deficiencies were found for two residents where medications were administered without current physician orders or proper discontinuation orders.
Deficiencies (2)
Failure to execute a written admission agreement at time of admission detailing services, goods, and resident obligations.
Failure to ensure all medications administered in accordance with medical care provider's written orders and professional standards.
Report Facts
Census: 30
Residents receiving medication management: 24
Sampled residents: 3
Inspection Report
Renewal
Deficiencies: 0
Date: Apr 10, 2014
Visit Reason
The Licensure Resurvey was conducted at the Sterling House of Salina Assisted Living Facility on 4/09/14 and 4/10/14 as part of the facility's licensure renewal process.
Findings
The resurvey resulted in no deficiency citations, indicating full compliance with regulatory requirements at the time of inspection.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Dec 12, 2011
Visit Reason
This document is a Plan of Correction submitted in response to a prior inspection or deficiency report.
Findings
No specific findings or deficiencies are detailed in this document; it serves as a record of the Plan of Correction status and related metadata.
Report Facts
POC added date: Plan of Correction added on 2011-10-14
POC modified date: Plan of Correction modified on 2012-01-03
Inspection start date: Inspection visit started on 2011-12-12
Inspection exit date: Inspection visit ended on 2011-12-13
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