Deficiencies (last 9 years)
Deficiencies (over 9 years)
2.4 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
60% better than Kansas average
Kansas average: 6 deficiencies/yearDeficiencies per year
8
6
4
2
0
Occupancy
Latest occupancy rate
58% occupied
Based on a March 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Re-Inspection
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 cited in the prior inspection have been corrected as of the compliance date 2025-03-06, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
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 verify compliance and investigate prior deficiencies.
Complaint Details
The inspection included attached complaints #191531, #184900, and #183557.
Findings
The facility failed to ensure food was served at the proper temperature and maintain complete food temperature logs. Additionally, the facility did not comply with tuberculosis guidelines for adult care homes, lacking required TB testing documentation for a newly hired Certified Medication Aide.
Deficiencies (2)
KAR 26-41-206 (d) Food Preparation. The facility staff failed to serve food at the proper temperature and maintain complete food temperature monitoring logs for multiple dates in February and March 2025.
K.A.R 26-41-207 (b) (5-6) (c) Infection Control Policies. The facility failed to ensure compliance with tuberculosis guidelines by lacking documentation of the second step of TB testing and a TB questionnaire for a newly hired Certified Medication Aide.
Report Facts
Deficiency cited: 2
Missing food temperature log dates: 24
Sampled residents: 3
Sampled newly hired employees: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CMA C | Certified Medication Aide | Named in infection control deficiency for lacking TB testing documentation. |
| Operator A | Confirmed all residents eat at the facility and acknowledged missing food temperature logs. | |
| Regional Administration Staff D | Confirmed incomplete daily completion of food temperature logs and missing TB documentation. |
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Mar 5, 2025
Visit Reason
This document is a plan of correction submitted in response to a resurvey with attached complaints (#191531, #184900, #183557) conducted at the facility on 03/05/2025.
Complaint Details
The plan of correction is related to complaints #191531, #184900, and #183557 attached to the resurvey.
Findings
The plan of correction addresses findings from a resurvey and complaint investigations conducted on 03/05/2025 at the facility.
Deficiencies (1)
The citations represent findings from a resurvey with attached complaints conducted on 03/05/2025 at the facility.
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Sep 6, 2023
Visit Reason
An offsite revisit survey was conducted to verify correction of all previous deficiencies cited on 2023-08-16.
Findings
All deficiencies have been corrected as of the compliance date of 2023-09-06, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Aug 15, 2023
Visit Reason
This document is a Plan of Correction submitted in response to findings from a resurvey conducted at the facility on August 15 and 16, 2023.
Findings
The Plan of Correction addresses citations identified during the resurvey conducted on August 15 and 16, 2023. The document outlines corrective actions related to those findings.
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 cited deficiencies at the facility.
Findings
The facility was found deficient in medication labeling, staff qualifications documentation, and infection control policies related to tuberculosis testing and questionnaires. Specific failures included unlabeled insulin pens for residents, missing criminal background check documentation for a staff member, and incomplete tuberculosis testing and questionnaires for residents and staff.
Deficiencies (3)
KAR 26-41-205 (g) (2) Medication Labeling: The facility failed to ensure prescription medication containers were labeled with a pharmacist-provided label for two residents' insulin injector pens.
26-41-102 (d) Staff Qualifications Employee Records: The facility failed to obtain evidence of criminal background checks conducted through the Kansas Department for Aging and Disability Services for one staff member.
26-41-207 (b) (5-6) (c) Infection Control Policies: The facility failed to comply with tuberculosis guidelines by lacking annual TB questionnaires for residents and TB testing for staff.
Report Facts
Residents receiving facility management of medications: 23
Sampled residents: 3
Sampled newly hired employees: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Operator A | Named in medication labeling, staff qualifications, and infection control deficiencies | |
| Licensed Nurse B | Named in medication labeling and infection control deficiencies | |
| Certified Medication Aide D | Named in medication labeling deficiency | |
| Administrative Staff C | Interviewed regarding staff background checks and TB testing |
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Apr 13, 2022
Visit Reason
The visit was a resurvey conducted on 04/12/22 and 04/13/22 to verify compliance following a previous 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 is a Plan of Correction representing the findings of a resurvey conducted on 04/12/22 and 04/13/22 at the facility.
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: 0
Date: Dec 2, 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 with regulation numbers 26-41-202 (a), 26-41-202 (h), 26-41-205 (d) (1-2), and 28-39-254 were corrected as of the revisit date.
Inspection Report
Re-Inspection
Census: 27
Deficiencies: 4
Date: Nov 14, 2019
Visit Reason
The inspection was a resurvey of an assisted living facility conducted on 11/7, 11/13, and 11/14/2019 to verify correction of previous deficiencies.
Findings
The facility failed to ensure negotiated service agreements included required information such as identification of outside service providers and payment sources, and signatures of all involved parties including residents. The facility also failed to administer PRN medications in accordance with professional standards, lacking documentation of nurse notification and reasons for administration. Additionally, the facility did not maintain chemical safety by leaving chemicals unsecured under the dining room sink.
Deficiencies (4)
KAR 26-41-202(a) The facility failed to ensure negotiated service agreements included identification of outside service providers and payment sources for services received by residents.
KAR 26-41-202(h) The facility failed to ensure each individual involved in the development of the negotiated service agreement signed the agreement, including the resident.
KAR 26-41-205(d) The facility failed to ensure designated staff administered PRN medications in accordance with professional standards, lacking documentation of nurse notification and reasons for administration.
KAR 28-39-254(a) The facility failed to maintain safety by leaving chemicals unsecured under the dining room sink.
Report Facts
Resident 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
Inspection Report
Follow-Up
Deficiencies: 1
Date: Nov 5, 2018
Visit Reason
This visit was conducted as a follow-up to verify correction of previously reported deficiencies at the facility.
Findings
The report confirms that the previously cited deficiency under regulation 26-41-102(a) was corrected as of the revisit date.
Deficiencies (1)
Regulation 26-41-102(a) deficiency was corrected as of 2018-11-05.
Inspection Report
Re-Inspection
Census: 29
Deficiencies: 1
Date: Sep 26, 2018
Visit Reason
The inspection was a resurvey conducted with complaints (#123692, #123891, #123893) at the assisted living facility on 9/25 and 9/26/2018.
Complaint Details
The resurvey was conducted in response to complaints #123692, #123891, and #123893.
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 a resident walked out of the building unattended and staff left the building to retrieve the resident.
Deficiencies (1)
26-41-102 (a) Staff Qualifications Sufficient Staff: The operator failed to ensure direct care staff or licensed nursing staff were in attendance at the facility at all times, resulting in a resident walking out unattended.
Report Facts
Resident census: 29
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Staff A | Provided a written statement about the resident walking out incident. | |
| Certified Staff B | Provided a written statement about the resident walking out incident. | |
| Administrative Nursing Staff C | Arrived at the facility to assess the resident after the incident. | |
| Administrative Staff D | Reported staffing situation during the incident. |
Inspection Report
Follow-Up
Deficiencies: 0
Date: Aug 8, 2017
Visit Reason
This revisit inspection was conducted to verify that previously reported deficiencies have been corrected and to confirm the date such corrective actions were accomplished.
Findings
All previously cited deficiencies listed by regulation or LSC provision numbers were corrected as of the revisit date. The report confirms completion of corrective actions for each deficiency.
Inspection Report
Renewal
Census: 26
Deficiencies: 8
Date: May 10, 2017
Visit Reason
Licensure Resurvey at an Assisted Living Facility in Salina, Kansas conducted on 5/10/17, 5/11/17, and 5/16/17 to assess compliance with state regulations and facility policies.
Findings
The facility failed to maintain copies of residents' advanced directives in medical records, did not thoroughly investigate allegations of abuse or neglect, failed to monitor outside provider services and ensure timely physician orders, and did not seek timely responses to pharmacist variance reports. Additionally, employee records lacked required criminal background documentation, emergency management plan reviews with employees were not conducted quarterly, and water temperatures at resident-accessible sinks exceeded safe limits.
Deficiencies (8)
KAR 26-39-102(b)(c) The facility failed to maintain signed copies of residents' advanced directives in medical records for two sampled residents.
KAR 26-41-101(f)(3)(C) The facility failed to thoroughly investigate an allegation of neglect related to a resident's pelvis fracture.
KAR 26-41-202(j) The facility failed to monitor services provided by outside resources and advocate for residents when services did not meet professional standards.
KAR 26-41-204(g)(h) The facility failed to ensure timely physician orders and documentation of skilled nursing care services and outcomes for two residents.
KAR 26-41-205(l)(2) The facility failed to ensure licensed nurse sought timely response from medical care provider following pharmacist variance reports for one resident.
KAR 26-41-102(d) The facility failed to maintain supporting documentation for criminal background checks for one certified medication aide.
KAR 26-41-104(d) The facility failed to conduct quarterly reviews of the emergency management plan with employees.
KAR 28-39-256 The facility failed to maintain water temperatures between 98°F and 120°F at all times in hand wash sinks accessible to residents.
Report Facts
Resident census: 26
Pharmacy review dates: 5
Water temperature: 138.2
Water temperature: 133.3
Water temperature: 124.5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Health and Wellness Director L | Health and Wellness Director | Interviewed regarding advanced directives, abuse investigation, therapy services, and medication variance reports |
| Executive Director M | Executive Director | Interviewed regarding advanced directives, abuse investigation, therapy services, emergency management, and employee records |
| Certified Medication Aide C | Certified Medication Aide | Employee record 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 measurements |
Inspection Report
Renewal
Census: 30
Deficiencies: 2
Date: Mar 29, 2016
Visit Reason
The inspection was a Licensure Resurvey of the assisted living facility conducted on multiple dates in March 2016 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 and payment obligations. Additionally, medication administration was not consistently in accordance with medical provider orders and professional standards for two residents.
Deficiencies (2)
KAR 26-39-102(a)(1)(C)(2)(3) Admission Policy: The Operator failed to execute a written agreement at admission detailing services, goods, and resident obligations for Resident #187 and failed to notify in writing of rates and charges.
KAR 26-41-205(d) Facility Administration of Medications: The Operator failed to ensure medications were administered according to medical orders and professional standards for Residents #185 and #187.
Report Facts
Census: 30
Residents receiving medication management: 24
Inspection Report
Renewal
Deficiencies: 0
Date: Apr 10, 2014
Visit Reason
The visit was a licensure resurvey of the Sterling House of Salina Assisted Living Facility conducted on April 9 and 10, 2014.
Findings
The licensure resurvey resulted in no deficiency citations.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: N085009 POC 175711
Visit Reason
This document is a Plan of Correction related to a prior inspection event for the facility identified as ASPEN with State ID N085009.
Findings
No deficiency records or findings are included in this Plan of Correction document.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: N085009 POC 175712
Visit Reason
This document is a Plan of Correction related to a prior inspection event identified by Event ID 175712 for the facility with State ID N085009.
Findings
No deficiency records or findings are included in this Plan of Correction document.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: N085009 POC 4PTZ11
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 corrective action plan reference.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: N085009 POC 4PTZ12
Visit Reason
This document is a Plan of Correction related to a prior inspection or regulatory finding for the facility identified as ASPEN with State ID N085009.
Findings
No deficiency records or findings are included in this Plan of Correction document.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: N085009 POC 80FH11
Visit Reason
This document is a Plan of Correction related to a prior inspection or regulatory finding for the facility identified as State ID N085009.
Findings
No deficiency records or findings are included in this Plan of Correction document.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: N085009 POC 82H311
Visit Reason
This document is a Plan of Correction related to a previous inspection or deficiency report for Sterling House of Salina.
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: N085009 POC CV2S11
Visit Reason
This document is a Plan of Correction related to a prior deficiency report for the facility identified as Aspen with State ID N085009.
Findings
No specific findings or deficiencies are detailed in this document. It serves as a placeholder or administrative record for the Plan of Correction submission.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: N085009 POC XO8OL11
Visit Reason
This document is a Plan of Correction related to a prior inspection or regulatory event for the facility identified as ASPEN with State ID N085009.
Findings
No specific deficiencies or findings are detailed in this document. It serves as a placeholder or record for the Plan of Correction submission.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: N085009 POC Q6EI11
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 corrective action plan reference.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: N085009 POC RACH11
Visit Reason
This document is a Plan of Correction related to a prior inspection event identified as RACH11 for the facility with State ID N085009.
Findings
No specific deficiencies or findings 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: N085009 POC RACH12
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 as a placeholder for the Plan of Correction with no records found.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: N085009 POC UNMZ11
Visit Reason
This document is a Plan of Correction related to a prior inspection report for the facility Brookdale Salina Kirwin.
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: N085009 POC UNMZ12
Visit Reason
This document is a Plan of Correction related to a previous inspection event identified as UNMZ12 for facility State ID N085009.
Findings
No deficiency records or findings are included in this Plan of Correction document.
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