Inspection Report Summary
The most recent inspection on September 23, 2025, found the facility in compliance with all regulations and no new deficiencies. Earlier inspections showed some deficiencies related mainly to functional capacity screenings, negotiated service agreements, and safe food storage, which were addressed promptly. Prior reports also noted issues with medication administration, documentation, and emergency preparedness, including one instance in 2023 where a medication error led to resident harm requiring hospitalization. Complaint investigations were mostly unsubstantiated except for a few substantiated cases involving resident care coordination and reporting failures. The facility appears to be improving over time, with recent follow-up inspections confirming correction of prior deficiencies.
Deficiencies (last 8 years)
Deficiencies (over 8 years)
5.1 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
15% better than Kansas average
Kansas average: 6 deficiencies/yearDeficiencies per year
12
9
6
3
0
Census
Latest occupancy rate
54 residents
Based on a September 2025 inspection.
Census over time
Inspection Report
Follow-Up
Deficiencies: 0
Date: Sep 23, 2025
Visit Reason
An offsite revisit survey was conducted to verify correction of all previous deficiencies cited on 09/16/25.
Findings
All deficiencies have been corrected as of the compliance date of 09/22/25, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Sep 15, 2025
Visit Reason
The document is a Plan of Correction submitted in response to findings from the licensure resurvey conducted on 09/15/25 and 09/16/25 at the facility.
Findings
The Plan of Correction addresses citations identified during the licensure resurvey conducted on the specified dates. No specific deficiencies or severity levels are detailed in this document.
Inspection Report
Renewal
Census: 54
Deficiencies: 3
Date: Sep 15, 2025
Visit Reason
The inspection was a licensure resurvey conducted on 09/15/25 and 09/16/25 to assess compliance with state regulations for the assisted living facility.
Findings
The facility was found deficient in conducting functional capacity screenings on admission, developing complete negotiated service agreements for residents receiving physical therapy, and maintaining safe and sanitary food storage conditions in the satellite kitchen refrigerator/freezer.
Deficiencies (3)
Failure to perform a functional capacity screening on Resident 2 at the time of admission.
Failure to ensure negotiated service agreements for Residents 1 and 2 included service descriptions, provider identification, and payment responsibility for physical therapy services.
Failure to store food under safe and sanitary conditions in the satellite kitchen refrigerator/freezer; food items lacked beyond use dates.
Report Facts
Census: 54
Admission date: Sep 18, 2023
Admission date: Jul 23, 2023
Functional Capacity Screen date: Oct 31, 2024
Functional Capacity Screen date: Jul 14, 2024
Negotiated Service Agreement date: Oct 31, 2024
Negotiated Service Agreement date: Jul 14, 2024
Physical Therapy order date: Aug 19, 2025
Rehabilitation Services Consent date: Aug 20, 2025
Rehabilitation Services Consent date: Jun 4, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nurse A | Confirmed deficiencies related to functional capacity screening and negotiated service agreements for Residents 1 and 2. | |
| Dietary Staff D | Dietary Staff | Confirmed food storage issues in the satellite kitchen refrigerator/freezer. |
Inspection Report
Follow-Up
Deficiencies: 0
Date: Apr 4, 2024
Visit Reason
An offsite revisit survey was conducted to verify correction of all previous deficiencies cited on 2024-03-13.
Findings
All deficiencies have been corrected as of the compliance date of 2024-03-26, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Report Facts
Previous deficiencies cited: 1
Inspection Report
Renewal
Census: 56
Deficiencies: 4
Date: Mar 13, 2024
Visit Reason
The inspection was a Re-Licensure survey conducted at Dove Estates Senior Living Community to assess compliance with state regulations for assisted living facilities.
Findings
The survey identified multiple deficiencies including failure to complete timely assessments for self-administration of medication, improper medication storage practices especially related to insulin pens, incomplete documentation of incidents and follow-up actions in resident records, and failure to conduct quarterly reviews of the facility's emergency management plan with residents.
Deficiencies (4)
Failed to ensure a licensed nurse completed an assessment for self-administration of medications prior to resident self-administering.
Failed to ensure medications, specifically insulin pens, were stored according to manufacturer recommendations including proper dating to prevent use beyond expiration.
Failed to document all incidents, symptoms, actions taken, and results in resident records.
Failed to ensure quarterly review of the facility's emergency management plan with all residents.
Report Facts
Census: 56
Sampled residents: 3
Insulin pen units remaining: 200
Insulin pen units remaining: 50
Insulin pen units remaining: 40
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Executive Director | Named as responsible for failure to ensure assessments, medication storage, documentation, and emergency plan reviews | |
| Administrative Licensed Nurse B | Interviewed and confirmed timing of medication self-administration assessment and documentation deficiencies | |
| Licensed Nurse C | Observed medication storage practices and acknowledged missing dates on insulin pens | |
| Administrative Staff A | Reported lack of records for quarterly emergency management plan reviews with residents |
Inspection Report
Renewal
Deficiencies: 0
Date: Mar 13, 2024
Visit Reason
The document is a Plan of Correction related to a Re-Licensure survey conducted at the Assisted Living Facility on 03/13/24.
Findings
The Plan of Correction addresses citations found during the Re-Licensure survey conducted on 03/13/24 at the facility.
Inspection Report
Re-Inspection
Deficiencies: 1
Date: Jul 31, 2023
Visit Reason
This is a revisit report completed by a State surveyor to show those deficiencies previously reported that have been corrected and the date such corrective action was accomplished.
Findings
The report indicates that previously cited deficiencies, specifically under regulation 26-41-205 (d) (1-2), have been corrected as of 07/31/2023.
Deficiencies (1)
Deficiency under regulation 26-41-205 (d) (1-2) corrected
Inspection Report
Abbreviated Survey
Census: 59
Deficiencies: 1
Date: Jul 5, 2023
Visit Reason
An Abbreviated Survey with complaint investigations was conducted on 07/05/2023 and 07/06/2023 at Dove Estates Senior Living Community, an assisted living facility.
Complaint Details
The survey included complaint investigations numbered 178086, 178155, 178258, 179167, and 181214.
Findings
The administrator failed to ensure designated staff ordered and administered a resident's (R5) medication, Sennosides-Docusate Sodium, according to physician orders. This failure resulted in the resident missing 31 consecutive doses, leading to constipation, rectal impaction, colonic obstruction, hospitalization, and bowel surgery.
Deficiencies (1)
Failure to ensure designated staff ordered and administered Sennosides-Docusate Sodium as ordered by the physician for one resident, resulting in harm.
Report Facts
Resident census: 59
Missed medication doses: 31
Medication administration days: 29
Medication administration days: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Medication Aide E | Certified Medication Aide | Reported medication ordering and administration procedures and that the medication was not available. |
| Licensed Nurse D | Licensed Nurse | Reported procedures for medication unavailability and lack of recall about resident's medication status. |
| Certified Nurse Aide G | Certified Nurse Aide | Reported resident's ability to perform personal care and alertness. |
| Certified Medication Aide H | Certified Medication Aide | Reported medication availability issues and communication with pharmacy. |
| Administrative Licensed Nurse C | Administrative Licensed Nurse | Reported pharmacy delivery and medication cart issues. |
| Pharmacist J | Pharmacist | Reported refill request and delivery dates for the medication. |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Jul 5, 2023
Visit Reason
The document is a Plan of Correction addressing findings from an Abbreviated Survey with complaint investigations conducted on 07/05/23 and 07/06/23 at an Assisted Living facility.
Complaint Details
The visit included complaint investigations for complaints numbered 178086, 178155, 178258, 179167, and 181214.
Findings
The Plan of Correction corresponds to deficiencies identified during an Abbreviated Survey combined with complaint investigations numbered 178086, 178155, 178258, 179167, and 181214.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Dec 1, 2022
Visit Reason
An offsite revisit survey was conducted to verify correction of all previous deficiencies cited on 2022-11-21.
Findings
All deficiencies have been corrected as of the compliance date of 2022-12-01, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Inspection Report
Re-Inspection
Census: 60
Deficiencies: 3
Date: Nov 21, 2022
Visit Reason
The inspection was a resurvey with complaint investigations 174382 and 161925 conducted at an assisted living facility to assess compliance with regulatory requirements.
Complaint Details
The visit included complaint investigations 174382 and 161925.
Findings
The facility failed to complete a Functional Capacity Screen and revise the Negotiated Service Agreement for one resident following a significant improvement in condition. Additionally, the facility did not verify licensure and certification for two newly hired staff requiring specialized education and training within required timeframes.
Deficiencies (3)
Failed to complete a Functional Capacity Screen for one resident following a significant change in condition.
Failed to review and revise the Negotiated Service Agreement for one resident following a significant change in status.
Failed to have evidence of licensure, registration, and certification for two newly hired staff requiring specialized education and training verified upon hire.
Report Facts
Census: 60
Number of sampled residents: 3
Number of focused record reviews: 2
Number of newly hired employees reviewed: 5
Months delay for licensure check: 5
Months delay for certification check: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Nurse F | Licensed Nurse | Named in deficiency for delayed licensure verification. |
| Certified Nurse Aide G | Certified Nurse Aide | Named in deficiency for delayed certification verification. |
| Certified Medication Aide D | Provided statements about resident functional status. | |
| Certified Medication Aide E | Provided statements about resident functional status. | |
| Administrative Licensed Nurse B | Administrative Licensed Nurse | Reported on assessments and acknowledged deficiencies. |
| Administrative Staff A | Provided employee records and reported on licensure checks. |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Nov 17, 2022
Visit Reason
The document is a Plan of Correction addressing findings from a Resurvey with complaint investigations conducted on 11/17/22 and 11/21/22 at an Assisted Living Facility.
Complaint Details
The visit included complaint investigations with IDs 174382 and 161925.
Findings
The Plan of Correction references citations from a Resurvey and complaint investigations but does not detail specific findings within this document.
Inspection Report
Routine
Deficiencies: 0
Date: Jun 30, 2020
Visit Reason
The special infection control survey for COVID-19 was conducted at the facility.
Findings
The survey resulted in findings of no deficiency citations.
Inspection Report
Re-Inspection
Deficiencies: 7
Date: Dec 6, 2018
Visit Reason
This report is a revisit conducted by a State surveyor 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 their regulation numbers were corrected as of the revisit date, December 6, 2018.
Deficiencies (7)
Deficiency related to regulation 26-41-101 (f) (1)
Deficiency related to regulation 26-41-101 (f) (3)
Deficiency related to regulation 26-41-202 (d)
Deficiency related to regulation 26-41-204 (a)
Deficiency related to regulation 26-41-204 (b)
Deficiency related to regulation 26-41-105 (f) (11)
Deficiency related to regulation 26-41-104 (a)
Inspection Report
Complaint Investigation
Census: 58
Deficiencies: 6
Date: Oct 29, 2018
Visit Reason
The inspection was a resurvey with complaint #127184 conducted over multiple dates in October 2018 to investigate allegations of neglect and compliance with regulatory requirements.
Complaint Details
Complaint #127184 triggered the resurvey. The complaint involved neglect of resident #611 who was found on the floor after a fall and not discovered for many hours, failure to report and investigate neglect, and other care deficiencies.
Findings
The facility was found deficient in ensuring residents were free from neglect, including failure to notify nursing staff when a resident missed meals, failure to report and investigate allegations of neglect, failure to revise negotiated service agreements after significant changes in condition, failure to provide and coordinate necessary health care services, incomplete documentation of incidents and injuries, and insufficient staffing for emergency evacuations.
Deficiencies (6)
Failure to ensure resident was not subjected to neglect when staff failed to notify nurse of missed meal leading to resident being found on floor after a fall.
Failure to report and investigate allegations of neglect to the department.
Failure to revise negotiated service agreements with significant changes in resident condition.
Failure of licensed nurse to provide or coordinate necessary health care services in accordance with functional capacity screening and negotiated service agreement.
Failure to document all incidents, symptoms, and indications of illness or injury including date, time, action taken, and results.
Failure to ensure sufficient staff to safely evacuate residents requiring assistance during emergencies or disasters.
Report Facts
Residents requiring two staff assist for transfer: 2
Residents requiring transfer assistance to toilet: 12
Residents identified with impaired cognition: 6
Staff participating in fire drill: 5
Staff participating in fire drill: 4
Time taken for fire drill: 7
Facility census: 58
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed nurse M | Licensed Nurse | Found resident #611 on floor after fall and called 911. |
| Licensed nurse A | Licensed Nurse | Put in place policy for notification when resident misses meal; admitted policy was not followed. |
| Licensed nurse O | Licensed Nurse | Interviewed regarding resident #644 care and incident follow-up. |
| Licensed nurse R | Licensed Nurse | Provided multiple progress notes and care documentation for resident #644. |
| Certified staff L | Certified Staff | Interviewed regarding resident #644 and #633 care needs and transfers. |
| Licensed nurse G | Licensed Nurse | Interviewed regarding staffing and resident care; involved in incident response. |
| Licensed nurse P | Licensed Nurse | Involved in resident #633 care and incident follow-up. |
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Dec 15, 2016
Visit Reason
This revisit inspection was conducted to verify that previously reported deficiencies at Dove Estates Senior Living Community had been corrected.
Findings
All previously cited deficiencies were corrected as of the revisit date, with each correction documented and completed on 2016-12-15.
Report Facts
Deficiencies corrected: 8
Inspection Report
Complaint Investigation
Census: 70
Deficiencies: 9
Date: Nov 23, 2016
Visit Reason
The inspection was a resurvey with investigation of complaints #97660 and #101380 at an assisted living facility.
Complaint Details
The inspection was conducted as a resurvey with investigation of complaints #97660 and #101380.
Findings
The facility failed to report allegations of abuse and neglect within 24 hours, did not ensure negotiated service agreements included refusals and risks, failed to provide lists of outside service providers, and did not adequately coordinate health care services to address residents' fall risks. Medication management deficiencies included improper ordering, storage, and handling of medications. Emergency preparedness was inadequate due to insufficient staffing for resident evacuation and lack of quarterly emergency plan reviews with all employees and residents.
Deficiencies (9)
Failure to report potential allegations of abuse and/or neglect to the department within 24 hours of each incident.
Failure to ensure negotiated service agreements included service refusals, potential negative outcomes, education, and acceptance of risk.
Failure to provide residents or their legal representatives with a list of providers available to provide needed services.
Failure to ensure licensed nurse provided or coordinated necessary health care services to address residents' risk for falls.
Failure to ensure all medications and biologicals administered were ordered from a pharmacy pursuant to a medical care provider's written order.
Failure to implement policy and procedure for receiving and identifying sample medications including proper documentation and resident notification.
Failure to securely store controlled medications in separately locked compartments within a locked medication room and restrict access to authorized personnel only.
Failure to ensure sufficient staff on the 10:00 p.m. to 6:00 a.m. shift to assist residents requiring two-person transfer in an emergency or disaster evacuation.
Failure to ensure quarterly review of the facility's emergency management plan with all employees and residents.
Report Facts
Residents in sample: 6
Closed records reviewed: 2
Resident census: 70
Falls for resident #525: 9
Falls for resident #522: 16
Emergency drill participants: 21
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing B | Director of Nursing | Named in multiple findings related to failure to report abuse, failure to ensure negotiated service agreements, failure to coordinate health care services, and medication management. |
| Administrator C | Administrator | Named in findings related to emergency preparedness and failure to provide lists of outside service providers. |
| Certified Medication Aide F | Certified Medication Aide | Interviewed regarding resident falls and medication management. |
| Certified Medication Aide D | Certified Medication Aide | Observed medication storage and emergency medication kits. |
| Licensed Nurse E | Licensed Nurse | Observed medication storage and confirmed medication room access. |
Inspection Report
Complaint Investigation
Census: 65
Deficiencies: 5
Date: Nov 18, 2015
Visit Reason
The inspection was an abbreviated survey with investigation of complaint #92485 at an assisted living facility conducted on 11/10/15, 11/12/15, 11/17/15, and 11/18/15.
Complaint Details
The complaint investigation was triggered by complaint #92485 regarding resident rights and care issues at the assisted living facility.
Findings
The investigation found multiple deficiencies including failure to afford resident #6 the right to refuse treatment, improper involuntary discharge despite unchanged care needs, lack of required functional capacity screening on admission for residents #4 and #6, failure to develop negotiated service agreements collaboratively with residents, and failure to develop health care service plans for residents requiring health care services.
Deficiencies (5)
Failure to ensure resident #6 was afforded the right to refuse treatment.
Failure to ensure resident #6 was permitted to remain in the facility and was not transferred and discharged when care needs did not change.
Failure to conduct a functional capacity screening on or before admission for resident #4.
Failure to develop a written negotiated service agreement collaboratively with residents #4 and #6.
Failure to develop a health care service plan for residents #4 and #6 who required health care services.
Report Facts
Census: 65
Closed records reviewed: 5
Residents sampled: 2
Involuntary discharge notice period: 30
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Named in multiple findings related to resident #6's care, hospital transfer, and failure to develop required plans. | |
| Residence Director | Involved in resident #6's involuntary discharge and hospital transfer. |
Inspection Report
Original Licensing
Census: 42
Deficiencies: 2
Date: Feb 5, 2015
Visit Reason
The inspection was an initial survey conducted over multiple days (2-2-15 to 2-5-15) to assess compliance with health care service regulations at Dove Estates Senior Living Community.
Findings
The facility failed to ensure licensed nurses provided or coordinated necessary health care services according to residents' functional capacity screenings and negotiated service agreements, specifically lacking documentation for leg brace application and two-person transfers for residents #100 and #200. Additionally, the licensed nurse failed to appropriately delegate nursing procedures related to finger stick blood sugars and lacked documentation of such delegation in resident plans and personnel files.
Deficiencies (2)
The facility failed to ensure licensed nurses provided or coordinated necessary health care services in accordance with functional capacity screening and negotiated service agreements, including lack of interventions for leg brace application and identification of two-person transfers.
The licensed nurse failed to appropriately delegate nursing procedures related to performing finger stick blood sugars to medication aides and failed to ensure documentation of delegation in resident plans and personnel files.
Report Facts
Census: 42
Residents sampled: 3
Blood glucose reading: 96
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Nurse A | Licensed Nurse | Interviewed and confirmed deficiencies related to resident transfers and leg brace documentation |
| Licensed Nurse E | Licensed Nurse | Interviewed and stated that certified staff had been trained to administer Accu Checks but lacked documented in-service training |
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