Deficiencies (last 8 years)
Deficiencies (over 8 years)
5.4 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
10% better than Kansas average
Kansas average: 6 deficiencies/yearDeficiencies per year
20
15
10
5
0
Occupancy
Latest occupancy rate
68% occupied
Based on a September 2025 inspection.
Occupancy rate over time
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Sep 23, 2025
Visit Reason
An offsite revisit survey was conducted to verify correction of all previous deficiencies cited on 2025-09-16.
Findings
All deficiencies have been corrected as of the compliance date of 2025-09-22, 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.
Findings
The plan of correction addresses citations identified during the licensure resurvey of the facility on the specified dates.
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, and maintaining safe and sanitary food storage conditions in the satellite kitchen refrigerator/freezer.
Deficiencies (3)
26-41-201 (a) Functional Capacity Screen on Admission was not performed for Resident 2 at the time of admission.
26-41-202 (a) Negotiated Service Agreements for Residents 1 and 2 lacked descriptions of services, identification of providers, and payment responsibilities for physical therapy services.
26-41-206 (e) (1) Facility Food Storage: Food items in the satellite kitchen refrigerator/freezer lacked beyond use dates, failing to ensure safe and sanitary storage.
Report Facts
Census: 54
Inspection Report
Re-Inspection
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.
Inspection Report
Renewal
Deficiencies: 0
Date: Mar 13, 2024
Visit Reason
The visit was conducted as a Re-Licensure survey of the Assisted Living Facility on March 13, 2024.
Findings
The document represents a Plan of Correction related to findings from the Re-Licensure survey conducted on March 13, 2024. Specific findings or deficiencies are not detailed in this document.
Inspection Report
Renewal
Census: 56
Deficiencies: 4
Date: Mar 13, 2024
Visit Reason
The inspection was a Re-Licensure survey conducted at the Assisted Living Facility to assess compliance with regulatory requirements.
Findings
The survey identified multiple deficiencies including failure to complete timely self-administration medication assessments, improper medication storage practices, incomplete documentation of resident incidents and symptoms, and inadequate disaster and emergency preparedness reviews with residents.
Deficiencies (4)
KAR 26-41-205(a)(1) The executive director failed to ensure a licensed nurse completed a self-administration of medication assessment for one resident prior to self-administering medications.
KAR 26-41-205(h)(1)(4) The executive director failed to ensure staff stored insulin pens with proper date labeling to prevent use beyond manufacturer expiration.
KAR 26-41-105(f)(11) The operator failed to ensure one resident's records contained complete documentation of incidents, symptoms, actions taken, and results.
KAR 26-41-104(d)(3) The executive director failed to ensure quarterly reviews of the facility's emergency management plan were conducted with all residents.
Report Facts
Census: 56
Inspection Report
Follow-Up
Deficiencies: 1
Date: Jul 31, 2023
Visit Reason
This visit was conducted as a follow-up to verify correction of previously reported deficiencies at the facility.
Findings
The report documents that previously reported deficiencies have been corrected as of the revisit date. Each deficiency is identified by regulation number and marked as completed.
Deficiencies (1)
26-41-205 (d) (1-2) regulation deficiency was corrected and completed by 07/31/2023.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Jul 5, 2023
Visit Reason
The document is a Plan of Correction submitted in response to an Abbreviated Survey with complaint investigations conducted on 07/05/23 and 07/06/23 at an Assisted Living facility.
Findings
The Plan of Correction addresses findings from an Abbreviated Survey combined with multiple complaint investigations at the facility.
Inspection Report
Abbreviated Survey
Census: 59
Deficiencies: 1
Date: Jul 5, 2023
Visit Reason
The inspection was an Abbreviated Survey combined with complaint investigations for the assisted living facility conducted on 07/05/23 and 07/06/23.
Complaint Details
The survey included complaint investigations numbered 178086, 178155, 178258, 179167, and 181214.
Findings
The facility failed to ensure designated staff ordered and administered a resident's medication (SennaS) as prescribed, resulting in the resident not receiving 31 consecutive doses. This caused constipation, rectal impaction, colonic obstruction, hospitalization, and bowel surgery.
Deficiencies (1)
KAR 26-41-205 (d) Facility administration of medications. The administrator failed to ensure designated staff ordered and administered SennaS as ordered by the physician for one resident, resulting in omission of 31 consecutive doses. This caused constipation, rectal impaction, and required hospitalization and surgery.
Report Facts
Resident census: 59
Consecutive doses missed: 31
Medication administration days: 29
Medication administration days: 4
Medication administration days: 15
Medication administration days: 24
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Medication Aide E | Certified Medication Aide | Reported medication ordering and administration procedures and lack of availability of SennaS. |
| Licensed Nurse D | Licensed Nurse | Reported medication administration procedures and lack of notification about missing SennaS. |
| 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 pharmacy notification and medication availability issues. |
| Administrative Licensed Nurse C | Administrative Licensed Nurse | Reported pharmacy communication and medication delivery issues. |
| Pharmacist J | Pharmacist | Reported refill request and delivery of SennaS medication. |
Inspection Report
Re-Inspection
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 Dove Estates Senior Living Community on 11/17/22 and 11/21/22.
Complaint Details
The inspection included complaint investigations 174382 and 161925.
Findings
The facility failed to complete required Functional Capacity Screens and revise Negotiated Service Agreements following significant changes in resident condition. Additionally, the facility did not verify licensure and certification for two newly hired staff requiring specialized education and training upon hire.
Deficiencies (3)
KAR 26-41-201 (c)(2) The executive director failed to ensure staff completed a Functional Capacity Screen for one resident following a significant change in condition.
KAR 26-41-202 (d)(2) The executive director failed to ensure staff reviewed and revised the Negotiated Service Agreement for one resident following a significant change in status.
KAR 26-41-102(d)(1) The executive director failed to have evidence of licensure, registration, and certification verified upon hire for two newly hired staff requiring specialized education and training.
Report Facts
Resident census: 60
Number of sampled residents: 3
Number of focused record reviews: 2
Number of newly hired employees reviewed: 5
Months delay in licensure check: 5
Months delay in certification check: 2
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Nov 17, 2022
Visit Reason
The document is a Plan of Correction responding to findings from a Resurvey with complaint investigations conducted on 11/17/22 and 11/21/22 at an Assisted Living Facility.
Findings
The Plan of Correction addresses citations resulting from a Resurvey combined with complaint investigations numbered 174382 and 161925.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Jun 30, 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: Dec 6, 2018
Visit Reason
This is a revisit inspection to verify that previously reported deficiencies have been corrected.
Findings
All previously cited deficiencies were corrected as of the revisit date. The report lists multiple regulatory provisions with completed corrections.
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
The complaint investigation involved allegations of neglect related to a resident (#611) who was found on the floor after missing meals and not being checked on, resulting in a hip fracture and pain. The investigation found failures in notification, reporting, and investigation of neglect allegations.
Findings
The facility failed to ensure residents were free from neglect, failed to report and investigate allegations of neglect, failed to revise negotiated service agreements after significant changes in condition, failed to provide and coordinate necessary health care services, failed to document incidents properly, and failed to ensure sufficient staff for emergency evacuations.
Deficiencies (6)
KAR 26-41-101(f)(1): The administrator failed to prevent neglect when staff did not notify the nurse after a resident missed meals, resulting in a resident lying on the floor overnight with a hip fracture.
KAR 26-41-101(f)(3): The administrator failed to report and investigate allegations of neglect to the department within required timeframes.
26-41-202(d)(2): The administrator failed to revise negotiated service agreements after significant changes in condition for residents #644 and #633.
26-41-204(a): The licensed nurse failed to provide or coordinate health care services meeting residents' needs, including fall risk and wound care interventions for residents #644 and #633.
26-41-105(f)(11): The administrator failed to ensure documentation of all incidents, symptoms, and indications of illness or injury including date, time, action taken, and results for residents #644 and #633.
26-42-104(a): The administrator failed to ensure sufficient staff to safely evacuate residents requiring assistance during emergencies, lacking documentation of evacuation ability with minimal staff.
Report Facts
Resident census: 58
Residents requiring two staff assist: 2
Residents requiring transfer assistance to toilet: 12
Residents with impaired cognition: 6
Fire drill staff participants: 5
Fire drill staff participants: 4
Pressure sore size: 6
Pressure sore size: 7
Pressure sore size: 2
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Dec 21, 2016
Visit Reason
This document is a Plan of Correction related to a prior inspection event identified as N1VK12 for facility State ID N087082.
Findings
No specific deficiencies or findings are detailed in this document. It serves as a placeholder or administrative record for the Plan of Correction submission.
Inspection Report
Follow-Up
Deficiencies: 9
Date: Dec 15, 2016
Visit Reason
This visit was conducted as a follow-up to verify that previously reported deficiencies have been corrected.
Findings
All deficiencies previously cited were corrected as of the revisit date. The report lists multiple regulation citations with completed corrections.
Deficiencies (9)
26-41-101 (f) (3): Previously cited deficiency corrected as of 12/15/2016.
26-41-202 (f): Previously cited deficiency corrected as of 12/15/2016.
26-41-202 (j): Previously cited deficiency corrected as of 12/15/2016.
26-41-204 (a): Previously cited deficiency corrected as of 12/15/2016.
26-41-205 (g) (1): Previously cited deficiency corrected as of 12/15/2016.
26-41-205 (g) (4): Previously cited deficiency corrected as of 12/15/2016.
26-41-205 (h): Previously cited deficiency corrected as of 12/15/2016.
26-41-104 (a): Previously cited deficiency corrected as of 12/15/2016.
26-41-104 (d): Previously cited deficiency corrected as of 12/15/2016.
Inspection Report
Complaint Investigation
Census: 70
Deficiencies: 9
Date: Nov 23, 2016
Visit Reason
Resurvey with investigation of complaints #97660 and #101380 at an assisted living facility.
Complaint Details
The inspection was 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 coordinate necessary 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)
KAR 26-41-101(f)(3) The administrator failed to report potential allegations of abuse and/or neglect to the department within 24 hours for residents #520 and #524.
KAR 26-41-202(f) The administrator failed to ensure negotiated service agreements included refusals, risks, education, and acceptance for residents #525 and #522.
KAR 26-41-202(j) The administrator failed to provide residents or legal representatives with a list of outside service providers for residents #520, #522, and #525.
KAR 26-41-204(a) The administrator failed to ensure licensed nurses provided or coordinated necessary health care services to address fall risks for residents #526, #520, and #524.
KAR 26-41-205(g) The administrator failed to ensure all medications administered were ordered from a pharmacy pursuant to a medical care provider's written order.
KAR 26-41-205(g)(4) Licensed nurses failed to implement policies for receiving and identifying sample medications for resident #524, including documentation and resident notification.
KAR 26-41-205(h)(1) The administrator failed to ensure controlled medications were stored in separately locked compartments within a locked medication room and restricted access to authorized personnel only.
KAR 26-41-104(a) The administrator failed to ensure sufficient staff on the 10:00 p.m. to 6:00 a.m. shift to assist residents requiring two-person transfer during emergencies.
KAR 26-41-104(d)(3) The administrator failed to ensure quarterly review of the emergency management plan with all employees and residents.
Report Facts
Resident census: 70
Falls: 9
Falls: 16
Falls: 6
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 administration. |
| Certified Medication Aide D | Certified Medication Aide | Observed medication room and emergency medication storage. |
| Licensed Nurse E | Licensed Nurse | Confirmed medication storage practices. |
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 Dove Estates Senior Living Community conducted on 11/10/15, 11/12/15, 11/17/15, and 11/18/15.
Complaint Details
Complaint #92485 triggered the investigation focusing on resident rights, admission, transfer, discharge practices, and care planning for residents #6 and #4.
Findings
The investigation found the administrator failed to ensure resident rights including refusal of treatment and improper involuntary discharge. The facility also failed to conduct required functional capacity screenings, develop negotiated service agreements, and health care service plans for residents requiring health care services.
Deficiencies (5)
KAR 26-39-103(f)(3) Resident Right Free Choice: The administrator failed to ensure resident #6 was afforded the right to refuse treatment, including transfer to hospital for psychiatric evaluation despite resident's refusal.
KAR 26-39-102(d)(1) Admission, Transfer, Discharge: The administrator failed to ensure resident #6 was permitted to remain in the facility and was not transferred and discharged when care needs did not change from admission.
KAR 26-41-201(a) Functional Capacity Screen on Admission: The director of nursing failed to conduct a functional capacity screening on or before admission for resident #4.
KAR 26-41-202(a) Negotiated Service Agreement: The administrator failed to ensure a written negotiated service agreement was developed in collaboration with residents #6 and #4 based on functional capacity screening, service needs, and preferences.
KAR 26-41-204(b) Health Care Services: The director of nursing failed to develop a health care service plan in collaboration with residents #6 and #4 who required health care services.
Report Facts
Resident census: 65
Closed records reviewed: 5
Residents sampled: 2
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Nov 18, 2015
Visit Reason
This document is a plan of correction related to deficiencies found during an abbreviated survey conducted on November 18, 2015.
Findings
No specific findings or deficiencies are detailed in this document. It serves as a plan of correction submission referencing a prior abbreviated survey.
Inspection Report
Original Licensing
Census: 42
Deficiencies: 2
Date: Feb 5, 2015
Visit Reason
The inspection was an initial survey conducted over multiple days to assess compliance with licensing requirements for the assisted living facility.
Findings
The facility failed to ensure licensed nursing staff provided or coordinated necessary health care services according to residents' functional capacity screenings and negotiated service agreements. Deficiencies included lack of documentation for required two-person transfers and leg brace application, and failure to properly delegate nursing procedures to medication aides with appropriate documentation.
Deficiencies (2)
KAR 26-41-204(a) The facility failed to ensure licensed nursing staff provided or coordinated necessary health care services in accordance with functional capacity screening and negotiated service agreements. Documentation lacked interventions for leg brace application and identification of residents requiring two-person transfers.
KAR 26-41-204(e) The licensed nurse failed to appropriately delegate nursing procedures to medication aides related to performing finger stick blood sugars and failed to ensure documentation of delegation was included in resident plans of care and personnel files.
Report Facts
Resident census: 42
Residents sampled: 3
Inspection Report
Plan of Correction
Deficiencies: 0
Date: N087082 POC 2VX811
Visit Reason
This document is a Plan of Correction related to a prior deficiency report for a senior living community's COVID-19 inspection.
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: N087082 POC C1ZY11
Visit Reason
This document is a Plan of Correction related to regulatory oversight of the facility following a deficiency report.
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: N087082 POC JNCE11
Visit Reason
This document is a Plan of Correction related to a previous deficiency report for the facility.
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: N087082 POC JNCE12
Visit Reason
This document is a Plan of Correction related to a previously identified deficiency report for the facility with State ID N087082.
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: N087082 POC N1VK11
Visit Reason
This document is a Plan of Correction related to a prior deficiency report for the facility identified as Aspen with State ID N087082.
Findings
No specific findings or deficiencies are detailed in this document. It serves as a placeholder or reference for the Plan of Correction associated with a previous inspection.
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