Inspection Report Summary
The most recent inspection on December 9, 2024, found the facility in compliance with all regulations and no new deficiencies. Prior inspections showed some deficiencies, notably a November 25, 2024 resurvey citing a lack of required dementia care training for most sampled employees. Earlier reports identified issues with nursing delegation, staff qualifications, emergency preparedness, and documentation, as well as incomplete background checks and food service concerns. Complaint investigations were mostly related to these findings, with no enforcement actions or fines listed in the available reports. The facility appears to have addressed prior deficiencies effectively, as indicated by the clean most recent inspection following correction plans.
Deficiencies (last 6 years)
Deficiencies (over 6 years)
4.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
22% better than Kansas average
Kansas average: 6 deficiencies/yearDeficiencies per year
8
6
4
2
0
Census
Latest occupancy rate
21 residents
Based on a November 2024 inspection.
This facility has shown a decline in demand based on occupancy rates.
Census over time
Inspection Report
Re-Inspection
Deficiencies: 0
Dec 9, 2024
Visit Reason
An offsite revisit survey was conducted to verify correction of all previous deficiencies cited on 2024-11-25.
Findings
All deficiencies have been corrected as of the compliance date of 2024-12-09 and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Inspection Report
Re-Inspection
Census: 21
Deficiencies: 1
Nov 25, 2024
Visit Reason
The inspection was a resurvey with attached complaints (#187507 and #187419) conducted to assess compliance with staff development requirements related to dementia care.
Findings
The facility failed to provide required employee orientation and in-service education on dementia and Alzheimer's care for 4 of 5 sampled employees, despite having residents with impaired cognition and a policy requiring such training.
Complaint Details
The resurvey was conducted with attached complaints #187507 and #187419.
Severity Breakdown
SS=F: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure provision of employee orientation and in-service education on treatment and appropriate response to persons exhibiting behaviors associated with dementia and Alzheimer's for 4 of 5 sampled employees. | SS=F |
Report Facts
Census: 21
Residents with impaired cognition: 10
Sampled employees: 5
Employees lacking dementia training: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Operator LN A | Operator / Licensed Nurse | Named in failure to ensure employee orientation and in-service education on dementia care |
| CMA B | Certified Medication Aide | Employee lacking dementia training upon hire |
| CMA C | Certified Medication Aide | Employee lacking dementia training upon hire |
| CNA D | Certified Nurse Aide | Employee lacking dementia training upon hire |
| CNA E | Certified Nurse Aide | Employee lacking dementia training upon hire |
Inspection Report
Plan of Correction
Deficiencies: 0
Nov 25, 2024
Visit Reason
The document is a plan of correction submitted in response to a resurvey with attached complaints (#187507 and #187419) conducted at the facility on 11/25/24.
Findings
The plan of correction addresses citations found during the resurvey and complaint investigations conducted on 11/25/24 at the facility.
Complaint Details
The visit was related to complaints #187507 and #187419 attached to the resurvey.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Aug 15, 2023
Visit Reason
An abbreviated survey was conducted at the assisted living facility Marquis Place on 08/15/2023.
Findings
The survey resulted in no deficiency citations.
Inspection Report
Plan of Correction
Deficiencies: 0
Aug 15, 2023
Visit Reason
An abbreviated survey was conducted at the assisted living facility on 08/15/23.
Findings
The abbreviated survey resulted in no deficiency citations.
Inspection Report
Follow-Up
Deficiencies: 0
Jun 5, 2023
Visit Reason
An offsite revisit survey was conducted on 06/05/23 for all previous deficiencies cited on 05/10/23 to verify correction of prior deficiencies.
Findings
All deficiencies cited in the previous inspection have been corrected as of the compliance date of 05/25/23, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Report Facts
Previous deficiencies cited: 1
Inspection Report
Complaint Investigation
Census: 19
Deficiencies: 6
May 10, 2023
Visit Reason
The inspection was a resurvey with complaints (#179908, #166708, and #166641) conducted at the facility to investigate compliance with nursing delegation, staff qualifications, emergency preparedness, food preparation, and authorized electronic monitoring requirements.
Findings
The facility was found deficient in multiple areas including failure to ensure licensed nurses properly delegated nursing procedures to medication aides, lack of competency assessments for medication aides, incomplete criminal background checks for staff, failure to conduct quarterly emergency management plan reviews with staff and residents, failure to serve food at proper temperatures, and failure to post conspicuous notices regarding electronic monitoring in resident rooms and facility entrance.
Complaint Details
The visit was a resurvey with complaints #179908, #166708, and #166641.
Severity Breakdown
E: 2
F: 3
D: 1
Deficiencies (6)
| Description | Severity |
|---|---|
| Failure to ensure licensed nurse delegated nursing procedures not included in medication aide curriculum to medication aides for residents requiring accuchecks. | E |
| Failure to ensure licensed nurse delegated nursing procedures not included in medication aide curriculum to medication aides for residents requiring insulin injections without competency assessment. | F |
| Failure to obtain evidence of supporting documentation for criminal background checks for newly hired staff as required. | F |
| Failure to ensure quarterly review of the facility's emergency management plan with staff and residents. | F |
| Failure to ensure facility staff served food at the proper temperature; missing supper food temperature logs for multiple dates. | D |
| Failure to post conspicuous notice at the entrance and each resident's room stating that rooms may be electronically monitored. | E |
Report Facts
Census: 19
Sample size: 3
Newly hired employees reviewed: 5
Missing supper food temperature log dates: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Operator/Licensed Nurse A | Operator/Licensed Nurse | Named in multiple findings including failure to ensure delegation of nursing procedures, failure to obtain criminal background checks, failure to ensure emergency preparedness reviews, failure to ensure proper food temperature, and failure to post electronic monitoring notices. |
| Certified Medication Aide C | Certified Medication Aide | Mentioned in relation to missing competency checkoffs for accuchecks and insulin pen dialing. |
| Certified Medication Aide D | Certified Medication Aide | Mentioned in relation to missing competency checkoffs for accuchecks and insulin pen dialing. |
| Certified Nurse Aide E | Certified Nurse Aide | Mentioned in relation to missing criminal background check documentation. |
| Dietary Staff B | Dietary Staff | Interviewed regarding food temperature monitoring logs. |
Inspection Report
Plan of Correction
Deficiencies: 0
May 10, 2023
Visit Reason
The document is a plan of correction addressing findings from a resurvey with complaints (#179908, #166708, and #166641) conducted at the facility on 05/10/23.
Findings
The plan of correction corresponds to citations found during the resurvey with complaints at the facility on 05/10/23.
Complaint Details
The visit was complaint-related, involving complaints #179908, #166708, and #166641.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Jul 30, 2020
Visit Reason
The special infection control survey for COVID-19 was conducted at the facility on 07/30/2020.
Findings
The survey resulted in findings of no deficiency citations.
Inspection Report
Follow-Up
Deficiencies: 0
May 13, 2019
Visit Reason
This revisit inspection was conducted to verify that previously reported deficiencies have been corrected and to document the dates such corrective actions were accomplished.
Findings
All previously cited deficiencies related to various regulatory provisions were corrected as of the revisit date, with completion dates documented for each.
Report Facts
Deficiencies corrected: 8
Inspection Report
Renewal
Census: 23
Deficiencies: 8
Apr 9, 2019
Visit Reason
The inspection was a Licensure Resurvey conducted at Marquis Place Assisted Living Facility in Concordia, Kansas on 4/03/19, 4/04/19, 4/08/19, and 4/09/19 to assess compliance with state regulations for assisted living facilities.
Findings
The facility was found deficient in multiple areas including incomplete functional capacity screenings, inadequate negotiated service agreements lacking service descriptions and licensed nurse names, missing medication regimen reviews, incomplete employee criminal background check documentation, and deficiencies in emergency management planning including lack of plans for water outage and missing residents, failure to conduct evacuation drills annually, and failure to make the emergency plan accessible to all staff, residents, and visitors.
Severity Breakdown
SS=E: 4
SS=F: 4
Deficiencies (8)
| Description | Severity |
|---|---|
| Failure to ensure functional capacity screens included all required elements and definitions for sampled residents. | SS=E |
| Negotiated service agreements lacked descriptions of services residents would receive. | SS=E |
| Negotiated service agreements lacked the name of the licensed nurse responsible for implementation and supervision of the health service plan. | SS=F |
| Medication regimen reviews were not kept in each resident's clinical record as required. | SS=F |
| Employee records lacked supporting documentation for criminal background checks for several newly hired employees. | SS=E |
| Emergency management plan lacked procedures for water outage and missing residents. | SS=F |
| Failure to conduct evacuation drills at least annually and failure to conduct quarterly reviews of the emergency management plan with employees and residents. | SS=F |
| Emergency management plan was not made available to staff not authorized to pass medications, residents, and visitors. | SS=E |
Report Facts
Residents in census: 23
Residents sampled: 3
Employees hired since last resurvey: 14
Employees reviewed for background checks: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Operator/LPN #G | Licensed Practical Nurse | Confirmed deficiencies in functional capacity screening, negotiated service agreements, medication regimen reviews, employee background checks, and emergency plan availability. |
| Administrator/RN #F | Registered Nurse | Confirmed deficiencies in functional capacity screening, negotiated service agreements, medication regimen reviews, and emergency management plan. |
Inspection Report
Re-Inspection
Deficiencies: 6
Jul 11, 2017
Visit Reason
This revisit report documents the correction of deficiencies previously reported during an earlier survey, verifying that corrective actions have been completed.
Findings
All previously cited deficiencies identified by regulation or LSC provision numbers have been corrected as of the revisit date.
Deficiencies (6)
| Description |
|---|
| Deficiency related to regulation 26-39-103 (i) |
| Deficiency related to regulation 26-41-202 (j) |
| Deficiency related to regulation 26-41-204 (a) |
| Deficiency related to regulation 26-41-205 (e) (f) |
| Deficiency related to regulation 26-41-102 (c) |
| Deficiency related to regulation 28-39-255 |
Inspection Report
Renewal
Census: 26
Deficiencies: 6
Jun 22, 2017
Visit Reason
The inspection was a Licensure Resurvey conducted at Marquis Place, an Assisted Living Facility in Concordia, Kansas, over multiple days from 6/19/17 to 6/22/17, to assess compliance with state regulations for renewal of licensure.
Findings
The facility was found deficient in multiple areas including failure to protect resident privacy and confidentiality, inadequate monitoring of outside service providers, failure to ensure licensed nurse coordination of health care services, incomplete documentation of verbal medication orders, lack of RN supervision for licensed practical nurses, and unsecured chemical storage in the laundry room.
Severity Breakdown
F: 3
E: 3
Deficiencies (6)
| Description | Severity |
|---|---|
| Failure to develop and implement policies and procedures to ensure personal and clinical records of residents are maintained confidentially, including posting confidential resident information in public areas. | F |
| Failure to ensure designated facility staff monitored services provided by outside resources and acted as advocates for residents receiving such services. | E |
| Failure to ensure a licensed nurse provided or coordinated necessary health care services in accordance with functional capacity screening and negotiated service agreements. | E |
| Failure to ensure all verbal medication orders were signed by the medical care provider within seven working days of receipt. | E |
| Failure to ensure a registered professional nurse was available to provide supervision to licensed practical nurses as required by state law. | F |
| Failure to provide locked cabinets for storage of chemicals and supplies in the laundry facility, allowing unlocked access to potentially hazardous materials. | F |
Report Facts
Census: 26
Residents with outside provider services: 10
Residents with facility managed medications: 23
Residents with impaired cognitive status: 14
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Facility Nurse #B | Interviewed regarding monitoring of outside services, medication orders, and laundry room safety | |
| Administrator #C | Interviewed regarding privacy policies, RN supervision, and chemical storage | |
| Facility Nurse #E | Interviewed regarding resident care needs and interventions | |
| Housekeeping staff #D | Interviewed regarding laundry room chemical cabinet locking |
Inspection Report
Renewal
Census: 31
Deficiencies: 1
Jan 21, 2016
Visit Reason
The inspection was a Licensure Resurvey at the assisted living facility conducted on 01/21/2016 and 01/22/2016.
Findings
The Administrator failed to ensure proper documentation of medication administration for Resident #187, including continuing to initial a discontinued medication on the medication administration record (MAR).
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure the documentation of each Resident's medication immediately before or following completion of the task. | SS=D |
Report Facts
Facility census: 31
Residents with facility managed medications: 28
Sampled residents: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Facility Nurse #F | Provided December 2015 MAR and discussed medication discontinuation |
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