Inspection Report
Re-Inspection
Deficiencies: 0
Aug 28, 2025
Visit Reason
An offsite revisit survey was conducted to verify correction of all previous deficiencies cited on 2025-08-12.
Findings
All deficiencies cited in the prior inspection have been corrected as of the compliance date 2025-08-25, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Report Facts
Previous deficiencies cited: Deficiencies cited on 2025-08-12 and corrected by 2025-08-25
Inspection Report
Plan of Correction
Deficiencies: 0
Aug 12, 2025
Visit Reason
This document represents the findings of a resurvey with attached complaints #195254 and #190591 at the assisted living facility conducted on 08/12/25.
Findings
The document is a plan of correction submitted in response to deficiencies identified during the resurvey and complaint investigations.
Complaint Details
The visit was related to complaints #195254 and #190591 attached to the resurvey.
Inspection Report
Re-Inspection
Census: 32
Deficiencies: 8
Aug 12, 2025
Visit Reason
The inspection was a resurvey with attached complaints #195254 and #190591 conducted at an assisted living facility to evaluate compliance with regulatory standards.
Findings
The inspection found multiple deficiencies including failure to notify legal representatives of resident condition changes, untimely staple removal, lack of medication self-administration assessments, incomplete medication management agreements, inadequate documentation of incidents, failure to conduct quarterly emergency plan reviews, unsafe food storage practices, and unsanitary food handling conditions.
Complaint Details
The visit was a resurvey with attached complaints #195254 and #190591.
Severity Breakdown
SS=D: 4
SS=E: 1
SS=F: 3
Deficiencies (8)
| Description | Severity |
|---|---|
| Failure to ensure licensed staff consulted with resident's physician and notified legal representative when resident developed a red area that became an open sore. | SS=D |
| Failure to provide timely staple removal for a resident. | SS=D |
| Failure to ensure licensed nurse performed assessments for residents' ability to self-administer medications. | SS=E |
| Failure to identify responsible party for administration and management of select medications in the negotiated service agreement. | SS=D |
| Failure to document all incidents, symptoms, and indications of illness or injury including date, time, action taken, and results for a resident's wound. | SS=D |
| Failure to provide evidence of quarterly reviews of the facility's emergency management plan with residents and staff. | SS=F |
| Failure to store food items under safe and sanitary conditions, including lack of date labels on opened or prepared food items and presence of moldy food and broken eggs. | SS=F |
| Failure to maintain sanitary conditions for food handling, including exposed mechanical components with insulation near food, dust and grease accumulation, and blank cleaning logs. | SS=F |
Report Facts
Resident census: 32
Red area size: 3
Staple removal delay: 2
Food items lacking date labels: 20
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nurse B | Confirmed multiple documentation and procedural deficiencies during interviews. | |
| Dietary Staff D | Confirmed food storage and sanitary condition deficiencies during observation and interview. | |
| Administrative Staff A | Confirmed lack of documentation for emergency management plan reviews. |
Inspection Report
Re-Inspection
Deficiencies: 0
Feb 19, 2024
Visit Reason
An offsite revisit survey was conducted to verify correction of all previous deficiencies cited on 2024-01-30.
Findings
All deficiencies have been corrected as of the compliance date of 2024-02-19, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Inspection Report
Complaint Investigation
Census: 30
Deficiencies: 3
Jan 30, 2024
Visit Reason
The inspection was a licensure resurvey with attached complaint investigations numbered 180225, 180179, and 180114 conducted at the facility.
Findings
The facility was found deficient in ensuring that negotiated service agreements were signed by all participants, over-the-counter medications were properly labeled with resident names, and resident records contained complete documentation of incidents, symptoms, actions taken, and results for residents R1, R2, and R3.
Complaint Details
The inspection included complaint investigations numbered 180225, 180179, and 180114. The complaints involved issues with unsigned negotiated service agreements, unlabeled over-the-counter medications, and incomplete documentation of incidents and follow-up actions in resident records.
Severity Breakdown
SS=D: 1
SS=E: 2
Deficiencies (3)
| Description | Severity |
|---|---|
| Failure to ensure the Negotiated Service Agreement (NSA) for Resident R1 was signed by all participants. | SS=D |
| Failure to ensure a licensed pharmacist or nurse placed the full name of the resident on over-the-counter medications. | SS=E |
| Failure to ensure resident records contained documentation of all incidents, symptoms, actions taken, and results for Residents R1, R2, and R3. | SS=E |
Report Facts
Census: 30
Falls documented for Resident R3: 6
Falls documented for Resident R2: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nurse B | Administrative Nurse | Interviewed and confirmed deficiencies related to unsigned NSA and incomplete documentation of incidents and follow-up. |
| Certified Medication Aide A | Certified Medication Aide | Observed handling unlabeled over-the-counter medications during facility tour. |
Inspection Report
Plan of Correction
Deficiencies: 0
Jan 30, 2024
Visit Reason
The document is a plan of correction related to the licensure resurvey of the facility, which included attached complaint investigations numbered 180225, 180179, and 180114, conducted on January 30, 2024.
Findings
The plan of correction addresses findings from the licensure resurvey and associated complaints for the facility conducted on January 30, 2024.
Report Facts
Complaint numbers referenced: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Shirley Boltz | Contact person for Plan of Correction assistance | |
| Mary Tegtmeier | Submitted and modified the Plan of Correction document |
Inspection Report
Plan of Correction
Deficiencies: 0
Jul 7, 2022
Visit Reason
The licensure resurvey with complaint number 159738 was conducted on 7/5/2022, 7/6/2022, and 7/7/2022 at the assisted living facility.
Findings
The inspection resulted in a finding of no deficiency citations.
Inspection Report
Complaint Investigation
Deficiencies: 0
Jul 7, 2022
Visit Reason
The licensure resurvey with complaint number 159738 was conducted on 7/5/2022, 7/6/2022, and 7/7/2022 at the assisted living facility Silvercrest at Deer Creek.
Findings
The inspection resulted in a finding of no deficiency citations.
Complaint Details
Complaint number 159738 was investigated and resulted in no deficiency citations.
Inspection Report
Renewal
Census: 28
Deficiencies: 1
Sep 9, 2020
Visit Reason
The inspection was conducted for re-licensure with attached complaints and a special infection control/COVID survey at the assisted living facility.
Findings
The facility failed to maintain safe hot water temperatures between 98 and 120 degrees Fahrenheit at sinks and showers in resident rooms, with multiple measurements exceeding 120F. The facility also lacked a policy for hot water monitoring.
Complaint Details
The survey included attached complaints and a special infection control/COVID survey.
Severity Breakdown
SS=F: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failed to ensure the facility water distribution system maintained a safe hot water temperature between 98 and 120 degrees Fahrenheit at sinks and showers in resident rooms. | SS=F |
Report Facts
Water temperature: 127.5
Water temperature: 125.4
Water temperature: 127.1
Water temperature: 123.8
Water temperature: 126.3
Water temperature: 123.6
Water temperature: 124
Water temperature: 122.9
Water temperature: 123.4
Census: 28
Residents with impaired cognitive status: 9
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Director #D | Interviewed regarding water temperature testing and facility policy | |
| Corporation Nurse #C | Interviewed by phone regarding facility policy on hot water monitoring | |
| Operator #A | Participated in phone interview regarding facility policy on hot water monitoring |
Inspection Report
Renewal
Deficiencies: 0
Nov 14, 2018
Visit Reason
A survey for re-licensure was conducted on 11/13/18 and 11/14/18 at the assisted living unit in Overland Park, KS.
Findings
The survey resulted in a finding of no deficiency citations.
Inspection Report
Renewal
Deficiencies: 0
Nov 15, 2016
Visit Reason
The licensure resurvey of the assisted living facility Silvercrest at Deer Creek was conducted on 11-14-16 and 11-15-16 to assess compliance for license renewal.
Findings
The inspection resulted in findings of no deficiency citations.
Inspection Report
Re-Inspection
Census: 31
Deficiencies: 1
Sep 21, 2015
Visit Reason
The visit was a resurvey conducted on 9-16-15, 9-17-15, and 9-21-15 to assess compliance with regulations following previous findings.
Findings
The facility failed to report and investigate allegations of abuse or neglect within 24 hours as required, specifically regarding a cognitively impaired resident (#233) who was found on the floor on three separate occasions without proper investigation or reporting to the department.
Complaint Details
The complaint investigation was substantiated as the operator/RN failed to report and investigate falls involving resident #233 on three occasions, which were not witnessed and lacked staff statements or further investigation.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to report allegations of abuse, neglect, or exploitation to the department within 24 hours and to start an investigation upon notification. | SS=D |
Report Facts
Census: 31
Sample size: 3
Falls incidents: 3
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