Deficiencies (last 10 years)
Deficiencies (over 10 years)
5.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
3% better than Kansas average
Kansas average: 6 deficiencies/yearDeficiencies per year
20
15
10
5
0
Occupancy
Latest occupancy rate
63% occupied
Based on a January 2026 inspection.
Occupancy rate over time
Inspection Report
Renewal
Census: 25
Deficiencies: 3
Date: Jan 29, 2026
Visit Reason
The inspection was a re-licensure survey combined with complaint investigations for an assisted living facility conducted on January 28 and 29, 2026.
Complaint Details
The survey included complaint investigations numbered 192191 and 195159.
Findings
The facility was found deficient in ensuring licensed nurses completed assessments for resident self-administration of medications, administering medications according to medical orders, and documenting incidents and follow-up actions for resident health issues and falls.
Deficiencies (3)
KAR 26-41-205(a)(1) The administrator failed to ensure licensed nurses completed assessments for self-administration of medications for two of three sampled residents prior to and annually during self-administration.
KAR 26-41-205(d) The operator failed to ensure staff administered medications in accordance with medical provider orders, resulting in a resident missing doses of Lisinopril due to pharmacy order issues.
KAR 26-41-105(f)(11) The administrator failed to ensure documentation of all incidents, symptoms, and follow-up actions for two residents, including incomplete nursing notes on diarrhea, vomiting, and falls.
Report Facts
Resident census: 25
Medication doses missed: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Nurse C | Reported on medication administration and documentation practices. | |
| Administrative Nurse B | Confirmed lack of self-administration assessments and documentation follow-up. |
Inspection Report
Renewal
Deficiencies: 0
Date: Jan 28, 2026
Visit Reason
The visit was a re-licensure survey combined with complaint investigations for the assisted living facility conducted on January 28 and 29, 2026.
Findings
The document is a plan of correction addressing findings from the re-licensure survey and complaint investigations. Specific deficiencies or findings are not detailed in this document.
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Jul 10, 2024
Visit Reason
An offsite revisit survey was conducted to verify correction of all previous deficiencies cited on 2024-06-18.
Findings
All deficiencies have been corrected as of the compliance date of 2024-07-03, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Jul 10, 2024
Visit Reason
An offsite revisit survey was conducted to verify correction of all previous deficiencies cited on 2024-06-18.
Findings
All deficiencies have been corrected as of the compliance date of 2024-07-03, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Jun 18, 2024
Visit Reason
The document is a plan of correction responding to findings from a licensure resurvey conducted on 06/18/2024, which included attached complaint numbers 182484 and 181526.
Findings
The plan of correction addresses citations identified during the licensure resurvey and complaint investigations conducted on 06/18/2024.
Inspection Report
Re-Inspection
Census: 28
Deficiencies: 3
Date: Jun 18, 2024
Visit Reason
The inspection was a licensure resurvey with attached complaint investigations numbered 182484 and 181526 conducted on 06/18/2024.
Complaint Details
The inspection included complaint investigations numbered 182484 and 181526.
Findings
The facility failed to ensure licensed nurses and medication aides did not administer insulin medication beyond the manufacturer's recommended expiration date. Additionally, the dietary staff failed to prepare and store food using safe methods, including improper thawing and lack of proper dating on stored food items.
Deficiencies (3)
26-41-205 (h) Medication Storage: The facility failed to ensure licensed nurses or certified medication aides did not administer insulin medication beyond the manufacturer's or pharmacy's recommended expiration date for a resident.
26-41-206 (d) Food Preparation: The facility dietary staff failed to prepare food using safe methods, including improper thawing of meat by placing a bag over a sink drain with running water without proper submersion or temperature control.
26-41-206 (e) (1) Facility Food Storage: The facility dietary staff failed to store food under safe and sanitary conditions, including lack of dates on refrigerated and frozen food items and opened containers.
Report Facts
Census: 28
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dietary Director B | Dietary Director | Confirmed the zip lock bag in the sink contained taco meat during food preparation observation. |
| Operator A | Interviewed regarding food thawing methods and food storage practices. | |
| LN C | Licensed Nurse | Observed unlocking medication cart and confirmed insulin pen storage and dating procedures. |
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Jun 29, 2023
Visit Reason
The abbreviated survey with review of facility report #181031 was conducted on 06/28/23 and 06/29/23 at the assisted living facility.
Findings
The survey resulted in a finding of no deficiency citations.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Jun 28, 2023
Visit Reason
The document is a plan of correction submitted following an abbreviated survey conducted on 06/28/23 and 06/29/23 at an assisted living facility.
Findings
The abbreviated survey resulted in a finding of no deficiency citations.
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Jan 25, 2023
Visit Reason
An offsite revisit survey was conducted to verify correction of all previous deficiencies cited on 2023-01-05.
Findings
All deficiencies cited in the previous inspection have been corrected as of the compliance date of 2023-01-20. No new noncompliance was found and the facility is in compliance with all regulations surveyed.
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Jan 25, 2023
Visit Reason
An offsite revisit survey was conducted to verify correction of all previous deficiencies cited on 2023-01-05.
Findings
All deficiencies cited in the previous inspection have been corrected as of the compliance date of 2023-01-20, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Inspection Report
Re-Inspection
Census: 35
Deficiencies: 4
Date: Jan 5, 2023
Visit Reason
This was a resurvey with attached complaints conducted at an assisted living facility to assess compliance with medication self-administration, medication management, labeling of over-the-counter medications, and tuberculosis guidelines.
Complaint Details
This inspection was a resurvey with attached complaints #170953, #170557, #165345, #161604, and #161601.
Findings
The facility failed to ensure assessments for safe self-administration of medications were completed, failed to identify responsible parties for administration of selected medications in negotiated service agreements, failed to label over-the-counter medications with residents' full names, and failed to maintain compliance with tuberculosis screening and testing guidelines for residents and staff.
Deficiencies (4)
KAR 26-41-205(a)(1) The facility failed to ensure an assessment was completed to determine that Resident 105 could safely and accurately self-administer insulin before beginning self-administration.
KAR 26-41-205(b) The facility failed to ensure Residents 104 and 106's negotiated service agreements identified who was responsible for administration and management of select medications.
KAR 26-41-205(g)(3) The facility failed to ensure a licensed pharmacist or nurse placed the full names of residents on the original packages of eight over-the-counter medications.
KAR 26-41-207(c) The facility failed to ensure compliance with tuberculosis guidelines, including missing yearly symptom screening for Resident 105 and incomplete or late TB testing and screening documentation for three staff members.
Report Facts
Census: 35
Over-the-counter medications unlabeled: 8
Days since last yearly symptom screening for Resident 105: 793
Days late for TB test for CMA E: 50
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Nurse B | Administrative Nurse | Confirmed Resident 105 self-administered insulin and confirmed missing assessments and TB screening documentation. |
| Certified Medication Aide D | Certified Medication Aide | Employee record lacked evidence of timely TB testing and symptom screening. |
| Certified Medication Aide E | Certified Medication Aide | Employee record lacked evidence of timely TB testing and symptom screening. |
| Administrative Staff A | Administrative Staff | Confirmed missing TB test results and symptom screening documentation for staff. |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Jan 4, 2023
Visit Reason
This document is a plan of correction submitted in response to a resurvey with attached complaints #170953, #170557, #165345, #161604, and #161601 conducted at the assisted living facility on 01/04/23 and 01/05/23.
Findings
The plan of correction addresses findings from a resurvey and multiple complaints at the assisted living facility conducted on the specified dates.
Inspection Report
Re-Inspection
Census: 29
Deficiencies: 3
Date: Apr 15, 2021
Visit Reason
The inspection was a resurvey with complaint investigations #147461 and #154875 conducted on 4/12-15/2021 at an assisted living facility.
Complaint Details
The visit was a resurvey with complaint investigations #147461 and #154875.
Findings
The executive director failed to ensure the development of negotiated service agreements for residents with specific needs, failed to ensure health care services met acceptable standards related to wound management, and failed to ensure disaster and emergency preparedness including quarterly review of the emergency management plan with employees.
Deficiencies (3)
KAR 26-41-202(a)(1) The executive director failed to ensure negotiated service agreements included necessary services for residents with communication difficulties and use of assistive devices.
KAR 26-41-204(i) The executive director failed to ensure a licensed nurse provided or coordinated necessary health care services related to pressure wound management for a resident.
KAR 26-41-104(d)(3)(4) The executive director failed to ensure quarterly review of the facility's emergency management plan with employees.
Report Facts
Census: 29
Deficiencies cited: 3
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Apr 15, 2021
Visit Reason
This document is a Plan of Correction related to deficiencies identified in a prior inspection of the facility.
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
Abbreviated Survey
Deficiencies: 0
Date: Jul 1, 2020
Visit Reason
The special infection control survey for COVID-19 was conducted at the facility on 07-01-2020.
Findings
The survey resulted in findings of no deficiency citations.
Inspection Report
Re-Inspection
Census: 31
Deficiencies: 3
Date: Jan 9, 2019
Visit Reason
Revisit for correction order 18-192 conducted on 1/8/19 and 1/9/19 to verify correction of previously cited deficiencies.
Findings
The facility failed to ensure accurate functional capacity screening and development of negotiated service agreements for residents, and failed to provide or coordinate necessary health care services in accordance with functional capacity screening and negotiated service agreements for multiple residents, particularly regarding fall risks, assistive devices, and dialysis needs.
Deficiencies (3)
KAR 26-41-201(d) Functional Capacity Screen Accurate. The facility failed to ensure designated staff accurately reflected resident #489's functional capacity at the time of screening regarding fall risk.
KAR 26-41-202(a) Negotiated Service Agreement. The facility failed to develop a written negotiated service agreement based on functional capacity screening and service needs for residents #307 and #489.
KAR 26-41-204(a) Health Care Services. The facility failed to ensure a licensed nurse provided or coordinated necessary health care services for residents #307, #318, and #411 in accordance with functional capacity screening and negotiated service agreements.
Report Facts
Resident census: 31
Sample size: 4
Fall risk score: 28
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed nurse B | Licensed Nurse | Interviewed and made entries regarding resident #489's hospital admission and fall risk; confirmed deficiencies in functional capacity screening and negotiated service agreements. |
| Certified medication aide A | Certified Medication Aide | Interviewed regarding resident #307's fall risk and use of side rails. |
| Operator C | Operator | Interviewed and confirmed deficiencies in negotiated service agreements and health service plans. |
| Licensed nurse D | Licensed Nurse | Documented resident #411's condition after fall. |
| Licensed nurse E | Licensed Nurse | Applied ice pads to resident #411 after fall. |
Inspection Report
Follow-Up
Deficiencies: 0
Date: Jan 9, 2019
Visit Reason
This revisit inspection was conducted to verify that previously cited deficiencies have been corrected by the facility.
Findings
All previously reported deficiencies were corrected as of the revisit date. The report lists multiple regulation citations with completed corrections.
Inspection Report
Re-Inspection
Deficiencies: 10
Date: Jan 9, 2019
Visit Reason
This is a revisit inspection to verify that previously reported deficiencies have been corrected and to document the dates such corrective actions were accomplished.
Findings
All previously cited deficiencies have been corrected as of the revisit date. Each deficiency is identified by regulation number and marked as completed.
Deficiencies (10)
26-41-201 (c): Deficiency corrected as of 01/09/2019.
26-41-202 (d): Deficiency corrected as of 01/09/2019.
26-41-204 (i): Deficiency corrected as of 01/09/2019.
26-41-205 (d)(4): Deficiency corrected as of 01/09/2019.
26-41-205 (h): Deficiency corrected as of 01/09/2019.
26-41-102 (d): Deficiency corrected as of 01/09/2019.
26-41-105 (c): Deficiency corrected as of 01/09/2019.
26-41-104 (d): Deficiency corrected as of 01/09/2019.
26-41-207 (b)(5-6)(c): Deficiency corrected as of 01/09/2019.
28-39-254: Deficiency corrected as of 01/09/2019.
Inspection Report
Complaint Investigation
Census: 29
Deficiencies: 11
Date: Nov 21, 2018
Visit Reason
The inspection was a resurvey with complaints (#131932, #132140, #134968) at an assisted living facility conducted on 11/15, 11/19, 11/20, and 11/21/2018.
Complaint Details
The inspection was complaint-driven, involving multiple complaints (#131932, #132140, #134968) that triggered the resurvey and focused reviews.
Findings
The facility was found deficient in multiple areas including failure to complete functional capacity screenings and negotiated service agreements timely, improper delegation and administration of insulin by certified medication aides, improper medication storage, lack of staff qualifications documentation, unsecured resident records, inadequate emergency preparedness reviews, failure to comply with tuberculosis screening guidelines, and unsecured hazardous chemicals.
Deficiencies (11)
K.A.R.26-41-201(c)(1) The facility failed to complete functional capacity screens for residents at least every 365 days as required.
KAR 26-41-202(a)(1)(2) The facility failed to develop negotiated service agreements for 4 residents that included all required service descriptions and provider identifications.
K.A.R.26-41-202(d)(1) The facility failed to review and revise negotiated service agreements for resident #117 at least every 365 days.
KAR 41-204(i) The facility failed to ensure qualified staff provided health care services when certified staff pierced a resident's skin prior to self-injection of insulin, placing the resident in immediate jeopardy.
KAR-26-41-205(d)(4) The facility failed to delegate blood sugar monitoring and insulin pen dialing to certified medication aides as required under the nurse practice act.
KAR 26-41-205(h)(1) The facility failed to store Tubersol solution according to professional standards, lacking date labeling on opened vials.
KAR 26-41-102(d)(1) The facility failed to have evidence of current certification and training for one certified medication aide who administered medications.
KAR 26-41-105(c)(5) The facility failed to safeguard resident records against unauthorized use, leaving medical records unsecured in an unlocked maintenance room.
KAR 26-41-104(d)(3) The facility failed to ensure quarterly review of the emergency management plan with employees and residents.
KAR 26-41-207 The facility failed to comply with tuberculosis guidelines by not ensuring annual TB skin tests or screenings for residents and new employees.
KAR 28-39-254(a) The facility failed to secure hazardous chemicals, leaving disinfectants and insecticides unlocked and accessible to residents.
Report Facts
Facility census: 29
Residents reviewed: 3
Focused reviews: 1
Certified medication aides reviewed: 5
Resident records found unsecured: 41
Boxes of resident records: 10
Staff attending emergency plan review: 11
Staff attending emergency plan review: 13
Residents attending emergency plan review: 18
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified staff M | Certified Medication Aide | Administered medications without current certification from January to June 2018 |
| Staff B | Certified Medication Aide | Observed piercing resident #117's skin with insulin pen prior to self-injection |
| Licensed nursing staff D | Licensed Nurse | Reported certified medication aides should dial insulin pen and hand it to resident for self-injection |
| Certified staff L | Certified Medication Aide | Reported dialing insulin pen and handing to resident without piercing skin |
| Administrative staff A | Administrator | Confirmed lack of delegation for medication aides and unsecured resident records |
| Administrative nursing staff E | Administrative Licensed Nursing Staff | Reported late functional capacity screens, late negotiated service agreements, and TB screening deficiencies |
Inspection Report
Re-Inspection
Deficiencies: 8
Date: Jan 22, 2018
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 were corrected as of the revisit date. Each deficiency is identified by regulation number and marked as completed.
Deficiencies (8)
26-39-103 (c): Previously cited deficiency corrected as of 01/22/2018.
26-41-101 (f) (3): Previously cited deficiency corrected as of 01/22/2018.
26-41-202 (j): Previously cited deficiency corrected as of 01/22/2018.
26-41-204 (a): Previously cited deficiency corrected as of 01/22/2018.
26-41-205 (d) (1-2): Previously cited deficiency corrected as of 01/22/2018.
26-41-205 (d) (3): Previously cited deficiency corrected as of 01/22/2018.
26-41-105 (c): Previously cited deficiency corrected as of 01/22/2018.
26-41-104 (a): Previously cited deficiency corrected as of 01/22/2018.
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Jan 22, 2018
Visit Reason
This is a revisit report 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 by regulation numbers were corrected as of the revisit date. The report confirms completion of corrective actions for each deficiency.
Inspection Report
Re-Inspection
Census: 31
Deficiencies: 8
Date: Dec 14, 2017
Visit Reason
The inspection was a resurvey with multiple complaints at the facility conducted over several days in December 2017.
Complaint Details
The inspection was triggered by multiple complaints alleging failures in notification of service changes, abuse and exploitation reporting, medication administration, and resident care.
Findings
The facility was found deficient in multiple areas including failure to notify residents of changes in services, inadequate reporting and investigation of abuse and exploitation allegations, failure to monitor outside service providers, failure to provide necessary health care services as per care plans, medication administration errors, failure to safeguard resident records, and insufficient staffing for emergency evacuations.
Deficiencies (8)
26-39-103(c)(2) The operator failed to notify residents or their legal representatives in writing of changes in charges or services at least 30 days before the effective date.
26-41-101(f)(3)(A)(B)(C)(D)(E)(F) The operator failed to report allegations of abuse, neglect, or exploitation within 24 hours, conduct timely investigations, take corrective actions, and maintain records.
26-41-202(j)(3) The designated facility staff failed to monitor services provided by outside resources and advocate for residents when services did not meet professional standards.
26-41-204(a) The operator failed to ensure licensed nurses provided or coordinated necessary health care services in accordance with functional capacity screening and negotiated service agreements.
26-41-205(d) The operator failed to ensure all medications were administered according to medical orders, professional standards, and manufacturer recommendations.
26-41-205(d)(3)(c) The licensed nurse or medication aide failed to remain with the resident until medication was ingested.
26-41-105(c)(4) The operator failed to safeguard resident records against theft as records were kept unsecured in an open cabinet accessible to all staff.
26-41-104(a) The operator failed to ensure sufficient staff to safely evacuate residents requiring assistance during emergencies or disasters and failed to document evacuation ability with minimal staff.
Report Facts
Resident census: 31
Evacuation staff count: 8
Evacuation staff count: 14
Insulin dose administered: 45
Insulin dose ordered: 60
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Nurse A | Named in medication administration and insulin dosing findings | |
| Certified Medication Aide D | Named in medication administration observation for resident #414 |
Inspection Report
Re-Inspection
Census: 31
Deficiencies: 5
Date: May 25, 2016
Visit Reason
The inspection was a resurvey of an assisted living facility conducted on 5/23/16, 5/24/16, and 5/25/16 to verify correction of previous deficiencies.
Findings
The facility failed to report and investigate multiple incidents of residents found on the floor or leaving the facility without staff awareness, failed to delegate glucometer testing and insulin pen preparation to certified medication aides, failed to obtain required employee registry verifications, and failed to maintain hot water temperatures within the required range in resident apartments.
Deficiencies (5)
KAR 26-41-101(f)(3)(A) The operator failed to report and investigate incidents involving residents found on the floor or leaving the facility without staff awareness to rule out abuse or neglect.
KAR 26-41-204(e) The licensed nurse failed to delegate glucometer testing of residents' blood sugar levels to certified medication aides as required.
KAR 26-41-205(d)(4) The licensed nurse failed to delegate preparation and dialing of an insulin pen to a certified medication aide.
KAR 26-41-102(d)(4) The operator failed to obtain supporting documentation from the Kansas nurse aide registry verifying no findings of abuse, neglect, or exploitation for two certified medication aides prior to employment.
KAR 28-39-256(c)(2)(B) The operator failed to ensure hot water temperatures in resident apartments were maintained between 98°F and 120°F and failed to monitor temperatures throughout the building.
Report Facts
Resident census: 31
Glucometer testing frequency: 4
Glucometer testing frequency: 2
Hot water temperature: 126.8
Hot water temperature: 124.8
Hot water temperature: 109.7
Inspection Report
Renewal
Deficiencies: 0
Date: Apr 9, 2014
Visit Reason
The licensure resurvey was conducted to assess compliance and determine if any deficiencies were present for license renewal.
Findings
The licensure resurvey resulted in a finding of no deficiency citations on 4-9-14.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: N087039 POC 75B811
Visit Reason
This document is a plan of correction related to a previous deficiency report for a COVID-19 related inspection at Vintage Park at Waterfront.
Findings
No specific findings are detailed in this document; it serves as a plan of correction linked to a prior deficiency report.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: N087039 POC JGO611
Visit Reason
This document is a Plan of Correction related to a prior deficiency report for the facility Vintage Park at Waterfront.
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: N087039 POC NQES12
Visit Reason
This document is a Plan of Correction related to a prior inspection event identified as NQES12 for the facility with State ID N087039.
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: N087039 POC Q7RN11
Visit Reason
This document is a Plan of Correction related to a previous deficiency report for the facility Vintage Park at Waterfront dated 12/14/2017.
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: N087039 POC Q7RN12
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 N087039.
Findings
No specific deficiencies or findings are detailed in this document. It serves as a record of the Plan of Correction submission and related contact information.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: N087039 POC S6QH11
Visit Reason
This document is a Plan of Correction related to a prior deficiency report for the facility Vintage Park at Waterfront.
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: N087039 POC UHJI11
Visit Reason
This document is a Plan of Correction related to a previously identified deficiency report for the facility.
Findings
No specific deficiencies or findings are detailed in this document. It serves as a placeholder or administrative record for the Plan of Correction.
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