5 Reports
Inspection Report — Mar 11, 2026
Complaint Investigation
Date: Mar 11, 2026
Visit Reason
Investigation of a complaint received on 2026-03-11 about medication administration errors and additional findings.
Complaint Details
Staff leave residents in dirty and soiled clothing: not established. The facility is short-staffed: not established. Staff do not receive appropriate training: not established. Medication errors such as pills found on the floor, medications in applesauce, and medications in resident rooms without orders: established. Additional findings: established.
Findings
Two violations were established related to medication administration and documentation. Other allegations including staff leaving residents in soiled clothing, short staffing, and inadequate training were not substantiated.
Deficiencies (2)
R 325.1932 Resident medications: medication was found on the floor of Resident A’s room on an unknown date, and no documentation was recorded on the incident, resulting in a violation.
R 325.1932 Resident medications: no documentation was completed by staff when medication was found on the floor of Resident A’s room, preventing determination of notification and re-education, resulting in a violation.
Report Facts
Corrective action plan due: 15
Inspection Report — May 30, 2024
Renewal
Date: May 30, 2024
Visit Reason
Renewal inspection of the adult foster care family home license.
Findings
The home was found in non-compliance with 4 rules; a written corrective action plan was required before the license is renewed.
Deficiencies (4)
R 325.1931 Employees; general provisions: Resident A’s service plan lacked detail regarding her specific care needs including mobility assistance and toileting; similar findings were noted with Resident B and Resident C.
R 325.1932 Resident’s medications: Resident A’s medication administration record showed the medication technician did not initial administration of Venlafaxine Cap 37.5 ER on 05/01 and 05/02.
R 325.1953 Menus: The menu for therapeutic and special diets was not posted as required.
R 325.1976 Kitchen and dietary: The walk-in refrigerator, freezer, and dry storage contained opened, unsealed, and undated items including cheese, vegetables, cereal, and raisins; cereal in the memory care unit was outdated.
Report Facts
Corrective action plan due: 15
Inspection Report — Nov 2, 2023
Renewal
Date: Nov 2, 2023
Visit Reason
License renewal notice; no inspection report attached. Administrative review without an on-site visit.
Findings
The license was renewed following an administrative review that revealed substantial compliance with applicable rules.
Report Facts
License length: 12
Inspection Report — Sep 12, 2023
Complaint Investigation
Date: Sep 12, 2023
Visit Reason
Investigation of a complaint received on 2023-09-11 about resident neglect, staffing, and additional findings.
Complaint Details
Residents neglected in memory care and staff not following service plans: established. Only one care staff member on third shift in memory care unit: established. Resident C sleeping in memory care unit recliner without care plan agreement: established. Resident B’s medication crushed without physician order: established.
Findings
Four rule violations were established related to resident care, staffing, and medication administration.
Deficiencies (4)
R 325.1931 Employees; general provisions: the facility failed to treat Resident A with dignity and did not have an appropriate service plan to address Resident A’s consistent urination on the bathroom floor, resulting in unsanitary conditions and safety risks.
R 325.1931 Employees; general provisions: one care staff person on duty in the memory care unit on third shift is insufficient to meet the needs of residents requiring assistance and supervision, and staff have left the memory care unit unattended during the summer months.
R 325.1931 Employees; general provisions: facility staff took Resident C, an assisted living resident, to the memory care unit during nighttime hours without documented care plan or authorized representative agreement, failing to provide care consistent with the service plan.
R 325.1932 Resident Medications: Resident B’s medication was administered crushed without a physician’s order authorizing crushing, violating medication administration requirements.
Report Facts
Corrective action plan due: 15
Inspection Report — Mar 30, 2021
Original Licensing
Date: Mar 30, 2021
Visit Reason
Original license application for a home for the aged.
Findings
The facility was found in substantial compliance with home for the aged public health code and administrative rules.
Report Facts
License period: 6
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