9 Reports
Inspection Report — Jun 25, 2026
Complaint Investigation
Date: Jun 25, 2026
Visit Reason
The survey was conducted following a complaint inspection to investigate medication management and administrator responsibilities.
Complaint Details
The complaint inspection cited deficiencies related to insulin management and administration practices, including insulin shortages and cross-use of insulin pens between residents.
Findings
Two deficiencies were found related to medication management and administrator oversight. The administrator failed to ensure insulin was in stock, and medications were administered using another resident's insulin pen due to lack of supply.
Deficiencies (2)
37.106.2814-1 Administrator: the administrator failed to ensure insulin was in stock prior to the weekend, risking resident well-being.
37.106.2848-6 Medications, administration and preparation: insulin was administered using another resident's NovoLog flex pen due to lack of available insulin.
Inspection Report — Jun 16, 2026
Complaint Investigation
Date: Jun 16, 2026
Visit Reason
The complaint inspection was conducted due to concerns about staffing and resident care.
Complaint Details
The cited finding involved inadequate staffing resulting in delayed response times to a resident's call lights, indicating insufficient supervision and care.
Findings
The facility failed to maintain sufficient staff to meet a resident's unscheduled needs, resulting in prolonged response times to call lights.
Deficiencies (1)
37.106.2816-6 Assisted living facility staffing: the facility failed to maintain sufficient staff to meet a resident's unscheduled needs, with call light response times exceeding 10 minutes on multiple occasions.
Report Facts
call_light_response_delays:
Inspection Report — Mar 19, 2026
Complaint Investigation
Date: Mar 19, 2026
Visit Reason
The inspection was conducted following a complaint regarding the facility's handling of hospice care and documentation.
Complaint Details
The complaint involved inadequate documentation and care coordination for a resident receiving hospice services, including failure to update service plans and medication records.
Findings
The facility failed to update the resident's service plan to reflect hospice care changes, did not document the resident's declining condition or treatments, and omitted physician orders for wound care from medication records.
Deficiencies (3)
37.106.2822-3 Resident service plan: category A: the facility did not update the resident's service plan to reflect the transition to hospice care or specific services provided.
37.106.2843-6 Personal care services: the facility failed to document the resident’s declining condition, observations, or treatments, and did not coordinate care or clarify responsibility for a Stage III pressure wound.
37.106.2849-1 Medications: records and documentation: physician orders for wound care were not entered into the resident’s medication administration records.
Inspection Report — Feb 11, 2026
Renewal
Date: Feb 11, 2026
Visit Reason
The survey was conducted as a renewal inspection of the assisted living facility.
Findings
Two deficiencies were found related to resident files. One category B resident lacked a practitioner's written order for admission and care, and two discharged resident files did not document the disposition of personal possessions.
Deficiencies (2)
50-5-226-3 Placement in assisted living facilities: one category B resident file lacked a practitioner's written order for admission and written orders for care.
37.106.2829-2 Resident file: two recently discharged resident files did not include the disposition of their personal possessions.
Inspection Report — Dec 19, 2025
Complaint Investigation
Date: Dec 19, 2025
Visit Reason
The inspection was conducted following a complaint investigation.
Complaint Details
The complaint investigation identified deficiencies related to the absence of documented disaster reviews and fire drills at the facility.
Findings
Two deficiencies were found related to the lack of documented disaster reviews and fire drills within the past year.
Deficiencies (2)
37.106.322-3 Minimum standards for all health care fa: no records were found documenting disaster reviews conducted with staff within the past year.
37.106.2866-9 Construction, building and fire codes: no fire drills were conducted or recorded at the facility during the past year.
Inspection Report — Jun 18, 2025
Complaint Investigation
Date: Jun 18, 2025
Visit Reason
The survey was conducted following a complaint inspection to review client records and medication administration practices.
Complaint Details
The cited finding involved failure to properly document missed medication doses and lack of practitioner notification regarding medication unavailability.
Findings
The facility failed to properly document missed medication doses and did not notify the practitioner or resolve the unavailability of scheduled medication for a resident.
Deficiencies (1)
37.106.2849-2 Medications: records and documentation: the facility did not document notification to the practitioner or resolve the unavailability of scheduled Morphine Sulfate ER doses missed by a resident.
Report Facts
missed_doses: 11
medication_dose_strength: 30
medication_dose_frequency: 4
Inspection Report — Jun 18, 2024
Complaint Investigation
Date: Jun 18, 2024
Visit Reason
The complaint investigation was prompted by resident and staff interviews and observations indicating inadequate assistance and medication management issues.
Complaint Details
The complaint investigation identified deficiencies related to inadequate resident assistance, medication management failures, staffing shortages, and physical plant issues.
Findings
The facility failed to provide adequate assistance to residents, had multiple medication administration and documentation errors, lacked proper staff training, and had physical plant deficiencies. There was no current RN employed, and physician orders were not timely transcribed into MARs.
Deficiencies (13)
50-5-225-1 Assisted living facilities services: residents could not rely on staff for assistance to the dining room or showering, and strong urine odor and wet disposable briefs were observed in a resident's room.
37.106.330-1 Minimum standards for all health care facilities: medication orders were not properly managed, with residents not receiving prescribed medications for extended periods.
37.106.2814-6 Administrator: staff acknowledged incomplete medication technician training.
37.106.2814-12 Administrator: incident reports lacked documentation of administrator or designee review.
37.106.2816-6 Assisted living facility staffing: insufficient staffing on night shifts resulted in delayed care and unmet resident needs.
37.106.2822-1 Resident service plan: category A: resident service plans were not followed, resulting in unkempt toenails and lack of compression sock use.
37.106.2843-3 Personal care services: incident reports lacked documentation of notification to legal representatives or physicians.
37.106.2846-1 Medications storage and disposal: medications were pre-dispensed into portion cups with resident room numbers and not stored in pharmacy containers.
37.106.2848-1 Medications administration and preparation: a resident was administered insulin without active involvement in self-administration.
37.106.2849-2 Medications records and documentation: multiple residents had missed or late medication administrations without proper documentation or reporting.
37.106.2865-6 Physical plant: resident rooms had dirty and ripped carpet, damaged baseboards, holes in walls, and strong urine odor with wet disposable briefs in trash cans.
37.106.2872-2 Requirements for category B facilities: no current Registered Nurse was employed at the facility.
37.106.2847-3 Medications practitioner orders: physician orders were not transcribed or entered into MAR for two weeks.
Report Facts
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Inspection Report — Jan 2, 2019
Renewal
Date: Jan 2, 2019
Visit Reason
The survey was conducted as a renewal inspection of the facility.
Findings
The facility failed to obtain annual practitioner orders for residents who keep their medications in their rooms and self-administer them.
Deficiencies (1)
37.106.2849-4 Medications: records and documentation: five of six resident files reviewed lacked documentation of an annual practitioner order for residents keeping medication in their rooms and self-administering.
Inspection Report — Nov 6, 2013
Renewal
Date: Nov 6, 2013
Visit Reason
The facility underwent a renewal inspection as part of its regular licensing process.
Findings
One deficiency was cited regarding medications and practitioner orders.
Deficiencies (1)
37.106.2847-2 Medications: practitioner orders: no specific finding text was provided in the document to detail the deficiency.
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