10 Reports
Inspection Report — Feb 12, 2026
Complaint Investigation
Date: Feb 12, 2026
Visit Reason
The visit was conducted to investigate complaints #130763-C and #130963-C, and to complete a revisit from 8/05/25 regarding complaints #129093-C and #129343-C.
Complaint Details
Complaint #130763-C was investigated with no insufficiencies cited. Complaint #130963-C was investigated with regulatory insufficiencies cited. The revisit addressed complaints #129093-C and #129343-C with regulatory insufficiencies recited.
Findings
Regulatory insufficiencies were cited during the investigation of Complaint #130963-C and the revisit from 8/05/25. No regulatory insufficiencies were cited during the investigation of Complaint #130763-C.
Violations (6)
481-67.2(3) Program Policies and Procedures: The program failed to follow established policies related to incident reporting for two tenants, as no incident reports were completed for injuries observed on Tenant #2 and Tenant #5.
481-67.5(2)f(4) Medications: The program failed to follow physician's orders for Tenant #4 by delaying administration of ordered medications for several days after the order date.
481-67.7(2)a Waiver of Criteria for Retention: The program failed to obtain a waiver for Tenant #2 who exceeded the program's level of care criteria.
481-69.22(3) Evaluation of Tenant: The program failed to complete evaluations with significant change for Tenant #2 when she stopped transferring out of bed and was nearing end of life.
481-69.26(1) Service Plans: The program failed to develop and update service plans based on evaluations for Tenant #3 and Tenant #4.
481-69.26(4)d Service Plans: The program failed to include a list of person-centered and spontaneous activities based on the abilities and interests of tenants with dementia, specifically Tenant #3 and Tenant #4.
Inspection Report — Feb 9, 2026
Renewal
Date: Feb 9, 2026
Visit Reason
The visit was a recertification (renewal) visit to determine compliance with certification of an Assisted Living Program. The visit also investigated Complaint #130889-C, Complaint #130913-C, Complaint #130964-C, and Mandatory Report #131405-A, as well as revisited FC#10907 for prior investigations of Incidents #128992-I, #129591-I, and #130033-I.
Complaint Details
Complaint #130889-C was investigated with no regulatory insufficiencies cited. Complaints #130913-C, #130964-C, and Mandatory Report #131405-A were investigated with regulatory insufficiencies cited.
Findings
Regulatory insufficiencies were cited related to internal investigations of abuse, waiver of criteria for retention, tenant incident reports, and service plans. No regulatory insufficiencies were cited during the investigation of Complaint #130889-C.
Violations (6)
481-67.2(3) Program Policies and Procedures: The program failed to follow established policies for internal investigations of abuse and the reporting of suspected abuse for 1 out of 7 tenants. Tenant #2 reported inappropriate conduct by a Medication Partner and the investigation was not completed within required timeframes.
481-67.7(2)a Waiver of Criteria for Retention: The program failed to obtain a waiver of the criteria of retention for 1 tenant who exceeded the program's level of care criteria (Tenant C1). No waiver was requested or completed.
481-69.25(1)o Tenant Documents: The program failed to complete an incident report when required for 1 out of 7 tenants reviewed (Tenant #6). Tenant #6 was diagnosed with a urinary tract infection and was placed on safety checks, but no incident report was completed.
481-69.26(1) Service Plans: The program failed to develop the service plan based on evaluations and update the plan as needed for 1 out of 7 tenants reviewed (Tenant C1). The service plan did not reflect the addition of an indwelling urinary catheter and required assistance.
481-69.26(4)a Service Plans: The program failed to ensure the service plan was individualized and included all identified needs for 3 out of 7 tenants (Tenant C1, Tenant #2, Tenant #3). Service plans lacked complete goals and individualized needs.
481-69.26(4)c Service Plans: The program failed to identify all service providers on the service plan for 1 out of 7 tenants reviewed (Tenant C1). The plan lacked information regarding hospice services.
Inspection Report — Oct 13, 2025
Complaint Investigation
Date: Oct 13, 2025
Visit Reason
The inspection was conducted to investigate Complaint #130292-C at Cedarstone Senior Living.
Complaint Details
Investigation of Complaint #130292-C found no regulatory insufficiencies.
Findings
No regulatory insufficiencies were cited during the investigation of the complaint.
Report Facts
Tenants without cognitive impairment: 60
Tenants with cognitive impairment: 2
Inspection Report — Aug 5, 2025
Complaint Investigation
Date: Aug 5, 2025
Visit Reason
The inspection was conducted related to the investigation of incidents involving tenant care and safety concerns, including failure to provide adequate and appropriate services to tenants and a fall with injury.
Complaint Details
The investigation was triggered by incidents involving Tenant #1 being left without her emergency pendant overnight and Tenant #2 suffering a fall with injury while unattended for an extended period. Tenant #2's fall was unwitnessed and resulted in a dislocated hip requiring surgery. Staff failed to provide care due to inaccurate leave of absence status in the computer system.
Findings
The Program failed to provide adequate and appropriate care for two tenants, including failure to ensure safety pendant use and proper care after a fall. Documentation deficiencies were noted including incomplete nurse's notes by exception, failure to complete incident reports, and service plans not updated to reflect tenant needs.
Violations (4)
Failure to provide adequate and appropriate services and cares for tenants, including failure to ensure safety pendant was replaced and failure to provide care after a fall.
Failure to document nurse's notes by exception, including follow-up on antibiotic treatments and wound care.
Failure to complete incident reports related to a fall with injury.
Failure to update service plans as needed to reflect tenant care needs, including after hospital return and wound care.
Report Facts
Number of tenants without cognitive impairment: 59
Number of tenants with cognitive impairment: 3
Fall unattended duration (hours): 14.25
Bruise size (cm): 4
Bruise size (cm): 2.6
Pain rating: 7
Pain rating: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Assisted Tenant #1 but failed to replace emergency pendant; suspended pending investigation | |
| Staff B | Assisted Tenant #1 and Tenant #2; reported incidents and provided care | |
| Staff E | Care partner responsible during Tenant #2's fall; suspended pending investigation | |
| Wellness Director | Oversaw Tenant #2's return and care; involved in incident response and investigation | |
| Executive Director | Involved in investigation and communication with family and corporate staff | |
| Staff G | Responded to pendant call for Tenant #2 fall | |
| Staff I | Administered medications to Tenant #2 | |
| Staff J | Assisted Tenant #2 and documented care | |
| Staff H | Administered eye drops to Tenant #2 | |
| Staff D | Completed skin assessments and assisted Tenant #1 | |
| Staff C | Interviewed regarding Tenant #1's pendant incident | |
| Staff F | Medication passer; involved in incident response for Tenant #2 | |
| Staff K | Assisted on floors; aware of Tenant #2's return | |
| Plant Operations Director | Found Tenant #2 on floor after fall and pressed pendant |
Inspection Report — Jul 17, 2025
Enforcement
Date: Jul 17, 2025
Visit Reason
This citation was issued following investigations #128992-I, #129591-I, and #130031-I conducted from 7/17/25 to 8/5/25 regarding an unwitnessed fall with injury involving Tenant #2 who returned to the facility on 7/21/25.
Complaint Details
Investigations #128992-I; #129591-I; #130031-I
Findings
Tenant #2 returned to the facility on 7/21/25 but was still listed as on medical leave in the computer system. Staff did not provide required care and supervision, resulting in Tenant #2 being found on the floor on 7/22/25 with a dislocated hip and other serious complications. Staff E was suspended pending investigation and received re-education. The facility planned further staff education and in-service training.
Violations (1)
481-67.3(2) Tenant rights: The facility failed to provide adequate care and supervision to Tenant #2 after her return on 7/21/25, as staff did not recognize she was present due to her status in the computer system and did not respond appropriately, resulting in an unwitnessed fall with injury and delayed assistance.
Report Facts
Fine amount: 7500
Inspection Report — Feb 20, 2025
Complaint Investigation
Date: Feb 20, 2025
Visit Reason
The inspection was conducted due to the investigation of Complaint #122780-C, Incident #122793-I, Incident #126079-I, and the recertification visit to determine compliance with certification of an Assisted Living Program.
Complaint Details
The visit was complaint-related, investigating Complaint #122780-C and related incidents #122793-I and #126079-I. The complaint involved failures in background checks, staff evaluations, tenant health assessments, and monitoring.
Findings
The program failed to complete required child and dependent adult abuse background checks prior to employment for 7 employees, failed to obtain a Department of Human Services evaluation for a staff member with a criminal history, failed to assess and document the health status of a tenant with a significant change in condition, and failed to monitor tenants as indicated in service plans, resulting in incidents including delayed treatment and a fall.
Violations (4)
Failed to ensure child and dependent adult abuse record checks were completed prior to employment for 7 of 7 employee files reviewed.
Failed to obtain an evaluation from the Department of Health and Human Services prior to employment for 1 staff with a criminal history.
Failed to assess and document the health status of 1 of 5 tenants reviewed after a significant change in condition, resulting in delayed treatment and hospitalization for brain bleeds.
Failed to check on tenants as indicated in service plans for 1 of 1 former tenants reviewed, resulting in a fall and lack of required status checks and toileting assistance.
Report Facts
Number of tenants without cognitive impairment: 53
Number of tenants with cognitive impairment: 0
Number of employees with missing abuse checks: 7
Fall risk score: 90
Blood sugar reading: 400
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff F | Failed to have child and dependent adult abuse record checks completed prior to employment | |
| Staff G | Failed to have child and dependent adult abuse record checks completed prior to employment; had criminal history without DHHS evaluation | |
| Staff H | Failed to have child and dependent adult abuse record checks completed prior to employment | |
| Staff I | Failed to have child and dependent adult abuse record checks completed prior to employment | |
| Staff J | Failed to have child and dependent adult abuse record checks completed prior to employment | |
| Staff K | Failed to have child and dependent adult abuse record checks completed prior to employment | |
| Staff L | Failed to have child and dependent adult abuse record checks completed prior to employment | |
| Staff A | Medication Partner | Alerted nurse about Tenant 2's high blood sugar and condition but nurse failed to assess tenant |
| Staff B | Care Partner | Observed Tenant 2's abnormal gait and alerted Medication Partner about high blood sugar |
| Staff D | Responded to Tenant C1 on floor after family notification; confirmed failure to complete required status and toileting checks | |
| Executive Director | Confirmed findings regarding background checks and tenant care failures | |
| Director of Wellness | Confirmed findings and provided interviews regarding tenant care and staff failures | |
| LPN | Licensed Practical Nurse | Failed to assess Tenant 2 despite multiple notifications of high blood sugar and abnormal gait |
Inspection Report — Feb 17, 2025
Enforcement
Date: Feb 17, 2025
Visit Reason
This citation was issued following a recertification visit conducted from 2/17/25 to 2/20/25. The citation addresses failures in conducting required background checks and employment prohibitions related to criminal history and abuse registry checks.
Findings
The program failed to ensure child and dependent adult abuse record checks were completed prior to employment for 7 of 7 employee files reviewed. Additionally, the program failed to obtain a required evaluation from the Department of Health and Human Services prior to employment for one staff member with a criminal history.
Violations (2)
67.19(3)b Conducting a background check: The program failed to ensure child and dependent adult abuse record checks were completed prior to employment for 7 of 7 employee files reviewed. Background checks dated from 9/5/24 to 1/28/25 did not include these required checks.
67.19(5) Employment prohibition: The program failed to obtain an evaluation from the Department of Health and Human Services prior to employment for 1 staff member with a criminal history. No evaluation letter was located for Staff G, hired 1/16/25.
Report Facts
Fine amount: 500
Inspection Report — Nov 27, 2023
Complaint Investigation
Date: Nov 27, 2023
Visit Reason
Investigation of Complaint #114443-C at Cedarstone Senior Living.
Complaint Details
Complaint #114443-C was investigated and found to have no regulatory insufficiencies.
Findings
No regulatory insufficiencies were cited during the complaint investigation.
Report Facts
Number of tenants without cognitive impairment: 49
Number of tenants with cognitive impairment: 3
Inspection Report — Apr 12, 2023
Original Licensing
Date: Apr 12, 2023
Visit Reason
Initial certification visit conducted to determine compliance with certification rules for an Assisted Living Program.
Findings
The program failed to complete required criminal, child, and dependent adult abuse background checks prior to employment for several staff, failed to request evaluations for staff with criminal histories, and failed to complete background checks within 30 days of employment for multiple staff. Additionally, the program failed to evaluate tenants' cognitive, functional, and health status prior to occupancy, within 30 days of occupancy, and annually or with significant change, and failed to develop service plans based on required assessments for all tenants reviewed.
Violations (7)
Failed to complete criminal, child, and dependent adult abuse background checks prior to employment for 2 of 7 staff reviewed.
Failed to request an evaluation from Department of Health and Human Services prior to employment for 1 staff with a criminal history.
Failed to complete criminal, child, and dependent adult abuse background checks within 30 calendar days of employment for 4 of 7 staff reviewed.
Failed to evaluate tenant's cognitive status prior to occupancy for 2 of 3 tenants reviewed.
Failed to evaluate tenant's functional, cognitive, and health status within 30 days of occupancy for 2 of 3 tenants reviewed.
Failed to evaluate tenant's functional, cognitive, and health status as warranted for 1 tenant with significant change in health status.
Failed to develop service plans based on required assessments for 3 tenants reviewed.
Report Facts
Number of tenants without cognitive impairment: 25
Number of tenants with cognitive impairment: 4
Staff reviewed: 7
Tenants reviewed: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Named in findings related to failure to request evaluation for criminal history and background check timing. | |
| Staff B | Named in findings related to failure to complete background checks prior to employment and within 30 days. | |
| Staff E | Named in findings related to failure to complete background checks prior to employment. | |
| Staff C | Named in findings related to failure to complete background checks within 30 days. | |
| Staff D | Named in findings related to failure to complete background checks within 30 days. | |
| Kersten Kleinlein | Executive Director | Signed plan of correction. |
Inspection Report — Apr 10, 2023
Enforcement
Date: Apr 10, 2023
Visit Reason
Initial certification survey conducted from April 10 to April 12, 2023, to determine compliance with employment background check requirements.
Findings
The program failed to complete required criminal, child, and dependent adult abuse background checks prior to employment for multiple staff and did not request timely evaluations for staff with criminal histories. Background checks were also not completed within 30 calendar days of employment for several staff.
Violations (3)
IAC 481-67.19(3) The program failed to complete criminal, child, and dependent adult abuse background checks prior to employment for 2 of 7 staff reviewed. Staff B and Staff E were hired without timely background checks.
IAC 481-67.19(3)c The program failed to request an evaluation from the Department of Health and Human Services prior to employment for 1 staff member with a criminal history (Staff A).
IAC 481-67.19(4) The program failed to complete background checks within 30 calendar days of employment for 4 of 7 staff reviewed (Staff A, Staff B, Staff C, and Staff D).
Report Facts
Fine amount: 500
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