Inspection Reports for
Monastery Heights Senior Living and Memory Care

Medication assistance · Emergency call response: Documentation of actions regarding whether the Resident took or refused medication was missing for two Residents, and there were 367 emergency call response times over the seven minute limit during December 2023, June 2024 and March 2025 (repeat finding).

Memory care unit: Documentation of the required operational review was incomplete for the second review of 2023 and both reviews of 2024; unsecured cleaning chemicals and hair care products were accessible to Residents in the kitchenette and laundry areas (repeat finding).

Resident screening and assessment · Resident care plans: Documentation of a physical/occupational therapist assessment every six months was missing for 15 Residents; several other required assessments and reviews were missing documentation (repeat finding).

Quality assurance program: Documentation that each service plan is identified by number or code and specific findings was missing for 2023 and 2024; medication audits and follow-up action documentation were incomplete; medication was observed unsecured and missing labels (repeat finding).

Incident reporting: The Residence filed 70 incident reports more than 24 hours after the occurrence of the incident or accident (repeat finding).

Controlled medication handling: One Resident’s controlled substance medication storage unit was unsecured and blister packs were compromised (repeat finding).

Resident progress notes: Documentation of significant occurrences in the Progress Notes was missing for two Residents (repeat finding).

Resident records: Two personnel records were missing signed job descriptions; four were missing criminal offender record information; the Special Care log did not consistently document necessary information.

Staffing: Documentation confirming quarterly staffing level assessments was missing for the third quarter of 2023 (repeat finding).

Staff training: Documentation to support consistent Introductory Visits was missing for five records; SAMM skills evaluations were missing for three records in 2024 (repeat finding).

Reports filed with the state: The Residence failed to update signage to reflect a name change completed on December 6, 2024.