Deficiencies per Year
4
3
2
1
0
Unclassified
Census Over Time
Census
Capacity
Inspection Report
Renewal
Census: 20
Capacity: 62
Deficiencies: 4
May 30, 2024
Visit Reason
The inspection was conducted as a renewal licensing study for Arbor Grove Assisted Living & Memory Care to assess compliance with state regulations and determine eligibility for license renewal.
Findings
The facility was found to be in non-compliance with several rules including inadequate detail in residents' service plans, incomplete medication administration logs, failure to post menus for therapeutic and special diets, and improper storage and dating of food items in the kitchen.
Deficiencies (4)
| Description |
|---|
| Resident service plans lacked detail regarding specific care needs such as mobility assistance and toileting. |
| Medication administration record for Resident A showed missing initials for medication administered on 05/01 and 05/02. |
| Menu for therapeutic and special diets was not posted as required. |
| Food items in the kitchen's walk-in refrigerator, freezer, and dry storage were opened, unsealed, and not dated; cereal in the memory care unit was outdated. |
Report Facts
Number of staff interviewed and/or observed: 5
Number of residents interviewed and/or observed: 20
Capacity: 62
Number of excluded employees followed up: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jennifer Herald | Authorized Representative | Named as authorized representative of the facility |
| Amanda Raglin | Administrator | Named as administrator of the facility |
| Kimberly Horst | Licensing Staff | Licensing consultant who signed the report |
Inspection Report
Renewal
Deficiencies: 0
Nov 2, 2023
Visit Reason
The document serves as a renewal notification for the Home for the Aged license of Arbor Grove Assisted Living & Memory Care, confirming substantial compliance with applicable public health codes and administrative rules over the past year.
Findings
An administrative review revealed substantial compliance with the public health code and administrative rules regulating home for the aged facilities, resulting in the renewal of the facility's license for 12 months effective 12/02/2023.
Report Facts
License duration: 12
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kimberly Horst | Licensing Staff | Signed the renewal notification letter |
Inspection Report
Complaint Investigation
Census: 9
Capacity: 62
Deficiencies: 4
Sep 19, 2023
Visit Reason
The inspection was conducted in response to complaints alleging neglect of residents in memory care, staff not following service plans, and insufficient staffing on the third shift in the memory care unit.
Findings
The investigation confirmed violations including residents not being changed in a timely manner, inadequate staffing on the third shift in memory care, improper care of Resident C contrary to the service plan, and medication administration errors for Resident B. Multiple violations of resident dignity, safety, and medication administration were established.
Complaint Details
The complaint alleged neglect of residents in memory care and failure of staff to follow service plans, as well as insufficient staffing on the third shift. The investigation substantiated these allegations and additional violations.
Deficiencies (4)
| Description |
|---|
| Residents in memory care were not consistently changed in a timely manner, and Resident A's service plan did not accurately reflect toileting needs. |
| Only one care staff member was assigned to the memory care unit on the third shift, which was insufficient to meet residents' needs and ensure safety. |
| Resident C was taken to the memory care unit at night and allowed to sleep in a recliner without documented care plan or consent. |
| Resident B's medication was crushed and administered without a physician's order. |
Report Facts
Capacity: 62
Memory care residents: 9
Residents demonstrating wandering: 6
Residents with altered sleep cycles: 5
Residents requiring one person assistance with care routines: 6
Residents requiring one person assistance with transfers or mobility: 2
Residents requiring hourly supervision: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Amanda Raglin | Administrator | Interviewed regarding allegations and facility operations |
| Julie Viviano | Licensing Staff | Author of the inspection report |
| Andrea L. Moore | Manager, Long-Term-Care State Licensing Section | Approved the inspection report |
Inspection Report
Complaint Investigation
Census: 8
Capacity: 62
Deficiencies: 1
Mar 7, 2023
Visit Reason
The inspection was conducted in response to an anonymous complaint alleging that the facility failed to protect memory care residents and that the memory care unit had insufficient staff.
Findings
The investigation found that the allegation of failure to protect memory care residents was not established, but the facility was found to have insufficient staff in the memory care unit at times, which posed potential harm to residents requiring two-person assist and other care needs.
Complaint Details
The complaint alleged that two residents wandered from the memory care unit into the enclosed courtyard and then into the assisted living unit, and that the memory care unit had insufficient staff. The failure to protect allegation was not substantiated, but the insufficient staffing allegation was substantiated.
Deficiencies (1)
| Description |
|---|
| Memory care unit has insufficient staff, with times when only one staff member is present despite residents requiring two-person assist and frequent checks. |
Report Facts
Capacity: 62
Census: 8
Staffing shifts with single caregiver: 2
Residents requiring two-person assist: 1
Residents that wander: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Amanda Raglin | Administrator | Interviewed regarding courtyard access, staffing, and resident safety |
| Allison Freed | Authorized Representative | Interviewed regarding securing the courtyard and corrective actions |
| Kimberly Horst | Licensing Staff | Conducted the investigation and authored the report |
Inspection Report
Original Licensing
Capacity: 62
Deficiencies: 0
Mar 30, 2021
Visit Reason
The visit was conducted as an original licensing study to determine compliance with applicable licensing statutes and administrative rules for Arbor Grove Assisted Living & Memory Care.
Findings
The facility was found to be in substantial compliance with home for the aged public health code and administrative rules. A temporary license with a maximum capacity of 62 beds was recommended for issuance.
Report Facts
Licensed bed capacity: 62
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kimberly Horst | Licensing Staff | Author of the licensing study report and recommendation for license issuance. |
| Russell B. Misiak | Area Manager | Approved the licensing study report and recommendation. |
| Amanda Warner | Administrator | Named as the facility administrator in the report. |
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