Inspection Report Summary
Most inspections at Arbor Rose Senior Living found multiple deficiencies related to documentation, service plans, medication storage, and staff qualifications, with several enforcement actions and fines issued over the past two years. The facility was fined multiple times, including penalties of $8,800 in January 2025 and $2,750 in November 2025, reflecting ongoing compliance challenges, particularly with manager designation, personnel records, and medication safety. The most recent inspection on November 13, 2025, identified repeated deficiencies in emergency documentation, service plans, medication storage, and safety measures, resulting in civil fines. Several complaint investigations found numerous issues, but no immediate jeopardy or license suspensions were reported. While the facility has faced persistent problems, the pattern of enforcement and fines suggests regulatory attention remains focused on improving management and resident care documentation.
Deficiencies per Year
36
27
18
9
0
Severe
High
Moderate
Low
Unclassified
Inspection Report
Enforcement
Deficiencies: 7
Nov 13, 2025
Visit Reason
The inspection was conducted to address multiple violations at Arbor Rose Senior Living, resulting in enforcement actions and civil fines.
Findings
The facility was found to have repeated deficiencies related to documentation, service plans, medication storage, and safety measures, posing risks to residents' health and safety. Civil fines totaling $2750 were assessed for these violations.
Deficiencies (7)
| Description |
|---|
| The manager failed to ensure that an assisted living center maintained a copy of the document provided to emergency responders and documentation of required actions for two years after the emergency. |
| The manager failed to ensure employees provided documentation of freedom from infectious tuberculosis for four of seven employees sampled. |
| The manager failed to ensure a written service plan included documentation of the resident's medical or health problems for two of ten residents sampled. |
| The manager failed to ensure a resident's written service plan included the amount, type, and frequency of assisted living services for one of ten residents sampled. |
| The manager failed to ensure a caregiver or assistant caregiver assisted with activities of daily living according to the resident's service plan and/or documented services in the resident's medical record for one of ten residents sampled. |
| The manager failed to ensure that medication stored by the assisted living facility was stored in a separate locked room, closet, cabinet, or self-contained unit used only for medication storage. |
| The manager failed to ensure that toxic materials were stored in a locked area and inaccessible to residents. |
Report Facts
Civil fines total amount: 2750
Number of residents sampled: 10
Number of employees sampled: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Ryan Love | Licensee/Director/Provider | Signed enforcement agreement and rights notification |
| Dawn Butler | Bureau Chief | Attended enforcement agreement meeting |
| Thomas Salow | Assistant Director | Attended enforcement agreement meeting |
| Aaron Telles | Deputy Bureau Chief | Attended enforcement agreement meeting |
| Laura Redpath | Compliance Officer Supervisor | Attended enforcement agreement meeting |
Inspection Report
Complaint Investigation
Capacity: 74
Deficiencies: 36
Sep 17, 2025
Visit Reason
State-compiled facility profile showing 9 inspections from 2023-03 to 2025-09 with deficiency history and complaint investigations.
Findings
Across multiple inspections, numerous deficiencies were cited including failures in emergency responder documentation, manager designation, personnel qualifications, service plan completeness, medication administration documentation, staff training, and resident care practices. Several deficiencies were repeated from prior inspections, indicating ongoing compliance challenges.
Complaint Details
Multiple complaint investigations were conducted on dates including 2025-01-02 to 2025-01-03, 2024-08-30, 2024-07-23, 2024-07-17, 2024-05-07, 2024-06-05, 2023-07-12, and 2023-06-05 with numerous deficiencies cited.
Deficiencies (36)
| Description |
|---|
| 36-420.04. Emergency responders; patient information; hospitals; discharge planning; patient screenings; discharge document: Failed to provide required documentation to emergency responders for residents. |
| A. A governing authority shall designate, in writing, a manager with required certification: Failed to designate a qualified manager in writing. |
| A. A manager shall ensure caregiver skills and knowledge are verified and documented before providing services: Failed to verify and document skills for personnel. |
| A. A manager shall ensure personnel provide evidence of freedom from infectious tuberculosis as required: Failed to provide TB evidence for personnel. |
| A. A manager shall ensure resident service plans include description of medical or health problems: Service plans lacked required medical problem descriptions. |
| A. A manager shall ensure resident service plans include level of service expected: Service plans lacked specification of expected service level. |
| A. A manager shall ensure resident service plans include amount, type, and frequency of services: Service plans lacked clear service details. |
| A. A manager shall ensure resident service plans are signed and dated by the manager when updated: Service plans were not signed and dated by manager. |
| C. A manager shall ensure caregivers provide services according to resident's service plan: Failed to provide ADL services as per service plan. |
| B. A manager shall ensure residents are treated with dignity, respect, and consideration: Failed to ensure dignity and respect due to staffing shortages and unmet needs. |
| F. A manager shall ensure personal care service plans include skin maintenance and hydration: Service plans lacked skin maintenance and hydration services. |
| C. A manager shall ensure directed care service plans include required elements: Directed care service plans lacked required skin maintenance and hydration services. |
| C. A manager shall ensure directed care service plans include signed and dated determination from medical provider: Missing current determination for resident's needs. |
| C. A manager shall ensure directed care service plans include cognitive stimulation activities: Missing cognitive stimulation activities in service plan. |
| C. A manager shall ensure directed care service plans include documentation of resident's weight or contraindication: Missing weight documentation or contraindication. |
| C. A manager shall ensure directed care service plans include coordination of communications with resident's representatives: Missing coordination of communications. |
| F. A manager shall ensure means of exiting facility controls or alerts employees of resident egress: Exit alerts were not operational or turned off. |
| B. A manager shall ensure medication administered is documented in resident's medical record: Medication administration was not documented for residents. |
| D. A manager shall ensure caregiver immediately notifies emergency contact and primary care provider after resident accident or emergency: Failed to notify and document notifications. |
| D. A manager shall ensure caregiver documents details of resident accident or emergency: Documentation of accidents and emergencies was incomplete or missing. |
| R9-10-113. Tuberculosis Screening: Failed to provide annual TB training and education to personnel. |
| C. A manager shall ensure personnel records include documentation of caregiver certification: Failed to document valid caregiver certification. |
| 36-420.01. Fall prevention and fall recovery training programs: Failed to develop and administer fall prevention and recovery training. |
| E. A manager shall ensure mechanical means to alert employees to resident needs or emergencies is available: Call pendant system was not working or alerting staff. |
| F. A manager shall ensure medication is stored in a separate locked area: Medication storage was unsecured and accessible. |
| A. A manager shall ensure documentation of disaster plan review includes date, time, participants, critique, and recommendations: Documentation was incomplete. |
| A. A manager shall ensure disaster drills are conducted on each shift quarterly and documented: Disaster drills were not conducted or documented on all shifts. |
| A. A manager shall ensure poisonous or toxic materials are stored in locked area inaccessible to residents: Toxic materials were stored unlocked and accessible. |
| A. A manager shall ensure caregivers have qualifications, experience, skills, and knowledge to meet resident needs: Caregivers lacked documented qualifications and skills. |
| C. A manager shall ensure personnel records include documentation of skills and knowledge applicable to job duties: Missing documentation for caregivers. |
| C. A manager shall ensure personnel records include documentation of education and experience applicable to job duties: Missing documentation for personnel. |
| C. A manager shall ensure caregivers document services provided in resident medical records: Services provided were not documented. |
| B. A manager shall ensure residents receive orientation to exits and evacuation routes within 24 hours of acceptance: Orientation documentation was missing for some residents. |
| C. A manager shall ensure policies and procedures for medication administration include process for documenting authorized individuals: Policy lacked documentation process. |
| C. A manager shall ensure policies and procedures are reviewed and updated at least every three years: Policies were outdated and not reviewed timely. |
| E. A manager shall ensure documentation required by Article 8 is provided to Department within two hours of request: Documentation was not provided timely. |
Report Facts
Inspections on page: 9
Total deficiencies: 49
Complaint inspections: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| E1 | Manager or Facility Staff | Named in multiple findings related to documentation, interviews, and acknowledgments of deficiencies |
| E2 | Manager or Facility Staff | Named in multiple findings related to documentation, interviews, and acknowledgments of deficiencies |
| E3 | Caregiver | Named in findings related to caregiver qualifications and skills |
| E4 | Caregiver | Named in findings related to invalid caregiver certification and personnel records |
| E5 | Caregiver | Named in findings related to personnel records and documentation |
| E6 | Caregiver | Named in findings related to TB screening and training |
| E7 | Staff | Named in interview regarding fall incident |
| E8 | Staff | Named in interview regarding call pendant system |
| E9 | Staff | Named in interview regarding call pendant system |
| O1 | Corporate Staff | Provided clarifications on resident care levels |
| O3 | Governing Authority or Compliance Officer | Acknowledged multiple deficiencies and staffing issues |
| O4 | Former Administrator | Named in manager designation deficiency and employment termination |
| Ryan M Love | Administrator | Named as current facility administrator |
Inspection Report
Enforcement
Deficiencies: 0
Apr 1, 2025
Visit Reason
State-compiled enforcement action report for ARBOR ROSE SENIOR LIVING detailing enforcement action #00125478 with associated penalty and payment schedule.
Findings
The report documents an enforcement action completed with a penalty amount of $8,800.00 and payment status marked as paid. No specific deficiencies or inspection findings are detailed on this page.
Report Facts
Total fines: 8800
Inspection Report
Enforcement
Deficiencies: 0
Feb 18, 2025
Visit Reason
State-compiled enforcement action report for ARBOR ROSE SENIOR LIVING detailing enforcement action #00121439 with associated penalty and payment schedule.
Findings
The report documents an enforcement action completed with a penalty amount of $7,850.00 and payment status marked as paid. No specific deficiency findings are detailed on this page.
Report Facts
Total fines: 7850
Inspection Report
Enforcement
Deficiencies: 1
Jan 31, 2025
Visit Reason
The inspection was conducted to address enforcement concerns related to licensing compliance at Arbor Rose Senior Living, specifically regarding the designation of a qualified assisted living facility manager.
Findings
The facility was found to have violated the requirement to designate a manager with the appropriate certificate, posing a health and safety risk. A civil fine of $8,800 was assessed as a penalty for this violation.
Deficiencies (1)
| Description |
|---|
| The governing authority failed to designate, in writing, a manager with the required assisted living facility manager certificate. |
Report Facts
Civil fine amount: 8800
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Ryan Love | Licensee/Director/Provider | Signed enforcement agreement and notification of rights |
| Dawn Butler | Bureau Chief | Signed enforcement agreement |
| Thomas Salow | Assistant Director | Signed enforcement agreement |
| Aaron Telles | Deputy Bureau Chief | Signed enforcement agreement |
| Kari Humphrey | Compliance Officer Supervisor (COS) | Signed enforcement agreement |
Inspection Report
Complaint Investigation
Deficiencies: 9
Jan 2, 2025
Visit Reason
The Department conducted an on-site complaint investigation at Arbor Rose Senior Living on January 2, 2025, to assess compliance with assisted living facility regulations.
Findings
The Compliance Officer found multiple violations related to training, management designation, caregiver skills verification, infectious tuberculosis evidence, and deficiencies in residents' written service plans across several sampled personnel and residents.
Complaint Details
The visit was complaint-related, conducted after an on-site complaint investigation initiated on January 2, 2025, and completed on January 3, 2025. The licensee was found not in substantial compliance and agreed to correct violations immediately.
Deficiencies (9)
| Description |
|---|
| Chief administrative officer failed to ensure training and education on tuberculosis signs and symptoms for two of three personnel sampled. |
| Governing authority failed to designate a qualified manager as required. |
| Manager failed to verify and document caregiver skills before providing physical health services for two of five personnel sampled. |
| Manager failed to ensure personnel expected to have direct resident interaction provided evidence of freedom from infectious tuberculosis for five personnel sampled. |
| Manager failed to ensure residents had written service plans including descriptions of medical or health problems for seven residents reviewed. |
| Manager failed to ensure residents had written service plans including level of service expected for seven residents reviewed. |
| Manager failed to ensure residents had written service plans including amount, type, and frequency of assisted living services for seven residents reviewed. |
| Manager failed to ensure residents' written service plans were updated, signed, and dated by the manager for seven residents reviewed. |
| Manager failed to ensure caregivers provided residents with activities of daily living according to the residents' service plans for seven residents sampled. |
Report Facts
Personnel sampled: 3
Personnel sampled: 5
Residents reviewed: 7
Inspection Report
Enforcement
Deficiencies: 1
Aug 30, 2024
Visit Reason
The document concerns enforcement action related to violations found at Arbor Rose Senior Living, specifically regarding failure to maintain proper personnel records and caregiver certification documentation.
Findings
The facility was found to have failed to ensure personnel records included documentation of caregiver certification for one of four caregivers reviewed, resulting in a penalty assessment for health and safety violations and providing false or misleading information to the Department.
Deficiencies (1)
| Description |
|---|
| The manager failed to ensure a personnel record for each employee included documentation of the individual's caregiver certification for one of four individuals hired as a caregiver reviewed. |
Report Facts
Civil fine amount: 500
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Rebecca Williams | Executive Director | Licensee/Director/Provider signing enforcement agreement |
| Dawn Butler | Bureau Chief | Signed enforcement agreement |
| Thomas Salow | Assistant Director | Signed enforcement agreement |
| Laura Redpath | Compliance Officer Supervisor | Signed enforcement agreement |
Inspection Report
Enforcement
Deficiencies: 0
Jul 25, 2023
Visit Reason
State-compiled enforcement action report for ARBOR ROSE SENIOR LIVING detailing enforcement action #00112908 with payment and completion status.
Findings
The document reports an enforcement action completed with a fine of $500.00 paid in full by the facility. No specific deficiencies or inspection findings are detailed on the page.
Report Facts
Total fines: 500
Inspection Report
Enforcement
Deficiencies: 3
Jul 12, 2023
Visit Reason
The inspection was conducted to investigate documentation deficiencies related to personnel records and resident medical records at Arbor Rose Senior Living.
Findings
The facility failed to document verification of skills and knowledge for two caregivers, failed to document experience for one caregiver, and failed to document services provided in four residents' medical records, resulting in civil fines.
Deficiencies (3)
| Description |
|---|
| Personnel records lacked documentation of skills and knowledge for two caregivers. |
| Personnel record lacked documentation of experience for one caregiver. |
| Caregiver failed to document services provided in four residents' medical records. |
Report Facts
Civil fines total: 500
Employees affected: 3
Residents affected: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Dylan Wells | Interim E.D. | Licensee/Director signing enforcement agreement |
| Tiffany Slater | Bureau Chief (BC) | Attendee on enforcement agreement |
| Thomas Salow | Assistant Director (AD) | Attendee on enforcement agreement |
| Ian Baxter | Compliance Officer Supervisor (COS) | Attendee on enforcement agreement |
| Cindy Graham | Deputy BC | Attendee on enforcement agreement |
| James Tiffany | Compliance Officer Supervisor (COS) | Attendee on enforcement agreement |
| Aaron Telles | Compliance Officer Supervisor (COS) | Attendee on enforcement agreement |
| Jewela West | Compliance Officer Supervisor (COS) | Attendee on enforcement agreement |
Inspection Report
Enforcement
Deficiencies: 0
Jun 20, 2023
Visit Reason
State-compiled enforcement action report for ARBOR ROSE SENIOR LIVING detailing enforcement action #00113165 with payment and penalty information.
Findings
The report documents an enforcement action completed on 2023-06-20 with a penalty amount of $750.00 fully paid by 2023-08-06.
Report Facts
Total fines: 750
Inspection Report
Enforcement
Deficiencies: 2
Jun 5, 2023
Visit Reason
The inspection was conducted due to concerns that a resident was given another resident's medication and that documentation of skills and knowledge verification was missing in two personnel records.
Findings
The facility failed to implement proper medication administration policies and procedures, posing a risk to residents. Additionally, personnel records for two of three caregivers lacked documentation of skills and knowledge applicable to their job duties, resulting in civil fines totaling $750.
Deficiencies (2)
| Description |
|---|
| Failure to implement policies and procedures to cover medication administration, posing a risk if a resident received medication not prescribed. |
| Failure to ensure personnel records included documentation of skills and knowledge for two of three caregivers sampled. |
Report Facts
Civil fines total: 750
Civil fine: 500
Civil fine: 250
Personnel members: 2
Residents affected: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Dylan Wells | Licensee/Director/Provider | Signed enforcement agreement and acknowledged rights. |
| Tiffany Slater | Bureau Chief (BC) | Attendee on enforcement agreement. |
| Thomas Salow | Assistant Director (AD) | Attendee on enforcement agreement. |
| Ian Baxter | Compliance Officer Supervisor (COS) | Attendee on enforcement agreement. |
| Cindy Graham | Deputy BC | Attendee on enforcement agreement. |
| James Tiffany | Compliance Officer Supervisor (COS) | Attendee on enforcement agreement. |
| Aaron Telles | Compliance Officer Supervisor (COS) | Attendee on enforcement agreement. |
| Jewela West | Compliance Officer Supervisor (COS) | Attendee on enforcement agreement. |
Inspection Report
Enforcement
Deficiencies: 0
Nodate Enforcement
Visit Reason
State-compiled enforcement action summary page for ARBOR ROSE SENIOR LIVING with no detailed inspection or deficiency data provided.
Findings
No specific inspection findings or deficiencies are detailed on this page.
Inspection Report
Enforcement
Deficiencies: 0
Nodate Enforcement 2
Visit Reason
State-compiled enforcement action summary page for ARBOR ROSE SENIOR LIVING.
Findings
No specific inspection findings or deficiencies are detailed on this page.
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