Inspection Report
Complaint Investigation
Deficiencies: 0
Oct 28, 2025
Visit Reason
A complaint investigation survey was conducted at the facility on 10/28/2025 based on ACTS reference numbers 102295 and 102308.
Findings
No deficiencies were identified during the complaint investigation survey.
Complaint Details
Complaint investigation survey conducted with ACTS reference numbers 102295 and 102308; no deficiencies identified.
Inspection Report
Complaint Investigation
Deficiencies: 1
Oct 3, 2025
Visit Reason
An unannounced complaint/incident investigation survey was conducted at the facility from 10/2/2025 through 10/3/2025 to determine compliance with state regulations related to glucose monitoring and management of services.
Findings
The facility failed to provide all care and services in accordance with the prevailing community standard of care for blood glucose monitoring for a resident. Specifically, there were no parameters for calling the physician or notification to the nurse regarding blood sugar checks, and the physician was not notified of glucose monitoring results outside specified ranges.
Complaint Details
The complaint investigation was unannounced and involved multiple ACTS reference numbers. The investigation found that the facility did not have specified parameters for notification to the physician or nurse regarding blood sugar checks, and the physician was not notified as required. Interviews with staff confirmed lack of notification parameters and physician notification.
Deficiencies (1)
| Description |
|---|
| Failure to provide all care and services in accordance with the prevailing community standard of care relative to monitoring of glucose for the singular resident reviewed. |
Report Facts
Blood sugar check results: 71
Blood sugar check results: 69
Blood sugar check results: 68
Insulin dosage: 10
Insulin dosage: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Susan Lehman | Administrator | Signed the plan of correction and involved in corrective actions |
Inspection Report
Complaint Investigation
Deficiencies: 0
Feb 6, 2025
Visit Reason
An unannounced complaint/incident investigation survey was conducted to determine compliance with state regulations.
Findings
No deficiencies were identified during the complaint/incident investigation survey.
Complaint Details
The investigation was related to complaint reference numbers 99348, 99067, and 99415 and found no deficiencies.
Inspection Report
Complaint Investigation
Deficiencies: 0
Aug 28, 2024
Visit Reason
An unannounced complaint/incident investigation survey was conducted at this residence.
Findings
No deficiencies were identified during the investigation.
Complaint Details
The investigation was unannounced and complaint/incident related; no deficiencies were found.
Inspection Report
Complaint Investigation
Deficiencies: 0
Jul 11, 2024
Visit Reason
An unannounced complaint/incident investigation survey was conducted at this residence.
Findings
No deficiencies were identified during the investigation.
Complaint Details
The investigation was complaint-related and no deficiencies were found, indicating no substantiated issues.
Inspection Report
Complaint Investigation
Deficiencies: 0
May 16, 2024
Visit Reason
An unannounced complaint/incident investigation survey was conducted at this residence.
Findings
No deficiencies were identified during the investigation.
Complaint Details
The investigation was unannounced and complaint/incident related; no deficiencies were found.
Inspection Report
Complaint Investigation
Deficiencies: 6
Jan 23, 2024
Visit Reason
An unannounced biennial State Licensure survey and a complaint/incident investigation survey were conducted at the assisted living residence from 01/22/2024 through 01/23/2024.
Findings
The facility was found deficient in multiple areas including failure to establish a quality assurance committee with required members and documentation, failure to post current administrator contact information, failure to review resident assessments and service plans timely, failure to securely store medications, and failure to post state survey results. Additionally, expired medications were found and the medication program required corrective actions.
Complaint Details
The complaint investigation was triggered by an incident where a resident was found on the floor with a large laceration and bleeding, later admitted to hospital with intracranial hemorrhage. The investigation revealed failures in resident assessment, service plan updates, and medication management.
Deficiencies (6)
| Description |
|---|
| Failed to establish a quality assurance committee including required members and maintain documentation. |
| Failed to post the name and contact information for the current administrator in a conspicuous public area. |
| Failed to review resident assessments and service plans at required intervals and update for condition changes. |
| Failed to securely store medications to prevent spoilage, dosage errors, administration errors, and inappropriate access. |
| Failed to post the most recent state licensing survey results in a conspicuous place on the premises. |
| Expired medications were found in the medication carts and corrective actions were ordered. |
Report Facts
Dates of quality assurance meeting minutes reviewed: 4
Resident falls discussed: 3
Medication carts observed: 3
Expired medication dates: 2
Inspection Report
Complaint Investigation
Deficiencies: 0
Dec 15, 2023
Visit Reason
An unannounced complaint/incident investigation survey was conducted at the facility based on multiple ACTS reference numbers.
Findings
No deficiencies were identified during the investigation conducted on 12/15/2023.
Complaint Details
The investigation was based on complaint/incident ACTS reference numbers 93016, 92883, 92247, 92246, and 92984. No deficiencies were found.
Inspection Report
Complaint Investigation
Deficiencies: 0
Sep 22, 2023
Visit Reason
An unannounced complaint/incident investigation survey was conducted at this residence.
Findings
No deficiencies were identified during the investigation.
Complaint Details
Unannounced complaint/incident investigation survey with no deficiencies identified.
Inspection Report
Complaint Investigation
Deficiencies: 0
May 3, 2023
Visit Reason
An unannounced complaint/incident investigation survey was conducted at this residence.
Findings
No deficiencies were identified during the investigation.
Complaint Details
The investigation was unannounced and complaint/incident based; no deficiencies were found.
Inspection Report
Complaint Investigation
Deficiencies: 0
Aug 29, 2022
Visit Reason
An unannounced complaint/incident investigation survey was conducted at this residence.
Findings
No deficiencies were identified during the investigation.
Complaint Details
The investigation was unannounced and complaint/incident based; no deficiencies were found.
Inspection Report
Plan of Correction
Deficiencies: 7
Feb 2, 2022
Visit Reason
An unannounced biennial State Licensure survey was conducted at this assisted living residence to assess compliance with licensure requirements and identify deficiencies.
Findings
The survey identified multiple deficiencies including failure to establish a Safe Resident Handling program, inadequate management of services, incomplete resident records, failure to follow physician orders especially regarding oxygen therapy and medications, incomplete resident assessments and service plans, and deficiencies in medication services documentation and supervision.
Deficiencies (7)
| Description |
|---|
| Failure to establish a Safe Resident Handling program including committee formation, hazard assessments, training, and performance evaluations. |
| Failure to provide care and services in accordance with prevailing community standards for multiple residents. |
| Failure to maintain complete resident records including medication administration records and physician orders. |
| Failure to review resident assessments at required intervals and to document changes in condition. |
| Failure to complete and review resident service plans timely and accurately. |
| Failure to conduct required nurse reviews and document physical assessments for residents. |
| Failure to conduct quarterly evaluations of medication aides and maintain proper documentation. |
Report Facts
Date Survey Completed: Feb 2, 2022
Plan of Correction Completion Dates: Mar 31, 2022
Plan of Correction Completion Dates: May 31, 2022
Personnel Hire Dates: Mar 19, 2019
Personnel Hire Dates: Nov 17, 2020
Quarterly Assessments Dates: Jan 16, 2021
Quarterly Assessments Dates: Apr 1, 2021
Quarterly Assessments Dates: Jun 4, 2021
Quarterly Assessments Dates: Oct 5, 2021
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| L. Almeida | Executive Director | Signed the plan of correction and involved in interviews and compliance responsibilities |
| Resident Services Director | Chairs Safe Resident Handling Committee, conducts resident handling hazard assessments, audits physician orders, and oversees compliance with service plans and medication services | |
| Staff A | Certified Medication Technician | Personnel record reviewed for hire date and quarterly assessments |
| Staff B | Certified Medication Technician | Personnel record reviewed for hire date and quarterly assessments |
Inspection Report
Complaint Investigation
Deficiencies: 0
Jan 25, 2022
Visit Reason
An unannounced complaint/incident investigation survey was conducted at this residence.
Findings
No deficiencies were identified during the investigation.
Complaint Details
The investigation was unannounced and complaint/incident related; no deficiencies were found.
Inspection Report
Complaint Investigation
Deficiencies: 0
Feb 5, 2021
Visit Reason
An unannounced complaint survey and focused survey related to COVID-19 infection control were conducted at the residence.
Findings
No deficiencies were identified during the complaint and focused COVID-19 infection control survey.
Complaint Details
The survey was complaint-related and focused on COVID-19 infection control; no deficiencies were found, indicating no substantiated issues.
Inspection Report
Deficiencies: 0
Jan 12, 2021
Visit Reason
An administrative review/offsite investigation was conducted at this residence.
Findings
No deficiencies were identified during the administrative review/offsite investigation.
Loading inspection reports...
