Inspection Report
Monitoring
Census: 84
Deficiencies: 1
Sep 11, 2025
Visit Reason
The inspection was a monitoring visit conducted on September 11, 2025, following a self-reported incident received on August 12, 2025, regarding allegations in Resident Care and Related Services.
Findings
The investigation supported the self-report of non-compliance related to supervision of resident schedules, care, and activities, including prevention of falls and wandering. Violations were issued based on the facility's failure to provide adequate supervision, as evidenced by a resident exiting the secure unit through a broken window mechanism.
Deficiencies (1)
| Description |
|---|
| Facility did not provide supervision of resident schedules, care, and activities, including attention to specialized needs such as prevention of falls and wandering from the premises. |
Report Facts
Number of residents present: 84
Number of resident records reviewed: 1
Number of staff interviews conducted: 5
Time resident was outside the facility: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Marshall Massenberg | Licensing Inspector | Named as the current inspector conducting the inspection |
Inspection Report
Renewal
Census: 84
Deficiencies: 6
Jan 17, 2025
Visit Reason
The inspection was conducted as a renewal of the facility's license to ensure compliance with applicable standards and laws.
Findings
The inspection found multiple violations related to annual reviews for special care unit appropriateness, tuberculosis risk assessments, missing individualized service plans, improper medication storage, medication administration not following physician's instructions, and unavailable PRN medications. Plans of correction were submitted to address these deficiencies.
Deficiencies (6)
| Description |
|---|
| Facility did not ensure an annual review of continued appropriateness for residence in the special care unit was completed. |
| Facility did not ensure that each resident received an annual tuberculosis risk assessment. |
| Facility did not ensure that the master service plan is filed in the resident's record. |
| Facility did not ensure that medication storage in resident rooms is limited to out-of-sight places for residents capable of self-administering medication. |
| Facility did not ensure that medications are administered in accordance with the physician's instructions. |
| Facility did not ensure that PRN medication is available and properly stored at the facility. |
Report Facts
Number of residents present: 84
Number of resident records reviewed: 6
Number of resident interviews: 2
Number of staff interviews: 3
Inspection Report
Monitoring
Deficiencies: 2
Oct 17, 2024
Visit Reason
The inspection was a monitoring visit to review compliance with administrative services, personnel, staffing, resident care, and building and grounds regulations.
Findings
The inspection found non-compliance with applicable standards related to medication administration and storage. Violations were documented regarding incorrect administration timing of Levothyroxine and the absence of PRN medications on the medication cart.
Deficiencies (2)
| Description |
|---|
| Facility did not ensure medications are administered in accordance with physician's instructions, specifically Levothyroxine administration timing. |
| Facility did not ensure PRN medications were available and properly stored; PRN Loperamide and Ondansetron were missing from the medication cart. |
Report Facts
Number of resident records reviewed: 2
Number of resident interviews: 1
Number of staff interviews: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Marshall Massenberg | Licensing Inspector | Inspector conducting the monitoring visit and named in contact information |
Inspection Report
Original Licensing
Deficiencies: 0
Jul 26, 2024
Visit Reason
Initial licensing inspection conducted as part of a change of ownership and to assess the facility for licensing approval.
Findings
The inspection included a tour of the physical plant and review of staff records. No violations of applicable standards or laws were found during the inspection.
Report Facts
Number of residents present: 0
Number of resident records reviewed: 0
Number of staff records reviewed: 1
Number of interviews conducted with residents: 0
Number of interviews conducted with staff: 1
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