Inspection Report
Modification
Capacity: 54
Deficiencies: 12
Nov 5, 2025
Visit Reason
State-compiled facility profile showing 4 inspections from 2023-02 to 2025-11 with deficiency history including complaint and annual compliance inspections.
Findings
Across four inspections, deficiencies were found related to personnel documentation, resident safety, emergency preparedness, and equipment maintenance. Two complaint investigations were conducted with one substantiated and resulting in multiple deficiencies, while the most recent modification inspection found no deficiencies.
Complaint Details
Two complaint investigations were conducted: one on February 2, 2023 with six allegations unsubstantiated and no deficiencies cited, and another on March 28, 2025 with multiple deficiencies found during the complaint and annual compliance inspection.
Deficiencies (12)
| Description |
|---|
| R9-10-803.A.9. Administration: Governing authority failed to make a documented good faith effort to contact previous employers for three of five employees reviewed. |
| R9-10-806.A.4.a-b. Personnel: Manager failed to ensure a caregiver's skills and knowledge were verified and documented before providing physical health services for one caregiver. |
| R9-10-807.A.1-2. Residency and Residency Agreements: Manager failed to ensure a resident provided evidence of freedom from infectious tuberculosis as specified. |
| R9-10-818.B.1-2. Emergency and Safety Standards: Manager failed to ensure resident orientation to exits was documented for four of five sampled residents. |
| A. A manager shall ensure that: 10. Before providing assisted living services to a resident, a manager or caregiver provides current documentation of first aid training and cardiopulmonary resuscitation training certification specific to adults. |
| A. Except as required in subsection (B), a manager shall ensure that a resident has a written service plan that is signed and dated by required parties. |
| B. A manager of an assisted living facility authorized to provide directed care services shall not accept or retain a resident who is confined to a bed or chair without required medical determinations. |
| C. A manager shall ensure that food is obtained, prepared, served, and stored properly including refrigerator containing a thermometer. |
| A. A manager shall ensure that the disaster plan required is reviewed at least once every 12 months. |
| A. A manager shall ensure that an evacuation drill for employees and residents is conducted at least once every six months. |
| A. A manager shall ensure that oxygen containers are secured in an upright position. |
| A. A manager shall ensure that equipment used at the assisted living facility is maintained in working order. |
Report Facts
Inspections on page: 4
Total deficiencies: 12
Complaint Inspections: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Brandon Gaffey | ED/ALM | Named in multiple deficiency findings as person responsible |
| Megan Murphy | Business Office | Named in deficiency #1 as person responsible |
| Edward Evangelista | Health & Wellness Director | Named in deficiencies #2 and #3 as person responsible |
| Richard Roallos | Maintenance Manager | Named in deficiency #4 as person responsible |
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