Deficiencies per Year
8
6
4
2
0
Severe
High
Moderate
Low
Unclassified
Census Over Time
Inspection Report
Complaint Investigation
Census: 62
Deficiencies: 0
Oct 13, 2025
Visit Reason
The inspection was conducted to investigate Complaint #130292-C at Cedarstone Senior Living.
Findings
No regulatory insufficiencies were cited during the investigation of the complaint.
Complaint Details
Investigation of Complaint #130292-C found no regulatory insufficiencies.
Report Facts
Tenants without cognitive impairment: 60
Tenants with cognitive impairment: 2
Total census: 62
Inspection Report
Complaint Investigation
Census: 62
Deficiencies: 4
Aug 5, 2025
Visit Reason
The inspection was conducted related to the investigation of incidents involving tenant care and safety concerns, including failure to provide adequate and appropriate services to tenants and a fall with injury.
Findings
The Program failed to provide adequate and appropriate care for two tenants, including failure to ensure safety pendant use and proper care after a fall. Documentation deficiencies were noted including incomplete nurse's notes by exception, failure to complete incident reports, and service plans not updated to reflect tenant needs.
Complaint Details
The investigation was triggered by incidents involving Tenant #1 being left without her emergency pendant overnight and Tenant #2 suffering a fall with injury while unattended for an extended period. Tenant #2's fall was unwitnessed and resulted in a dislocated hip requiring surgery. Staff failed to provide care due to inaccurate leave of absence status in the computer system.
Deficiencies (4)
| Description |
|---|
| Failure to provide adequate and appropriate services and cares for tenants, including failure to ensure safety pendant was replaced and failure to provide care after a fall. |
| Failure to document nurse's notes by exception, including follow-up on antibiotic treatments and wound care. |
| Failure to complete incident reports related to a fall with injury. |
| Failure to update service plans as needed to reflect tenant care needs, including after hospital return and wound care. |
Report Facts
Total census: 62
Number of tenants without cognitive impairment: 59
Number of tenants with cognitive impairment: 3
Fall unattended duration (hours): 14.25
Bruise size (cm): 4
Bruise size (cm): 2.6
Pain rating: 7
Pain rating: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Assisted Tenant #1 but failed to replace emergency pendant; suspended pending investigation | |
| Staff B | Assisted Tenant #1 and Tenant #2; reported incidents and provided care | |
| Staff E | Care partner responsible during Tenant #2's fall; suspended pending investigation | |
| Wellness Director | Oversaw Tenant #2's return and care; involved in incident response and investigation | |
| Executive Director | Involved in investigation and communication with family and corporate staff | |
| Staff G | Responded to pendant call for Tenant #2 fall | |
| Staff I | Administered medications to Tenant #2 | |
| Staff J | Assisted Tenant #2 and documented care | |
| Staff H | Administered eye drops to Tenant #2 | |
| Staff D | Completed skin assessments and assisted Tenant #1 | |
| Staff C | Interviewed regarding Tenant #1's pendant incident | |
| Staff F | Medication passer; involved in incident response for Tenant #2 | |
| Staff K | Assisted on floors; aware of Tenant #2's return | |
| Plant Operations Director | Found Tenant #2 on floor after fall and pressed pendant |
Inspection Report
Complaint Investigation
Census: 53
Deficiencies: 4
Feb 20, 2025
Visit Reason
The inspection was conducted due to the investigation of Complaint #122780-C, Incident #122793-I, Incident #126079-I, and the recertification visit to determine compliance with certification of an Assisted Living Program.
Findings
The program failed to complete required child and dependent adult abuse background checks prior to employment for 7 employees, failed to obtain a Department of Human Services evaluation for a staff member with a criminal history, failed to assess and document the health status of a tenant with a significant change in condition, and failed to monitor tenants as indicated in service plans, resulting in incidents including delayed treatment and a fall.
Complaint Details
The visit was complaint-related, investigating Complaint #122780-C and related incidents #122793-I and #126079-I. The complaint involved failures in background checks, staff evaluations, tenant health assessments, and monitoring.
Deficiencies (4)
| Description |
|---|
| Failed to ensure child and dependent adult abuse record checks were completed prior to employment for 7 of 7 employee files reviewed. |
| Failed to obtain an evaluation from the Department of Health and Human Services prior to employment for 1 staff with a criminal history. |
| Failed to assess and document the health status of 1 of 5 tenants reviewed after a significant change in condition, resulting in delayed treatment and hospitalization for brain bleeds. |
| Failed to check on tenants as indicated in service plans for 1 of 1 former tenants reviewed, resulting in a fall and lack of required status checks and toileting assistance. |
Report Facts
Number of tenants without cognitive impairment: 53
Number of tenants with cognitive impairment: 0
Total census: 53
Number of employees with missing abuse checks: 7
Fall risk score: 90
Blood sugar reading: 400
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff F | Failed to have child and dependent adult abuse record checks completed prior to employment | |
| Staff G | Failed to have child and dependent adult abuse record checks completed prior to employment; had criminal history without DHHS evaluation | |
| Staff H | Failed to have child and dependent adult abuse record checks completed prior to employment | |
| Staff I | Failed to have child and dependent adult abuse record checks completed prior to employment | |
| Staff J | Failed to have child and dependent adult abuse record checks completed prior to employment | |
| Staff K | Failed to have child and dependent adult abuse record checks completed prior to employment | |
| Staff L | Failed to have child and dependent adult abuse record checks completed prior to employment | |
| Staff A | Medication Partner | Alerted nurse about Tenant 2's high blood sugar and condition but nurse failed to assess tenant |
| Staff B | Care Partner | Observed Tenant 2's abnormal gait and alerted Medication Partner about high blood sugar |
| Staff D | Responded to Tenant C1 on floor after family notification; confirmed failure to complete required status and toileting checks | |
| Executive Director | Confirmed findings regarding background checks and tenant care failures | |
| Director of Wellness | Confirmed findings and provided interviews regarding tenant care and staff failures | |
| LPN | Licensed Practical Nurse | Failed to assess Tenant 2 despite multiple notifications of high blood sugar and abnormal gait |
Inspection Report
Complaint Investigation
Census: 52
Deficiencies: 0
Nov 27, 2023
Visit Reason
Investigation of Complaint #114443-C at Cedarstone Senior Living.
Findings
No regulatory insufficiencies were cited during the complaint investigation.
Complaint Details
Complaint #114443-C was investigated and found to have no regulatory insufficiencies.
Report Facts
Number of tenants without cognitive impairment: 49
Number of tenants with cognitive impairment: 3
Total census: 52
Inspection Report
Original Licensing
Census: 29
Deficiencies: 7
Apr 12, 2023
Visit Reason
Initial certification visit conducted to determine compliance with certification rules for an Assisted Living Program.
Findings
The program failed to complete required criminal, child, and dependent adult abuse background checks prior to employment for several staff, failed to request evaluations for staff with criminal histories, and failed to complete background checks within 30 days of employment for multiple staff. Additionally, the program failed to evaluate tenants' cognitive, functional, and health status prior to occupancy, within 30 days of occupancy, and annually or with significant change, and failed to develop service plans based on required assessments for all tenants reviewed.
Deficiencies (7)
| Description |
|---|
| Failed to complete criminal, child, and dependent adult abuse background checks prior to employment for 2 of 7 staff reviewed. |
| Failed to request an evaluation from Department of Health and Human Services prior to employment for 1 staff with a criminal history. |
| Failed to complete criminal, child, and dependent adult abuse background checks within 30 calendar days of employment for 4 of 7 staff reviewed. |
| Failed to evaluate tenant's cognitive status prior to occupancy for 2 of 3 tenants reviewed. |
| Failed to evaluate tenant's functional, cognitive, and health status within 30 days of occupancy for 2 of 3 tenants reviewed. |
| Failed to evaluate tenant's functional, cognitive, and health status as warranted for 1 tenant with significant change in health status. |
| Failed to develop service plans based on required assessments for 3 tenants reviewed. |
Report Facts
Number of tenants without cognitive impairment: 25
Number of tenants with cognitive impairment: 4
Total census: 29
Staff reviewed: 7
Tenants reviewed: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Named in findings related to failure to request evaluation for criminal history and background check timing. | |
| Staff B | Named in findings related to failure to complete background checks prior to employment and within 30 days. | |
| Staff E | Named in findings related to failure to complete background checks prior to employment. | |
| Staff C | Named in findings related to failure to complete background checks within 30 days. | |
| Staff D | Named in findings related to failure to complete background checks within 30 days. | |
| Kersten Kleinlein | Executive Director | Signed plan of correction. |
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