Inspection Report
Complaint Investigation
Deficiencies: 0
Nov 13, 2025
Visit Reason
An unannounced complaint/incident investigation survey was conducted to determine compliance with state regulations.
Findings
No deficiency was identified during the investigation.
Complaint Details
The visit was triggered by an unannounced complaint/incident investigation with ACTS reference numbers 102440.
Inspection Report
Complaint Investigation
Deficiencies: 2
Oct 24, 2025
Visit Reason
An unannounced biennial State Licensure survey and a complaint/incident investigation survey were conducted at the facility on 10/24/2025.
Findings
Deficiencies were identified related to the State Licensure survey, including failure to review and approve the Quality Assurance plan at required intervals and failure to provide care and services in accordance with community standards and physician orders for medication administration.
Complaint Details
The complaint investigation found that the residence failed to review and approve the QA plan at required intervals since January 2022. Additionally, the community's electronic Medication Administration Record (MAR) was not updated timely, and Resident ID#1 was not administered prescribed monthly Vitamin D2 due to a discontinued medication order not being properly reflected in the MAR. Compliance was achieved on 10/28/2025.
Deficiencies (2)
| Description |
|---|
| Failure to review and approve the Quality Assurance (QA) plan at intervals not to exceed twelve months as required. |
| Failure to provide care and services in accordance with prevailing community standards of practice and a written physician's order for medication administration for one resident. |
Report Facts
Dates medication not signed off on MAR: 4
Vitamin D2 dosage: 1.25
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| James John | Executive Director | Signed the plan of correction document dated 11/10/2025. |
Inspection Report
Complaint Investigation
Deficiencies: 1
Jun 24, 2025
Visit Reason
An unannounced complaint/incident investigation survey was conducted from 06/23/2025 through 06/24/2025 to determine compliance with state regulations based on multiple ACTS reference numbers.
Findings
The investigation identified a deficiency related to medication services, specifically the failure to ensure medications were stored securely to prevent spoilage, dosage errors, administration errors, and inappropriate access. A resident was found to have self-injected insulin that belonged to another resident due to unlocked medication storage.
Complaint Details
The complaint investigation was unannounced and based on multiple ACTS reference numbers. The deficiency was substantiated as the residence failed to ensure secure medication storage, leading to a resident self-injecting insulin intended for another resident.
Deficiencies (1)
| Description |
|---|
| Failure to ensure medications are stored securely and in such a manner to prevent spoilage, dosage errors, administration errors, and/or inappropriate access for the single resident reviewed for a medication administration error. |
Report Facts
Units of insulin: 60
Date of incident report: Jun 17, 2025
Date of surveyor observation: Jun 23, 2025
Compliance date: Jul 14, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Certified Medication Technician (CMT) | Interviewed during survey on 06/23/2025 and revealed resident medication details. |
| Lauren J. Yohn | Executive Director | Signed the plan of correction document dated 07/14/2025. |
| Director of Wellness | Interviewed on 06/24/2025 but could not provide evidence of proper insulin storage. |
Inspection Report
Complaint Investigation
Deficiencies: 0
Nov 20, 2024
Visit Reason
An unannounced complaint/incident investigation survey was conducted to determine compliance with state regulations.
Findings
No deficiencies were identified during the investigation.
Complaint Details
The investigation was based on ACTS reference numbers 98389, 97679, 97200, and 96706. No deficiencies were found.
Inspection Report
Complaint Investigation
Deficiencies: 0
Jul 17, 2024
Visit Reason
An unannounced complaint/incident investigation survey was conducted at this residence.
Findings
No deficiencies were identified during the complaint investigation survey.
Complaint Details
The survey was conducted in response to a complaint or incident investigation; no deficiencies were found.
Inspection Report
Complaint Investigation
Deficiencies: 0
May 7, 2024
Visit Reason
An unannounced complaint/incident investigation survey was conducted at the residence.
Findings
No deficiencies were identified during the investigation.
Complaint Details
The investigation was unannounced and related to a complaint or incident; no deficiencies were found.
Inspection Report
Complaint Investigation
Deficiencies: 0
Mar 1, 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 related to a complaint or incident; no deficiencies were found.
Inspection Report
Complaint Investigation
Deficiencies: 2
Dec 5, 2023
Visit Reason
An unannounced biennial State Licensure survey and a complaint/incident investigation survey were conducted at the facility on 12/05/2023.
Findings
Deficiencies were identified related to failure to complete nurse reviews every 30 days for 4 sample residents, and failure to review service plans at intervals not to exceed 12 months for 2 of 4 sample residents. Resident files lacked evidence of timely nurse reviews and updated service plans reflecting outside services.
Complaint Details
The visit was complaint-related as an unannounced complaint/incident investigation survey was conducted along with the biennial licensure survey.
Deficiencies (2)
| Description |
|---|
| Failure to complete nurse reviews every 30 days as required for 4 sample residents. |
| Failure to review and update service plans at intervals not to exceed 12 months and when resident condition changes for 2 of 4 sample residents. |
Report Facts
Sample residents reviewed: 4
Sample residents reviewed: 4
Nurse review frequency: 30
Service plan review interval: 12
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Lauren Yahn | Administrator | Signed as Laboratory Director or Provider/Supplier Representative. |
| Director of Wellness | Interviewed during survey but no full name provided. |
Inspection Report
Complaint Investigation
Deficiencies: 0
Sep 28, 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; no deficiencies identified.
Inspection Report
Follow-Up
Deficiencies: 0
Apr 26, 2023
Visit Reason
An offsite follow-up review to the complaint investigation survey conducted on 2023-03-21 was performed to verify correction of the prior deficiency.
Findings
The prior deficiency identified during the complaint investigation survey was corrected.
Complaint Details
This visit was a follow-up to a complaint investigation survey conducted on 2023-03-21. The prior deficiency was corrected.
Inspection Report
Plan of Correction
Deficiencies: 1
Mar 21, 2023
Visit Reason
An unannounced complaint/incident investigation survey was conducted at Charlesgate Senior Living Center due to a complaint regarding staff licensing and medication aide qualifications.
Findings
The investigation found that a staff member's medication aide license had expired and was not valid at the time of the complaint investigation. The facility acknowledged the issue and took corrective actions including removing the staff member from the schedule until the issue was resolved and implementing new monitoring systems to ensure compliance with licensing requirements.
Complaint Details
The complaint was substantiated as the staff member's medication aide license had expired on 06/22/2022 and was not valid during the investigation on 03/21/2023. Corrective actions were taken to address this isolated incident.
Deficiencies (1)
| Description |
|---|
| Staff member worked as a medication aide without a valid medication aide license issued by the Department of Health. |
Report Facts
Date survey completed: Mar 21, 2023
License expiration date: Jun 22, 2022
License original issue date: Apr 26, 2022
License validity period: 2
Date plan of correction completed: Apr 19, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| James J Yahn | Administrator | Signed the plan of correction document |
| ID-A | Staff member whose medication aide license was expired and involved in the deficiency |
Inspection Report
Complaint Investigation
Deficiencies: 0
Aug 2, 2022
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: 4
Jul 18, 2022
Visit Reason
An unannounced complaint/incident investigation survey was conducted at Charlesgate Senior Living Center to investigate compliance with policies regarding advanced directives and Do-Not-Resuscitate (DNR) orders.
Findings
The facility failed to have written policies and procedures that adequately address advanced directives and resuscitation instructions. The nursing office's yellow binder and residents' clinical records lacked complete and properly signed advanced directives for residents with DNR orders. The facility was unable to demonstrate sufficient evidence to identify residents with active DNR orders during emergencies.
Complaint Details
The complaint investigation found deficiencies related to advanced directives and DNR order documentation. The findings were substantiated by record reviews and staff interviews, including the Director of Nurses.
Deficiencies (4)
| Description |
|---|
| Failure to have written policies and procedures addressing advanced directives including sufficient instructions for emergencies and resuscitation. |
| Lack of a complete and properly maintained list of residents with active DNR orders in the nursing office binder and clinical charts. |
| Resident charts failed to provide supporting documentation signed by residents for advanced directives. |
| Incorrect filing of Medical Orders for Life Sustaining Treatment (MOLST) forms in the nursing office binder. |
Report Facts
Dates of corrective actions: Corrective actions were completed on 7/18/2022, 7/21/2022, 7/25/2022, and 8/5/2022 as documented in the plan of correction.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Lauren J. Yelin | Administrator | Signed the statement of deficiencies and plan of correction. |
| Director of Nurses | Interviewed during survey and provided information about the facility's system for identifying residents with DNR orders. | |
| Wellness Director | Responsible for re-educating residents on advanced directives and code status as part of the corrective action. |
Inspection Report
Complaint Investigation
Deficiencies: 0
Apr 26, 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
Plan of Correction
Deficiencies: 5
Dec 23, 2021
Visit Reason
The inspection report documents a biennial state licensure survey and a complaint/incident investigation survey conducted at Charlesgate Senior Living Center on 12/23/2021.
Findings
The report identifies deficiencies related to resident assessments, service plans, and medication administration documentation for multiple residents. The facility failed to accurately document residents' smoking status, medication self-administration abilities, and medication storage and labeling. Corrective actions and updates to assessments and service plans were implemented to address these issues.
Complaint Details
The visit included a complaint/incident investigation survey conducted on 12/23/2021 as part of the biennial licensure survey.
Deficiencies (5)
| Description |
|---|
| Failure to report resident's needs and gather information for individualized service plans for three of four residents reviewed. |
| Failure to document a description of services and interventions needed on the service plan for three of four residents reviewed. |
| Failure to accurately reflect residents' medication administration status and cognitive ability to self-administer medications. |
| Failure to ensure medications are stored with proper labeling, securely, and in accordance with manufacturer guidelines, including insulin pens without dates to determine when opened. |
| Medication card instructions did not match physician's orders for some residents. |
Report Facts
Date of survey: Dec 23, 2021
Residents reviewed: 4
Residents with insulin pens undated: 5
Residents impacted by smoking assessment update: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Lauren J. Yohn | Administrator | Signed the plan of correction document and acknowledged assessment and medication administration deficiencies. |
| Wellness Director | Interviewed regarding residents' medication management and acknowledged medication card discrepancies. | |
| Certified Medication Technician (CMT) | Observed during survey and involved in medication administration and education. | |
| Certified Nursing Assistant (CNA) | Observed during survey in medication storage area. | |
| Administrator | Acknowledged service plan and medication administration documentation deficiencies during interview. |
Inspection Report
Complaint Investigation
Deficiencies: 0
Dec 23, 2021
Visit Reason
An unannounced complaint/incident investigation survey and a biennial State licensure survey were conducted at the facility.
Findings
No deficiencies were identified relative to the compliant survey.
Complaint Details
The visit was an unannounced complaint/incident investigation survey. No deficiencies were found.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Sep 1, 2021
Visit Reason
An unannounced focused survey was conducted at this residence related to COVID19 infection control.
Findings
No deficiencies were identified during the COVID19 infection control focused survey.
Inspection Report
Complaint Investigation
Deficiencies: 0
Jun 10, 2021
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 no deficiencies were found, indicating no substantiated issues.
Inspection Report
Complaint Investigation
Deficiencies: 0
Feb 17, 2021
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.
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