Deficiencies per Year
20
15
10
5
0
Unclassified
Census Over Time
Inspection Report
Complaint Investigation
Deficiencies: 1
Mar 6, 2025
Visit Reason
The Department completed a complaint investigation of the Assisted Living Facility on 03/06/2025 based on complaint numbers 163668, 164456, and 165094.
Findings
The facility was found not to meet Assisted Living Facility requirements related to medication services. Specifically, there was no process for verifying that medications had been delivered or picked up by self-medication residents. No residents were harmed or without medications. The deficiency was corrected on-site during the visit.
Complaint Details
Complaint investigation included complaint numbers 163668, 164456, and 165094. The deficiency was substantiated as the facility did not meet medication service requirements.
Deficiencies (1)
| Description |
|---|
| No process for verifying that medications had been delivered or picked up by self-medication residents. |
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Lisa Mason | NCI ALF Licensor | Department staff who did the inspection and provided consultation. |
| Manfay Chan | Allied Health Field Manager | Signed the letter and provided contact information. |
Inspection Report
Follow-Up
Deficiencies: 1
Feb 20, 2025
Visit Reason
The Department completed a follow-up inspection of the Charlton Place Assisted Living Facility to verify correction of previously cited deficiencies related to medication safety assessments.
Findings
The follow-up inspection found no deficiencies and confirmed that the facility meets Assisted Living Facility licensing requirements. The prior deficiencies related to failure to assess residents' safety in self-medication were corrected.
Complaint Details
Complaint investigation conducted from 2024-12-05 through 2024-12-18 regarding residents on self-medication with no safety assessment in place. The investigation found failed provider practice with citations written.
Deficiencies (1)
| Description |
|---|
| Failure to obtain sufficient information to provide a safe self-medication system for 6 of 6 sampled residents, placing residents at risk for harm when taking medication without a safety assessment of understanding the prescribed medications. |
Report Facts
Resident sample size: 6
Residents independently administering medications: 21
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Lisa Mason | NCI ALF Licensor | Department staff who conducted the on-site verification and complaint investigation |
| Staff A | Director of Nursing | Interviewed regarding medication safety assessment policy; unaware if policy existed |
| Staff C | Medication Technician | Interviewed and reported 21 residents independently administering medications and unawareness of self-medication policy |
| Staff B | Resident Care Coordinator | Interviewed and unaware of medication safety assessments |
| Staff D | Medication Technician | Interviewed and aware of residents independently administering medications but unaware of self-medication policy |
Inspection Report
Follow-Up
Census: 76
Deficiencies: 2
Dec 12, 2023
Visit Reason
The visit was a follow-up inspection of Charlton Place Assisted Living Facility to verify correction of previously cited deficiencies.
Findings
The follow-up inspection on 12/12/2023 found no deficiencies and confirmed that the facility meets Assisted Living Facility licensing requirements. Previous deficiencies related to pet health records and maintenance issues were corrected.
Deficiencies (2)
| Description |
|---|
| Failure to ensure pets living in the facility had regular examinations and immunizations by a licensed veterinarian. |
| Failure to maintain safety and quality of common resident areas, including gouged and scuffed walls, dim lighting, dirty air intake vents, cracked and uneven flooring, and damaged baseboard heating units. |
Report Facts
Current residents: 76
Sample residents reviewed: 3
Former residents reviewed: 0
Dates of unannounced inspection: Inspection dates from 05/31/2023 to 06/08/2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Melisa Moran | Assisted Living Facility Nursing Consultant Institutional | Department staff who did on-site verification and inspection |
| Cathleen Davis | ALF Licensor | Department staff who did on-site verification and inspection |
| Shirley Grew | LTC Surveyor | Department staff who inspected the Assisted Living Facility |
| Lisa Mason | NCI ALF Licensor | Department staff who inspected the Assisted Living Facility |
| Bob Clay | Administrator | Signed Plan/Attestation Statements for correction of deficiencies |
Inspection Report
Life Safety
Deficiencies: 20
Feb 22, 2023
Visit Reason
The Office of the State Fire Marshal conducted an inspection at the Charlton Place residential care facility on 02/22/2023 to assess compliance with fire safety and life safety code requirements.
Findings
The inspection found multiple violations related to fire safety, including improper storage of combustible materials, failure to maintain required clearances, inadequate power supply connections, lack of required cleaning and maintenance records, and deficiencies in fire protection systems such as sprinkler and suppression system documentation, exit sign illumination, and fire extinguisher inspections.
Deficiencies (20)
| Description |
|---|
| Waste bin containers exceeding 40 gallons lacked lids and were constructed of combustible materials. |
| Improper disposal of smoking debris outside the east exit, littered on ground and in unsuitable combustible containers and trash cans. |
| Facility failed to maintain storage of combustible material at least 18 inches below sprinkler head deflector in storage closets on Floors 1 and 2. |
| Large amount of combustible storage and accumulation found in the main electrical/boiler room. |
| Power strip plugged into another power strip along corridor wall in Nurse's office. |
| Unable to provide reports showing two semi-annual kitchen hood cleanings performed in past 12 months. |
| Unable to provide annual inventory records showing all fire-resistance-rated construction has been inspected/repaired in past 12 months. |
| Unsealed sheetrock patch in ceiling of first floor housekeeping room. |
| Roof access hatch in second floor record storage room failed to be closed and latched. |
| Fire doors not annually inspected, tested, and repaired; fire door to apartment #202 missing screws holding bottom hinge causing door sag and gap. |
| Facility unable to provide fire sprinkler system documentation including quarterly inspection reports, annual confidence test, 3-year full flow trip test, 5-year inspection/test, and backflow test reports. |
| Unable to provide reports showing two semi-annual suppression system servicings performed in past 12 months. |
| Unable to provide documentation showing annual servicing of fire alarm system performed in past 12 months. |
| Unable to provide documentation showing smoke detector sensitivity testing performed in last 5 years. |
| Unable to provide documentation showing monthly inspection of carbon monoxide alarms performed in past 12 months. |
| Exit signs failed to be fully illuminated under normal operation at multiple locations including south exit stairwell, northwest exit by apartment #109, and north exit by apartment #125. |
| Unable to provide documentation showing 30-second monthly battery testing of emergency lighting and exit signs performed in past 12 months. |
| Unable to provide documentation showing 90-minute annual battery testing of emergency lighting and exit signs performed in past 12 months. |
| Fire extinguishers in elevator equipment room and main electrical room missing monthly inspection documentation. |
| Unable to provide records showing twelve planned and unannounced fire drills conducted in past 12 months as required. |
Report Facts
Inspection date: Feb 22, 2023
Waste bin capacity: 40
Storage clearance: 18
Fire drill frequency: 12
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Bob Chapman | Executive Director / Administrator | Named as Owner or Authorized Representative signing the inspection documents |
| Lysandra Davis | Deputy State Fire Marshal | Conducted the inspection and signed the report |
Inspection Report
Complaint Investigation
Census: 83
Deficiencies: 1
Sep 8, 2022
Visit Reason
The inspection was conducted due to a complaint alleging that a resident did not have running water in his room, poor environmental conditions, and concerns about the resident's overall wellbeing.
Findings
The investigation found that the facility failed to maintain and provide safe and sanitary living quarters for the resident, resulting in a citation for failed provider practice. Specific deficiencies included unsanitary room conditions such as soiled linens, strong urine odor, and unclean bathroom facilities.
Complaint Details
Complaint investigation found the facility did not meet licensing requirements due to failure to maintain safe and sanitary living quarters for a resident. Citation was issued.
Deficiencies (1)
| Description |
|---|
| Facility failed to maintain one of three sampled resident's rooms safe and sanitary, placing the resident in an unsafe living environment and decreasing quality of life. |
Report Facts
Total residents: 83
Resident sample size: 5
Closed records sample size: 0
Correction timeframe: 45
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Anissa Bearden | Licensor | Department staff who conducted the on-site verification and investigation |
| Manfay Chan | Field Manager | Signed enforcement and correspondence letters related to the investigation |
| Staff B | RN Director of Nursing | Provided statements regarding room condition and resident care during investigation |
| Staff C | Medical Assistant | Stated that resident's room was to be cleaned daily by housekeeping |
Inspection Report
Complaint Investigation
Census: 83
Deficiencies: 1
Sep 8, 2022
Visit Reason
The inspection was conducted as a complaint investigation regarding allegations that all residents were restricted from having visitors during a COVID-19 outbreak at the facility.
Findings
The facility failed to allow residents visitation rights during the COVID-19 outbreak, which caused emotional distress to residents. This failure was found to be a violation of resident rights under licensing laws.
Complaint Details
The complaint alleged that all residents were restricted from having visitors during a COVID-19 outbreak. The investigation confirmed the facility restricted visitation, causing emotional distress to residents. The complaint was substantiated with citation(s) written.
Deficiencies (1)
| Description |
|---|
| Facility failed to ensure residents' representatives visitations were not restricted for two of four sampled residents, placing residents at risk for decreased quality of life. |
Report Facts
Total residents: 83
Resident sample size: 4
Closed records sample size: 1
Correction timeframe: 45
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Anissa Bearden | Licensor | Investigator who conducted the complaint investigation and on-site verification |
| Manfay Chan | Field Manager | Named in relation to enforcement actions and correspondence |
| Bob Clay | Administrator | Signed the Plan of Correction documents |
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