Inspection Report
Follow-Up
Deficiencies: 0
Oct 8, 2025
Visit Reason
The Department completed a follow-up inspection of the Assisted Living Facility to verify correction of previously cited deficiencies.
Findings
The follow-up inspection found no deficiencies and confirmed that the facility meets Assisted Living Facility licensing requirements. Previous deficiencies related to medication refusal and medication services were corrected.
Report Facts
Residents reviewed: 10
Residents with medication refusal issue: 1
Residents with medication notification issue: 1
Number of times metoprolol was held: 47
Dates resident refused medication: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Carla Rose | NCI Community Licensor | Department staff who conducted the inspection |
| Tethra Wales | Assisted Living Facility Licensor | Department staff who conducted the inspection |
| Stephanie Jenks | Community Field Manager | Signed follow-up inspection letter |
| Jessica Salquist | Regional Administrator | Signed enforcement and deficiency letters |
| Staff H | Resident Care Manager | Interviewed regarding medication notification procedures |
| Staff G | Registered Nurse | Interviewed regarding medication orders and procedures |
| Staff F | Administrator | Interviewed regarding documentation of communication with provider |
Inspection Report
Life Safety
Deficiencies: 2
Jul 1, 2025
Visit Reason
The Office of the State Fire Marshal conducted an inspection at the facility to assess compliance with fire protection and safety codes, specifically focusing on testing and maintenance of sprinkler systems and backflow preventers.
Findings
The inspection found that forward flow testing of the backflow preventers was required and scheduled for 7/1/25 with an extension until 7/2/25. The testing was completed as noted. Previous inspection on 05/05/2025 noted inability to provide documentation for the annual dry system trip test and required testing and maintenance corrections.
Deficiencies (2)
| Description |
|---|
| Forward flow testing of the backflow preventers shall be required. |
| Facility is unable to provide documentation for the Annual dry system trip test. |
Report Facts
Next inspection scheduled date: Jul 31, 2026
Next inspection scheduled date: Jun 4, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Barbara McMullen | Deputy State Fire Marshal | Signed inspection documents and conducted inspection |
| Steven Caselli | Maintenance | Signed as Owner or Authorized Representative |
| Rylee Mason | Owner | Signed as Owner or Authorized Representative |
Inspection Report
Follow-Up
Census: 38
Deficiencies: 0
Dec 18, 2023
Visit Reason
The Department completed a follow-up inspection of the Assisted Living Facility on 12/18/2023 to verify correction of previously cited deficiencies.
Findings
The follow-up inspection found no deficiencies, indicating the facility meets Assisted Living Facility licensing requirements. Previous deficiencies were corrected as documented.
Report Facts
Sample residents reviewed: 7
Sample residents with deficiencies: 6
Sample staff with deficiencies: 1
Deficiencies cited: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Joy Pipgras | LTC Surveyor | Department staff who conducted on-site verification and inspection |
| Tethra Wales | Assisted Living Facility Licensor | Department staff who conducted on-site verification and inspection |
| Veronica Jackson | Assisted Living Facility Licensor | Department staff who conducted the full inspection on 10/27/2023 |
| Stephanie Jenks | Field Manager | Signed letters related to inspection and enforcement actions |
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