Deficiencies per Year
4
3
2
1
0
Unclassified
Census Over Time
Inspection Report
Monitoring
Census: 49
Deficiencies: 2
Jun 10, 2025
Visit Reason
The inspection was a monitoring visit conducted to review compliance with resident care standards, particularly related to adults with serious cognitive impairments, following a self-reported incident regarding resident care in the secure unit.
Findings
The investigation supported the self-report of non-compliance related to monitoring residents with serious cognitive impairments, including failure to ensure adequate supervision and use of safety measures such as door alarms and security bracelets. Violations were issued based on incidents where a resident was able to exit the memory care unit unsupervised.
Deficiencies (2)
| Description |
|---|
| Failed to ensure monitoring of residents with serious cognitive impairments, such as door alarms, cameras, constant staff oversight, security bracelets that are part of an alarm system, or delayed egress mechanisms. |
| Failed to ensure that it provided supervision of resident schedules, care, and activities, including attention to specialized needs, such as prevention of wandering from the premises. |
Report Facts
Number of residents present: 49
Number of resident records reviewed: 1
Number of staff records reviewed: 1
Number of staff interviews conducted: 2
Inspection Report
Monitoring
Census: 51
Deficiencies: 0
Dec 4, 2024
Visit Reason
The inspection was a monitoring visit conducted to review compliance with applicable standards and laws at the assisted living facility.
Findings
The inspection found no violations with applicable standards or laws. The licensing inspector completed a tour of the physical plant, reviewed resident and staff records, conducted interviews, and observed various facility operations.
Report Facts
Resident records reviewed: 6
Staff records reviewed: 3
Resident interviews conducted: 3
Staff interviews conducted: 4
Inspection Report
Monitoring
Census: 51
Deficiencies: 2
Nov 21, 2024
Visit Reason
The inspection was a monitoring visit conducted to review compliance with resident care standards, particularly related to residents with serious cognitive impairments, following a self-reported incident regarding resident care.
Findings
The investigation supported the self-report of non-compliance related to inadequate monitoring and supervision of residents with serious cognitive impairments, resulting in residents wandering from the memory care unit. Violations were issued based on these findings.
Deficiencies (2)
| Description |
|---|
| Failed to ensure monitoring of residents with serious cognitive impairments, such as door alarms, cameras, constant staff oversight, security bracelets that are part of an alarm system, or delayed egress mechanisms. |
| Failed to ensure that it provided supervision of resident schedules, care, and activities, including attention to specialized needs, such as prevention of wandering from the premises. |
Report Facts
Number of residents present: 51
Number of resident records reviewed: 1
Number of staff interviews conducted: 2
Inspection Report
Monitoring
Census: 48
Deficiencies: 2
Jul 19, 2024
Visit Reason
The inspection was a monitoring visit conducted on July 19, 2024, following a self-reported incident received on May 16, 2024, regarding allegations related to the secure environment for residents with serious cognitive impairments.
Findings
The investigation supported the self-report of non-compliance with regulations related to monitoring and supervision of residents with serious cognitive impairments, resulting in violations being issued. The facility failed to ensure proper monitoring such as functioning door alarms and supervision to prevent residents from wandering off the premises.
Deficiencies (2)
| Description |
|---|
| Failed to ensure monitoring of residents with serious cognitive impairments, including door alarms, cameras, staff oversight, security bracelets, or delayed egress mechanisms. |
| Failed to provide supervision of resident schedules, care, and activities, including prevention of wandering from the premises. |
Report Facts
Number of residents present: 48
Number of resident records reviewed: 1
Number of staff interviews conducted: 1
Inspection Report
Renewal
Census: 50
Deficiencies: 2
Dec 12, 2023
Visit Reason
The inspection was conducted as a renewal inspection of the assisted living facility to assess compliance with applicable standards and laws.
Findings
The inspection found non-compliance with certain standards, including failure to ensure required infection control training for staff and failure to provide written assurance of appropriate licensing to a resident at admission. Violation notices were issued with plans of correction required.
Deficiencies (2)
| Description |
|---|
| Facility failed to ensure that at least two of the required hours of training focused on infection control and prevention for staff. |
| Facility failed to ensure that the assisted living facility administrator provided written assurance to a resident that the facility has the appropriate license to meet his care needs at the time of admission. |
Report Facts
Number of residents present: 50
Number of resident records reviewed: 8
Number of staff records reviewed: 4
Number of resident interviews conducted: 3
Number of staff interviews conducted: 2
Inspection Report
Monitoring
Census: 42
Deficiencies: 2
Mar 7, 2023
Visit Reason
The inspection was a monitoring visit conducted to review compliance with applicable standards and laws at the assisted living facility.
Findings
The inspection found non-compliance with applicable standards related to emergency preparedness and resident emergency exercises. Violations were documented and a violation notice was issued.
Deficiencies (2)
| Description |
|---|
| Facility failed to ensure the semi-annual review of the emergency preparedness and response plan for all staff, residents, and volunteers, with documentation by signing and dating. |
| Facility failed to ensure that at least once every six months, all staff on duty participate in an exercise practicing procedures for resident emergencies, with documentation maintained for at least two years. |
Report Facts
Number of residents present: 42
Number of resident records reviewed: 8
Number of staff records reviewed: 4
Number of interviews with residents: 3
Number of interviews with staff: 5
Inspection Report
Renewal
Census: 29
Deficiencies: 3
Dec 7, 2021
Visit Reason
An unannounced renewal inspection was conducted to assess compliance with licensing standards, including a review of facility conditions, resident care, staff records, and emergency preparedness.
Findings
The inspection identified violations related to staff tuberculosis screening records, failure to post current first aid/CPR certification listings, and incomplete documentation of resident participation in fire and emergency evacuation drills.
Deficiencies (3)
| Description |
|---|
| Facility failed to ensure that each staff record contained a current tuberculosis (TB) screening. |
| Facility failed to post a listing of all staff who have current certification in first aid or CPR so that the information is readily available to all staff at all times. |
| Facility failed to ensure that it documented the number of residents participating in fire and emergency evacuation drills. |
Report Facts
Census: 29
Sample size of records reviewed: 3
Inspection Report
Monitoring
Census: 30
Deficiencies: 1
Apr 1, 2021
Visit Reason
A monitoring inspection was initiated due to the need for regulatory oversight during a state of emergency health pandemic, conducted remotely with a virtual tour and document review.
Findings
The inspection found non-compliance with staff training requirements, specifically that orientation and training required within the first seven working days of employment were not completed timely or properly documented.
Deficiencies (1)
| Description |
|---|
| The facility failed to ensure that the orientation and training required in subsections B and C occurred within the first seven working days of employment, including missing signatures and trainer initials on training documentation. |
Report Facts
Inspection dates: 2
Resident census: 30
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