Inspection Report
Renewal
Census: 62
Capacity: 110
Deficiencies: 3
May 13, 2025
Visit Reason
The inspection was conducted as a renewal inspection of the facility's license, with an unannounced full inspection on 05/13/2025 and 05/14/2025.
Findings
The facility was found to have fully implemented its submitted plan of correction. Two specific deficiencies were noted: failure to conspicuously post a granted waiver related to staff education status, and incomplete or inaccurate resident assessments regarding mobility and medication self-administration.
Deficiencies (3)
| Description |
|---|
| The home failed to conspicuously and publicly post a waiver dated 03/17/25 related to a direct care staff member receiving education outside of the United States. |
| Resident #2's most recent assessment did not include an accurate assessment for moderate mobility as indicated on the resident's medical evaluation. |
| Resident #3's most recent assessment did not include an assessment that the resident cannot self-administer medications, contrary to the medical evaluation. |
Report Facts
License Capacity: 110
Residents Served: 62
Current Hospice Residents: 1
Total Daily Staff: 62
Waking Staff: 47
Inspection Report
Renewal
Census: 59
Capacity: 110
Deficiencies: 4
Jan 18, 2023
Visit Reason
The inspection was conducted as a renewal review of the facility's license to ensure compliance with regulatory requirements.
Findings
The inspection identified several deficiencies including lack of emergency telephone numbers posted near telephones, uncovered food in storage, unsecured fireplace screens while in use, and a staff member not completing required medication administration training on time. Plans of correction were accepted and implemented for all deficiencies.
Deficiencies (4)
| Description |
|---|
| No emergency telephone numbers posted on or near telephones in the home's kitchen. |
| A bag of hamburger patties was open and exposed to air in the walk-in freezer. |
| The gas fireplace in the home's 2nd floor lounge was in use without a secure screen or protective guard. |
| Staff person administering medications had not completed required evaluation and practicum since March 2022. |
Report Facts
Resident census: 59
Total licensed capacity: 110
Number of hamburger patties: 30
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Dining Services Manager | Responsible for obtaining emergency phone stickers, covering food, and education of staff | |
| Administrator | Placed protective screen on fireplace and educated staff on fireplace safety and medication training | |
| Clinical Care Coordinator | Educated on medication administration regulation and observed staff medication competency |
Inspection Report
Renewal
Census: 61
Capacity: 110
Deficiencies: 2
Sep 21, 2021
Visit Reason
The inspection was conducted as a renewal inspection of the facility license.
Findings
The submitted plan of correction from the previous inspection was determined to be fully implemented. Two specific violations were noted: lack of written notification to the local fire department regarding emergency evacuation details, and a medication storage issue involving a prescribed medication that was not available on site. Both violations had plans of correction accepted and implemented.
Deficiencies (2)
| Description |
|---|
| The home did not have documentation of written notification to the local fire department of the address of the home, location of the bedrooms, and the assistance needed to evacuate in an emergency. |
| Resident #1 was prescribed a medication that was not available in the home on 09/22/21. |
Report Facts
License Capacity: 110
Residents Served: 61
Current Hospice Residents: 1
Resident Age 60 or Older: 61
Resident Diagnosed with Intellectual Disability: 1
Notice
Capacity: 110
Deficiencies: 0
Aug 25, 2021
Visit Reason
This document serves as a renewal notification and license issuance for Garden Spot Village Personal Care Home, confirming receipt of the renewal application and advising that an annual inspection will be conducted within the next twelve months.
Findings
No inspection findings are reported in this document; it is a license renewal notice and certificate of compliance.
Report Facts
Maximum capacity: 110
Secure Dementia Care Unit capacity: 30
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jamie L. Buchenauer | Deputy Secretary, Office of Long-term Living | Signed the renewal notification letter. |
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