Inspection Report Summary
Most inspections found deficiencies related primarily to medication management, resident safety, and staff qualifications, with several substantiated complaints involving rough handling of residents and failures in timely medical attention. The facility received civil penalties for repeat violations, including unsecured medications and inadequate supervision of residents with dementia, some posing immediate health and safety risks. Enforcement actions included fines and a licensee warning, but no license suspensions or revocations are listed in the available reports. The most recent inspection on September 11, 2025, was a complaint investigation with no deficiencies found, reflecting some improvement compared to earlier reports. Several complaint investigations were unsubstantiated, indicating that not all concerns raised were confirmed by inspectors.
Deficiencies per Year
8
6
4
2
0
High
Moderate
Unclassified
Census Over Time
Census
Capacity
Inspection Report
Complaint Investigation
Census: 91
Capacity: 128
Deficiencies: 0
Sep 11, 2025
Visit Reason
An unannounced complaint investigation visit was conducted in response to allegations received on 2025-09-02 regarding staff not maintaining a comfortable temperature for residents and not following the facility menu.
Findings
The investigation found that residents generally reported comfortable room temperatures with air conditioning units available, though some work orders for AC issues were open. Regarding the menu, residents reported occasional shortages of daily specials or preferred items, but alternatives were always available. The allegations were determined to be unsubstantiated due to insufficient evidence.
Complaint Details
The complaint investigation was unsubstantiated. Allegations included staff not maintaining comfortable temperatures and not following the facility menu. Interviews, observations, and record reviews did not provide sufficient evidence to prove violations.
Report Facts
Capacity: 128
Census: 91
Work order duration: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Katie Brown | Licensing Program Analyst | Conducted the complaint investigation visit |
| Sarah Dennis | Administrator | Met with Licensing Program Analyst during investigation |
| Jami Young | Director of Nursing | Interviewed during investigation |
| Sergiy Pidgirny | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Census: 70
Capacity: 128
Deficiencies: 0
Aug 26, 2025
Visit Reason
The visit was an unannounced Case Management - Health & Safety Inspection conducted in conjunction with opening a complaint (control number 24-AS-20250825091006).
Findings
The facility was observed to be clean and well-maintained with proper lighting, safety features in bathrooms, and adequate supplies for residents. Medications and cleaning supplies were securely stored, and no citations were issued during this inspection.
Complaint Details
The inspection was conducted in conjunction with opening a complaint (control number 24-AS-20250825091006). No citations or deficiencies were found during this inspection.
Report Facts
Facility Capacity: 128
Resident Census: 70
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Sarah Dennis | Administrator | Met with Licensing Program Analyst during the inspection |
| Katie Brown | Licensing Program Analyst | Conducted the Case Management - Health & Safety Inspection |
Inspection Report
Annual Inspection
Census: 93
Capacity: 128
Deficiencies: 6
Aug 18, 2025
Visit Reason
The inspection was an unannounced annual inspection conducted by the Licensing Program Analyst to evaluate compliance with licensing requirements at Kingston Bay Senior Living Facility.
Findings
The inspection found multiple deficiencies related to medication administration, medication storage, documentation, resident reappraisals, use of bed rails, and facility cleanliness. A civil penalty was assessed for repeat violations, and plans of correction were requested for all deficiencies.
Severity Breakdown
Type A: 2
Type B: 4
Deficiencies (6)
| Description | Severity |
|---|---|
| Licensee did not assist residents with self-administered medications as needed; medication audit revealed discrepancies and missed doses. | Type A |
| Centrally stored medications were not kept in a safe and locked place; medications were unsecured in resident apartments. | Type A |
| Failure to maintain a record of each dose of PRN medication administered to residents. | Type B |
| Failure to conduct reappraisals documenting significant changes in resident condition, including skin condition changes. | Type B |
| Full bed rails were used on a resident's hospital bed without physician orders. | Type B |
| Facility was not clean and sanitary; sticky floors, urine on bathroom floor, ants in rooms, and musty odor observed. | Type B |
Report Facts
Census: 93
Total Capacity: 128
Civil Penalty: Assessed for repeat violation (exact amount not stated)
Plan of Correction Due Dates: Sep 1, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Katie Brown | Licensing Program Analyst | Conducted the annual inspection and authored the report |
| Sarah Dennis | Administrator | Facility Administrator involved in inspection and plans of correction |
| Jami Young | Director of Nursing | Director of Nursing involved in medication audit and inspection |
Inspection Report
Annual Inspection
Census: 93
Capacity: 128
Deficiencies: 0
Jul 29, 2025
Visit Reason
The Licensing Program Analyst arrived unannounced to conduct the Annual Inspection of the facility.
Findings
The facility was found to be clean and well-maintained with no citations issued during this inspection. Resident apartments and common areas met requirements, including safety features and hygiene supplies. Fire extinguishers were properly serviced and resident files were reviewed.
Report Facts
Fire extinguisher service date: Mar 19, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Katie Brown | Licensing Program Analyst | Conducted the Annual Inspection and met with the Administrator. |
| Sarah Dennis | Administrator | Facility Administrator who met with the Licensing Program Analyst during the inspection. |
Inspection Report
Annual Inspection
Census: 93
Capacity: 128
Deficiencies: 0
Jul 29, 2025
Visit Reason
The visit was an unannounced Case Management visit conducted in conjunction with the Annual Inspection, related to the SOC341 submitted by the facility on 2025-07-28.
Findings
During the visit, the Licensing Program Analyst reviewed resident and staff files and interviewed the Administrator. There were no citations or deficiencies found during this inspection.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Sarah Dennis | Administrator | Met with Licensing Program Analyst during inspection. |
| Katie Brown | Licensing Program Analyst | Conducted the Case Management visit and Annual Inspection. |
| Sergiy Pidgirny | Licensing Program Manager | Named as Licensing Program Manager on the report. |
Inspection Report
Complaint Investigation
Census: 90
Capacity: 128
Deficiencies: 0
Jul 18, 2025
Visit Reason
An unannounced complaint investigation visit was conducted in response to multiple allegations received on 2025-03-20 regarding resident care issues at Kingston Bay Senior Living Facility.
Findings
The investigation reviewed allegations including unmet toileting needs, delayed response to call buttons, improper medication dispensing, and untimely meal provision. All allegations were found to be unsubstantiated or unfounded based on interviews, record reviews, and observations, with no citations issued.
Complaint Details
The complaint investigation addressed allegations that facility staff were not meeting resident toileting needs, not responding timely to call buttons, not dispensing medication as prescribed, and not providing timely meals. The findings were unsubstantiated or unfounded, and no citations were issued.
Report Facts
Capacity: 128
Census: 90
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Katie Brown | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Sarah Dennis | Administrator | Facility administrator present during the investigation |
| Frankie Tamayo | Assistant Director of Nursing | Met with Licensing Program Analyst during the investigation |
Inspection Report
Complaint Investigation
Census: 84
Capacity: 128
Deficiencies: 1
May 28, 2025
Visit Reason
The visit was an unannounced Case Management - Health & Safety Inspection conducted in conjunction with a complaint investigation (Complaint Control Number 24-AS-20250527121130).
Findings
The facility was generally clean and well-maintained with proper storage and safety measures observed. However, a deficiency was cited for failure to ensure that items posing danger to residents were locked and inaccessible, specifically hygiene items left unlocked and accessible to residents.
Complaint Details
The visit was conducted in conjunction with a complaint investigation under Complaint Control Number 24-AS-20250527121130.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Licensee did not ensure items which could pose danger to residents were locked and inaccessible; shampoo, hairspray, cleansing spray, and peri wash were left unlocked and accessible. | Type B |
Report Facts
Facility Capacity: 128
Census: 84
Deficiency Count: 1
Plan of Correction Due Date: Jun 9, 2025
Fire Extinguisher Service Date: Mar 19, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Sarah Dennis | Administrator | Met with Licensing Program Analyst during inspection |
| Frankie Tamayo | Memory Care Director | Met with Licensing Program Analyst during inspection |
| Jami Young | Director of Nursing, LVN | Met with Licensing Program Analyst during inspection |
| Katie Brown | Licensing Program Analyst | Conducted the inspection and signed the report |
| Sergiy Pidgirny | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 84
Capacity: 128
Deficiencies: 1
May 28, 2025
Visit Reason
An unannounced complaint investigation was conducted following a complaint received on 05/27/2025 regarding staff handling a resident roughly resulting in a skin tear.
Findings
The investigation substantiated that staff pulled Resident R1 by the legs and arms to move them away from another resident, causing a skin tear on R1's right arm. This was found to be a violation of personal rights and posed an immediate health and safety risk.
Complaint Details
The complaint was substantiated based on interviews and staff statements. The allegation that staff handled a resident roughly resulting in a skin tear was confirmed.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Licensee did not ensure R1's personal rights were met. Staff pulled R1 by the legs and arms causing a skin tear on the right arm, violating personal rights and posing immediate health and safety risk. | Type A |
Report Facts
Capacity: 128
Census: 84
Deficiency Type: 1
Plan of Correction Due Date: May 29, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Katie Brown | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Sarah Dennis | Administrator | Facility administrator met with Licensing Program Analyst during investigation and received report |
| Sergiy Pidgirny | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
Inspection Report
Complaint Investigation
Census: 87
Capacity: 128
Deficiencies: 2
May 23, 2025
Visit Reason
Unannounced complaint investigation visit conducted due to allegations including rough handling of residents by staff, inappropriate speech by staff, and staff lacking required qualifications.
Findings
The investigation substantiated that staff member S1 handled residents roughly and spoke inappropriately, causing discomfort. Another staff member, S3, worked as a caregiver without completing required training and without First Aid/CPR certification. An allegation regarding failure to notify a resident's responsible party of a fall was unsubstantiated.
Complaint Details
The complaint investigation was substantiated for allegations that staff handled residents roughly and spoke inappropriately, and that a staff member lacked required qualifications. The allegation that staff did not notify a resident's responsible party of a fall was unsubstantiated.
Severity Breakdown
Type B: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Residents confirm S1 speaks in a demeaning manner and is rough causing discomfort during care. This is a potential health & safety risk to persons in care. | Type B |
| S3 worked as a caregiver without completing RCFE requirements and without First Aid/CPR Certification. This is a potential health & safety risk to persons in care. | Type B |
Report Facts
Capacity: 128
Census: 87
Plan of Correction Due Date: Jun 2, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Katie Brown | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Jami Young | Director of Nursing | Met with Licensing Program Analyst during investigation |
| Robert Huntley | Administrator | Facility administrator mentioned in report |
Inspection Report
Complaint Investigation
Census: 87
Capacity: 128
Deficiencies: 0
May 23, 2025
Visit Reason
Unannounced complaint investigation visit conducted in response to multiple allegations including inadequate staffing, presence of pests, failure to seek timely medical attention, and failure to observe resident's change in condition.
Findings
The investigation found that staffing levels included shifts with only one caregiver per floor, but it was unknown if this contributed to resident falls. Pest control procedures were in place and documented. Medical attention was delayed due to the responsible party's refusal to send the resident to the hospital despite increasing confusion and falls. All allegations were unsubstantiated with no citations issued.
Complaint Details
The complaint investigation was unsubstantiated. Allegations included inadequate staffing, pests, failure to seek timely medical attention, and failure to observe resident condition changes. Evidence did not prove violations occurred.
Report Facts
Capacity: 128
Census: 87
Complaint receipt date: Feb 21, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Katie Brown | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Jami Young | Director of Nursing | Met with Licensing Program Analyst during investigation |
| Robert Huntley | Administrator | Facility administrator named in report header |
| Sergiy Pidgirny | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Census: 97
Capacity: 128
Deficiencies: 0
Apr 17, 2025
Visit Reason
An office meeting was held to discuss identified issues and concerns associated with the operation of the facility, including complaint accumulation, staffing concerns, and reporting requirements.
Findings
The report documents an office meeting addressing operational concerns at the facility. The licensee was provided with applicable regulations and offered technical support. No specific deficiencies or penalties are detailed in the report.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Sarah Dennis | Executive Director | Named as facility administrator and attendee of the office meeting. |
| Sergiy Pidgirny | Licensing Program Manager | Named as licensing program manager and attendee of the office meeting. |
| Katie Brown | Licensing Program Analyst | Named as licensing program analyst and attendee of the office meeting. |
Inspection Report
Complaint Investigation
Capacity: 128
Deficiencies: 2
Dec 10, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by complaints alleging the facility billed a resident beyond the terms of the Admission Agreement, did not assess a resident at hospital for a change of condition prior to discharge, and unlawfully evicted a resident.
Findings
The investigation substantiated that the facility billed a resident beyond the Admission Agreement terms and failed to assess the resident prior to hospital discharge, posing potential health and safety risks. The allegation of unlawful eviction was found to be unfounded. Deficiencies were cited related to Admission Agreements and Reappraisals, and a Plan of Correction was developed.
Complaint Details
The complaint investigation was substantiated for allegations that the facility billed a resident beyond the Admission Agreement and failed to assess the resident prior to hospital discharge. The allegation of unlawful eviction was found to be unfounded.
Severity Breakdown
Type B: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Licensee did not ensure compliance with all applicable terms of the Admission Agreement; resident was not billed accurately after vacating the facility on 8/13/24. | Type B |
| Facility did not conduct an assessment prior to discharge from the hospital despite significant changes in resident's condition. | Type B |
Report Facts
Capacity: 128
Plan of Correction Due Date: Jan 7, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Katie Brown | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Rebecca Langdon | Interim Administrator | Met with Licensing Program Analyst during the investigation |
| Robert Huntley | Administrator | Facility Administrator named in the report |
| Sergiy Pidgirny | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
| Director of Nursing | Director of Nursing | Observed resident's decline and changes of condition after hospital return |
Inspection Report
Complaint Investigation
Capacity: 128
Deficiencies: 1
Dec 10, 2024
Visit Reason
An unannounced complaint investigation visit was conducted due to allegations that staff administered incorrect medication to a resident resulting in hospitalization and failed to report an incident involving a resident as required.
Findings
The investigation substantiated the allegations that the facility staff administered incorrect medication to a resident resulting in hospitalization and failed to provide a written report of the incident to the responsible party, although verbal notification was made. A deficiency was cited related to reporting requirements.
Complaint Details
The complaint was substantiated. The allegations included staff administering incorrect medication resulting in hospitalization and failure to report the incident as required. The facility reported the medication error and fall verbally to the responsible party but did not provide a written report. A citation was issued for failure to meet reporting requirements.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Licensee did not ensure that a written report was provided to the Responsible Person of R1 after a medication error and fall resulting in hospitalization. | Type B |
Report Facts
Capacity: 128
Deficiency Plan of Correction Due Date: Jan 7, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Katie Brown | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Sergiy Pidgirny | Licensing Program Manager | Oversaw the complaint investigation |
| Rebecca Langdon | Interim Administrator | Met with Licensing Program Analyst during the investigation |
Inspection Report
Complaint Investigation
Census: 91
Capacity: 128
Deficiencies: 1
Oct 23, 2024
Visit Reason
The visit was an unannounced Case Management inspection conducted due to submitted Special Incident Reports involving medication errors.
Findings
The facility was found to have failed to ensure that Med Techs assisted residents with self-administered medications as ordered, resulting in two residents receiving other residents' medications. One resident subsequently fell and required hospital evaluation. A deficiency was cited in the area of Incidental Medical and Dental Care.
Complaint Details
The visit was triggered by Special Incident Reports regarding medication errors where two residents were given the wrong medications. One resident experienced a fall and was hospitalized. A deficiency was cited accordingly.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Licensee did not ensure that the facility Med Tech assisted R1 and R2 with self-administered medications as ordered by their Physicians. R1 and R2 were given other resident's medications by facility Med Techs. R2 fell and required medical care. This poses an immediate health & safety risk to residents in care. | Type A |
Report Facts
Census: 91
Total Capacity: 128
Deficiency Count: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Rob Huntley | Administrator | Met with Licensing Program Analyst during inspection and involved in exit interview |
| Gabriel Facio | Assistant Director of Nursing (ADON), LVN | Met with Licensing Program Analyst during inspection |
| Katie Brown | Licensing Program Analyst | Conducted the unannounced Case Management visit and authored the report |
Inspection Report
Complaint Investigation
Capacity: 128
Deficiencies: 1
Sep 6, 2024
Visit Reason
The visit was an unannounced Case Management - Health Checks conducted in conjunction with complaint control number 24-AS-20240404121910 to address concerns about the safety of residents related to an intimate relationship between two residents.
Findings
The facility was aware of an intimate relationship between Residents R1 and R2 but failed to implement precautions to ensure the safety of R1, who has a diagnosis of Dementia. A deficiency was cited for failure to provide adequate care and supervision, and an immediate civil penalty was assessed for repeat violations.
Complaint Details
The visit was conducted in conjunction with complaint control number 24-AS-20240404121910. The complaint was substantiated as the facility failed to ensure safety and supervision related to the intimate relationship between residents.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Licensee did not ensure R1's physical health, mental health, safety, or welfare once aware of the intimate sexual relationship between R1 and R2. The facility did not prevent multiple incidents of inappropriate interactions between R1 and R2, posing an immediate health and safety risk. | Type A |
Report Facts
Facility capacity: 128
Deficiency count: 1
Plan of Correction due date: Sep 9, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Katie Brown | Licensing Program Analyst | Conducted the inspection and authored the report |
| Rob Huntley | Administrator | Facility administrator met during the inspection and involved in exit interview |
| Sergiy Pidgirny | Licensing Program Manager | Supervisor overseeing the inspection |
Inspection Report
Complaint Investigation
Capacity: 128
Deficiencies: 2
Sep 6, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit conducted due to multiple allegations including failure to provide residents clean linen, ensuring cleaning and hygiene products are inaccessible to residents, resident dehydration, and ensuring resident laundry needs are met.
Findings
The investigation substantiated that staff did not provide clean linens to residents and failed to ensure hygiene products were inaccessible to residents with dementia, citing specific observations of soiled linens and accessible hygiene products. The allegation of resident dehydration was unsubstantiated due to insufficient evidence. The allegation regarding resident laundry service was found to be unfounded with residents reporting satisfaction and adequate laundry services observed.
Complaint Details
The complaint investigation was substantiated for allegations related to unclean linens and accessible hygiene products, unsubstantiated for resident dehydration, and unfounded for laundry service issues.
Severity Breakdown
Type B: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Licensee did not ensure hygiene supplies were inaccessible to residents, with shampoo, conditioner, and mouthwash accessible in bathrooms of residents with dementia. | Type B |
| Licensee did not ensure that resident R5's bed linens were clean; dried brown smears were observed on sheets and floor. Damaged nightstand and bathroom door frame posed potential health and safety risks. | Type B |
Report Facts
Facility capacity: 128
Plan of Correction Due Date: Sep 16, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Katie Brown | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Robert Huntley | Administrator | Facility administrator met during the investigation and received report |
| Sergiy Pidgirny | Licensing Program Manager | Oversaw the complaint investigation report |
Inspection Report
Complaint Investigation
Census: 91
Capacity: 128
Deficiencies: 2
Aug 12, 2024
Visit Reason
The visit was an unannounced complaint investigation triggered by allegations that staff did not prevent inappropriate interactions between residents and did not follow reporting requirements.
Findings
The investigation substantiated that staff failed to prevent multiple inappropriate interactions between residents R1 and R2, both with dementia, and failed to implement safety precautions. Additionally, the facility did not submit required incident reports timely, including reports to law enforcement, CCLD, and Ombudsman.
Complaint Details
The complaint was substantiated. Allegations included staff failing to prevent inappropriate interactions between residents and failing to follow reporting requirements. Evidence showed multiple incidents involving residents R1 and R2 were not properly reported or managed, including delayed reporting to law enforcement.
Severity Breakdown
Type A: 1
Type B: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Licensee did not ensure R1's physical health, mental health, safety, or welfare once aware of the behaviors of R2. The facility did not prevent multiple incidents of inappropriate interactions between R1 and R2, posing an immediate health and safety risk. | Type A |
| Licensee did not ensure that Incident reports were submitted as required after incidents occurred which threaten the welfare, safety or health of R1. | Type B |
Report Facts
Capacity: 128
Census: 91
Deficiency Type A due date: Aug 13, 2024
Deficiency Type B due date: Aug 26, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Katie Brown | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Robert Huntley | Administrator | Facility administrator met with Licensing Program Analyst during investigation and received report |
| Sergiy Pidgirny | Licensing Program Manager | Named in report as Licensing Program Manager overseeing the investigation |
Inspection Report
Complaint Investigation
Census: 91
Capacity: 128
Deficiencies: 0
Aug 12, 2024
Visit Reason
The visit was an unannounced Case Management - Health Checks inspection conducted in conjunction with a complaint (Control Number 24-AS-20240404121910).
Findings
During the visit, the Licensing Program Analyst toured the facility, reviewed resident files, and interviewed staff. No citations were issued.
Complaint Details
The visit was conducted in conjunction with a complaint (Control Number 24-AS-20240404121910). No citations or deficiencies were found.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Rob Huntley | Administrator/Director | Met with Licensing Program Analyst during the inspection. |
| Jordan Valencia | Assistant Director of Nursing | Interviewed by Licensing Program Analyst during the inspection. |
| Katie Brown | Licensing Program Analyst | Conducted the unannounced Case Management - Health Checks visit. |
Inspection Report
Capacity: 128
Deficiencies: 0
Jul 12, 2024
Visit Reason
The inspection visit was an unannounced case management - other inspection regarding the immediate exclusion of Staff 1 (S1) from the facility.
Findings
No deficiency was observed during the visit. The Licensing Program Analyst confirmed that Staff 1 was disassociated from the facility on 10/7/2022.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Katie Brown | Licensing Program Analyst | Conducted the inspection and discussed Staff 1 exclusion with the Administrator. |
| Rob Huntley | Administrator | Met with Licensing Program Analyst during the inspection and received the report. |
Inspection Report
Annual Inspection
Census: 82
Capacity: 128
Deficiencies: 4
Jun 11, 2024
Visit Reason
The Licensing Program Analyst conducted an unannounced annual inspection to evaluate compliance with regulatory requirements at Kingston Bay Senior Living Facility.
Findings
The inspection found deficiencies in the areas of Administrator qualifications and duties, oxygen administration, hospice care, and resident records. A Plan of Correction was developed and agreed upon by the Administrator.
Deficiencies (4)
| Description |
|---|
| Residents R1 and R3 do not have a current Hospice Plan of Care maintained in their files. |
| Resident R4's Physician Report has not been updated as required; it incorrectly states R4 cannot administer glucose testing or insulin injections despite orders for both. |
| Administrator's certification is not current; certificate expired 5/31/24 and renewal documents have not been submitted. |
| Resident R2, who resides in memory care, cannot self-administer oxygen as required; oxygen tubing was found on the floor and resident thought oxygen was off. |
Report Facts
Capacity: 128
Census: 82
Deficiency due date: Jul 11, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Rob Huntley | Administrator | Facility Administrator involved in inspection and Plan of Correction |
| Katie Brown | Licensing Program Analyst | Conducted the annual inspection |
| Sergiy Pidgirny | Licensing Program Manager | Supervisor overseeing the inspection |
Inspection Report
Complaint Investigation
Census: 93
Capacity: 128
Deficiencies: 1
May 9, 2024
Visit Reason
A Health & Safety Inspection was conducted in conjunction with opening a complaint (Control Number 24-AS-20240508111233) to assess compliance with medication storage regulations.
Findings
The inspection found that multiple resident apartments had medications not stored appropriately, constituting a deficiency. A civil penalty was assessed for a repeat violation, and a Plan of Correction was developed with the facility administrator.
Complaint Details
The visit was triggered by a complaint (Control Number 24-AS-20240508111233).
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Licensee did not ensure that resident medications were centrally stored and locked. Unsecured medications were observed in multiple apartments (125, 105, 110, 127, 137, 202, 242, 231, 313). | Type A |
Report Facts
Civil Penalty: A civil penalty is being assessed for a repeat violation.
Deficiencies cited: 1
Apartments with unsecured medications: 9
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Rob Huntley | Administrator | Met with Licensing Program Analyst and involved in exit interview and Plan of Correction. |
| Leonel Lopez | Director of Nursing | Met with Licensing Program Analyst during facility tour where medication storage deficiencies were observed. |
| Katie Brown | Licensing Program Analyst | Conducted the Health & Safety Inspection and authored the report. |
| Sergiy Pidgirny | Licensing Program Manager | Supervisor of the inspection. |
Inspection Report
Complaint Investigation
Census: 91
Capacity: 128
Deficiencies: 1
Apr 23, 2024
Visit Reason
The inspection was conducted as a Case Management - Health Checks inspection in conjunction with a 10-day complaint visit to address concerns related to medication storage.
Findings
The Licensing Program Analyst observed unsecured medications in the apartments of three residents who, according to physician reports and care plans, cannot store their own medications. A deficiency was cited for failure to ensure medications were centrally stored and locked.
Complaint Details
The visit was complaint-related, conducted in conjunction with a 10-day complaint visit. The deficiency cited relates to unsecured medications contrary to physician reports and facility care plans.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Licensee did not ensure that resident medications were centrally stored and locked. Unsecured medications were observed in the apartments of Residents R1, R2, and R3. | Type A |
Report Facts
Census: 91
Total Capacity: 128
Deficiencies cited: 1
Plan of Correction Due Date: Apr 24, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Katie Brown | Licensing Program Analyst | Conducted the inspection and cited deficiencies |
| Rob Huntley | Administrator | Met with Licensing Program Analyst during inspection |
| Sergiy Pidgirny | Licensing Program Manager / Supervisor | Supervisor overseeing the inspection |
Inspection Report
Complaint Investigation
Capacity: 128
Deficiencies: 0
Jan 8, 2024
Visit Reason
An unannounced complaint investigation visit was conducted in response to a complaint received on 2023-09-19 alleging questionable death, rough handling causing bruising, medication distribution issues, and delayed medical attention.
Findings
The investigation included interviews, record reviews, and observations, concluding that the allegations were unsubstantiated due to lack of preponderance of evidence. No citations were issued.
Complaint Details
The complaint involved allegations of questionable death, rough handling causing bruising, failure to distribute medication as prescribed, and failure to seek timely medical attention. The investigation found no evidence to substantiate these allegations.
Report Facts
Facility capacity: 128
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Katie Brown | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Leonel Lopez | Director of Nursing | Interviewed during the investigation |
| Robert Huntley | Administrator | Facility administrator involved in exit interview and report signing |
Inspection Report
Complaint Investigation
Capacity: 128
Deficiencies: 2
Dec 20, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations including unclean facility transportation bus and lack of infection control procedures.
Findings
The investigation substantiated that the facility transportation van was not clean and staff had not completed required annual infection control training. The Infection Control Plan was outdated and needed revision.
Complaint Details
The complaint investigation was substantiated based on the preponderance of evidence standard. Allegations included unclean transportation bus and lack of infection control procedures. Deficiencies were cited accordingly.
Severity Breakdown
Type B: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Licensee did not ensure the facility van was maintained in a clean, safe and sanitary condition; trash was observed and personal items were not properly stored. | Type B |
| Licensee did not ensure all staff are trained as required in the area of Infection Control; five staff training logs were reviewed and found deficient. | Type B |
Report Facts
Capacity: 128
Deficiency count: 2
Plan of Correction Due Date: Dec 29, 2023
Staff training logs reviewed: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Katie Brown | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Rob Huntley | Administrator | Facility administrator met during the investigation and involved in Plan of Correction |
| Sergiy Pidgirny | Licensing Program Manager | Oversaw the complaint investigation process |
Inspection Report
Complaint Investigation
Census: 81
Capacity: 128
Deficiencies: 0
Nov 30, 2023
Visit Reason
An unannounced complaint investigation was conducted in response to a complaint alleging that staff were not meeting residents' incontinence needs.
Findings
The investigation found that Resident 1 is independent in activities of daily living and the facility is aware of changes in the resident's needs. The care plan is being updated and interventions are being implemented. The allegation was unsubstantiated due to lack of preponderance of evidence.
Complaint Details
The complaint alleging staff were not meeting residents' incontinence needs was investigated and found to be unsubstantiated.
Report Facts
Complaint Control Number: 24
Capacity: 128
Census: 81
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Katie Brown | Licensing Program Analyst | Conducted the complaint investigation |
| Rob Huntley | Administrator | Met with Licensing Program Analyst during investigation |
| Leonel Lopez | Director Of Nursing, LVN | Met with Licensing Program Analyst during investigation |
Inspection Report
Complaint Investigation
Census: 68
Capacity: 128
Deficiencies: 1
Sep 21, 2023
Visit Reason
Unannounced Health & Safety inspection conducted in conjunction with a 10-Day complaint investigation (Control Number 24-AS-20230919144634).
Findings
The facility was generally found clean and well-maintained with required furnishings, safety equipment, and supplies properly stored. However, a deficiency was cited because medications belonging to one resident (R1) were left unlocked and accessible to another resident (R2), posing an immediate health and safety risk.
Complaint Details
The visit was triggered by a complaint investigation under Control Number 24-AS-20230919144634.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Medications were not centrally stored and were accessible to another resident, posing an immediate health and safety risk. | Type A |
Report Facts
Capacity: 128
Census: 68
Deficiency count: 1
Plan of Correction Due Date: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Katie Brown | Licensing Program Analyst | Conducted the inspection and authored the report. |
| Rob Huntley | Administrator | Facility administrator met with the Licensing Program Analyst during the inspection. |
| Sergiy Pidgirny | Licensing Program Manager | Supervisor overseeing the inspection. |
Inspection Report
Annual Inspection
Census: 74
Capacity: 128
Deficiencies: 2
Jul 26, 2023
Visit Reason
The Licensing Program Analyst conducted an unannounced Annual Inspection to evaluate compliance with regulatory requirements at Kingston Bay Senior Living Facility.
Findings
The inspection found that the facility generally met physical and safety standards; however, deficiencies were cited related to staff training documentation and incomplete resident records, posing potential health, safety, or personal rights risks.
Deficiencies (2)
| Description |
|---|
| Failure to provide evidence of all required initial or annual training for direct care staff on postural supports, restricted conditions, or health services. |
| Resident records were incomplete and missing required documents. |
Report Facts
Staff reviewed: 3
POC Due Date: Aug 9, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Rob Huntley | Administrator | Met with Licensing Program Analyst during inspection and named in Plan of Correction agreement |
| Leo Lopez | Director of Nursing | Met with Licensing Program Analyst during inspection |
| Katie Brown | Licensing Program Analyst | Conducted the inspection and authored the report |
| Sergiy Pidgirny | Licensing Program Manager | Supervisor of Licensing Program Analyst |
Inspection Report
Complaint Investigation
Census: 77
Capacity: 128
Deficiencies: 0
Jul 19, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations received on 2023-03-24 regarding medication administration, unqualified staff administering injections, and staff vaping while oxygen tanks are in use.
Findings
The investigation found that medications were routinely given as scheduled, staff were trained to assist with injections using the 'Hand Over Hand Technique,' and no evidence was found of staff vaping in the facility. The allegations were unsubstantiated and no citations were issued.
Complaint Details
The complaint investigation was unsubstantiated as there was not a preponderance of evidence to prove the alleged violations occurred.
Report Facts
Capacity: 128
Census: 77
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Katie Brown | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Robert Huntley | Administrator | Met with Licensing Program Analyst during the investigation |
| Leonel Lopez | Director of Nursing | Met with Licensing Program Analyst during the investigation |
Inspection Report
Complaint Investigation
Census: 86
Capacity: 128
Deficiencies: 1
Sep 21, 2022
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by a complaint received on 2022-05-02 regarding personal rights violations and resident care needs.
Findings
The investigation substantiated that Resident 1 exhibited inappropriate outbursts and disturbances violating the personal rights of other residents. The allegation that Resident 1 needed a higher level of care was unsubstantiated as the facility determined the care needs were appropriate and issued a 30-day notice due to disruptive behaviors.
Complaint Details
The complaint investigation was substantiated for violation of personal rights due to Resident 1's disruptive and disrespectful behavior. The allegation that Resident 1 needed a higher level of care was unsubstantiated.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure residents were accorded dignity in their personal relationships with staff and others, evidenced by Resident 1's inappropriate behavior including yelling, cussing, and throwing items. | Type B |
Report Facts
Capacity: 128
Census: 86
Plan of Correction Due Date: Oct 30, 2022
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Katie Brown | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Christopher Smith | Interim Administrator | Met with Licensing Program Analyst during investigation and received report |
| Sergiy Pidgirny | Licensing Program Manager | Oversaw the complaint investigation |
Inspection Report
Complaint Investigation
Census: 86
Capacity: 128
Deficiencies: 0
Sep 21, 2022
Visit Reason
An unannounced complaint investigation visit was conducted in response to an allegation of a questionable death at the facility.
Findings
The investigation reviewed the resident's facility file, hospice file, and death certificate, finding the cause of death consistent with the primary hospice diagnosis. Interviews revealed inconsistent reports, and the allegation was determined to be unsubstantiated due to lack of preponderance of evidence.
Complaint Details
The complaint involved an allegation of a questionable death. The allegation was found to be unsubstantiated after review of documentation and interviews.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Katie Brown | Evaluator / Licensing Program Analyst | Conducted the complaint investigation and delivered findings. |
| Christopher Smith | Interim Administrator | Met with the Licensing Program Analyst during the investigation and received the report. |
Inspection Report
Complaint Investigation
Census: 86
Capacity: 128
Deficiencies: 1
Sep 21, 2022
Visit Reason
The visit was conducted to address an incident on 2022-09-14 where Resident 1 went absent without leave (AWOL). The facility submitted a Special Incident Report to the Community Care Licensing Division on 2022-09-20.
Findings
The facility failed to ensure the safety of Resident 1, who was able to jump over the facility wall and leave without staff knowledge, posing an immediate health and safety risk. A citation was issued for not meeting safety requirements related to dementia care and wandering behaviors.
Complaint Details
The visit was complaint-related due to an incident involving Resident 1 going absent without leave. The facility submitted a Special Incident Report and a citation was issued.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Licensee did not ensure that the needs of Resident 1's known wandering and exit seeking behaviors were met, allowing Resident 1 to jump over the facility wall and walk away without staff knowing Resident 1's whereabouts. | Type A |
Report Facts
Capacity: 128
Census: 86
Plan of Correction Due Date: Oct 28, 2022
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Christopher Smith | Interim Administrator | Met with Licensing Program Analyst during the visit |
| Katie Brown | Licensing Program Analyst | Conducted the case management visit and authored the report |
| Sergiy Pidgirny | Licensing Program Manager | Supervisor overseeing the licensing evaluation |
Inspection Report
Capacity: 128
Deficiencies: 1
Jun 29, 2022
Visit Reason
The visit was a Case Management - Health Checks conducted by Licensing Program Analyst Katie Brown to evaluate the facility's compliance and safety conditions.
Findings
The inspection found that disinfectants and cleaning solutions were stored unlocked and accessible to residents under bathroom sinks in Memory Support rooms 330, 307, and 301, posing an immediate health and safety risk.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Disinfectants and cleaning solutions were unlocked and accessible to residents under bathroom sinks in Memory Support rooms 330, 307, and 301. | Type A |
Report Facts
Plan of Correction Due Date: Jun 30, 2022
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Katie Brown | Licensing Program Analyst | Conducted the Case Management visit and documented findings |
| Lai Saeteum | Associate Executive Director | Met with Licensing Program Analyst during the visit |
| Sergiy Pidgirny | Licensing Program Manager | Supervisor and Licensing Program Manager overseeing the inspection |
Inspection Report
Complaint Investigation
Census: 94
Capacity: 128
Deficiencies: 0
Jun 14, 2022
Visit Reason
The visit was an unannounced complaint investigation triggered by an allegation that staff does not ensure the facility has adequate staffing to meet residents' needs.
Findings
The investigation reviewed staffing calendars and timesheets for January 2025 and found that the facility provided full staff coverage for all shifts. The allegation was found to be unfounded and dismissed with no citations issued.
Complaint Details
The complaint alleged inadequate staffing to meet residents' needs. The allegation was investigated and found to be unfounded.
Report Facts
Capacity: 128
Census: 94
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Katie Brown | Licensing Program Analyst | Conducted the complaint investigation |
| Becky Langdon | Interim Administrator/Operations Specialist | Met with Licensing Program Analyst during the investigation |
| Francisco Tamayo | Wellness Assistant | Met with Licensing Program Analyst and Interim Administrator to review staffing calendar and timesheets |
Inspection Report
Annual Inspection
Census: 73
Capacity: 128
Deficiencies: 0
Apr 25, 2022
Visit Reason
The Licensing Program Analyst conducted an unannounced Annual Infection Control Inspection to evaluate infection control procedures and compliance with COVID-19 related requirements.
Findings
The inspection found that infection control procedures were properly implemented, including symptom screenings, testing, visitation requirements, quarantine/isolation procedures, staffing, PPE use, and cleaning protocols. No deficiencies were cited during the inspection.
Report Facts
Forms requested: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Paige Williamson | Administrator | Met with Licensing Program Analyst during inspection |
| Katie Brown | Licensing Program Analyst | Conducted the Annual Infection Control Inspection |
| Sergiy Pidgirny | Licensing Program Manager | Named in report header |
Inspection Report
Complaint Investigation
Census: 73
Capacity: 128
Deficiencies: 0
Apr 25, 2022
Visit Reason
The visit was an unannounced Health and Safety Inspection conducted in conjunction with a 10-day complaint investigation (Control Number 24-AS-20220422110820).
Findings
The facility was found to be clean, odor free, and all walkways were unobstructed. Resident areas, kitchen, medication storage, and safety equipment were all observed to be in good condition. No deficiencies were cited during this Health & Safety Inspection.
Complaint Details
The visit was related to a complaint investigation with Control Number 24-AS-20220422110820. No deficiencies were cited, indicating no substantiated violations.
Report Facts
Facility Capacity: 128
Resident Census: 73
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Paige Williamson | Administrator | Facility Administrator met during the inspection and involved in the exit interview |
| Katie Brown | Licensing Program Analyst | Conducted the Health and Safety Inspection and complaint investigation |
| Sergiy Pidgirny | Licensing Program Manager | Named in the report as Licensing Program Manager |
Inspection Report
Follow-Up
Census: 83
Capacity: 128
Deficiencies: 1
Dec 8, 2021
Visit Reason
The visit was a Case Management follow-up to review Special Incident Reports (SIR) that were not submitted to the licensing agency within seven days of occurrence.
Findings
The facility failed to submit timely Special Incident Reports for incidents occurring on 9/14/21, 11/12/21, 11/13/21, 11/15/21, and 11/28/21, posing a potential health and safety risk to persons in care.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Licensee did not submit complete Special Incident Reports to CCLD within 7 days for incidents on 11/12/21, 11/13/21, 11/15/21, 11/28/21, and 9/14/21. | Type B |
Report Facts
Incident dates: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Katie Brown | Licensing Program Analyst | Conducted the Case Management visit and authored the report |
| Paige Williamson | Administrator | Facility Administrator met during the visit and was involved in the exit interview |
| Sergiy Pidgirny | Licensing Program Manager | Supervisor overseeing the licensing evaluation |
Inspection Report
Census: 83
Capacity: 128
Deficiencies: 0
Dec 8, 2021
Visit Reason
The visit was a Case Management follow-up to a Special Incident Report regarding an alleged physical altercation between two residents that occurred on 2021-10-03.
Findings
The Licensing Program Analyst reviewed resident files and interviewed the administrator. No deficiencies were cited during this Case Management visit.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Paige Williamson | Administrator | Met with Licensing Program Analyst during the Case Management visit and interviewed about the incident. |
| Katie Brown | Licensing Program Analyst | Conducted the unannounced Case Management visit. |
| Sergiy Pidgirny | Licensing Program Manager | Named in the report header. |
Inspection Report
Follow-Up
Census: 79
Capacity: 128
Deficiencies: 0
Sep 17, 2021
Visit Reason
The visit was an unannounced Case Management follow-up to incidents that occurred on 6/17/21 and 8/7/21, both reported by Special Incident Report (SIR).
Findings
The visit reviewed the incidents involving a resident absent without leave and a physical altercation between two residents. Documentation and corrective actions were reviewed, including window stops and room changes. No deficiencies were cited during this visit.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Katie Brown | Licensing Program Analyst | Conducted the Case Management visit and reviewed incidents. |
| Paige Williamson | Administrator | Met with Licensing Program Analyst during the visit and involved in incident follow-up. |
| Gladys Willhite | Business Office Manager | Met with Licensing Program Analyst during the visit. |
| Sergiy Pidgirny | Licensing Program Manager | Named in the report header. |
Inspection Report
Follow-Up
Census: 79
Capacity: 128
Deficiencies: 1
Aug 3, 2021
Visit Reason
The visit was an unannounced Case Management follow-up regarding an incident on 2021-07-27 involving a medication error.
Findings
A deficiency was found where the licensee did not ensure that Resident (R1) was assisted in taking the correct medication, posing an immediate health and safety risk to persons in care.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Licensee did not ensure that Resident (R1) was assisted in taking the correct medication. | Type A |
Report Facts
Deficiency due date: Aug 4, 2021
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Paige Williamson | Administrator | Met with Licensing Program Analyst during visit and named in findings |
| Katie Brown | Licensing Program Analyst | Conducted the Case Management Visit and authored the report |
| Sergiy Pidgirny | Licensing Program Manager | Supervisor named in report |
Inspection Report
Capacity: 128
Deficiencies: 0
Aug 3, 2021
Visit Reason
The visit was a Case Management - Other type of unannounced inspection to obtain a copy of documents from a resident's facility file.
Findings
The Licensing Program Analyst obtained a copy of documents from the resident's facility file. No other findings or deficiencies are stated.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Paige Williamson | Administrator | Met with during the visit and named as facility administrator. |
| Sergiy Pidgirny | Licensing Program Manager | Named as Licensing Program Manager. |
| Katie Brown | Licensing Program Analyst | Conducted the visit and obtained documents from resident's file. |
Inspection Report
Annual Inspection
Census: 73
Capacity: 128
Deficiencies: 0
May 25, 2021
Visit Reason
Licensing Program Analysts conducted an Annual Inspection as a required 1-year unannounced visit to evaluate compliance with licensing regulations.
Findings
The inspection included a tour of assisted living and memory care areas, review of infection control measures including PPE and staff training, and observation of COVID-19 mitigation practices. No deficiencies were observed during the inspection.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Paige Williamson | Administrator | Met with Licensing Program Analysts during the inspection and discussed the purpose of the visit. |
| Katie Brown | Licensing Program Analyst | Conducted the Annual Inspection. |
| Shawna Doucette | Licensing Program Analyst | Conducted the Annual Inspection. |
| Sergiy Pidgirny | Licensing Program Manager | Named as Licensing Program Manager on the report. |
Inspection Report
Complaint Investigation
Census: 68
Capacity: 128
Deficiencies: 0
Apr 8, 2021
Visit Reason
The visit was an unannounced complaint investigation triggered by an allegation that facility staff did not administer medication in a timely manner.
Findings
Based on interviews and records review, there was not a preponderance of evidence to prove the alleged violation occurred; therefore, the allegation was found to be unsubstantiated.
Complaint Details
The complaint investigation was unsubstantiated as there was insufficient evidence to prove the allegation that medication was not administered timely.
Report Facts
Capacity: 128
Census: 68
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Paige Williamson | Administrator | Met with during complaint investigation and discussed allegation |
| Mary Garza | Licensing Program Analyst | Conducted complaint investigation visit |
| Melinda Hoffmann | Licensing Program Manager | Named in report header |
Inspection Report
Complaint Investigation
Census: 68
Capacity: 128
Deficiencies: 0
Apr 7, 2021
Visit Reason
The visit was an unannounced complaint investigation triggered by allegations that a resident sustained serious injuries due to multiple falls and that staff did not seek timely medical attention for residents.
Findings
The investigation found the complaint to be unfounded, determining that the allegations were false or without reasonable basis. No injuries were confirmed from the reported falls, and staff actions were deemed appropriate.
Complaint Details
The complaint alleged that a resident sustained serious injuries due to multiple falls and that staff did not seek timely medical attention. The investigation concluded the allegations were unfounded and dismissed the complaint.
Report Facts
Capacity: 128
Census: 68
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Darius Williams | Licensing Program Analyst | Conducted the complaint investigation visit |
| Paige Williamson | Administrator | Facility administrator interviewed during the investigation |
Inspection Report
Complaint Investigation
Census: 69
Capacity: 128
Deficiencies: 0
Mar 22, 2021
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by a complaint alleging that staff did not respond to call buttons in a timely manner and failed to inform the responsible party of changes in a resident's condition.
Findings
The investigation found the allegation that staff did not respond to call buttons in a timely manner to be unsubstantiated due to lack of evidence. The allegation that staff failed to inform the responsible party of changes in the resident's condition was determined to be unfounded based on interviews and records review.
Complaint Details
The complaint alleged staff did not respond to call buttons timely and failed to inform the responsible party of changes in resident condition. The first allegation was unsubstantiated due to insufficient evidence. The second allegation was unfounded as the facility followed policy and notified the appropriate responsible party.
Report Facts
Capacity: 128
Census: 69
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Paige Williamson | Administrator | Met with during investigation and named in findings |
| Katie Brown | Licensing Program Analyst | Conducted the complaint investigation |
Inspection Report
Complaint Investigation
Census: 68
Capacity: 128
Deficiencies: 0
Mar 19, 2021
Visit Reason
The inspection was conducted as an unannounced complaint investigation following a complaint received on 07/07/2020 alleging that the facility does not have adequate staffing.
Findings
The investigation found the allegation that the facility does not have adequate staffing to be unfounded. Staff and residents confirmed that staff respond promptly and there are no issues with care. The complaint was dismissed.
Complaint Details
The complaint alleged inadequate staffing at the facility. The complaint was investigated and found to be unfounded.
Report Facts
Capacity: 128
Census: 68
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Paige Williamson | Administrator | Spoke with Licensing Program Analyst regarding complaint and investigation findings |
| Les Xiong | Licensing Program Analyst | Conducted complaint investigation |
| Sergiy Pidgirny | Licensing Program Manager | Named in report header |
Inspection Report
Complaint Investigation
Capacity: 128
Deficiencies: 1
Feb 12, 2021
Visit Reason
Unannounced complaint investigation visit conducted due to allegations including staff not seeking medical attention for a resident in a timely manner, questionable death, failure to notify authorized representative of health changes, failure to meet resident's needs, and staff not properly trained.
Findings
The investigation substantiated the allegation that staff did not seek medical attention for a resident in a timely manner, specifically failing to call 911 when requested. Other allegations including questionable death, failure to notify authorized representative, failure to meet resident's needs, and improper staff training were found to be unfounded or unsubstantiated.
Complaint Details
The complaint investigation was substantiated for failure to seek timely medical attention for a resident. Other allegations including questionable death, failure to notify authorized representative timely, failure to meet resident's needs, and improper staff training were found to be unfounded or unsubstantiated.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility staff did not call 911 when resident stated she was having a Heart Attack despite requests from resident and responsible party. | Type A |
Report Facts
Facility capacity: 128
Plan of Correction due date: Feb 16, 2021
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Paige Williamson | Administrator | Facility administrator met during investigation |
| Katie Brown | Evaluator / Licensing Program Analyst | Investigator conducting complaint investigation |
| Sergiy Pidgirny | Licensing Program Manager | Licensing program manager overseeing investigation |
Inspection Report
Complaint Investigation
Census: 68
Capacity: 128
Deficiencies: 0
Jan 27, 2021
Visit Reason
The visit was conducted as a Healthy and Safety Check in conjunction with a complaint dated 1/27/2021, focusing on Covid-19 precautionary measures and related procedures.
Findings
No deficiencies were cited during the inspection. The Licensing Program Analyst and the Administrator reviewed Covid-19 mitigation procedures, personnel protective equipment, and fall/injury procedures.
Complaint Details
The visit was related to a complaint referenced as LIC 9099 dated 1/27/2021. The complaint was investigated through a health and safety check.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Paige Williamson | Administrator | Met with Licensing Program Analyst during the health and safety check and reviewed Covid-19 mitigation procedures. |
| Darius Williams | Licensing Program Analyst | Conducted the Healthy and Safety Check with the facility Administrator. |
| Serigy Pidgirny | Licensing Program Manager | Named in the report header and signature section. |
Inspection Report
Complaint Investigation
Census: 70
Capacity: 128
Deficiencies: 1
Oct 29, 2020
Visit Reason
The inspection was an unannounced complaint investigation triggered by a complaint received on 05/06/2020 regarding medication administration and staffing concerns at Kingston Bay Senior Living Facility.
Findings
The investigation substantiated that staff did not administer residents' morning medications as prescribed by a physician, resulting in a failure to meet medical needs and posing an immediate health and safety risk. Another allegation regarding insufficient staff to meet residents' needs was unsubstantiated.
Complaint Details
The complaint was substantiated regarding medication administration delays due to only one Med-Tech on duty who fell behind, confirming medications were not administered as prescribed. The allegation of insufficient staff to meet residents' needs was unsubstantiated based on resident interviews.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility failed to administer residents’ morning medications as prescribed by a physician. | Type A |
Report Facts
Capacity: 128
Census: 70
Deficiencies cited: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Paige Williamson | Administrator | Named in medication administration findings and discussions |
| See Moua | Licensing Program Analyst | Conducted the complaint investigation |
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