Inspection Report Summary
Most inspections found no deficiencies, including the most recent annual inspection on August 7, 2025, which was clean with no violations noted. There was a medication error in May 2025 where two residents’ medications were mixed up, resulting in a cited deficiency for failure to administer medication as prescribed, though no harm occurred. Earlier in August 2024, a deficiency was cited for staff not meeting required training hours, but no other serious issues or enforcement actions were reported. Several complaint investigations over the past years were unsubstantiated, addressing concerns about medication management, facility cleanliness, and resident care. The facility’s record shows improvement since the more serious deficiencies in 2020 related to delayed medical care after a resident injury, with recent reports reflecting better compliance and fewer issues.
Deficiencies per Year
4
3
2
1
0
High
Moderate
Unclassified
Census Over Time
Census
Capacity
Inspection Report
Annual Inspection
Census: 71
Capacity: 88
Deficiencies: 0
Aug 7, 2025
Visit Reason
The visit was an unannounced annual inspection conducted to evaluate the health and safety compliance of the facility.
Findings
The inspection found no deficiencies or violations related to health, safety, or personal rights. The facility was found to have adequate food supply, proper medication storage, and all staff had criminal record clearances.
Report Facts
Residents receiving hospice services: 6
Resident files reviewed: 10
Resident medications reviewed: 2
Staff files reviewed: 10
Rooms toured: 8
Hot water temperature: 105.6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Anyssa Hill | Executive Director | Met with Licensing Program Analyst during inspection |
| Cheyenne Ratajczak | Licensing Program Analyst | Conducted the annual inspection |
| Laura Munoz | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Follow-Up
Census: 72
Capacity: 88
Deficiencies: 1
May 9, 2025
Visit Reason
The visit was an unannounced case management follow-up on an Unusual Incident/Injury Report regarding a medication error reported on 2025-04-28.
Findings
The facility staff mixed up medication cups for two residents, resulting in Resident #1 receiving Resident #2's medication Seroquel 25mg. Resident #1 had no adverse reaction. The facility immediately contacted poison control and the resident's doctor. A deficiency was cited for failure to administer medication as prescribed, posing a potential health and safety risk.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to give Resident #1 their medication as prescribed, posing a potential health and safety risk. | Type B |
Report Facts
Capacity: 88
Census: 72
Plan of Correction Due Date: May 23, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Anyssa Hill | Executive Director | Met with Licensing Program Analyst during inspection and involved in incident |
| Cheyenne Ratajczak | Licensing Program Analyst | Conducted the inspection visit and authored the report |
| Laura Munoz | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Complaint Investigation
Census: 71
Capacity: 88
Deficiencies: 0
Apr 2, 2025
Visit Reason
The visit was an unannounced case management inspection triggered by an incident report submitted by the facility concerning an incident that occurred on 2025-03-15.
Findings
During the visit, Licensing Program Analysts interviewed the Executive Director and Memory Care Director regarding the incident and reviewed resident documents. No deficiencies were cited at this time.
Complaint Details
The visit was complaint-related due to an incident report submitted by the facility. The complaint was investigated through interviews and document review, and no deficiencies were found.
Report Facts
Incident date: Mar 15, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Anyssa Hill | Executive Director | Met during the visit and interviewed regarding the incident |
| Michael Clymo | Former Executive Director | Mentioned as no longer the ED as of March 17, 2025 |
| Cheyenne Ratajczak | Licensing Program Analyst | Conducted the inspection visit |
| Cassandra Mikkelson | Licensing Program Analyst | Conducted the inspection visit |
Inspection Report
Complaint Investigation
Census: 71
Capacity: 88
Deficiencies: 0
Dec 18, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by an allegation that facility staff mismanaged a client's medication.
Findings
The investigation included interviews with staff and residents, observation of medication administration records and the medication room, and a facility tour. The allegation was found to be unsubstantiated as no evidence of medication mismanagement was observed or reported.
Complaint Details
The complaint alleged that facility staff mismanaged a client's medication. After investigation, including interviews with six staff members and thirteen residents, and review of medication records, the allegation was found to be unsubstantiated due to lack of preponderance of evidence.
Report Facts
Estimated Days of Completion: 15
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Michael Clymo | Executive Director | Met with investigators during the complaint investigation and exit interview |
| Cassandra Mikkelson | Licensing Program Analyst | Conducted the complaint investigation |
| Anthony Perez | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Complaint Investigation
Census: 70
Capacity: 88
Deficiencies: 0
Oct 2, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations received on 2024-09-09 regarding facility odor, resident hygiene needs, and facility upkeep.
Findings
The Licensing Program Analyst investigated three allegations: the facility being malodorous, staff not meeting residents' hygiene needs, and the facility being unkempt. After touring the facility, interviewing staff, and observing residents and common areas, all allegations were found to be unfounded.
Complaint Details
The complaint investigation was unannounced and addressed allegations that the facility was malodorous, staff were not meeting residents' hygiene needs, and the facility was unkempt. After investigation, all allegations were determined to be unfounded, meaning they were false or without reasonable basis.
Report Facts
Capacity: 88
Census: 70
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Michael Clymo | Administrator | Met with Licensing Program Analyst during inspection |
| Bethany Mirlohi | Licensing Program Analyst | Conducted the complaint investigation |
| Troy Ordonez | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 71
Capacity: 88
Deficiencies: 0
Aug 29, 2024
Visit Reason
The inspection was an unannounced case management visit to review a death report received from the facility.
Findings
During the inspection, no deficiencies were cited. The Licensing Program Analyst reviewed the resident file and spoke with the Health Services Director about the incident.
Complaint Details
The visit was triggered by a death report received from the facility. No deficiencies were cited during the investigation.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kelly Kolodziej | Health Services Director | Met with Licensing Program Analyst during the inspection and discussed the incident. |
| Bethany Mirlohi | Licensing Program Analyst | Conducted the unannounced case management visit and reviewed the death report. |
Inspection Report
Annual Inspection
Census: 74
Capacity: 88
Deficiencies: 1
Aug 22, 2024
Visit Reason
The visit was an unannounced annual inspection conducted to evaluate the health, safety, and compliance of the facility with regulatory requirements.
Findings
The inspection found no immediate health, safety, or personal rights violations in the areas toured. However, deficiencies were cited related to staff training requirements, specifically that 3 out of 10 care staff did not meet mandated training hours.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Licensee did not comply with training requirements for 3 out of 10 care staff, including dementia care and hospice care training. | Type B |
Report Facts
Residents receiving hospice care: 2
Resident files reviewed: 10
Staff files reviewed: 10
Resident medications reviewed: 3
Care staff non-compliant with training: 3
Total care staff reviewed: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Michael Clymo | Administrator | Met with Licensing Program Analyst during inspection |
| Bethany Mirlohi | Licensing Program Analyst | Conducted the annual inspection and authored the report |
| Troy Ordonez | Licensing Program Manager | Supervisor overseeing the inspection |
Inspection Report
Census: 66
Capacity: 88
Deficiencies: 0
May 15, 2024
Visit Reason
The inspection was an unannounced case management visit to discuss two separate incident reports received from the facility.
Findings
The facility appeared to have followed proper protocol and regulation on each incident. No deficiencies were cited during the inspection.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Michael Clymo | Administrator | Met with Licensing Program Analyst during the inspection and discussed incident reports. |
Inspection Report
Annual Inspection
Census: 69
Capacity: 88
Deficiencies: 0
Aug 24, 2023
Visit Reason
The inspection was conducted as a required unannounced annual visit using the CARE Tool to evaluate the facility's compliance with regulations.
Findings
The facility was found to be clean, well-maintained, and spacious with adequate food supplies and proper storage of medications and harmful substances. Staff files and resident documentation were reviewed and found to be in order. No deficiencies were cited at this visit.
Report Facts
Resident files reviewed: 7
Hot water temperature range: 105
Hot water temperature range: 107
Hot water temperature tested: 110
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Michael Clymo | Executive Director | Met with Licensing Program Analyst and participated in facility tour and CARE tool review |
Inspection Report
Complaint Investigation
Census: 73
Capacity: 88
Deficiencies: 0
Oct 21, 2022
Visit Reason
Unannounced complaint investigation visit conducted in response to allegations that a resident sustained unexplained fractures and bruising while in care.
Findings
The investigation found no preponderance of evidence to prove the alleged violations occurred; the allegations were determined to be unsubstantiated based on medical records, staff interviews, and expert opinion.
Complaint Details
The complaint involved allegations that a resident sustained unexplained fractures and bruising while in care. The investigation included interviews, medical record reviews, and expert consultation. The fractures were of indeterminate age and possibly unrelated to the bruising. The resident had Osteopenia and a high fracture risk. The allegations were found to be unsubstantiated.
Report Facts
Facility capacity: 88
Resident census: 73
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Lavinia Muscan | Licensing Program Analyst | Conducted the complaint investigation |
| Michael Clymo | Administrator | Met with Licensing Program Analyst during investigation |
| Laura Munoz | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Annual Inspection
Census: 74
Capacity: 88
Deficiencies: 0
Sep 22, 2022
Visit Reason
The inspection was an unannounced Required-1 Year Inspection focusing on the infection control domain to ensure compliance with health and safety regulations.
Findings
The facility was found to be in substantial compliance with no immediate health, safety, or personal rights violations observed. No deficiencies were cited as a result of the inspection.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Michael Clymo | Executive Director | Met with Licensing Program Analyst during inspection and explained the purpose of the visit. |
| Sarena Keosavang | Licensing Program Analyst | Conducted the Required-1 Year Inspection and infection control domain evaluation. |
| Anthony Perez | Licensing Program Manager | Named as Licensing Program Manager on the report. |
Inspection Report
Complaint Investigation
Census: 74
Capacity: 88
Deficiencies: 0
Sep 14, 2022
Visit Reason
An unannounced complaint investigation visit was conducted in response to allegations received on 2022-04-25 regarding an outbreak, unsafe and uncomfortable environment, and unsanitary conditions at the facility.
Findings
The investigation found the allegation of an outbreak to be unsubstantiated as the local public health did not consider the GI illness an outbreak. The allegations that the facility failed to provide a safe and comfortable environment and that the facility was unsanitary were both found to be unfounded based on resident and staff interviews and observations during the inspection.
Complaint Details
The complaint investigation was unannounced and addressed allegations of a facility outbreak, unsafe and uncomfortable environment, and unsanitary conditions. The outbreak allegation was unsubstantiated, while the other two allegations were unfounded.
Report Facts
Residents with GI illness symptoms: 10
Complaint receipt date: Complaint received on 2022-04-25.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Michael Clymo | Administrator | Met with Licensing Program Analyst during the investigation and named in the exit interview. |
| Lavinia Muscan | Licensing Program Analyst | Conducted the complaint investigation. |
| Laura Munoz | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation. |
Inspection Report
Annual Inspection
Census: 71
Capacity: 88
Deficiencies: 0
Aug 18, 2021
Visit Reason
The inspection was a Required - 1 Year unannounced visit to conduct an annual inspection utilizing the infection control domain.
Findings
The facility was found to be in substantial compliance with no immediate health, safety, or personal rights violations observed. No deficiencies were cited as a result of the inspection.
Report Facts
Apartments toured: 10
Public restrooms toured: 6
Dining rooms toured: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Pouya Ansari | Administrator | Met with Licensing Program Analyst during inspection and involved in infection control domain review. |
| Konnor Leitzell | Licensing Program Analyst | Conducted the Required - 1 Year Inspection and infection control domain evaluation. |
| Troy Ordonez | Licensing Program Manager | Named in the report as Licensing Program Manager. |
Inspection Report
Complaint Investigation
Census: 64
Capacity: 88
Deficiencies: 4
Nov 9, 2020
Visit Reason
The inspection was conducted as a case management incident investigation following a self-reported incident by the facility regarding a resident found outside after apparently falling out of a window on 07/06/2020.
Findings
The facility failed to seek timely medical care for the resident after the injury, despite the resident's complaints of pain and requests for hospital evaluation. Deficiencies were cited for failure to observe changes in the resident's condition and failure to provide requested medical care, posing immediate and potential health and safety risks.
Complaint Details
The investigation was triggered by a self-reported incident where a resident fell from a window on 07/06/2020. The facility delayed medical care despite the resident's complaints and requests for hospital evaluation. The complaint was substantiated with cited deficiencies.
Severity Breakdown
Type A: 2
Deficiencies (4)
| Description | Severity |
|---|---|
| The licensee failed to observe the resident's change in condition and seek timely medical care, posing an immediate health and safety risk. | — |
| The facility failed to provide medical care after the resident requested hospital evaluation multiple times, posing a potential health and safety risk. | — |
| The licensee did not immediately telephone 9-1-1 after the resident sustained an injury resulting in imminent threat to health. | Type A |
| The staff did not ensure the resident received requested medical care. | Type A |
Report Facts
Capacity: 88
Census: 64
Deficiencies cited: 4
Plan of Correction Due Date: Nov 10, 2020
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Pouya Ansari | Administrator | Facility administrator involved in the incident and exit interview |
| Konnor Leitzell | Licensing Program Analyst | Conducted investigation and authored report |
| Troy Ordonez | Licensing Program Manager | Supervising licensing official named in report |
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