Inspection Report
Renewal
Census: 18
Capacity: 46
Deficiencies: 2
Sep 19, 2025
Visit Reason
The visit was conducted as a renewal licensing study to evaluate compliance with licensing rules and regulations for Passion and Caring Home for the Elderly.
Findings
The facility was found to be in non-compliance with medication administration documentation and plumbing maintenance requirements, specifically missed documentation on medication administration records for multiple residents and a leaking faucet in bathroom #1.
Deficiencies (2)
| Description |
|---|
| Multiple missed documentation noted on Resident A, B, C, D, and E’s medication administration records. |
| The faucet on the sink in bathroom #1 leaked, indicating a plumbing maintenance issue. |
Report Facts
Number of residents interviewed and/or observed: 18
Number of staff interviewed and/or observed: 3
Facility capacity: 46
Inspection Report
Renewal
Census: 18
Capacity: 46
Deficiencies: 0
Oct 10, 2023
Visit Reason
The inspection was conducted as a renewal inspection to determine compliance with applicable licensing statutes and rules for the Passion and Caring Home for the Elderly.
Findings
The facility was found to be in substantial compliance with the public health code and administrative rules regulating home for the aged facilities. Renewal of the license is recommended.
Report Facts
Number of staff interviewed and/or observed: 3
Number of residents interviewed and/or observed: 18
Capacity: 46
Inspection Report
Original Licensing
Capacity: 46
Deficiencies: 1
Feb 15, 2017
Visit Reason
The visit was conducted as part of an original licensing study and a special investigation report review, including a capacity reduction request from 47 to 46 beds due to inconsistencies in room sheets and floor plans.
Findings
The facility's licensed capacity was reduced from 47 to 46 beds after an engineering inspection found discrepancies between the original room sheets and the current floor plan. The facility lacks a barrier-free bathroom and has limited accessibility features. A corrective action plan was submitted addressing bathroom accessibility and resident placement criteria.
Deficiencies (1)
| Description |
|---|
| The doorway into the first floor bathroom did not meet minimum requirements to be considered a barrier-free room. |
Report Facts
Capacity reduction: 1
Bathroom floor clearance: 4.5
Bathroom doorway width: 30
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Gena Payne | Owner/Authorized Representative/Administrator | Named in relation to corrective action plan and facility capacity update |
| Pier-George Zanoni | Engineer | Conducted on-site inspection and updated room sheets |
| Andrea Krausmann | Licensing Staff | Author of the report and recommendation |
Inspection Report
Original Licensing
Capacity: 47
Deficiencies: 5
Oct 29, 2003
Visit Reason
The inspection was conducted as an original licensing study for the Passion and Caring Home for the Elderly to determine compliance with applicable licensing statutes and administrative rules.
Findings
The facility was found to be in substantial compliance with licensing requirements, but several violations were noted including incomplete medication administration records, lack of criminal background checks for employees, absence of annual tuberculosis testing documentation, broken garage windows with shattered glass, and hot water temperature exceeding the regulated limit.
Deficiencies (5)
| Description |
|---|
| Medication administration records did not contain a full and complete record of treatments provided, with missing entries and no explanations for omissions. |
| Employee records lacked required criminal background checks. |
| Resident records lacked evidence of annual tuberculosis testing. |
| Broken windowpanes in garage with shattered glass around window frames. |
| Hot water temperature at bathtub faucet exceeded the regulated maximum of 110 degrees Fahrenheit, measuring 121 degrees Fahrenheit. |
Report Facts
Facility capacity: 47
Hot water temperature: 121
Medication omission dates: 4
Medication omission dates: 4
Number of bedrooms: 16
Number of beds: 45
Resident records reviewed: 4
Employee records reviewed: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Gena Payne | Administrator/Licensee Designee, R.N. | Discussed employee criminal background check requirements and licensing application |
| Linda Denniston | Licensing Staff | Conducted licensing study and authored report |
| Barbara Smalley | Area Manager | Approved licensing study report |
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