Deficiencies per Year
4
3
2
1
0
Unclassified
Census Over Time
Census
Capacity
Inspection Report
Renewal
Census: 10
Capacity: 20
Deficiencies: 3
Apr 22, 2025
Visit Reason
The inspection was conducted as a renewal licensing study for the facility to assess compliance with applicable rules and regulations.
Findings
The facility was found to be non-compliant with several rules including failure to complete a resident assessment plan at admission, incomplete resident funds transaction forms for multiple residents, and maintenance issues with the floor in the heat plant room.
Deficiencies (3)
| Description |
|---|
| Resident B's written assessment plan was not completed at the time of admission. |
| Resident Funds Part II forms were not completed for Residents A, B, and C, and no authorization for substitute forms was documented. |
| The floor in the heat plant room was not in good condition and required repair or replacement. |
Report Facts
Number of residents interviewed and/or observed: 10
Facility capacity: 20
Number of staff interviewed and/or observed: 4
Date of on-site inspection: Apr 22, 2025
Date of Bureau of Fire Services Inspection: Mar 5, 2025
Inspection Report
Complaint Investigation
Capacity: 20
Deficiencies: 3
Jan 16, 2024
Visit Reason
The inspection was conducted in response to a complaint alleging multiple issues regarding Resident A's care and facility conditions, including missing personal items, inadequate foot care, malfunctioning pressure mattress, improper diabetic diet, insufficient personal care, and poor bedroom carpet condition.
Findings
The investigation found that the direct care staff did not provide Resident A with a diabetic diet as ordered, and the resident's assessment plan and inventory of valuables form were not properly updated or maintained, constituting violations. Other allegations including missing personal items, foot care, pressure mattress care, personal hygiene, and carpet condition were not substantiated or found to be in violation.
Complaint Details
The complaint alleged missing personal clothing and hygiene products, failure to follow physician's foot care orders, malfunctioning alternating pressure mattress, failure to provide diabetic diet, inadequate personal care, and stained carpet in Resident A's bedroom. Only the diabetic diet and related documentation issues were substantiated.
Deficiencies (3)
| Description |
|---|
| Direct care staff did not provide Resident A with a diabetic diet as ordered by the physician. |
| Resident A's assessment plan was not updated to reflect the diabetic diet order. |
| Resident A's Inventory of Valuables form was not on file in the resident record. |
Report Facts
Facility capacity: 20
Complaint receipt date: Jan 5, 2024
Investigation initiation date: Jan 9, 2024
Report due date: Mar 5, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Megan Fry | Administrator and Licensee Designee | Named as licensee designee and administrator of the facility |
| Darlene Gonzalez | Resident Care Coordinator | Interviewed regarding care and facility issues |
| Aaron Biller | Director of Dining Services | Interviewed regarding dietary services and diabetic diet |
| Heidi Smith | Direct Care Staff | Interviewed regarding Resident A's care |
| Heaven Abram | Direct Care Staff | Interviewed regarding Resident A's care |
| Zachary Fisher | Executive Director | Corresponded regarding Resident A's care and documentation |
Inspection Report
Renewal
Census: 19
Capacity: 20
Deficiencies: 1
Apr 24, 2023
Visit Reason
The inspection was conducted as a Renewal Licensing Study to assess compliance with licensing requirements and to determine if the facility's license should be renewed.
Findings
The facility was found to be in substantial compliance with rules and requirements overall, but was cited for non-compliance related to emergency preparedness, specifically the evacuation plan not being updated to accurately reflect a resident's needs.
Deficiencies (1)
| Description |
|---|
| The facility's written emergency procedure and evacuation plan had not been updated to accurately reflect Resident A’s needs. |
Report Facts
Number of residents interviewed and/or observed: 19
Capacity: 20
Number of staff interviewed and/or observed: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Julie Elkins | Licensing Consultant | Author of the inspection report and contact for questions |
| Megan Fry | Administrator | Licensee designee and administrator of the facility |
Inspection Report
Original Licensing
Capacity: 20
Deficiencies: 0
Oct 9, 2020
Visit Reason
The visit was conducted as an original licensing study to determine compliance with applicable licensing statutes and administrative rules for the facility Prestige Way #2.
Findings
The facility was found to be in substantial compliance with licensing requirements, including physical plant standards and program descriptions. A temporary license with a maximum capacity of 20 residents was recommended and issued.
Report Facts
Facility capacity: 20
Room count: 16
Staff to resident ratio: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Megan Fry | Licensee Designee | Named as licensee designee with qualifications and experience in therapeutic recreation and care for aged and Alzheimer's population. |
| Amanda Dunlap | Administrator | Named as administrator with medical assistant certification and experience in adult foster care. |
| Derrick Britton | Licensing Consultant | Author of the licensing study report and recommendation. |
| Dawn N. Timm | Area Manager | Approved the licensing report. |
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