Inspection Reports for
Prospect Manor

The facility was found to have some deficiencies including hot water temperature exceeding regulatory limits, maintenance issues such as a broken sliding door and shelf, and minor repairs needed for soap dispensers and window screens. Overall, the facility maintains adequate staffing, training, and operational requirements with no residents having prohibited health conditions.

The complaint investigation was substantiated for failure to notify the responsible party of an incident on 6/11/25. The allegation that staff did not provide adequate supervision resulting in a resident attack was unsubstantiated due to lack of preponderance of evidence.

The investigation substantiated that facility staff failed to notify the responsible party of an incident on 6/11/25, despite attempts to notify on 5/7/25. The allegation of inadequate supervision resulting in a resident attack was unsubstantiated due to insufficient evidence, though the facility took action after the first incident by relocating the resident involved.

The complaint alleging lack of staff supervision resulting in resident eloping was substantiated based on interviews, record review, and evidence that Resident #1 was found outside the facility and hospitalized. The resident is not able to leave unassisted and staff failed to prevent elopement.

The investigation substantiated that Resident #1, who cannot leave the facility unassisted, eloped from the facility and was found by law enforcement hospitalized for dehydration. Staff interviews and record reviews confirmed the resident's inability to leave unassisted and the facility's failure to provide adequate supervision.

The facility was generally found to be in good repair and clean, with adequate supplies and safety equipment. However, deficiencies were noted related to water temperature exceeding regulatory limits and the absence of skid mats in some bathrooms.

The complaint alleged that facility staff did not provide adequate supervision resulting in a resident eloping from the facility. The allegation was substantiated based on interviews, document reviews, and observations. Immediate $500 civil penalties were assessed due to lack of care and supervision.

The investigation substantiated that a resident with dementia left the facility unattended and was missing for several hours. The facility failed to properly assess or reassess the resident based on changes in condition, posing an immediate health and safety risk.

The investigation was triggered by complaint 28-AS-20230922133247. The complaint was substantiated as deficiencies were found related to failure to report incidents, falsification of records, and missing medical assessment documentation.

The facility failed to report incidents when a resident refused wound care, falsified records regarding wound care provision, and lacked a medical assessment in the resident's file prior to admission.

The complaint alleged staff neglected a resident's wound care. The allegation was substantiated based on interviews and document review. The resident refused wound care on multiple days, but the facility failed to notify the physician or take appropriate action. An immediate civil penalty of $500 was issued.

The investigation substantiated that the facility neglected resident R1's wound care by retaining him with a stage 4 wound and failing to meet basic service requirements. Staff and residents denied the allegation, but records showed R1 refused wound care and the facility failed to notify appropriate parties or take action to meet R1's higher care needs.

The facility was found to have several deficiencies including water temperature exceeding required limits, medication administration errors, and maintenance issues such as a caved-in kitchen wall and a broken shower faucet. Plans of correction were submitted with due dates for remediation.

The complaint investigation was substantiated for the allegation that staff were sleeping during shifts, based on camera evidence and staff resignation. The allegation of bedbugs was unsubstantiated after interviews and inspections.

The allegation that staff were sleeping on the job was substantiated based on camera footage and staff resignation. The allegation of bedbugs in the facility was unsubstantiated after interviews, tours, and pest control report reviews.

The inspection found several deficiencies related to water temperature in resident rooms and kitchen sinks, posing immediate health and safety risks. The facility was otherwise clean and well-maintained with appropriate staffing and safety equipment.

The complaint was substantiated based on interviews, text messages, and observations. Resident #1 was found to be a victim of sexual abuse by Staff #1. The relationship was deemed non-consensual due to the resident being overly medicated. An immediate civil penalty was issued.

The investigation substantiated that Resident #1 was sexually abused by Staff #1, who admitted to hugging and kissing the resident and was found hiding in the resident's closet. An immediate civil penalty of $500 was issued.

The visit was complaint-related and involved a case management review of medication administration. Specific complaints involved medication labeling and documentation errors.

The inspection found medication sheets were not updated for morning doses, medication bubble packs were out of cycle, and a pharmacy labeling error was observed. Deficiencies were cited related to medication labeling and documentation.

The complaint investigation was substantiated for the allegation that the facility elevator was in disrepair. Other allegations regarding activities, medication administration, and fire escape routes were unsubstantiated.

The elevator was found to be in disrepair and not working for about a month, substantiating that allegation. Allegations regarding lack of activities, improper medication administration, and unsafe escape routes were unsubstantiated based on interviews and document reviews.

A technical violation was issued during the visit, but no deficiencies were noted. The facility was found to be compliant with infection control measures, food storage, medication review, and COVID-19 protocols.

The complaint investigation was substantiated regarding residents smoking inside the facility. Other allegations including bed bugs, cockroaches, smoke alarms, obstructed room door, elevator disrepair, and lack of resident council were unsubstantiated.

The investigation substantiated that residents were smoking inside the facility, specifically in rooms and balconies, posing a health and safety risk. All other allegations including bed bugs, cockroaches, smoke alarms, obstructed room door, elevator disrepair, and absence of a resident council were found unsubstantiated based on observations, interviews, and document review.

The complaint investigation was substantiated based on observations of facility disrepair and environmental safety issues. The preponderance of evidence standard was met.

The investigation substantiated the allegation of disrepair, noting issues such as a plastic-covered hole in the dining room ceiling, refrigerator and freezer temperatures above required limits, cracked and ripped window screens, balcony screen door off rails, peeling ceiling paint, and rusted sink drains. Water temperatures in several rooms were below the required range.

The oxygen tanks previously observed in storage room #229 were removed, and staff were observed wearing face masks properly per CDC guidelines. The administrator submitted documentation of staff training, and the deficiencies have been cleared.

The inspection found that smoke was caused by a smoldering structural member which was extinguished. Two oxygen tanks were improperly stored in a room above the incident site, posing a safety risk, and deficiencies related to oxygen equipment disposal were cited.

Staff #1 was observed wearing a face covering under the chin, not covering nose or mouth, and staff #2 removed their mask during the tour citing feeling out of breath. This posed an immediate health, safety, and personal rights risk to residents and staff.

The complaint investigation was substantiated for allegations of medication mishandling, inadequate feeding, poor record keeping, failure to meet incontinence needs, and lack of laundry services. Allegations regarding insufficient administrator presence, staff qualifications, and health-related services were unsubstantiated.

The investigation substantiated multiple allegations including mishandling of residents' medications, inadequate feeding, poor record keeping, failure to meet incontinence needs, and lack of laundry services during the period when Temporary Manager #1 was operating the facility. Other allegations regarding administrator presence, staff qualifications, and health-related services were unsubstantiated.

The complaint investigation was triggered by allegations received on 01/08/2021 regarding failure to report incidents, lack of planned activities, inability to assist residents with dementia, failure to distribute mail, and failure to prevent wandering. The investigation found the allegations about mail distribution and wandering to be substantiated, while other allegations were unsubstantiated.

The investigation substantiated that residents did not receive personal mail in a timely manner and that staff failed to prevent a resident with a history of wandering from leaving the facility unsupervised on two occasions. Other allegations, including improper incident reporting, lack of planned activities during COVID-19, and inability to assist residents with dementia, were found to be unsubstantiated.