Inspection Report Summary
Most inspections found no deficiencies, with the facility consistently maintaining clean, safe, and well-maintained conditions. The most recent report from December 31, 2024, was a complaint investigation that found no substantiated issues regarding staff behavior. Two earlier complaint investigations in 2024 also found all allegations unsubstantiated, showing a pattern of concerns that were not confirmed. However, there were two substantiated deficiencies in the past: a medication error in December 2021 where a resident received another’s medication, and an incident in January 2024 when a gate was left open during construction, posing a safety risk. Since then, no deficiencies have been cited, indicating improvement in compliance and safety practices.
Deficiencies per Year
4
3
2
1
0
High
Moderate
Census Over Time
Census
Capacity
Inspection Report
Complaint Investigation
Census: 64
Capacity: 72
Deficiencies: 0
Dec 31, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations received on 2024-10-15 regarding staff behavior towards residents.
Findings
The investigation found no corroborated evidence that staff spoke to or handled residents inappropriately. Observations and interviews conducted in all four cottages serving memory care residents did not reveal any inappropriate staff behavior. Both allegations were unsubstantiated.
Complaint Details
The complaint involved allegations that staff did not ensure residents were spoken to or handled in an appropriate manner. After interviews, observations, and review of documentation, these allegations were found to be unsubstantiated.
Report Facts
Capacity: 72
Census: 64
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Michael Bilger | Licensing Program Analyst | Conducted the complaint investigation and observations |
| Irene Charnell | Executive Director | Met with Licensing Program Analyst during the investigation |
| Liza King | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Complaint Investigation
Census: 67
Capacity: 72
Deficiencies: 0
Dec 4, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations received on 2024-10-15 regarding pest presence, staff health, and equipment maintenance at the facility.
Findings
The investigation found no preponderance of evidence to substantiate the allegations. Observations and interviews confirmed the facility is kept free of pests, staff are in good health to perform assigned tasks, and equipment is maintained and in good repair. All allegations were unsubstantiated.
Complaint Details
The complaint investigation addressed three allegations: 1) facility not kept free of pests, 2) staff not in good health to perform tasks, and 3) equipment not maintained and in good repair. All allegations were found unsubstantiated based on interviews, observations, and record reviews.
Report Facts
Facility capacity: 72
Census: 67
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Michael Bilger | Licensing Program Analyst | Conducted the complaint investigation and interviews |
| Irene Charnell | Executive Director | Met with Licensing Program Analyst during investigation |
| Liza King | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Annual Inspection
Census: 67
Capacity: 72
Deficiencies: 0
Oct 10, 2024
Visit Reason
The inspection was conducted as a required 1 year annual inspection to evaluate the facility's compliance with health and safety regulations.
Findings
The facility was found to be clean, odor-free, and in good repair with all rooms properly furnished and sufficiently lit. Water temperatures, food supplies, fire safety equipment, carbon monoxide detectors, first aid kits, and medication storage were all in compliance. No deficiencies were cited during the inspection.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kevin Gould | Licensing Program Analyst | Conducted the inspection and authored the report. |
| Irene Charnell | Administrator | Met with Licensing Program Analyst and participated in the facility tour. |
Inspection Report
Complaint Investigation
Census: 71
Capacity: 72
Deficiencies: 0
Jun 20, 2024
Visit Reason
An unannounced case management inspection was conducted to address concerns of recent falls within the last week at the facility.
Findings
The Licensing Program Analyst reviewed recent falls and incident reports, observed residents, and met with one resident regarding a recent fall. All recently reported falls had varying circumstances and occurred at different times and locations. No deficiencies were observed during the inspection.
Complaint Details
The visit was complaint-related due to concerns about recent falls. No deficiencies were found, and the complaint was effectively investigated.
Report Facts
Capacity: 72
Census: 71
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kevin Gould | Licensing Program Analyst | Conducted the inspection and investigation of recent falls |
| Nicole Hemenover | RSC, LVN | Met with the Licensing Program Analyst to discuss recent falls |
Inspection Report
Complaint Investigation
Census: 69
Capacity: 72
Deficiencies: 0
May 9, 2024
Visit Reason
Unannounced complaint investigation visit conducted to investigate allegations including staff not preventing resident altercations, locking a resident out of the facility, failure to follow reporting requirements, and indecent exposure incidents.
Findings
Based on interviews with staff and residents, the investigation was unable to corroborate the allegations. No evidence was found to support claims of resident pushing, indecent exposure, or locking residents out. The allegations were determined to be unsubstantiated.
Complaint Details
The complaint investigation was unsubstantiated. Allegations included staff failing to prevent resident pushing, locking a resident out, failure to report incidents, and indecent exposure. Interviews with five staff and three residents did not corroborate these claims. The department found no preponderance of evidence to prove violations occurred.
Report Facts
Staff interviewed: 5
Residents interviewed: 3
Capacity: 72
Census: 69
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kevin Gould | Licensing Program Analyst | Conducted the complaint investigation and inspection |
| Irene Charnell | Administrator | Facility administrator met with during investigation |
| Czarrina A Camilon-Lee | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Complaint Investigation
Census: 67
Capacity: 72
Deficiencies: 1
Jan 18, 2024
Visit Reason
The visit was an unannounced case management incident investigation triggered by an incident report of a resident (R1) who was reported AWOL from the facility day club program on 01/10/2024.
Findings
The investigation found that the facility gate was left slightly ajar by construction staff on 01/10/2024, allowing R1 to leave the facility grounds unsupervised for less than 10 minutes. This was a violation of Title 22 regulations regarding the licensee's responsibility for resident health and safety.
Complaint Details
The visit was complaint-related based on an incident report received on 01/15/2024 regarding resident R1 being AWOL from the facility day club program. The complaint was substantiated by findings of gate left open by construction staff.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure the facility gates stayed locked during construction services, posing an immediate health and safety issue to persons in care. | Type A |
Report Facts
Census: 67
Total Capacity: 72
Deficiencies cited: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Irene Charnell | Administrator | Met during inspection and named in report |
| Jamie Ivey Canady | Licensing Program Analyst | Conducted the inspection and authored the report |
| Czarrina A Camilon-Lee | Licensing Program Manager | Supervisor named in report |
Inspection Report
Annual Inspection
Census: 60
Capacity: 72
Deficiencies: 0
Oct 24, 2023
Visit Reason
The inspection was conducted as a required 1 year annual inspection to evaluate the facility's compliance with health and safety regulations.
Findings
The facility was found to be clean, odor-free, and in good repair with all required furniture and sufficient lighting. Water temperatures, food supplies, fire safety equipment, carbon monoxide detectors, first aid kit, and medication storage were all in compliance. No deficiencies were cited during the inspection.
Report Facts
Water temperature readings: 111
Water temperature readings: 112
Water temperature readings: 106
Water temperature readings: 114
Census: 60
Capacity: 72
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Irene Charnell | Administrator | Met with Licensing Program Analyst during inspection and participated in facility tour |
| Kevin Gould | Licensing Program Analyst | Conducted the inspection and authored the report |
| Czarrina A Camilon-Lee | Licensing Program Manager | Named in report header |
Inspection Report
Annual Inspection
Census: 68
Capacity: 72
Deficiencies: 0
Oct 17, 2022
Visit Reason
The inspection was an unannounced Required - 1 Year visit conducted to evaluate the facility's compliance with regulations.
Findings
The Licensing Program Analyst toured the facility, inspected physical conditions, safety equipment, medication storage, and first aid supplies. No violations were observed during the visit.
Report Facts
Residents utilizing hospice services: 6
Temperature range inside facility: 73
Temperature range inside facility: 77
Hot water temperature range: 106.3
Hot water temperature range: 109.3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Casey Simon | Administrator | Met with Licensing Program Analyst during inspection |
| Victoria Brown | Licensing Program Analyst | Conducted the Required - 1 Year inspection visit |
| Nicole Hemenover | Resident Service Director | Met with Licensing Program Analyst during inspection |
| Stephen Richardson | Licensing Program Manager | Named in report header |
Inspection Report
Capacity: 72
Deficiencies: 0
Jun 30, 2022
Visit Reason
The purpose of the office meeting was to discuss and review procedures to ensure the facility remains in substantial compliance while participating in the Mitigation of Major Hip Injury due to falls in an at-risk, Older Adult population with a wearable smart belt (Tango Belt Study).
Findings
No deficiencies were cited during this visit. The facility is requesting a waiver to participate in the Tango Belt Study. The meeting covered study involvement, purpose, participation requirements, staff training, study duration, confidentiality protocols, resident safety, and belt wear time.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Brenda Chappell | Executive Director | Named as facility representative and participant in the meeting regarding the Tango Belt Study. |
| Nicole Hemenover | Resident Service Director | Named as participant in the meeting regarding the Tango Belt Study. |
| Casey Simon | Director of Community Relations | Named as participant in the meeting regarding the Tango Belt Study. |
| Stacy Barlow | Assistant Program Administrator | Named as participant in the meeting regarding the Tango Belt Study. |
| Liza King | Acting Regional Manager/Licensing Program Manager | Named as participant in the meeting regarding the Tango Belt Study. |
| Victoria Brown | Licensing Program Analyst | Named as participant in the meeting regarding the Tango Belt Study. |
| Wamis Singhatat | CEO | Representative of Active Protective Technologies Inc., participant in the meeting regarding the Tango Belt Study. |
| Rebecca Tarbert | Director of Clinical Programs/Physical Therapist | Representative of Active Protective Technologies Inc., participant in the meeting regarding the Tango Belt Study. |
Inspection Report
Complaint Investigation
Census: 70
Capacity: 72
Deficiencies: 1
Dec 30, 2021
Visit Reason
The visit was an unannounced case management incident investigation to conclude an investigation that began on 02/26/2021 regarding a medication error where a resident received medication belonging to another resident.
Findings
The investigation found that staff administered incorrect medication to resident R1 that belonged to resident R2, indicating the licensee did not ensure prescribed medications were administered as prescribed, posing a potential health and safety risk.
Complaint Details
Investigation was initiated due to a complaint about a medication error where resident R1 received medication belonging to resident R2. The preponderance of evidence standard was met confirming the deficiency.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Staff administered the incorrect medication to R1 that belonged to R2, failing to ensure prescribed medication(s) were administered as prescribed. | Type B |
Report Facts
Capacity: 72
Census: 70
Deficiency count: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Victoria Brown | Licensing Program Analyst | Conducted the investigation and authored the report |
| Brenda Chappell | Administrator | Facility administrator met during the investigation |
| Stephen Richardson | Licensing Program Manager | Supervisor overseeing the licensing evaluation |
Inspection Report
Complaint Investigation
Census: 71
Capacity: 72
Deficiencies: 0
Oct 27, 2021
Visit Reason
The inspection visit was an unannounced complaint investigation triggered by an allegation that a resident sustained a major injury while in care.
Findings
The investigation found no negligence on behalf of the staff. The facility reported the incident timely and sought immediate medical attention. The allegation was determined to be unsubstantiated due to lack of preponderance of evidence. No deficiencies were cited.
Complaint Details
The complaint alleged that a resident sustained a major injury while in care. The investigation included review of medical records, interviews with staff, and facility documentation. The resident fell and was sent to the hospital for a cheek laceration and fractures. Staff actions were found appropriate and timely. The allegation was unsubstantiated.
Report Facts
Estimated Days of Completion: 120
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Victoria Brown | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Stephen Richardson | Licensing Program Manager | Named as Licensing Program Manager on the report |
| Brenda Chappell | Administrator | Facility administrator met with Licensing Program Analyst during investigation |
Inspection Report
Complaint Investigation
Census: 71
Capacity: 72
Deficiencies: 0
Oct 20, 2021
Visit Reason
The visit was an unannounced complaint investigation regarding the allegation that the facility was not allowing a resident to leave the facility.
Findings
The investigation found that the resident left the facility several times over an eight-month period with visitors and appointments, and there was no court order restricting the resident's movement. The allegation was found to be unfounded with no violations cited.
Complaint Details
The complaint alleged that the facility was not allowing a resident to leave. The allegation was investigated and found to be unfounded based on documentation, interviews, and observation. No violations were cited.
Report Facts
Estimated Days of Completion: 120
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Victoria Brown | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Brenda Chappell | Administrator | Facility administrator met during the investigation |
| Stephen Richardson | Licensing Program Manager | Named in the report as Licensing Program Manager |
Inspection Report
Annual Inspection
Census: 71
Capacity: 72
Deficiencies: 0
Oct 20, 2021
Visit Reason
The inspection was a Required - 1 Year unannounced visit to evaluate the facility's compliance with regulations and ensure safety and proper operation.
Findings
No violations were observed during the visit. The facility was found to be in compliance with safety standards, medication storage, and first aid requirements. The administrator will research hot water heater temperatures to ensure compliance.
Report Facts
Facility capacity: 72
Census: 71
Inspection duration: 2
Hot water temperature range: 88
Hot water temperature range: 123
Indoor temperature range: 72
Indoor temperature range: 77
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Brenda Chappell | Administrator | Met with Licensing Program Analyst during inspection |
| Victoria Brown | Licensing Program Analyst | Conducted the inspection visit |
| Stephen Richardson | Licensing Program Manager | Named in report header |
Inspection Report
Complaint Investigation
Census: 71
Capacity: 72
Deficiencies: 0
Oct 15, 2021
Visit Reason
The inspection was an unannounced complaint investigation visit conducted to investigate allegations that a resident was not allowed to have visitors and was not allowed to have contact with people via phone.
Findings
The investigation found that visitation protocols were in place and followed, with residents receiving visitors and using the facility phone as needed. The allegations were found to be unfounded with no violations cited during the visit.
Complaint Details
The complaint alleged that a resident was not allowed to have visitors and was not allowed to have contact with people via phone. The investigation concluded the allegations were unfounded based on interviews and documentation.
Report Facts
Estimated Days of Completion: 120
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Victoria Brown | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Brenda Chappell | Administrator | Facility administrator met with the Licensing Program Analyst during the investigation |
| Stephen Richardson | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Complaint Investigation
Census: 56
Capacity: 72
Deficiencies: 0
Feb 26, 2021
Visit Reason
The visit was conducted as a case management incident investigation due to a reported medication error where one resident received medication belonging to another resident.
Findings
No violations were cited during this unannounced tele-visit as further investigation is needed. Interviews were conducted and documentation was requested related to the medication error incident.
Complaint Details
The visit was triggered by a complaint regarding a medication error involving residents R1 and R2. The complaint remains under further investigation with no substantiation or violations cited at this time.
Report Facts
Capacity: 72
Census: 56
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Brenda Chappell | Executive Director | Interviewed during the visit and participated in exit interview |
| Victoria Brown | Licensing Program Analyst | Conducted the tele-visit and interviews |
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