Inspection Report
Renewal
Census: 20
Deficiencies: 4
May 21, 2025
Visit Reason
The inspection was a renewal visit conducted to assess compliance with applicable standards and laws for the assisted living facility.
Findings
The inspection found non-compliance with several standards including failure to train staff prior to being placed in charge, insufficient annual staff training hours, inadequate monitoring of a resident with restraints, and lack of emergency water supply for 48 hours.
Deficiencies (4)
| Description |
|---|
| Facility failed to train the staff member prior to being placed in charge. |
| Facility failed to ensure staff received 12 hours of annual training relevant to the population in care. |
| Facility failed to monitor the condition of a resident with restraints, including checking at least every 30 minutes. |
| Facility failed to ensure the availability of at least 48 hours of drinking water. |
Report Facts
Number of residents present: 20
Number of resident records reviewed: 2
Number of staff records reviewed: 2
Number of interviews conducted with residents: 1
Number of interviews conducted with staff: 3
Documented training hours for staff 1: 7.5
Required annual training hours: 12
Inspection Report
Complaint Investigation
Census: 18
Deficiencies: 0
Jan 9, 2025
Visit Reason
The inspection was conducted as a complaint investigation to review allegations of non-compliance with standards or law at the assisted living facility.
Findings
The evidence gathered during the investigation did not support the allegations of non-compliance with standards or law. The inspection findings will be posted publicly and an exit meeting was planned to review the findings.
Complaint Details
The inspection was complaint-related, but the allegations were not substantiated based on the evidence gathered during the investigation.
Report Facts
Number of resident records reviewed: 1
Number of staff records reviewed: 1
Number of interviews conducted with residents: 2
Number of interviews conducted with staff: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Sarah Pearson | Licensing Inspector | Inspector conducting the complaint investigation |
Inspection Report
Complaint Investigation
Census: 14
Deficiencies: 2
Jun 24, 2024
Visit Reason
The inspection was conducted as a complaint investigation to review allegations related to resident care and accommodations at the assisted living facility.
Findings
The investigation supported some but not all allegations, identifying non-compliance in Resident Care and Related Services and Resident Accommodations and Related Provisions. Violations included failure to offer at least one hour of daily activities and failure to administer medications within the facility's standard dosing schedule.
Complaint Details
The evidence gathered supported some of the allegations related to Resident Care and Related Services and Resident Accommodations and Related Provisions. A violation notice was issued. The licensee has the opportunity to submit a plan of correction within five business days of the exit interview.
Deficiencies (2)
| Description |
|---|
| Facility failed to offer at least one hour of activities each day. |
| Facility failed to administer medication not later than one hour after the facility's standard dosing schedule. |
Report Facts
Number of residents present: 14
Number of resident records reviewed: 4
Number of staff records reviewed: 1
Number of interviews with residents: 2
Number of interviews with staff: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Sarah Pearson | Licensing Inspector | Conducted the inspection and is contact for questions |
Inspection Report
Renewal
Census: 14
Deficiencies: 2
Jun 24, 2024
Visit Reason
The inspection was conducted as a renewal of the facility's license, including a tour of the physical plant and review of resident and staff records.
Findings
The inspection found non-compliance with applicable standards related to medication management, specifically that medications were not locked when unsupervised and medications were not kept in pharmacy-issued containers with proper labeling.
Deficiencies (2)
| Description |
|---|
| Facility failed to ensure medications were locked when unsupervised. |
| Facility failed to ensure medications remained in pharmacy issued container with prescription or direction label until administered. |
Report Facts
Number of residents present: 14
Number of resident records reviewed: 3
Number of staff records reviewed: 3
Number of interviews conducted with residents: 2
Number of interviews conducted with staff: 2
Inspection Report
Renewal
Census: 17
Deficiencies: 0
May 24, 2023
Visit Reason
The inspection was conducted as a renewal inspection to review the facility's compliance with licensing requirements.
Findings
The Licensing Inspector reviewed multiple areas including administration, personnel, resident care, emergency preparedness, and health care oversight. Six records and five interviews were conducted, and all self-reported incidents since the last inspection were reviewed. Residents were observed in activities and documentation such as pharmacy review, menus, and fire drills were examined.
Report Facts
Records reviewed: 6
Interviews conducted: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Sarah Pearson | Inspector | Named as the current inspector conducting the inspection |
Inspection Report
Original Licensing
Census: 20
Deficiencies: 0
Dec 16, 2022
Visit Reason
This was an initial inspection conducted to evaluate the facility for licensure.
Findings
The Licensing Inspector reviewed 4 records and conducted 4 interviews. Residents were observed during activities and meals. The inspector was not able to review all standards at the time of inspection. All requested documentation was in order and a recommendation will be made for licensure.
Report Facts
Records reviewed and interviews conducted: 4
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