Inspection Report
Renewal
Census: 32
Deficiencies: 0
Jun 12, 2025
Visit Reason
The visit was conducted as a recertification to determine compliance with certification for an Assisted Living Program and to investigate Complaint #125030-C.
Findings
No regulatory insufficiencies were cited during the recertification or the complaint investigation.
Complaint Details
Complaint #125030-C was investigated and no regulatory insufficiencies were found.
Report Facts
Number of tenants without cognitive impairment: 24
Number of tenants with cognitive impairment: 8
Total census: 32
Inspection Report
Complaint Investigation
Census: 35
Deficiencies: 1
Jan 10, 2024
Visit Reason
The inspection was conducted as an investigation into Incident #114254-M concerning the care and service plan adequacy for tenants at the assisted living program.
Findings
The program failed to address the identified needs and preferences of Tenant #2 in her service plan, specifically regarding assistance with bathing, dressing, use of a splint for finger fractures, and other care requirements. Staff interviews and tenant statements confirmed these deficiencies.
Complaint Details
The visit was complaint-related, investigating Incident #114254-M. The complaint was substantiated by findings that Tenant #2's service plan did not reflect her medical and care needs, leading to inadequate assistance and potential harm.
Deficiencies (1)
| Description |
|---|
| Failure to address Tenant #2's identified needs and preferences on the service plan, including assistance with bathing, dressing, and care related to finger fractures and splint use. |
Report Facts
Number of tenants without cognitive disorder: 33
Number of tenants with cognitive disorder: 2
Total census: 35
Inspection Report
Renewal
Census: 37
Deficiencies: 4
Jun 1, 2023
Visit Reason
The inspection was conducted as a recertification visit to determine compliance with certification rules for an Assisted Living Program.
Findings
The inspection found multiple regulatory insufficiencies including failure to provide dependent adult abuse training within 6 months of employment for 3 of 7 staff, failure to complete required criminal and abuse background checks prior to employment for 1 of 7 staff, failure to evaluate tenants' functional, cognitive, and health status within 30 days of occupancy for 3 tenants, and failure to provide food safety and sanitation training prior to handling food for 5 staff.
Complaint Details
No regulatory insufficiencies were cited during the investigation of Complaint #109146-C.
Deficiencies (4)
| Description |
|---|
| Failed to provide 2 hours of dependent adult abuse training within 6 months of employment for 3 of 7 staff reviewed (Staff A, Staff B, Staff C). |
| Failed to complete a criminal, child, and dependent adult abuse background check prior to employment for 1 of 7 staff reviewed (Staff A). |
| Failed to evaluate tenant's functional, cognitive, and health status within 30 days of occupancy for 3 of 3 tenants reviewed (Tenant #1, Tenant #2, Tenant #3). |
| Failed to provide training on food safety and sanitation prior to handling food for 5 of 5 staff reviewed who prepared or served food (Staff A, Staff B, Staff C, Staff D, Staff E). |
Report Facts
Number of tenants without cognitive disorder: 36
Number of tenants with cognitive disorder: 1
Total Population: 37
Staff reviewed for dependent adult abuse training: 7
Staff failed dependent adult abuse training: 3
Staff reviewed for background checks: 7
Staff failed background check prior to employment: 1
Tenants reviewed for evaluation: 3
Tenants failed evaluation within 30 days: 3
Staff reviewed for food safety training: 5
Staff failed food safety training: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Named in findings for dependent adult abuse training, background check, and food safety training deficiencies | |
| Staff B | Named in findings for dependent adult abuse training and food safety training deficiencies | |
| Staff C | Named in findings for dependent adult abuse training and food safety training deficiencies | |
| Staff D | Named in findings for food safety training deficiency | |
| Staff E | Named in findings for food safety training deficiency |
Inspection Report
Renewal
Census: 27
Deficiencies: 6
Mar 23, 2021
Visit Reason
The inspection was a recertification visit conducted to determine compliance with certification rules for an Assisted Living Program.
Findings
No regulatory insufficiencies were cited regarding the onsite infection control survey. Several regulatory insufficiencies were cited related to medication administration, staffing training and delegation, dependent adult abuse training, service plan updates, and nurse reviews.
Deficiencies (6)
| Description |
|---|
| Failure to ensure 2 of 7 staff reviewed were properly trained before administering medication to tenants. |
| Newly hired registered nurse failed to ensure 4 of 7 universal workers reviewed were sufficiently trained to carry out assigned tasks within 60 days of hire. |
| Failure to ensure 5 of 7 staff reviewed were trained by the registered nurse within 30 days of employment. |
| Failure to ensure 4 of 7 staff reviewed received dependent adult abuse training within six months of hire and every three years thereafter. |
| Failure to update service plans with significant changes for 1 of 3 tenants reviewed who received personal care services. |
| Failure to conduct nurse reviews every 90 days for 3 of 3 tenants reviewed who received health-related care. |
Report Facts
Number of tenants without cognitive disorder: 27
Number of tenants with cognitive disorder: 0
Total census of Assisted Living Program: 27
Staff reviewed for medication training: 7
Staff not properly trained for medication administration: 2
Universal workers reviewed for training within 60 days: 7
Universal workers not sufficiently trained within 60 days: 4
Staff reviewed for training within 30 days: 7
Staff not trained within 30 days: 5
Staff reviewed for dependent adult abuse training: 7
Staff not trained for dependent adult abuse within 6 months: 4
Tenants reviewed for service plan updates: 3
Tenants with service plans not updated with significant change: 1
Tenants reviewed for nurse reviews every 90 days: 3
Tenants without nurse reviews every 90 days: 3
Inspection Report
Complaint Investigation
Census: 15
Deficiencies: 0
Oct 9, 2017
Visit Reason
Investigation of Complaint #69719-C at the assisted living program.
Findings
No regulatory insufficiencies were cited during the investigation of the complaint.
Complaint Details
Complaint #69719-C was investigated and found to have no regulatory insufficiencies.
Report Facts
Number of tenants without cognitive disorder: 14
Number of tenants with cognitive disorder: 1
Total Population of Program at time of on-site: 15
TOTAL census of Assisted Living Program: 15
Inspection Report
Annual Inspection
Census: 11
Deficiencies: 1
Mar 20, 2017
Visit Reason
The inspection was conducted as an initial visit to determine compliance with certification of an Assisted Living Program.
Findings
The facility was cited for failing to complete required 90 day nurse reviews for tenants receiving program-administered prescription medications. The facility has updated tenant review forms and set agreements for pharmacy reviews to ensure compliance.
Deficiencies (1)
| Description |
|---|
| Program failed to complete 90 day nurse reviews as required for 2 of 2 tenants receiving program-administered prescription medications. |
Report Facts
Number of tenants without cognitive disorder: 9
Number of tenants with cognitive disorder: 2
Total Population of Program at time of on-site: 11
Total census of Assisted Living Program: 11
Tenants reviewed for 90 day nurse reviews: 2
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