Inspection Report
Complaint Investigation
Census: 47
Capacity: 51
Deficiencies: 1
Jun 25, 2025
Visit Reason
The inspection was conducted as a complaint investigation regarding medication storage practices at the assisted living facility.
Findings
The surveyor observed that controlled medications were not stored with physical separation for each resident's medication. Although medications were kept in a locked section of the medication cart, they lacked separate cubicles or labeling for individual residents.
Complaint Details
Complaint Investigation 2025-AHP-41646. The finding was reviewed with the Administrator during the exit meeting on 6/25/2025.
Severity Breakdown
Class III: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Medications administered by the assisted living program were not stored in a cabinet equipped with separate cubicles or physical separation for each resident's medications as required. | Class III |
Report Facts
Census: 47
Total Capacity: 51
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Lyndsay Renadette | Administrator | Named in relation to the exit meeting reviewing the medication storage finding |
Inspection Report
Complaint Investigation
Census: 47
Capacity: 51
Deficiencies: 1
Jun 25, 2025
Visit Reason
The inspection was conducted as a complaint investigation to assess compliance with medication storage regulations at Sunnybrook Assisted Living Program.
Findings
The surveyor observed that controlled medications were stored in a locked section of the medication cart but were not separated by each resident, failing to meet the requirement for physical separation in medication storage.
Complaint Details
Complaint investigation number 2025-AHP-41646. The finding was reviewed with the Administrator during the exit meeting on 6/25/2025.
Severity Breakdown
Class III: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Medications were not stored in a cabinet equipped with separate cubicles or physical separation for each resident's medications as required. | Class III |
Report Facts
Census: 47
Total Capacity: 51
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Lyndsay Renadette | Administrator | Administrator present during exit meeting and named in report header |
Inspection Report
Biennial Survey
Census: 48
Capacity: 51
Deficiencies: 1
Feb 27, 2024
Visit Reason
The visit was a biennial survey to assess compliance with the Regulations Governing the Licensing and Functioning of Assisted Housing Programs for the Assisted Living Program.
Findings
The facility was found not in substantial compliance due to failure to complete reassessments at least every six months for one of three residents, specifically Resident #2 whose reassessment was delayed from 8/22/2022 to 5/8/2023.
Deficiencies (1)
| Description |
|---|
| Failure to complete a reassessment at least every six months for one of three residents (Resident #2). |
Report Facts
Census: 48
Total Capacity: 51
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Tracy Jo Hoppe | Administrator | Named as Administrator who confirmed the finding at the exit meeting |
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