Inspection Report
Monitoring
Census: 88
Capacity: 115
Deficiencies: 5
Sep 9, 2025
Visit Reason
The visit was a monitoring inspection conducted on 09/09/2025 to review the facility's compliance with previously submitted plan of correction.
Findings
The inspection found multiple deficiencies related to sanitary conditions, outdated food, use of disposable dishes, combustible storage, and lack of a proper kitchen fire extinguisher in the temporary kitchen. All deficiencies had corrective actions implemented by 10/30/2025, with ongoing monitoring and retraining planned.
Deficiencies (5)
| Description |
|---|
| Temporary freezer on second floor had an open pie box and ice tray with cups thrown inside. |
| Unlabeled, undated eclairs found in second-floor temporary refrigerator. |
| Use of paper plates and disposable cups in the temporary kitchen on the second floor on a regular basis. |
| Portable flame stove near window with curtains, PAM cooking spray, and Sterno candle lamp butane fuel cartridge in temporary second floor kitchen. |
| No fire extinguisher with minimum 2A-10BC rating in the temporary kitchen on the second floor. |
Report Facts
Residents Served: 88
License Capacity: 115
Secured Dementia Care Unit Capacity: 38
Secured Dementia Care Unit Residents Served: 35
Hospice Current Residents: 8
Residents Age 60 or Older: 88
Residents with Mental Illness: 2
Residents with Mobility Need: 63
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Mia Johnson | Reviewer | Reviewer of the document submission |
Inspection Report
Renewal
Census: 83
Capacity: 115
Deficiencies: 14
Jul 21, 2025
Visit Reason
The inspection was conducted as a full, unannounced visit for renewal, complaint, and incident reasons.
Findings
The inspection identified multiple deficiencies including breaches in record confidentiality, improper assistance with activities of daily living resulting in injury, missing resident rights posters, unqualified direct care staff, sanitary issues, maintenance and safety concerns, and medication storage discrepancies. Plans of correction were accepted and implemented with ongoing monitoring and retraining scheduled.
Deficiencies (14)
| Description |
|---|
| Resident records were accessible on open laptops and in an unlocked office, breaching confidentiality. |
| Resident #2 was transferred solo despite requiring two-person assistance, resulting in a fracture. |
| Resident rights poster was not posted in a conspicuous and public place in the Secure Dementia Care Unit. |
| Direct care staff person did not have a valid high school diploma or registry status as required. |
| Stairwell D was littered with debris from sheetrock. |
| Trash outside the home was not properly contained; dumpster lids were open and trash was on the ground. |
| Bathrooms in rooms 102 and 110 lacked operable windows or ventilation fans. |
| Ice machine in the main kitchen was dirty with a yellow-brown substance inside. |
| Hot water temperature in resident-accessible areas exceeded 120°F. |
| Pathway light fixture was overturned and lying sideways on the ground in front of the front porch. |
| Resident in room 102 did not have access to a bedside lamp that could be turned on/off at bedside. |
| Clothing and debris were found behind washing machines and dryers in the laundry room, posing combustible storage risk. |
| Fire drill evacuation time exceeded the maximum safe evacuation time specified by a fire safety expert. |
| Medication count discrepancy for morphine syringes for resident #3; narcotics log did not match actual count. |
Report Facts
License Capacity: 115
Residents Served: 83
Residents in Secured Dementia Care Unit: 32
Capacity of Secured Dementia Care Unit: 38
Hospice Residents: 6
Staffing Hours: 140
Waking Staff: 105
Fire Drill Evacuation Time: 940
Maximum Safe Evacuation Time: 900
Morphine Syringes on Hand: 20
Morphine Syringes Logged: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Medication Care Manager | Closed additional tabs on laptop to protect resident health information. | |
| Reminiscence Supervisor | Locked office doors and placed resident rights posters. | |
| Resident Care Director | Conducted community walk and retraining related to confidentiality and medication storage. | |
| Executive Director | Conducted investigations, retraining, audits, and oversaw plan of correction implementation. | |
| Resident Care Coordinator | Conducted laundry room checks and retraining on combustible storage. | |
| Business Office Coordinator | Conducted audits of employee files and fire safety training. | |
| Maintenance Assistant | Replaced exhaust fan motor and attended fire safety training. | |
| Area Facilities Manager | Cleaned debris, managed trash issues, inspected ventilation and lighting. |
Inspection Report
Renewal
Census: 77
Capacity: 115
Deficiencies: 12
Jul 30, 2024
Visit Reason
The inspection was conducted as a renewal inspection of the facility license, with an unannounced full inspection on 07/30/2024 and 07/31/2024.
Findings
The inspection found multiple deficiencies including training gaps for direct care staff, unsecured poisonous materials, malfunctioning emergency lighting, exterior hazards, improper refrigerator temperatures, lack of familiarity with emergency preparedness plan, incomplete resident medical evaluations, missing posted menus, medication record inaccuracies, improper medication storage, failure to follow prescriber's orders, and incomplete resident record content. All deficiencies had plans of correction accepted and were implemented by 09/23/2024.
Deficiencies (12)
| Description |
|---|
| Direct care staff person C and direct care staff person D did not receive required annual training on meeting residents' needs. |
| Laundry room in the Secured Dementia Care Unit was unlocked with poisonous materials accessible to residents. |
| Emergency lights in stair tower D were flashing. |
| Several raised lips and missing bricks on walkway outside the Secured Dementia Care Unit posed tripping hazards. |
| Refrigerator temperature in the kitchen was above 40°F (45°F and 42°F). |
| Administrator was not familiar with the emergency preparedness plan for the local municipality. |
| Resident #1's most recent medical evaluation was not current. |
| Weekly menus were not posted one week in advance as required. |
| Resident #2's medication record did not include a current list of medications; discrepancies found in medication dosages. |
| Resident #3's medication card had punctured blister foil with medication still present. |
| Resident #4 did not receive prescribed probiotic medication for the full 10 days as ordered. |
| Resident #3's face sheet did not include hair color, eye color, or distinguishing marks. |
Report Facts
License Capacity: 115
Residents Served: 77
Secured Dementia Care Unit Capacity: 36
Secured Dementia Care Unit Residents Served: 30
Hospice Residents: 7
Total Daily Staff: 128
Waking Staff: 96
Residents with Mobility Need: 51
Residents 60 Years or Older: 77
Residents Diagnosed with Mental Illness: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Healthcare Manager | Healthcare Manager (HCM) | Named in findings related to medical evaluations, medication audits, and staff retraining. |
| Executive Director | Executive Director (ED) | Named in multiple findings related to plan of correction implementation and staff retraining. |
| Maintenance Coordinator | Maintenance Coordinator (MC) | Named in findings related to lighting repairs and exterior hazard corrections. |
| Dining Services Coordinator | Dining Services Coordinator (DSC) | Named in findings related to refrigerator temperature and menu posting. |
| Resident Care Director | Resident Care Director | Named in medication packaging discussion. |
| REM Care Coordinator | REM Care Coordinator | Named in findings related to locking poisonous materials. |
Inspection Report
Follow-Up
Census: 78
Capacity: 115
Deficiencies: 5
Jan 3, 2024
Visit Reason
The inspection was a follow-up visit to verify the implementation of a previously submitted plan of correction related to complaints and incidents at the facility.
Findings
The facility was found to have fully implemented the submitted plan of correction addressing multiple resident abuse incidents, reporting violations, and staff training deficiencies. Several abuse incidents involving staff aggression and improper care were documented, with staff members disciplined or terminated and retraining initiated.
Complaint Details
The visit was complaint-related, triggered by allegations of resident abuse including verbal and physical aggression by staff, failure to report abuse timely, and improper treatment of residents. The complaints were substantiated with multiple documented violations and staff disciplinary actions.
Deficiencies (5)
| Description |
|---|
| Failure to immediately report suspected abuse incidents as required by law. |
| Resident abuse including verbal aggression, physical abuse, and inappropriate restraint by staff. |
| Failure to treat residents with dignity and respect, including staff yelling and mocking residents. |
| Direct care staff providing unsupervised ADL services without completing required training and competency testing. |
| Use of prohibited procedures including manual and mechanical restraints and chemical restraints. |
Report Facts
License Capacity: 115
Residents Served: 78
Staffing Hours: 132
Waking Staff: 99
Residents in Secured Dementia Care Unit: 29
Hospice Residents: 6
Residents 60 Years or Older: 77
Residents with Mobility Need: 54
Inspection Report
Follow-Up
Census: 81
Capacity: 115
Deficiencies: 3
Sep 28, 2023
Visit Reason
The inspection was a partial, unannounced follow-up visit triggered by an incident to verify the implementation of a previously submitted plan of correction.
Findings
The facility was found to have fully implemented the submitted plan of correction related to timely reporting of incidents, contract signatures, and support plan signatures. Continued compliance must be maintained.
Deficiencies (3)
| Description |
|---|
| Failure to timely report alleged physical abuse incidents to the Department within 24 hours. |
| Resident-home contract was not signed by the resident. |
| Residents did not sign their support plans despite participation in their development. |
Report Facts
License Capacity: 115
Residents Served: 81
Residents in Secured Dementia Care Unit: 30
Capacity of Secured Dementia Care Unit: 38
Hospice Residents: 7
Residents 60 Years or Older: 80
Residents Diagnosed with Mental Illness: 3
Residents Diagnosed with Intellectual Disability: 2
Residents with Mobility Need: 58
Residents with Physical Disability: 1
Total Daily Staff: 139
Waking Staff: 104
Inspection Report
Complaint Investigation
Census: 77
Capacity: 115
Deficiencies: 5
Jul 31, 2023
Visit Reason
The inspection was conducted as a complaint investigation following an unannounced partial inspection on 07/31/2023.
Findings
Multiple deficiencies were identified including unlocked poisonous materials accessible to residents, unsanitary conditions with urine found on a bathroom floor, broken shower floor water retainer posing a tripping hazard, unfinished bathroom ceiling repair, and missed meal delivery to a resident.
Complaint Details
The inspection was complaint-driven as indicated by the reason 'Complaint' and the visit was a partial unannounced inspection on 07/31/2023.
Deficiencies (5)
| Description |
|---|
| Unlocked poisonous materials (soaps) accessible to residents not assessed as capable of safely using or avoiding poisons. |
| Urine found on the floor next to the toilet in resident 3's restroom. |
| Resident 2's shower floor plastic water retainer was broken and in poor condition, creating a tripping hazard. |
| Bathroom ceiling for resident 2 had an unfinished repair that had not been painted or sanded. |
| Resident 4 reported a missed meal delivery; meal was eventually provided after delay. |
Report Facts
License Capacity: 115
Residents Served: 77
Secured Dementia Care Unit Capacity: 36
Residents Served in Dementia Unit: 24
Current Hospice Residents: 8
Residents Age 60 or Older: 77
Residents with Mobility Need: 68
Inspection Report
Complaint Investigation
Census: 78
Capacity: 115
Deficiencies: 1
Apr 10, 2023
Visit Reason
The inspection was conducted as a complaint and incident investigation to review compliance with resident care and staffing requirements.
Findings
The inspection found that a resident did not receive a response to a call bell for an hour and 43 minutes due to mismanagement of direct care staff. The facility submitted a plan of correction which was accepted and fully implemented.
Complaint Details
The visit was complaint-related and involved an incident where a resident experienced delayed response to a call bell. The plan of correction was accepted and fully implemented.
Deficiencies (1)
| Description |
|---|
| Resident #1 did not receive a response to a pushed call bell for an hour and 43 minutes due to mismanagement of available direct care staff. |
Report Facts
Residents served: 78
License capacity: 115
Capacity: 35
Residents served: 29
Current residents: 9
Time delay: 103
Total daily staff: 140
Waking staff: 105
Inspection Report
Complaint Investigation
Census: 73
Capacity: 115
Deficiencies: 0
Feb 22, 2023
Visit Reason
The inspection was conducted as a complaint investigation during an unannounced partial licensing inspection.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Complaint Details
The inspection was triggered by a complaint; however, no deficiencies or citations were found.
Report Facts
Total Daily Staff: 127
Waking Staff: 95
Residents Served: 73
License Capacity: 115
Secured Dementia Care Unit Capacity: 38
Secured Dementia Care Unit Residents Served: 29
Hospice Current Residents: 6
Residents Diagnosed with Mental Illness: 3
Residents Diagnosed with Intellectual Disability: 2
Residents with Mobility Need: 54
Residents Aged 60 Years or Older: 73
Residents Receiving Supplemental Security Income: 0
Residents with Physical Disability: 0
Inspection Report
Renewal
Census: 71
Capacity: 115
Deficiencies: 15
Jan 11, 2023
Visit Reason
The inspection was an unannounced full renewal inspection with an incident review conducted from 01/11/2023 to 01/13/2023.
Findings
The facility was found to have multiple deficiencies including issues with resident refunds after death, abuse incidents, privacy violations related to video recording, bathroom ventilation problems, furniture and equipment maintenance, elevator certification, exterior hazards, lighting in resident rooms, lint accumulation in dryers, fire drill compliance, medical evaluation documentation, menu change notifications, service description accuracy, and support plan documentation and signatures. Plans of correction were accepted and implemented by 03/02/2023.
Deficiencies (15)
| Description |
|---|
| Resident refund after death was not issued within required timeframe. |
| Physical and verbal abuse of a resident by staff member. |
| Use of video recording devices without proper resident notification or signage. |
| Bathrooms lacked operable ventilation fans due to inoperable rooftop exhaust fans. |
| Bathroom off personal care dining room flooded and overflowed twice during inspection. |
| Elevator did not have a current certificate of operation at time of inspection. |
| Fallen lamp post with shattered glass and electrical hazard in parking lot. |
| Resident rooms 137 and 240 lacked operable bedside lighting. |
| Accumulation of lint in commercial dryer lint trap. |
| Unannounced fire drills were not held during December 2022 and June 2022. |
| Resident medical evaluation documentation did not reflect current medication self-administration ability. |
| Menu change not posted in advance; dessert substitution without notice. |
| Written description of services included transportation service that was not available due to bus inspection status. |
| Resident support plan did not document wheelchair need and had inaccurate medication self-administration status. |
| Residents #5 and #6 did not sign their support plan signature pages. |
Report Facts
License Capacity: 115
Residents Served: 71
Secured Dementia Care Unit Capacity: 38
Secured Dementia Care Unit Residents Served: 27
Hospice Current Residents: 5
Total Daily Staff: 121
Waking Staff: 91
Residents 60 Years or Older: 71
Residents Diagnosed with Mental Illness: 2
Residents Diagnosed with Intellectual Disability: 2
Residents with Mobility Need: 50
Bus Inspection Expiration: 2024
Inspection Report
Follow-Up
Census: 85
Capacity: 115
Deficiencies: 5
Apr 12, 2022
Visit Reason
The inspection was a partial, unannounced follow-up visit conducted due to an incident, with a focus on verifying the implementation of a previously submitted plan of correction.
Findings
The facility was found to have multiple deficiencies including insufficient waking hours staffing, direct care staff providing unsupervised ADL services without completing required training, incomplete resident records, inappropriate treatment of residents by staff, and missing resident signatures on support plans. The submitted plan of correction was accepted and fully implemented with ongoing monitoring.
Deficiencies (5)
| Description |
|---|
| At least 75% of the personal care service hours were not provided during waking hours; only 109 of 115.5 required hours were provided. |
| Direct care staff person provided unsupervised ADL services without completing and passing the Department-approved direct care training course and competency test. |
| Resident #1's record did not include a copy of the incident reportable. |
| Staff person A was disrespectful to Resident #1 by yelling and making inappropriate statements in the dining room. |
| Resident #1 participated in the development of the support plan but did not sign the support plan. |
Report Facts
License Capacity: 115
Residents Served: 85
Required direct care hours: 115.5
Provided direct care hours during waking hours: 109
Total Daily Staff: 154
Waking Staff: 116
Notice
Capacity: 115
Deficiencies: 0
Sep 16, 2021
Visit Reason
This document serves as a renewal notification and license issuance for the Personal Care Home 'Sunrise of Granite Run' following receipt of the renewal application dated September 14, 2021.
Findings
The Department has issued a regular license in response to the renewal application and advises that an onsite inspection will be conducted within the next twelve months to ensure compliance with applicable regulations.
Report Facts
Maximum capacity: 115
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jamie L. Buchenauer | Deputy Secretary, Office of Long-term Living | Signed the renewal notification letter. |
Inspection Report
Renewal
Census: 74
Capacity: 115
Deficiencies: 11
Sep 13, 2021
Visit Reason
The inspection was conducted as a renewal inspection of the facility license for Sunrise of Granite Run.
Findings
Multiple deficiencies were identified related to housekeeping, maintenance, food storage, medical evaluations, medication storage, treatment of residents, and sanitary conditions. Plans of correction were accepted and implemented with ongoing monitoring.
Deficiencies (11)
| Description |
|---|
| Housekeeping tasks incomplete with soiled laundry and trash improperly placed in hallways and bathrooms. |
| Trash dumpster outside the home was uncovered with trash spilling over. |
| Caulking around sinks and toilets in bathrooms was not in good repair in multiple locations. |
| Emergency telephone numbers were not posted on or by telephones in rooms 217 and 236. |
| Ice cream containers in the freezer were opened and unsealed. |
| A dented can of slow cooked baked beans was found in the kitchen. |
| Resident medical evaluations did not include special health or dietary needs for residents #2 and #3. |
| Glucometer for resident #1 was not calibrated to the correct year. |
| Staff member was observed addressing maintenance coordinator with disrespectful language in front of residents and others. |
| Glucometer for resident #1 had undocumented numbers stored in the machine. |
| Ice cream freezer had spilled ice cream and stains. |
Report Facts
License Capacity: 115
Residents Served: 74
Secured Dementia Care Unit Capacity: 38
Residents Served in Dementia Unit: 23
Hospice Residents: 6
Residents with Mobility Need: 68
Residents 60 Years or Older: 74
Residents Diagnosed with Mental Illness: 4
Residents Diagnosed with Intellectual Disability: 2
Residents with Physical Disability: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Personal Care Coordinator (PCC) | Named in housekeeping deficiency plan of correction. | |
| Housekeeper | Named in housekeeping deficiency plan of correction and disciplinary action. | |
| Maintenance Coordinator (MC) | Named in multiple deficiencies including trash cleanup, telephone numbers audit, and treatment of residents incident. | |
| Dining Services Coordinator (DSC) | Named in food storage and outdated food deficiencies. | |
| Health Care Manager (HCM) | Named in medical evaluation, glucometer calibration, and sanitary conditions deficiencies. | |
| Executive Director (ED) | Named in education and quality management meetings related to deficiencies. | |
| Wellness Team | Named in education and monitoring related to medical and glucometer deficiencies. |
Inspection Report
Complaint Investigation
Census: 68
Capacity: 115
Deficiencies: 0
Jul 23, 2021
Visit Reason
The inspection was conducted as a complaint investigation at the facility Sunrise of Granite Run.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Complaint Details
The inspection was complaint-related; however, no deficiencies or citations were found, and the complaint was not substantiated.
Report Facts
License Capacity: 115
Residents Served: 68
Secured Dementia Care Unit Capacity: 38
Secured Dementia Care Unit Residents Served: 24
Total Daily Staff: 130
Waking Staff: 98
Residents Diagnosed with Mental Illness: 3
Residents Diagnosed with Intellectual Disability: 2
Residents with Mobility Need: 62
Residents 60 Years or Older: 68
Inspection Report
Follow-Up
Census: 70
Capacity: 115
Deficiencies: 3
May 17, 2021
Visit Reason
The inspection was a partial, unannounced visit conducted due to an incident, to review the submitted plan of correction for the facility.
Findings
The facility was found to have deficiencies related to resident treatment, sanitary conditions, and support plan documentation. The submitted plan of correction was determined to be not fully implemented as of the inspection date.
Deficiencies (3)
| Description |
|---|
| Resident #1 was not treated with dignity and respect by staff, who responded inappropriately when the resident needed assistance with bowel incontinence care. |
| The exterior of the toilet bowl in resident #1's bathroom was streaked with feces and was not cleaned during the inspection. |
| The home updated resident #1's support plan but could not provide the signature page for the update. |
Report Facts
License Capacity: 115
Residents Served: 70
Secured Dementia Care Unit Capacity: 38
Secured Dementia Care Unit Residents Served: 24
Total Daily Staff: 128
Waking Staff: 96
Inspection Report
Complaint Investigation
Census: 69
Capacity: 115
Deficiencies: 0
Mar 9, 2021
Visit Reason
The inspection was conducted as a complaint and incident investigation with a partial, unannounced inspection.
Findings
No regulatory citations or deficiencies were identified as a result of the inspection conducted on multiple dates in March 2021.
Complaint Details
The inspection was triggered by a complaint and incident, but no deficiencies or regulatory citations were substantiated.
Report Facts
Inspection Dates: 6
Total Daily Staff: 114
Waking Staff: 86
Residents Served: 69
License Capacity: 115
Secured Dementia Care Unit Capacity: 31
Secured Dementia Care Unit Residents Served: 23
Current Hospice Residents: 11
Residents Age 60 or Older: 69
Residents Diagnosed with Mental Illness: 2
Residents Diagnosed with Intellectual Disability: 1
Residents with Mobility Need: 45
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