Deficiencies per Year
12
9
6
3
0
Unclassified
Census Over Time
Census
Capacity
Inspection Report
Renewal
Census: 92
Capacity: 118
Deficiencies: 6
May 12, 2025
Visit Reason
The inspection was conducted as a renewal inspection of THE 501 AT MATTISON ESTATE facility on 05/12/2025 and 05/13/2025.
Findings
The inspection identified multiple deficiencies including hot water temperatures exceeding 120°F in resident areas, lack of operable bedside lighting for a resident, unlabeled and undated leftover food in the kitchen, inaccurate fire drill evacuation records, incomplete medication records for a resident self-administering medications, and damaged medication blister packs. Plans of correction were submitted and fully implemented by 07/01/2025.
Deficiencies (6)
| Description |
|---|
| Hot water temperature in resident living units exceeded 120°F at multiple sinks. |
| Resident #1 did not have access to a source of light that can be turned on/off at bedside. |
| Unlabeled, undated pie found in the main kitchen freezer. |
| Fire drill records did not include the correct number of residents evacuated during drills on 3/28/25 and 4/7/25. |
| Resident #1's medication record did not include a current list of medications despite medications being present in the living unit. |
| Resident #2's Tramadol 50 mg blister pack had tears in three places. |
Report Facts
License Capacity: 118
Residents Served: 92
Special Care Unit Capacity: 42
Special Care Unit Residents Served: 29
Hospice Residents: 4
Residents Age 60 or Older: 91
Residents with Mental Illness: 2
Residents with Intellectual Disability: 1
Residents with Mobility Need: 37
Residents with Physical Disability: 0
Hot Water Temperature: 132.6
Hot Water Temperature: 135.1
Fire Drill Residents Evacuated (Incorrect Log): 28
Fire Drill Residents Evacuated (Incorrect Log): 26
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Health and Wellness Director | Health and Wellness Director (HWD) | Removed damaged medication blister pack and conducted re-education and audits related to medication storage. |
| Maintenance Director | Maintenance Director | Adjusted hot water temperatures and was retrained regarding fire drill evacuation documentation. |
| ALM | Assistant Living Manager (ALM) | Placed operable lamp at bedside, conducted audits on lighting and food storage, and responsible for ongoing compliance. |
| F&B Director | Food and Beverage Director | In-serviced dining staff on food storage regulations and responsible for auditing kitchen food storage. |
| Nurse on duty | Nurse | Contacted prescriber to secure necessary prescription order for resident medication. |
Inspection Report
Renewal
Census: 74
Capacity: 118
Deficiencies: 10
Jun 4, 2024
Visit Reason
The inspection was conducted as a renewal, complaint, and incident review of THE 501 AT MATTISON ESTATE facility on 06/04/2024 and 06/05/2024.
Findings
The inspection found multiple deficiencies including failure to post required documents, issues with fire safety inspections and drills, medication management errors such as discontinued medications remaining in carts, incorrect medication labeling, improper storage procedures, incomplete medication administration records, failure to follow prescriber orders, illegible record entries, and missing official death certificate in a resident's record. All deficiencies had plans of correction accepted and were implemented by 08/30/2024.
Deficiencies (10)
| Description |
|---|
| Residence did not post a copy of the required chapter in a conspicuous and public place. |
| Annual fire safety inspection was overdue; last completed on 11/29/2023. |
| Fire drill during sleeping hours not conducted every 6 months as required. |
| Discontinued medication (Mirtazapine 7.5 mg) remained in medication cart after discontinuation. |
| Pharmacy labels for medications did not match prescriber orders for residents #2 and #4. |
| Resident #1's glucometer was not calibrated to correct date and time; missing glucose monitoring entries. |
| Medication administration records missing staff initials for narcotic medications for residents #4 and #5. |
| Resident #4 was administered Tramadol 50 mg only 4 hours apart, not following prescribed 6-hour interval. |
| Controlled substance log had write overs and crossed out entries without proper notation. |
| Resident #6's record did not include an official death certificate after passing away unexpectedly. |
Report Facts
License Capacity: 118
Residents Served: 74
Special Care Unit Capacity: 42
Special Care Unit Residents Served: 24
Hospice Residents: 1
Residents Age 60 or Older: 74
Residents with Mobility Need: 47
Total Daily Staff: 121
Waking Staff: 91
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Health and Wellness Director | Health and Wellness Director (HWD) | Named in multiple medication management and compliance findings and corrective actions. |
| Building Engineer | Building Engineer | Named in fire safety inspection and fire drill compliance findings and corrective actions. |
| Assisted Living Manager | ALM | Responsible for ongoing compliance and monitoring of corrective actions. |
Inspection Report
Monitoring
Census: 17
Capacity: 118
Deficiencies: 7
Jan 24, 2023
Visit Reason
The visit was a monitoring inspection conducted on 01/24/2023 to review the facility's compliance with regulations and the implementation of a previously submitted plan of correction.
Findings
The inspection identified multiple deficiencies including unsigned resident contracts, missing signed statements acknowledging receipt of resident rights, improper food storage and outdated food items, incomplete medical evaluations, lack of resident education on medication refusal rights, and delayed support plan documentation. All deficiencies had plans of correction accepted and were implemented by early March 2023.
Deficiencies (7)
| Description |
|---|
| Resident-residence contract for resident #1 was not signed by the resident. |
| Resident #1's record did not contain a signed statement acknowledging receipt of resident rights and complaint procedures. |
| Food was stored in unsealed containers including opened provolone cheese, chicken breast not in sealed container, and opened bags of grits and hot cocoa mix. |
| Outdated or spoiled food found: three unlabeled, undated blocks of cheese, a tray of chicken breast, and a dented can of pumpkin puree. |
| Medical evaluation for resident #2 did not include immunization history. |
| Resident #2 was not educated on the right to refuse medication if a medication error is suspected. |
| Resident #2's initial support plan was not completed within 72 hours of admission to the special care unit. |
Report Facts
License Capacity: 118
Residents Served: 17
Special Care Unit Capacity: 42
Special Care Unit Residents Served: 4
Total Daily Staff: 25
Waking Staff: 19
Inspection Report
Complaint Investigation
Census: 8
Capacity: 118
Deficiencies: 0
Dec 9, 2022
Visit Reason
The inspection was conducted as a complaint investigation at THE 501 AT MATTISON ESTATE facility on 12/09/2022.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Complaint Details
The inspection was complaint-related and the follow-up type was noted as Not Required, indicating no substantiated deficiencies.
Report Facts
License Capacity: 118
Residents Served: 8
Memory Care Capacity: 42
Memory Care Residents Served: 1
Inspection Report
Original Licensing
Capacity: 42
Deficiencies: 4
Sep 12, 2022
Visit Reason
The inspection was an initial licensing inspection of a newly licensed assisted living residence that is not yet serving four or more residents.
Findings
The facility was found to be in substantial but not complete compliance with regulations. Several deficiencies were cited related to exterior hazards, fire safety areas, fire extinguisher inspections, and fire drills, all of which had accepted plans of correction with completion dates in September and October 2022.
Deficiencies (4)
| Description |
|---|
| The courtyard in the Secured Dementia Care Unit had artificial turf that was not secured, causing ripples and posing a tripping hazard. |
| The 3rd floor memory care unit with capacity for 42 residents with mobility needs did not have a fire safe area specified in writing within the past year by a fire safety expert. |
| Fire extinguishers on the first, second, and third floors had not been inspected by a fire safety expert. |
| The residence lacked a written maximum evacuation time or fire safe areas determined by a fire safety expert's inspection. |
Report Facts
License Capacity: 42
Residents Served: 0
Inspection Date: Sep 12, 2022
Plan of Correction Completion Date: Oct 14, 2022
Plan of Correction Completion Date: Sep 27, 2022
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