Inspection Report
Biennial Survey
Census: 29
Capacity: 31
Deficiencies: 1
Oct 7, 2025
Visit Reason
The biennial survey was conducted to assess compliance with the Assisted Housing Program Licensing Rule for The Inn at City Hall.
Findings
The facility was found not in compliance with the requirement to update a consumer's service plan to reflect significant changes, specifically failing to document revisions reflecting the start of hospice care for one consumer.
Deficiencies (1)
| Description |
|---|
| Failure to update a consumer’s service plan to reflect significant change in condition for 1 of 3 consumer records reviewed. |
Report Facts
Census: 29
Total Capacity: 31
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Samantha Rae Tracy | Administrator | Named as administrator responsible for the facility and plan of correction |
Inspection Report
Biennial Survey
Census: 29
Capacity: 31
Deficiencies: 1
Oct 7, 2025
Visit Reason
The visit was a biennial survey to assess compliance with the Assisted Housing Program Licensing Rule for assisted living facilities.
Findings
The facility was found not in compliance with the requirement to update a consumer's service plan to reflect a significant change in condition. Specifically, Consumer #2's service plan was not updated to document the start of hospice care.
Deficiencies (1)
| Description |
|---|
| Failed to update a consumer’s service plan to reflect a significant change in condition for 1 of 3 consumer records reviewed (Consumer #2). |
Report Facts
Census: 29
Total Capacity: 31
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Samantha Rae Tracy | Administrator | Interviewed regarding the deficiency related to service plan updates |
Inspection Report
Complaint Investigation
Census: 27
Capacity: 31
Deficiencies: 3
Jan 29, 2025
Visit Reason
The inspection was conducted following reports received on 12/30/2024 alleging missing medications for Resident #1 and Resident #2, specifically 115 Oxycodone pills and 42 Belbuca Film Patches respectively.
Findings
The facility failed to protect residents from exploitation and failed to use safe and acceptable procedures for medication documentation and inventory. Specifically, missing controlled substances were not identified timely due to incomplete medication counts, and weekly inventory counts for Schedule II controlled substances were not maintained as required.
Complaint Details
The investigation was triggered by two complaints received on 12/30/2024 regarding missing medications for Resident #1 (115 Oxycodone pills) and Resident #2 (42 Belbuca Film Patches). The complaints were substantiated based on record reviews and interviews confirming missing medications and failure to maintain required medication counts.
Severity Breakdown
Class III: 2
Class II: 1
Deficiencies (3)
| Description | Severity |
|---|---|
| Failure to protect residents from exploitation related to missing 115 Oxycodone pills and 42 Belbuca Film Patches. | Class III |
| Failure to use safe and acceptable procedures for documenting residents' medications. | Class III |
| Failure to maintain weekly inventory counts in the bound book for Schedule II controlled substances for two residents. | Class II |
Report Facts
Missing Oxycodone pills: 115
Missing Belbuca Film Patches: 42
Residents present: 27
Total licensed capacity: 31
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Samatha Rae Tracy | Administrator | Interviewed and confirmed findings related to missing medications and inventory counts |
Inspection Report
Biennial Survey
Census: 31
Capacity: 31
Deficiencies: 2
Oct 11, 2023
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 Inn at City Hall Assisted Living Program.
Findings
The facility was found non-compliant in medication management, specifically failing to ensure availability of medications for administration for 2 of 3 consumer records reviewed and failing to remove expired medications from active use for 1 of 3 consumer records reviewed.
Deficiencies (2)
| Description |
|---|
| Medications were not available for administration for 2 of 3 consumer records reviewed. |
| Expired medication (Aspirin 81 pain reliever with expiration date 6/2022) was found in active use for 1 of 3 consumer records reviewed. |
Report Facts
Consumers with unavailable medications: 2
Consumers with expired medications in active use: 1
Census: 31
Total Capacity: 31
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