Deficiencies per Year
8
6
4
2
0
Moderate
Unclassified
Census Over Time
Inspection Report
Follow-Up
Deficiencies: 0
Oct 20, 2025
Visit Reason
An offsite revisit survey was conducted on 10/20/25 to verify correction of all previous deficiencies cited on 10/01/25.
Findings
All deficiencies have been corrected as of the compliance date of 10/16/25, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Report Facts
Previous deficiencies cited: 1
Inspection Report
Re-Inspection
Census: 33
Deficiencies: 2
Oct 1, 2025
Visit Reason
This document reports the findings of a resurvey with an attached complaint (186031) at an assisted living facility conducted on 09/30/2025-10/01/2025.
Findings
The facility failed to ensure that negotiated service agreements (NSA) for residents 2 and 3 were revised every 365 days and upon change in condition. Additionally, the facility failed to maintain chemical safety by storing all chemicals in locked areas, as several aerosol cans were found accessible in public bathrooms.
Complaint Details
The resurvey was conducted with an attached complaint number 186031.
Severity Breakdown
SS=E: 1
SS=F: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to revise Negotiated Service Agreements for Residents 2 and 3 every 365 days and upon change in condition. | SS=E |
| Failure to ensure all chemicals were stored within locked areas, exposing residents and visitors to potential hazards. | SS=F |
Report Facts
Census: 33
Deficiency sample size: 3
Closed chart review: 1
Number of aerosol cans found: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Heather Williams | Executive Director | Named in relation to removal of chemicals and conducting staff education on chemical safety. |
| Jenna McClain | Surveyor | Conducted the community tour identifying chemical safety issues. |
| Administrative Nurse C | Interviewed regarding residents' negotiated service agreements and confirmed deficiencies. | |
| Administrative Staff A | Confirmed lack of facility policy regarding negotiated service agreements and chemical storage. | |
| Amber Siebenmorgen | Wellness Director | Responsible for reviewing and revising negotiated service agreements and conducting chart audits. |
Inspection Report
Plan of Correction
Deficiencies: 0
Sep 30, 2025
Visit Reason
This document represents the findings of a resurvey with an attached complaint investigation conducted at the assisted living facility from 09/30/25 to 10/01/25.
Findings
The document is a plan of correction submitted in response to deficiencies identified during the resurvey and complaint investigation conducted on the specified dates.
Complaint Details
The plan of correction is related to complaint number 186031 attached to the resurvey.
Inspection Report
Re-Inspection
Deficiencies: 0
Mar 21, 2024
Visit Reason
An offsite revisit survey was conducted to verify correction of all previous deficiencies cited on 2024-02-22.
Findings
All deficiencies have been corrected as of the compliance date of 2024-03-11, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Inspection Report
Re-Inspection
Census: 26
Deficiencies: 5
Feb 22, 2024
Visit Reason
The inspection was a resurvey with a complaint (#182327) at an assisted living facility conducted on 02/21/2024 and 02/22/2024.
Findings
The facility was found deficient in multiple areas including failure to complete a Functional Capacity Screen (FCS) following a significant change in a resident's condition, failure to revise the Negotiated Service Agreement (NSA) accordingly, improper labeling of over-the-counter and prescription medications, and non-compliance with tuberculosis screening guidelines for residents and new employees.
Complaint Details
The inspection was triggered by complaint #182327.
Severity Breakdown
SS=D: 2
SS=E: 1
SS=F: 2
Deficiencies (5)
| Description | Severity |
|---|---|
| Failed to ensure designated staff completed a Functional Capacity Screen for resident R101 following a significant change in her ability to walk. | SS=D |
| Failed to ensure the Negotiated Service Agreement for resident R101 was revised following a significant change in condition. | SS=D |
| Failed to ensure a licensed pharmacist or nurse placed the full name of the resident on the original package of over-the-counter medications for four residents. | SS=E |
| Failed to ensure each prescription medication container had a label provided by a dispensing pharmacist affixed to the container. | SS=F |
| Failed to ensure compliance with tuberculosis guidelines, including missing annual TB symptom screening for resident R101 and incomplete TB screening documentation for three of five new employees. | SS=F |
Report Facts
Census: 26
Residents with unlabeled OTC medications: 4
Sampled residents: 3
New employee records reviewed: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Nurse B | Licensed Nurse | Provided statements regarding resident R101's condition and need for updated Functional Capacity Screen and Negotiated Service Agreement; also noted missing TB screening documentation. |
| Certified Nurse Aide F | Certified Nurse Aide | Reported resident R101 required staff assistance with ambulation and transfers into wheelchair. |
| Administrative Staff A | Administrative Staff | Acknowledged missing tuberculosis screening documentation for employees and resident. |
Inspection Report
Plan of Correction
Deficiencies: 0
Feb 21, 2024
Visit Reason
The document is a plan of correction addressing findings from a resurvey conducted with a complaint #182327 at the assisted living facility on 02/21/24 and 02/22/24.
Findings
The plan of correction references citations resulting from the resurvey with complaint #182327, but specific findings or deficiencies are not detailed in this document.
Complaint Details
The visit was complaint-related, associated with complaint #182327.
Inspection Report
Re-Inspection
Deficiencies: 0
Aug 25, 2022
Visit Reason
The visit was a resurvey conducted with complaints 169355, 168575, 168420, 165823, 162308, 171741, and 161907 at the facility.
Findings
The resurvey conducted on 08/24/22 - 08/25/22 resulted in no citations.
Complaint Details
The visit was complaint-related involving multiple complaints, but no citations were issued.
Inspection Report
Plan of Correction
Deficiencies: 0
Aug 24, 2022
Visit Reason
The document represents the findings of a resurvey with complaints at the facility conducted on 08/24/22 - 08/25/22.
Findings
The resurvey with complaints resulted in no citations.
Complaint Details
The resurvey was related to complaints 169355, 168575, 168420, 165823, 162308, 171741, and 161907.
Inspection Report
Routine
Deficiencies: 0
Jun 11, 2020
Visit Reason
The special infection control survey for COVID-19 was conducted at the facility on 06/11/2020.
Findings
The survey resulted in findings of no deficiency citations.
Inspection Report
Renewal
Census: 32
Deficiencies: 1
Jan 8, 2020
Visit Reason
The inspection was conducted for re-licensure of the assisted living facility on January 7 and 8, 2020.
Findings
The facility failed to ensure employee records contained supporting documentation from the nurse aide registry and criminal background checks upon hire for 4 certified staff and 1 non-certified staff. Documentation was submitted late or missing, violating staff qualification requirements.
Severity Breakdown
SS=F: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Employee records lacked supporting documentation from the nurse aide registry and criminal background checks upon hire for certified and non-certified staff. | SS=F |
Report Facts
Census: 32
Certified staff with late or missing documentation: 4
Non-certified staff with late or missing documentation: 1
Days late for KBI check submission: 43
Days late for nurse aide registry check: 64
Inspection Report
Follow-Up
Deficiencies: 2
Jan 16, 2019
Visit Reason
This report documents a revisit inspection to verify that previously reported deficiencies have been corrected and to confirm the dates such corrective actions were accomplished.
Findings
The revisit report confirms that the identified deficiencies related to regulations 26-41-205(h) and 26-41-102(d) have been corrected as of 01/16/2019.
Deficiencies (2)
| Description |
|---|
| Deficiency related to regulation 26-41-205(h) |
| Deficiency related to regulation 26-41-102(d) |
Inspection Report
Renewal
Census: 31
Deficiencies: 2
Dec 6, 2018
Visit Reason
The inspection was conducted as a survey for re-licensure with attached complaints at the assisted living facility.
Findings
The facility failed to ensure medications were stored according to manufacturers' recommendations and regulations, and employee records lacked timely documentation of required licensure, registry checks, and criminal background checks upon hire.
Severity Breakdown
E: 1
F: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Licensed nurses or medication aides failed to store all medications and biologicals securely and properly according to manufacturer and pharmacy provider recommendations and regulations. | E |
| Employee records lacked supporting documentation for licensure, registry checks, and criminal background checks upon hire for multiple certified and licensed staff. | F |
Report Facts
Census: 31
Days after hire for registry and background checks: 43
Days after hire for registry check: 2
Days after hire for nurse license check: 119
Days after hire for registry and background checks: 168
Medication refrigerator temperature: 33.9
Inspection Report
Re-Inspection
Census: 25
Deficiencies: 3
May 24, 2017
Visit Reason
The inspection was a licensure re-survey conducted on 5/22, 5/23, and 5/24/2017 at an assisted living facility to assess compliance with health care service requirements.
Findings
The facility failed to ensure that a licensed nurse provided or coordinated necessary health care services in accordance with functional capacity screenings and negotiated service agreements for three sampled residents. Deficiencies included missing entries in health care service plans for self-administration of medications and treatments, fall interventions, and emergency evacuation assistance.
Severity Breakdown
SS=E: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Health Care Service Plan (HCSP) lacked entries for self-administration of cough drops and use of a pressure reduction gel cushion for resident #522. | SS=E |
| HCSP lacked entry for self-administration of creams and nebulizer treatments for resident #523. | SS=E |
| HCSP lacked entries for fall interventions and plan for emergency evacuation assistance for resident #524 who requires assistance of 2 staff at times. | SS=E |
Report Facts
Census: 25
Sampled residents: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| licensed nurse #B | Interviewed and confirmed deficiencies related to health care service plans and resident care |
Inspection Report
Renewal
Deficiencies: 0
Feb 25, 2016
Visit Reason
The licensure resurvey was conducted as a renewal inspection of the facility.
Findings
The inspection resulted in a finding of no deficiency citations on 2/24/16 and 2/25/16.
Inspection Report
Renewal
Deficiencies: 0
Apr 1, 2014
Visit Reason
The visit was a licensure resurvey at the assisted living facility to assess compliance for renewal of licensure.
Findings
The licensure resurvey conducted on 3/31/14 and 4/01/14 resulted in no deficiency citations.
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