Deficiencies per Year
8
6
4
2
0
Severe
High
Moderate
Low
Unclassified
Census Over Time
Inspection Report
Renewal
Census: 17
Deficiencies: 1
Mar 6, 2025
Visit Reason
A relicensure survey was conducted from March 5 through March 6, 2025, to assess compliance with applicable construction and safety standards for the assisted living center.
Findings
The facility failed to ensure an annual fire inspection was completed in 2024, with no documentation available for a 2024 fire marshal inspection. The last inspection was completed on October 6, 2023. The facility submitted a plan of correction which was accepted, and a revisit confirmed substantial compliance as of March 13, 2025.
Severity Breakdown
SS=F: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failed to ensure an annual fire inspection was completed in 2024. | SS=F |
Report Facts
Facility Census: 17
Date of last fire marshal inspection: Oct 6, 2023
Date of accepted correction: Mar 13, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| James M Jakubovitz | Administrator | Signed the plan of correction |
| Tempal Killman | Enforcement Analyst | Signed enforcement letters and correspondence |
Inspection Report
Renewal
Deficiencies: 1
Oct 6, 2023
Visit Reason
A relicensure survey was conducted from October 4, 2023 through October 6, 2023 to assess compliance with assisted living center regulations.
Findings
The facility failed to ensure medications were reviewed monthly by a registered nurse or pharmacist for six of six sampled residents. The Director of Nursing stated the pharmacist reviewed medications quarterly and was unaware monthly reviews were required.
Severity Breakdown
Level B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failed to ensure medications were reviewed monthly by an RN or pharmacist for six sampled residents. | Level B |
Report Facts
Residents receiving medications: 15
Sampled residents with medication review deficiency: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| James M. Jakubovitz | Administrator | Named as the facility administrator in the plan of correction and correspondence. |
| Lisa Calvin | Enforcement Analyst II | Signed enforcement correspondence related to the inspection. |
| Tempal Killman | Administrative Assistant II | Signed letter acknowledging acceptance of plan of correction. |
Inspection Report
Renewal
Census: 13
Deficiencies: 6
Mar 28, 2019
Visit Reason
A state licensure survey was conducted on March 28, 2019, as part of a re-licensure inspection of the assisted living center facility.
Findings
Deficiencies were found related to assessment timeframes, use of assessment, medication staffing, quality assurance committee, and maintenance of records. The deficiencies represented the potential for more than minimal harm. A follow-up survey was conducted on June 20, 2019, and all deficient practices were cleared.
Severity Breakdown
SS=E: 3
SS=F: 3
Deficiencies (6)
| Description | Severity |
|---|---|
| Failed to complete admission assessments within thirty days before or at the time of admission for sampled residents. | SS=E |
| Failed to complete comprehensive assessments within required timeframes for sampled residents. | SS=E |
| Failed to use assessment results to develop care plans for sampled residents. | SS=E |
| Failed to ensure monthly medication reviews by a registered nurse or pharmacist and quarterly medication reviews by a consultant pharmacist for residents. | SS=F |
| Failed to establish and maintain an internal quality assurance committee that meets at least quarterly. | SS=F |
| Failed to maintain organized, accurate clinical records for sampled residents. | SS=F |
Report Facts
Current census: 13
Census: 15
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Lisa Calvin | Long Term Care Enforcement Reviewer | Signed acceptance letter of plan of correction |
| Sue Davis | Enforcement Coordinator | Signed letter regarding informal dispute resolution process and follow-up survey results |
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