Our House

FACILITY EVALUATION REPORT

This report details the findings of a complaint investigation conducted on August 21, 2025. All allegations regarding staff causing injury, failure to seek medical attention, failure to report incidents, and staff impairment were found to be unsubstantiated. The investigation concluded that there was insufficient evidence to prove any violation occurred.

The facility was inspected on 03/20/2025 and was generally found to be clean with appropriate safety measures like grab bars and operational detectors. However, several deficiencies were noted, including overdue fire extinguisher servicing and an expired administrator certificate. The facility was also required to submit several updated administrative documents.

The annual inspection identified four deficiencies, all classified as Type B non-compliance issues. Key areas of concern include staff training deficits related to specialized care (dementia, hospice), general staff safety (First Aid), and medication storage security. The facility was required to submit multiple plans of correction by March 8, 2024, to address these findings.

The inspection was a Case Management follow-up regarding a self-reported medication error. Two deficiencies were cited: one concerning the lack of a comprehensive plan for incidental medical and dental care, and a more severe deficiency regarding the over-medication of a resident. Both citations are classified as Type A, indicating immediate health and safety risks.

The facility underwent an annual required inspection and was found to be generally clean with several safety measures in place, including operational smoke/CO detectors and proper storage of toxins. No deficiencies were cited during the physical inspection, although the LPA requested several updated documents from the facility.

The facility underwent an annual required inspection and was found to be clean with no deficiencies cited at the time of the visit. The inspector noted several required documents that the licensee must update and submit by 3/31/2022.