6 Reports
Inspection Report — Mar 10, 2026
Renewal
Date: Mar 10, 2026
Visit Reason
Scheduled renewal visit to determine compliance with certification of an Assisted Living Program for People with Dementia. The visit also included investigation of Incident #130730-I and Complaints #130683-C and #130684-C.
Complaint Details
Incident #130730-I, Complaints #130683-C and #130684-C were investigated during the visit.
Findings
No regulatory insufficiencies were cited during the investigation of Incident #130730-I and Complaints #130683-C and #130684-C.
Inspection Report — May 7, 2025
Renewal
Date: May 7, 2025
Visit Reason
The visit was conducted as a recertification to determine compliance with an Assisted Living Program for People with Dementia and to investigate Incident #127266-I.
Findings
No regulatory insufficiencies were cited during the recertification visit.
Report Facts
Number of tenants without cognitive impairment: 18
Number of tenants with cognitive impairment: 11
Inspection Report — Aug 17, 2023
Renewal
Date: Aug 17, 2023
Visit Reason
The inspection was a recertification visit conducted to determine compliance with certification rules for an Assisted Living Program.
Findings
The inspection identified multiple regulatory deficiencies including failure to provide required staff training within specified timeframes, failure to evaluate and update tenant service plans following significant health changes, and failure to provide dementia-specific education within 30 days of employment.
Violations (5)
Program's Registered Nurse failed to provide training within 30 days of hire to ensure staff were competent to meet tenant needs.
Program failed to provide 2 hours of dependent adult abuse training within 6 months of employment for some staff.
Program failed to evaluate functional, cognitive, and health status as needed for a tenant with significant health change.
Program failed to update service plans based on required evaluations for a tenant with significant health change.
Program failed to provide 8 hours of dementia-specific education and training within 30 days of employment for some staff.
Report Facts
Number of tenants without cognitive impairment: 21
Number of tenants with cognitive impairment: 9
Staff reviewed for nurse delegation training: 4
Staff reviewed for dependent adult abuse training: 7
Staff reviewed for dementia-specific training: 7
Hours of dementia training required: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Holly Smith | Registered Nurse | Confirmed findings related to staff training and tenant evaluations |
| Staff B | Caregiver staff reviewed for nurse delegation, dependent adult abuse, and dementia training deficiencies | |
| Staff C | Caregiver staff reviewed for nurse delegation and dependent adult abuse training deficiencies | |
| Staff F | Caregiver staff reviewed for nurse delegation and dementia training deficiencies; no longer employed as of 8/21/23 | |
| Staff A | Staff reviewed for dependent adult abuse training deficiency; no longer employed as of 8/29/23 | |
| Staff D | Staff reviewed for dementia training deficiency | |
| Staff E | Staff reviewed for dementia training deficiency; no longer employed as of 9/1/23 |
Inspection Report — Aug 16, 2022
Complaint Investigation
Date: Aug 16, 2022
Visit Reason
Investigation of complaints #100550-C and #101438-C regarding the Assisted Living Program for People with Dementia.
Complaint Details
Investigation of Complaint #100550-C and #101438-C found no regulatory insufficiencies.
Findings
No regulatory insufficiencies were cited during the investigation of the complaints.
Report Facts
Number of tenants without cognitive disorder in General Population Program: 28
Number of tenants with cognitive disorder in General Population Program: 4
Number of tenants without cognitive disorder in Memory Care Unit: 0
Number of tenants with cognitive disorder in Memory Care Unit: 10
Inspection Report — Jun 28, 2021
Renewal
Date: Jun 28, 2021
Visit Reason
Recertification visit conducted to determine compliance with certification of an Assisted Living Program and investigation of Complaint #96085-C and onsite infection control survey.
Complaint Details
Complaint #96085-C was investigated with no regulatory insufficiencies cited.
Findings
No regulatory insufficiencies were cited during the recertification visit, complaint investigation, or infection control survey.
Report Facts
Number of tenants without cognitive disorder in General Population Program: 32
Number of tenants with cognitive disorder in General Population Program: 5
Number of tenants without cognitive disorder in Memory Care Unit: 0
Number of tenants with cognitive disorder in Memory Care Unit: 9
Inspection Report — Feb 11, 2020
Complaint Investigation
Date: Feb 11, 2020
Visit Reason
The investigation of Complaint #87571-C resulted in a regulatory insufficiency related to nurse review and medication administration for tenants receiving assistance with medications and treatments.
Complaint Details
Complaint #87571-C was investigated, resulting in a regulatory insufficiency related to nurse review and medication administration.
Findings
The program failed to ensure health care professionals' orders were current for tenants receiving medication assistance, with discrepancies found in medication orders, administration records, and documentation for multiple tenants. Several medication orders lacked proper signatures, dates, or were inconsistent with clinical summaries and MARs.
Violations (1)
Failure to ensure health care professionals' orders were current for tenants receiving medication assistance, including discrepancies in medication orders and administration documentation.
Report Facts
Number of tenants without cognitive disorder: 28
Number of tenants with cognitive disorder: 0
Number of tenants without cognitive disorder: 1
Number of tenants with cognitive disorder: 9
Viewing
Loading inspection reports...
