5 Reports
Inspection Report — Apr 29, 2026
Renewal
Date: Apr 29, 2026
Visit Reason
The visit was a recertification (renewal) visit to determine compliance with certification of an Assisted Living Program. The investigation also included Complaint #131077-C.
Complaint Details
Complaint #131077-C
Findings
One regulatory insufficiency was cited related to program policies and procedures. The program failed to follow policies related to accident and emergency responses and incident reports for 2 of 3 tenants reviewed.
Violations (1)
481-67.2(2) Program Policies and Procedures: The program failed to follow policies related to accident and emergency responses and incident reports for 2 of 3 tenants reviewed. Tenant C1 had an incident on 12/21/25 where staff delayed calling emergency services, and Tenant C2 had multiple incidents not properly reported or managed according to policy.
Inspection Report — Apr 23, 2026
Enforcement
Date: Apr 23, 2026
Visit Reason
Investigation #131077-C was conducted from April 23 to April 28, 2026, to review compliance with policies and procedures related to accident and emergency responses and incident reports for tenants.
Complaint Details
Investigation #131077-C
Findings
The program failed to follow its policies regarding accident and emergency responses and incident reporting for two tenants. Tenant C1 was found incontinent and on the floor without timely reporting of his refusal to eat and increased sleeping. Tenant C2 had multiple incidents involving behavioral issues and hospitalizations that were not properly reported on incident forms.
Violations (1)
481-67.2(2) The program failed to follow policies related to accident and emergency responses and incident reports for 2 out of 3 tenants reviewed. Staff did not report Tenant C1's refusal to eat and increased sleeping prior to his incident, and Tenant C2's multiple behavioral incidents were not documented on incident reports as required.
Report Facts
Fine amount: 4000
Inspection Report — Oct 24, 2024
Complaint Investigation
Date: Oct 24, 2024
Visit Reason
The inspection was conducted to investigate Complaint #122058-C and to perform a recertification visit to determine compliance with certification of an Assisted Living Program.
Complaint Details
Complaint #122058-C was investigated and found to have no regulatory insufficiencies.
Findings
No regulatory insufficiencies were cited during the complaint investigation or the recertification visit.
Report Facts
Number of tenants without cognitive impairment: 18
Number of tenants with cognitive impairment: 1
Inspection Report — Aug 31, 2021
Renewal
Date: Aug 31, 2021
Visit Reason
The inspection was conducted as a recertification visit to determine compliance with certification requirements for an Assisted Living Program.
Findings
The inspection found no regulatory insufficiencies during the onsite infection control survey. However, deficiencies were cited related to documentation of tenant health-related care and individualized service plans reflecting tenant needs and preferences.
Violations (2)
Failure to document nurses' notes by exception for a tenant's health-related care.
Failure to develop individualized service plans reflecting tenants' identified needs and preferences for assistance.
Report Facts
Number of tenants without cognitive disorder: 16
Number of tenants with cognitive disorder: 0
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse Manager | Interviewed and confirmed findings related to documentation and service plans; responsible for reviewing regulations and educating staff. | |
| Staff A | Interviewed regarding tenant bathing assistance and refusals. |
Inspection Report — Jan 28, 2020
Complaint Investigation
Date: Jan 28, 2020
Visit Reason
The investigation was conducted as a result of Complaint #87102-C which resulted in a regulatory insufficiency.
Complaint Details
Investigation of Complaint #87102-C resulted in a regulatory insufficiency.
Findings
The program failed to develop individualized service plans reflecting the identified needs of tenants, as evidenced by deficiencies in service plans for tenants #2, #3, and #4. Multiple incidents of falls and inadequate documentation of interventions and treatments were noted.
Violations (1)
Failure to develop service plans that reflected the identified needs of tenants, including history of falls, interventions, and treatment plans.
Report Facts
Number of tenants without cognitive disorder: 16
Number of tenants with cognitive disorder: 0
Number of tenants reviewed for service plan deficiencies: 4
Number of falls/incidents documented for Tenant #3: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Toni Allen | Manager | Signed as Laboratory Director's or Provider/Supplier Representative on the report. |
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