10 Reports
Inspection Report — Feb 9, 2026
Enforcement
Date: Feb 9, 2026
Visit Reason
Investigation of Complaint #130842-C and Incidents #130476-M and #130494-I related to abuse allegations, menu substitution, and food safety concerns.
Complaint Details
Complaint #130842-C, Incidents #130476-M and #130494-I
Findings
The Program failed to follow established policies related to abuse reporting, allowed staff to make degrading comments and take inappropriate photos of tenants, failed to document nurse's notes by exception, did not complete evaluations and update service plans as needed, failed to maintain tenant records for three years after discharge, failed to discharge a tenant exceeding retention criteria, and failed to ensure staff completed required dementia-specific training within required timeframes.
Violations (9)
481-67.2(3) Program Policies and Procedures: The Program failed to follow established policies related to abuse reporting, including failure to report and document incidents involving staff sharing inappropriate photos and videos of tenants and making degrading comments.
481-67.3(1) Tenant Rights: Staff made degrading and disrespectful comments to tenants, including mocking physical conditions and using profanity, violating tenants' rights to dignity and respect.
481-69.22(3) Evaluation of Tenant: The Program failed to complete evaluations as needed for tenants showing significant decline or changes in condition, including weight loss and health deterioration.
481-69.23(1)b Criteria for Admission / Retention of Tenants: The Program failed to discharge a tenant who required routine two-person assistance with transfers and other care, exceeding retention criteria.
481-69.25(1)i Tenant Documents: The Program failed to document nurse's notes by exception related to abuse allegations and tenant distress for multiple tenants.
481-69.25(2) Tenant Documents: The Program failed to maintain tenant records for three years after transfer or death, as required.
481-69.26(1) Service Plans: The Program failed to update service plans as needed and to develop plans reflecting tenants' changing service needs.
481-69.30(1) Dementia Specific Education for Personnel: The Program failed to ensure staff completed eight hours of dementia-specific training within 30 days of hire.
481-69.30(3)b Dementia-Specific Education for Personnel: The Program failed to ensure staff completed eight hours of dementia-specific continuing education annually.
Inspection Report — Aug 20, 2025
Complaint Investigation
Date: Aug 20, 2025
Visit Reason
The inspection was conducted related to Complaint #128415-C and Incident #129285-I involving regulatory insufficiencies in food safety, tenant care, and notification procedures.
Complaint Details
The visit was complaint-related involving Complaint #128415-C and Incident #129285-I. Tenant #1's fall and injury were substantiated with findings of inadequate care and failure to follow service plans.
Findings
The program failed to follow established policies related to food safety and sanitation, including unlabeled foods and incomplete temperature logs. Additionally, the program failed to provide adequate care to Tenant #1, who sustained a pelvic fracture after a fall due to staff not using a required gait belt. The program also failed to notify the Department within 24 hours of the major injury. Furthermore, several dietary staff lacked proper orientation and annual training on food safety.
Violations (4)
Failed to follow established policy and procedure related to food safety and sanitation, including unlabeled foods and incomplete temperature logs.
Failed to provide adequate care to Tenant #1 who fell and sustained a pelvic fracture due to staff not using a gait belt as required by the service plan.
Failed to notify the Department within 24 hours or next business day of an accident causing major injury to Tenant #1.
Failed to provide orientation on sanitation and safe food handling prior to handling food and annual in-service training on food protection for 4 of 7 dietary staff.
Report Facts
Number of tenants without cognitive impairment: 32
Number of tenants with cognitive impairment: 19
Incident date: Jun 4, 2025
Report date to Department: Jun 7, 2025
Number of dietary staff lacking proper training: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Staff who failed to use gait belt with Tenant #1 leading to fall and injury; received counseling and re-education | |
| Staff B | Staff who provided interview regarding fall incident involving Tenant #1 | |
| Staff C | Staff who provided interview regarding fall incident involving Tenant #1 | |
| Regional Nurse Specialist | Completed electronic report of incident and explained delay in reporting due to Former Director's departure | |
| Culinary Coordinator | Provided information on food safety training and staff responsibilities | |
| Former Director | Conducted investigation of Tenant #1 fall and confirmed staff failure to use gait belt |
Inspection Report — Aug 18, 2025
Enforcement
Date: Aug 18, 2025
Visit Reason
Investigation #129285-I was conducted from 8/18/25 to 8/20/25 regarding a fall incident involving Tenant #1 on 6/4/25 where the facility failed to provide adequate care and treatment as required by the tenant's service plan.
Findings
Tenant #1 fell on 6/4/25 when Staff A did not use the required gait belt during ambulation, resulting in a pelvic fracture and hospitalization. The facility failed to provide care, treatment, and services that were adequate and appropriate as required by Tenant #1's service plan.
Violations (1)
IAC 481-67.3(2) Tenant Rights: The program failed to provide adequate and appropriate care and services to Tenant #1 by not using the required gait belt during ambulation, which led to a fall and pelvic fracture.
Report Facts
Fine amount: 3000
Inspection Report — Apr 1, 2025
Plan of Correction
Date: Apr 1, 2025
Visit Reason
The inspection was conducted as a complaint investigation related to Incident #125272-I and Complaint #124843-C at Emery Place, an assisted living program for people with dementia.
Complaint Details
The visit was related to the investigation of Complaint #124843-C and Incident #125272-I. No regulatory insufficiencies were identified related to Incident #125272-I. Deficiencies were cited related to Complaint #124843-C.
Findings
The program failed to follow established policies and procedures related to administration of PRN medications for one tenant, failed to complete required evaluations for one tenant, and failed to update service plans as needed for one tenant. The Plan of Correction is attached to address these deficiencies.
Violations (3)
Program failed to follow established policy and procedure related to administration of PRN medications for Tenant #1.
Program failed to complete evaluations as needed for Tenant #1.
Program failed to update service plans as needed for Tenant #1.
Report Facts
Number of tenants without cognitive impairment: 29
Number of tenants with cognitive impairment: 16
Number of tenants reviewed for evaluations and service plans: 5
Inspection Report — Oct 1, 2024
Complaint Investigation
Date: Oct 1, 2024
Visit Reason
The inspection was conducted related to the investigation of Complaints #117848-C and #122653-C, the recertification visit to determine compliance with certification of a Dedicated Dementia Specific Assisted Living Program, and the revisit of FC 10179.
Complaint Details
The visit was complaint-related involving Complaints #117848-C and #122653-C. The investigation found multiple regulatory insufficiencies related to tenant care, medication administration, documentation, and transfer procedures.
Findings
The program failed to include required information regarding involuntary transfer procedures and internal appeals in the occupancy agreement, failed to follow established policies related to medications and incident reports, failed to provide adequate care and services, failed to administer medications as ordered, and failed to maintain proper documentation and service plans. Multiple tenants had medication errors, refusals of care, and incomplete evaluations or service plans.
Violations (10)
Occupancy agreement did not include required information on involuntary transfer procedures and internal appeals.
Program failed to follow established policies and procedures related to medications and incident reports.
Program failed to provide adequate and appropriate care, treatment, and services to tenants.
Medications and treatments were not administered as prescribed by the tenant's physician or advanced registered nurse practitioner.
Certified and noncertified staff did not receive adequate training regarding service plan tasks including wound care, pain management, rehabilitation needs, and hospice care.
Program failed to complete evaluations as needed with significant change.
Program failed to notify tenant's primary care provider of involuntary transfer.
Program failed to maintain proper tenant documentation including nurse's notes by exception.
Service plans were not developed or updated as required based on evaluations and significant changes.
Service plans were not signed and dated by all parties within 30 days of occupancy.
Report Facts
Tenants without cognitive impairment: 32
Tenants with cognitive impairment: 16
Tenants reviewed for medication and incident reports: 9
Tenants with medication errors: 5
Tenants reviewed for care adequacy: 6
Tenants reviewed for evaluations: 6
Tenants reviewed for documentation: 3
Tenants reviewed for service plans: 6
Inspection Report — Nov 15, 2023
Complaint Investigation
Date: Nov 15, 2023
Visit Reason
The inspection was conducted due to investigations of multiple incidents and complaints related to the assisted living program.
Complaint Details
The visit was complaint-related triggered by multiple incidents and complaints including medication errors, inadequate care, and staffing concerns.
Findings
The Program failed to implement established policies and procedures related to incident reports, visual checks, medication administration, tenant rights, adequate and appropriate care, medication management, staffing, nurse delegation, service plans, nurse reviews, and activities. Multiple tenants experienced medication errors, inadequate care, insufficient staffing, and lack of proper documentation and evaluations.
Violations (18)
Failure to implement policies and procedures related to incident reports, visual checks, and medication administration.
Failure to ensure tenants were treated with consideration, respect, and full recognition of personal dignity and autonomy.
Failure to provide adequate and appropriate care and services to tenants, including wound care, transfers, and medication administration.
Failure to administer medications by trained staff with proper certification prior to administration.
Failure to administer medications as prescribed, including medication refusals not properly handled and medications not available.
Failure to maintain sufficient staffing to meet tenants' needs, resulting in delayed care and medication administration.
Failure to provide nurse delegated training within 30 days of employment for some staff.
Failure to ensure staff were competent to meet tenants' needs including training on service plan tasks such as continuous glucometer use and colostomy care.
Failure to ensure staff documented occurrences that differed from tenants' normal health, functional, and cognitive status.
Failure to provide appropriate activities reflecting individual tenant differences in the memory care units.
Failure to provide 30-day written notice to tenants regarding changes in medication services and fees.
Failure to complete evaluations as needed with significant change for multiple tenants.
Failure to update service plans as needed and ensure they reflect tenants' service needs.
Failure to obtain signatures from tenants or legal representatives on updated service plans after significant changes.
Failure to complete nurse reviews as needed related to changes in tenants' health status.
Failure to discharge tenants requiring routine two-person assistance with transfers, contrary to admission/retention criteria.
Failure to notify tenant or legal representative of need for involuntary transfer, reason for transfer, and ombudsman contact information.
Failure to document nurse's notes by exception for significant changes in tenant condition.
Report Facts
Medication refusal dates: 5
Medication manager training delay: 30
Staff on shift: 3
Pendant response delay: 83
Medication administration delay: 120
Activities scheduled: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Medication Manager | Named in medication error and training deficiency findings |
| Staff K | Medication Manager | Named in medication training delay and staffing findings |
| Staff B | Named in sleeping on duty and fall incident findings | |
| Staff R | Named in sleeping on duty findings | |
| Staff S | Named in sleeping on duty findings | |
| Healthcare Coordinator | Named in multiple findings related to medication refusals, evaluations, and transfers | |
| Executive Director | Named in staffing and activities findings | |
| Hospice Nurse #1 | Named in transfer and care findings for Tenant #10 | |
| Hospice Nurse #2 | Named in transfer and care findings for Tenant #7 and Tenant #9 |
Inspection Report — Oct 11, 2023
Enforcement
Date: Oct 11, 2023
Visit Reason
This citation was issued following investigations of multiple complaints and incidents (#116765-C, #116105-C, #115274-C, #114895-C, #113795-C, #113773-C, #113678-C, #113845-I, #114030-I, and #112318-I) conducted between October 11, 2023 and November 15, 2023. The citation addresses failures in providing adequate and appropriate care, treatment, and services to tenants.
Complaint Details
Investigations #116765-C, #116105-C, #115274-C, #114895-C, #113795-C, #113773-C, #113678-C, #113845-I, #114030-I, and #112318-I
Findings
The facility failed to provide adequate and appropriate care to three discharged tenants, resulting in serious adverse outcomes including wounds, falls, hospitalizations, and deaths. Documentation and care plans were not properly followed, and staff failed to perform required safety checks and administer medications as prescribed.
Violations (3)
481-67.3(2) Tenant rights: The program failed to provide adequate and appropriate services to Tenant C4, who developed a large sacral stage II decubitus ulcer with infection that was not identified or treated timely, resulting in hospitalization and IV antibiotics. Staff failed to document wound care and timely interventions.
481-67.3(2) Tenant rights: Staff failed to perform required safety checks and provide adequate supervision to Tenant C2, who fell, sustained a brain bleed, and subsequently died. Visual checks were not completed as scheduled and family was not properly notified.
481-67.3(2) Tenant rights: Tenant C1, with a history of falls, experienced three falls in one day resulting in a femur fracture and death. Staff failed to follow fall guidelines, perform timely visual checks, administer medications, and properly notify healthcare coordinators and family.
Report Facts
Fine amount: 10000
Inspection Report — Jan 19, 2023
Complaint Investigation
Date: Jan 19, 2023
Visit Reason
The inspection was conducted to investigate complaints #105704-C, #107942-C, and #107944-C at the assisted living facility Emery Place.
Complaint Details
Investigation of Complaints #105704-C, #107942-C, and #107944-C found no regulatory insufficiencies.
Findings
No regulatory insufficiencies were cited during the investigation of the complaints.
Report Facts
Number of tenants without cognitive impairment: 39
Number of tenants with cognitive impairment: 13
Inspection Report — Jan 19, 2022
Complaint Investigation
Date: Jan 19, 2022
Visit Reason
The investigation of Complaints #95611-C, #95612-C, #95613-C and #98302-C and the recertification visit were conducted to determine compliance with certification for a Dedicated Dementia Specific Assisted Living Program.
Complaint Details
Complaints #95611-C, #95612-C, #95613-C and #98302-C were investigated as part of this visit.
Findings
The inspection identified regulatory insufficiencies related to tenant rights, including failure to treat a tenant with dignity and respect, failure to provide adequate care and treatment resulting in injury, and failure to administer medications as prescribed. Additional deficiencies were found in nurse delegation, documentation, and service plans.
Violations (7)
Program failed to treat a tenant with consideration, respect, and full recognition of personal dignity and autonomy related to pharmacy choice and medication administration.
Program failed to provide adequate and appropriate care, treatment and services to a tenant who fell, sustained injury, and was sent out for evaluation.
Program failed to administer medications and complete treatments as prescribed for multiple tenants.
Program failed to ensure staff received nurse delegation training within 30 days of employment.
Program failed to document nurse's notes by exception for multiple tenants.
Program failed to update service plans as needed and ensure signatures of involved parties.
Program failed to complete nurse reviews when significant changes in tenant condition occurred.
Report Facts
Number of tenants without cognitive disorder in general population: 28
Number of tenants with cognitive disorder in general population: 1
Number of tenants without cognitive disorder in memory care unit: 7
Number of tenants with cognitive disorder in memory care unit: 25
Number of tenants reviewed for medication administration deficiency: 7
Number of tenants reviewed for documentation deficiency: 7
Number of tenants reviewed for nurse review deficiency: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Debbie Crosser | Director | Named in Plan of Correction signature |
Inspection Report — Jan 10, 2022
Enforcement
Date: Jan 10, 2022
Visit Reason
The citation was issued following Recertification and Infection Control Visits and investigations of Complaints #95611-C, #95612-C, #95613-C, and #98302-C conducted from January 10 to January 26, 2022.
Complaint Details
Complaints #95611-C, #95612-C, #95613-C, and #98302-C were investigated during the recertification and infection control visits.
Findings
The facility failed to provide adequate and appropriate care, treatment, and services to Tenant #4 after a fall on February 5, 2021, resulting in a severe skin avulsion injury to the left elbow that was not properly assessed or treated in a timely manner. The lack of thorough nursing assessment and delayed medical evaluation led to hospitalization and surgery for the tenant.
Violations (1)
481-67.3(2) Tenant rights: The program failed to provide adequate and appropriate care, treatment, and services to Tenant #4 after a fall, including insufficient nursing assessment and delayed medical treatment of a severe skin avulsion injury to the left elbow. The tenant required hospitalization, IV antibiotics, and outpatient surgery due to substandard wound care.
Report Facts
Fine amount: 3000
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