8 Reports
Inspection Report — Jan 29, 2026
Renewal
Date: Jan 29, 2026
Visit Reason
The visit was a recertification (renewal) visit to determine compliance with certification of an Assisted Living Program for People with Dementia. The visit also investigated multiple complaints (#130823-C, #131188-C) and incidents (#130172-M, #130453-I, #131032-I, #131049-I).
Complaint Details
Complaints #130823-C and #131188-C and Incidents #130172-M, #130453-I, #131032-I, and #131049-I were investigated during the visit.
Findings
Multiple regulatory insufficiencies were cited related to program policies and procedures, tenant rights, program notification to the department, medications, staffing, record checks, tenant documents, service plans, nurse review, dementia-specific education for personnel, and structural requirements. The facility failed to follow established policies, adequately protect tenants, report disasters timely, administer medications properly, ensure staff training, conduct background checks, maintain tenant records, and maintain a safe environment.
Violations (13)
481-67.2(3) Program Policies and Procedures: The program failed to follow established policies and procedures related to abuse and incident reports, including incomplete investigations and failure to document additional reports.
481-67.3(1) Tenant Rights: The program failed to treat a tenant with consideration, respect, and full recognition of personal dignity and autonomy, as evidenced by staff verbally and physically degrading a tenant and inadequate handling of aggressive behaviors.
481-67.4(2) Program Notification to Department: The program failed to report three disasters caused by water/flooding in the building that potentially affected all tenants in a timely manner.
481-67.5(2)f(4) Medications: The program failed to administer treatments and medications as ordered, including incomplete medication administration records and failure to follow orders for incentive spirometer use.
481-67.9(4)g Staffing: The program failed to ensure certified and noncertified staff completed dependent adult abuse training within six months of employment, affecting 3 of 5 staff reviewed.
481-67.19(3)b Record Checks: The program failed to submit a person's maiden name on a background check and failed to conduct required background checks for one staff member.
481-69.22(3) Evaluation of Tenant: The program failed to complete evaluations as needed with significant changes for 6 of 8 tenants reviewed, including incomplete progress notes and failure to update service plans.
481-69.25(1)i Tenant Documents: The program failed to maintain documentation for 5 of 8 tenants reviewed, including incomplete nurse's notes and incident reports.
481-69.26(1) Service Plans: The program failed to develop and update service plans reflecting the needs of 6 of 8 tenants reviewed, including failure to address behavioral issues and medication needs.
481-69.27(1)c Nurse Review: The program failed to complete nurse reviews for a tenant involved in an incident, including failure to assess and document changes in condition.
481-69.30(1)b Dementia Specific Education for Personnel: The program failed to provide eight hours of dementia-specific education within 30 days of hire to 3 of 4 staff reviewed.
481-69.30(3)b Dementia-Specific Continuing Education for Personnel: The program failed to provide annual dementia-specific continuing education to 5 of 5 staff reviewed employed more than one year.
481-69.35(1)b Structural Requirements: The program failed to maintain a well-maintained, clean, safe, and sanitary environment, including a malfunctioning door, water damage, mold issues, and delayed repairs affecting all tenants.
Inspection Report — Jan 15, 2025
Complaint Investigation
Date: Jan 15, 2025
Visit Reason
The inspection was conducted as a complaint investigation related to complaints #124879-C, #125733-C, and #123764-C at Garnett Place, an assisted living program for people with dementia.
Complaint Details
No regulatory insufficiencies were cited related to complaints #124879-C and #125733-C. One regulatory insufficiency was cited during the investigation of complaint #123764-C.
Findings
The program failed to update service plans as needed to reflect the identified needs of tenants, specifically related to wandering, exit seeking behaviors, urinary tract infections, urinary incontinence, and toileting refusal. This deficiency pertained to 3 of 4 current tenants reviewed and 2 of 4 discharged tenants reviewed.
Violations (1)
Failure to update service plans as needed to reflect the identified needs of tenants, including wandering, exit seeking behaviors, urinary tract infections, urinary incontinence, and toileting refusal.
Report Facts
Number of tenants without cognitive impairment: 7
Number of tenants with cognitive impairment: 6
Number of current tenants reviewed: 4
Number of discharged tenants reviewed: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Mia McQuinn | Community Director | Named in relation to interview and findings about tenant care and service plans |
Inspection Report — Jul 25, 2024
Complaint Investigation
Date: Jul 25, 2024
Visit Reason
The inspection was conducted to investigate complaints #117522-C, #118869-C, #120657-C and to conduct a recertification visit to determine compliance with certification of an Assisted Living Program for People with Dementia.
Complaint Details
The inspection was triggered by complaints #117522-C, #118869-C, and #120657-C.
Findings
The facility was found deficient in multiple areas including medication administration errors, failure to provide supervision as trained, failure to evaluate tenant needs after significant changes, failure to revise service plans when needs changed, failure to maintain operating alarm systems on exit doors, and failure to maintain fencing around an enclosed courtyard.
Violations (6)
Failed to administer medication as ordered to 1 of 5 discharged tenants reviewed (Tenant C1).
Staff failed to provide supervision based on training to 1 of 3 current tenants (Tenant #3) and 1 of 5 discharged tenants (Tenant C3).
Failed to evaluate the needs of 1 of 5 discharged tenants reviewed when needs changed (Tenant C2).
Failed to revise the service plan when needs changed for 1 of 5 discharged tenants (Tenant C2) and 1 of 3 current tenants (Tenant #1).
Failed to ensure an operating alarm system was connected and in use at all times at each exit door potentially affecting 4 of 10 tenants with cognitive impairment.
Failed to properly maintain the fencing surrounding an enclosed courtyard.
Report Facts
Number of tenants without cognitive impairment: 10
Number of tenants with cognitive impairment: 4
Number of discharged tenants reviewed: 5
Number of current tenants reviewed: 3
Number of tenants with cognitive impairment potentially affected by alarm system deficiency: 4
Inspection Report — Jan 30, 2024
Complaint Investigation
Date: Jan 30, 2024
Visit Reason
The inspection was conducted as a complaint investigation into multiple complaints and incidents related to medication administration and facility safety at Garnett Place, an assisted living program for people with dementia.
Complaint Details
The investigation was triggered by complaints #113475-C, #115248-I, #116159-C, and #116281-C. No regulatory insufficiencies were cited for complaints #113475-C and #115248-I. The findings relate to complaints #116159-C and #116281-C.
Findings
The investigation found that the program failed to administer medication as prescribed to one discharged tenant, Tenant C1, and failed to have an operating alarm system connected to each exit door, potentially affecting all tenants. Additionally, the program failed to maintain the building and grounds in a safe manner, including unsecured doors and a missing fence section.
Violations (3)
Failed to administer medication as prescribed to Tenant C1.
Failed to have an operating alarm system connected to each exit door in a dementia-specific program.
Failed to maintain the building and grounds in a safe, clean, and sanitary manner, including unsecured doors and missing fence section.
Report Facts
Number of tenants without cognitive disorder: 11
Number of tenants with cognitive disorder: 9
Number of pills destroyed: 36
Number of discharged tenants reviewed: 1
Number of staff reeducated: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Bob B | Interim Director | Signed the inspection report |
| Catie Campbell | Received immediate plan of correction for alarm system deficiency |
Inspection Report — Apr 19, 2023
Complaint Investigation
Date: Apr 19, 2023
Visit Reason
Investigation of Complaints #112259-C and #112360-C, and Incident #112263-I at the assisted living facility.
Complaint Details
Investigation of Complaints #112259-C and #112360-C, and Incident #112263-I found no regulatory insufficiencies.
Findings
No regulatory insufficiencies were cited during the investigation of the complaints and incident.
Report Facts
Number of tenants without cognitive impairment: 15
Number of tenants with cognitive impairment: 8
Inspection Report — Apr 11, 2023
Complaint Investigation
Date: Apr 11, 2023
Visit Reason
The inspection was conducted as a complaint investigation into multiple complaints and an incident, specifically Complaint #111312-C, Complaint #109928-C, Incident #108433-I, and Complaint #110091-C.
Complaint Details
The investigation included Complaints #111312-C, #109928-C, #110091-C and Incident #108433-I. The deficiency was cited during the investigation of Complaint #110091-C. No regulatory insufficiencies were found for the other complaints and incident.
Findings
No regulatory insufficiencies were found for Complaints #111312-C, #109928-C, and Incident #108433-I. One regulatory insufficiency was cited related to failure to retain a copy of the occupancy agreement for 1 of 3 discharged tenants reviewed (Tenant C2).
Violations (1)
Program failed to retain a copy of the occupancy agreement for 1 of 3 discharged tenants reviewed (Tenant C2).
Report Facts
Number of tenants without cognitive disorder: 15
Number of tenants with cognitive disorder: 8
Discharged tenants reviewed: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Lisa Wubank | Director | Signed the plan of correction |
| Regional Nurse Specialist | Confirmed the finding on 4/11/23 at 2:35 PM |
Inspection Report — Aug 9, 2022
Complaint Investigation
Date: Aug 9, 2022
Visit Reason
The investigation of Complaints #98826-C, #103064-C, #103226-C and #105759-C and the recertification visit were conducted to determine compliance with certification for a Dedicated Dementia Specific Assisted Living Program.
Complaint Details
The visit was complaint-related involving multiple complaints (#98826-C, #103064-C, #103226-C, #105759-C) regarding tenant care and compliance with certification for a Dedicated Dementia Specific Assisted Living Program.
Findings
The Program failed to complete evaluations as needed with significant change, failed to follow established policies and procedures related to incident reports, failed to ensure tenants received housekeeping and laundry services as indicated in the occupancy agreement, failed to administer medications and complete treatments per physician order, failed to document nurse's notes by exception, failed to ensure staff received nurse delegated training within 30 days of employment, failed to ensure service plans were developed and updated as needed, failed to obtain signatures by all parties when service plans were updated with significant change, failed to ensure physician orders were current and medications were administered consistent with orders, and failed to have an operating door alarm on all exit doors.
Violations (10)
Failed to complete tenant evaluations as needed with significant change for 2 of 3 current tenants and 1 of 2 discharged tenants.
Failed to follow established policies and procedures related to incident reports for 1 of 3 current tenants and 2 of 2 discharged tenants.
Failed to ensure tenants received housekeeping and laundry services as indicated in the occupancy agreement, affecting all tenants.
Failed to administer medications and complete treatments per physician order for 2 of 3 current tenants and 1 of 2 discharged tenants.
Failed to document nurse's notes by exception for 2 of 2 discharged tenants.
Failed to ensure staff received nurse delegated training on all tasks within 30 days of employment for 7 of 8 staff reviewed.
Failed to ensure service plans were developed and updated as needed to reflect identified tenant needs for 3 of 3 current tenants and 1 of 2 discharged tenants.
Failed to obtain signatures by all parties when service plans were updated with significant change for 3 of 3 current tenants and 2 of 2 discharged tenants.
Failed to ensure physician orders were current and medications were administered consistent with orders for 2 of 2 discharged tenants.
Failed to have an operating door alarm on all exit doors, specifically the lower level exit door (northeast door) was not alarmed.
Report Facts
Tenants without cognitive disorder: 18
Tenants with cognitive disorder: 5
Staff with delayed nurse delegated training: 7
Housekeeping documented apartment cleans: 3
Inspection Report — Feb 24, 2020
Complaint Investigation
Date: Feb 24, 2020
Visit Reason
The investigation was conducted as a complaint investigation related to regulatory insufficiencies at Garnett Place, an assisted living program for people with dementia.
Complaint Details
The investigation of Complaint #87497-C resulted in regulatory insufficiencies.
Findings
The inspection found deficiencies in individualized service plans, staffing and safety checks. Specific tenants' service plans did not reflect their current needs or use of assistive devices. Safety checks were inconsistently documented, and staff failed to consistently monitor tenants as required.
Violations (2)
The program failed to develop service plans reflecting the identified needs of tenants.
The program failed to consistently check on tenants as indicated in their service plans.
Report Facts
Number of tenants without cognitive disorder: 22
Number of tenants with cognitive disorder: 0
Number of tenants reviewed for service plans: 7
Number of tenants with safety checks reviewed: 7
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