4 Reports
Inspection Report — Sep 16, 2025
Renewal
Date: Sep 16, 2025
Visit Reason
Recertification visit conducted to determine compliance with certification rules for an Assisted Living Program for People with Dementia.
Findings
No regulatory insufficiencies were cited during the recertification visit.
Inspection Report — Jan 22, 2025
Complaint Investigation
Date: Jan 22, 2025
Visit Reason
Investigation of Incident #121206-I at an assisted living program for people with dementia.
Complaint Details
Investigation of Incident #121206-I; no deficiencies found.
Findings
No regulatory insufficiencies were cited during the investigation.
Report Facts
Tenants without cognitive impairment: 1
Tenants with cognitive impairment: 5
Inspection Report — Jun 28, 2023
Recertification
Date: Jun 28, 2023
Visit Reason
The inspection was conducted as a recertification visit to determine compliance with certification rules for an Assisted Living Program.
Complaint Details
No regulatory insufficiencies were cited during the investigation of Complaint #110171-C.
Findings
The program failed to meet multiple regulatory requirements including timely nurse delegation training, dependent adult abuse training, tenant evaluations prior to and within 30 days of occupancy, updating service plans based on evaluations, conducting nurse reviews at least every 90 days, and providing dementia-specific education within 30 days of employment.
Violations (7)
Failed to provide nurse delegation training to staff within 30 days of hire to ensure staff competency.
Failed to provide two hours of dependent adult abuse training within six months of employment for staff.
Failed to evaluate tenants' functional, cognitive, and health status prior to admission for 2 tenants.
Failed to evaluate tenants' functional, cognitive, and health status within 30 days of occupancy for 2 tenants.
Failed to update service plans based on required evaluations for 2 tenants.
Failed to assess and document health status of tenants receiving personal or health-related care at least every 90 days.
Failed to provide eight hours of dementia-specific education and training within 30 days of employment for 7 caregiver staff.
Report Facts
Number of tenants without cognitive impairment: 2
Number of tenants with cognitive impairment: 6
Number of caregiver staff reviewed for nurse delegation training: 3
Number of staff reviewed for dependent adult abuse training: 5
Number of tenants reviewed for evaluations and service plans: 2
Number of tenants reviewed for nurse review: 2
Number of caregiver staff reviewed for dementia training: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Failed dependent adult abuse training, dementia training, and nurse delegation training | |
| Staff B | Failed nurse delegation training and dementia training | |
| Staff C | Failed dependent adult abuse training and dementia training | |
| Staff D | Failed nurse delegation training, dependent adult abuse training, and dementia training | |
| Staff E | Failed dependent adult abuse training and dementia training (partial 3.5 hours completed) | |
| Staff F | Failed dementia training | |
| Staff G | Failed dementia training |
Inspection Report — Dec 16, 2020
Complaint Investigation
Date: Dec 16, 2020
Visit Reason
The inspection was conducted to investigate Complaint 91007-C and to perform an onsite infection control survey.
Complaint Details
Investigation of Complaint 91007-C found no regulatory insufficiencies.
Findings
No regulatory insufficiencies were cited during the investigation of Complaint 91007-C or the onsite infection control survey.
Report Facts
Number of tenants without cognitive disorder: 0
Number of tenants with cognitive disorder: 3
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