6 Reports
Inspection Report — Apr 16, 2026
Renewal
Date: Apr 16, 2026
Visit Reason
The visit was a recertification visit to determine compliance with certification of a Dedicated Dementia Specific Assisted Living Program and included an investigation of Incident #130983-I.
Complaint Details
Incident #130983-I
Findings
Multiple regulatory insufficiencies were cited including failure to follow incident reporting policies, inadequate care related to elopement and safety, failure to complete timely evaluations and update service plans reflecting significant changes and tenant refusals.
Violations (6)
481-67.2(3) Program Policies and Procedures: The program failed to follow established policy and procedure related to the completion of incident reports for 2 of 4 tenants reviewed, as incident reports were not completed for incidents involving Tenant #1 and Tenant #3.
481-67.3(2) Tenant Rights: The program failed to provide adequate and appropriate care related to elopement and safety for Tenant #1, who exited the memory care unit unnoticed due to staff not hearing door alarms and not following the service plan to keep the tenant supervised during active exit seeking.
481-69.22(2) Evaluation of Tenant: The program failed to complete evaluations within 30 days of occupancy for Tenant #2, who moved to the memory care unit on 3/7/26 but had evaluations completed on 3/6/26 prior to occupancy in that unit.
481-69.22(3) Evaluation of Tenant: The program failed to complete evaluations as needed with significant change for Tenant #2 and Tenant #4, including failure to evaluate Tenant #2 after a 16.2 pound weight loss and failure to evaluate Tenant #4 after decline and hospice involvement.
481-69.26(1) Service Plans: The program failed to develop service plans reflecting the specific needs of tenants for Tenant #1 and Tenant #3, including failure to update plans after elopement and to reflect refusals of care and treatments.
481-69.26(3) Service Plans: The program failed to update service plans within 30 days and as needed with significant change for Tenant #2 and Tenant #4, including failure to update Tenant #2's plan after nutritional supplement orders and weight loss, and failure to update Tenant #4's plan timely after decline and hospice care changes.
Inspection Report — Jul 2, 2024
Complaint Investigation
Date: Jul 2, 2024
Visit Reason
The inspection was conducted during the investigation of Incident #121790-I and the recertification visit to determine compliance with certification of an Assisted Living Program for People with Dementia.
Complaint Details
The visit was complaint-related, investigating Incident #121790-I involving a tenant who eloped and staff response failures.
Findings
The program failed to follow Life Safety policies regarding staff response to memory care door alarms, resulting in inadequate supervision of a tenant who eloped. Additionally, staff failed to supervise the tenant according to training, service plans were not updated to address increased wandering behaviors, and occupancy agreements were not signed prior to move-in for some tenants.
Violations (4)
Failed to follow Life Safety policy on staff response to memory care door alarms for a tenant who eloped.
Staff failed to supervise a tenant admitted in the past four months according to training received.
Failed to ensure occupancy agreements were signed prior to tenants taking occupancy.
Service plan did not address identified needs of a tenant admitted within the past four months, including increased wandering and exit-seeking behaviors.
Report Facts
Tenants without cognitive impairment: 2
Tenants with cognitive impairment: 19
Incident date: Jun 24, 2024
Date survey completed: Jul 2, 2024
Date of admission Tenant #1: Mar 24, 2023
Date occupancy agreement signed Tenant #1: Apr 1, 2023
Date of admission Tenant #2: Aug 7, 2023
Date occupancy agreement signed Tenant #2: Aug 8, 2023
Dates of 1:1 supervision documented: 5
Date of nurse review Tenant #1: May 13, 2023
Date of informal 30-day notice to Tenant #1 family: May 17, 2023
Inspection Report — Jul 1, 2024
Enforcement
Date: Jul 1, 2024
Visit Reason
The document is a recertification visit combined with an investigation identified as #121790-I conducted from 7/1/24 to 7/2/24.
Findings
The facility failed to follow Life Safety policies regarding staff response to memory care door alarms, resulting in inadequate supervision of a tenant who eloped. Staff did not immediately respond or search for the tenant after alarms sounded, contrary to policy and training.
Violations (2)
481-67.2(3) The program failed to follow Life Safety policy on staff response to memory care door alarms. Staff did not search for Tenant #1 after alarms sounded and allowed the tenant to elope without proper supervision.
481-67.9(4) Staff failed to provide supervision in accordance with nurse delegation training. Staff did not supervise Tenant #1 properly despite documented exit-seeking behaviors and training to provide 1:1 supervision.
Report Facts
Fine amount: 1000
Inspection Report — Oct 27, 2022
Complaint Investigation
Date: Oct 27, 2022
Visit Reason
The inspection was conducted as a result of investigation 103862-I concerning regulatory insufficiencies related to incident reporting and life safety policies in an assisted living program for people with dementia.
Complaint Details
Investigation 103862-I was complaint-related and found regulatory insufficiencies in incident reporting and life safety policy adherence for Tenant C1. The complaint was substantiated based on record reviews and staff interviews.
Findings
The program failed to document all unusual occurrences for one tenant, Tenant C1, who had multiple elopements, including one undocumented incident. Additionally, the program failed to follow the Life Safety - Memory Care policy, as staff did not respond immediately to door alarms during elopements. The facility has since updated policies and procedures, retrained staff, and implemented new alarm notification systems.
Violations (2)
Failed to document all unusual occurrences for 1 of 1 tenants reviewed (Tenant C1) involving multiple elopements, including an undocumented incident.
Failed to follow the Life Safety - Memory Care policy, resulting in delayed staff response to door alarms during tenant elopements.
Report Facts
Number of tenants: 21
Tenants without cognitive impairment: 1
Tenants with GDS of 4 or above: 20
Inspection Report — Oct 25, 2022
Enforcement
Date: Oct 25, 2022
Visit Reason
Investigation #103862-I was conducted following self-reported incidents involving Tenant C1 eloping from the Memory Care unit.
Complaint Details
Investigation #103862-I
Findings
The program failed to follow its Life Safety - Memory Care policy by not responding immediately to door alarms, resulting in Tenant C1 eloping twice from the secure Memory Care unit.
Violations (1)
67.2(3) The program failed to follow the Life Safety - Memory Care policy. Staff did not respond immediately to door alarms, allowing Tenant C1 to exit the secure Memory Care unit twice without prompt intervention.
Report Facts
Fine amount: 500
Inspection Report — Apr 8, 2021
Annual Inspection
Date: Apr 8, 2021
Visit Reason
Recertification visit to determine compliance with certification for a Dedicated Dementia Specific Assisted Living Program and an onsite infection control survey.
Findings
The Program failed to follow medication policies, complete nurse delegation training timely, complete dependent adult abuse training timely, complete background checks prior to employment, complete evaluations and service plans as needed with significant changes, provide required dementia-specific education including hands-on training within 30 days of hire, and maintain required safety equipment in a transport vehicle.
Violations (10)
Failed to follow policy and procedure related to medications affecting 1 of 4 tenants observed on medication pass and potentially all tenants with medications administered by the Program.
Failed to complete nurse delegated training within 30 days of hire for 3 of 6 staff reviewed.
Failed to complete dependent adult abuse training within six months of employment for 2 of 2 staff reviewed employed six months or greater.
Failed to complete background checks prior to employment for 1 of 6 staff reviewed.
Failed to request Department of Human Services evaluation to determine if employment was prohibited for 1 staff reviewed.
Failed to complete evaluations as needed with significant change for 3 of 3 tenants reviewed.
Failed to complete service plans as needed and failed to develop service plans to reflect identified needs of 3 tenants reviewed.
Failed to ensure staff completed eight hours of dementia-specific education within 30 days of hire for 3 of 6 staff reviewed.
Did not provide dementia-specific training including hands-on training for 2 of 6 staff reviewed.
Failed to maintain required safety equipment (first-aid kit, fire extinguisher, safety triangles) in a vehicle used to transport tenants.
Report Facts
Medication errors: 3
Staff reviewed for nurse delegation training: 6
Staff failed nurse delegation training within 30 days: 3
Staff reviewed for dependent adult abuse training: 2
Staff failed dependent adult abuse training within 6 months: 2
Staff reviewed for background checks: 6
Staff failed background checks prior to employment: 1
Tenants reviewed for evaluations and service plans: 3
Staff reviewed for dementia-specific education: 6
Staff failed dementia-specific education within 30 days: 3
Staff failed hands-on dementia-specific training: 2
Inspection date: Apr 8, 2021
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff G | Administered medications incorrectly to Tenant #2 | |
| Staff B | Failed nurse delegation training within 30 days; failed background checks prior to employment; required record check evaluation not completed prior to work | |
| Staff E | Failed nurse delegation training within 30 days; failed dementia-specific hands-on training | |
| Staff F | Failed nurse delegation training within 30 days | |
| Staff C | Failed dependent adult abuse training within 6 months; failed dementia-specific education within 30 days; failed dementia-specific hands-on training | |
| Staff D | Failed dependent adult abuse training within 6 months; failed dementia-specific education within 30 days | |
| Staff A | Failed dementia-specific education within 30 days | |
| Staff H | Confirmed transport vehicle lacked required safety equipment | |
| Director of Health and Wellness | Interviewed regarding medication errors, training, evaluations, and background checks | |
| Executive Director | Interviewed regarding training, evaluations, and background checks |
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