12 Reports
Inspection Report — Oct 15, 2025
Renewal
Date: Oct 15, 2025
Visit Reason
Recertification visit conducted to determine compliance with certification of an Assisted Living Program for People with Dementia.
Findings
No regulatory insufficiencies were cited during the recertification visit for the Assisted Living Program for People with Dementia.
Report Facts
Number of tenants without cognitive impairment: 1
Number of tenants with cognitive impairment: 14
Inspection Report — Sep 11, 2024
Complaint Investigation
Date: Sep 11, 2024
Visit Reason
The inspection was conducted to investigate complaints related to incidents of elopement and wandering behaviors involving tenants at Oak Park Place Memory Care.
Complaint Details
The visit was triggered by complaints identified as Incident #122568-I and Incident #122589-I concerning elopement and wandering incidents involving tenants.
Findings
The program failed to follow its policy on incident reporting by not including witness statements for an elopement incident. Additionally, the program lacked written procedures addressing appropriate staff responses to tenants at risk of elopement or wandering, and no specific policy existed for staff response when a tenant with cognitive disorder or dementia was missing.
Violations (3)
Failed to include statements from individuals who witnessed the incident in the incident report for Tenant 1's elopement.
No written procedures regarding appropriate staff response when a tenant's service plan indicates a risk of elopement or wandering behavior.
No written procedures regarding appropriate staff response if a tenant with cognitive disorder or dementia is missing.
Report Facts
Number of tenants with cognitive impairment: 18
Number of tenants without cognitive impairment: 0
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Rand Rasmussen | Director of Housing | Named in Plan of Correction response |
| Regional MDS Coordinator | Interviewed regarding policies and incident reports | |
| Regional Nurse | Interviewed and confirmed findings |
Inspection Report — Jan 17, 2024
Renewal
Date: Jan 17, 2024
Visit Reason
The inspection was conducted to investigate Complaint #115152-C and to recertify compliance with certification requirements for an Assisted Living Program for People with Dementia.
Complaint Details
The complaint investigation involved review of Tenant #3's elopement incident occurring on 12/28/23. The program failed to notify the Department within 24 hours as required. The complaint was substantiated based on these findings.
Findings
The inspection found regulatory insufficiencies related to program notification failures, incomplete staff evaluations, incomplete tenant documentation, and inadequate dementia-specific training for staff. Specific deficiencies included failure to notify the department of tenant elopement, failure to complete required background checks, incomplete documentation of routine personal care tasks, and insufficient dementia-specific training hours for staff.
Violations (4)
Program failed to notify the Department within required timeframe when a tenant eloped from the program.
Employment prohibition not met; failure to obtain evaluation from the department of health and human services prior to hire for staff with a history of child abuse.
Failure to maintain complete tenant documentation including routine personal care tasks and safety checks.
Program failed to ensure 3 of 4 staff received 8 hours of dementia-specific training within 30 days of employment.
Report Facts
Global Deterioration Scale score: 5
Hours of dementia-specific training: 4.5
Hours of dementia-specific training: 5
Hours of dementia-specific training: 6.25
Task checks documented: 84
Task checks documented: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff F | Staff member with history of child abuse; evaluation process not completed prior to hire. | |
| Staff C | Staff member with 4.5 hours dementia-specific training on file; failed to complete 8 hours within 30 days. | |
| Staff G | Staff member with 6.25 hours dementia-specific training on file; failed to complete 8 hours within 30 days. | |
| Director of Housing | Confirmed elopement incident and deficiencies related to notification and training. |
Inspection Report — Jan 16, 2024
Renewal
Date: Jan 16, 2024
Visit Reason
The visit was a recertification to determine compliance with certification of an Assisted Living Program.
Findings
The program failed to obtain an evaluation from the department of human services prior to hiring one staff member with a history of child abuse.
Violations (1)
67.19(5) Employment prohibition: The program did not complete the required evaluation process with the department of human services before hiring one staff member with a history of child abuse.
Report Facts
Fine amount: 500
Inspection Report — May 19, 2023
Complaint Investigation
Date: May 19, 2023
Visit Reason
The inspection was conducted as part of an investigation into Complaint #112178-C regarding regulatory insufficiency related to tenant care and medication administration.
Complaint Details
The visit was triggered by Complaint #112178-C. The complaint was substantiated as the program failed to provide appropriate services to Tenant #1, resulting in a medication error and adverse health effects.
Findings
The program failed to provide appropriate services to one tenant by incorrectly updating medication administration records, leading to a medication error where Tenant #1 was given Risperdal instead of Ropinirole. This error resulted in the tenant experiencing neurological symptoms and hospitalization.
Violations (1)
Failure to provide appropriate care and treatment as evidenced by medication administration errors for Tenant #1.
Report Facts
Medication tablets received: 14
Date of survey completion: May 19, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Candice Heinkel | Director | Signed the Plan of Correction submitted on behalf of the facility |
Inspection Report — Apr 12, 2023
Enforcement
Date: Apr 12, 2023
Visit Reason
This citation was issued for a civil penalty related to medication administration errors discovered during the survey period from 4/12/23 to 5/19/23.
Complaint Details
Type of Action: 112178-C
Findings
The program failed to provide appropriate medication services to Tenant #1 by incorrectly discontinuing Ropinirole and administering Risperdal, which was not intended by the tenant's primary care provider. This medication error led to the tenant experiencing neurological symptoms and hospitalization.
Violations (1)
481-67.3(2) Tenant rights: The program failed to provide appropriate services by administering Risperdal instead of Ropinirole to Tenant #1, resulting in neurological symptoms and hospitalization.
Report Facts
Fine amount: 5000
Inspection Report — Mar 14, 2023
Complaint Investigation
Date: Mar 14, 2023
Visit Reason
The inspection was conducted in response to complaints #108006-C, #108716-C, and #109298-C regarding regulatory insufficiencies at Oak Park Place Memory Care.
Complaint Details
Complaints #108006-C, #108716-C, and #109298-C were investigated. The investigation found failures in incident reporting, abuse investigations, staff substance use, and care provision.
Findings
The program failed to follow policies and procedures related to incident reporting, abuse/staff misconduct investigations, and staff drug/alcohol use. Additionally, failures were noted in providing adequate care, completing evaluations and nurse reviews, documenting nurse's notes, and updating service plans as required.
Violations (9)
Failure to follow policies and procedures regarding completion of incident reports for tenants and abuse/staff misconduct investigations.
Failure to provide adequate and appropriate care and treatment for a tenant.
Failure to provide policy and procedure addressing provisions related to head injuries.
Failure to complete evaluations as needed with significant change for tenants.
Failure to document nurse's notes by exception for current and discharged tenants.
Failure to ensure service plans were based on evaluations and updated when needs changed.
Failure to ensure service plans were updated and signed within 30 days of occupancy.
Failure to ensure service plans were updated and signed at least annually.
Failure to complete nurse reviews as needed for tenants with significant changes in condition.
Report Facts
Number of tenants without cognitive disorder: 1
Number of tenants with cognitive disorder: 16
Number of falls for Tenant #4: 11
Date of survey completion: Mar 14, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Candice Heinkel | Director of Housing | Named in relation to investigation and plan of correction. |
| Staff C | Reported noticing Tenant #2's bruised eye and involved in investigation. | |
| Staff G | Former staff interviewed regarding Tenant #2's bruising and staff misconduct. | |
| Staff A | Reported bruising on Tenant #3 and staff misconduct. | |
| Staff B | Reported staff smoking marijuana on shift. | |
| Staff H | Terminated for being under the influence at work. | |
| Staff I | Reported to smoke marijuana on shift. | |
| Staff D | Reported for verbal abuse to tenants. | |
| Staff E | Reported Tenant #4 used her pendant. | |
| Staff F | Reported Tenant #4 used her pendant frequently. |
Inspection Report — Aug 10, 2022
Complaint Investigation
Date: Aug 10, 2022
Visit Reason
The inspection was conducted as a complaint investigation into multiple complaints (#100892-C, #100876-C, #100173-C, and #105135-C) regarding regulatory compliance at Oak Park Place Memory Care.
Complaint Details
The investigation was triggered by complaints #100892-C, #100876-C, #100173-C, and #105135-C. No deficiencies were found for complaints #100892-C and #100876-C. Deficiencies were cited related to complaints #100173-C and #105135-C.
Findings
No regulatory insufficiencies were found for complaints #100892-C and #100876-C. However, deficiencies were cited related to failure to follow dependent adult abuse policies, retention of a tenant with aggressive behavior, and failure to develop service plans based on evaluations for discharged tenants.
Violations (3)
Failure to follow the program's policy on Dependent Adult Abuse, including delayed investigation of an alleged abuse incident involving Tenant #1.
Retention of a tenant (Tenant #1) who displayed physical aggression and was dangerous to self and others despite interventions.
Failure to develop service plans based on evaluations for 2 of 3 discharged tenants (Tenants C1 and C3).
Report Facts
Number of tenants without cognitive disorder: 0
Number of tenants with cognitive disorder: 18
Number of tenants reviewed for abuse policy: 3
Number of discharged tenants reviewed for service plans: 3
Number of discharged tenants with deficient service plans: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Elizabeth Greene | Director of Housing | Signed the Plan of Correction and involved in monitoring compliance |
| Regional Nurse | Conducted investigation into dependent adult abuse and confirmed findings | |
| Interim Director of Housing | Reported delayed investigation of abuse incident and participated in investigation |
Inspection Report — Sep 23, 2021
Renewal
Date: Sep 23, 2021
Visit Reason
The inspection was conducted as a recertification visit to determine compliance with certification for an Assisted Living Program and to investigate Complaint #93153-C.
Complaint Details
No regulatory insufficiencies were cited regarding Complaint 96787-C or Complaint 96470-C. The inspection included investigation of Complaint #93153-C.
Findings
The inspection found regulatory insufficiencies related to tenant rights, staffing, evaluation of tenants, and dementia-specific education for personnel. Specific deficiencies included failure to ensure adequate bathing services, incomplete dependent adult abuse training for staff, incomplete evaluations for tenants with significant changes, and insufficient dementia-specific training with hands-on components for staff.
Violations (4)
Failure to ensure 1 of 7 tenants received adequate and appropriate bathing services.
Failure to ensure 4 out of 9 staff completed dependent adult abuse training within 6 months of employment.
Failure to complete evaluations as needed for 2 tenants who experienced significant changes.
Failure to ensure 5 of 9 staff received 8 hours of dementia-specific training including hands-on instruction.
Report Facts
Number of tenants with cognitive disorder: 13
Number of tenants without cognitive disorder: 0
Staff members reviewed for dependent adult abuse training: 9
Staff members who failed to complete dependent adult abuse training: 4
Staff members reviewed for dementia-specific training: 9
Staff members who failed to complete dementia-specific training including hands-on: 5
Tenants reviewed for evaluation compliance: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Elizabeth Greene | Director of Housing | Signed the Plan of Correction and confirmed findings with Director of Nursing. |
| Staff F | Named in findings related to dependent adult abuse training and dementia-specific training deficiencies. | |
| Staff G | Named in findings related to dependent adult abuse training and dementia-specific training deficiencies. | |
| Staff H | Named in findings related to dependent adult abuse training and dementia-specific training deficiencies. | |
| Staff I | Named in findings related to dependent adult abuse training and dementia-specific training deficiencies. | |
| Director of Housing | Confirmed findings with Director of Nursing on 9/28/21. | |
| Director of Nursing | Confirmed findings with Director of Housing on 9/28/21. |
Inspection Report — Jan 22, 2020
Complaint Investigation
Date: Jan 22, 2020
Visit Reason
Investigation into Complaint #87587-C regarding the Assisted Living Program for People with Dementia.
Complaint Details
Investigation into Complaint #87587-C found no regulatory insufficiencies.
Findings
No regulatory insufficiencies were cited during the complaint investigation.
Report Facts
Number of tenants without cognitive disorder: 1
Number of tenants with cognitive disorder: 11
Inspection Report — Nov 7, 2019
Complaint Investigation
Date: Nov 7, 2019
Visit Reason
The inspection was conducted to investigate Complaint #85988-C and to conduct a recertification visit to determine compliance with certification for a Dedicated Dementia Specific Assisted Living Program.
Complaint Details
The visit was triggered by Complaint #85988-C and included a recertification visit for compliance with certification for a Dedicated Dementia Specific Assisted Living Program.
Findings
The inspection found multiple regulatory insufficiencies related to staffing, nurse delegation training, record checks, tenant evaluations, and service plans. Specific issues included insufficient trained staff to meet tenant needs, failure to complete nurse delegations within 30 days, incomplete criminal background checks prior to employment, failure to complete tenant evaluations within 30 days of occupancy, and failure to update service plans based on significant changes.
Violations (6)
Program failed to provide a sufficient number of trained staff to fully meet tenants' identified needs.
Program failed to ensure nurse delegations were completed within 30 days of beginning employment for 1 of 3 staff reviewed.
Program failed to complete a criminal history and abuse record background check prior to employment for 1 of 6 staff reviewed.
Program failed to ensure evaluations were completed within 30 days of taking occupancy and as needed with significant change for 1 tenant reviewed.
Program failed to update service plans within 30 days of taking occupancy and as needed with significant change for 1 tenant reviewed.
Program failed to ensure service plans reflected identified needs for 3 tenants reviewed.
Report Facts
Calls during 9-29-19 to 10-6-19: 22
Calls during 10-6-19 to 10-13-19: 7
Calls during 10-13-19 to 10-20-19: 21
Calls during 10-20-19 to 10-27-19: 6
Staff reviewed: 6
Tenants reviewed: 3
Inspection Report — ScannedReport 2511 2026 02 04 094539
Complaint Investigation
Date: ScannedReport 2511 2026 02 04 094539
Visit Reason
Investigation of Complaint #130893-C.
Complaint Details
Complaint #130893-C
Findings
No regulatory insufficiencies were cited during the investigation.
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