14 Reports
Inspection Report — Jan 29, 2026
Complaint Investigation
Date: Jan 29, 2026
Visit Reason
The investigation was conducted due to multiple complaints and incidents including Incident #130601-I, Incident #130917-I, Incident #131319-I, Complaint #130546-C, Complaint #130942-C, Complaint #130355-C, Complaint #130591-C, and Complaint #130659-C.
Complaint Details
Complaint #130546-C, Complaint #130942-C, Complaint #130355-C, Complaint #130591-C, Complaint #130659-C, Incident #130601-I, Incident #130917-I, Incident #131319-I
Findings
Regulatory insufficiencies were cited related to tenant rights, service plans, and structural requirements. The program failed to ensure tenants were treated with respect and dignity, failed to address social outbursts in service plans, and failed to maintain the kitchen in a clean and sanitary condition.
Violations (3)
481-67.3(1) Tenant Rights: The program failed to ensure the right for female tenants to be treated with respect by addressing the actions of one tenant who was verbally abusive and offensive toward others. The Executive Director confirmed the failure to ensure all tenants were treated with respect.
481-69.26(4)a Service Plans: The program failed to ensure the needs of one tenant were addressed in the service plan to prevent social outbursts. The tenant displayed verbal outbursts directed at other tenants which were not addressed in the service plan.
481-69.35(1)b Structural Requirements: The program failed to ensure the kitchen was kept in a clean and sanitary condition. The kitchen had black substance on walls and long dark brown streaks under the sink, and cleaning was inadequate.
Inspection Report — May 1, 2025
Complaint Investigation
Date: May 1, 2025
Visit Reason
The inspection was conducted as part of investigations of Complaint #124959 and Incident #125805-I at the assisted living facility.
Complaint Details
Investigations of Complaint #124959 and Incident #125805-I found no regulatory insufficiencies.
Findings
No regulatory insufficiencies were cited during the investigations of the complaint and incident.
Report Facts
Number of tenants without cognitive impairment: 42
Number of tenants with cognitive impairment: 5
Inspection Report — Sep 26, 2024
Complaint Investigation
Date: Sep 26, 2024
Visit Reason
Investigation of Incident #122409-C at the assisted living program for people with dementia.
Complaint Details
Investigation of Incident #122409-C found no regulatory insufficiencies.
Findings
No regulatory insufficiencies were cited during the investigation.
Report Facts
Number of tenants without cognitive impairment: 44
Number of tenants with cognitive impairment: 2
Inspection Report — Jun 12, 2024
Date: Jun 12, 2024
Visit Reason
The visit was conducted as a recertification survey to determine compliance with certification of an Assisted Living Program for People with Dementia, including investigation of two incidents and one complaint.
Complaint Details
Complaint #119858-C was investigated and found to have no regulatory insufficiencies.
Findings
No regulatory insufficiencies were cited during the investigation of Incident #121109-I, Incident #121108-I, Complaint #119858-C, and the recertification visit.
Report Facts
Number of tenants without cognitive impairment: 45
Number of tenants with cognitive impairment: 7
Inspection Report — Apr 1, 2024
Complaint Investigation
Date: Apr 1, 2024
Visit Reason
The inspection was conducted to investigate multiple incidents and complaints reported at the facility.
Complaint Details
Investigation covered Incident #119578-I, Complaint #118824-C, Incident #117249-I, Complaint #117206-C, Complaint #117251-C, and Incident #119665-I with no deficiencies found.
Findings
No regulatory insufficiencies were cited during the investigation of the listed incidents and complaints.
Report Facts
Number of tenants without cognitive impairment: 46
Number of tenants with cognitive impairment: 6
Inspection Report — Sep 5, 2023
Complaint Investigation
Date: Sep 5, 2023
Visit Reason
The inspection was conducted following the investigation of multiple complaints and a mandatory report concerning potential abuse and neglect at the facility.
Complaint Details
The visit was complaint-related, triggered by multiple complaints and a mandatory report. The allegations involved suspected abuse of Tenant #5 by staff, delayed reporting of the incident by staff members, and failure to follow abuse reporting policies. The Administrator confirmed the findings and reported the allegations to the Department.
Findings
The facility failed to follow its written policy regarding the identification and reporting of dependent adult abuse for one tenant. Staff delayed reporting suspected abuse, and improper care was observed during a shower incident causing distress to the tenant.
Violations (2)
Failure to follow the written policy regarding identification and reporting of dependent adult abuse for Tenant #5.
Failure to immediately notify the Administrator of suspected dependent adult abuse regarding Tenant #5.
Report Facts
Number of tenants without cognitive impairment: 46
Number of tenants with cognitive impairment: 7
Number of tenants reviewed: 5
Number of shifts worked by Staff I between incident and report: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Observed and reported abuse incident involving Tenant #5 | |
| Staff C | New hire trainee | Observed and reported abuse incident involving Tenant #5 |
| Staff I | Staff member alleged to have mistreated Tenant #5 and placed on suspension | |
| Administrator | Administrator | Confirmed findings, reported allegations to Department, and managed investigation |
Inspection Report — Aug 24, 2023
Enforcement
Date: Aug 24, 2023
Visit Reason
This citation was issued following an investigation of suspected dependent adult abuse involving Tenant #5 at Sunset Park Place. The citation addresses failures in timely reporting and adherence to the program's abuse reporting policies.
Complaint Details
Type of Action: 114766-M
Findings
The program failed to immediately notify the Administrator of suspected abuse involving Tenant #5, resulting in a delayed report to the Department. Staff did not follow the program's written policies for identifying and reporting dependent adult abuse.
Violations (2)
52.2(2) Reporting suspected dependent adult abuse in facilities or programs: The program staff failed to notify the Administrator immediately of suspected abuse regarding Tenant #5, reporting the concerns a week late after the incident occurred.
67.2(3) The program shall follow the policies and procedures established by the program: The program failed to follow its written policy on identifying and reporting dependent adult abuse for Tenant #5, including allowing the tenant to be showered in a manner that caused distress and not reporting concerns promptly.
Report Facts
Fine amount: 500
Inspection Report — Jan 18, 2023
Complaint Investigation
Date: Jan 18, 2023
Visit Reason
The inspection was conducted as an investigation of Incident #110009-I and Complaint #112069-C related to an elopement event involving Tenant #1 at the assisted living program.
Complaint Details
The investigation was triggered by a complaint and incident involving Tenant #1 eloping from the facility on 12/28/22. The complaint was substantiated based on observations, interviews, and record reviews.
Findings
The program failed to follow its policies and procedures related to elopement, door alarm response, visual checks, and keys/door codes for one tenant who eloped. Staff did not adequately check the perimeter of the building when the alarm was triggered, and visual checks were not completed as scheduled. The tenant was found outside in cold weather with frostbite on her feet.
Violations (1)
Failure to follow policies and procedures related to elopement, door alarm response, visual checks, and keys/door codes for one tenant who eloped.
Report Facts
Number of tenants without cognitive impairment: 42
Number of tenants with cognitive impairment: 10
Date survey completed: Jan 18, 2023
Inspection Report — Jan 9, 2023
Enforcement
Date: Jan 9, 2023
Visit Reason
This citation was issued for failure to follow policies and procedures related to an elopement incident involving Tenant #1, including door alarm response, visual checks, and key/door code protocols.
Findings
The facility failed to follow its elopement, door alarm, visual checks, and key/code policies and procedures, resulting in Tenant #1 eloping and being exposed to cold weather for approximately 30 to 44 minutes. Tenant #1 was hospitalized and treated for frostbite to her feet.
Violations (1)
67.2(3) The program failed to follow its policies and procedures related to elopement, door alarm response, visual checks, and keys/door codes for Tenant #1 who eloped and was exposed to cold weather for over 30 minutes. Staff did not promptly respond to alarms, did not complete scheduled visual checks, and did not have keys or door codes to access exit doors.
Report Facts
Fine amount: 4000
Inspection Report — Jun 9, 2022
Renewal
Date: Jun 9, 2022
Visit Reason
The recertification visit was conducted to determine compliance with certification for a Dementia-Specific Assisted Living Program and to investigate Complaint #98727-C.
Complaint Details
Investigation of Complaint #98727-C was conducted with no regulatory insufficiencies found.
Findings
No regulatory insufficiencies were cited during the recertification visit for the Dementia-Specific Assisted Living Program.
Report Facts
Number of tenants without cognitive disorder in General Population: 48
Number of tenants with cognitive disorder in General Population: 2
Number of tenants without cognitive disorder in Memory Care Unit: 0
Number of tenants with cognitive disorder in Memory Care Unit: 8
Inspection Report — Nov 4, 2021
Complaint Investigation
Date: Nov 4, 2021
Visit Reason
The inspection was conducted as an investigation of Complaint #96754-C and included an onsite infection control survey.
Complaint Details
Investigation of Complaint #96754-C. The complaint was substantiated as evidenced by the cited regulatory insufficiencies.
Findings
The program failed to provide adequate and appropriate care for 1 of 3 tenants reviewed, specifically Tenant #2, with issues including inadequate shower assistance, lack of task documentation for personal care, and failure to implement task sheets for routine personal care assistance.
Violations (2)
Program failed to provide adequate and appropriate care for Tenant #2, including failure to provide shower assistance and proper documentation of personal care tasks.
Program failed to implement task sheets for completion of routine personal care assistance for Tenant #2.
Report Facts
Number of tenants without cognitive disorder in General Population: 43
Number of tenants with cognitive disorder in General Population: 4
Number of tenants without cognitive disorder in Memory Care Unit: 9
Number of tenants with cognitive disorder in Memory Care Unit: 9
Score on Global Deterioration Scale (GDS) for Tenant #2: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jerry Bell | Community Director | Signed the Plan of Correction |
Inspection Report — Aug 26, 2021
Complaint Investigation
Date: Aug 26, 2021
Visit Reason
The inspection was conducted as a result of the investigation of Incidents #97317-I, #97631-I and Complaint #97858-C, focusing on regulatory insufficiencies related to tenant evaluations, service plans, and respite care services.
Complaint Details
Investigation of Incidents #97317-I, #97631-I and Complaint #97858-C. The complaint was substantiated as evidenced by multiple regulatory insufficiencies found during the investigation.
Findings
The program failed to complete initial evaluations and service plans prior to tenant occupancy and did not ensure service plans reflected tenant needs. There were multiple incidents involving tenants with cognitive impairments, including safety concerns and behavioral issues. The program also failed to ensure documented care needs were followed for respite care individuals.
Violations (4)
Failed to complete an initial evaluation prior to signing the occupancy agreement for 1 of 1 tenants reviewed.
Failed to develop a service plan prior to signing the occupancy agreement for 1 of 1 tenants reviewed.
Failed to ensure service plans reflected the identified needs of 2 of 5 tenants reviewed.
Failed to ensure documented care needs were followed by staff for 1 of 1 respite care individuals reviewed.
Report Facts
Tenants without cognitive disorder (General Population): 51
Tenants with cognitive disorder (General Population): 3
Tenants without cognitive disorder (Memory Care Unit): 0
Tenants with cognitive disorder (Memory Care Unit): 9
Tenants reviewed for service plans: 5
Respite care individuals reviewed: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jerry Bell | Community Director | Signed the Plan of Correction and named in corrective actions. |
Inspection Report — Jan 20, 2021
Complaint Investigation
Date: Jan 20, 2021
Visit Reason
The inspection was conducted as a complaint investigation related to tenant rights and care concerns at Sunset Park Place, specifically Complaint #95128-C.
Complaint Details
Complaint #95128-C was investigated from 1/12/21 through 1/20/21. The complaint was substantiated based on findings of inadequate care and documentation for Tenant #1.
Findings
The investigation found that Tenant #1 experienced inadequate care related to shoulder pain and bruising, with documentation and communication deficiencies noted in nursing records and medication administration. The tenant was hospitalized with a fractured rib and clavicle after a fall.
Violations (1)
Failure to provide adequate care and treatment for Tenant #1, including lack of documentation of shoulder pain and no pain medications given on 1/5/21.
Report Facts
Total Population: 57
General Population without cognitive disorder: 45
General Population with cognitive disorder: 3
Memory Care Unit with cognitive disorder: 9
Memory Care Unit without cognitive disorder: 0
Inspection Report — Sep 2, 2020
Complaint Investigation
Date: Sep 2, 2020
Visit Reason
The inspection was conducted as an investigation of Complaint #90770-C and included an onsite infection control survey.
Complaint Details
Complaint #90770-C was investigated and found to have no insufficiencies.
Findings
No insufficiencies were cited during the complaint investigation or the onsite infection control survey.
Report Facts
Number of tenants without cognitive disorder: 49
Number of tenants with cognitive disorder: 7
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