4 Reports
Inspection Report — Apr 13, 2026
Complaint Investigation
Date: Apr 13, 2026
Visit Reason
Facility Reported Incident Survey
Findings
The establishment failed to ensure accurate Alzheimer's special care staffing disclosures, maintain properly signed and updated service plans for three residents, and prevent elopement of a resident from a secured memory care building. Safety mechanisms on windows were inadequate prior to the incident but were updated during the survey.
Deficiencies (3)
A1100 (295.1100 Alzheimer's and Related Dementias Special Care Disclosure) - The establishment failed to ensure accurate information was listed on Alzheimer's Disease and Related Dementias Special Care Disclosure, including staffing ratios and nurse coverage.
A4010 (295.4010 Service Plan) - The establishment failed to ensure service plans were signed by all parties and reviewed immediately after significant changes for three residents, including missing signatures and lack of fall prevention interventions.
A4060 (295.4060 Alzheimer's and Dementia Programs) - The establishment failed to prevent elopement of a resident from a secured memory care building and failed to ensure safety precautions were in place to prevent recurrence, resulting in substantial probability of severe harm.
Report Facts
Residents affected: 3
Residents affected: 1
Inspection Report — Oct 28, 2025
Annual Inspection
Date: Oct 28, 2025
Visit Reason
Annual Survey conducted on 10/28/2025.
Findings
The establishment failed to ensure service plans addressed hospice services and all activities of daily living for two residents. Additionally, food service staff were observed not wearing hair coverings while preparing resident food, violating sanitation requirements.
Deficiencies (2)
A4010 (295.4010 Service Plan) - The establishment failed to ensure that service plans addressed hospice services and all activities of daily living for two of three residents reviewed.
A8000 (295.8000 Food Service) - The establishment failed to meet the Food Service Sanitation Code by not wearing hair coverings while preparing resident food, risking contamination.
Report Facts
Residents affected: 2
Inspection Report — Nov 12, 2024
Annual Inspection
Date: Nov 12, 2024
Visit Reason
Annual Survey Conducted on 11/12/2024.
Findings
The facility failed to comply with the Health Care Worker Background Check Act and Code for one employee whose background check eligibility was not yet determined. The Executive Director stated the employee will be fingerprinted to comply.
Deficiencies (2)
A1060 (295.1060 Remedies and Sanctions) - The facility failed to comply with the Health Care Worker Background Check Act and Code, involving 1 of 8 employees reviewed who lacked documentation of the required background check.
A3040 (295.3040 Health Care Worker Background Check) - The facility failed to comply with the Health Care Worker Background Check Act and Code, involving 1 of 8 employees reviewed whose eligibility was listed as 'Not Yet Determined' in the Health Care Worker Registry.
Report Facts
Employees reviewed: 8
Employees affected: 1
Inspection Report — 6023436 View POC 001 State survey response 4570
Date: 6023436 View POC 001 State survey response 4570
Visit Reason
The document does not contain an A 000 Initial Comment block specifying the visit type.
Findings
The document contains a single Type 3 violation related to employee fingerprinting compliance.
Deficiencies (1)
A1060 (295.1060 Remedies and Sanctions) - The employee is expected to complete fingerprinting at the earliest opportunity and will not be scheduled for shifts until fingerprint results and eligibility are confirmed.
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