7 Reports
Inspection Report — Mar 25, 2026
Renewal
Date: Mar 25, 2026
Visit Reason
Recertification visit to determine compliance with certification of an Assisted Living Program. Investigation of Complaint #130702-C.
Complaint Details
Complaint #130702-C
Findings
No regulatory insufficiencies were cited during the investigation of Complaint #130702-C.
Inspection Report — Nov 20, 2024
Renewal
Date: Nov 20, 2024
Visit Reason
The inspection was conducted as a recertification visit to determine compliance with certification of an Assisted Living Program for People with Dementia.
Findings
The program failed to complete required cognitive evaluations prior to occupancy and annually with significant change, and failed to develop service plans based on all evaluations as required.
Violations (3)
Evaluation prior to occupancy was not completed for Tenant #5 before signing the occupancy agreement.
Evaluation annually and with significant change was not completed as required for tenants reviewed.
Service plans were not developed based on evaluations as required.
Report Facts
Number of tenants without cognitive impairment: 48
Number of tenants with cognitive impairment: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Christy Nikkel | Executive Director | Signed the Plan of Correction and is responsible for ensuring compliance with occupancy agreement and assessment completion. |
Inspection Report — Nov 9, 2023
Complaint Investigation
Date: Nov 9, 2023
Visit Reason
The inspection was conducted as part of an investigation of Complaints #111295-C and #111751-C regarding regulatory insufficiencies at the assisted living program.
Complaint Details
The investigation was triggered by Complaints #111295-C and #111751-C. The findings were substantiated as the program did not meet evaluation requirements for Tenant C-1.
Findings
The program failed to evaluate a tenant's functional, cognitive, and health status as required annually and with significant change, as evidenced by incomplete documentation and lack of updated service plans for Tenant C-1. The Administrator confirmed these findings.
Violations (1)
Failure to evaluate a tenant's functional, cognitive, and health status annually and with significant change to determine continued eligibility and service needs.
Report Facts
Number of tenants without cognitive impairment: 55
Number of tenants with cognitive impairment: 10
Number of tenants reviewed for evaluation: 3
Number of baths completed by Tenant C-1: 6
Date of speech therapy evaluation: Sep 20, 2022
Date of tenant's 90 day review: Dec 27, 2022
Date of service plan: Dec 27, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Christy Nikkel | Executive Director | Signed the Plan of Correction letter |
Inspection Report — Aug 17, 2022
Complaint Investigation
Date: Aug 17, 2022
Visit Reason
The visit was conducted to investigate complaint 106447-C at the assisted living program for people with dementia.
Complaint Details
Complaint 106447-C was investigated and found to have no regulatory insufficiencies.
Findings
No regulatory insufficiencies were cited during the investigation of the complaint.
Report Facts
Number of tenants without cognitive disorder: 64
Number of tenants with cognitive disorder: 5
Inspection Report — Jan 12, 2022
Renewal
Date: Jan 12, 2022
Visit Reason
The inspection was conducted as a recertification visit to determine compliance with certification of an Assisted Living Program, including investigation of multiple complaints and a review of infection control.
Complaint Details
The inspection included investigation of complaints #95310-C, #96672-C, #97579-C, #100079-C, and #100159-C.
Findings
The inspection found regulatory insufficiencies related to medication administration, tenant evaluations, service plans, nurse reviews, admission/retention criteria, and dementia-specific education for personnel. No deficiencies were cited during the infection control visit.
Violations (7)
Program failed to administer medications as ordered for 1 of 7 discharged tenants reviewed.
Program failed to complete required evaluations within 30 days of admission for 2 of 5 tenants reviewed.
Program failed to evaluate functional, cognitive, and health status as warranted by significant change for 7 of 7 former tenants and 3 of 5 current tenants reviewed.
Program failed to initiate discharge or waiver request when tenant exceeded level of care requiring routine two-person assistance.
Program failed to develop service plans based on required evaluations for 7 of 7 former tenants and 3 of 5 current tenants reviewed.
Program failed to ensure comprehensive nurse reviews every 90 days or as warranted for 4 of 5 tenants reviewed.
Program failed to provide 8 hours of dementia-specific education within 30 days of employment for 3 of 7 staff reviewed.
Report Facts
Number of tenants without cognitive disorder: 48
Number of tenants with cognitive disorder: 7
Number of discharged tenants reviewed for medication administration: 7
Number of tenants reviewed for evaluations within 30 days: 5
Number of former tenants reviewed for evaluation of significant change: 7
Number of current tenants reviewed for evaluation of significant change: 5
Number of former tenants reviewed for service plans: 7
Number of current tenants reviewed for service plans: 5
Number of tenants reviewed for nurse reviews: 5
Number of staff reviewed for dementia training: 7
Inspection Report — Sep 1, 2020
Routine
Date: Sep 1, 2020
Visit Reason
The inspection was conducted as an onsite infection control survey for an Assisted Living Program for People with Dementia.
Findings
No regulatory insufficiencies were cited during the onsite infection control survey completed on 09/01/2020.
Report Facts
Number of tenants without cognitive disorder: 53
Number of tenants with cognitive disorder: 7
Inspection Report — Dec 11, 2019
Renewal
Date: Dec 11, 2019
Visit Reason
The recertification visit was conducted to determine compliance with certification of an Assisted Living Program for People with Dementia.
Findings
The program failed to ensure that staff received required dementia-specific education and training within specified timeframes, including initial training within 30 days of employment, annual continuing education, and hands-on dementia training. Several staff members lacked documentation of required training.
Violations (3)
Program failed to ensure staff received eight hours of dementia-specific education within 30 days of employment for 4 of 8 staff reviewed.
Program failed to ensure staff received at least eight hours of annual dementia-specific continuing education for 2 of 2 staff reviewed over one year.
Program failed to include hands-on dementia training for 3 of 8 staff reviewed.
Report Facts
Number of tenants without cognitive disorder: 52
Number of tenants with cognitive disorder: 14
Staff reviewed for initial dementia training: 8
Staff reviewed for annual dementia training: 2
Staff reviewed for hands-on dementia training: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Named in deficiency for not completing required dementia training within 30 days | |
| Staff B | Named in deficiency for not completing required dementia training within 30 days and hands-on training | |
| Staff C | Named in deficiency for not completing required annual dementia training and hands-on training | |
| Staff D | Named in deficiency for not completing required dementia training within 30 days, annual training, and hands-on training | |
| Staff E | Named in deficiency for not completing required dementia training within 30 days | |
| Office Director | Confirmed findings on 12-10-19 and 12-11-19 |
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