7 Reports
Inspection Report — Oct 27, 2025
Complaint Investigation
Date: Oct 27, 2025
Visit Reason
Investigation of Incident #130455-I at an assisted living program serving people with dementia.
Complaint Details
Investigation of Incident #130455-I; no regulatory insufficiencies found.
Findings
No regulatory insufficiencies were cited during the investigation.
Report Facts
Tenants without cognitive impairment: 25
Tenants with cognitive impairment: 12
Inspection Report — Jun 19, 2025
Complaint Investigation
Date: Jun 19, 2025
Visit Reason
The inspection was conducted as an investigation of Incident #128041-C at the assisted living program for people with dementia.
Complaint Details
Investigation of Incident #128041-C with no regulatory insufficiencies cited.
Findings
No regulatory insufficiencies were cited during the investigation of Incident #128041-C.
Report Facts
Number of tenants without cognitive impairment: 26
Number of tenants with cognitive impairment: 11
Inspection Report — Mar 27, 2025
Complaint Investigation
Date: Mar 27, 2025
Visit Reason
Investigation of Incident #127418-I at the assisted living program for people with dementia.
Complaint Details
Investigation of Incident #127418-I; no regulatory insufficiencies found.
Findings
No regulatory insufficiencies were cited during the investigation.
Report Facts
Number of tenants without cognitive impairment: 25
Number of tenants with cognitive impairment: 3
Inspection Report — Jan 7, 2025
Renewal
Date: Jan 7, 2025
Visit Reason
The visit was conducted as a recertification visit to determine compliance with certification rules for an Assisted Living Program and included investigation of two complaints.
Complaint Details
Investigation of Complaints #121443-C and #121982-C found no regulatory insufficiencies.
Findings
No regulatory insufficiencies were cited during the investigation of Complaints #121443-C and #121982-C, nor during the recertification visit for the Assisted Living Program.
Report Facts
Tenants without cognitive impairment: 30
Tenants with cognitive impairment: 11
Inspection Report — Jul 26, 2022
Renewal
Date: Jul 26, 2022
Visit Reason
The visit was conducted as a recertification visit to determine compliance with certification of an Assisted Living Program for People with Dementia.
Complaint Details
No regulatory insufficiencies were cited during the investigation of Complaint #100155-C and #106168-C.
Findings
No regulatory insufficiencies were cited during the investigation of two complaints. However, during the recertification visit, regulatory insufficiencies were cited related to evaluation of tenants, service plans, and dementia-specific education for personnel.
Violations (3)
Program failed to evaluate a tenant's functional, cognitive, and health status at least annually for 1 of 2 tenants reviewed.
Program failed to update service plans on an annual basis for 1 of 2 tenants reviewed.
Program failed to provide 8 hours of dementia training within 30 days of employment for 2 of 8 staff reviewed.
Report Facts
Number of tenants without cognitive disorder in General Population Program: 20
Number of tenants with cognitive disorder in General Population Program: 4
Number of tenants without cognitive disorder in Memory Care Unit: 0
Number of tenants with cognitive disorder in Memory Care Unit: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Executive Director | Confirmed findings related to dementia-specific education for personnel and tenant evaluations. | |
| RN Director of Health and Wellness | Registered Nurse | Confirmed findings and completed the full annual assessment and updated service plan for Tenant #1. |
| Staff A | Staff member who did not receive dementia training within 30 days of employment. | |
| Staff B | Staff member who did not receive dementia training within 30 days of employment. |
Inspection Report — Nov 2, 2020
Complaint Investigation
Date: Nov 2, 2020
Visit Reason
Investigation of Complaint #90640-C and an onsite infection control survey.
Complaint Details
Complaint #90640-C was investigated and found to have no regulatory insufficiencies.
Findings
No regulatory insufficiencies were cited during the investigation of the complaint or the onsite infection control survey.
Report Facts
Number of tenants without cognitive disorder in General Population Program: 29
Number of tenants with cognitive disorder in General Population Program: 4
Number of tenants without cognitive disorder in Memory Care Unit: 0
Number of tenants with cognitive disorder in Memory Care Unit: 10
Inspection Report — Feb 13, 2020
Complaint Investigation
Date: Feb 13, 2020
Visit Reason
The inspection was conducted as an investigation of Complaint #87586-C regarding the admission and retention criteria for tenants requiring assistance with standing, transfer, or evacuation.
Complaint Details
Investigation of Complaint #87586-C found regulatory insufficiency related to admission and retention criteria for tenants requiring two-person assistance. The complaint was substantiated with observations and staff interviews confirming the issue.
Findings
The program failed to ensure that two of three tenants reviewed did not exceed the level of care criteria requiring routine two-person assistance for transfers. Observations and interviews confirmed that tenants required two staff for transfers, but this was not consistently provided.
Violations (1)
Failure to meet criteria for admission and retention of tenants requiring routine, two-person assistance with standing, transfer, or evacuation.
Report Facts
Number of tenants without cognitive disorder in General Population Program: 31
Number of tenants with cognitive disorder in General Population Program: 2
Number of tenants without cognitive disorder in Memory Care Unit: 0
Number of tenants with cognitive disorder in Memory Care Unit: 10
Date of observations: Feb 10, 2020
Date of observations: Feb 11, 2020
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Windsor Manor DHW | Director of Health & Wellness | Named in plan of correction to ensure criteria for admission/retention and staff education |
| Staff A | Observed and reported tenant transfer assistance requirements | |
| Staff B | Observed and reported tenant transfer assistance requirements | |
| Staff C | Observed and reported tenant transfer assistance requirements | |
| Executive Director | Stated tenant transfer assistance requirements |
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