Inspection Reports for
Coterie Cathedral Hill

The complaint was unsubstantiated. Allegations included medication mismanagement, delayed call button response, failure to provide care as per care plan, failure to notify responsible party of care plan changes, and overcharging. The facility provided documentation and interviews that disproved these allegations or showed compliance with policies.

The investigation found no preponderance of evidence to substantiate the allegations. Staff were found to handle medications appropriately, respond to call buttons within policy timeframes, provide care as requested by the resident's private caregivers, notify responsible parties of care plan changes, and properly explain level of care charges. No deficiencies were cited during the visit.

The resident was evaluated at the hospital and returned to the facility with discharge instructions. The resident is ambulatory and allowed to leave the facility unassisted. The resident has recovered to baseline with no injuries or changes in status. No citations were issued.

The complaint alleged staff financially abused a resident. The allegation was found to be unfounded and dismissed.

The investigation found that the allegation was unfounded as the person identified was not a staff member of the facility but the owner of an independent company providing pet services. The complaint was dismissed.

The visit was triggered by a complaint regarding an incident on 10/10/2025 where resident #1 slapped resident #2 after being pinched. The incident was witnessed by the Memory Care Director and reported to responsible parties. The complaint was investigated and found to have no injuries or further aggressive behavior.

The facility reported the incident, assessed the involved resident with no injuries noted, and there were no further aggressive behaviors observed. No deficiencies were cited during the visit.

The administrator had no information on how the check was altered, as payments are processed remotely. The incident was reported to local law enforcement and the responsible party is working with the bank. No deficiencies were cited during this visit.

The visit was triggered by a complaint of suspected abuse involving an unknown caller impersonating facility staff and obtaining money from a resident. The complaint was investigated and substantiated as a scam from an outside source, not involving facility staff.

The facility confirmed no calls were made to the resident by staff, and the resident was a victim of an external scam. The facility submitted an incident report to Community Care Licensing and sent a scam prevention notice to all residents. No deficiencies were cited during this visit.

The complaint involved an unknown caller pretending to be from the facility who requested a money transfer from resident R1. The resident provided bank information and funds were transferred. The facility confirmed no such call was made by staff. The resident filed a police report independently, but no report number was provided.

The facility confirmed that no calls were made to the resident by staff and that the resident was the victim of an external scam. The facility submitted an incident report to Community Care Licensing and sent a scam prevention notice to all residents. No deficiencies were cited during this visit.

The allegation that staff did not safeguard resident's funds was investigated and found to be unsubstantiated due to lack of evidence and the facility's limited involvement.

The investigation found no preponderance of evidence to substantiate the allegation. The facility was not involved in the service sign-up, only provided a referral, and has taken steps to restrict the business affiliate's access and reported the situation to appropriate authorities. The allegation was determined to be unsubstantiated.

The facility was found to be clean, well-maintained, and operating safely with no deficiencies cited. Resident care, staff training, medication management, and safety systems were all in order.

The facility was found to be clean, well-maintained, and compliant with safety regulations including fire safety systems. Staff files, resident service plans, and medication records were all in order. No deficiencies were cited during the visit.

Complaint alleged facility staff not meeting resident needs for resident R1 in ADL tasks including room checks, continence care, and medication administration. The complaint was found unsubstantiated due to contradictory information and lack of evidence.

The investigation found that the allegations were unsubstantiated due to lack of corroborating evidence. Staff documented ADL tasks as completed, often noting completion by outside private caregiver services. Medication administration times were within facility policy allowances, and medication prescription instructions did not specify exact times.

The complaint alleged that facility staff were not meeting resident R1's needs for ADL and medication administration. The investigation found no preponderance of evidence to prove violations, and the complaint was unsubstantiated.

The investigation found that the allegations were unsubstantiated. Evidence showed that ADL tasks were documented as completed, often by an outside private caregiver who dismissed facility staff. Medication administration times were within the facility's allowed one-hour window, and medication records indicated compliance with prescribed instructions.

Complaint alleges facility devices not properly working including elevator and swimming pool lift. The allegation was found to be unsubstantiated due to contradicting information and lack of corroborating evidence.

The investigation found that one of four elevators was not operating on the date of the alleged incident, but three elevators were functioning and accessible. The swimming pool lift was in the process of repair and awaiting parts. Documentation of repair services was provided, and at the time of final inspection, all devices were operating. Due to lack of corroborating evidence, the complaint was found to be unsubstantiated.

The complaint alleged that facility devices, including elevators and the swimming pool lift, were not properly working. The allegation was found to be unsubstantiated due to contradictory information and lack of corroborating evidence.

The investigation found that one of four resident-utilized elevators was not operating on the date of the alleged incident, but three elevators were functioning and accessible. The swimming pool lift was under repair and awaiting parts. The facility demonstrated awareness and action toward repairs. Due to contradictory information and lack of corroborating evidence, the allegation was found to be unsubstantiated.

The complaint was investigated and found to be unfounded, meaning the allegations were false, could not have happened, or were without reasonable basis.

The investigation found that both residents had signed admission agreements and did not move in due to increased care needs and rates. The facility upheld the 60-day notice rule and charged accordingly. The allegations were determined to be unfounded and the complaint was dismissed.

The complaint was investigated and found to be unfounded, meaning the allegations were false, could not have happened, or lacked reasonable basis. The complaint was dismissed.

The investigation found that both residents involved had signed admission agreements and did not move into the facility but were charged for a 60-day notice period as per the agreement. Additional services were required after signing, which increased rates accordingly. The allegations were determined to be unfounded.

The facility was found to be in compliance with all regulations; no deficiencies were cited. The physical plant, safety measures, medication storage, and documentation were all satisfactory.

The facility was found to be in compliance with all regulations, including proper water temperature, safety equipment, food storage, medication management, and staff documentation. No deficiencies were cited during the visit.

The complaint alleged insufficient staffing to meet resident care needs. The allegation was unsubstantiated after investigation.

The investigation included interviews, document reviews, and observations of the memory care unit. No staff shortages were identified, and the facility scheduling demonstrated adequate staffing to meet residents' needs. The allegation was determined to be unsubstantiated due to lack of preponderance of evidence.

The complaint alleged insufficient staffing to meet residents' care needs. The allegation was unsubstantiated after investigation.

The investigation included interviews, document reviews, and observations of the memory care unit. No staff shortages were identified, and the facility scheduling demonstrated adequate staffing to meet residents' needs. The allegation was found to be unsubstantiated due to lack of preponderance of evidence.

The resident had left the facility with other residents for a community walk with their spouse and returned to notify staff they wished to continue walking without signing in or out. This was not considered abnormal practice. No deficiencies were cited during this visit.

The resident had left the facility with other residents for a community walk with their spouse and returned to notify staff they wished to continue walking without signing in or out. This was not considered abnormal practice. No deficiencies were cited during this visit.

The visit was triggered by a report of suspected abuse where a resident alleged sexual abuse by a private duty aide. The aide was fingerprinted through the agency and removed from the facility upon the report. Documentation regarding the aide is to be submitted to the Licensing Program Analyst.

No deficiencies were cited during the visit. The private duty aide involved in the abuse allegation was removed from the facility, and the facility has suggested residents hire from preferred agencies.

The visit was complaint-related due to a report of suspected sexual abuse by a private duty aide. The aide was fingerprinted through the agency and removed from the facility. Documentation regarding the aide is to be submitted to the Licensing Program Analyst.

The Licensing Program Analyst found that the private duty aide was removed from the facility upon the report. The facility has suggested residents hire from preferred agencies. No deficiencies were cited during this visit.

The complaint alleged that staff did not comply with infection control practices resulting in a health and safety risk. The complaint was found to be unfounded, meaning the allegation was false, could not have happened, or was without reasonable basis.

The investigation found that infection control plans were in place and being followed, COVID-19 positive residents were isolated, staff were observed using appropriate protective equipment, and notifications to family members were ongoing. The allegation was determined to be unfounded and no citations were issued.

The complaint alleged that staff did not comply with infection control practices resulting in a health and safety risk. The complaint was found to be unfounded, meaning the allegation was false, could not have happened, or was without reasonable basis.

The investigation found that infection control plans were in place and being followed, COVID cases were isolated, and staff were observed complying with infection control protocols. The complaint was determined to be unfounded with no citations issued.

The complaint alleged that staff did not address a scabies outbreak and failed to meet residents' hygiene needs. The investigation found no preponderance of evidence to substantiate these allegations.

The investigation found that the facility did respond appropriately to the scabies outbreak by notifying authorities, treating affected residents and staff, and providing hygiene care. The allegations were determined to be unsubstantiated due to lack of evidence.

The complaint was unsubstantiated. Allegations included failure to address a scabies outbreak and failure to meet residents' hygiene needs. Interviews and record reviews showed timely treatment and hygiene care were provided.

The investigation found that the facility identified and treated residents and staff for scabies promptly after diagnosis confirmation, cleaned resident apartments, and provided showers and linen changes. The allegations were unsubstantiated due to lack of evidence.

Complaint was about the facility being without hot water. The allegation was investigated through interviews, water temperature testing, and record review. The complaint was found to be unsubstantiated.

The investigation found that a maintenance staff accidentally punctured a hot water pipe causing no hot water for 4 days. The building engineer and contractors repaired the issue promptly, restoring hot water the same day. Water temperature tests and resident interviews confirmed hot water was adequate and daily routines were not interrupted. The allegation was deemed unsubstantiated due to lack of preponderance of evidence.

The complaint alleged that facility doors were not in good repair, causing a resident to fall and be locked outside on the rooftop. The investigation included interviews with the resident, other residents, the building engineer, and a facility tour. The resident confirmed a fall unrelated to the doors and denied being locked out. The building engineer reported no prior issues and confirmed recent servicing of the rooftop door. The complaint was unsubstantiated.

The investigation found that the 3rd floor and rooftop doors were functioning properly, and residents interviewed did not report concerns about the doors. The allegations were deemed unsubstantiated due to lack of evidence.

The complaint alleged the facility was without hot water. The investigation included interviews, water temperature testing, and record review. The allegation was found to be unsubstantiated.

The investigation found that a maintenance staff accidentally punctured a hot water pipe causing a temporary loss of hot water for 4 days. The hot water was restored the same day of the incident, and temperatures were maintained within an adequate range. Resident interviews indicated their daily routines were not interrupted. The allegation was deemed unsubstantiated due to lack of preponderance of evidence.

The complaint involved allegations that facility doors were not in good repair, causing a resident to fall and be locked out on the rooftop. The investigation included interviews with the resident, other residents, and the building engineer. The allegations were found to be unsubstantiated.

The investigation found that the 3rd floor and rooftop doors were functioning properly, and residents, including the complainant, did not report issues with the doors. The allegations were deemed unsubstantiated due to lack of evidence.

The facility staff safely escorted the resident back after the resident left the facility unattended. No injuries occurred and no deficiencies were cited during the visit.

The Licensing Program Analyst found that the resident left the facility briefly but was safely escorted back by staff without injury. The facility plans to update the resident's care plan to implement safety measures. No deficiencies were cited during this visit.

The inspection involved gathering documentation and interviews related to the incident. Additional documents and staff interviews were requested for further follow-up.

The inspection gathered information including physician reports and resident status documentation. No injuries were noted to the resident. Additional documents and staff interviews were requested for further follow-up.

The facility was observed to be spacious, clean, well-lit, and comfortable with no residents present during the inspection. Safety measures such as emergency exit plans, locked medication rooms, and controlled access to certain areas were noted. COVID-19 signage and PPE supplies were observed throughout the facility. Immediate licensure is recommended pending final approval.

The facility was observed to be spacious, clean, with comfortable temperature and good lighting. Safety measures including emergency exit plans, COVID-19 signage, and secure medication rooms were in place. No residents were present during the inspection. Immediate licensure was recommended pending final approval.

The applicant/administrator participated in a telephone interview (COMP II) confirming understanding of facility operation, admission policies, staffing requirements, restrictive health conditions, general provisions, emergency preparedness, complaints and reporting, and pre-licensing readiness. Identification was verified and required documentation was obtained.

The applicant/administrator demonstrated understanding of facility operation, admission policies, staffing requirements, restrictive health conditions, general provisions, emergency preparedness, complaints and reporting, and pre-licensing readiness. No deficiencies or violations were noted.