Deficiencies per Year
8
6
4
2
0
Severe
High
Moderate
Low
Unclassified
Census Over Time
Inspection Report
Complaint Investigation
Census: 28
Deficiencies: 3
Sep 16, 2025
Visit Reason
The inspection was conducted to investigate complaints #129627-I, #129504-C, and #130350-I, and to conduct a recertification visit to determine compliance with certification of an Assisted Living Program for People with Dementia.
Findings
No regulatory insufficiencies were cited for complaints #129627-I and #129504-C. However, deficiencies were found related to criteria for admission/retention of tenants requiring two-person assistance, and failures in updating and individualizing service plans for tenants, including those with behavioral issues and mobility needs.
Complaint Details
The investigation included complaints #129627-I and #129504-C, which had no regulatory insufficiencies cited. The deficiencies cited were related to complaint #130350-I and the recertification visit.
Deficiencies (3)
| Description |
|---|
| Program retained 2 of 4 tenants who regularly required two staff for transfers, violating criteria for admission/retention. |
| Program failed to update the service plan for 1 of 4 residents with a fractured spine within 30 days of a significant change. |
| Program failed to ensure service plans included the needs of 3 of 4 tenants reviewed, including behavioral and mobility needs. |
Report Facts
Total census: 28
Tenants requiring two-person assistance: 2
Residents reviewed for service plans: 4
Tenants with unmet service plan needs: 3
Date of incident report: Aug 29, 2025
Inspection Report
Complaint Investigation
Census: 29
Deficiencies: 2
May 21, 2025
Visit Reason
The inspection was conducted to investigate complaints #128133-C, 127571-C, and 125640-C, as well as Incident #126023-I at Quartet Senior Living MC.
Findings
No regulatory insufficiencies were found related to Incident #126023-I. However, regulatory insufficiencies were cited for failure to implement a system or written procedure to address tenant emergency needs for cognitively impaired tenants, and failure to ensure staff received required dementia-specific education within 30 days of employment.
Complaint Details
The visit was complaint-related, investigating complaints #128133-C, 127571-C, and 125640-C. No regulatory insufficiencies were cited during the investigation of Incident #126023-I.
Deficiencies (2)
| Description |
|---|
| Failed to implement a system or written procedure to address tenant emergency needs when tenants are unable to use/understand Personal Emergency Response System (PERS)/pendant, potentially affecting 29 tenants. |
| Failed to ensure staff received a minimum of eight hours of dementia-specific education within 30 days of employment, affecting 2 staff members. |
Report Facts
Number of tenants without cognitive impairment: 5
Number of tenants with cognitive impairment: 24
Total census: 29
Staff members without required dementia training: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Failed to complete eight hours of dementia-specific training within 30 days of employment | |
| Staff B | Failed to complete eight hours of dementia-specific training within 30 days of employment |
Inspection Report
Complaint Investigation
Census: 21
Deficiencies: 2
Sep 9, 2024
Visit Reason
The inspection was conducted as an investigation into Complaint #121670-C regarding regulatory insufficiencies at Quartet Senior Living MC.
Findings
The investigation found that the program retained a tenant (Tenant C1) who displayed verbal and physical aggression despite interventions, resulting in harm to another tenant. Additionally, the program failed to develop and sign a preliminary service plan prior to occupancy for another tenant (Tenant #3).
Complaint Details
The visit was triggered by Complaint #121670-C. The complaint involved retention of a tenant who was aggressive and dangerous, and failure to provide timely notice and service plans. The findings were substantiated by interviews and record reviews.
Deficiencies (2)
| Description |
|---|
| The program retained a tenant who displayed verbal and physical aggression and was dangerous to self or others. |
| Failure to ensure a preliminary service plan was developed and signed prior to the signing of an occupancy agreement for one tenant. |
Report Facts
Total census: 21
Tenants without cognitive impairment: 3
Tenants with cognitive impairment: 18
Discharge date of Tenant C1: Jul 5, 2024
Date of service plan for Tenant #3: Aug 26, 2024
Date occupancy agreement signed for Tenant #3: Aug 28, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Regional Director of Operations | Confirmed findings on 9/9/24 at 11:00 AM | |
| Assistant Director of Nursing | Updated Tenant #3's daughter and coordinated move to Memory Care | |
| Resident Services Director | Resident Services Director (RSD) | Trained staff on communication and monitoring aggression; monitors compliance |
Inspection Report
Complaint Investigation
Census: 14
Deficiencies: 7
Feb 21, 2024
Visit Reason
Investigation of Complaint #118032-C and revisit to the initial certification visit at Quartet Senior Living MC.
Findings
The program failed to complete incident reports for all accidents or unusual occurrences, failed to administer medications as prescribed, failed to complete evaluations and nurse's notes as needed with significant changes, and failed to update service plans timely and accurately. Additionally, a nurse review was not completed following a significant health change for a discharged tenant.
Complaint Details
The visit was triggered by Complaint #118032-C and included a revisit to the initial certification visit.
Deficiencies (7)
| Description |
|---|
| Failed to complete incident reports for all accidents or unusual occurrences affecting tenants. |
| Failed to administer medications as prescribed for a discharged tenant. |
| Failed to complete evaluations as needed with significant change for current and discharged tenants. |
| Failed to document nurse's notes by exception for current tenants. |
| Failed to update service plans as needed for current and discharged tenants. |
| Failed to update and sign service plans within 30 days of tenant occupancy for a recently admitted tenant. |
| Failed to complete nurse reviews as needed with a change in health status for a discharged tenant. |
Report Facts
Number of tenants without cognitive impairment: 1
Number of tenants with cognitive impairment: 13
Total census: 14
Medication Incident Report date: 2023
Medication administration record dates: 2023
Admission date: 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Clinical Director | Interviewed on 2/21/24 confirming incident reports, MARs, orders, evaluations, nurse's notes, service plans, and nurse reviews were provided for tenants reviewed. |
Inspection Report
Complaint Investigation
Census: 18
Deficiencies: 6
Sep 13, 2023
Visit Reason
The inspection was conducted as a complaint investigation (#112734-C) and an initial certification visit to determine compliance with certification of a Dedicated Dementia Specific Assisted Living Program.
Findings
The Program failed to follow established policies and procedures related to medication administration and blood glucose testing, failed to provide nurse delegated training within 30 days for some staff, failed to complete cognitive evaluations prior to occupancy for some tenants, failed to complete evaluations with significant change, and failed to update service plans to reflect tenant needs and behaviors. Additionally, a service plan was not signed within 30 days for one tenant.
Complaint Details
The inspection was triggered by Complaint #112734-C, which involved concerns about medication administration and other care issues.
Deficiencies (6)
| Description |
|---|
| Failed to follow established policies and procedures related to medication administration and blood glucose testing, including hand hygiene and medication omissions. |
| Failed to provide nurse delegated training within 30 days of employment for 2 of 3 staff reviewed. |
| Failed to complete cognitive evaluations prior to taking occupancy for 2 of 5 current tenants and 1 of 2 discharged tenants. |
| Failed to complete evaluations with significant change for 1 tenant who experienced multiple significant health and behavioral changes. |
| Failed to update service plans to reflect service needs and behavioral interventions for 5 current tenants and 2 discharged tenants. |
| Failed to obtain signed service plans within 30 days of occupancy for 1 tenant. |
Report Facts
Total census: 18
Number of tenants without cognitive impairment: 5
Number of tenants with cognitive impairment: 13
Number of medication administration omissions: 15
Number of staff reviewed for nurse delegated training: 3
Number of tenants reviewed for cognitive evaluations: 5
Number of tenants reviewed for service plan updates: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Direct Care Staff | Failed to receive nurse delegated training within 30 days |
| Staff B | Direct Care Staff | Failed to receive nurse delegated training within 30 days |
| Staff C | Observed administering medications without proper hand hygiene | |
| Clinical Director | Clinical Director | Confirmed expectations for hand hygiene, nurse delegated training, evaluations, and service plans |
| Staff D | Provided information about tenant relationships and behaviors | |
| Staff E | Provided information about tenant relationships and behaviors | |
| Staff F | Licensed Practical Nurse (LPN) | Evaluator of Staff A's competency, not a registered nurse |
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