Inspection Reports for
Addington Place of Clinton

The program failed to ensure that evaluations by the Department of Health and Human Services were completed for staff with criminal histories prior to employment. Specifically, two staff members (Staff A and Staff C) were employed without completed evaluations as required.

The program failed to ensure evaluations were completed by the Department of Health and Human Services for staff with a criminal history prior to employment. Two staff files reviewed showed no completed evaluations despite criminal history records requiring further action.

No regulatory insufficiencies were cited during the investigation of Complaint #122851-C, Incident #122709-I, or the revisit of #122196-M.

No regulatory insufficiencies were cited during the investigation of Complaint #122851-C, Incident #122709-I, or the revisit of #122196-M. However, a regulatory insufficiency was cited for failure to ensure evaluations were completed by the Department of Health and Human Services for 4 staff with criminal or founded child abuse history.

The visit was triggered by a complaint (Mandatory Report #122196-M) regarding the safety and care of Tenant #1 who eloped from the facility through an unlocked courtyard door. The complaint was substantiated based on findings of staff negligence and failure to follow training protocols.

The investigation found that staff failed to provide services in accordance with nurse delegated training, resulting in a tenant eloping through an unlocked courtyard door. Additionally, staff failed to complete required safety checks and dependent adult abuse training documentation was missing for one staff member.

Program staff failed to provide services according to nurse delegated training, resulting in Tenant #1 eloping through an unlocked courtyard door. Staff failed to complete required safety checks, door alarm responses, and visual contact with tenants, contributing to the incident.

Two regulatory insufficiencies were cited: failure to provide adequate care for one tenant with dementia, evidenced by unaddressed weight loss and inadequate meal service; and failure to complete employee background checks prior to hire for three employees.

The facility failed to ensure employee background checks were completed prior to hire for 3 of 10 employees reviewed. A fine of $500 was assessed for this violation.

The visit was complaint-related for Complaint #107142-C. No regulatory insufficiencies were cited for Complaints #109394-C, #106894-C or Incident #104713-I.

No regulatory insufficiencies were found for complaints #109394-C, #106894-C, or Incident #104713-I. Deficiencies were cited for Complaint #107142-C including failure to have an activity calendar available to all tenants, and failure to maintain one tenant's apartment carpeting in a safe and well-maintained condition.

The investigation included complaints 104480-A, 104479-A, 104476-A, 104477-A, 104621-A which found no regulatory insufficiencies. The incident 104472-M was substantiated with a finding of failure to train contracted staff.

No regulatory insufficiencies were found related to the complaints investigated, but a regulatory insufficiency was cited for failure to provide appropriate training to one contracted employee (Staff A) as evidenced by an incident involving improper toileting assistance.

The visit was triggered by complaints #104609-C and #103783-C. The investigation substantiated issues with tenant care, staffing, and service plan compliance.

The investigation found multiple deficiencies including inadequate care and services related to tenant belongings, insufficient staffing to meet tenant needs, retention of tenants requiring two-person assistance, retention of tenants displaying unmanageable aggression, and failure to update service plans as needed.

The visit was complaint-related involving investigation of incidents and complaints #97330-C, #97708-I, and #101239-C. No regulatory insufficiencies were cited regarding Complaint #97330-C or the onsite infection control survey. The investigation focused on incidents involving tenants #5 and #6, including failure to complete incident reports and inadequate care.

The program was found to have multiple regulatory insufficiencies including failure to complete incident reports, inadequate tenant care and treatment, medication administration issues, insufficient staffing, lack of dementia-specific education for personnel, failure to ensure alarm system functionality, and deficient record checks. Several tenants experienced unsafe conditions and inadequate care. A plan of correction was submitted to address these deficiencies.

Incident 99708-I

The program failed to ensure the alarm system was utilized on all exit doors, allowing a tenant with severe cognitive decline to leave the building unnoticed. The main entrance door was often unlocked and unalarmed, posing a risk to tenants with cognitive impairments.