3 Reports
Inspection Report — Jun 6, 2024
Renewal
Date: Jun 6, 2024
Visit Reason
The visit was conducted as a recertification visit to determine compliance with certification rules for an Assisted Living Program for People with Dementia.
Complaint Details
No regulatory insufficiencies were cited during the investigation of Complaint #115541-C and Complaint #116990-C.
Findings
Several regulatory insufficiencies were cited related to staffing, dementia-specific education for personnel, and life safety emergency policies. The program failed to ensure nurse delegation assessments within 60 days, dementia training within required timeframes, and a working alarm on one exit door in the memory care wing.
Violations (4)
The Program's Registered Nurse failed to document an assessment ensuring 3 of 3 staff reviewed were competent in assigned tasks and job duties within the first 60 days of employment.
The Program failed to ensure 8 hours of dementia-specific training was completed within 30 days of employment for 1 of 1 staff reviewed hired within the past year.
The Program failed to ensure 2 of 2 staff employed longer than a year had at least 8 hours of dementia-specific continuing education annually.
The Program failed to have a working alarm on 1 of 3 exit doors in the memory care wing which could affect 16 tenants residing in that wing.
Report Facts
Number of tenants without cognitive impairment: 50
Number of tenants with cognitive impairment: 15
Tenants affected by alarm deficiency: 16
Staff reviewed for nurse delegation assessment: 3
Staff reviewed for dementia training within 30 days: 1
Staff reviewed for annual dementia continuing education: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Betsy Walrath | Wellness Administrator | Named in relation to nurse delegation and training deficiencies; confirmed findings and provided corrective action plans. |
| Staff F | Staff member whose personnel file lacked RN documentation ensuring competency in assigned tasks. | |
| Staff H | Staff member whose personnel file lacked RN documentation ensuring competency and dementia training. | |
| Staff I | Staff member reviewed for dementia-specific continuing education compliance. | |
| Staff C | Staff member who did not complete required dementia-specific training within 30 days. |
Inspection Report — Apr 18, 2023
Complaint Investigation
Date: Apr 18, 2023
Visit Reason
Investigation of Complaint #107931-C regarding the Assisted Living Program for People with Dementia.
Complaint Details
Complaint #107931-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 impairment: 60
Number of tenants with cognitive impairment: 9
Inspection Report — Nov 10, 2021
Renewal
Date: Nov 10, 2021
Visit Reason
The inspection was conducted as a recertification to determine compliance with certification for a Dementia-Specific Assisted Living Program, including an investigation of a complaint and an onsite infection control survey.
Complaint Details
No regulatory insufficiencies were cited during the investigation of Complaint #100484-C.
Findings
The facility was found to have regulatory insufficiencies related to failure to evaluate tenants within 30 days of occupancy, failure to update service plans within 30 days of occupancy, and failure to ensure all exit doors had operating alarm systems in the dementia-specific program. No deficiencies were cited during the complaint investigation or infection control survey.
Violations (3)
Failed to evaluate 2 out of 4 tenants within 30 days of occupancy.
Failed to update 3 of 4 tenants' service plans within 30 days of occupancy.
Failed to ensure all exit doors in the dementia-specific program contained an operating alarm system.
Report Facts
Number of tenants without cognitive disorder: 34
Number of tenants with cognitive disorder: 7
Date of violations: Nov 10, 2021
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director | Confirmed findings related to evaluation, service plans, and alarm system deficiencies. | |
| Maintenance Director | Confirmed that no exit doors had fully installed operating alarm systems and described partial installation. |
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