Inspection Reports for
The Falls at Cordingly Dam

Emergency call response: During the months of December 2023, June 2024 and February 2025, there were 863 e-call response times over the 15-minute limit (repeat finding).

Memory care unit: Three Resident accessible heating elements were operational without required safeguards to only allow supervised access.

Resident screening and assessment · Resident care plans: Documentation of an assessment conducted by a physical/occupational therapist every six months for three Residents noting that the Resident can independently navigate around the bed rail/ U-bar was missing for 17 Residents (repeat finding).

Quality assurance program: Documentation of the staff member responsible for follow up action was missing for the second and third quarters of the 2023 calendar year reviewed. One Personal Care staff carried a Resident’s medication blister pack outside of the Resident’s unit. AGE observed a family filled medication cassette unsecured in one Resident’s unit. AGE observed four over the counter medications stored within one Resident’s secured controlled substance medication storage unit that were not listed on the Resident’s physician prescribed medication list. AGE observed unsecured over the counter medications in one Resident’s unit. One Resident’s controlled substance medication storage unit contained two expired medications.

Incident reporting: The Residence filed 39 incident reports greater than 24 hours after the occurrence of the incident or accident (repeat finding).

Compliance review process: Records provided were not provided in an auditable manner. After July 2023, the Residence’s electronic medical record system does not clearly document assessments and service plans in a manner that clearly delineates the required periods of review.