Inspection Reports for
Turtle & Crane Assisted Living

.161.04 Designated smoking areas: residents were observed smoking in non-designated areas by the back sliding door in building #1 and the front door of building #3; the administrator confirmed this practice.

.250.09 Resident sleeping rooms: water temperatures were not maintained between 105 and 120 degrees F, with temperatures ranging from 124.1 to 138.7 degrees F in various buildings; the administrator acknowledged the out-of-range temperatures.

.305.03 Change in resident health status: nursing assessments were not conducted when residents experienced changes in physical or mental health status, including falls, speech issues, hallucinations, and lumps requiring provider assessment; the administrator confirmed assessments were not completed.

.310.01.c Medication distribution: medication refrigerator temperatures where insulin was stored were not maintained between 38 and 45 degrees F, with documented out-of-range temperatures over multiple days and no corrective action taken; the facility nurse was unaware.

.310.04.e Psychotropic or behavior modifying medication: residents taking psychotropic medications did not have six-month medication reviews completed; the administrator confirmed reviews were not completed.

.320.03 Signature, date, and approval of agreement: negotiated service agreements were not signed and dated by residents or legal guardians, with last signatures over a year old and no signatures on updates; the administrator stated the process did not include obtaining signatures on updates.

.405.02.c Prohibited applications: relocatable power taps were used to supply power to a microwave in room #6 of building #3, which is prohibited.

39-3321.2.d Qualifications and requirements of administrator: the facility did not develop interventions to prevent recurrences after residents' incidents, including multiple falls by residents #1 and #2; the administrator confirmed interventions were not implemented.

39-3321.2.e Qualifications and requirements of administrator: the administrator did not complete investigations and written reports within 30 days of accidents and incidents, including multiple falls by residents #1 and #6; the administrator confirmed investigations were not completed.

.260.07 Toxic Chemicals: the facility did not secure various cleaning chemicals in the laundry room and kitchen of building #2, making them accessible to cognitively impaired residents on several occasions.

.305.06 Self-Administered Medication: Resident #8 was not assessed prior to nor every 90 days to ensure safety in self-administering medications; the nurse was unaware and had not completed the assessment.

.310.01.g Medication Distribution System: the facility did not ensure all residents' as-needed medications were available, including PRN inhaler, eye drops, and blood pressure medication for Resident #6 and laxatives and acid reducers for Resident #8.

.330.04.c.iv Resident Care Records: the administrator did not ensure staff documented reasons why three residents did not receive prescribed medications, including refusals and insurance authorization delays.

.330.04.c.vii Resident Care Records: assessments for changes in residents' physical and mental conditions were not consistently documented, despite diagnoses and incidents such as Clostridium difficile and multiple falls.

.330.04.c.xi Resident Care Records: investigations into incidents and accidents were completed but interventions to prevent recurrence were not consistently documented, including fall prevention measures for Resident #6.

.335.02 Standard Precautions: the facility did not follow infection control procedures; medication technicians administered eye drops without gloves and failed to perform hand hygiene, previously cited on 2/12/25.

.215.01 Administrator responsibility: the former administrator did not ensure all facility policies were implemented and allowed a staff member accused of abuse to work for eight days before the investigation was completed.

.305.02.b Current medication orders and treatment orders: the facility nurse did not ensure residents received medications as ordered, including Resident #1 not receiving the correct dosage of trazodone from 1/6/25 to 1/15/25 (previously cited 4/11/2024).

.335.02 Standard precautions: the facility did not follow standard infection control procedures, with kitchens in multiple houses having debris, dried substances, and grime requiring deep cleaning.

.510 Requirements to protect residents from abuse: the facility failed to protect Resident #3 from abuse by Staff member B, did not immediately notify Adult Protective Services, did not complete thorough investigations, and allowed the staff member to continue working for eight days after allegations, resulting in abuse and affecting all residents.

.305.03 Resident Health Status: the facility nurse did not consistently conduct nursing assessments when a resident experienced changes in physical or mental health status, including after a fall, choking incident, and dental surgery.

.305.02.b Current Medication Orders and Treatment Orders: the facility nurse did not ensure residents received medications as ordered; a resident was ordered to have medications crushed but was observed receiving them whole.