6 Reports
Inspection Report — Jan 25, 2023
Complaint Investigation
Date: Jan 25, 2023
Visit Reason
Investigation of Incident #105263 and Complaint #105304 at Whispering Creek Senior Living MC.
Complaint Details
Investigation of Incident #105263 and Complaint #105304 found no regulatory insufficiencies.
Findings
No regulatory insufficiencies were cited during the investigation of Incident #105263 or Complaint #105304.
Report Facts
Number of tenants without cognitive disorder: 1
Number of tenants with cognitive disorder: 12
Inspection Report — May 18, 2022
Renewal
Date: May 18, 2022
Visit Reason
The visit was a recertification inspection conducted to determine compliance with certification for an Assisted Living Program for People with Dementia.
Complaint Details
No regulatory insufficiencies were cited during the investigation of complaints 103865-C or 103943-C.
Findings
No regulatory insufficiencies were cited during complaint investigations, but one deficiency was cited during the recertification visit related to preliminary service plans not being signed by those who developed the plan for 2 of 3 tenants reviewed.
Violations (1)
Preliminary service plans were not signed by those who developed the plan for 2 of 3 tenants reviewed.
Report Facts
Number of tenants without cognitive disorder: 0
Number of tenants with cognitive disorder: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Joni Ogden | Executive Director | Signed Plan of Correction response letter |
Inspection Report — Aug 25, 2021
Complaint Investigation
Date: Aug 25, 2021
Visit Reason
The inspection was conducted as an investigation of Mandatory Report #98878-M related to regulatory insufficiencies in the Assisted Living Program for People with Dementia at Whispering Creek Senior Living MC.
Complaint Details
The visit was triggered by a complaint investigation of Mandatory Report #98878-M. The findings were substantiated as confirmed by the Executive Director.
Findings
The inspection found deficiencies including failure to follow program policies and procedures regarding incident reports, specifically a delayed incident report for bruising on a tenant, and failure to ensure dementia-specific continuing education for direct-contact personnel employed by a contracting agency.
Violations (2)
Program failed to ensure the policy regarding incident reports was followed for 1 of 1 tenants reviewed, including delayed documentation of bruising and incident report completion.
Program failed to ensure staff employed by a contracting agency received the required minimum of eight hours of dementia-specific continuing education annually.
Report Facts
Number of tenants without cognitive disorder: 39
Number of tenants with cognitive disorder: 12
Number of tenants with cognitive disorder: 0
Number of tenants without cognitive disorder: 0
Dementia training hours required: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff C | Interviewed regarding incident report documentation and bruising on Tenant #2 | |
| Staff G | Certified Nurse Aide | Employed by contracting agency, failed to receive required dementia training |
| Jacque Kreber | Executive Director | Confirmed findings and signed Plan of Correction |
Inspection Report — Aug 25, 2021
Complaint Investigation
Date: Aug 25, 2021
Visit Reason
The inspection was conducted as an investigation of Incident #99172-1, related to safety and security concerns in the dementia-specific program and memory care unit.
Complaint Details
The visit was complaint-related, investigating Incident #99172-1 involving tenant elopement through an unlocked courtyard gate. The incident was self-reported by the program, and no injuries were noted. The complaint was substantiated based on observations and interviews.
Findings
The program failed to ensure an operating alarm system was connected to the exit door in the dementia unit, and the courtyard gate was left unlocked, allowing a tenant to elope. The facility did not maintain the courtyard off the memory care unit as safe and secure at all times.
Violations (2)
Failure to ensure the exit door in the dementia unit had an operating alarm system connected at all times.
Failure to maintain the courtyard off the memory care unit safe and secure, resulting in an unlocked gate and tenant elopement.
Report Facts
Number of tenants without cognitive disorder in General Population Program: 39
Number of tenants with cognitive disorder in General Population Program: 0
Number of tenants without cognitive disorder in Memory Care Unit: 0
Number of tenants with cognitive disorder in Memory Care Unit: 12
GDS score of Tenant #1: 7
GDS score threshold for memory care unit: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jacque Kreber | Executive Director | Confirmed finding of propped open exit door on 08/25/21 and signed Plan of Correction letter |
| Deb Dixon | Program Coordinator | Recipient of Plan of Correction letter |
Inspection Report — Aug 18, 2021
Enforcement
Date: Aug 18, 2021
Visit Reason
This citation was issued following a survey conducted from August 18 to August 25, 2021, regarding compliance with life safety and structural safety requirements. The facility self-reported an incident of elopement by Tenant #1 on August 13, 2021.
Findings
The facility failed to maintain an operating alarm system on the dementia unit exit door, which was routinely propped open and disabled. Additionally, the courtyard gate intended to secure the memory care unit was left unlocked, allowing Tenant #1 to leave the courtyard unsupervised, though no injuries occurred.
Violations (2)
481—69.32(231C) Life safety—emergency policies and procedures and structural safety requirements: The program failed to ensure the exit door in the dementia unit had an operating alarm system at all times. Staff were observed disabling the alarm and propping the door open, compromising resident safety.
481—69.35(231C) Structural requirements: The program failed to keep the courtyard off the memory care unit safe and secure. The gate was left unlocked after landscaping work, allowing Tenant #1 to elope through the unsecured gate.
Report Facts
Fine amount: 2000
Inspection Report — Jan 8, 2020
Renewal
Date: Jan 8, 2020
Visit Reason
The recertification visit was conducted to determine compliance with certification requirements for the Assisted Living Program for People with Dementia.
Findings
The program failed to ensure that staff received the required eight hours of dementia-specific education within 30 days of employment for 2 of 3 staff reviewed, as evidenced by record reviews and interviews.
Violations (1)
Program failed to ensure staff received eight hours of dementia-specific education within 30 days of employment for 2 of 3 staff reviewed.
Report Facts
Number of tenants without cognitive disorder: 1
Number of tenants with cognitive disorder: 8
Number of staff reviewed: 3
Number of staff not completing required training within 30 days: 2
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