Inspection Reports for
Country Manor Memory Care

Complaint #130478-C, Complaint #131093-C, Complaint #131499-C

The program failed to provide adequate and appropriate care, treatment, and services to tenants, including medication administration, service plan accuracy, nurse reviews, and documentation. Multiple deficiencies were identified related to tenant rights, medications, evaluations, service plans, nurse reviews, and tenant documentation.

The program failed to ensure medication and treatments were administered as prescribed to one tenant. Specifically, wound care orders were not followed correctly, medication changes were not implemented timely, and some prescribed medications were not administered.

The inspection included investigation of complaints #125899-C and #126002-C. The complaints involved aggressive behavior by Tenant #1, including hitting staff and other tenants, and failure of staff to complete detailed incident reports. The tenant was hospitalized after an altercation. The complaint was substantiated as evidenced by multiple findings related to incident reporting and tenant evaluations.

The facility was found to have multiple regulatory insufficiencies related to incident reporting, evaluation of tenants, service plans, nurse reviews, and life safety emergency policies. Deficiencies included failure to complete detailed incident reports, failure to include witness statements, failure to complete evaluations prior to occupancy, failure to update service plans timely, failure to conduct nurse reviews every 90 days, and failure to have operating door alarms connected to each exit door.

The visit was triggered by Complaint #114635-C. The complaint involved medication administration and tenant care issues. The hospice nurse provided wound care orders that were not implemented or discontinued as required. The Executive Director confirmed not receiving wound orders from the hospice nurse. The cardiologist recommended amputation of a tenant's toe due to wound complications.

The investigation found deficiencies related to medication administration, evaluation of tenants, and service plans. Specific issues included failure to administer medications as ordered, incomplete evaluations after significant changes in tenant condition, and failure to update service plans to reflect tenant needs.

No regulatory insufficiencies were cited during the investigation into Incident #111401-1, but regulatory insufficiencies were cited during the investigations into Complaints #114550-C and #114551-C.

The program failed to provide appropriate care to 1 of 5 discharged tenants, specifically Tenant C5, who was diagnosed with Alzheimer's and had medication and documentation deficiencies. The program also failed to administer medication properly to Tenant C5 and did not document health care visits and medication administration as required.

The report includes investigations into multiple complaints (#109854-C, #110767-C, #107888-C, #107954-C, #109955-C, #110978-C) and an incident (#110283-I). No regulatory insufficiencies were cited during the investigation of Complaint #109854-C, Complaint #110767-C, and Incident #110283-I. Deficiencies were cited during investigations of other complaints.

The program failed to follow its policies and procedures regarding tenant care, including sexual behavior management, emergency transfers, tenant rights, staffing adequacy, staff training, background checks, and individualized service plans. Several tenants' needs were not properly identified or addressed, and supervision was insufficient.

The investigation involved complaints #100368-C, #100369-C, #100403-C, #102661-C, #106548-C and incidents #103873-I, #102385-I, #102453-I. No regulatory insufficiencies were cited for complaints #100368-C, #100369-C, #100403-C, #102661-C. Deficiencies were cited during investigation of complaint #106548-C and incidents #102385-I and #102453-I.

No regulatory insufficiencies were found for some complaints, but deficiencies were cited related to failure to follow established program policies and procedures for two tenants, and failure to follow narcotic protocols for one tenant, including missing narcotics and inconsistent narcotic counts.

Investigation into Incident #97334-I, Incident #98432-I, Complaint #97302-C, and Complaint #97536-C found no regulatory insufficiencies.

No regulatory insufficiencies were cited during the investigation of the incidents and complaints.

The visit was complaint-related involving Incident #96229-I and Complaints #96943-C and #96955-C. The complaints involved inappropriate sexual behavior between tenants with dementia and medication administration errors. The sexual relationship between tenants was not fully disclosed to legal representatives, and medication errors included extra doses and missing medications.

The program failed to follow policies regarding sexuality in dementia care, including inadequate communication with legal representatives about tenant intimacy. Medication administration errors occurred, including an extra dose of Melatonin given to a tenant and discrepancies in medication counts. Evaluations and service plans were not completed or updated timely in response to significant changes in tenant behavior.

The visit was complaint-related involving Complaints #93240-C, #93988-C and #94640-C.

Multiple regulatory insufficiencies were identified including failure to follow established policies and procedures related to infection control, incident reporting, and resident care. Specific findings included improper nebulizer use with a COVID-19 positive tenant, failure to include witness statements in incident reports, inadequate care leading to severe injury and hospitalization of a tenant, insufficient staffing to prevent elopement, incomplete nurse delegations, incomplete background checks, failure to document nurses' notes by exception, incomplete service plans, failure to complete nurse reviews for COVID-19 positive tenants, failure to note physician orders with time, date and signature, failure to complete required visual checks, and structural issues including a damaged fence and a malfunctioning exit door.

Investigations related to complaints #93240-C, 93988-C, and 94640-C.

The facility failed to provide adequate and appropriate care to Tenant #1, who was found on the floor with severe wounds and exposed tendons, resulting in hospitalization and death. The facility also failed to complete required background checks for several staff prior to employment. Additionally, the facility failed to maintain the building's courtyard fence, which allowed Tenant #2 to elope.

Complaint #91827-C was investigated. The complaint was substantiated based on findings of medication errors and inadequate staff training related to diabetes care for Tenant #1.

The investigation found regulatory insufficiencies in tenant rights and staffing. Specifically, the program failed to ensure adequate care and treatment for a tenant with diabetes, including medication administration errors and insufficient staff training on insulin administration and blood sugar monitoring.

Complaint #91827-C

The facility failed to ensure adequate and appropriate care for Tenant #1, who experienced low blood sugar incidents due to improper insulin administration by Staff A. The registered nurse failed to ensure that uncertified staff were properly trained to meet the needs of tenants with diabetes.

Complaint visit conducted 11/18/19 - 11/19/19 regarding Incident #86493-I involving Tenant #1 eloping from the facility and sustaining injuries. The complaint was substantiated based on interviews, record reviews, and observations.

The program failed to consistently provide adequate services to meet tenant needs, resulting in an elopement incident where Tenant #1 was found outside the facility with injuries. The service plan did not include the tenant's exit-seeking behavior, and the courtyard door was found propped open multiple times, allowing unauthorized exit.