Inspection Reports for Aegis Living Queen Anne Rodgers Park

The Department of Social and Health Services conducted a full and complaint investigation at the assisted living facility to assess compliance and address alleged deficiencies.

The licensee failed to monitor and evaluate one resident’s pain issue, placing the resident at risk for diminished quality of life. This deficiency is recurring, having been cited multiple times in previous years.

The visit was complaint-related and the deficiency was substantiated, resulting in a civil fine of $700.00.

The inspection and complaint investigation were conducted due to a complaint regarding a resident who developed a pressure wound that worsened from Stage 2 to Stage 3, leading to hospitalization.

The facility was found non-compliant with several licensing requirements including failure to update resident assessments, incomplete negotiated service agreements, unsafe medication administration practices, failure to monitor and document medication refusals, inadequate nursing delegation, poor skin management leading to a pressure wound, inconsistent food temperature monitoring, unsecured toxic chemicals accessible to residents, and failure to properly monitor residents' well-being including pain management.

The complaint involved a resident whose pressure wound worsened from Stage 2 to Stage 3, leading to hospitalization. The investigation found multiple deficiencies related to wound care, medication administration, and resident safety.

The Office of the State Fire Marshal conducted a fire safety inspection at the facility on 09/16/2024.

Multiple fire safety violations were observed including blocked electrical panels, combustible materials near sprinklers, door latches not functioning, missing inspection paperwork, damaged fire extinguishers, and unsecured gas tanks. The facility was disapproved due to these deficiencies.

The Department completed a complaint investigation of the Assisted Living Facility on 08/14/2024 following complaint number 140421 regarding missed medications and medication refill issues.

The investigation found that the facility failed to document repeated attempts to refill multiple medications for a resident, placing residents at risk. Infection control practices were in place with no failed practice identified. A failed provider practice was identified and citation(s) were written.

The complaint alleged a named resident missed medications multiple times due to medication unavailability, lack of notification to the legal representative, and no attempts to contact the physician for refills. The investigation substantiated failure to document refill attempts but found no failed practice in infection control.

The inspection was conducted as an unannounced on-site complaint investigation following allegations that a resident called for help with toileting and no one responded, and staff told the resident to use a brief and would clean up later because they were busy.

The investigation substantiated that a staff caregiver told the resident she was busy and the resident could be incontinent in the brief, returning approximately 34 minutes later to assist and change the brief. The facility terminated the staff member and provided staff training. The facility failed to ensure one caregiver had completed the required 70 hours of Basic Long Term Care training, placing residents at risk of harm.

The complaint was substantiated. The named resident called for help with toileting and no one came. Staff told the resident to use a brief and would clean up later because they were busy. The caregiver returned 34 minutes later to assist and change the brief. The facility terminated the staff member and provided training.

The Department of Social and Health Services completed a complaint investigation at the assisted living facility due to concerns about resident care, specifically related to skin condition monitoring and reporting.

The licensee failed to identify, monitor, evaluate, and take action in response to changes in a resident's skin condition, resulting in a large, infected unstageable wound without proper nursing care or medical treatment. Additionally, the facility failed to implement policies regarding skin management and reporting significant changes in the resident's condition.

Complaint investigation conducted on February 27, 2024, substantiated by findings of failure to monitor and report changes in a resident's skin condition leading to serious wound development.

The inspection was conducted as an unannounced on-site complaint investigation regarding allegations of negligent care leading to a pressure wound, failure to notify the resident's physician or legal representative, and inadequate medical treatment at the Assisted Living Facility.

The investigation found that the facility failed to properly assess, monitor, and treat a resident's pressure wound, did not notify the physician or legal representative timely, and failed to follow policies regarding wound care and reporting changes in condition. These failures contributed to the resident developing a large, infected, unstageable pressure wound that led to hospitalization and death.

The complaint alleged that a named resident developed a pressure wound due to negligent care, the facility failed to notify the resident's physician or legal representative, did not provide adequate medical treatment beyond ointment, and the resident may not have been receiving adequate nourishment or fluids. The complaint was substantiated with citations issued.

The Office of the State Fire Marshal conducted a fire protection inspection at the facility to assess compliance with fire safety codes and regulations.

Multiple fire safety deficiencies were identified, including broken electrical covers, unlatched fire doors, unsecured oxygen tanks, and missing documentation for quarterly inspections and fire/smoke damper testing.

The Department completed a follow-up inspection of the Assisted Living Facility on 05/26/2023 to verify correction of previously cited deficiencies.

The follow-up inspection found no deficiencies and confirmed that the facility meets the Assisted Living Facility licensing requirements. Previous deficiencies related to staff CPR training and tuberculosis skin testing were corrected.

The Department of Social and Health Services completed a follow-up visit to impose civil fines based on uncorrected deficiencies previously cited related to staff training and testing compliance.

The facility failed to ensure required CPR training for one staff member and two-step tuberculosis skin testing for two staff members, placing 97 residents at risk. These deficiencies were previously cited and remain uncorrected.

The visit was a follow-up inspection of the Assisted Living Facility to verify correction of previously cited deficiencies related to monitoring residents' well-being and safety checks.

The follow-up inspection found no deficiencies and confirmed that the facility meets the Assisted Living Facility licensing requirements. The prior complaint investigation found that the facility failed to respond to motion alert sensors and conduct scheduled safety checks, contributing to a resident fall with injury.

The complaint investigation was substantiated, finding that the facility failed to provide care with monitoring according to the assessment and negotiated service agreement at the time of a resident fall. The resident's motion sensors were not responded to and the 11:00 PM safety check was not done, resulting in a fall with fractured ribs and spine injury.