Inspection Reports for Alderbrook Village

An offsite revisit survey was conducted to verify correction of all previous deficiencies cited on 2025-02-06.

All previously cited deficiencies have been corrected as of the compliance date of 2025-02-26, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.

The inspection was a licensure resurvey conducted on 02/05/2025 and 02/06/2025 to assess compliance with state regulations for the facility.

The facility was found deficient in multiple areas including failure to ensure all individuals involved in the development of negotiated service agreements signed the agreements, lack of nurse identification responsible for health care services in agreements, failure to perform required assessments for residents self-administering medication, incomplete documentation of medication administration responsibilities, missing criminal background checks for newly hired staff, and failure to conduct quarterly reviews of the emergency preparedness plan with residents.

The document is a plan of correction submitted in response to findings from a licensure resurvey conducted on February 5 and 6, 2025.

The plan of correction addresses citations identified during the licensure resurvey of the facility conducted on February 5 and 6, 2025.

The inspection was an abbreviated survey conducted in response to complaints regarding resident elopement and staff neglect at Alderbrook Village LLC.

The facility failed to prevent a resident (R1) from eloping, failed to report the elopement timely, failed to investigate the incident properly, and failed to implement adequate interventions for exit-seeking behaviors. Additional deficiencies included incomplete functional capacity screening documentation, unsigned negotiated service agreements, lack of coordinated health care services for wandering residents, expired insulin pens without proper dating, incomplete incident documentation, and failure to post required electronic monitoring notices.

The complaint investigation was triggered by an incident on 09/16/2023 when resident R1 eloped from the facility and was found 0.2 miles away at a local restaurant. The restaurant staff called the police. The facility failed to report the elopement timely, failed to investigate, and failed to implement interventions to prevent further elopements.

Revisit for correction order 23-SCCC-217 conducted on 10/03/23 and 10/04/23 to verify compliance with previously cited deficiencies.

The facility failed to conduct required functional capacity screenings and develop or revise negotiated service agreements for residents exhibiting significant changes. Deficiencies included lack of licensed nurse identification on service plans, incomplete training and competency for medication aides, improper labeling of over-the-counter medications, inadequate emergency preparedness training, unsafe food storage practices, failure to comply with tuberculosis screening guidelines for residents and employees, and unsecured chemicals and oxygen cylinders compromising resident safety.

The document is a plan of correction related to an abbreviated survey conducted for complaints #183163 at the facility on 10/03/23 and 10/04/23.

The plan of correction addresses findings from an abbreviated survey triggered by complaints at the facility conducted on the specified dates.

The visit was complaint-related, referencing complaints #183163.

The inspection was a resurvey with complaints #181812, 181837, 181946, 182136, and 182552 at an assisted living facility conducted on 09/07/23 and 09/11/23.

The facility was found deficient in multiple areas including failure to make the most recent survey report available to residents, incomplete functional capacity screenings, missing negotiated service agreements and revisions, lack of updated nurse assignments in service agreements, inadequate training and competencies for medication aides, improper labeling of medications, incomplete employee records, deficient emergency preparedness plans, unsafe food storage practices, infection control noncompliance, failure to comply with tuberculosis screening guidelines, and unsecured chemicals posing safety risks.

The inspection was a resurvey with complaints #181812, 181837, 181946, 182136, and 182552.

This document is a Plan of Correction addressing findings from a resurvey with complaints #181812, 181837, 181946, 182136, and 182552 conducted at the assisted living facility on 09/07/23 and 09/11/23.

The Plan of Correction corresponds to deficiencies identified during the resurvey related to multiple complaints at the assisted living facility.

The visit was complaint-related involving multiple complaints (#181812, 181837, 181946, 182136, and 182552).

An offsite revisit survey was conducted to verify correction of all previous deficiencies cited on 2022-09-07.

All deficiencies cited in the previous inspection have been corrected as of the compliance date 2022-09-20, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.

The document is a Plan of Correction submitted in response to findings from the licensure resurvey conducted on 09/06/22 at the facility.

The Plan of Correction addresses citations identified during the licensure resurvey of the facility on 09/06/22.

The inspection was a licensure resurvey conducted to assess compliance with regulatory requirements for the facility.

The facility was found deficient in multiple areas including failure to include the licensed nurse's name on residents' negotiated service agreements, failure to provide quarterly emergency management plan reviews to staff and residents, and failure to maintain compliance with tuberculosis testing guidelines for residents and newly hired employees.

This revisit inspection was conducted to verify that previously reported deficiencies have been corrected and to document the date such corrective actions were accomplished.

All previously cited deficiencies were corrected as of the revisit date, with completion dates documented for each regulation cited.

Licensure resurvey with complaint #158614 and #150666 conducted over four days from 12/28/2020 to 12/31/2020.

The facility was found deficient in multiple areas including failure to post emergency phone numbers, lack of annual self-administration medication assessments for residents, inadequate delegation and documentation of medication administration tasks, improper labeling of over-the-counter medications, failure to provide disaster and emergency preparedness training quarterly, failure to provide therapeutic diets as ordered, incomplete infection control policies compliance, and unsecured chemicals posing safety risks.

The inspection was conducted as a licensure resurvey with complaints #158614 and #150666.

The special infection control survey for COVID-19 was conducted at the facility on 7-9-2020.

The survey resulted in findings of no deficiency citations.

The visit was a revisit for notice of assessment 19-31 of the assisted living facility conducted on 3/19/19 and 3/20/19.

The facility failed to ensure that resident #10's record contained documentation of all incidents, symptoms, and other indications of illness or injury including the date, time of occurrence, action taken, and results of the action. Multiple incidents involving the resident were not documented in the record as required.

This report documents a revisit inspection to verify that previously reported deficiencies have been corrected and to confirm the dates such corrective actions were accomplished.

The revisit inspection found that the previously cited deficiencies identified by regulation numbers 26-41-101 (f)(1) and 26-41-101 (f)(3) were corrected as of 03/19/2019.

The inspection was an abbreviated/complaint survey conducted due to complaints #137688 and #137691 at the facility on 1/31/19, 2/4/19, 2/5/19, and 2/6/19.

The facility was found to have neglected resident #2 who was found outside in cold weather, wedged under an air conditioner unit with inadequate clothing and a low body temperature. The licensed nurse failed to assess the resident timely. The administrator failed to report the neglect allegation timely, start and complete an investigation, and submit required reports. Documentation of incidents for resident #2 was incomplete.

The complaint investigation involved allegations of neglect related to resident #2 eloping and being found outside in cold weather without proper clothing and no timely nurse assessment. The neglect was substantiated with findings of immediate jeopardy.

This revisit report documents the correction of previously cited deficiencies at the facility following an earlier survey.

All previously reported deficiencies identified by regulation or Life Safety Code provisions were corrected as of the revisit date.

The inspection was a resurvey with investigation of complaints #115371, #119360, #124270, and #131841 at an assisted living facility.

The facility was found deficient in multiple areas including failure to provide proper admission agreements, incomplete negotiated service agreements, inadequate monitoring of outside services, failure to provide necessary health care services according to plans, lack of documentation for self-administration of medications, improper medication administration practices, lack of RN supervision for LPN, and incomplete documentation of incidents.

The visit was a resurvey with investigation of complaints #115371, #119360, #124270, and #131841.

This is a revisit report completed by a State surveyor to show those deficiencies previously reported that have been corrected and the date such corrective action was accomplished.

All previously reported deficiencies identified by regulation or LSC provision numbers have been corrected as of the revisit date.

The inspection was a resurvey with complaint #101770 conducted on 7-12-16, 7-13-16, 7-18-16, and 7-19-16 to assess compliance with medication administration, staff qualifications, emergency preparedness, dietary services, and other regulatory requirements.

The facility failed to administer medications according to medical orders, specifically missing 11 doses of escitalopram for one resident. Several over-the-counter medications lacked residents' full names on containers. Employee records for three certified staff lacked required criminal background checks. The emergency management plan was not reviewed quarterly with residents, and weekly menu plans were not made available to residents.

The visit was a resurvey following complaint #101770.

The licensure resurvey of the assisted living facility was conducted on 2/11/15 and 2/12/15 to assess compliance for license renewal.

The inspection resulted in no deficiency citations being found at the facility.

This document is a Plan of Correction related to a prior inspection event identified by ASPEN Event ID BGD211 and State ID N018010.

No specific findings or deficiencies are detailed in this document; it serves as a record of the Plan of Correction status and related administrative data.

N018010_DR2567B_2_1.pdf

N018010_DR2567B_3_2.pdf