Inspection Reports for
Alderbrook Village

The facility was found deficient in multiple areas including failure to ensure signatures on negotiated service agreements, lack of nurse identification for health care services, missing assessments for safe self-administration of 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.

All deficiencies previously reported were corrected and the corrective actions were completed as of the revisit date.

The facility failed to conduct required functional capacity screenings following significant changes in resident conditions, failed to develop and update negotiated service agreements appropriately, lacked identification of licensed nurses responsible for health service plans, failed to train medication aides on delegated insulin administration, failed to label over-the-counter medications with resident names, failed to conduct required emergency preparedness training, failed to store food and chemicals safely, and failed to comply with tuberculosis screening requirements for residents and new employees.

The visit was complaint-related due to allegations of resident elopement and neglect. The complaint was substantiated with findings that resident R1 eloped on 09/16/23, and the facility failed to report, investigate, and document the incident properly.

The facility failed to prevent resident elopement, did not report the incident timely, lacked proper investigation and documentation, failed to provide adequate health care services for wandering behaviors, and had medication storage and documentation deficiencies. Additionally, the facility failed to post required electronic monitoring notices.

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

The facility had multiple deficiencies including failure to keep the most recent survey report available to residents, incomplete functional capacity screenings, missing negotiated service agreements, lack of updated nurse assignments, incomplete medication aide competencies, improper medication labeling, incomplete employee background checks, inadequate emergency plans, unsafe food storage, infection control lapses, and unsecured chemicals.

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

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

The facility was found deficient in multiple areas including failure to post emergency telephone numbers, lack of annual self-administration medication assessments for residents, improper delegation and documentation of medication administration tasks, failure to label over-the-counter medications with resident names, inadequate disaster and emergency preparedness training, failure to provide therapeutic diets as ordered, noncompliance with infection control policies including tuberculosis screening, and unsecured hazardous chemicals.

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 resident #10 were not properly documented by licensed nursing staff.

The complaint investigation involved allegations of neglect when resident #2 eloped outside in cold weather and was found in a bush with inadequate clothing and no timely nurse assessment. The investigation found failures in reporting, assessment, documentation, and corrective actions.

The facility failed to prevent neglect when a resident was found eloped outside in freezing temperatures without proper assessment or documentation. The administrator also failed to report and investigate the neglect allegation timely and thoroughly. Documentation of incidents and follow-up assessments were incomplete.

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

The facility failed to meet multiple regulatory requirements including admission policies, negotiated service agreements, health care services coordination, medication administration, and supervision by a registered nurse. Deficiencies were found in documentation, monitoring of outside services, medication management, and incident reporting.

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

This inspection was a resurvey following complaint #101770.

The facility failed to administer medications according to medical orders for one resident, failed to label over-the-counter medications with residents' full names, lacked criminal background checks in employee records for three certified staff, failed to conduct quarterly emergency management plan reviews with residents, and did not provide weekly menu plans to residents.