Inspection Report
Re-Inspection
Deficiencies: 0
Dec 16, 2024
Visit Reason
An offsite revisit survey was conducted to verify correction of all previous deficiencies cited on 2024-11-18.
Findings
All deficiencies have been corrected as of the compliance date of 2024-12-11 and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Report Facts
Previous deficiencies cited: 1
Inspection Report
Re-Inspection
Census: 89
Deficiencies: 8
Nov 18, 2024
Visit Reason
The inspection was a Re-Licensure Survey with complaint investigations 185986 and 190261 conducted at an assisted living facility.
Findings
The survey identified multiple deficiencies including failure to complete functional capacity screening and negotiated service agreements on admission, lack of proper signatures on service agreements, improper labeling of over-the-counter and sample medications, failure to monitor and document food temperatures in memory care units, unsafe food storage practices, and inadequate infection control related to sanitary conditions in food service.
Complaint Details
The visit included complaint investigations 185986 and 190261.
Severity Breakdown
SS=D: 4
SS=E: 4
Deficiencies (8)
| Description | Severity |
|---|---|
| Failure to complete Functional Capacity Screen on or before admission for one resident. | SS=D |
| Failure to complete initial Negotiated Service Agreement at admission for one resident. | SS=D |
| Failure to ensure all involved parties signed the Negotiated Service Agreement for one resident. | SS=D |
| Failure to ensure residents' full names were on all over-the-counter medications and containers. | SS=E |
| Failure to include required information and verification on sample medication packaging for one resident. | SS=D |
| Failure to monitor and document food temperatures in the Memory Care units to ensure proper preparation and serving temperatures. | SS=E |
| Failure to store food under safe and sanitary conditions; food items in walk-in cooler were not labeled, sealed, or dated properly. | SS=E |
| Failure to ensure sanitary conditions for food service by not documenting hot water temperature and chemical sanitizer strength daily in the Memory Care unit kitchen. | SS=E |
Report Facts
Census: 89
Residents sampled: 3
Memory Care residents: 13
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nurse B | Administrative Nurse | Reported on Functional Capacity Screen and Negotiated Service Agreement completion and signatures. |
| Administrative Staff J | Administrative Staff | Reported sending Negotiated Service Agreement to resident's legal representative and spouse. |
| Dietary Staff C | Dietary Staff | Acknowledged lack of food temperature logs and need for proper food storage labeling. |
| Dietary Staff D | Dietary Staff | Reported food temperature monitoring practices in Memory Care. |
| Dietary Staff E | Dietary Staff | Reported food preparation and temperature monitoring in kitchen and Memory Care. |
| Certified Medication Aide F | Certified Medication Aide | Observed medication labeling issues during medication cart inspection. |
| Certified Medication Aide G | Certified Medication Aide | Observed medication labeling issues during medication cart inspection. |
| Certified Medication Aide H | Certified Medication Aide | Observed medication labeling issues and use of 'stock' medications. |
| Certified Medication Aide I | Certified Medication Aide | Observed multiple over-the-counter medications without full resident names. |
Inspection Report
Plan of Correction
Deficiencies: 0
Nov 14, 2024
Visit Reason
The document addresses findings from a Re-Licensure Survey with complaint investigations 185986 and 190261 conducted at the Assisted Living Facility on 11/14/24 and 11/18/24.
Findings
The citations represent the findings from the Re-Licensure Survey and complaint investigations conducted on the specified dates. The document is a Plan of Correction responding to those findings.
Complaint Details
The visit included complaint investigations numbered 185986 and 190261.
Report Facts
Complaint investigation numbers: 185986
Complaint investigation numbers: 190261
Inspection Report
Abbreviated Survey
Deficiencies: 0
Oct 16, 2023
Visit Reason
The abbreviated survey was conducted in response to complaints #183303 and #182260 at the assisted living facility.
Findings
The survey resulted in a finding of no deficiency citations.
Complaint Details
The survey was complaint-related for complaints #183303 and #182260 and found no deficiencies.
Inspection Report
Plan of Correction
Deficiencies: 0
Oct 16, 2023
Visit Reason
The abbreviated survey was conducted on 10/16/23 in response to complaints #183303 and #182260 at the assisted living facility.
Findings
The survey resulted in a finding of no deficiency citations.
Inspection Report
Follow-Up
Deficiencies: 0
Jun 29, 2023
Visit Reason
An offsite revisit survey was conducted on 06/29/23 to verify correction of all previous deficiencies cited on 06/07/23.
Findings
All deficiencies cited in the previous inspection have been corrected as of the compliance date of 06/28/23, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Inspection Report
Re-Inspection
Deficiencies: 0
Jun 29, 2023
Visit Reason
An offsite revisit survey was conducted to verify correction of all previous deficiencies cited on 2023-06-07.
Findings
All deficiencies cited in the previous inspection have been corrected as of the compliance date 2023-06-28, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Inspection Report
Follow-Up
Deficiencies: 0
Jun 29, 2023
Visit Reason
An offsite revisit survey was conducted on 06/29/23 to verify correction of all previous deficiencies cited on 06/07/23.
Findings
All deficiencies cited in the previous inspection have been corrected as of the compliance date of 06/28/23, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Inspection Report
Re-Inspection
Deficiencies: 0
Jun 29, 2023
Visit Reason
An offsite revisit survey was conducted to verify correction of all previous deficiencies cited on 2023-06-07.
Findings
All deficiencies cited in the previous inspection have been corrected as of the compliance date of 2023-06-28, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Report Facts
Previous deficiencies cited: 1
Inspection Report
Re-Inspection
Census: 65
Deficiencies: 8
Jun 7, 2023
Visit Reason
Re-Licensure survey with complaint investigations 177868, 177487, 175966, and 170044 for an Assisted Living Facility conducted on 06/07/23 and 06/08/23.
Findings
The facility was found deficient in multiple areas including incomplete negotiated service agreements for residents, failure to review and revise service agreements after significant changes, lack of licensed nurse identification on health care service plans, improper labeling of over-the-counter medications, inadequate handling of sample medications, lack of electronic medical record policies, incomplete documentation of incidents and wounds, and failure to conduct quarterly emergency management plan reviews with all employees and residents.
Complaint Details
The inspection included complaint investigations numbered 177868, 177487, 175966, and 170044.
Severity Breakdown
E: 3
D: 2
F: 3
Deficiencies (8)
| Description | Severity |
|---|---|
| Negotiated Service Agreements lacked descriptions of services, providers, and payment responsibilities for residents R5, R6, and R7. | E |
| Failure to review and revise Negotiated Service Agreements following significant changes in resident condition, specifically for R7 starting Home Health wound care. | D |
| Negotiated Service Agreements did not include the name of the licensed nurse responsible for implementation and supervision of the Health Care Service Plan for residents R5, R6, and R7. | F |
| Over-the-counter medications were not labeled with the resident's full name on both the original package and medication container. | E |
| Failure to properly document receipt, labeling, and resident notification for sample medications, specifically for resident R4. | D |
| Lack of policy addressing protection, safeguarding, confidentiality, and preservation of electronic medical records. | F |
| Failure to document incidents, symptoms, and changes in resident condition, including wound documentation for R7 and medication administration changes for R4. | E |
| Failure to conduct quarterly reviews of the facility's emergency management plan with all employees and residents. | F |
Report Facts
Census: 65
Complaint investigations: 4
Sample residents reviewed: 3
Focused record reviews: 2
Sample medications without proper labeling: 12
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Licensed Nurse C | Acknowledged deficiencies in negotiated service agreements and documentation | |
| Administrative Licensed Nurse B | Reported lack of labeling on over-the-counter medications | |
| Certified Medication Aide D | Observed unlabeled over-the-counter medications | |
| Certified Medication Aide E | Observed unlabeled over-the-counter medications | |
| Administrative Staff A | Reported lack of emergency management plan reviews and policy development |
Inspection Report
Renewal
Deficiencies: 0
Dec 22, 2021
Visit Reason
The licensure resurvey was conducted on 12/20/2021, 12/21/2021, and 12/22/2021 at the assisted living facility to assess compliance for license renewal.
Findings
The survey resulted in a finding of no deficiency citations at the facility.
Inspection Report
Plan of Correction
Deficiencies: 0
Dec 22, 2021
Visit Reason
The licensure resurvey was conducted on 12/20/2021, 12/21/2021, and 12/22/2021 at the assisted living facility.
Findings
The resurvey resulted in a finding of no deficiency citations.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Jul 1, 2020
Visit Reason
The special infection control survey for COVID-19 was conducted at the facility on 07-01-2020.
Findings
The survey resulted in findings of no deficiency citations.
Inspection Report
Re-Inspection
Census: 72
Deficiencies: 3
Jul 2, 2019
Visit Reason
The inspection was a resurvey with complaints #141243 and #133072 conducted over multiple days from 2019-06-19 to 2019-07-02 to assess compliance with regulatory requirements.
Findings
The facility failed to conduct Functional Capacity Screenings (FCS) following significant changes in condition for sampled residents, failed to ensure licensed nurses provided necessary health care services in accordance with FCS and negotiated service agreements, and failed to document incidents including an elopement. Multiple deficiencies were identified related to resident safety and care coordination.
Complaint Details
The resurvey was conducted in response to complaints #141243 and #133072.
Severity Breakdown
Level E: 1
Level D: 2
Deficiencies (3)
| Description | Severity |
|---|---|
| Designated facility staff failed to conduct a Functional Capacity Screening following any significant change in condition for residents #211 and #677. | Level E |
| Administrator failed to ensure licensed nurse provided or coordinated necessary health care services for resident #456 in accordance with Functional Capacity Screening and Negotiated Service Agreement regarding use of a bed assistive device. | Level D |
| Administrator failed to ensure each resident record contained documentation of all incidents, symptoms, and other indications of illness or injury including date, time, action taken, and results for resident #852. | Level D |
Report Facts
Census: 72
Sample size: 6
Dates of inspection: 2019-06-19 to 2019-07-02
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Nurse A | Licensed Nurse | Interviewed and confirmed deficiencies related to Functional Capacity Screening and incident documentation. |
| Licensed Nurse H | Licensed Nurse | Documented multiple resident incidents and behaviors related to resident #211 and #677. |
| Licensed Nurse I | Licensed Nurse | Administered medication and notified director of nurses and family regarding resident #211. |
| Licensed Nurse J | Licensed Nurse | Reported resident found outside and safely returned to unit. |
| Licensed Nurse K | Licensed Nurse | Documented verbal abuse incident involving resident #677. |
| Licensed Nurse G | Licensed Nurse | Received call from police regarding missing resident #852. |
Inspection Report
Re-Inspection
Deficiencies: 3
Dec 28, 2017
Visit Reason
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.
Findings
The report documents that previously cited deficiencies identified by regulation numbers 26-41-204 (a), 26-41-104 (d), and 26-41-207 (b)(5-6)(c) have been corrected as of 12/28/2017.
Deficiencies (3)
| Description |
|---|
| Deficiency related to regulation 26-41-204 (a) |
| Deficiency related to regulation 26-41-104 (d) |
| Deficiency related to regulation 26-41-207 (b)(5-6)(c) |
Inspection Report
Re-Inspection
Census: 90
Deficiencies: 6
Nov 30, 2017
Visit Reason
The inspection was a resurvey conducted over multiple days in November 2017 to assess compliance with previously cited deficiencies at Avita Senior Living at Rolling Hills.
Findings
The facility was found deficient in multiple areas including failure to conduct functional capacity screenings after significant changes in condition, failure to revise negotiated service agreements accordingly, inadequate provision and coordination of health care services for cognitively impaired residents with falls, medication administration errors including delayed administration of prescribed medications, incomplete disaster preparedness reviews with residents and staff, and failure to comply with tuberculosis screening requirements for staff.
Severity Breakdown
SS=D: 3
SS=G: 1
SS=E: 2
Deficiencies (6)
| Description | Severity |
|---|---|
| Failure to conduct Functional Capacity Screen following significant change in condition for resident #300. | SS=D |
| Failure to review and revise Negotiated Service Agreement following significant change in condition for resident #300. | SS=D |
| Failure to ensure licensed nurse provided or coordinated necessary health care services for cognitively impaired residents (#111, #100, #500) with falls/unsteadiness. | SS=G |
| Failure to administer medications in accordance with medical orders and professional standards for resident #300. | SS=D |
| Failure to ensure quarterly review of emergency management plan with residents and staff. | SS=E |
| Failure to comply with tuberculosis screening guidelines for new employees. | SS=E |
Report Facts
Census: 90
Residents sampled: 6
Falls recorded for resident #111: 13
Falls recorded for resident #100: 7
Falls recorded for resident #500: 19
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Licensed nurse A | Interviewed regarding failure to conduct functional capacity screening, medication administration, and tuberculosis screening compliance. | |
| Certified staff J | Interviewed regarding resident #300 transfer assistance and behaviors. | |
| Certified staff K | Interviewed regarding resident #300 transfer assistance and behaviors. | |
| Certified staff L | Interviewed regarding resident care and falls. | |
| Certified staff M | Personnel record reviewed; lacked two-step TB skin test. | |
| Licensed nurse N | Personnel record reviewed; lacked two-step TB skin test. | |
| Administrative staff O | Personnel record reviewed regarding TB screening compliance. |
Inspection Report
Re-Inspection
Deficiencies: 0
Dec 29, 2015
Visit Reason
This revisit inspection was conducted to verify that previously reported deficiencies had been corrected and to document the dates such corrective actions were accomplished.
Findings
All previously cited deficiencies listed by regulation numbers were corrected as of the revisit date, with no uncorrected deficiencies noted.
Report Facts
Deficiencies corrected: 8
Inspection Report
Complaint Investigation
Census: 94
Deficiencies: 8
Dec 2, 2015
Visit Reason
The inspection was a resurvey with investigation of complaint #84254 at an assisted living facility conducted over multiple dates in November and December 2015.
Findings
The investigation found multiple deficiencies including failure to report and investigate resident falls promptly, incomplete functional capacity screenings, lack of negotiated service agreements with required details and signatures, inadequate health care services coordination especially related to fall risks, poor maintenance of resident records, failure to conduct quarterly emergency management plan reviews, and failure to prepare mechanically altered diets and thickened liquids according to medical orders.
Complaint Details
The visit was triggered by complaint #84254 involving failure to report and investigate resident falls and other care deficiencies.
Severity Breakdown
SS=E: 6
SS=F: 2
Deficiencies (8)
| Description | Severity |
|---|---|
| Failure to report and investigate resident falls within 24 hours as required. | SS=E |
| Failure to conduct functional capacity screenings at least annually and after significant changes. | SS=E |
| Failure to develop negotiated service agreements with required service descriptions and collaboration. | SS=E |
| Failure to ensure signatures on negotiated service agreements by all involved parties. | SS=E |
| Failure to provide or coordinate necessary health care services in accordance with functional capacity and service agreements. | SS=E |
| Failure to maintain resident records according to accepted standards including discharge documentation. | SS=F |
| Failure to conduct quarterly review of emergency management plan with employees and residents. | SS=F |
| Failure to prepare mechanically altered diets and thickened liquids according to medical care provider or licensed dietitian instructions. | SS=E |
Report Facts
Residents sampled: 6
Resident census: 94
Falls recorded: 24
Dates of resident falls: 11
Document
Deficiencies: 0
N087067 POC CUV911
Visit Reason
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Findings
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