Inspection Reports for
Braley Care Homes Memory Care Facility

Deficiencies were cited related to failure to update service plans after significant resident condition changes and failure to ensure residents received medications as ordered and documented. Additionally, inadequate housekeeping and maintenance issues were observed in the facility.

The facility failed to maintain a safe, sanitary, and accident-free environment due to a damaged ADA shower stall. The administrator acknowledged the deficiency and planned corrective action.

Investigation of Complaint #38951 on 05/27/25 with census 15. The complaint was substantiated regarding failure to report major incidents and failure to maintain confidentiality of resident medical records.

The Licensee failed to report a major incident involving a resident sent to the emergency room due to decreased oxygen levels and failed to maintain confidentiality of resident medical records by sending confidential records with the wrong resident to the hospital. The complaint was substantiated.

The facility was found deficient in ensuring medications had diagnoses listed on medication administration records for residents, and in maintaining adequate housekeeping and maintenance of the physical environment. Several maintenance issues were noted including damaged carpet, missing bathroom fixtures, and unclean sinks. The Administrator and Registered Nurse failed to ensure compliance with medication administration rules.

The facility failed to maintain a safe, sanitary, and accident-free living environment due to a broken ADA shower chair base that had broken through the fiberglass wall of the second bathroom shower.

The facility failed to ensure transfer summaries included functional needs/service plans for three residents, did not complete an annual tuberculosis screen on time for one resident, and had inadequate housekeeping and maintenance issues such as damaged carpet, missing bathroom fixtures, and unclean areas.

The facility failed to ensure proper release and documentation of a deceased resident's belongings to the estate administrator or executor. Additionally, housekeeping and maintenance deficiencies were noted, including damaged carpet, missing bathroom fixtures, and unclean areas.

The facility failed to ensure the emergency disaster preparedness plan was reviewed and updated annually since 2017, and there were deficiencies in housekeeping and maintenance including damaged carpet, missing bathroom fixtures, and unclean sinks. These findings were discussed with the Facility Administrator.

The facility was found deficient in medication administration practices, including failure to ensure medications and treatments were administered as required by law, improper transcription of physician orders, missed medication doses, and inadequate supervision of medication assistive personnel. Additionally, housekeeping and maintenance deficiencies were noted from an earlier behavioral health survey.

Deficiencies were cited during the annual licensure survey conducted from August 7-10, 2017. A follow-up survey on October 2, 2017, with a census of 16, confirmed that the deficiencies were corrected.

The facility failed to maintain hot water temperatures within the required range of 105°F to 115°F in two hallway bathrooms and two private resident room bathrooms, with temperatures observed at 122°F and 118°F respectively. Maintenance corrected the issue by lowering the temperatures by 2:30 p.m. on the day of the survey.

Complaint investigation conducted December 31, 2012 - January 4, 2013, with follow-up on February 13, 2013. Substantiation status not explicitly stated.

The investigation found multiple deficiencies including failure to administer medications as ordered for 12 of 15 residents, incomplete and inaccurate medication administration records, failure to ensure physician orders were signed within 30 days, inadequate monitoring of residents following incidents, and poor housekeeping and maintenance conditions in the facility.

The complaint investigation was triggered by concerns about medication administration and documentation. The complaint was substantiated based on findings of missing prescriptions, incomplete MARs, and inadequate staff training.

The investigation found multiple deficiencies including failure to maintain proper prescriptions and medication administration records for seven residents, missed medication doses, inadequate documentation of verbal orders, insufficient housekeeping and maintenance, and lack of staff training on oxygen unit use and medication administration.

The facility failed to maintain a safe environment, including issues such as an energized but inoperative ceiling light, lack of ground fault protection on an electrical outlet near water, use of a hot portable heater, and accumulation of dust in a ceiling vent. The administrator was cited for these deficiencies and corrective actions were planned.

The facility was found deficient in multiple areas including employee training, personnel records, contract completeness, resident health care standards, medication administration, verbal order signatures, activity documentation, and dietary services. Housekeeping and maintenance issues were also noted, including damaged carpet and missing bathroom fixtures.

The facility was found deficient in multiple areas including failure to complete timely nurse aide abuse registry checks prior to hiring, inadequate housekeeping and maintenance, failure to post required resident rights and house rules, incomplete and outdated resident service plans, failure to conduct timely quarterly reviews of medication assistive personnel, lack of posted monthly activity calendars, failure to weigh residents monthly and report unplanned weight changes, unsafe storage of portable oxygen tanks, and unsecured storage of toxic and hazardous materials accessible to confused residents.

The facility was found deficient in ensuring timely quarterly reviews of approved medication assistive personnel (AMAP), proper documentation of credentials and training, and in providing required documentation of physician notification for residents' unplanned weight changes. Additionally, housekeeping and maintenance issues were noted from earlier observations.