Deficiencies per Year
12
9
6
3
0
Unclassified
Inspection Report
Complaint Investigation
Deficiencies: 2
Dec 18, 2024
Visit Reason
The inspection was conducted as a complaint investigation to review compliance with medication orders and staffing adequacy following concerns raised.
Findings
The facility failed to document adherence to a physician's ordered nutritional treatment for a resident and had insufficient staffing to respond promptly to emergency call lights, with recorded response times of 17 to 37 minutes.
Complaint Details
Complaint inspection triggered by concerns regarding medication orders and staffing response times; substantiation status not stated.
Deficiencies (2)
| Description |
|---|
| Failure to document following physician's ordered treatment of a high-protein nutritional shake for Resident #1. |
| Insufficient staffing leading to excessive emergency call light response times of 21, 17, and 37 minutes. |
Report Facts
Emergency call light response times: 21
Emergency call light response times: 17
Emergency call light response times: 37
Weight loss: 20
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Crissy Freese | Administrator | Named as facility administrator |
| Laura Ashford | Survey Team Leader | Named as survey team leader for complaint inspection |
Inspection Report
Deficiencies: 3
Jun 13, 2023
Visit Reason
The inspection was a Provisional Status Inspection conducted to evaluate compliance with regulatory requirements at Brookdale Spring Meadows.
Findings
The inspection identified three core issues: lack of administrator review documentation on incident reports, unsecured oxygen tanks in resident rooms, and chemicals not locked in storage in laundry rooms.
Deficiencies (3)
| Description |
|---|
| 10 incident reports had no documentation of administrator review or corrective action to avoid reoccurrence; repeat citation from 1/19/2023 |
| Unsecured oxygen tanks found in Resident #1 and Resident #2 rooms during facility tour |
| Both laundry rooms had chemicals out and not locked in storage during facility tour |
Report Facts
Incident reports reviewed: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Elicia Ruiz | Administrator | Named as facility administrator in relation to lack of documentation on incident reports |
| Markland Noelle | Survey Team Leader | Led the Provisional Status Inspection |
Inspection Report
Complaint Investigation
Deficiencies: 9
Jan 19, 2023
Visit Reason
The inspection was conducted as a complaint investigation triggered by concerns related to staffing, medication errors, and emergency room visits at Brookdale Spring Meadows.
Findings
The investigation found numerous deficiencies including inadequate staffing levels, conflicting staff schedules, multiple medication errors including late administration and incorrect dosages, missing incident reports for confirmed incidents, delayed emergency call responses, unsecured medication storage, and improper medication handling by unqualified staff.
Complaint Details
The complaint investigation substantiated multiple issues including inadequate staffing, medication errors, missing incident reports, and delayed emergency responses.
Deficiencies (9)
| Description |
|---|
| Inadequate staffing with only one caregiver and one medication technician on certain shifts; administrator unresponsive to calls; staff schedules do not reflect actual hours worked. |
| Missing incident reports for confirmed incidents and medication errors, including residents sent to emergency room without documentation. |
| 187 emergency call response times greater than 10 minutes, with some delays up to over 50 minutes. |
| Unlocked cabinet containing resident medications with no key available to lock it. |
| Medication errors including incorrect dosing of Clonazepam and 208 medications given late, some over 4 hours late. |
| Medication organizers being set up by medication technicians not authorized by law. |
| Resident sent home with another resident's medication; no incident report or notification to doctor documented. |
| Resident's blood sugar not checked and insulin given late resulting in emergency room visit; no evidence of reporting to practitioner. |
| No record of destruction of unused half portions of Clonazepam tablets as required. |
Report Facts
Administrator call attempts with no response: 17
Residents sent to emergency room: 5
Emergency call response delays over 10 minutes: 187
Emergency call response delays 21-30 minutes: 43
Emergency call response delays 31-40 minutes: 11
Emergency call response delays 41-50 minutes: 7
Emergency call response delays over 50 minutes: 5
Medications given late: 208
Incorrect Clonazepam doses given: 16
Resident blood sugar level: 458
Inspection Report
Complaint Investigation
Deficiencies: 1
Feb 26, 2020
Visit Reason
The inspection was conducted as a complaint investigation to address concerns related to food service practices at the facility.
Findings
The surveyor observed several bowls of starters including fruit, yogurt, and lettuce left uncovered on trays in the main dining room during lunch service. Although staff moved the bowls to containers of ice, the starters remained uncovered for the duration of the lunch service.
Complaint Details
The visit was triggered by a complaint, and the inspection focused on food service practices. Substantiation status is not stated.
Deficiencies (1)
| Description |
|---|
| Bowls of starters (fruit, yogurt, lettuce) were left uncovered on trays in the main dining room during lunch service. |
Inspection Report
Renewal
Deficiencies: 2
Jan 13, 2017
Visit Reason
The inspection was conducted as a renewal inspection of the assisted living facility to assess compliance with staffing and resident service plan regulations.
Findings
The inspection found that while each resident has a Personal Service Plan serving as both needs assessment and service plan, there was no documentation that direct care staff signed off on reviewing these plans. Additionally, the Personal Service Plan documents lacked emergency contact numbers and resident practitioner information.
Deficiencies (2)
| Description |
|---|
| No documentation of direct care staff signing off as having reviewed individual resident service plans. |
| Resident service plans did not include emergency contact numbers or resident practitioner information. |
Inspection Report
Renewal
Deficiencies: 3
Jan 8, 2016
Visit Reason
The inspection was conducted as a renewal inspection of the Brookdale Spring Meadows facility to assess compliance with regulatory standards.
Findings
The inspection found that in 5 of 12 resident files reviewed, the Resident Needs Assessment was not dated, making it unclear if it was completed prior to admission. Additionally, the facility did not meet life safety code requirements regarding door locking mechanisms in resident apartments and common bathrooms.
Deficiencies (3)
| Description |
|---|
| Resident Needs Assessment (RNA) was not dated in 5 of 12 resident files, preventing determination if assessment was done prior to admission. |
| Doors inside one-bedroom apartments are not single motion doorknobs as required by NFPA 101 Life Safety Code. |
| Common use bathrooms on both floors have deadbolt locking mechanisms, which are not permitted as these bathrooms are accessible to residents. |
Report Facts
Resident files reviewed: 12
Resident files with undated RNA: 5
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