Inspection Reports for Brown Deer Place

The inspection was conducted as a complaint investigation and review of regulatory insufficiencies related to complaints #124468-C, #127787-C, and incident #125841-I.

The program failed to have complete policies and procedures for incident reporting, medication administration, service plans, documentation, and food safety. Multiple incidents lacked proper documentation, medication administration was not consistently recorded, and food safety protocols were not fully followed. Staff training and service plan updates were also deficient.

The investigation was related to complaints #124468-C and #127787-C and incident #125841-I. There were no regulatory insufficiencies identified related to complaint #125118-C.

The inspection was conducted as a complaint investigation into allegations related to medication administration and potential abuse at Brown Deer Place, an assisted living program for people with dementia.

The investigation found that staff failed to follow medication administration policies, including giving a tenant (Tenant #1) more Risperidone medication than prescribed and storing medications in unlocked areas accessible to tenants. Staff also failed to report suspected abuse promptly. Tenant #1 was subjected to chemical restraints without proper safeguards, and staff behavior toward the tenant was inappropriate.

The complaint investigation was triggered by allegations that Staff A administered higher doses of Risperidone than prescribed to Tenant #1 and failed to report the medication errors and suspected abuse in a timely manner. The investigation substantiated these concerns, leading to Staff A's termination and re-education of all staff.

The inspection was conducted as part of the investigation of Complaint #123059-C regarding regulatory compliance at the assisted living program.

The program failed to ensure that the service plan was signed and dated for 1 of 4 tenants reviewed (Tenant 2). The service plan for Tenant 2 was unsigned and undated since admission.

Investigation of Complaint #123059-C found failure to ensure signed and dated service plans for Tenant 2.

The inspection was conducted as a complaint investigation into multiple complaints (#115147-C and #116487-C) regarding the assisted living program for people with dementia at Brown Deer Place.

The investigation found that the program failed to produce detailed incident reports for 2 of 6 discharged tenants and failed to ensure service plans addressed the needs of current and discharged tenants. No regulatory insufficiencies were cited for other complaints investigated.

No regulatory insufficiencies were cited during the investigation into Complaint #116587-C, Incident #117795-I, Complaint #117824-C, or Complaint #118690-C. Regulatory insufficiencies were cited during the investigation into Complaint #115147-C and Complaint #116487-C.

The inspection was conducted to investigate complaints #112945-C and #114783-C and to conduct a recertification visit for compliance with certification of a Dedicated Dementia Specific Assisted Living Program.

The Program failed to follow established policies related to incident report completion, medication administration by qualified staff, consistent medication administration as prescribed, timely nurse delegation training, proper service plan updates and signatures, dementia-specific training within 30 days of hire, dependent adult abuse training within six months, and ensuring drivers had appropriate licenses. No regulatory insufficiencies were found related to complaint #114420-C.

The inspection included investigation of complaints #112945-C and #114783-C. No regulatory insufficiencies were cited related to complaint #114420-C.

The inspection was conducted as part of an investigation into Incident #104684-I involving an alleged theft reported by the family of a discharged tenant.

The program failed to follow established policies and procedures regarding the completion of incident reports related to the alleged theft of checks from a discharged tenant. An incident report was not completed despite the incident being reported and investigated.

The visit was complaint-related due to an alleged theft incident involving Tenant C1. The complaint was substantiated by the finding that no incident report was completed as required.

The inspection was a recertification visit to determine compliance with certification of an Assisted Living Program for People with Dementia.

The inspection found multiple regulatory insufficiencies related to staff training and background checks, including failure to provide required dependent adult abuse training, incomplete criminal and abuse background checks prior to employment, failure to submit evaluations for staff with criminal histories, and deficiencies in dementia-specific education and hands-on training for staff.

The inspection was conducted as a complaint investigation into multiple complaints (#91579-C, #94972-C) and an incident (#95191-I), as well as an onsite infection control survey and investigation of Complaint #92892-C.

The program failed to adequately meet the treatment needs of one former tenant (Tenant C6) with significant wounds and ulcers, failed to complete an initial assessment for a recently admitted tenant (Tenant #2), and failed to update service plans for four tenants (C1, C6, #7, #9) as their needs changed. No regulatory insufficiencies were cited during the infection control survey or investigation of Complaint #92892-C.

The investigation was triggered by complaints #91579-C, #94972-C, and incident #95191-I. Complaint #92892-C was also investigated but no regulatory insufficiencies were found. The complaint investigation found failures in treatment adequacy, assessment completion, and service plan updates.

Investigation into Complaint #85619-C at an Assisted Living Program for People with Dementia.

No regulatory insufficiencies were cited during the complaint investigation.

Investigation into Complaint #85619-C found no regulatory insufficiencies.

The visit was conducted to investigate Complaint #84095-C at the Assisted Living Program for People with Dementia.

The investigation of Complaint #84095-C did not result in any regulatory insufficiencies.

Complaint #84095-C was investigated and found not substantiated as no regulatory insufficiencies were identified.

The visit was a recertification inspection to determine compliance with certification for a Dedicated Dementia Specific Assisted Living Program.

No regulatory insufficiencies were cited during the recertification visit for the Assisted Living Program for People with Dementia.

The inspection was conducted as a plan of correction following investigations of incidents #70770-I and #70951-I at the assisted living program.

No regulatory insufficiencies were cited during the investigations of the incidents mentioned.

Recertification conducted to determine compliance with certification for an Assisted Living Program.

No regulatory insufficiencies were cited during the recertification inspection of the Assisted Living Program.

Investigation of Incident #63811-I at Brown Deer Place, an assisted living facility with a dementia-specific program.

No regulatory insufficiencies were cited during the investigation of the incident.

Investigation of Incident #63811-I found no regulatory insufficiencies.

The visit was conducted as a Final Recertification Monitoring Evaluation Report to determine compliance with certification for an Assisted Living Program at Hawthorne Inn at Windmill Pointe.

Regulatory insufficiencies were noted in the areas of program policies and procedures and service plans. Specifically, medication administration policies were not consistently followed, and service plans were not individualized to tenant needs and preferences.

The inspection was conducted as a complaint/incident investigation following allegations related to tenant falls, staff duties outside scope of practice, staffing shortages, and deficiencies in service plans, food service, and record checks at Hawthorne Inn at Windmill Pointe.

The investigation found regulatory insufficiencies in staffing, service plans, food service, and record checks. A tenant fall was investigated and assessed appropriately with no noted regulatory insufficiencies in that area. The program was assessed a $500 civil penalty for failure to perform required record checks.

The complaint investigation included allegations of a tenant fall without assessment, staff performing duties outside their scope of practice, staffing shortages, and incomplete service plans. The tenant fall was found to be appropriately handled with no regulatory insufficiency. No staff were found to have performed duties outside their scope. Staffing was deemed sufficient. Some service plans were incomplete or unsigned. Food service staff lacked required training. Record checks were incomplete, leading to a civil penalty.

The inspection was conducted as a final complaint/incident investigation following allegations related to staff not answering call lights or turning them off without responding, and complaints about smells on the unit.

No regulatory insufficiencies were identified. Staff responded promptly to call lights, and there was no evidence of staff injuring tenants or turning off call lights without answering. No unpleasant smells or misuse of sprays were detected during the investigation.

The complaint alleged that staff did not answer call lights or turned them off without answering, and that there were unpleasant smells on the unit with only a spray used. The investigation found no substantiated regulatory insufficiencies related to these allegations.

The inspection was conducted as a Final Complaint/Incident Investigation and Recertification Monitoring Evaluation following a complaint that a tenant was found on the floor and subsequently diagnosed with a fractured hip.

The investigation found no regulatory insufficiencies related to the incident of the tenant found on the floor. However, regulatory insufficiencies were noted regarding the primary van driver's license validity and staff criminal history background checks.

The complaint alleged a tenant was found on the floor, was responsive and in no distress, but was later diagnosed with a fractured hip after being transported to a hospital. The tenant passed away several days later. The complaint investigation included interviews with staff and review of incident reports and tenant records. The complaint was not substantiated as a regulatory insufficiency.

An on-site monitoring evaluation was conducted at Hawthorne Inn at Windmill Pointe to review the Plan of Correction and assess compliance with regulatory requirements.

The program did not receive any regulatory insufficiencies during this certification period. However, a regulatory insufficiency was noted regarding the inconsistent completion of 90 day health reviews for tenants.

An on-site monitoring evaluation was conducted at Hawthorne Inn to review the Plan of Correction in response to the Recertification Monitoring Evaluation Report and to assess compliance with regulatory requirements.

The program had several regulatory insufficiencies including inconsistent medication administration documentation, incomplete nurse review documentation, and lack of a first aid kit in the transportation vehicle. Tenant satisfaction was generally positive with no substantiated regulatory insufficiencies during the certification period.

An on-site monitoring evaluation revisit was conducted at Hawthorn Inn on April 12, 2005, as part of a re-certification monitoring evaluation with conditional certification.

The program had received multiple insufficiencies related to occupancy agreements, tenant evaluations, service plans, medications, staffing, and record checks from a prior January monitoring visit. Several regulatory insufficiencies were noted, including failure to assess cognitive status of some tenants, incomplete service plans, medication order documentation issues, lack of caregiver skills documentation, and failure to obtain criminal and adult abuse history checks prior to hire. Plans of correction were outlined for these deficiencies.

The visit was a re-certification monitoring evaluation conducted to assess compliance with Iowa assisted living program regulations and to evaluate tenant care and program operations.

The monitoring evaluation identified multiple regulatory insufficiencies including improper signing of occupancy agreements, inadequate tenant evaluations by non-professionals, incomplete tenant documentation, failure to update service plans timely, medication administration errors, lack of proper nurse reviews, insufficient staff training documentation, and missing employee dependent adult abuse record checks.

No substantiated complaints during this certification period.