Inspection Reports for
Country Crest Assisted Living

The visit was triggered by an incident report involving Resident 1 who was found on the floor with pain and diagnosed with a fracture. The complaint was investigated and no deficiencies were cited.

The investigation found that Resident 1 was not always compliant with wearing the prescribed immobilizer brace after a fracture diagnosis. The facility updated the care plan to include more hands-on assistance and use of mobility aids. No deficiencies were cited during this visit.

The complaint involved an unwitnessed incident where Resident 2 allegedly hit Resident 1 in the head with a pumpkin. Resident 1 had a bump on the head, EMS was called, but the family refused hospital evaluation. The incident was reported to police and long-term care ombudsman. No further incidents were found.

The investigation found no further incidents between the residents involved, and no deficiencies were cited during the visit. The facility implemented measures to prevent recurrence, including increased supervision and medication review.

The complaint involved an incident where Resident 1 grabbed Resident 2 by the shoulder and exhibited erratic driving behavior during an outing. The facility responded by reporting to Adult Protective Services, police, and the ombudsman. The complaint was investigated during the visit.

The investigation found that Resident 1 became angry and physically grabbed Resident 2 during an outing, causing distress. The facility reported the incident to Adult Protective Services, local police, and the ombudsman. Both residents moved out of the facility shortly after. No deficiencies were cited as a result of the visit.

The complaint alleged that staff did not meet training requirements and that resident files were not properly stored. Both allegations were found unsubstantiated after investigation.

The investigation found the allegations unsubstantiated. Staff training requirements were met as verified by competency forms, and resident files were properly secured in a locked business office. No deficiencies were cited.

The facility has corrected previously cited deficiencies including air conditioner repair, flooring replacement, sewage repair, pest control, flood damage repair in the elevator room, and floor cleanliness. No new deficiencies were issued during this visit.

The visit was complaint-related based on two incident reports involving resident falls resulting in fractures. The incidents were investigated and substantiated with detailed findings on each resident's fall and injury circumstances.

The investigation found that Resident 1 sustained a fractured sacrum after multiple falls and unmanaged pain, and Resident 2 sustained a left hip fracture after a fall due to an unlocked wheelchair. The facility plans to conduct fall prevention training with staff and submit a fall prevention plan. No deficiencies were cited during this visit.

The facility was found to be clean, well-maintained, and in good repair with no deficiencies cited. All required safety inspections and drills were up to date, and medications and food storage were properly managed.

The meeting confirmed that despite multiple lawsuits against Pacifica Senior Living and related entities, there was no financial impact on the properties, residents, or staff of the company. Management communicated that Pacifica Senior Living was no longer managing the communities, and there were no vendor issues or pending suits against the Pacifica entities.

The visit was triggered by a complaint related to a resident elopement incident. The complaint was investigated and no deficiencies were cited.

The investigation found that Resident 1 had walked out of the memory care unit and was outside for about 10 minutes before being escorted back inside by another resident and staff. The facility conducted an elopement drill and increased staff checks to prevent recurrence. No deficiencies were cited during this visit.

The Licensing Program Analyst served an order of immediate exclusion effective 11/14/2024, indicating that Staff 1 (S1) cannot work, be present, or have contact with clients in any licensed facility. The facility confirmed that S1 is currently not working there.

The visit was triggered by a death report complaint related to Resident 1's fall and subsequent care. The report included details of the resident's injuries, hospital stays, and care transitions. Resident 1 was DNR and allowed a natural death at the skilled nursing facility.

The investigation detailed Resident 1's falls, injuries, hospitalizations, and eventual death. No deficiencies were cited as a result of the visit.

The complaint included allegations that staff were not following proper infection control requirements, staff left residents unattended, and the facility did not have sufficient emergency food supplies. All allegations were determined to be unsubstantiated based on observations, interviews, and document reviews.

All allegations were found to be unsubstantiated after investigation. Observations and document reviews showed compliance with infection control, adequate resident supervision despite staffing shortages, and sufficient emergency food supplies.

The visit was triggered by a complaint related to an incident where a Memory Care Resident slipped and fell, resulting in a compression fracture. The resident will not return to the facility and will be admitted to skilled nursing. No deficiencies were substantiated.

The resident was assessed with no immediate injuries noted but complained of hip pain and was transported to a hospital where a compression fracture was diagnosed. No deficiencies were cited during this visit.

The complaint investigation was unsubstantiated. Allegations included staff not responding to resident call buttons and staff not providing residents with food of good quality. Evidence showed the call button system malfunctioned temporarily but was fixed, and food quality issues were related to shared kitchen constraints and menu requirements.

The investigation found that the call button system was malfunctioning on one date but was subsequently repaired, and staff response times were within an acceptable range. Regarding food quality, residents generally found the food to be 'OK' with some complaints about tough meat and blandness, but the facility shares a kitchen and menu with a post-acute facility and is working on new menus. Both allegations were unsubstantiated.

The complaint investigation was triggered by allegations that a resident sustained pressure wounds, was left in a soiled diaper for an extended time, and that the facility did not communicate with the authorized representative. After review of medical records, staff interviews, and nursing notes, all allegations were determined to be unsubstantiated.

The investigation found all allegations unsubstantiated, including claims that a resident sustained pressure wounds while in care, was left in a soiled diaper for an extended period, and that the facility failed to communicate with the authorized representative. No deficiencies were cited.

The facility was found to be in substantial compliance with no immediate health, safety, or personal rights violations observed. No deficiencies were cited as a result of the inspection.

Investigation concerned an incident where Resident 1 expressed suicidal ideation and attempted to throw themselves down stairs. EMS and police were notified; resident refused hospital transport. Facility took measures to ensure resident safety and ongoing care.

The facility responded by moving the resident to a secure memory care unit with 1 to 1 care, updating the care plan, adjusting medications, and arranging behavioral and therapy dog visits. No deficiencies were cited during the investigation.

The complaint alleged staff mismanaged a resident’s medication. The resident provided a medication change order that did not come from the neurologist. The nurse contacted the resident’s GP who advised holding the medication until verification from the neurologist. The resident was eventually hospitalized and the neurologist made the appropriate medication change. The allegation was unsubstantiated due to lack of preponderance of evidence.

The investigation included interviews with the administrator, physician, resident, and staff, as well as review of relevant documents. It was found that although the allegation may have occurred, there was insufficient evidence to substantiate the claim, and the findings were unsubstantiated.

No immediate health, safety, or personal rights violations were observed during the tour of the facility. The facility was found to be in substantial compliance with infection control requirements and no deficiencies were cited.

Investigation of an incident where a resident was found unresponsive in the Memory Care Unit patio area due to heat and sun exposure, requiring medical attention. Additional interviews and investigation were noted as necessary.

The Licensing Program Analyst conducted staff and resident interviews as part of the investigation. No deficiencies were cited during this visit.