Inspection Reports for Daylesford Crossing
1450 Lancaster Ave, Paoli, PA 19301, United States, PA, 19301
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Inspection Report
Complaint Investigation
Census: 83
Capacity: 100
Deficiencies: 1
Mar 20, 2025
Visit Reason
The inspection visit occurred due to a complaint and incident investigation at the facility.
Findings
The facility was found to have a deficiency related to the failure to complete a written cognitive preadmission screening within 72 hours prior to admission to the secured dementia care unit. The submitted plan of correction was accepted and fully implemented.
Complaint Details
The visit was complaint-related and included an incident. The submitted plan of correction was accepted and fully implemented.
Deficiencies (1)
| Description |
|---|
| Failure to complete a written cognitive preadmission screening within 72 hours prior to admission to the secured dementia care unit. |
Report Facts
Residents Served: 83
License Capacity: 100
Capacity: 24
Residents Served: 18
Current Residents: 9
Residents Age 60 or Older: 83
Residents with Mental Illness: 1
Residents with Mobility Need: 33
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Health and Wellness Director | Responsible for assessments and re-education regarding preadmission screening requirements. | |
| Executive Director | Conducted audit of preadmission screening forms and responsible for ongoing compliance. |
Inspection Report
Complaint Investigation
Census: 60
Capacity: 100
Deficiencies: 2
Mar 12, 2025
Visit Reason
The inspection was conducted as a complaint and incident investigation regarding allegations of resident abuse and reporting violations.
Findings
The facility failed to immediately report suspected resident abuse to the local area agency on aging and the Department within required timeframes. Staff involved in the delayed reporting are no longer employed, and re-education and monitoring plans have been implemented.
Complaint Details
The complaint involved allegations that a resident was hit in the head and that the facility delayed reporting this abuse to the appropriate agencies. The allegations were substantiated by the findings of delayed reporting.
Deficiencies (2)
| Description |
|---|
| Failure to immediately report suspected abuse of a resident as required by the Older Adult Protective Services Act. |
| Failure to report the incident to the Department’s personal care home regional office or complaint hotline within 24 hours. |
Report Facts
License Capacity: 100
Residents Served: 60
Secured Dementia Care Unit Capacity: 24
Secured Dementia Care Unit Residents Served: 22
Hospice Current Residents: 8
Residents Age 60 or Older: 60
Residents with Mobility Need: 35
Total Daily Staff: 95
Waking Staff: 71
Inspection Report
Renewal
Census: 75
Capacity: 100
Deficiencies: 12
Oct 7, 2024
Visit Reason
The inspection was conducted as a full, unannounced review for renewal, complaint, and incident reasons at the facility.
Findings
The inspection identified multiple deficiencies including failure to post current license and emergency procedures conspicuously, privacy concerns related to video monitoring, unlocked poisonous materials and medications, inadequate lighting in a resident's bedroom, lack of soap dispensers in secured dementia care unit bathrooms, incomplete fire drill records, non-fire resistant cushions in the smoking area, and medication storage and record-keeping issues. Plans of correction were accepted with proposed completion dates and ongoing compliance monitoring.
Deficiencies (12)
| Description |
|---|
| The home's 2600 regulations book and current license inspection summary, dated 12/28/23, was not posted in a conspicuous and public place in the home. |
| A sign indicated video monitoring in the home, but cameras record and retain footage for 3 to 4 weeks, raising privacy concerns. |
| Lysol Disinfectant Spray was unlocked, unattended, and accessible to residents in the secured dementia care unit, where residents cannot safely use or avoid poisons. |
| Resident in bedroom 112 did not have access to a source of light that can be turned on/off at bedside. |
| The secured dementia care unit's bathrooms located in resident bedrooms did not have a soap dispenser. |
| The home's emergency procedures were not posted in a conspicuous and public place in the home. |
| Fire drill records for multiple dates did not include the exit routes used for evacuation. |
| The home's designated smoking area had cushions present that did not indicate they are fire resistant. |
| Several unlocked, unattended medications were found in Resident #1's and Resident #2's bedrooms; Resident #2 shares a room with a resident unable to self-administer medications. |
| Resident #2's record did not include a current list of medications. |
| Two bottles of spray were unlocked, unattended, and accessible in resident bedroom 112. |
| Four loose pills were found in Resident #1's medicine cabinet. |
Report Facts
License Capacity: 100
Residents Served: 75
Secured Dementia Care Unit Capacity: 24
Secured Dementia Care Unit Residents Served: 15
Current Hospice Residents: 8
Total Daily Staff: 109
Waking Staff: 82
Inspection Report
Complaint Investigation
Census: 69
Capacity: 100
Deficiencies: 0
Dec 28, 2023
Visit Reason
The inspection was conducted as a complaint and incident investigation at the facility.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Complaint Details
The inspection was triggered by a complaint and incident; no deficiencies or citations were found.
Report Facts
License Capacity: 100
Residents Served: 69
Secured Dementia Care Unit Capacity: 19
Secured Dementia Care Unit Residents Served: 12
Hospice Current Residents: 8
Residents Age 60 or Older: 69
Residents with Mobility Need: 36
Inspection Report
Monitoring
Census: 75
Capacity: 100
Deficiencies: 1
Jul 20, 2023
Visit Reason
The inspection was a monitoring visit conducted on July 20, 2023, to review the facility's compliance and the implementation of a previously submitted plan of correction.
Findings
The facility was found to be in compliance with applicable regulations after the plan of correction was fully implemented. A prior deficiency related to incomplete cognitive preadmission screenings for residents in the secured dementia care unit was corrected.
Deficiencies (1)
| Description |
|---|
| Resident #1 and Resident #2 had incomplete written cognitive preadmission screenings that did not indicate a diagnosis as required for admission to the secured dementia care unit. |
Report Facts
License Capacity: 100
Residents Served: 75
Memory Care Capacity: 24
Memory Care Residents Served: 16
Hospice Residents: 14
Residents with Mental Illness: 3
Residents with Mobility Need: 60
Residents 60 Years or Older: 75
Inspection Report
Monitoring
Census: 75
Capacity: 100
Deficiencies: 1
Jul 20, 2023
Visit Reason
The visit was a monitoring inspection conducted as a partial, unannounced review of the facility on 07/20/2023 to verify compliance and the implementation of a submitted plan of correction.
Findings
The submitted plan of correction was determined to be fully implemented. A deficiency was noted regarding incomplete written cognitive preadmission screenings for two residents admitted to the Secure Dementia Care Unit, which was corrected and followed up with reeducation and auditing plans.
Deficiencies (1)
| Description |
|---|
| Resident #1 and Resident #2 admitted to the Secure Dementia Care Unit had incomplete written cognitive preadmission screenings that did not indicate a diagnosis. |
Report Facts
License Capacity: 100
Residents Served: 75
Capacity: 24
Residents Served: 16
Current Residents: 14
Resident Support Staff: 39
Total Daily Staff: 174
Waking Staff: 131
Residents Age 60 or Older: 75
Residents with Mental Illness: 3
Residents with Mobility Need: 60
Inspection Report
Renewal
Census: 80
Capacity: 100
Deficiencies: 22
May 22, 2023
Visit Reason
The inspection was conducted as part of a renewal, complaint, provisional, and incident review for Daylesford Crossing facility.
Findings
The facility was found to be in compliance overall, but multiple deficiencies were identified related to medication administration errors, staff qualifications and training, safety and emergency preparedness, documentation, and facility maintenance. Plans of correction were submitted and accepted with ongoing monitoring and re-education required.
Deficiencies (22)
| Description |
|---|
| Resident 1 did not receive prescribed medications several times in April 2023 and medication errors were not reported to the department. |
| Direct care staff person A does not have a high school diploma, GED, or active registry status on the Pennsylvania nurse aide registry. |
| Staff person A did not receive orientation on fire safety and emergency preparedness topics on the first day of work. |
| Staff person A did not complete training on resident rights, emergency medical plan, mandatory abuse reporting, and reporting of incidents within 40 hours of work. |
| Direct care staff person B did not receive training in personal care service needs during training year 2022. |
| The home's dumpster was not covered on 5/22/23 at 10:34 am. |
| Exit from the courtyard to the courtyard stairwell was blocked by 2 chairs on 5/23/23 at 10:40 am. |
| Resident 2 did not have a medical evaluation documented on a form specified by the Department. |
| A 2-week menu was not posted in the home on 5/22/23. |
| Staff person B administered medications without proper certification. |
| Resident 4's medications were incorrectly labeled. |
| Morphine was administered to Resident 1 but not signed out on the controlled substance log; glucose readings for Resident 2 were inconsistently documented. |
| Resident 1 refused scheduled medications several times in April 2023 and refusals were not reported to the prescriber. |
| Resident 1 was not administered Morphine Sulfate on several dates as prescribed. |
| Resident 3's prescribed medication was not available in the home on 5/23/23. |
| Medication errors were not reported to the resident, designated person, and prescriber. |
| Staff person B had not completed a Department-approved medication administration course but administered medications. |
| Staff person B administered insulin without completing required diabetes education and competency testing. |
| Resident 5’s preadmission screening form did not include a determination that the resident's needs could be met by the home. |
| Resident 2’s initial assessment did not include an assessment for understanding instructions. |
| Resident 3’s assessment did not mention history of suicide attempt or ideations. |
| Directions for operating the home's locking mechanism were not conspicuously posted near the door to the courtyard exit in the Secure Dementia Care Unit. |
Report Facts
Inspection Dates: 2
Staffing Hours: 126
Waking Staff: 95
License Capacity: 100
Residents Served: 80
Memory Care Capacity: 24
Memory Care Residents Served: 17
Hospice Residents: 12
Residents Age 60 or Older: 80
Residents Diagnosed with Mental Illness: 3
Residents with Mobility Need: 46
Medication Errors: 3
Medication Audits: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Health & Wellness Director | Named in multiple medication error findings, re-education, and compliance monitoring | |
| Executive Director | Named in re-education and compliance monitoring related to staff training and facility safety | |
| Business Office Manager | Responsible for auditing employee files and training compliance | |
| Dining Services Director | Responsible for menu posting compliance | |
| Building Engineer | Responsible for daily audits of dumpster and exit obstructions |
Inspection Report
Renewal
Census: 80
Capacity: 100
Deficiencies: 20
May 22, 2023
Visit Reason
The inspection was conducted as a renewal review combined with complaint, provisional, and incident reasons, including unannounced full inspections on 05/22/2023 and 05/23/2023.
Findings
Multiple deficiencies were identified including medication errors, staff qualification issues, incomplete staff training, improper medication administration, labeling errors, storage and documentation problems, failure to follow prescriber's orders, incomplete resident assessments, and safety concerns such as obstructed egress and missing instructions on locking devices. Plans of correction were accepted and implemented by 08/08/2023.
Deficiencies (20)
| Description |
|---|
| Resident 1 did not receive prescribed medications several times in April 2023 and medication errors were not reported to the department. |
| Direct care staff person A does not have a high school diploma, GED, or active registry status on the Pennsylvania nurse aide registry. |
| Staff person A did not receive orientation on fire safety and emergency preparedness topics on first day of work. |
| Staff person A did not complete training within 40 scheduled working hours on resident rights, emergency medical plan, abuse reporting, and incident reporting. |
| Direct care staff person B did not receive training in personal care service needs during training year 2022. |
| The home's record of direct care staff training does not include the date dementia training was completed for staff person B and the content of the training. |
| On 5/22/23, the home's dumpster was not covered. |
| On 5/23/23, the exit from the courtyard to the courtyard stairwell was blocked by 2 chairs. |
| Resident 2 did not have a medical evaluation documented on a form specified by the Department. |
| On 5/22/23, a 2-week menu was not posted in the home. |
| Staff person B administered medications without proper certification and training compliance. |
| Resident 4's medications were incorrectly labeled with pharmacy labels not matching prescriber orders. |
| Medication administered to Resident 1 was not signed out on the controlled substance log; glucose readings for Resident 2 were inconsistently documented. |
| Resident 1 refused to take scheduled medications several times in 2023 and refusals were not reported to the prescriber. |
| The home did not follow prescriber's orders for Residents 1, 2, and 3 regarding medication administration and availability. |
| Medication errors were not immediately reported to the resident, designated person, and prescriber for Residents 1, 2, and 3. |
| Resident 5's preadmission screening form did not include a determination that the resident's needs could be met by the home. |
| Resident 2's initial assessment did not include an assessment for understanding instructions. |
| Resident 3's additional assessment did not mention history of suicide attempt or ideations after significant change of condition. |
| Directions for operating the home's locking mechanism were not conspicuously posted near the door to the courtyard exit in the Secure Dementia Care Unit. |
Report Facts
License Capacity: 100
Residents Served: 80
Memory Care Capacity: 24
Memory Care Residents Served: 17
Hospice Current Residents: 12
Residents Diagnosed with Mental Illness: 3
Residents with Mobility Need: 46
Residents Age 60 or Older: 80
Total Daily Staff: 126
Waking Staff: 95
Inspection Report
Complaint Investigation
Census: 78
Capacity: 100
Deficiencies: 1
Feb 6, 2023
Visit Reason
The inspection visit on 02/06/2023 was conducted as a complaint investigation and included a fine. The visit was unannounced and included a follow-up on a plan of correction submission.
Findings
The inspection found a medication administration record violation where a resident's medication was not documented as administered at the correct time. The submitted plan of correction was accepted and later determined to be fully implemented.
Complaint Details
The visit was complaint-related and included a fine. The plan of correction was accepted on 02/15/2023 and fully implemented by 04/06/2023.
Deficiencies (1)
| Description |
|---|
| Resident #1’s medication administration record did not indicate that Levothyroxine was administered at the correct time on 1/19/23. |
Report Facts
License Capacity: 100
Residents Served: 78
Secured Dementia Care Unit Capacity: 24
Secured Dementia Care Unit Residents Served: 16
Hospice Residents: 9
Residents with Mobility Need: 25
Inspection Report
Complaint Investigation
Census: 72
Capacity: 100
Deficiencies: 0
Jan 23, 2023
Visit Reason
The inspection was conducted as a complaint and incident investigation at the facility.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Complaint Details
The inspection was complaint-related with no deficiencies found; substantiation status is not explicitly stated.
Report Facts
License Capacity: 100
Residents Served: 72
Secured Dementia Care Unit Capacity: 24
Secured Dementia Care Unit Residents Served: 17
Hospice Residents: 9
Residents Age 60 or Older: 72
Residents with Mobility Need: 41
Total Daily Staff: 113
Waking Staff: 85
Inspection Report
Monitoring
Census: 73
Capacity: 100
Deficiencies: 0
Dec 12, 2022
Visit Reason
The visit was a monitoring inspection conducted by the Pennsylvania Department of Human Services, Bureau of Human Service Licensing, to assess compliance at the facility.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Report Facts
Residents Served: 73
License Capacity: 100
Secured Dementia Care Unit Capacity: 24
Secured Dementia Care Unit Residents Served: 20
Hospice Current Residents: 7
Residents Age 60 or Older: 73
Residents Diagnosed with Mental Illness: 1
Residents with Mobility Need: 38
Resident Support Staff Hours: 0
Total Daily Staff Hours: 111
Waking Staff Hours: 83
Inspection Report
Enforcement
Census: 74
Capacity: 100
Deficiencies: 1
Nov 18, 2022
Visit Reason
The inspection was conducted due to an incident, as part of a licensing inspection on multiple dates in November and December 2022, resulting in violations found related to abuse and regulatory noncompliance.
Findings
The facility was found to have violations related to abuse, specifically a staff member stealing a resident's credit card and attempting unauthorized purchases. The Department revoked the facility's certificate of compliance and issued a first provisional license pending correction of violations.
Severity Breakdown
Class II: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| A resident was neglected and financially abused by a staff member who stole a credit card and attempted unauthorized purchases. | Class II |
Report Facts
Fine Per Resident Per Day: 5
Calculated Fine Per Day: 370
License Capacity: 100
Residents Served: 74
Secured Dementia Care Unit Capacity: 24
Secured Dementia Care Unit Residents Served: 16
Current Hospice Residents: 6
Residents Age 60 or Older: 74
Residents with Mobility Need: 37
Inspection Report
Complaint Investigation
Census: 75
Capacity: 100
Deficiencies: 6
Oct 13, 2022
Visit Reason
The inspection was conducted as a complaint and incident investigation at Daylesford Crossing on October 13, 2022.
Findings
Multiple violations were found including failure to report medication errors, abuse/mistreatment of a resident, improper medication administration, unsanitary medication storage, failure to follow medication procedures, and incomplete training records for medication technicians.
Complaint Details
The visit was complaint-related and included substantiated findings of abuse and medication errors. Staff person A was terminated due to abuse and medication administration violations.
Deficiencies (6)
| Description |
|---|
| Failure to report medication errors to the Department within 24 hours. |
| Resident mistreatment by staff including rough handling and verbal frustration. |
| Improper medication administration procedures including leaving medications unattended and not ensuring residents took medications. |
| Unsanitary practice of using tape on narcotic medication blister packs to hold medication after foil was broken. |
| Failure to follow proper medication procedures including documentation and accountability for discontinued narcotics. |
| Medication administration training records lacked trainer name, documentation of successful completion, and date of recertification. |
Report Facts
Census at Inspection: 75
License Capacity: 100
Fine Calculation: 370
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff person A | Named in findings for medication errors and resident mistreatment; terminated. | |
| Staff person B | Observed staff person A mistreating resident and intervened. | |
| Staff person C | Failed to follow medication procedures for narcotics accountability. | |
| Executive Director | Responsible for re-education and oversight of corrective actions. | |
| Health and Wellness Director | Responsible for auditing compliance with medication administration and abuse prevention. | |
| Charge Nurse | Responsible for auditing medication and incident reporting compliance. |
Inspection Report
Follow-Up
Census: 73
Capacity: 100
Deficiencies: 1
Sep 26, 2022
Visit Reason
The inspection visit was conducted as a renewal inspection with a follow-up to verify the submission and implementation of a plan of correction.
Findings
The submitted plan of correction related to a direct care staff qualification violation was fully implemented and accepted. The facility demonstrated compliance with staffing qualifications and corrective actions.
Deficiencies (1)
| Description |
|---|
| Direct care staff person A does not have a high school diploma, GED, or active registry status on the Pennsylvania nurse aide registry. |
Report Facts
License Capacity: 100
Residents Served: 73
Secured Dementia Care Unit Capacity: 20
Secured Dementia Care Unit Residents Served: 17
Hospice Residents: 6
Resident Age 60 or Older: 73
Residents with Mobility Need: 36
Total Daily Staff: 109
Waking Staff: 82
Inspection Report
Monitoring
Census: 71
Capacity: 100
Deficiencies: 0
May 19, 2022
Visit Reason
The visit was an unannounced partial inspection conducted as an incident and monitoring review of the facility.
Findings
No regulatory citations or deficiencies were identified during the inspection.
Report Facts
Total Daily Staff: 105
Waking Staff: 79
License Capacity: 100
Residents Served: 71
Secured Dementia Care Unit Capacity: 24
Secured Dementia Care Unit Residents Served: 20
Residents Age 60 or Older: 71
Residents with Mobility Need: 34
Inspection Report
Follow-Up
Census: 71
Capacity: 100
Deficiencies: 2
Mar 17, 2022
Visit Reason
The inspection was a partial, unannounced visit conducted due to an incident at the facility, with a follow-up type of Plan of Correction (POC) submission.
Findings
The inspection found a physical abuse incident involving a staff member and a resident, resulting in the staff member's termination. Additionally, the staff member lacked required dementia care training for working in the secured dementia care unit (SDCU). The facility implemented corrective actions including staff re-education and ongoing audits to ensure compliance.
Deficiencies (2)
| Description |
|---|
| Resident was physically abused by staff person A, who grabbed the resident by the neck, slapped them, and threatened further harm. |
| Staff person A did not have the required 6 hours of dementia care and services training to work in the secured dementia care unit. |
Report Facts
Residents Served: 71
License Capacity: 100
Secured Dementia Care Unit Capacity: 24
Secured Dementia Care Unit Residents Served: 17
Total Daily Staff: 106
Waking Staff: 80
Residents with Mobility Need: 35
Residents Age 60 or Older: 71
Inspection Report
Follow-Up
Census: 73
Capacity: 100
Deficiencies: 6
Jan 14, 2022
Visit Reason
The inspection was a partial, unannounced visit triggered by an incident at the facility, with follow-up reviews conducted to verify the implementation of the submitted plan of correction.
Findings
The facility was found to have multiple violations related to abuse, incident reporting, treatment of residents, storage of poisonous materials, furniture and equipment repair, and operable bedside lighting. Staff person A was terminated due to abuse incidents. The facility implemented corrective actions including staff re-education, audits, and repairs. Follow-up inspections confirmed the plan of correction was fully implemented.
Deficiencies (6)
| Description |
|---|
| Failure to report an incident to the Department within 24 hours as required. |
| Resident #1 was verbally and physically abused by staff A, including yelling, grabbing, kicking, and kicking away the walker. |
| Resident #2 was treated without dignity and respect, being yelled at aggressively by staff A. |
| Poisonous materials (toothpaste and skin barrier cream) were unlocked and accessible to resident #1 who was not assessed as capable of safely using them. |
| Closet door handle missing and toilet paper holder broken in resident room #6A. |
| Resident #1 did not have access to an operable bedside lamp. |
Report Facts
License Capacity: 100
Residents Served: 73
Secured Dementia Care Unit Capacity: 24
Residents Served in Dementia Unit: 18
Total Daily Staff: 118
Waking Staff: 89
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Named in findings related to verbal and physical abuse of residents and incident reporting violations. |
Inspection Report
Complaint Investigation
Census: 73
Capacity: 100
Deficiencies: 6
Jan 14, 2022
Visit Reason
The inspection was conducted as a complaint investigation due to an incident involving alleged abuse and mistreatment of residents at the facility.
Findings
The inspection found multiple violations related to abuse, treatment of residents, and safety issues including physical and verbal abuse by staff, improper storage of poisonous materials, and maintenance deficiencies. Staff involved were terminated and corrective actions including re-education and audits were implemented.
Complaint Details
The complaint involved allegations of physical and verbal abuse by staff member 'Staff A' towards residents #1 and #2. The abuse included yelling, physical force, and neglect. Staff A was terminated following the incident. The facility was required to re-educate staff and implement audits to ensure compliance and prevent recurrence.
Deficiencies (6)
| Description |
|---|
| Staff yelled at resident #1 to stand up and physically forced the resident, resulting in the resident falling and being kicked by staff. |
| Resident #1 was physically and verbally abused by staff, including kicking the walker away as the resident crawled. |
| Resident #2 was addressed in an aggressive tone and verbally abused by staff during incontinence care. |
| Poisonous materials such as toothpaste and skin barrier cream were unlocked and accessible to resident #1 who was not assessed as capable of safe use. |
| Closet door handle missing and toilet paper holder broken in resident room #6A. |
| Resident #1 did not have access to an operable lamp or source of lighting at bedside. |
Report Facts
Residents served: 73
License capacity: 100
Residents served in secured dementia care unit: 18
Capacity of secured dementia care unit: 24
Residents served in secured dementia care unit (May 2022 inspection): 20
Residents served (May 2022 inspection): 71
Inspection Report
Renewal
Census: 68
Capacity: 100
Deficiencies: 8
Jul 29, 2021
Visit Reason
The inspection was a renewal inspection conducted on 07/29/2021 and 07/30/2021 to review compliance with licensing requirements for Daylesford Crossing.
Findings
The inspection identified multiple deficiencies including delays in refunding charges after resident deaths, lack of operable bedside lamps for some residents, insufficient emergency water supply, unclear pet policy, medication storage and counting discrepancies, incomplete medication administration course documentation, and incomplete preadmission screening forms. Plans of correction were accepted and implemented for all deficiencies.
Deficiencies (8)
| Description |
|---|
| Delays in refunding previously paid charges to residents' estates within 30 days after death and removal of personal belongings. |
| Residents 6 and 7 did not have access to a source of light that can be turned on/off at bedside. |
| The home did not maintain at least a 3-day supply of emergency drinking water; had only 162 gallons instead of required 201 gallons. |
| The home pet policy rules did not specify what pets are permitted on the premises. |
| Medication storage procedures were deficient: discrepancy in narcotic tablet count for Resident 7 with 20 tablets in cart but 19 recorded on MAR. |
| Medication procedures deficient: improper documentation and counting of controlled substances for Resident 7. |
| Annual medication administration practicum for staff person B was incomplete and missing required signatures and documentation. |
| Resident 8 preadmission screening form was incomplete and missing required determinations and sections. |
Report Facts
Residents served: 68
License capacity: 100
Residents served in secured dementia care unit: 18
Capacity of secured dementia care unit: 24
Current hospice residents: 10
Residents requiring emergency water: 67
Required emergency water gallons: 201
Available emergency water gallons: 162
Total daily staff: 105
Waking staff: 79
Resident with mobility need: 37
Medication tablets discrepancy: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| staff person A | Named in medication storage and medication procedures deficiencies related to narcotic tablet count discrepancies. | |
| staff person B | Named in deficiency related to incomplete annual medication administration practicum documentation. |
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