Inspection Reports for Gardens at Ridgecrest Village
4126 Northwest Blvd., Davenport, IA, 528064264
Back to Facility ProfileInspection Report Summary
The most recent inspection on March 11, 2025, found no deficiencies during the recertification visit and investigation of an incident. Earlier inspections showed a mixed history, with some reports citing deficiencies related primarily to medication administration, staff training, service plan development, and dementia-specific education. Several complaint investigations substantiated issues with tenant care documentation, staffing adequacy, and safety monitoring, including incidents of tenant elopement and medication errors; the facility received civil penalties ranging from $500 to $2,500 in past years. Enforcement actions such as fines were noted, but license suspensions or revocations were not listed in the available reports. The inspection record suggests improvement over time, with the most recent visit showing compliance after previous citations and corrective actions.
Deficiencies (last 15 years)
Deficiencies (over 15 years)
4.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
7% worse than Iowa average
Iowa average: 4.4 deficiencies/yearDeficiencies per year
12
9
6
3
0
Census
Latest occupancy rate
12 residents
Based on a March 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Census over time
Inspection Report
Plan of Correction
Census: 12
Deficiencies: 0
Date: Mar 11, 2025
Visit Reason
The visit was conducted as a recertification visit to determine compliance with certification of an Assisted Living Program for People with Dementia and to investigate Incident #123244-I.
Findings
No regulatory insufficiencies were cited during the investigation of Incident #123244-I or the recertification visit.
Inspection Report
Renewal
Census: 13
Deficiencies: 7
Date: May 24, 2023
Visit Reason
The inspection was a recertification visit to determine compliance with certification of a Dedicated Dementia Specific Assisted Living Program.
Findings
The Program failed to administer medications as ordered, failed to provide adequate nurse delegation training on activities of daily living and service plan tasks, failed to ensure dependent adult abuse training was completed timely, failed to develop individualized service plans reflecting tenant needs, failed to provide food safety training to staff, and failed to ensure dementia-specific education was completed within 30 days of employment for staff.
Deficiencies (7)
Failed to administer medications as ordered, including administering non-prescribed eye drops and missing supplement orders in electronic records.
Failed to provide training on activities of daily living for non-certified staff.
Failed to provide nurse delegated training on service plan tasks including wound care.
Failed to ensure staff completed dependent adult abuse training within six months of employment.
Failed to develop individualized service plans reflecting tenant identified needs and preferences.
Failed to provide orientation and annual in-service training on food safety to staff responsible for food preparation and service.
Failed to ensure staff completed eight hours of dementia-specific education and training within 30 days of employment.
Report Facts
Total census: 13
Number of tenants without cognitive impairment: 2
Number of tenants with cognitive impairment: 11
Number of staff reviewed for training deficiencies: 5
Number of tenants files reviewed for service plans: 3
Number of staff reviewed for dementia training deficiency: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Non-certified staff with incomplete ADL training, delayed dependent adult abuse training, no food safety training, and no dementia-specific education within 30 days. | |
| Staff B | Medication Manager | Failed to have nurse delegated training on wound care, no food safety training, and no dementia-specific education within 30 days. |
| Staff C | Non-certified staff with incomplete ADL training, no food safety training, and no dementia-specific education within 30 days. | |
| Staff D | Non-certified staff with incomplete ADL training, no food safety training, and no dementia-specific education within 30 days. | |
| Staff E | Medication Manager | Failed to have nurse delegated training on wound care and no food safety training. |
| Staff F | Observed administering incorrect eye drops to Tenant #4 and involved in medication error incident. | |
| Assisted Living Director | Interviewed confirming training and service plan deficiencies and corrective actions. |
Inspection Report
Annual Inspection
Census: 8
Deficiencies: 0
Date: Sep 3, 2020
Visit Reason
The inspection was conducted as a recertification to determine compliance with certification for an Assisted Living Program serving people with dementia.
Findings
No regulatory insufficiencies were cited during the onsite infection control survey or the recertification inspection.
Inspection Report
Renewal
Census: 62
Deficiencies: 3
Date: Apr 12, 2018
Visit Reason
The inspection was conducted as a recertification visit to determine compliance with certification for a Dedicated Dementia Specific Assisted Living Program.
Findings
The inspection identified multiple regulatory insufficiencies including failure to obtain required criminal background evaluations for staff, incomplete dependent adult abuse training for staff, and failure to develop individualized service plans reflecting tenants' needs and preferences.
Deficiencies (3)
Criminal, dependent adult abuse, and child abuse record checks were not completed for Staff E, who had a criminal conviction.
Program failed to ensure staff completed dependent adult abuse training within six months of employment for 2 of 6 staff reviewed.
Program failed to develop service plans that reflected tenants' identified needs for 4 of 6 tenants reviewed.
Report Facts
Number of tenants without cognitive disorder: 51
Number of tenants with cognitive disorder: 2
Number of tenants without cognitive disorder: 0
Number of tenants with cognitive disorder: 9
Total Census of Assisted Living Program for People with Dementia: 62
Staff E hire date: Aug 2, 2017
Staff D hire date: Oct 10, 2017
Staff F hire date: Jul 8, 2017
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff E | Named in findings related to criminal background check and employment prohibition | |
| Staff D | Named in findings related to dependent adult abuse training not completed | |
| Staff F | Named in findings related to dependent adult abuse training completed |
Inspection Report
Monitoring
Census: 60
Deficiencies: 1
Date: May 26, 2016
Visit Reason
The visit was conducted as a Final Recertification Monitoring Evaluation to determine compliance with certification for an Assisted Living Program at Oakwood Place.
Findings
A regulatory insufficiency was cited related to structural requirements, specifically the failure to maintain a building that was well-maintained, clean, safe, and sanitary. The dementia unit kitchen lacked a commercial vent hood needed for the preparation of fried foods.
Deficiencies (1)
The program failed to maintain a building that was well-maintained, clean, safe and sanitary; specifically, the dementia unit kitchen did not have a commercial vent hood needed for the preparation of fried foods.
Report Facts
Number of tenants without cognitive disorder in general population: 42
Number of tenants with cognitive disorder in general population: 3
Total population of general population program: 45
Number of tenants without cognitive disorder in dementia-specific program: 1
Number of tenants with cognitive disorder in dementia-specific program: 14
Total population of dementia-specific program: 15
Total census of Assisted Living Program: 60
Date survey completed: May 26, 2016
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Mary K. Harris | Director | Named as facility director in the report address |
| Mary K. Harris | RN Nurse Manager | Signed plan of correction related to the deficiency |
Inspection Report
Complaint Investigation
Census: 53
Deficiencies: 0
Date: Apr 15, 2015
Visit Reason
The inspection was conducted as a complaint/incident investigation regarding the level of care at Oakwood Place AL in Davenport, IA.
Complaint Details
Allegation: Level of Care. Findings: Unsubstantiated. No regulatory insufficiencies were cited during the complaint investigation #51751-C.
Findings
No regulatory insufficiencies were identified. The allegation of level of care was found to be unsubstantiated after review of tenant files, observations, incident reports, policies, and interviews.
Report Facts
Number of tenants without cognitive disorder in General Population Program: 36
Number of tenants with cognitive disorder in General Population Program: 3
Total Population of General Population Program: 39
Number of tenants without cognitive disorder in Dementia-Specific Program: 0
Number of tenants with cognitive disorder in Dementia-Specific Program: 14
Total Population of Dementia-Specific Program: 14
Total census of Assisted Living Program: 53
Inspection Report
Complaint Investigation
Census: 53
Deficiencies: 1
Date: Dec 17, 2014
Visit Reason
The inspection was conducted following a complaint/incident investigation regarding regulatory insufficiency in program policies and procedures at Oakwood Place Assisted Living.
Complaint Details
The complaint investigation was substantiated with findings of regulatory insufficiency in program policies and procedures related to incident reporting and medication administration errors.
Findings
The investigation found that the program failed to follow its policies and procedures related to incident reporting and medication administration, including a medication error involving Tenant #1. There was a breakdown in communication and failure to properly evaluate and mitigate hazards related to medication errors.
Deficiencies (1)
Program policies and procedures, including those for incident reports, were not followed, resulting in a medication error and failure to properly communicate and manage the incident.
Report Facts
Total census of Assisted Living Program: 53
Number of tenants without cognitive disorder in General Population Program: 39
Number of tenants with cognitive disorder in General Population Program: 2
Total population of General Population Program: 41
Number of tenants without cognitive disorder in Dementia-Specific Program: 0
Number of tenants with cognitive disorder in Dementia-Specific Program: 12
Total population of Dementia-Specific Program: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Mary K. Harris | RN Manager | Named in relation to medication error investigation and plan of correction |
| Rose Boccella | Program Coordinator, Adult Services Bureau | Author of cover letter and contact for questions |
Inspection Report
Complaint Investigation
Census: 52
Deficiencies: 0
Date: Jun 5, 2014
Visit Reason
The inspection was conducted as a Final Complaint/Incident Investigation following complaints regarding tenant elopement, medication administration without physician orders, tenant care concerns, and structural issues at Oakwood Place Assisted Living in Davenport, Iowa.
Complaint Details
The complaint investigation involved allegations of tenant elopement, medications given without physician orders, tenant struck out at staff, verbal abuse, and structural issues such as blocked exits and damaged window screens. The investigation found no substantiated regulatory insufficiencies related to these complaints.
Findings
The investigation found no regulatory insufficiencies in most areas including medication administration, staffing, tenant rights, and structural requirements. Several tenant incidents were documented, including elopements and exit seeking behaviors, but no substantiated abuse or neglect was found. Documentation and service plans were reviewed with no major deficiencies noted.
Report Facts
Census: 52
Complaint/Incident Investigation Dates: June 5, 9, 10, 11 and 17, 2014
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Mary K. Harris | RN Manager | Named as manager of Oakwood Place AL in the complaint investigation report |
| Jim Berkley | Program Coordinator | Signed the cover letter for the Final Complaint/Incident Investigation Report |
Inspection Report
Complaint Investigation
Census: 54
Deficiencies: 1
Date: Feb 11, 2014
Visit Reason
The inspection was conducted as a Final Complaint Investigations, Complaint/Incident Revisits & Recertification Monitoring Evaluation for Oakwood Place Assisted Living in Davenport, IA, following complaints and allegations regarding service plan and staffing.
Complaint Details
The complaint investigations involved allegations including tenants not meeting assisted living requirements, staff verbal abuse, medication contamination, tenant falls, wounds not assessed, staff sleeping on duty, and incomplete activities in the dementia unit. Most allegations were not substantiated or had no regulatory insufficiencies noted.
Findings
The report found regulatory insufficiencies in the areas of service plan and staffing. Multiple complaint/incident investigations and revisits were conducted, with observations and tenant file reviews revealing no current tenants exceeding admission criteria but noting issues with service plans, medication management, tenant rights, and staffing. No regulatory insufficiencies were noted in admission criteria, tenant rights, evaluation, or structural requirements. No staff sleeping on duty was found. The Plan of Correction was required to address cited insufficiencies.
Deficiencies (1)
Regulatory insufficiencies related to service plan and staffing were identified during complaint investigations and revisits.
Report Facts
Number of tenants without cognitive disorder: 44
Number of tenants with cognitive disorder: 10
Total census: 54
Community meeting participants: 16
Inspection Report
Complaint Investigation
Census: 49
Deficiencies: 6
Date: Oct 28, 2013
Visit Reason
The inspection was a Final First Revisit and Complaint/Incident Investigation Report for Oakwood Place Assisted Living, triggered by multiple complaints alleging regulatory insufficiencies related to tenant care, safety, and rights.
Complaint Details
The complaint investigation included allegations of tenants eloping from the secured dementia unit, aggressive behaviors toward staff and other tenants, failure to provide adequate evaluations and service plans, failure to transport tenants as planned, medication administration issues, staffing shortages, and failure to report theft of money or medications. Some allegations were substantiated with detailed observations and interviews.
Findings
The program was found to have repeated regulatory insufficiencies in areas including Criteria for Admission and Retention, Tenant Rights, Evaluations, and Service Plans. Specific tenant incidents of elopement, aggressive behaviors, inadequate evaluations, and failure to update service plans were documented. The program was assessed a $2,500 civil penalty.
Deficiencies (6)
Failure to comply with regulatory requirements in Criteria for Admission and Retention, Tenant Rights, Evaluations, and Service Plans.
Failure to adequately assess and seek medical evaluation for tenants in a timely manner.
Failure to complete required health, functional, and cognitive evaluations with identified significant changes.
Failure to update service plans to reflect individualized tenant needs and changes.
Failure to maintain adequate staffing levels to meet tenant needs, especially in secured dementia unit.
Failure to maintain secure outdoor courtyard gate with proper key control.
Report Facts
Civil penalty amount: 2500
Census: 49
Complaint Intake Numbers: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Mary Katherine Harris | RN Manager | Named in complaint allegations regarding tenant care and admission practices. |
| Jim Berkley | Program Coordinator | Contact person for appeals and civil penalty payment. |
| Maribeth Freland | RN Monitor | Monitor involved in complaint/incident investigation. |
| Margaret Kaltefleiter | RN Monitor | Monitor involved in complaint/incident investigation. |
Inspection Report
Complaint Investigation
Census: 48
Deficiencies: 5
Date: Jul 29, 2013
Visit Reason
The inspection was conducted as a complaint/incident investigation following allegations related to tenant rights, medication administration, and missing items at Oakwood Place Assisted Living. The investigation occurred on July 29-31, 2013.
Complaint Details
The complaint investigation included three complaint intake numbers (44432-C, 44725-I, 44433-M) involving tenant falls, missing narcotics, and missing personal property. The investigation substantiated regulatory insufficiencies in tenant rights, medication administration, and program reporting.
Findings
The report identified regulatory insufficiencies in tenant rights, nurse review, evaluation, and service plans. Specific findings included failure to timely evaluate a tenant after a fall, missing narcotics, and multiple tenants reporting missing personal items. The program was assessed a $1,500 civil penalty for repeated regulatory insufficiencies.
Deficiencies (5)
Failure to evaluate Tenant #1 in a timely manner after a fall resulting in a fractured pelvis.
Missing narcotics for Tenant #8 with inadequate medication counts and controls.
Multiple tenants reported missing money, gift cards, and jewelry from their apartments.
Failure to complete nurse reviews and evaluations for tenants with significant changes in condition.
Failure to update service plans timely for tenants with changes in condition.
Report Facts
Civil penalty amount: 1500
Reduced civil penalty amount: 975
Number of tenants present: 48
Dates of investigation: July 29, 30, and 31, 2013
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jim Berkley | Program Coordinator | Contact person for hearing and compliance questions |
| Jim Friberg | Acting Bureau Chief, Adult Services Bureau | Signed the demand letter |
| Mary Kathleen Harris | Director | Director of Oakwood Place Assisted Living named in report |
Inspection Report
Complaint Investigation
Census: 54
Deficiencies: 1
Date: Jun 10, 2013
Visit Reason
The inspection was conducted as a complaint/incident investigation following complaints regarding tenant rights, policies and procedures, and service plans at Oakwood Place Assisted Living Program.
Complaint Details
The complaint investigation included allegations of tenant suicidal ideations and elopement tendencies, concerns about tenant safety, verbal abuse by staff, failure to assess wounds, staff sleeping on duty, staff working under influence of drugs or alcohol, forced medication administration, staff taking medications home, smoke permeating activity room, and lack of structured activities. Some allegations were substantiated with regulatory insufficiencies noted, while others had no regulatory insufficiencies.
Findings
The report found regulatory insufficiencies related to tenant rights, service plans, and policies. Multiple complaints were investigated including allegations of suicidal ideations, tenant safety concerns, verbal abuse, medication administration issues, and lack of structured activities. The program failed to update service plans for three tenants and had prior regulatory insufficiencies.
Deficiencies (1)
Failure to update service plans for three tenants
Report Facts
Civil penalty amount: 500
Reduced civil penalty amount: 325
Complaint/Incident Intake numbers: 43967-C, 44077-C, 44123-C
Tenant census: 54
General Population tenants: 42
Dementia-Specific tenants: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Mary K. Harris | RN Manager | Named in relation to findings and complaint investigation |
| Jim Berkley | Program Coordinator | Contact person for appeals and civil penalty payment |
| Stephanie Cummins | Monitor | Conducted complaint/incident investigation |
| Margaret Kaltefleiter | RN MS | Conducted complaint/incident investigation |
Inspection Report
Complaint Investigation
Census: 53
Deficiencies: 9
Date: Aug 28, 2012
Visit Reason
The inspection was conducted as a final complaint/incident investigation of Oakwood Place Assisted Living in response to multiple complaint/incident allegations regarding tenant care, tenant rights, evaluation, service plans, medications, staffing, and life safety.
Complaint Details
The complaint investigation was substantiated with multiple allegations including tenant falls resulting in injury, staff mistreatment allegations, inadequate wound care, medication errors, insufficient staffing, and failure to follow infection control and safety protocols. Some allegations were not substantiated, such as forced activities and fundraising concerns.
Findings
The investigation reviewed multiple allegations including tenant falls, staff behavior, wound care, medication administration, and supervision. Several regulatory insufficiencies were noted related to evaluation timelines, service plan updates, and staffing adequacy. No deficiencies were noted in some complaint areas such as tenant rights and fundraising activities. The program accepted the plan of correction submitted.
Deficiencies (9)
A program shall evaluate each tenant's functional, cognitive and health status within 30-days of occupancy and as needed with significant change, but not less than annually.
When a tenant needs personal care or health-related care, the service plan shall be updated within 30 days of the tenant's occupancy and as needed with significant change, but not less than annually.
The service plan shall be individualized and indicate tenant's identified needs and preferences for assistance.
A program shall not knowingly admit or retain a tenant who is dangerous to self or others, or displays unmanageable verbal abuse or aggression.
The program did not consistently complete a medication review as part of a 90-day nurse review for tenants with recent medication changes.
Staffing was inadequate at times with only two staff members present in the general population and one staff leaving for an hour, leaving the program with insufficient supervision.
The program did not follow infection control guidelines related to isolation supplies and delegation of wound care.
Background checks were not properly completed for all staff; one staff member was removed due to embezzlement conviction.
The operating alarm system in the dementia unit was not connected to each exit door as required.
Report Facts
Total census: 53
Number of tenants without cognitive disorder (general population): 39
Number of tenants with cognitive disorder (general population): 2
Total population of general population program: 41
Number of tenants without cognitive disorder (dementia-specific): 1
Number of tenants with cognitive disorder (dementia-specific): 11
Total population of dementia-specific program: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jim Berkley | Program Coordinator | Signed letter regarding acceptance of Plan of Correction |
| Hal Chase | RN BSN MPH | Monitor for complaint/incident investigation |
| Lori Miner | RN BSN | Monitor for complaint/incident investigation |
Inspection Report
Complaint Investigation
Census: 59
Deficiencies: 0
Date: Apr 17, 2012
Visit Reason
The inspection was conducted as a complaint/incident investigation triggered by allegations that tenants were left isolated in halls for hours, staffing was inadequate, and tenants were forced to hurry or pay for meal tray service.
Complaint Details
The complaint alleged tenants were left isolated in halls for hours, staffing was insufficient to meet tenant needs, and tenants were forced to hurry or pay for meal tray service. The investigation found these allegations unsubstantiated with no regulatory insufficiencies noted.
Findings
The investigation found no regulatory insufficiencies. Tenants reported staff were kind and services prompt, meals were served on time, and tenants did not feel rushed or forced to purchase tray service. Staffing levels were adequate and occupancy agreements were properly documented.
Report Facts
Number of tenants without cognitive disorder: 44
Number of tenants with cognitive disorder: 15
Total Population of Program at time of on-site: 59
Group meeting attendees: 11
Optional meal tray service charge: 3.75
Staffing documented: 4
Staffing documented: 4
Staffing documented: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Mary Kathleen Harris | Director | Facility director named in report heading |
| Joyce Kix | RN | Monitor involved in complaint investigation |
| Maribeth Freland | RN | Monitor involved in complaint investigation |
| Jim Berkley | Program Coordinator | Author of cover letter and contact for questions |
Inspection Report
Complaint Investigation
Census: 51
Deficiencies: 1
Date: Jan 18, 2012
Visit Reason
The inspection was conducted as a complaint/incident investigation regarding allegations of improper care related to a tenant's colostomy, signs of urinary tract infection, and wound care issues at Oakwood Place Assisted Living.
Complaint Details
The complaint alleged a tenant was not receiving proper attention for colostomy care, a tenant showed signs of a urinary tract infection but no urinalysis was obtained, and a tenant had a wound with MRSA that was not properly observed. The investigation substantiated issues with service plans but found no regulatory insufficiencies related to colostomy or UTI care.
Findings
The investigation found that Tenant #1 received assistance with colostomy care but had some skin picking issues without signs of infection. Tenant #2 showed possible UTI signs and was treated accordingly. Tenant #3 had a wound with MRSA but showed improvement. The service plans for Tenants #2 and #3 failed to reflect identified needs, resulting in a regulatory insufficiency.
Deficiencies (1)
The service plan failed to reflect the identified needs for Tenant #2 and Tenant #3.
Report Facts
Total census: 51
Number of tenants without cognitive disorder: 38
Number of tenants with cognitive disorder: 13
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Mary K. Harris | RN Manager | Named as facility manager in relation to complaint investigation |
| Stephanie Cummins | MA | Monitor for complaint investigation |
| Margaret Kaltefleiter | RN MS | Monitor for complaint investigation |
Inspection Report
Monitoring
Census: 70
Deficiencies: 1
Date: Nov 7, 2011
Visit Reason
The visit was conducted as a Final Recertification Monitoring Evaluation to review the Plan of Correction submitted in response to a Preliminary Recertification Monitoring Evaluation Report and to evaluate compliance with Iowa Administrative Code chapters 481-67 and 481-69.
Findings
The program did not receive any regulatory insufficiencies during the certification period. However, personnel records for five employees showed lack of documentation of initial orientation and/or annual in-service training for safe food handling, constituting a regulatory insufficiency.
Deficiencies (1)
Personnel records for five employees lacked documentation of initial orientation and/or annual in-service training for safe food handling by a person certified in Safe Food Protection and Handling.
Report Facts
Total census: 70
Number of tenants without cognitive disorder: 54
Number of tenants with cognitive disorder: 16
Number of tenants in General Population Program: 55
Number of tenants in Dementia-Specific Program by Dedication: 15
Number of tenants at community meeting: 15
Number of employees reviewed for training records: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Mary K. Harris | RN Director | Director of Oakwood Place Assisted Living Program |
| Joyce Kix | RN | Monitor for the evaluation visit |
| Maribeth Freland | RN | Monitor for the evaluation visit |
Inspection Report
Complaint Investigation
Census: 50
Deficiencies: 0
Date: Jul 20, 2011
Visit Reason
A complaint investigation was conducted due to an allegation that a tenant was hospitalized and upon return exceeded the appropriate level of care.
Complaint Details
Complaint Allegation: It was alleged that a tenant was hospitalized and upon return exceeded the appropriate level of care. The complaint investigation found no tenants exceeded level of care and no regulatory insufficiencies were noted.
Findings
The investigation found that six tenant files reviewed did not exceed the level of care. Two tenants recently hospitalized did not exceed the criteria for level of care. The RN Manager and staff did not identify any tenants exceeding level of care. No regulatory insufficiencies were identified.
Report Facts
Current number of tenants without cognitive disorder: 35
Current number of tenants with cognitive disorder: 1
Total Population of General Population Program: 36
Total Population of Dementia Specific Program: 14
Total Census of Assisted Living Program: 50
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Mary K. Harris | RN Manager | Named as facility manager in relation to complaint investigation |
| James Berkley | RN BS | Monitor for complaint investigation |
| Stephanie Cummins | MA | Monitor for complaint investigation |
| Margaret Kaltefleiter | RN MS | Monitor for complaint investigation |
Inspection Report
Complaint Investigation
Census: 50
Deficiencies: 0
Date: Jul 20, 2011
Visit Reason
The inspection was a Final Complaint Investigation Revisit and Incident Investigation Revisit conducted at Oakwood Place Assisted Living on July 20 & 21, 2011, following up on previous regulatory insufficiencies and complaints related to tenant care and program compliance.
Complaint Details
The complaint investigation focused on Tenant #1 regarding not knowingly admitting or retaining a tenant who chronically eloped. The revisit confirmed Tenant #1 was discharged on 3-3-11. No current tenants had eloped or received scheduled welfare checks. Staffing and medication administration concerns from the March 15, 2011 visit were resolved with no regulatory insufficiencies noted.
Findings
No regulatory insufficiencies were identified during this revisit. The investigation found that tenant #1 was discharged and no current tenants had eloped or exceeded the appropriate level of care. Staffing levels were sufficient, medications were administered on time, and the electronic monitoring wander system was functioning properly.
Report Facts
Current number of tenants without cognitive disorder: 35
Current number of tenants with cognitive disorder: 1
Total Population of General Population Program: 36
Total Population of Dementia Specific Program: 14
Total Census of Assisted Living Program: 50
Dates of investigation revisit: 2
Date of report: 2011
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Mary K. Harris | RN Manager | Named in relation to findings and statements about tenant elopement and welfare checks |
| James Berkley | RN BS | Monitor for the investigation |
| Stephanie Cummins | MA | Monitor for the investigation |
| Margaret Kaltefleiter | RN MS | Monitor for the investigation |
Inspection Report
Complaint Investigation
Census: 50
Deficiencies: 0
Date: Jul 20, 2011
Visit Reason
The visit was a final incident investigation revisit conducted on July 20 & 21, 2011, to follow up on a regulatory insufficiency related to tenant rights from a previous February 15, 2011 visit.
Complaint Details
The complaint involved a regulatory insufficiency regarding tenant #1's rights to adequate care, treatment, and services. The revisit found no substantiated deficiencies.
Findings
No regulatory insufficiencies were identified during this revisit. Tenant files and staff observations indicated no elopements or welfare check deficiencies, and tenant meetings showed positive feedback with no concerns noted.
Report Facts
Current number of tenants without cognitive disorder: 35
Current number of tenants with cognitive disorder: 1
Total Population of General Population Program: 36
Total Population of Dementia Specific Program: 14
Total Census of Assisted Living Program: 50
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Mary K. Harris | RN Manager | Named in relation to the incident investigation and findings |
| James Berkley | Program Coordinator | Monitor and author of the report |
| James Berkley | RN BS | Monitor during the incident investigation revisit |
| Stephanie Cummins | MA | Monitor during the incident investigation revisit |
| Margaret Kaltefleiter | RN MS | Monitor during the incident investigation revisit |
Inspection Report
Complaint Investigation
Census: 50
Deficiencies: 7
Date: Jul 20, 2011
Visit Reason
A complaint investigation on-site revisit was conducted at Oakwood Place Assisted Living on July 20 & 21, 2011 to assess regulatory insufficiencies related to medications and monitoring, plans of correction, and requests for reconsideration.
Complaint Details
Complaint Intake #33452R-C related to medication administration, nurse review, staffing, and tenant rights. The complaint was substantiated with regulatory insufficiencies found during the April 4 & 5, 2011 visit and revisited on July 20 & 21, 2011.
Findings
The investigation found regulatory insufficiencies in medication administration and documentation, nurse review, staffing, and tenant rights. The program received a $500 civil penalty and submitted a plan of correction which was reviewed. The Department may conduct a monitoring revisit to ensure compliance.
Deficiencies (7)
Medication pass observed with staff not washing or sanitizing hands prior to administration and improper documentation of medication administration.
Lack of documented results for as needed medication and incomplete medication administration records.
Administration of medications not always provided by registered nurse, licensed practical nurse, advanced nurse practitioner, or unlicensed assistive personnel in accordance with nurse delegation requirements.
Regulatory insufficiency related to ensuring health care professionals' orders are current and monitoring tenant health status.
Insufficient number of trained staff available at all times to meet tenants' identified needs.
Tenants' rights to receive adequate and appropriate care, treatment, and services were assessed with no noted regulatory insufficiency.
Plan of Correction submitted indicated all tenants' medication administration records would be reviewed monthly to ensure documentation and results completion.
Report Facts
Civil penalty amount: 500
Plan of Correction submission date: Aug 9, 2011
Census count: 50
General Population Program tenants without cognitive disorder: 35
General Population Program tenants with cognitive disorder: 1
General Population Program total population: 36
Dementia Specific Program total population: 14
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Mary K. Harris | RN Manager | Named as manager of Oakwood Place Assisted Living in relation to the complaint investigation |
| James Berkley | RN BS | Monitor and Program Coordinator mentioned in relation to the complaint investigation and civil penalty |
| Stephanie Cummins | MA | Monitor involved in the complaint investigation |
| Margaret Kaltefleiter | RN MS | Monitor involved in the complaint investigation |
Inspection Report
Complaint Investigation
Census: 54
Deficiencies: 4
Date: Apr 4, 2011
Visit Reason
A complaint investigation on-site visit was conducted at Oakwood Place Assisted Living on April 4 & 5, 2011, to assess regulatory insufficiencies related to medications, nurse review, staffing, and tenant rights.
Complaint Details
The complaint investigation addressed allegations including tenants requiring total care, wandering tenants, medication administration delays, missing medications, inadequate staffing, and tenant rights violations. Several allegations were not substantiated, and no regulatory insufficiencies were noted related to medications. Staffing and tenant rights issues were noted.
Findings
The investigation found no regulatory insufficiencies related to medication administration delays or missing medications, but noted issues with nurse review, staffing adequacy, and tenant rights. Several complaint allegations were not substantiated, and some regulatory insufficiencies were noted in staffing and tenant rights.
Deficiencies (4)
Regulatory insufficiency related to nurse review when a tenant does not receive personal or health-related care and significant change occurs.
Regulatory insufficiency to assess and document tenant health status at least every 90 days and when changes occur.
Regulatory insufficiency for sufficient number of trained staff to fully meet tenants' identified needs.
Regulatory insufficiency that all tenants have the right to receive adequate and appropriate care, treatment, and services.
Report Facts
Current number of tenants without cognitive disorder: 30
Current number of tenants with cognitive disorder: 2
Total Population of General Population Program: 32
Total Population of Dementia Specific Program: 12
Total Census of Assisted Living Program: 54
Civil penalty amount: 2500
Inspection Report
Complaint Investigation
Census: 51
Deficiencies: 2
Date: Mar 15, 2011
Visit Reason
The inspection was conducted as a complaint and incident investigation visit at Oakwood Place on March 15, 2011, related to allegations about tenant exclusion criteria and staffing issues.
Complaint Details
Complaint Allegation #33087-C alleged that four tenants exceeded the criteria for level of care provided in assisted living. Incident Allegation #33130-I involved a tenant leaving the program without an escort on 3-1-11 at 11:45 p.m. The complaint investigators documented multiple safety and staffing issues and found substantiated regulatory insufficiencies.
Findings
The report found regulatory insufficiencies related to the criteria for exclusion of tenants and staffing. Specific issues included a tenant leaving the program unsupervised, failure to provide adequate safety checks, and insufficient staffing to meet tenant needs.
Deficiencies (2)
Failure to meet criteria for exclusion of tenant resulting in safety risks and unsupervised elopement.
Short staffing leading to inability to properly shower or toilet tenants and incomplete safety checks.
Report Facts
Civil penalty amount: 1500
Days for Plan of Correction submission: 10
Current number of tenants without cognitive disorder: 35
Current number of tenants with cognitive disorder: 1
Total Population of General Population Program: 36
Total Population of Dementia Specific Program: 15
Total Census of Assisted Living Program: 51
Civil penalty amount if reduced by 35%: 975
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Joyce Kix | RN | Monitor involved in complaint investigation |
| Maribeth Freland | RN | Monitor involved in complaint investigation |
| Margaret Kaltefleiter | RN | Monitor involved in complaint investigation |
| Jim Berkley | Program Coordinator mentioned in relation to civil penalty and appeals |
Inspection Report
Complaint Investigation
Census: 57
Deficiencies: 1
Date: Mar 1, 2011
Visit Reason
An incident investigation on-site visit was conducted at Oakwood Place Assisted Living on March 1, 2011, following a tenant elopement incident where a tenant with dementia left the program without staff knowledge.
Complaint Details
The complaint involved a tenant with dementia who left the program without staff knowledge. The investigation substantiated regulatory insufficiency related to tenant elopement and monitoring failures.
Findings
The investigation found regulatory insufficiency as the program knowingly admitted or retained a tenant who chronically eloped despite interventions. The electronic monitoring system failed to alert staff timely, and staff were unable to prevent the tenant from leaving the program multiple times.
Deficiencies (1)
Program shall not knowingly admit or retain a tenant who, despite intervention, chronically elopes.
Report Facts
Current number of tenants without cognitive disorder: 42
Current number of tenants with cognitive disorder: 3
Total Population of General Population Program: 45
Total Population of Dementia Specific Program: 12
Total Census of Assisted Living Program: 57
Civil penalty amount: 1000
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Bert Vigen | Administrator | Named in relation to the incident investigation and facility administration |
| Hal L. Chase | RN BSN MPH | Monitor conducting the investigation |
| Jim Berkley | Program Coordinator | Contact person for appeals and hearings related to the investigation |
Inspection Report
Complaint Investigation
Census: 55
Deficiencies: 1
Date: Feb 15, 2011
Visit Reason
The visit was conducted as a Final Incident Investigation following a report that a tenant with dementia left the program without staff knowledge.
Complaint Details
The complaint alleged that a tenant with dementia left the program without staff knowledge. The tenant was an 87-year-old with Alzheimer's Dementia and other diagnoses. The program had implemented welfare checks every 30 minutes, but documentation lapses occurred and the tenant left without an escort. No adverse outcome was noted. The program reported the incident appropriately.
Findings
The investigation found that a tenant with dementia left the program without an escort and there were approximately 100 lapses in documentation regarding the tenant's whereabouts. The program failed to ensure the safety of the tenant with cognitive impairment according to the planned service plan.
Deficiencies (1)
Failure to ensure the safety of a tenant with cognitive impairment according to the planned service plan.
Report Facts
Current number of tenants without cognitive disorder: 38
Current number of tenants with cognitive disorder: 3
Total Population of General Population Program: 41
Total Population of Dementia Specific Program: 14
Total Census of Assisted Living Program: 55
Approximate lapses in documentation: 100
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Joyce Kix | RN | Monitor during incident investigation |
| Maribeth Freland | RN | Monitor during incident investigation |
Inspection Report
Monitoring
Census: 50
Deficiencies: 0
Date: Dec 1, 2010
Visit Reason
The on-site monitoring visit was conducted as a final incident investigation following reports of a tenant eloping from Oakwood Place Assisted Living.
Complaint Details
The investigation was triggered by incidents on 10-17-10 and 10-18-10 where a tenant eloped but was returned without injury. The tenant's family and doctor were notified, and no subsequent elopements occurred. The complaint was substantiated with no regulatory insufficiencies noted.
Findings
No regulatory insufficiencies were identified during the investigation. The tenant was returned safely without injury, and the program had interventions in place to manage elopement risks.
Report Facts
Current number of tenants without cognitive disorder: 35
Current number of tenants with cognitive disorder: 3
Total Population of General Population Program: 38
Total Population of Dementia Specific Program: 12
Total Census of Assisted Living Program: 50
Civil penalty: 1500
Estimated installation timeframe (weeks): 2
Estimated installation timeframe (weeks): 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Stephanie Cummins | Monitor | Conducted the on-site monitoring visit |
Inspection Report
Complaint Investigation
Census: 53
Deficiencies: 0
Date: Oct 6, 2010
Visit Reason
The inspection was conducted as a complaint investigation following allegations related to involuntary transfer protocols at Oakwood Place Assisted Living.
Complaint Details
The complaint alleged that appropriate involuntary transfer protocol was not followed. The investigation reviewed tenant files and found no regulatory insufficiency related to the allegation.
Findings
No regulatory insufficiencies were identified during the complaint investigation. The report details tenant transfers and related observations but concludes no violations.
Report Facts
Current number of tenants without cognitive disorder: 37
Current number of tenants with cognitive disorder: 3
Total Population of General Population Program: 40
Total Population of Dementia Specific Program: 13
Total Census of Assisted Living Program: 53
Civil penalty: 1500
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Mary K. Harris | RN Manager | Named as facility manager and recipient of report |
| Stephanie Cummins | MA | Monitor conducting the investigation |
| Tamara Halvorson | ASB Certification Coordinator | Author of cover letter transmitting the report |
Inspection Report
Complaint Investigation
Census: 58
Deficiencies: 3
Date: Apr 28, 2010
Visit Reason
The inspection was conducted as a final incident and complaint investigation at Oakwood Place Assisted Living following complaints and a self-reported incident related to the program. The investigation was triggered by complaints received and incidents occurring on April 28 & 29 and May 3 & 4, 2010.
Complaint Details
The complaint investigation included allegations of a tenant not being toileted appropriately, verbal abuse by staff, staff threatening other staff in front of tenants and family, nurse not following up appropriately when a tenant's condition changed, and medications missing without family awareness. Some allegations were substantiated, such as regulatory insufficiencies in documentation and medication management, while others like verbal abuse and staff conflicts were not substantiated.
Findings
The investigation found substantiated regulatory insufficiencies in tenant documents, service plans, food service, staffing, dementia-specific education, and record checks. Specific complaints about toileting, verbal abuse, staff conflicts, medication management, and bruising were investigated with some allegations substantiated and others not. The facility was found to have regulatory insufficiencies related to documentation, medication disposal, and reporting of incidents.
Deficiencies (3)
Documentation for each tenant shall be maintained including incident reports involving tenants such as medication errors, accidents, falls and elopements.
A program’s policies and procedures must meet the minimum standard set by applicable requirements related to reporting incidents including allegations of dependent adult abuse.
The program did not follow their medication policy regarding disposal and documentation of medications.
Report Facts
Civil monetary penalty: 1500
Civil monetary penalty: 4000
Current number of tenants without cognitive disorder: 44
Current number of tenants with cognitive disorder: 2
Total Population of General Population Program: 46
Total Population of Dementia Specific Program: 12
Total Census of Assisted Living Program: 58
Missing tablets: 26
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kathy Harris | Director of Nursing | Named in relation to medication error finding and investigation |
| Ann Martin | Bureau Chief, Adult Services Bureau | Signed letter regarding final incident and complaint investigation report |
Inspection Report
Complaint Investigation
Census: 51
Deficiencies: 9
Date: Mar 9, 2010
Visit Reason
The inspection was conducted as a Final Complaint and Incident Investigation and Recertification Monitoring Report for Oakwood Place at Ridgecrest Retirement Village, Davenport, IA, related to regulatory insufficiencies and a complaint intake.
Complaint Details
Complaint Intake #25717-C and Incident Intake #27568-M involved allegations of medication misappropriation and potential verbal abuse. The complaint was investigated with observations of medication discrepancies and staff interactions with tenants. No regulatory insufficiency was noted for medication misappropriation, but verbal abuse and failure to report suspected dependent adult abuse were noted as regulatory insufficiencies.
Findings
The report identified regulatory insufficiencies in tenant documents, service plans, food service, staffing, dementia-specific education, and record checks. A civil penalty of $1,500 was assessed. The Plan of Correction submitted was reviewed and approved.
Deficiencies (9)
Documentation for each tenant shall be maintained by the program and include incident reports involving the tenant, including medication errors, accidents, falls, and elopements.
The service plan shall be individualized and indicate the tenant’s identified needs and preferences for assistance.
Personnel responsible for food preparation or service shall have orientation on sanitation and safe food handling and annual in-service training on food protection.
A sufficient number of trained staff shall be available at all times to fully meet tenant’s identified needs.
All personnel employed by or contracting with a dementia-specific program shall receive a minimum of eight hours dementia-specific education and training annually.
Prospective employees shall have a criminal history check, dependent adult abuse, and child abuse check before starting work.
All tenants have rights to be treated with consideration, respect, and full recognition of personal dignity and autonomy.
Reporting suspected dependent adult abuse in facilities or programs must be done immediately to the person in charge and the Department within 24 hours.
Program policies and procedures must meet minimum standards and include policies related to reporting incidents including allegations of dependent adult abuse.
Report Facts
Civil penalty amount: 1500
Reduced penalty amount: 975
Census - General Population Program tenants without cognitive disorder: 35
Census - General Population Program tenants with cognitive disorder: 3
Total Population of General Population Program: 38
Total Population of Dementia Specific Program: 13
Total Census of Assisted Living Program: 51
Missing Tramadol tablets: 92
Destroyed Alprazolam tablets: 14
Expired Alprazolam tablets destroyed: 44
Alprazolam tablets filled on 6-1-09: 45
Alprazolam tablets destroyed approximately one year after dispensing: 44
Tramadol tablets administered between 12-8-09 and 2-10: 256
Tramadol tablets unaccounted for: 92
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Mary Kathleen Harris | Director of Nursing (DON) | Interviewed regarding medication discrepancies and access to medications |
| Ann Martin | Bureau Chief, Adult Services Bureau | Signed the demand letter and report conclusion |
| Stephanie Cummins | Monitor | Conducted the monitoring visit |
| Joyce Kix | RN, Monitor | Conducted the monitoring visit |
| Chris Nothaft | Certification Coordinator | Contact person for questions regarding the report |
Inspection Report
Complaint Investigation
Census: 48
Deficiencies: 1
Date: Dec 7, 2009
Visit Reason
A complaint investigation on-site visit was conducted at Oakwood Place Assisted Living on December 7, 8, 9 and 10, 2009, in response to complaints regarding medication errors, food service issues, staffing documentation, and structural maintenance.
Complaint Details
Complaint investigation involved complaints #25355-C and #26329-C. Allegations included medication errors involving Vicodin dosing and narcotic count, staff not notifying tenant or physician about medication issues, dirty dining room tables and chairs, meal refusals, lack of nurse delegated task documentation, and maintenance issues such as elevator and toilet problems. The complaint investigator found no substantiated regulatory insufficiencies except for staffing training documentation.
Findings
The investigation found multiple complaint allegations including medication errors, dining room cleanliness issues, meal refusals, lack of nurse delegated task documentation, and maintenance concerns. However, no regulatory insufficiencies were noted in medication administration, food service, or structural requirements. One regulatory insufficiency was noted related to staffing training documentation.
Deficiencies (1)
The program owner or Management Corporation did not ensure that personnel employed by or contracting with the program received training appropriate to assigned tasks and target population.
Report Facts
Current number of tenants without cognitive disorder: 36
Current number of tenants with cognitive disorder: 1
Total Population of General Population Program: 37
Total Population of Dementia Specific Program: 11
Total Census of Assisted Living Program: 48
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Michael Streepy | RN | Monitor for the complaint investigation |
Inspection Report
Complaint Investigation
Census: 54
Deficiencies: 0
Date: Jan 7, 2009
Visit Reason
A complaint investigation was conducted at Oakwood Place Assisted Living in response to allegations including tenant combativeness, medication issues, staffing concerns, and tenant bruises.
Complaint Details
Complaint allegations included tenants being combative and inadequately clothed, an empty prescription bottle found in a tenant's apartment, short staffing in the dementia unit, staff complaints about hiring and burnout, and bruises on a tenant suspected to be caused by another person. All allegations were investigated and found to have no regulatory insufficiencies.
Findings
The investigation found no regulatory insufficiencies related to the complaints. Staff interviews and observations indicated appropriate supervision and staffing, and no evidence of abuse or neglect was found.
Report Facts
Current number of tenants with dementia or cognitive disorder: 14
Current number of tenants without cognitive disorder: 25
Total Population of DSP: 39
Total Population of dementia specific program: 15
Total Census of ALP: 54
Civil penalty amount removed: 1000
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Hal Chase | RN BSN MPH | Monitor involved in complaint investigation |
| Stephanie Cummins | MA | Monitor involved in complaint investigation |
| Ann Martin | RN, Bureau Chief | Monitor and letter signatory for Adult Services Bureau |
Inspection Report
Complaint Investigation
Census: 59
Deficiencies: 0
Date: Jul 22, 2008
Visit Reason
A complaint investigation was conducted at Oakwood Place Assisted Living in response to Complaint #18710 regarding the adequacy of the activity program for tenants.
Complaint Details
Complaint #18710 alleged that the program does not have an activity program to meet the needs of tenants. The complaint was investigated and found to be unsubstantiated with no regulatory insufficiencies noted.
Findings
The investigation found that the program provides appropriate programming for tenants based on individual interests, with scheduled activities and service plans reviewed. No regulatory insufficiencies were identified despite some tenant concerns about activity variety and the Activity Director's involvement.
Report Facts
Current number of tenants without cognitive disorder: 36
Current number of tenants with cognitive disorder: 8
Current number of tenants in Dementia Specific Program providing specialized care: 13
Current number of tenants without cognitive disorder in DSP: 2
Total Population: 59
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Lincoln Newsom | RN | Monitor conducting the complaint investigation |
Inspection Report
Monitoring
Census: 58
Deficiencies: 0
Date: Feb 21, 2008
Visit Reason
An on-site monitoring evaluation was conducted at Oakwood Place Assisted Living to assess compliance with assisted living program regulations as part of a recertification monitoring evaluation.
Findings
There were no regulatory insufficiencies noted during this on-site evaluation. Previous certification period had substantiated regulatory insufficiencies in medications and activities, but none were found at this visit.
Report Facts
Current number of tenants without cognitive disorder: 36
Current number of tenants with cognitive disorder: 11
Current number of tenants in Dementia Specific Program: 11
Total Population: 58
Inspection Report
Complaint Investigation
Census: 54
Deficiencies: 5
Date: May 17, 2005
Visit Reason
A complaint investigation on-site visit was conducted at Oakwood Place Assisted Living on May 17, 2005, to investigate allegations related to tenant care and program compliance.
Complaint Details
The complaint investigation was substantiated with findings related to occupancy, tenant transfers, and care level appropriateness.
Findings
The investigation found multiple regulatory insufficiencies including failure to use an objective scored cognitive tool prior to occupancy, failure to evaluate tenants as needed or with changes in condition, failure to obtain valid tenant documents, failure to have appropriately signed service plans, and failure to initiate transfers for tenants requiring higher levels of care.
Deficiencies (5)
The program did not use an objective scored cognitive tool prior to occupancy.
The program did not evaluate as needed or with a change in condition.
The program did not obtain valid tenant documents.
The program did not have appropriately signed service plans.
The program did not initiate transfer for tenants who on a routine basis have unmanageable incontinence, are dangerous to self and are routine two or more person transfers.
Report Facts
Current number of tenants without cognitive disorder: 38
Current number of tenants with cognitive disorder: 4
Total Population: 42
Current number of tenants in Dementia Specific Program: 12
Current number of tenants without cognitive disorder: 0
Total Population: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Crystal Maring | Director RN BSN | Named as Director and involved in findings related to tenant assessments and documentation |
| Stephanie Cummins | SW MA | Monitor conducting the complaint investigation |
Inspection Report
Complaint Investigation
Census: 63
Deficiencies: 1
Date: Sep 13, 2004
Visit Reason
A complaint investigation was conducted at Oakwood Place Assisted Living due to allegations regarding tenant care levels, medication administration by unqualified aides, and inadequate supervision to prevent falls.
Complaint Details
The complaint alleged five tenants were total care, incontinent, and non-weight bearing requiring a higher level of care; unqualified aides passing medications and inaccurate narcotic counting; and inadequate supervision to prevent falls with lack of incident reporting. The complaint was substantiated in part with one regulatory insufficiency found related to tenant care level retention.
Findings
The investigation found one regulatory insufficiency related to retaining a tenant requiring a higher level of care without proper documentation of transfer arrangements. Medication administration and staffing were found to be adequate with no regulatory insufficiencies noted.
Deficiencies (1)
The program has retained a tenant who requires a higher level of care without documentation of transfer arrangements.
Report Facts
Current number of tenants without cognitive disorder: 52
Current number of tenants with cognitive disorder: 11
Current number of tenants in Dementia Specific Program: 11
Total General Population: 52
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Beverly A. Johnson | RN | Monitor conducting the complaint investigation |
| Bert Vigen | Executive Director | Facility executive director named in report header |
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