Inspection Reports for
Gardens at Ridgecrest Village

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.

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.

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.

The complaint investigation was substantiated with findings of regulatory insufficiency in program policies and procedures related to incident reporting and medication administration errors.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

The complaint investigation was substantiated with findings related to occupancy, tenant transfers, and care level appropriateness.

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.

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.

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.