Inspection Reports for Gaslight Village Assisted Living & Memory Care

The investigation was initiated due to a complaint alleging that the Resident of Concern (ROC) was not provided with appropriate interventions to prevent falls.

The investigation found that the ROC experienced 11 documented falls between admission and hospice care, with inadequate interventions or updates to the service plan to prevent reoccurrence. The facility failed to implement sufficient fall prevention measures despite multiple incidents and changes in the resident's condition.

The complaint alleged that the complainant's father died unexpectedly after multiple falls at the facility, with concerns that enhanced fall precautions were not implemented after the first fall. The complaint was substantiated with violations established.

The inspection was conducted as a Renewal Licensing Study to evaluate compliance with licensing rules and regulations for Gaslight Village Assisted Living facility.

The facility was found to be in non-compliance with multiple rules including failure to update administrator information, incomplete resident service plans, lack of designated shift supervisors, incomplete medication administration records, incomplete resident registers, inadequate ventilation in some areas, water temperature below required levels, and incomplete sanitization logs in the kitchen.

The investigation was initiated due to a complaint alleging that Resident A did not receive prescribed breathing treatments as ordered after returning to the facility from rehab on 08/10/2023.

The investigation confirmed that Resident A had a physician order for breathing treatments starting 08/10/2023, but the treatments were not administered until 08/12/2023, resulting in a violation of medication administration rules.

The complaint alleged that Resident A returned from rehab on 08/10/2023 and did not receive breathing treatments as ordered three to five times daily. The violation was established based on review of medication administration records and interviews.

The document serves as a notification of license renewal following an administrative review of licensing activity for the past year, confirming substantial compliance with applicable public health codes and administrative rules.

The administrative review found substantial compliance with the public health code and administrative rules regulating home for the aged facilities, resulting in the renewal of the facility's license for 12 months effective November 22, 2022.

The inspection was conducted in response to a complaint alleging the facility did not provide interventions to prevent resident-to-resident altercations between the Resident of Concern (ROC) and Resident B, concerns about privacy violations by the facility director, and questions about staff ability to manage aggressive residents in the memory care unit.

The investigation found that the facility failed to provide adequate interventions to prevent altercations between residents and that only one of four caregivers had completed all required dementia-related training. The allegation of privacy violation by the director was not substantiated.

The complaint alleged that the facility failed to prevent altercations between the Resident of Concern and Resident B, that the facility director disclosed the ROC's toileting behaviors inappropriately, and that care staff were inadequately trained to manage aggressive residents. The privacy violation allegation was not substantiated. The other two allegations were substantiated.

The visit was conducted as an original licensing study to determine compliance with applicable licensing statutes and administrative rules for Gaslight Village Assisted Living, LLC.

The facility was found to be in substantial compliance with the home for the aged public health code and administrative rules. Technical assistance was provided, and a temporary license with a maximum capacity of 51 residents was recommended.