Deficiencies per Year
16
12
8
4
0
Severe
High
Moderate
Low
Unclassified
Census Over Time
Inspection Report
Complaint Investigation
Census: 30
Deficiencies: 9
Feb 11, 2025
Visit Reason
The inspection was conducted to investigate complaints #123049-C, #125889-C, #126386-C, Incident #126382-I, and to perform a recertification visit to determine compliance with certification of an Assisted Living Program for People with Dementia.
Findings
The inspection found multiple deficiencies including failure to secure narcotics properly, inadequate response to falls with injury, failure to provide adequate care and services for tenants with significant injuries, medication administration errors, incomplete service plans, and failure to provide required nurse reviews and information in service plans. The facility was cited for not following program policies and procedures, tenant rights violations, medication errors, and service plan deficiencies.
Complaint Details
The visit was complaint-related involving multiple complaint numbers and an incident report. The complaints included concerns about medication security, falls with injury, and adequacy of care and services. The complaint was substantiated as evidenced by cited deficiencies.
Deficiencies (9)
| Description |
|---|
| Failure to secure morphine in a locked refrigerator as required by program policy. |
| Failure to provide adequate care and services for tenants with falls and significant injuries, including failure to notify nurse immediately and failure to provide 30-minute checks. |
| Failure to ensure medications and treatments were administered as prescribed for 3 of 7 tenants reviewed. |
| Failure to develop and update service plans to include all service needs for tenants. |
| Failure to provide information in service plans regarding hospice services and outside services for tenants on hospice. |
| Failure to conduct quarterly nurse reviews for tenants receiving program-administered medications. |
| Failure to conduct nurse reviews related to tenant medications and failure to include nurse review documentation in tenant records. |
| Failure to provide required nurse review of prescription medications for adverse reactions and ensure prescription orders are current and administered consistently. |
| Failure to indicate frequency of tenant checks in service plans as required for dementia-specific assisted living program. |
Report Facts
Number of tenants without cognitive impairment: 1
Number of tenants with cognitive impairment: 29
Total census: 30
Number of tenants reviewed for medication administration: 7
Number of tenants with medication errors: 3
Number of tenants reviewed for service plans: 5
Number of tenants reviewed for hospice service plan information: 4
Number of tenants reviewed for nurse quarterly medication reviews: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Joan Randall | Executive Director | Signed the report and involved in interviews and corrective actions |
| Staff B | Interviewed regarding fall incident and notification procedures | |
| Staff C | Interviewed as overnight staff who found tenant after fall | |
| Staff D | Staff person present during fall incident and assisted tenant | |
| Director of Health and Wellness (DOHW) | Conducted staff training, audits, and education related to deficiencies | |
| Assistant Director of Health and Wellness (ADHW) | Interviewed and involved in corrective actions and documentation |
Inspection Report
Renewal
Census: 21
Deficiencies: 1
May 3, 2023
Visit Reason
The inspection was conducted as a recertification visit to determine compliance with certification for an Assisted Living Program for People with Dementia, including investigations #112468-A and 110791-C.
Findings
The program failed to follow its medication administration policies affecting one discharged tenant, specifically related to discrepancies in narcotic medication administration and documentation for Morphine Sulphate.
Deficiencies (1)
| Description |
|---|
| Failure to follow program policies and procedures related to medication administration for one discharged tenant, including not signing out Morphine doses as required. |
Report Facts
Number of tenants without cognitive disorder: 6
Number of tenants with cognitive disorder: 15
Total census: 21
Doses of Morphine administered without proper sign-out: 7
Total Morphine administered (mL): 1.75
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Health and Wellness | Confirmed staff did not follow medication administration policies on 5/3/23 |
Inspection Report
Complaint Investigation
Census: 18
Deficiencies: 7
Mar 31, 2022
Visit Reason
The inspection was conducted as part of the Investigation of Incident #100654-I and Incident #103582-I, with no regulatory insufficiencies cited during the investigation of Complaint #103600-C.
Findings
The program failed to follow policies and procedures related to elopement risk assessments, tenant evaluations within 30 days of occupancy, evaluations with significant change, service plan development and updates, nurse reviews every 90 days or with health changes, and failed to ensure an operating alarm system was connected to exit doors in the dementia unit.
Complaint Details
The visit was complaint-related, investigating Incident #100654-I and Incident #103582-I. No regulatory insufficiencies were cited during the investigation of Complaint #103600-C.
Deficiencies (7)
| Description |
|---|
| Failed to follow policy for elopement risk assessments for 2 of 3 tenants reviewed. |
| Failed to evaluate tenant's functional, cognitive, and health status within 30 days of occupancy for 2 of 3 tenants reviewed. |
| Failed to evaluate functional, cognitive, and health status as needed with significant change for 1 of 3 tenants reviewed. |
| Failed to base service plans on required evaluations for 3 of 3 tenants reviewed. |
| Failed to include a list of person-centered planned and spontaneous activities for tenants unable to plan their own activities for 3 of 3 tenants reviewed. |
| Failed to complete comprehensive nurse reviews every 90 days or with change in health status for 2 of 3 tenants reviewed. |
| Failed to ensure an operating alarm system was connected to exit doors of the dementia unit, resulting in a tenant eloping from the memory care unit. |
Report Facts
Number of tenants without cognitive disorder: 3
Number of tenants with cognitive disorder: 15
Total census: 18
Temperature: 65
Relative humidity: 47
Wind speed: 18
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Luminations (memory care unit) | Confirmed findings related to assessments, evaluations, and service plans | |
| Regional Director of Health and Wellness | Confirmed findings related to the location and safety concerns of the memory care unit | |
| Staff A | Reported that the Activity Director propped open courtyard doors leading to tenant elopement | |
| Staff B | Acknowledged exit doors were propped open and tenant walked outside unsupervised | |
| Staff C | Confirmed exit doors to courtyard were occasionally propped open | |
| Staff D | Stated exit doors were propped open occasionally to allow tenant access with staff supervision |
Inspection Report
Complaint Investigation
Census: 18
Deficiencies: 1
Mar 31, 2022
Visit Reason
The inspection was conducted as an investigation of complaint 101828-M regarding the adequacy and appropriateness of care provided to tenants at the Assisted Living Program for People with Dementia.
Findings
The program failed to provide adequate and appropriate care to Tenant #2, who sustained injuries after a staff member forcefully grabbed her arm causing her to fall and hit her head. The staff involved were terminated for their failure to follow policy and provide appropriate care, including failure to send the tenant to the emergency room after the head injury.
Complaint Details
Investigation of complaint 101828-M found that Tenant #2 was injured due to staff actions and inadequate response to the injury. Staff E was terminated for disorderly conduct and failure to provide appropriate redirection. The Director of Health and Wellness was terminated for failure to send Tenant #2 to the emergency room as required by policy.
Deficiencies (1)
| Description |
|---|
| Failure to provide adequate and appropriate care, treatment, and services to Tenant #2 resulting in injury and inadequate follow-up. |
Report Facts
Number of tenants without cognitive disorder: 3
Number of tenants with cognitive disorder: 15
Total census: 18
Date of incident: Jan 15, 2022
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff E | Named in finding for causing Tenant #2 to fall and for failure to provide appropriate care | |
| Director of Health and Wellness | Director of Health and Wellness | Named in finding for failure to send Tenant #2 to emergency room and terminated for performance issues |
| Executive Director | Executive Director | Provided statements regarding staff terminations and findings |
Inspection Report
Complaint Investigation
Census: 16
Deficiencies: 14
Jun 7, 2021
Visit Reason
The inspection was conducted as a recertification visit, complaint investigations (#96602-C, #96606-C, #96677-C), and an onsite infection control survey to determine compliance with certification for a Dedicated Dementia Specific Assisted Living Program.
Findings
Multiple regulatory insufficiencies were identified including medication administration by uncertified staff, failure to administer medications as prescribed, incomplete nurse delegation training, incomplete background checks, incomplete tenant evaluations and service plans, failure to complete nurse reviews as required, inadequate food service training and practices, and failure to provide dementia-specific education within required timeframes.
Complaint Details
The visit included investigations of Complaints #96602-C, #96606-C, and #96677-C.
Deficiencies (14)
| Description |
|---|
| Staff administering medications did not complete a department-approved medication aide or medication manager course prior to administering medications. |
| Medications were not administered as prescribed for Tenant #4, including administration times not matching physician orders. |
| Nurse delegation training was not documented as completed within 60 days of the new registered nurse's hire date for multiple staff. |
| Nurse delegated training by the registered nurse was not completed within 30 days of employment for multiple staff. |
| Background check failed to include maiden name for one staff member when using the single contact repository (SING). |
| Cognitive evaluations were not completed prior to tenant occupancy for Tenant #3. |
| Evaluations were not completed within 30 days of occupancy for Tenant #3. |
| Evaluations were not completed as needed with significant change for Tenants #1 and #4. |
| Service plans were not updated as needed, not based on evaluations, and did not reflect service needs for all five tenants reviewed. |
| Service plan was not developed within 30 days of occupancy for Tenant #3. |
| Nurse reviews were not completed as needed and every 90 days for Tenants #4 and #5, including delayed assessment of injury of unknown origin for Tenant #4. |
| Staff responsible for food preparation or service did not complete orientation on sanitation and safe food handling prior to handling food. |
| Program failed to utilize commercial dishwashers for warewashing and failed to document daily testing of sanitizer chemicals parts per million and water temperatures. |
| Personnel employed by or contracting with the dementia-specific program did not receive the required minimum of eight hours of dementia-specific education within 30 days of employment. |
Report Facts
Census: 16
Staff reviewed: 6
Staff reviewed: 6
Tenants reviewed: 5
Tenants reviewed: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff F | Administered medications without completing required medication aide or manager course | |
| Director of Health and Wellness | Confirmed medication administration and nurse delegation training deficiencies; involved in corrective actions | |
| Staff G | Licensed Practical Nurse | Provided training and completed nurse delegation for staff; involved in medication administration training |
| Executive Director | Confirmed background check deficiencies and dementia education training | |
| Staff E | Background check missing maiden name |
Inspection Report
Original Licensing
Census: 6
Deficiencies: 4
Aug 28, 2019
Visit Reason
An initial certification visit was conducted to determine compliance with certification for a Dedicated Dementia Specific Assisted Living Program.
Findings
The program failed to meet several regulatory requirements including written occupancy agreements, administration and documentation of medications, staff training on insulin administration, and development of service plans reflecting tenant needs. Plans of correction were provided with deadlines to address these insufficiencies.
Deficiencies (4)
| Description |
|---|
| Written Occupancy Agreement required |
| Program Policies and Procedures regarding administration and documentation of medications |
| Staff training documentation on insulin administration |
| Failure to develop service plans reflecting identified needs of tenants |
Report Facts
Number of tenants without cognitive disorder: 0
Number of tenants with cognitive disorder: 6
Total Census of Assisted Living Program for People with Dementia: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Executive Director | Named as responsible for completing service agreements and reviewing files to ensure correction of occupancy agreement deficiency | |
| Director of Health and Wellness (DOHW) | Named as responsible for reviewing medication orders and ensuring correction of medication administration deficiencies |
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