Inspection Reports for Independence Court of Quakertown
1660 Park Ave, Quakertown, PA 18951, PA, 18951
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Inspection Report
Complaint Investigation
Census: 70
Capacity: 120
Deficiencies: 4
Aug 13, 2025
Visit Reason
The inspection was conducted as a complaint investigation, as indicated by the reason stated on the inspection information section. The visit was unannounced and partial in nature.
Findings
The inspection identified multiple deficiencies including failure to report an incident involving missed medication administration within the required 24-hour period, unsecured resident records left unattended and accessible, and incomplete medication administration records with missing staff initials. Plans of correction were accepted and implemented by 09/17/2025.
Complaint Details
The inspection was triggered by a complaint, as explicitly stated under the Inspection Information section. The report does not specify substantiation status.
Deficiencies (4)
| Description |
|---|
| Failure to report an incident to the Department within 24 hours regarding a resident not receiving prescribed medication brimonidine for approximately 8 days. |
| Resident records were left unlocked, unattended, and accessible in the director of resident care's office. |
| Medication administration records were inaccurately documented, indicating medication was given when it was not present, and missing initials of staff administering medications. |
| Failure to follow prescriber's orders due to medication not being administered because it was unavailable in the home. |
Report Facts
License Capacity: 120
Residents Served: 70
Current Hospice Residents: 11
Medication cart audit frequency: 3
Medication technician audit days: 3
Inspection Report
Follow-Up
Census: 74
Capacity: 120
Deficiencies: 7
Jun 25, 2025
Visit Reason
The inspection visit on 06/25/2025 was a partial, unannounced follow-up inspection triggered by a complaint and incident to review the facility's compliance and plan of correction implementation.
Findings
The facility was found to have multiple deficiencies including neglect related to improper readmission of a resident on NPO status without proper assessment or nutrition/hydration provision, verbal abuse by a staff member, medication storage and labeling issues, incomplete annual medical evaluations and assessments, and unsigned support plans. The submitted plan of correction was accepted and fully implemented by 09/04/2025.
Complaint Details
The inspection was complaint-related, triggered by a complaint and incident involving neglect and abuse of a resident. The complaint was substantiated as deficiencies were found regarding neglect and verbal abuse.
Deficiencies (7)
| Description |
|---|
| Resident was readmitted on NPO order without alternative nutrition/hydration and was neglected, not fed or hydrated properly until speech therapy intervention. |
| Staff member verbally abused a resident by making a derogatory comment referring to the resident as a 'demon'. |
| Resident's most recent annual medical evaluation was not completed timely. |
| Loose pill found in medication cart and punctured blister pack observed. |
| Over-the-counter (OTC) medications and complementary alternative medicines (CAM) were not labeled with resident names. |
| Resident's additional assessments were not completed timely as required. |
| Resident participated in support plan development but did not sign or date the support plan. |
Report Facts
License Capacity: 120
Residents Served: 74
Current Hospice Residents: 7
Residents 60 Years or Older: 74
Residents with Mental Illness: 2
Residents with Mobility Need: 25
Residents with Physical Disability: 5
Inspection Report
Complaint Investigation
Census: 74
Capacity: 120
Deficiencies: 21
Apr 17, 2025
Visit Reason
The inspection was conducted as a complaint and incident investigation with unannounced partial inspections on April 17, 24, and 25, 2025.
Findings
Multiple violations were found including inadequate assistance with activities of daily living, abuse by staff, insufficient staffing levels, medication administration errors, lack of proper staff qualifications and training, sanitary and safety issues, and incomplete resident assessments and support plans.
Complaint Details
The inspection was complaint-driven, triggered by allegations of neglect, abuse, and medication errors. Substantiation status is not explicitly stated.
Deficiencies (21)
| Description |
|---|
| Resident #1 waited over an hour multiple times for assistance with transfers and toileting. |
| Staff person A engaged in sexual activity with resident #4 and was terminated. |
| Residents experienced neglect due to insufficient staffing causing toileting accidents and long waits for assistance. |
| Resident #6's painful skin condition was untreated despite prescribed topical creams. |
| Staff persons B and D lacked required high school diploma or GED. |
| Direct care staffing hours were below required minimums on 3/22/2025. |
| Less than 75% of personal care service hours were provided during waking hours on 3/22/2025. |
| Resident #1 did not receive required two-person assistance on 4/24/2025. |
| No staff certified in First Aid/CPR were present during multiple shifts. |
| Staff persons B, E, and F did not complete required direct care training and competency test before providing care. |
| Spill of liquid-thickener found in medication refrigerator. |
| Lighting in first-floor hallway was malfunctioning. |
| Rear egress from kitchen was blocked by trash bags and a hand cart. |
| Resident #6's special dietary needs were not posted in the kitchen. |
| Resident #7 self-administered medication without proper assessment. |
| Resident #8's medications were administered by an unqualified resident #7. |
| Medications and syringes were left unattended and unlocked. |
| Discontinued and expired medications were found in medication carts. |
| Prescription medications and creams were not available in the home as prescribed. |
| Medication administration records lacked initials for administered medications. |
| Resident #6 received wrong insulin injection and missed topical cream application. |
Report Facts
Residents served: 74
License capacity: 120
Staffing hours required: 103
Staffing hours provided: 97.75
Waking hours staffing: 75.25
Residents with mobility needs: 25
Residents with mobility needs: 35
Residents served: 69
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff person A | Engaged in sexual activity with resident #4 and was terminated | |
| Staff person B | Lacked criminal background check and high school diploma; removed from medication administration | |
| Staff person C | Left medications unattended and administered wrong insulin | |
| Staff person D | Lacked criminal background check and high school diploma | |
| Staff person E | Administered medication without trainer attestation; removed from medication administration | |
| Staff person F | Administered medication without completing required training; removed from medication administration | |
| Staff person G | Administered medication without proper training; retrained | |
| Director of Nursing | Director of Nursing | Named in multiple corrective actions and training plans |
| Executive Director | Executive Director | Named in multiple corrective actions and training plans |
Inspection Report
Renewal
Census: 84
Capacity: 120
Deficiencies: 7
Dec 11, 2024
Visit Reason
The inspection was conducted as a renewal inspection of the facility's license, with unannounced full notice visits on 12/11/2024 and 12/12/2024.
Findings
The inspection found multiple deficiencies related to safety and medication management, including improper placement of carbon monoxide alarms, uncovered dumpster lids, medication storage issues, expired medications, labeling errors, and missing resident signatures on support plans. All deficiencies had plans of correction accepted and were implemented by 01/28/2025.
Deficiencies (7)
| Description |
|---|
| Carbon monoxide alarm was located within two feet of the boiler, violating placement requirements. |
| Large dumpster outside the home was uncovered, violating trash containment requirements. |
| Medication cards had punctured blister foil exposing medication to contamination. |
| Discontinued nasal spray medications were not discarded within the required six weeks after opening. |
| Pharmacy label for Resident #5’s ear drops did not include a change of direction order. |
| OTC medications belonging to Resident #6 were not labeled with the resident's name. |
| Resident #7 participated in support plan development but did not sign the support plan. |
Report Facts
License Capacity: 120
Residents Served: 84
Current Hospice Residents: 8
Total Daily Staff: 98
Waking Staff: 74
Residents Age 60 or Older: 85
Residents Diagnosed with Mental Illness: 8
Residents with Mobility Need: 14
Residents with Physical Disability: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Resident #1 | Named in medication storage deficiency regarding punctured blister foil. | |
| Resident #2 | Named in medication storage deficiency regarding punctured blister foil. | |
| Resident #3 | Named in discontinued medication deficiency regarding expired nasal spray. | |
| Resident #4 | Named in discontinued medication deficiency regarding expired nasal spray. | |
| Resident #5 | Named in medication labeling deficiency regarding ear drops. | |
| Resident #6 | Named in OTC medication labeling deficiency. | |
| Resident #7 | Named in support plan signature deficiency. |
Inspection Report
Complaint Investigation
Census: 81
Capacity: 120
Deficiencies: 6
Jul 1, 2024
Visit Reason
The inspection was conducted as a partial, unannounced visit triggered by a complaint and incident involving violations of resident confidentiality and treatment.
Findings
Multiple violations were found including breaches of resident confidentiality through unauthorized photographs and recordings by Staff A, failure to treat residents with dignity and respect, privacy violations, unsafe medication storage allowing child access, and medication administration documentation errors. Corrective actions including staff termination, training, and ongoing quality assurance measures were implemented.
Complaint Details
The visit was complaint-related involving Adult Protective Services (APS) and Area Agency on Aging (AAA) complaints regarding unauthorized photographs, privacy violations, and medication administration issues. The complaint was substantiated with multiple violations found.
Deficiencies (6)
| Description |
|---|
| Staff A took unauthorized photographs of residents' health information and shared them with an unauthorized individual. |
| Staff A took pictures of residents at vulnerable moments and shared them with an unauthorized individual, violating dignity and respect. |
| Staff A video recorded residents during escort and shared videos with unauthorized individual, violating privacy. |
| Staff A allowed a child, approximately 5 years old, access to an open medication drawer. |
| Medication administration records lacked initials of staff administering medications and failed to document PRN medication administrations properly. |
| Failure to follow prescriber's orders regarding medication administration times. |
Report Facts
License Capacity: 120
Residents Served: 81
Total Daily Staff: 92
Waking Staff: 69
Residents Diagnosed with Mental Illness: 7
Residents with Mobility Need: 11
Residents Aged 60 or Older: 81
Residents with Physical Disability: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Named in multiple violations including unauthorized photographs, privacy breaches, and medication storage violation | |
| Staff member B | Named in medication administration documentation violation | |
| Nancy Morgan | Bucks County Ombudsman | Conducted in-service training for staff on record confidentiality and resident rights |
| Director of Nursing | Conducted staff training on medication storage, administration, and narcotic audit procedures |
Inspection Report
Complaint Investigation
Census: 78
Capacity: 120
Deficiencies: 2
Mar 14, 2024
Visit Reason
The inspection was conducted as a complaint and incident investigation at Independence Court of Quakertown on an unannounced partial inspection visit.
Findings
The facility was found to have failed to report an unwitnessed resident fall to the department within 24 hours and failed to treat a resident with dignity and respect during a bathroom assistance incident, resulting in staff termination and corrective actions including staff in-service and ongoing monitoring.
Complaint Details
The visit was complaint-related involving an unwitnessed fall incident and treatment of residents with dignity and respect. The complaint was substantiated by findings of failure to report the incident and improper staff conduct.
Deficiencies (2)
| Description |
|---|
| Failure to submit an incident report to the department regarding an unwitnessed resident fall. |
| Staff member forcibly removed resident's hands from grab bar and used a loud and demanding voice, causing distress and complaint of shoulder pain. |
Report Facts
License Capacity: 120
Residents Served: 78
Current Residents in Hospice: 6
Residents Diagnosed with Mental Illness: 11
Residents Diagnosed with Intellectual Disability: 1
Residents with Mobility Need: 12
Residents with Physical Disability: 4
Total Daily Staff: 90
Waking Staff: 68
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Submitted incident report and involved in corrective action plan | |
| Administrator | Responsible for staff in-service, investigation, and termination of staff member involved in dignity and respect violation |
Inspection Report
Renewal
Census: 78
Capacity: 120
Deficiencies: 5
Aug 28, 2023
Visit Reason
The inspection was conducted as a renewal visit to review the facility's compliance with licensing requirements.
Findings
The inspection identified several deficiencies including improper use of common washcloths without labeling, incomplete emergency procedures, missing emergency evacuation diagrams on the second floor, presence of expired medications, and unavailability of a prescribed medication. The facility submitted a plan of correction which was fully implemented by the follow-up date.
Deficiencies (5)
| Description |
|---|
| Two common washcloths were used in rooms 246a and 246b without labeling indicating resident ownership. |
| The home's written emergency procedures lacked contact information for each resident’s designated person, local and state emergency management contacts, and a plan to provide confidential emergency medical information. |
| No emergency evacuation diagram was posted on the second floor of the home. |
| Expired medication (Lotrimin Powder) belonging to resident 1 was found in the resident's room, not destroyed according to regulations. |
| Prescribed medication Hyosyamine for resident 1 was not available in the home on the day of inspection. |
Report Facts
License Capacity: 120
Residents Served: 78
Current Hospice Residents: 9
Residents Age 60 or Older: 7
Residents Diagnosed with Mental Illness: 6
Residents Diagnosed with Intellectual Disability: 1
Residents with Mobility Need: 10
Residents with Physical Disability: 5
Inspection Report
Plan of Correction
Census: 74
Capacity: 120
Deficiencies: 3
Mar 7, 2023
Visit Reason
The inspection was conducted as a follow-up to verify the implementation of the submitted plan of correction related to an incident involving resident #1's aggressive behavior during medication administration.
Findings
The facility was found to have implemented the plan of correction fully, addressing deficiencies related to safe management techniques, prohibitions on manual restraints, and additional resident assessments for behavior changes.
Deficiencies (3)
| Description |
|---|
| Resident #1 demonstrates agitation and aggression when seeking medication; the home failed to implement positive interventions to modify or eliminate the behavior. |
| Use of manual restraint prohibited; resident #1 became agitated and aggressive, and staff held the resident's arms to avoid being struck. |
| Resident #1's assessment did not include behaviors of aggression and agitation related to medication administration or a plan to address this need. |
Report Facts
Inspection dates: 4
Licensed capacity: 120
Residents served: 74
Total daily staff: 86
Waking staff: 65
Inspection Report
Census: 74
Capacity: 120
Deficiencies: 0
Nov 22, 2022
Visit Reason
The inspection was conducted as a licensing inspection with a reason noted as 'Incident'. The inspection was partial, unannounced, and included off-site reviews on 11/22/2022, 11/23/2022, and 11/28/2022.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Report Facts
License Capacity: 120
Residents Served: 74
Current Hospice Residents: 4
Residents 60 Years or Older: 74
Residents Diagnosed with Mental Illness: 8
Residents Diagnosed with Intellectual Disability: 2
Residents with Mobility Need: 12
Residents with Physical Disability: 2
Total Daily Staff: 86
Waking Staff: 65
Inspection Report
Renewal
Census: 68
Capacity: 120
Deficiencies: 16
Aug 22, 2022
Visit Reason
The inspection was a renewal visit conducted on 08/22/2022 and 08/23/2022 to review compliance with licensing requirements for Independence Court of Quakertown.
Findings
The inspection identified multiple deficiencies related to privacy, sanitary conditions, trash receptacles, bathroom ventilation, surfaces, furniture and equipment, food protection, medication storage, and resident record content. Plans of correction were submitted and accepted with implementation dates by 10/29/2022.
Deficiencies (16)
| Description |
|---|
| No signs of surveillance posted in a public and conspicuous place despite video camera at facility entrance. |
| Ice freezer had brown substance resembling mold and white stain around door. |
| Uncovered, unattended trash can observed in main kitchen. |
| Trash outside dumpsters included wood table top and shopping cart. |
| Bathroom lacked operable window or ventilation fan; fan was inoperable. |
| Kitchen ceiling had hole from water leak damage. |
| Walk-in freezer in disrepair with water leaking from ceiling covering freezer floor. |
| Table and chairs placed in handicap parking space without caution signs. |
| Uncovered trays of chicken breasts stored in walk-in refrigerator. |
| Unlabeled, undated sandwiches and chicken breasts in kitchen refrigerators. |
| Home lacked sufficient 3-day supply of emergency drinking water; only 96 gallons available for 68 residents requiring 204 gallons. |
| Combustible materials stored near heat sources in boiler room. |
| Weekly menu for one week in advance not posted in conspicuous and public place. |
| Two loose pills found in medication cart drawer. |
| Medication administration records did not match blister card counts for multiple residents. |
| Resident records missing information such as color of hair, color of eyes, race, religious affiliation, and dietary restrictions. |
Report Facts
Residents served: 68
License capacity: 120
Current hospice residents: 3
Residents 60 years or older: 62
Residents diagnosed with mental illness: 10
Residents diagnosed with intellectual disability: 2
Residents with mobility need: 15
Residents with physical disability: 1
Total daily staff: 83
Waking staff: 62
Emergency drinking water required: 204
Emergency drinking water available: 96
Emergency drinking water ordered: 136
Inspection Report
Census: 73
Capacity: 120
Deficiencies: 0
Nov 8, 2021
Visit Reason
The inspection was a partial, unannounced visit conducted due to an incident at the facility.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Report Facts
Residents Served: 73
License Capacity: 120
Current Hospice Residents: 8
Resident Support Staff: 86
Waking Staff: 65
Residents Age 60 or Older: 70
Residents Diagnosed with Mental Illness: 8
Residents Diagnosed with Intellectual Disability: 1
Residents with Mobility Need: 13
Residents with Physical Disability: 4
Inspection Report
Complaint Investigation
Census: 73
Capacity: 120
Deficiencies: 5
Sep 9, 2021
Visit Reason
The inspection was conducted as a complaint investigation following concerns about resident care and incident reporting at the facility.
Findings
The inspection found multiple deficiencies including failure to report an incident involving a resident found unresponsive in the heat, neglect and abuse related to resident care, unqualified direct care staff, lack of rabies vaccination certificates for visiting dogs, and incomplete medical evaluation documentation for a resident.
Complaint Details
The visit was complaint-related, triggered by concerns about resident neglect and abuse, failure to report incidents, and staff qualifications. The complaint was substantiated based on the findings.
Deficiencies (5)
| Description |
|---|
| Failure to report an incident of a resident found unresponsive in the heat to the Department within 24 hours. |
| Resident neglect and abuse: resident left unattended outside in heat, unresponsive, and staff failed to contact emergency personnel or physician as required. |
| Direct care staff person did not have a high school diploma, GED, or active registry status on the Pennsylvania nurse aide registry. |
| Lack of current rabies vaccination certificates for two dogs visiting the home. |
| Resident's medical evaluation did not include required diagnoses related to medications prescribed. |
Report Facts
Residents Served: 73
License Capacity: 120
Total Daily Staff: 81
Waking Staff: 61
Residents Age 60 or Older: 71
Residents Diagnosed with Mental Illness: 4
Residents Diagnosed with Intellectual Disability: 1
Residents with Mobility Need: 8
Notice
Capacity: 120
Deficiencies: 0
Aug 17, 2021
Visit Reason
The document serves as a renewal notification for the operation license of Independence Court of Quakertown Personal Care Home, confirming receipt of the renewal application and advising of the requirement for an annual onsite inspection within the next twelve months.
Findings
No inspection findings are reported in this document; it is a licensing and renewal notification letter with an enclosed certificate of compliance.
Report Facts
Maximum capacity: 120
Inspection Report
Complaint Investigation
Census: 75
Capacity: 120
Deficiencies: 4
Aug 3, 2021
Visit Reason
The inspection visit was conducted as a complaint investigation to review compliance with regulatory requirements at Independence Court of Quakertown.
Findings
The inspection identified deficiencies related to treatment of residents, accommodations for disabilities, and support plan documentation including medical/dental care and signatures. Plans of correction were accepted and implemented with specified completion dates.
Complaint Details
The visit was complaint-related as indicated by the inspection reason. The complaint involved concerns about resident treatment and support plan adequacy. The plan of correction was accepted and fully implemented.
Deficiencies (4)
| Description |
|---|
| Staff person A failed to demonstrate sensitivity regarding the sexual behaviors of resident #1, describing the behavior as 'sick' and causing distress to the resident. |
| The home failed to utilize tactile accommodations for resident #2 with a visual impairment, compromising safety and independence. |
| The assessment and support plan for resident #1 did not document sexual behaviors or how this need would be met. |
| Resident #1 participated in the development of the support plan but did not sign it. |
Report Facts
License Capacity: 120
Residents Served: 75
Staffing Hours - Total Daily Staff: 83
Staffing Hours - Waking Staff: 62
Residents Age 60 or Older: 72
Residents Diagnosed with Mental Illness: 8
Residents Diagnosed with Intellectual Disability: 1
Residents with Mobility Need: 8
Residents with Physical Disability: 4
Inspection Report
Complaint Investigation
Census: 75
Capacity: 120
Deficiencies: 4
Aug 3, 2021
Visit Reason
The inspection was conducted as a complaint investigation during an unannounced partial inspection on 08/03/2021.
Findings
The inspection identified deficiencies related to resident dignity and respect, physical accommodations for a resident with a visual impairment, and incomplete documentation in resident support plans. Plans of correction were accepted and implemented with follow-up dates scheduled.
Complaint Details
The visit was complaint-related as indicated by the inspection information section stating 'Reason: Complaint'.
Deficiencies (4)
| Description |
|---|
| Staff person A failed to demonstrate sensitivity regarding the sexual behaviors of resident #1, describing the behavior as 'sick' and laughing at the resident, causing distress. |
| The home failed to provide tactile accommodations for resident #2 with a visual impairment, compromising safety and independence. |
| Resident #1's support plan did not document sexual behaviors or how this need would be met. |
| Resident #1 participated in the development of the support plan but did not sign it. |
Report Facts
License Capacity: 120
Residents Served: 75
Staffing Hours - Total Daily Staff: 83
Staffing Hours - Waking Staff: 62
Residents Age 60 or Older: 72
Residents Diagnosed with Mental Illness: 8
Residents Diagnosed with Intellectual Disability: 1
Residents with Mobility Need: 8
Residents with Physical Disability: 4
Inspection Report
Renewal
Census: 77
Capacity: 120
Deficiencies: 21
Jun 3, 2021
Visit Reason
The inspection was conducted as a renewal inspection of the facility's license, with an unannounced full inspection on 06/03/2021 and an exit conference on 06/04/2021.
Findings
The inspection identified multiple deficiencies including lack of carbon monoxide detectors near gas appliances, incomplete staff orientation records, inoperable bathroom exhaust fan, broken bathroom equipment, improper medication administration and documentation, food safety violations including improper refrigeration temperatures and outdated food, incomplete fire drill records, and issues with medication storage and administration procedures. Plans of correction were accepted and implemented with follow-up audits and staff training scheduled.
Deficiencies (21)
| Description |
|---|
| No carbon monoxide detector near gas hot water heaters and gas dryer on the 1st floor. |
| Staff person A did not receive proper first day orientation on fire safety and emergency preparedness. |
| Staff person A did not complete training on resident rights and mandatory abuse reporting within 40 hours. |
| Bathroom in resident's room lacked operable window or ventilation fan; fan was inoperable. |
| Broken toilet paper holder in resident's bathroom. |
| Resident had a mattress without fire retardant properties without required waiver documentation. |
| No toilet paper available in resident's bathroom at time of inspection. |
| Refrigerator temperatures in kitchen were above required limits, containing resident food. |
| Opened, undated bags of food found in walk-in freezer. |
| Fire drill record did not include number of residents in home at time of drill. |
| Staff member did not document medication administration immediately after giving medications to resident. |
| Prescription medication container label missing or incomplete for resident's as needed medication. |
| Medication administration record did not document administration of prescribed medication for resident. |
| Medication administration record did not include initials of staff administering medication for resident. |
| Resident was not educated on right to refuse medication if medication error suspected. |
| Resident's preadmission screening form did not include determination that needs could be met by facility. |
| Trash can in kitchen was uncovered. |
| Resident had medication on cart without current order. |
| Glucometer calibration overdue and PRN medications not available in home for resident. |
| Medication storage and documentation procedures incomplete, including documentation of controlled substances. |
| Resident prescribed medication was not given as ordered; discrepancies in medication administration record and glucometer readings. |
Report Facts
License Capacity: 120
Residents Served: 77
Staffing Hours: 90
Waking Staff: 68
Hospice Residents: 7
Residents Age 60 or Older: 72
Residents Diagnosed with Mental Illness: 8
Residents Diagnosed with Intellectual Disability: 1
Residents with Mobility Need: 13
Residents with Physical Disability: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff member B | Named in medication administration deficiency for not documenting medication immediately. | |
| Staff person A | Named in deficiencies related to incomplete orientation and training. | |
| Director of Nursing | Director of Nursing | Named in multiple findings related to medication administration, staff training, and corrective actions. |
| Maintenance Director | Maintenance Director | Named in deficiencies related to carbon monoxide detectors and bathroom exhaust fan repairs. |
| Administrator | Administrator | Named in deficiencies related to staff training, fire drill record corrections, and resident education. |
Inspection Report
Complaint Investigation
Census: 82
Capacity: 120
Deficiencies: 12
Mar 10, 2021
Visit Reason
The inspection was conducted as a complaint investigation following complaints received about the facility's compliance with regulations.
Findings
The inspection found multiple deficiencies including delayed staff response to call bells, unsanitary conditions with strong urine odors, unlocked resident records, missing bedroom furniture and supplies for residents, incomplete or outdated medical evaluations and support plans, and inadequate documentation of resident photographs. The facility was cited for neglect related to delayed care and failure to meet residents' mobility and medical needs.
Complaint Details
The visit was complaint-related as indicated by the inspection reason and was triggered by complaints about resident neglect, delayed care, and unsanitary conditions.
Deficiencies (12)
| Description |
|---|
| Failure to provide immediate access to home records upon request by Department agents. |
| Resident records were unlocked, unattended, and accessible to unauthorized persons. |
| Residents experienced neglect due to delayed response times to call bell requests, some exceeding 2 hours. |
| Inadequate staffing during certain hours as reported by staff, though contradicted by scheduling records. |
| Strong urine odor and unsanitary conditions observed in hallways, resident rooms, and laundry area. |
| Resident #3's bedroom lacked a chair, pillow, and operable bedside lamp. |
| Damaged wall in resident room 129 was under repair but not completed at time of inspection. |
| Resident #3's medical evaluation was outdated and did not reflect current mobility needs. |
| Resident #2's and #3's assessments were not updated to reflect significant changes including falls and pressure ulcers. |
| Resident #2 was assessed as totally immobile but call bell response was delayed over an hour. |
| Support plans for residents #2, #5, and #6 did not document how wound care needs would be met. |
| Resident records for #5, #6, #7, and #8 lacked photographs no more than 2 years old. |
Report Facts
License Capacity: 120
Residents Served: 82
Staffing: 98
Waking Staff: 74
Call bell delays: 11
Call bell delays evening: 8
Resident falls: 6
Inspection Report
Complaint Investigation
Census: 82
Capacity: 120
Deficiencies: 10
Mar 10, 2021
Visit Reason
The inspection was conducted as a complaint investigation with unannounced partial inspections on March 10 and 12, 2021, to review compliance with regulations and verify submitted plans of correction.
Findings
Multiple deficiencies were found including delayed staff response to call bells, unsanitary conditions with strong urine odors, unlocked resident records, lack of required bedroom furnishings, incomplete resident assessments, and missing photographs in resident records. Plans of correction were accepted and verified in follow-up inspections.
Complaint Details
The inspection was complaint-driven, triggered by allegations related to neglect and inadequate care, including delayed response to call bells and unsanitary conditions. The complaint was substantiated based on observed violations.
Deficiencies (10)
| Description |
|---|
| Delayed staff response to call bell requests, with some responses taking over 2 hours. |
| Resident records were unlocked, unattended, and accessible in the wellness room. |
| Strong smell of urine in hallways, laundry room, and resident bedrooms indicating unsanitary conditions. |
| No chair available in resident #3's bedroom. |
| Resident #3's bed did not have a pillow. |
| Resident #3 did not have access to an operable lamp at bedside. |
| Damaged plaster on wall in room 129 measuring approximately 5 feet by 4 feet. |
| Resident #2 and #3 had not received updated assessments reflecting significant changes in mobility and care needs. |
| Resident records for #5, #6, #7, and #8 did not include photographs less than 2 years old. |
| Resident #1's record did not include a photograph less than 2 years old. |
Report Facts
License Capacity: 120
Residents Served: 82
Staffing Hours: 98
Waking Staff: 74
Residents with Mobility Need: 16
Residents with Physical Disability: 4
Number of call bell delays over 40 minutes: 11
Damaged wall size: 20
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Claire Mendez | Human Services Licensing Supervisor | Signed the letter confirming plan of correction implementation. |
Inspection Report
Complaint Investigation
Census: 82
Capacity: 120
Deficiencies: 10
Mar 10, 2021
Visit Reason
The inspection was conducted as a complaint investigation following concerns raised about resident care and facility conditions.
Findings
Multiple deficiencies were found including delayed staff response to call bells, unsanitary conditions with strong urine odors, unlocked resident records, inadequate resident room furnishings, incomplete medical evaluations and support plans, and damaged facility infrastructure. Plans of correction were accepted and implemented.
Complaint Details
The visit was complaint-related, triggered by allegations of neglect and inadequate care, including delayed response to call bells and unsanitary conditions. The complaint was substantiated with multiple violations found.
Deficiencies (10)
| Description |
|---|
| Delayed staff response to call bell requests, with some responses taking over 2 hours. |
| Resident records were unlocked, unattended, and accessible in a common area. |
| Strong smell of urine in hallways and resident rooms; resident found heavily soiled. |
| No chair available in resident #3's bedroom. |
| Resident #3's bed did not have a pillow. |
| Resident #3 did not have an operable lamp or source of light at bedside. |
| Damaged plaster wall in resident room measuring 5 feet by 4 feet. |
| Resident #2 and #3 lacked updated assessments reflecting significant changes in condition. |
| Resident #5, #6, and #2 support plans did not document how wound care needs would be met. |
| Resident #5, #6, #7, and #8 records lacked photographs less than 2 years old. |
Report Facts
License Capacity: 120
Residents Served: 82
Staffing Hours: 98
Waking Staff: 74
Residents Served: 76
Staffing Hours: 84
Waking Staff: 63
Call bell response delays: 11
Call bell response delays: 8
Damaged wall size: 20
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Claire Mendez | Human Services Licensing Supervisor | Signed letter confirming plan of correction implementation. |
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