Inspection Report Summary
The most recent inspection on June 6, 2024, identified deficiencies related to staffing, dementia-specific training, nurse delegation assessments, and a nonworking alarm on an exit door in the memory care wing. Earlier inspections showed a pattern of issues with tenant evaluations, service plan updates, and emergency safety measures, particularly in the dementia-specific program. Complaint investigations were generally unsubstantiated, except for one in 2018 where tenant rights were cited due to medication removal without permission. No fines, immediate jeopardy findings, or license actions were listed in the available reports. The facility’s deficiencies have remained fairly consistent over time, with ongoing challenges in staff training and documentation, and no clear trend of significant improvement or worsening.
Deficiencies (last 14 years)
Deficiencies are regulatory violations found during state inspections.
Deficiencies per year
Census
Based on a June 2024 inspection.
Census over time
| Description |
|---|
| The Program's Registered Nurse failed to document an assessment ensuring 3 of 3 staff reviewed were competent in assigned tasks and job duties within the first 60 days of employment. |
| The Program failed to ensure 8 hours of dementia-specific training was completed within 30 days of employment for 1 of 1 staff reviewed hired within the past year. |
| The Program failed to ensure 2 of 2 staff employed longer than a year had at least 8 hours of dementia-specific continuing education annually. |
| The Program failed to have a working alarm on 1 of 3 exit doors in the memory care wing which could affect 16 tenants residing in that wing. |
| Name | Title | Context |
|---|---|---|
| Betsy Walrath | Wellness Administrator | Named in relation to nurse delegation and training deficiencies; confirmed findings and provided corrective action plans. |
| Staff F | Staff member whose personnel file lacked RN documentation ensuring competency in assigned tasks. | |
| Staff H | Staff member whose personnel file lacked RN documentation ensuring competency and dementia training. | |
| Staff I | Staff member reviewed for dementia-specific continuing education compliance. | |
| Staff C | Staff member who did not complete required dementia-specific training within 30 days. |
| Description |
|---|
| Failed to evaluate 2 out of 4 tenants within 30 days of occupancy. |
| Failed to update 3 of 4 tenants' service plans within 30 days of occupancy. |
| Failed to ensure all exit doors in the dementia-specific program contained an operating alarm system. |
| Name | Title | Context |
|---|---|---|
| Director | Confirmed findings related to evaluation, service plans, and alarm system deficiencies. | |
| Maintenance Director | Confirmed that no exit doors had fully installed operating alarm systems and described partial installation. |
| Description |
|---|
| Failure to ensure tenant was treated with consideration, respect, and full recognition of personal dignity and autonomy as evidenced by removal of medications without permission. |
| Name | Title | Context |
|---|---|---|
| Amber Roberts | Executive Director | Signed Plan of Correction letter dated March 7, 2018 |
| Description |
|---|
| Program failed to evaluate functional, cognitive and health status prior to signing the occupancy agreement for 2 of 5 tenants reviewed. |
| Program failed to evaluate functional, cognitive and health status within 30 days of occupancy for 4 of 5 tenants reviewed. |
| Program failed to create a preliminary service plan as required for 2 of 5 tenants reviewed. |
| Program failed to ensure service plans were updated within 30 days of admission for 2 of 3 tenants reviewed. |
| Program failed to ensure tenants who received program administered medications were monitored every 90 days as required for 3 of 5 tenants reviewed. |
| Name | Title | Context |
|---|---|---|
| Vonnie Potter | Executive Director | Interviewed confirming missing documentation and nurse review findings; signed Plan of Correction letter |
| Description |
|---|
| Dependent adult abuse training curriculum was not approved by the director of public health. |
| Service plans did not meet the specific service needs of individual tenants, including lack of interventions for pressure ulcers, weight loss, and impaired skin integrity. |
| Nurse reviews were not completed with changes of condition to assess and document health status and monitor progress related to previous recommendations. |
| Description |
|---|
| Evaluation regulatory insufficiency related to incomplete evaluations and failure to determine continued eligibility or changes in services. |
| Service plan regulatory insufficiency due to service plans not meeting identified tenant needs and not being updated appropriately. |
| Nurse review regulatory insufficiency due to incomplete nurse reviews, lack of medication review documentation, and failure to monitor tenants after significant condition changes. |
| Name | Title | Context |
|---|---|---|
| Lori Miner | RN BSN | Monitor conducting the complaint/incident investigation. |
| Description |
|---|
| A program shall evaluate each tenant’s functional, cognitive and health status within 30 days of occupancy and as needed, but evaluations were not completed as required. |
| Service plans were not developed based on functional and health evaluations as required by regulations. |
| Name | Title | Context |
|---|---|---|
| Margaret Kaltefleiter | RN MS | Monitor for the complaint/incident investigation |
| Ann Martin | RN | Monitor for the complaint/incident investigation |
| Rose Boccella | Program Coordinator | Signed cover letter for the report |
| Description |
|---|
| Missing Hydrocodone and Tylenol tablets for multiple tenants and incomplete narcotic counts. |
| Medication administration not always performed by a registered nurse or licensed personnel as required. |
| Name | Title | Context |
|---|---|---|
| Hal L. Chase | RN BSN MPH | Monitor conducting the complaint/incident investigation |
| Name | Title | Context |
|---|---|---|
| Hal L. Chase | RN BSN MPH | Monitor conducting the evaluation |
| Name | Title | Context |
|---|---|---|
| Joyce Kix | RN | Monitor during complaint investigation |
| Lori Miner | RN BSN | Monitor during complaint investigation |
| Name | Title | Context |
|---|---|---|
| Joyce Kix | RN | Monitor conducting the complaint investigation |
| Connie Schaffer | Certification Coordinator | Signed cover letter transmitting the complaint investigation report |
| Description |
|---|
| The program does not consistently complete a cognitive evaluation annually as required. |
| The program does not design service plans to meet the specific needs of the individual tenant. |
| The program does not consistently update service plans within 30-days of admission and annually and does not have a multi-disciplinary team of three staff sign the service plans as required. |
| Description |
|---|
| The program did not consistently complete annual functional, cognitive and health evaluations. |
| The program did not consistently complete annual service plan updates. |
| The program did not consistently complete a nurse review every 90 days. |
| The program did not provide appropriate programming for each tenant. |
| The program did not complete appropriate employee record checks. |
| Name | Title | Context |
|---|---|---|
| Tim Perry | Administrator | Named in complaint allegation regarding removal of tenant medical records and medication documentation |
| Hal L. Chase | RN BSN MPH Monitor | Conducted monitoring visit |
| Connie Schaffer | Monitor | Conducted monitoring visit |
| Name | Title | Context |
|---|---|---|
| Tim Perry | Administrator | Administrator of Waterford at Ames Assisted Living |
| Mary Oliver | LISW | Monitor during complaint investigation |
| Jan O’Briant | LISW | Monitor during complaint investigation |
Loading inspection reports...