Deficiencies per Year
16
12
8
4
0
Unclassified
Census Over Time
Census
Capacity
Inspection Report
Renewal
Census: 54
Capacity: 70
Deficiencies: 11
Nov 6, 2024
Visit Reason
The inspection was conducted as a renewal and incident review of the facility to assess compliance with licensing requirements and submitted plans of correction.
Findings
The inspection identified multiple deficiencies including breaches in resident record confidentiality, privacy violations, improper bedside mobility device documentation, unsecured medications, incomplete medication administration training, and incomplete emergency procedure postings. Plans of correction were accepted and implemented by early December 2024.
Deficiencies (11)
| Description |
|---|
| Medication cart was unattended with unlocked computer screen exposing confidential medication records and resident information. |
| Staff member took a picture of a resident on personal cell phone prior to hospital transfer, violating privacy. |
| Bedside mobility devices for residents were not securely attached, posing risk of entrapment. |
| Emergency procedures were not posted in a conspicuous and public place in the home. |
| Fire department notification lacked description of residents' mobility needs for evacuation. |
| Resident self-administered medications without physician assessment to approve self-administration. |
| Prescription medications and syringes were found unlocked and accessible in multiple resident rooms. |
| Medication administration record for a resident incorrectly stated frequency of patch application. |
| Several staff members had incomplete or outdated medication administration training and observations. |
| Staff members had not completed Department-approved diabetes education program but administered insulin. |
| Resident support plans did not document specific needs, risks, or device identification for bedside mobility devices. |
Report Facts
License Capacity: 70
Residents Served: 54
Current Hospice Residents: 3
Residents Age 60 or Older: 54
Residents with Mobility Need: 9
Residents Requiring Assistance for Evacuation: 7
Total Daily Staff: 63
Waking Staff: 47
Inspection Report
Complaint Investigation
Census: 58
Capacity: 70
Deficiencies: 1
Apr 2, 2024
Visit Reason
The inspection visit occurred as a complaint investigation to review compliance following a complaint at the facility.
Findings
The submitted plan of correction was determined to be fully implemented. The report details medication administration errors where residents were not given prescribed medications as ordered, followed by corrective actions including staff training and audits.
Complaint Details
The visit was complaint-related, with a follow-up type of Plan of Correction (POC) submission. The plan of correction was accepted and implemented with training and audits to prevent medication errors.
Deficiencies (1)
| Description |
|---|
| Resident was not administered prescribed medications as ordered on multiple occasions. |
Report Facts
License Capacity: 70
Residents Served: 58
Current Residents in Hospice: 2
Residents 60 Years or Older: 58
Residents Diagnosed with Mental Illness: 1
Residents with Mobility Need: 7
Residents with Physical Disability: 1
Total Daily Staff: 65
Waking Staff: 49
Resident Support Staff: 0
Medication Audit Population Percentage: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| DL | Employee | Performed training on Avoiding Common Medication Errors |
| Director of Wellness | Director of Wellness | Responsible for completing monthly medication audits |
| ED | Executive Director | Completed audit of resident MAR/TAR for February, March, and April |
Inspection Report
Renewal
Census: 57
Capacity: 70
Deficiencies: 11
Dec 20, 2023
Visit Reason
The inspection was conducted as a full, unannounced visit for renewal and complaint purposes on 12/20/2023 and 12/21/2023.
Findings
The facility was found to have multiple deficiencies including medication administration errors, failure to report incidents timely, incomplete criminal background checks, improper storage of poisonous materials, fire drill deficiencies, incomplete medical evaluations, staff training gaps, medication labeling errors, and incomplete preadmission screening documentation. Plans of correction were accepted and implemented with follow-up audits scheduled.
Deficiencies (11)
| Description |
|---|
| Failure to report medication incident to the Department within 24 hours. |
| Staff member hired without required State Police Criminal Background Check. |
| Poisonous materials stored in unlabeled or improperly labeled containers. |
| Fire drill not conducted during sleeping hours as required every 6 months. |
| Resident's medical evaluation did not include Medical Professional License Number. |
| Staff member providing transportation without completing required direct care staff training. |
| Prescription medications not properly labeled with current administration instructions. |
| Medication administration records inaccurately indicated medications were given when they were not. |
| Failure to follow prescriber's medication orders, including administering discontinued medications. |
| Preadmission screening forms completed after resident admission dates. |
| Resident support plan did not reflect alternate sleeping arrangements for a resident using a recliner due to CHF. |
Report Facts
License Capacity: 70
Residents Served: 57
Total Daily Staff: 67
Waking Staff: 50
Residents with Mobility Need: 10
Residents with Physical Disability: 1
Residents Diagnosed with Mental Illness: 1
Residents 60 Years or Older: 57
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Executive Director | Named in multiple findings related to education, audits, and plan of correction implementation. | |
| Medical Concierge | Involved in training and medication administration oversight. | |
| LPN | Involved in medication administration training and audits. | |
| HR Employee | Conducted audits of staff background checks. | |
| EVS Director | Involved in fire drill scheduling and education. | |
| Medication Administration Trainer | Conducted hands-on training with medication technicians. | |
| Driver | Completed direct caregiver course as part of staff training. |
Inspection Report
Complaint Investigation
Census: 51
Capacity: 70
Deficiencies: 1
May 2, 2023
Visit Reason
The inspection was conducted as a complaint investigation following an unannounced partial inspection on 05/02/2023.
Findings
A deficiency was found related to unsanitary conditions where Resident #1's nebulizer mouthpiece and tubing were observed to be unclean and appeared to contain mold or mildew. The submitted plan of correction was determined to be fully implemented.
Complaint Details
The visit was complaint-related as indicated by the inspection reason. The plan of correction was accepted and fully implemented.
Deficiencies (1)
| Description |
|---|
| Resident #1's nebulizer mouthpiece and tubing were unclean and appeared to contain mold or mildew. |
Report Facts
License Capacity: 70
Residents Served: 51
Current Hospice Residents: 2
Residents Age 60 or Older: 50
Residents Diagnosed with Mental Illness: 7
Residents with Mobility Need: 6
Residents with Physical Disability: 1
Inspection Report
Renewal
Census: 45
Capacity: 70
Deficiencies: 13
Aug 23, 2022
Visit Reason
The inspection was an unannounced full renewal inspection conducted to review compliance with licensing requirements and regulations.
Findings
Multiple deficiencies were identified including expired carbon monoxide alarm batteries, missing resident-home contracts, lack of CPR/First Aid certified staff during night shifts, incomplete staff orientation and training records, unsafe resident personal equipment, unsanitary conditions, exterior hazards, medication record inaccuracies, unlabeled medications, improper medication storage procedures, missing preadmission screening forms, and incomplete resident support plans. Plans of correction were accepted and implemented with specified completion dates.
Deficiencies (13)
| Description |
|---|
| Carbon monoxide alarms had batteries dated 10/2019 and were not replaced timely. |
| Resident 1 did not have a resident-home contract completed coinciding with admission date. |
| No staff certified in CPR and first aid were present during multiple night shifts when 45-47 residents were present. |
| Staff Member A lacked documentation of first day direct care orientation training in fire safety and emergency preparedness. |
| Staff Member A lacked training record for Rights/Abuse 40 Hours training. |
| Resident personal equipment (bed enabler bars) posed potential limb or head entrapment risks due to gaps and unsecured fastenings. |
| Glucometer was observed stained with blood and sanitation practices were not consistently maintained. |
| Exterior west emergency exit ramp was covered with slippery green moss and wet leaves, presenting a hazard. |
| Resident 4's medication administration record (MAR) included medications not found in resident's room and vice versa. |
| Over-the-counter (OTC) medications and complementary and alternative medicine (CAM) were found in medication carts not labeled with resident names. |
| Medication storage devices were not calibrated to correct date and time, causing discrepancies with MAR documentation. |
| Resident 1's preadmission screening form was missing, so determination of service needs was not documented. |
| Resident 1's initial support plan was not completed within 30 days of admission. |
Report Facts
Residents present during inspection: 45
Licensed capacity: 70
Staff present: 48
Waking staff: 36
Deficiency completion dates: Oct 1, 2022
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Erin Garcia | Executive Director | Named in relation to training and education plans for CPR/First Aid and other compliance requirements. |
| Bonnie Fulk | Director of Wellness (DOW) | Named in relation to medication audits, staff education, and compliance monitoring. |
Notice
Capacity: 70
Deficiencies: 0
Mar 14, 2021
Visit Reason
The document serves as a certificate of compliance and a renewal notice for the Personal Care Home license of Juniper Village at Lebanon I. It also informs the facility that an annual onsite inspection will be conducted within the next twelve months as required by state regulations.
Findings
The Department has issued a regular license in response to the renewal application and advises that an annual inspection will be conducted to ensure compliance with applicable laws and regulations.
Report Facts
Maximum capacity: 70
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jamie L. Buchenauer | Deputy Secretary | Signed the renewal notice letter |
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