Deficiencies per Year
12
9
6
3
0
Severe
High
Moderate
Low
Unclassified
Census Over Time
Inspection Report
Complaint Investigation
Census: 21
Deficiencies: 4
Jul 2, 2024
Visit Reason
The inspection was conducted during the investigation of Incident #121790-I and the recertification visit to determine compliance with certification of an Assisted Living Program for People with Dementia.
Findings
The program failed to follow Life Safety policies regarding staff response to memory care door alarms, resulting in inadequate supervision of a tenant who eloped. Additionally, staff failed to supervise the tenant according to training, service plans were not updated to address increased wandering behaviors, and occupancy agreements were not signed prior to move-in for some tenants.
Complaint Details
The visit was complaint-related, investigating Incident #121790-I involving a tenant who eloped and staff response failures.
Deficiencies (4)
| Description |
|---|
| Failed to follow Life Safety policy on staff response to memory care door alarms for a tenant who eloped. |
| Staff failed to supervise a tenant admitted in the past four months according to training received. |
| Failed to ensure occupancy agreements were signed prior to tenants taking occupancy. |
| Service plan did not address identified needs of a tenant admitted within the past four months, including increased wandering and exit-seeking behaviors. |
Report Facts
Total census: 21
Tenants without cognitive impairment: 2
Tenants with cognitive impairment: 19
Incident date: Jun 24, 2024
Date survey completed: Jul 2, 2024
Date of admission Tenant #1: Mar 24, 2023
Date occupancy agreement signed Tenant #1: Apr 1, 2023
Date of admission Tenant #2: Aug 7, 2023
Date occupancy agreement signed Tenant #2: Aug 8, 2023
Dates of 1:1 supervision documented: 5
Date of nurse review Tenant #1: May 13, 2023
Date of informal 30-day notice to Tenant #1 family: May 17, 2023
Inspection Report
Complaint Investigation
Census: 21
Deficiencies: 2
Oct 27, 2022
Visit Reason
The inspection was conducted as a result of investigation 103862-I concerning regulatory insufficiencies related to incident reporting and life safety policies in an assisted living program for people with dementia.
Findings
The program failed to document all unusual occurrences for one tenant, Tenant C1, who had multiple elopements, including one undocumented incident. Additionally, the program failed to follow the Life Safety - Memory Care policy, as staff did not respond immediately to door alarms during elopements. The facility has since updated policies and procedures, retrained staff, and implemented new alarm notification systems.
Complaint Details
Investigation 103862-I was complaint-related and found regulatory insufficiencies in incident reporting and life safety policy adherence for Tenant C1. The complaint was substantiated based on record reviews and staff interviews.
Deficiencies (2)
| Description |
|---|
| Failed to document all unusual occurrences for 1 of 1 tenants reviewed (Tenant C1) involving multiple elopements, including an undocumented incident. |
| Failed to follow the Life Safety - Memory Care policy, resulting in delayed staff response to door alarms during tenant elopements. |
Report Facts
Number of tenants: 21
Tenants without cognitive impairment: 1
Tenants with GDS of 4 or above: 20
Inspection Report
Annual Inspection
Census: 19
Deficiencies: 10
Apr 8, 2021
Visit Reason
Recertification visit to determine compliance with certification for a Dedicated Dementia Specific Assisted Living Program and an onsite infection control survey.
Findings
The Program failed to follow medication policies, complete nurse delegation training timely, complete dependent adult abuse training timely, complete background checks prior to employment, complete evaluations and service plans as needed with significant changes, provide required dementia-specific education including hands-on training within 30 days of hire, and maintain required safety equipment in a transport vehicle.
Deficiencies (10)
| Description |
|---|
| Failed to follow policy and procedure related to medications affecting 1 of 4 tenants observed on medication pass and potentially all tenants with medications administered by the Program. |
| Failed to complete nurse delegated training within 30 days of hire for 3 of 6 staff reviewed. |
| Failed to complete dependent adult abuse training within six months of employment for 2 of 2 staff reviewed employed six months or greater. |
| Failed to complete background checks prior to employment for 1 of 6 staff reviewed. |
| Failed to request Department of Human Services evaluation to determine if employment was prohibited for 1 staff reviewed. |
| Failed to complete evaluations as needed with significant change for 3 of 3 tenants reviewed. |
| Failed to complete service plans as needed and failed to develop service plans to reflect identified needs of 3 tenants reviewed. |
| Failed to ensure staff completed eight hours of dementia-specific education within 30 days of hire for 3 of 6 staff reviewed. |
| Did not provide dementia-specific training including hands-on training for 2 of 6 staff reviewed. |
| Failed to maintain required safety equipment (first-aid kit, fire extinguisher, safety triangles) in a vehicle used to transport tenants. |
Report Facts
Census: 19
Medication errors: 3
Staff reviewed for nurse delegation training: 6
Staff failed nurse delegation training within 30 days: 3
Staff reviewed for dependent adult abuse training: 2
Staff failed dependent adult abuse training within 6 months: 2
Staff reviewed for background checks: 6
Staff failed background checks prior to employment: 1
Tenants reviewed for evaluations and service plans: 3
Staff reviewed for dementia-specific education: 6
Staff failed dementia-specific education within 30 days: 3
Staff failed hands-on dementia-specific training: 2
Inspection date: Apr 8, 2021
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff G | Administered medications incorrectly to Tenant #2 | |
| Staff B | Failed nurse delegation training within 30 days; failed background checks prior to employment; required record check evaluation not completed prior to work | |
| Staff E | Failed nurse delegation training within 30 days; failed dementia-specific hands-on training | |
| Staff F | Failed nurse delegation training within 30 days | |
| Staff C | Failed dependent adult abuse training within 6 months; failed dementia-specific education within 30 days; failed dementia-specific hands-on training | |
| Staff D | Failed dependent adult abuse training within 6 months; failed dementia-specific education within 30 days | |
| Staff A | Failed dementia-specific education within 30 days | |
| Staff H | Confirmed transport vehicle lacked required safety equipment | |
| Director of Health and Wellness | Interviewed regarding medication errors, training, evaluations, and background checks | |
| Executive Director | Interviewed regarding training, evaluations, and background checks |
Inspection Report
Renewal
Census: 19
Deficiencies: 0
Mar 25, 2019
Visit Reason
The visit was conducted as a recertification to determine compliance with certification of an Assisted Living Program for People with Dementia, including investigation of a complaint and incident.
Findings
No regulatory insufficiencies were cited during the recertification visit or the investigation of Complaint #81354-C and Incident #81882-I.
Complaint Details
Investigation of Complaint #81354-C and Incident #81882-I found no regulatory insufficiencies.
Report Facts
Number of tenants without cognitive disorder: 2
Number of tenants with cognitive disorder: 19
Total census: 19
Inspection Report
Complaint Investigation
Census: 20
Deficiencies: 3
Nov 13, 2018
Visit Reason
The investigation was conducted in response to Complaint #78690-C regarding tenant rights violations at Keystone Place at Forevergreen.
Findings
The program failed to ensure tenants were treated with consideration, respect, and full recognition of personal dignity and autonomy related to staff taking and transmitting electronic images and recordings of tenants via social media. Additionally, the program failed to complete required criminal and abuse background checks prior to employment and re-hiring of staff.
Complaint Details
Complaint #78690-C was investigated and resulted in regulatory insufficiencies related to tenant rights violations and background check deficiencies.
Deficiencies (3)
| Description |
|---|
| Failure to ensure tenants were treated with consideration, respect, and full recognition of personal dignity and autonomy related to staff taking and transmitting electronic images and recordings of tenants via social media. |
| Failure to complete a complete criminal history background check and child and dependent adult abuse record checks prior to employment for 1 of 7 staff reviewed. |
| Failure to complete a background check within 30 days of receipt of results for 1 of 7 staff reviewed. |
Report Facts
Number of tenants without cognitive disorder: 1
Number of tenants with cognitive disorder: 19
Total census: 20
Staff reviewed for background checks: 7
Staff with incomplete background check prior to re-hire: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Mary Jo Pipkin | Executive Director | Named in plan of correction letter and interview statements |
| Staff A | Reported taking and transmitting electronic images and recordings of tenants | |
| Staff B | Subject of background check deficiency and involved in social media incident | |
| Staff E | Reported sharing images on social media | |
| Staff F | Reported sharing images on social media and re-hired by the program | |
| Executive Director | Interviewed regarding background check and social media incidents | |
| Nurse | Interviewed regarding social media incidents |
Inspection Report
Complaint Investigation
Census: 62
Deficiencies: 3
Apr 2, 2018
Visit Reason
The inspection was conducted as an investigation of Complaint #74567 regarding regulatory insufficiencies in the Assisted Living Program for People with Dementia at Keystone Place at Forevergreen.
Findings
The program failed to complete required functional, cognitive, and health evaluations for tenants with significant changes, failed to timely complete nursing notes for multiple tenants, and failed to update service plans to reflect needed changes. Several tenants' records showed late or incomplete documentation and lack of timely evaluations.
Complaint Details
Investigation of Complaint #74567 revealed multiple regulatory insufficiencies related to tenant evaluations, documentation, and service plans.
Deficiencies (3)
| Description |
|---|
| Failure to complete functional, cognitive, and health evaluations within 30 days of occupancy and with significant changes for 3 of 7 tenants. |
| Failure to timely complete nursing notes for 6 of 7 tenants. |
| Failure to update service plans as warranted by needed changes for 3 of 7 tenants. |
Report Facts
Number of tenants without cognitive disorder in general population: 38
Number of tenants with cognitive disorder in general population: 4
Number of tenants without cognitive disorder in memory care unit: 2
Number of tenants with cognitive disorder in memory care unit: 18
Total census of Assisted Living Program for People with Dementia: 62
Number of tenants affected by evaluation deficiency: 3
Number of tenants affected by nursing notes deficiency: 6
Number of tenants affected by service plan deficiency: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Mary Jo Pipkin | Executive Director | Signed the Plan of Correction letter dated April 26, 2018 |
| Staff A | Registered Nurse | Interviewed regarding late documentation and nursing notes |
| Staff B | Licensed Practical Nurse | Interviewed regarding documentation timeliness |
| Director of Health Care Services | Confirmed late entries and deficiencies during interview | |
| Previous Director of Nursing | Director of Nursing (DON) | Responsible for late entries prior to departure |
Inspection Report
Original Licensing
Census: 30
Deficiencies: 4
Apr 27, 2017
Visit Reason
The inspection was conducted as an initial certification visit to determine compliance with certification for an Assisted Living Program.
Findings
The program failed to meet requirements related to medication administration policies and procedures, service plans, and dementia-specific education for personnel. Deficiencies were noted in documentation of medication administration, updating and signing of service plans, and provision of hands-on dementia training for staff.
Deficiencies (4)
| Description |
|---|
| Program failed to follow policy and procedure related to administration of as needed (PRN) medications for 2 of 4 tenant files reviewed and one tenant observed on medication pass; documentation of reason for administration was missing. |
| Program failed to update service plans as needed and ensure service plans met specific service needs for 3 of 4 tenant files reviewed. |
| Program failed to ensure service plans were signed by tenant or legal representative when significant changes triggered review and update for 2 of 4 tenant files. |
| Program failed to provide dementia-specific hands-on training for 5 of 7 staff files reviewed. |
Report Facts
Number of tenants without cognitive disorder: 13
Number of tenants with cognitive disorder: 17
Total census of Assisted Living Program: 30
Tenant files reviewed: 4
Staff files reviewed: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Mary Jo Pipkin | Executive Director | Signed Plan of Correction letter |
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