Inspection Reports for
On With Life Long Term Care

The investigation was triggered by complaints #1790227-C and #1790228-A, and a facility reported incident #1790229-M. Complaint #1790228-A resulted in a deficiency. The facility reported incident #1790229-M also resulted in a deficiency.

The facility failed to ensure accurate control, accountability, and disposition of scheduled controlled narcotic medication, specifically Dronabinol, with discrepancies found in medication counts and improper handling by staff. Video evidence and staff interviews confirmed medication mishandling and missing pills.

The complaint investigation revealed that a Dronabinol pill was missing from the facility. Video footage showed Staff A removing the pill and disposing of it improperly. Staff A admitted to taking and throwing away the pill without reporting it. The facility reported the incident to the police and state board of nursing. The investigation found failures in narcotic counting procedures and medication disposal protocols.

The facility failed to properly control and account for Dronabinol medication for Resident #1, including not disposing of the medication after discharge and inaccurate narcotic counts. Video footage showed a staff member removing and improperly disposing of a Dronabinol pill. The facility's narcotic counting and disposal protocols were not followed, and signatures on narcotic count sheets were altered improperly.

Investigation included Complaints #117031-C and #123453-C. Substantiation status is not explicitly stated.

The facility failed to serve food under sanitary conditions to prevent foodborne illness, including improper glove use and hairnet coverage by dietary staff. Additionally, infection control standards were not met due to a catheter bag not being maintained properly, lying on the floor without a cover.

The facility failed to serve food under sanitary conditions, including improper glove use and incomplete hairnet coverage by dietary staff, and failed to maintain infection control standards related to catheter care for one resident.

The facility was found deficient in several areas including inaccurate pneumococcal vaccination status documentation for one resident, failure to follow comprehensive care plan interventions for one resident, inadequate respiratory care for two residents requiring humidified air through tracheostomy, and failure to provide pneumococcal immunizations as recommended.

The facility was found deficient in accurately reflecting pneumococcal vaccination status for one resident, failing to follow care plan interventions for another resident, not providing appropriate respiratory care for two residents, and lacking proper policies and procedures for flu and pneumonia vaccinations. All deficiencies were cited with minimal harm and affected a few residents.

Complaint #103688-C was investigated and found to be not substantiated.

The facility failed to ensure a medication error rate of less than 5%, with two medication errors observed out of 27 opportunities, resulting in a 7.41% medication error rate. Errors included administering Tobradex ointment instead of prescribed eye drops and giving non-enteric coated aspirin when the order specified enteric coated aspirin.

The investigation was triggered by complaints regarding mistreatment and injuries to Resident #1. Facility reported incidents 98580-I, 98581-I, and 100161-I were substantiated; incident 100165-I was not substantiated.

The facility failed to ensure resident rights were respected, as evidenced by mistreatment of Resident #1 by staff. The facility also failed to report injuries of unknown origin timely for Resident #1. The facility reported a census of 31 residents.

Complaint #88373-C was investigated and found not substantiated according to 42 CFR Part 483, Subpart B-C.

The facility failed to adequately assess one resident for self-administration of medications and failed to provide proper catheter care using correct infection control practices, potentially risking infections. The facility implemented performance improvement plans and re-education for staff to address these issues.