Deficiencies per Year
4
3
2
1
0
Severe
High
Moderate
Low
Unclassified
Inspection Report
Follow-Up
Census: 37
Deficiencies: 1
Jun 4, 2025
Visit Reason
The document addresses a follow-up inspection and a complaint investigation conducted at Orchard Pointe Senior Alzheimer Community to verify compliance with assisted living facility licensing laws and regulations.
Findings
The follow-up inspection found no deficiencies, indicating the facility meets licensing requirements. However, the complaint investigation found that one staff member was not qualified to administer insulin injections to two residents, placing them at risk.
Complaint Details
Complaint investigation referenced complaint number 179282. The complaint investigation was unannounced and included review of 9 of 37 current residents. The complaint was substantiated by findings of unqualified staff administering insulin.
Deficiencies (1)
| Description |
|---|
| Failure to ensure 1 of 4 staff was qualified to administer insulin by injection to 2 of 2 residents, placing insulin-dependent residents at risk of health decline. |
Report Facts
Residents reviewed: 9
Staff qualified to administer insulin: 1
Residents affected: 2
Dates of complaint investigation: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Susan Carmichael | Nursing Consultant Institutional | Department staff who inspected the Assisted Living Facility. |
| Kathy Heinz | Long Term Care Surveyor | Department staff who inspected the Assisted Living Facility. |
| Staff C | Medication Technician | Staff member found unqualified to administer insulin injections to residents prior to completing Nurse Delegation Diabetes training. |
| Staff B | Registered Nurse Delegator | Interviewed and confirmed Staff C completed Nurse Delegation Diabetes training on 03/17/2025. |
| Manfay Chan | Allied Health Field Manager | Signed enforcement and follow-up letters. |
Inspection Report
Complaint Investigation
Deficiencies: 1
Feb 10, 2025
Visit Reason
The inspection was conducted as an unannounced on-site complaint investigation regarding a staff med tech administering a resident's long-acting insulin after it had been discontinued by the resident's physician, leading to harm.
Findings
The facility failed to ensure that one resident's medication was not administered following discontinuation, resulting in harm (seizure). The med tech admitted to administering the medication from memory despite the order being discontinued and removed from the medication administration system. Additional discontinued insulin pens remained available in the facility refrigerator.
Complaint Details
The complaint involved a staff med tech continuing to administer a resident's long-acting insulin after discontinuation by the physician, causing low blood glucose and a seizure. The complaint was substantiated with a citation issued.
Deficiencies (1)
| Description |
|---|
| Failure to ensure that a resident's medication was not administered following discontinuation by the physician, resulting in harm. |
Report Facts
Resident sample size: 4
Days medication administered after discontinuation: 19
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Michael Goulet | Complaint Investigator | Conducted the complaint investigation and follow-up inspection |
| Staff A | Med Tech | Admitted to administering discontinued medication from memory |
| Staff B | Director of Nursing Services | Noted that additional discontinued insulin pens remained in the facility refrigerator |
| Staff C | Resident Care Coordinator | Noted discontinuation of medication in the facility medication administration system |
| Manfay Chan | Allied Health Field Manager | Signed the follow-up inspection letter confirming no deficiencies |
Inspection Report
Life Safety
Deficiencies: 3
Jan 13, 2025
Visit Reason
The Office of the State Fire Marshal conducted an inspection at Orchard Pointe SR Alzheimer Comm facility to assess compliance with fire safety and life safety code requirements.
Findings
The facility was found disapproved due to failure to maintain sprinkler heads free of debris, failure to maintain portable fire extinguishers properly, and failure to provide documentation of annual servicing of the emergency generator.
Deficiencies (3)
| Description |
|---|
| Facility failed to maintain sprinkler head in kitchen above entry door, sprinkler head loaded with debris. |
| Facility failed to maintain portable fire extinguisher in back of kitchen by dish washing area, extinguisher mounted above 5 feet. |
| Facility failed to provide documentation showing annual servicing of generator. |
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Angela N Davis | Executive Director | Named as Owner or Authorized Representative signing the inspection documents. |
| Raul Murcia | Deputy State Fire Marshal | Conducted the inspection and signed the report. |
Loading inspection reports...
