Deficiencies per Year
8
6
4
2
0
Unclassified
Inspection Report
Complaint Investigation
Deficiencies: 1
Jan 12, 2022
Visit Reason
The inspection was conducted as a complaint investigation triggered by concerns related to resident units and their accessibility features.
Findings
The inspection found that resident units #2 and #13 were not fitted with single motion doorknobs and would require special knowledge to open. Additionally, these units have locks that need to be serviced with planned resident evaluations quarterly to show the ability to use a lock and key.
Complaint Details
Complaint inspection conducted; no substantiation status explicitly stated.
Deficiencies (1)
| Description |
|---|
| Resident units #2 and #13 are not fitted with single motion doorknobs and require special knowledge to open; locks need servicing with quarterly resident evaluation showing ability to use lock and key. |
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Amanda MacDonald | Administrator | Named as facility administrator during complaint inspection. |
| Noelle Markland | Survey Team Leader | Led the complaint inspection team. |
Inspection Report
Complaint Investigation
Deficiencies: 4
Aug 24, 2021
Visit Reason
A Complaint Inspection survey was conducted at Renaissance Senior Care, Dillon South on 08/24/2021 following a complaint that triggered the investigation.
Findings
Core issue deficiencies were cited related to personal care services and administration, including failure to properly monitor a resident leading to a fall with injuries, failure to report high blood pressures and injuries to the nurse and physician promptly, delayed notification of legal representative and practitioner about the fall, and inadequate pain assessment and medication following the incident.
Complaint Details
The complaint investigation substantiated deficiencies in personal care services and administration related to Resident #1's fall and subsequent care.
Deficiencies (4)
| Description |
|---|
| Resident #1 was left unobserved on the toilet, resulting in a fall and injuries due to staff failing to lock wheelchair in place. |
| High blood pressures and injuries of Resident #1 were not reported to the Registered Nurse or physician promptly, risking life-threatening consequences. |
| Legal representative and practitioner were not notified of Resident #1's fall with injury until the following day. |
| No nurse pain assessment documented and only one dose of pain medication administered despite multiple signs of pain after Resident #1's fall. |
Report Facts
Incident date: Aug 9, 2021
Blood pressure readings: 203150
Blood pressure readings: 17398
Progress note entries: 7
Pain medication doses: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Amanda MacDonald | Administrator | Named as Administrator interviewed regarding lack of documentation and reporting |
| Noelle Markland | Survey Team Leader | Led the complaint inspection survey |
Inspection Report
Renewal
Deficiencies: 5
Jun 2, 2021
Visit Reason
The inspection was conducted as a renewal inspection of Renaissance Senior Care, Dillon South to assess compliance with regulatory standards.
Findings
The inspection identified multiple deficiencies including lack of documentation in the disaster plan for acquisition of supplies and off-site evacuation agreements, missing thermometers in food storage areas, absence of privacy curtains or screens in resident rooms, lack of documentation for non-combustible treatment of curtains, and missing documentation that service plans were provided to residents or their legal representatives.
Deficiencies (5)
| Description |
|---|
| No documentation of acquisition of blankets, water, and food in disaster plan; no written agreement for off-site evacuation documented or updated annually. |
| Standup refrigerator/freezer and deep freezer in garage lacked thermometers to monitor or record temperatures. |
| No privacy curtain or screen in double occupancy room; movable screen not located. |
| No documentation that curtains were treated with non-combustible treatment in resident rooms #1 and #2; no documentation that any curtains in facility had this treatment. |
| No documentation that copies of service plans were given to residents or their legal representatives in review of 3 residents' service plans. |
Report Facts
Residents' service plans reviewed: 3
Residents referenced for curtain treatment: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Amanda MacDonald | Administrator | Named as facility administrator during inspection |
| Noelle Markland | Survey Team Leader | Named as survey team leader for renewal inspection |
Inspection Report
Renewal
Deficiencies: 2
Jul 28, 2020
Visit Reason
The inspection was conducted as a renewal inspection of the facility license.
Findings
Two deficiencies were identified: an expired first aide certification in the Administrator's file and the absence of a privacy curtain or screen in a double occupancy room as stated by the Administrator during a virtual tour.
Deficiencies (2)
| Description |
|---|
| Expired first aide certification in Administrator's file (expired September 2016). |
| No privacy curtain or screen available in double occupancy room. |
Inspection Report
Complaint Investigation
Deficiencies: 2
Sep 13, 2018
Visit Reason
The inspection was conducted as a complaint investigation at Renaissance Senior Care, Dillon South.
Findings
Two core issues were identified related to written policies and procedures, and personal care services.
Complaint Details
The visit was triggered by a complaint, as indicated by the survey type 'Complaint Inspection'.
Deficiencies (2)
| Description |
|---|
| WRITTEN POLICIES AND PROCEDURES |
| PERSONAL CARE SERVICES |
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Tara Wooten | Survey Team Leader | Named as the survey team leader conducting the complaint inspection. |
Inspection Report
Renewal
Deficiencies: 4
May 25, 2018
Visit Reason
The inspection was conducted as a renewal inspection of Renaissance Senior Care, Dillon South, to assess compliance with licensing requirements and facility regulations.
Findings
The survey found repeat deficiencies including missing May activity calendar, lack of access to certain facility records due to administrator absence, and outdated resident certifications. Employee files were initially unavailable but later found compliant upon follow-up inspection.
Deficiencies (4)
| Description |
|---|
| Missing May activity calendar in the dining room, a repeat deficiency from the 2015 renewal survey. |
| Surveyor did not have access to all facility records including updated Resident Needs Assessments for Residents #1-#9, fire drills for 2017 and 2018, closed resident files, refrigerator and freezer temperatures, incident reports, and updated certifications for Residents #1-#6, #8-#9. |
| Employee files were not available for review upon initial survey as required by ARM 37.106.2817(2), but were found compliant during follow-up inspection. |
| Resident #1's certification by a licensed healthcare professional was last updated in May 2018, with the prior certification from 2016, a repeat deficiency from the 2015 renewal survey. |
Report Facts
Number of residents with missing updated Resident Needs Assessments: 9
Number of residents with missing updated certifications: 8
Number of staff files requested: 3
Inspection Report
Renewal
Deficiencies: 1
May 10, 2017
Visit Reason
The inspection was conducted as a renewal inspection of the facility license.
Findings
The report notes that a staff and resident fire drill was conducted only once in 2016, based on interview with the administrator and document review.
Deficiencies (1)
| Description |
|---|
| Only one staff and resident fire drill was conducted in 2016. |
Inspection Report
Renewal
Deficiencies: 4
Dec 12, 2016
Visit Reason
The inspection was conducted as a renewal inspection of the Renaissance Senior Care facility in Dillon to assess compliance with regulatory requirements.
Findings
The inspection identified deficiencies including inaccessible call system strings in bathrooms of rooms 3 and 9, undated and unlabeled food items in the refrigerator, hot water temperatures in rooms 3, 7, and 9 below standard, and an outdated fire inspection record from 9/1/2015.
Deficiencies (4)
| Description |
|---|
| Room #3 and #9 did not have a string attached to the call system in the bathroom, making it inaccessible to an individual collapsed on the floor. |
| Three food items in the refrigerator were not dated and labeled, including two items not covered. |
| Hot water temperature in room #3 was 129 degrees, room #7 was 129.2 degrees, and room #9 was 126 degrees. |
| Last fire inspection on record was completed on 9/1/2015. |
Report Facts
Hot water temperature: 129
Hot water temperature: 129.2
Hot water temperature: 126
Date of last fire inspection: Sep 1, 2015
Inspection Report
Renewal
Deficiencies: 5
Dec 18, 2015
Visit Reason
The inspection was conducted as a renewal inspection of Renaissance Senior Care, Dillon South facility to assess compliance with assisted living regulations.
Findings
The inspection identified multiple deficiencies including outdated health care plan reviews, missing thermometer in the kitchen freezer, refrigerator temperature logs not maintained for over three months, deadbolts on exit doors, non-single motion doorknobs on resident rooms, and excessively high water temperatures in several locations.
Deficiencies (5)
| Description |
|---|
| Resident #1's last Health Care Plan review was in April 2015 and last certification by a Licensed Health Care Professional was on 1/15/2015. |
| The Activity Calendar posted was dated September 2015. |
| Main entrance door and back patio door both had dead bolts; no resident room doorknobs were single motion. |
| Refrigerator temperature logs have not been kept for greater than 3 months; no thermometer found in the kitchen freezer. |
| Temperatures were greater than 120 degrees in 3 out of 4 locations tested: laundry sink (130.0), community bathroom (128.8), and one resident room bathroom (129.1). |
Report Facts
Temperature reading: 130
Temperature reading: 128.8
Temperature reading: 129.1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Tara Wooten | Survey Team Leader | Named as Survey Team Leader for the renewal inspection |
Inspection Report
Complaint Investigation
Deficiencies: 5
Jan 22, 2015
Visit Reason
The inspection was conducted as a complaint investigation at Renaissance Senior Care, Dillon South to address concerns related to safety, resident care, and documentation.
Findings
The inspection identified multiple deficiencies including lack of keypad code posting causing safety issues, residents dependent on care without proper practitioner orders, missing family notifications for incident reports, inadequate documentation of personal care services and medical notifications, and a repeat deficiency regarding lack of physician order for a bed rail.
Complaint Details
Inspection was complaint-driven as indicated by the survey type 'Complaint Inspection' and the nature of deficiencies related to safety and care concerns.
Deficiencies (5)
| Description |
|---|
| Code sequence not posted for keypad in facility causing safety issue as people without code could not exit in emergency. |
| Residents #1 & #2 dependent in more than four activities of daily living without practitioner's written orders for admission and care. |
| Incident reports on residents #1 & #2 with no notification of family members documented. |
| Resident #2 shows significant weight loss; no documentation supporting service plan needs being met; incident reports without medical practitioner notification; no progress notes in resident files. |
| Resident #1 has a half rail on bed without physician order for safety device; repeat deficiency for this facility. |
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Linda Egebjerg | Survey Team Leader | Named as survey team leader conducting the complaint inspection. |
Inspection Report
Renewal
Deficiencies: 3
Nov 14, 2013
Visit Reason
The inspection was conducted as a renewal inspection of the assisted living facility Renaissance Senior Care, Dillon South.
Findings
The report identifies three core issues related to placement in assisted living facilities and physical plant requirements, citing specific rules 50-5-226-3, 50-5-226-7, and 37.106.2865-12.
Deficiencies (3)
| Description |
|---|
| Placement in assisted living facilities |
| Placement in assisted living facilities |
| PHYSICAL PLANT |
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Shelley Lowe | Survey Team Leader | Named as Survey Team Leader for the renewal inspection |
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