Inspection Reports for
Rotary Senior Living

The investigation was complaint-driven, focusing on allegations of mistreatment and neglect of Resident #2 and failure to report abuse timely. The complaint was substantiated with findings of dignity violations and reporting failures.

The facility failed to treat a resident with dignity and respect, failed to timely report alleged abuse to authorities, and failed to properly assess and document skin conditions and wound care for a resident with an infected wound. The facility identified a census of 31 residents.

The investigation was triggered by Incident #123222-I involving Tenant #1 eloping from the secured memory care area on 08/29/24. The complaint was substantiated as the alarm system was found not to be working properly.

The facility failed to ensure the alarm system connected to each exit door in the dementia-specific program operated properly, resulting in a tenant eloping. Corrective actions included door realignment, installation of an audible door alarm system, updated door check policies, staff education, and implementation of systematic long-term solutions.

The facility failed to provide the Notice of Medicare Non-Coverage (NOMNC) to two residents and did not have the required 8 hours of Registered Nurse coverage on a specific date. The facility reported a census of 32 residents during the survey.

The facility failed to provide required Medicare Non-Coverage notices to residents, timely notify the Long Term Care Ombudsman of hospital transfers, inform residents or representatives of bed hold policies, ensure diet orders matched actual meals served, and maintain required RN coverage hours.

The complaint investigation found that staff failed to complete narcotic counts as required on 11/7/23 and 11/8/23 and did not destroy discontinued Oxycodone medication for Resident #1. The narcotic medication card and count sheet were missing, and an investigation was initiated.

The facility failed to perform scheduled controlled medication counts as required by policy and did not destroy discontinued narcotic medication for one resident. The narcotic medication card and count sheet went missing, prompting an investigation.

The inspection was triggered by complaints #113691-C, #117974-C, and #112850-C. The findings were substantiated as the program failed in multiple regulatory requirements related to staff training, documentation, service plans, and nurse reviews.

The program failed to ensure certified and noncertified staff received training regarding service plan tasks, failed to document doctor-ordered tasks on medication administration records, failed to develop service plans prior to admission and based on evaluations, and failed to complete nurse reviews for tenants as required.

The facility was found deficient in multiple areas including failure to ensure correct code status documentation, failure to notify physicians of significant weight loss and abnormal blood glucose levels, incomplete discharge summaries, inadequate resident care such as repositioning and toileting, improper posting of nurse staffing information, inaccurate medical record documentation, lapses in infection control practices, and failure to properly document immunization education and consent.

The complaint investigation substantiated that the facility failed to timely report a resident altercation, failed to initiate CPR as ordered, had inconsistent code status documentation, and failed to assess residents after a physical altercation.

The facility failed to timely notify the Department of Inspections and Appeals of a resident altercation, failed to initiate CPR as ordered for a resident who expired, had inconsistent documentation of residents' code status, and failed to assess residents following a physical altercation. The facility reported a census of 38 residents.