Inspection Report
Follow-Up
Deficiencies: 10
Sep 12, 2024
Visit Reason
The inspection was a health care licensure and follow-up survey conducted to assess compliance with regulatory requirements and verify correction of previously cited deficiencies.
Findings
The facility failed to implement effective corrective actions to prevent incident recurrence, did not complete required nursing assessments, and lacked comprehensive assessments and interim care plans for several residents. Additional issues included incomplete psychotropic medication reviews, inadequate documentation of schedules, and absence of a Certified Food Protection Manager.
Deficiencies (10)
| Description |
|---|
| The facility did not ensure effective corrective action was put into place to prevent incidents' recurrence for multiple residents who fell. |
| The facility Registered Nurse did not perform initial and/or quarterly assessments for 9 of 10 sampled residents. |
| Residents were not assessed by a facility nurse after experiencing changes in condition. |
| Residents were not assessed every 90 days to ensure safety in self-administering medications. |
| Psychotropic medication reviews were not completed for residents taking such medications longer than six months. |
| Comprehensive assessments prior to admission were not completed for several residents. |
| Interim care plans were not developed for several residents upon admission. |
| Negotiated Service Agreements did not consistently or clearly reflect residents' needs or describe specific services. |
| As-worked schedules did not document exact times the administrator or RN were at the facility. |
| The facility did not have a Certified Food Protection Manager at the time of survey. |
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| David Weeks | CEO | Named as facility administrator confirming lack of corrective actions and documentation. |
| Jenny Walker | Survey Team Leader | Led the health care licensure and follow-up survey. |
Inspection Report
Life Safety
Deficiencies: 7
Apr 17, 2024
Visit Reason
The inspection was conducted as a fire life safety and sanitation licensure survey for the facility.
Findings
The facility had multiple life safety deficiencies including unclear designated smoking areas, lack of safety barriers for the fireplace, missing documentation for damper testing, absence of audible/visual notification devices in resident rooms, and prohibited use of relocatable power taps (RPT) for medical equipment and appliances in several rooms.
Deficiencies (7)
| Description |
|---|
| Facilities designated smoking area is not clearly marked with signage and location is not clearly designated within facility written policy. |
| Facility failed to provide a safety barrier for the fireplace located in the front entryway sitting area. |
| The facility failed to present documentation of the last known damper testing for dynamic dampers located in the main entry/clear-story stairwell. Dampers are required to be tested not less than each four years. |
| No resident sleeping rooms are provided with audible/visual notification devices as required by NFPA 101, Chapter 9, Section 9.6.3. Facility population includes hearing and vision impaired residents. |
| Medical equipment is prohibited from being plugged into a relocatable power tap (RPT). Room #106 has an oxygen concentrator plugged into a RPT. |
| Daisy-chains are prohibited with the use of a RPT. Room #144 has a device plugged into a RPT, plugged into a surge protector and then into the wall outlet. |
| Appliances are prohibited from being plugged into a RPT. Room #145 has a refrigerator, coffeemaker, microwave and water dispenser plugged into a RPT. Room #121 has a coffeemaker plugged into a RPT. |
Report Facts
Facility License Number: RC-1265
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| David Weeks | CEO | Administrator of the facility |
| Jeremy Wilson | Survey Team Leader | Led the fire life safety and sanitation licensure survey |
Inspection Report
Complaint Investigation
Census: 90
Deficiencies: 8
Oct 2, 2023
Visit Reason
The inspection was conducted as a health care complaint investigation regarding the facility's handling of resident care, missing resident protocols, and staff interventions.
Findings
The facility failed to implement policies and procedures effectively, including delayed reporting of a missing resident who later died, ineffective fall prevention interventions, insufficient staffing to meet resident needs, incomplete and inaccurate resident care documentation, and improper delegation of medication administration.
Complaint Details
The investigation was triggered by a complaint related to the facility's handling of a missing resident (Resident #9) who was not promptly reported missing, resulting in the resident's death. Additional complaints involved inadequate fall prevention, insufficient staffing, and poor documentation.
Deficiencies (8)
| Description |
|---|
| Failure to implement missing resident/elopement procedures leading to delayed police notification after Resident #9 went missing and subsequent death. |
| Ineffective and inappropriate interventions to prevent recurrent falls among residents with dementia or cognitive impairment. |
| Failure to notify Licensing and Certification within one business day of incidents involving Resident #9's death and hospitalizations of Residents #5 and #8 after falls. |
| Negotiated Service Agreements not updated to reflect significant changes in residents' health status and care needs. |
| Resident care records were not kept current, complete, or authentic; caregiver notes lacked dates, times, signatures, and proper documentation of behaviors and incidents. |
| Failure to evaluate and document behaviors of residents exhibiting maladaptive behaviors and failure to develop behavior plans with interventions. |
| Insufficient staffing on all shifts, especially evenings and weekends, leading to inadequate supervision and delayed assistance to residents. |
| Medication administration by staff without proper delegation by the facility nurse. |
Report Facts
Resident falls: 11
Residents present: 90
Staff passing medications without delegation: 7
Staff members in building during nights/weekends: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kaylyn Dault | Administrator | Named as the facility administrator responsible for oversight and acknowledged issues with interventions and reporting. |
| Stacey Brown | Survey Team Leader | Led the health care complaint investigation survey. |
Inspection Report
Original Licensing
Deficiencies: 4
May 26, 2023
Visit Reason
The inspection was conducted as an initial licensure survey for the healthcare facility.
Findings
The facility's Registered Nurse failed to perform required quarterly assessments for multiple residents, medications were not administered or available as ordered, and psychotropic medication reviews were not consistently completed. The facility staff acknowledged being behind on completing required assessments and reviews.
Deficiencies (4)
| Description |
|---|
| The facility's Registered Nurse did not perform the quarterly assessments for 6 of 10 sampled residents, with one assessment seven months overdue. |
| The facility RN did not ensure residents received their medications as ordered, including missed doses for Resident #2 and Resident #9. |
| Resident #2 and two unsampled residents did not have ordered PRN medications available. |
| Psychotropic medication reviews were not consistently completed for residents taking such medications longer than six months. |
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kaylyn Dault | Administrator | Named as facility administrator in the report header. |
| Jenny Walker | Survey Team Leader | Named as survey team leader conducting the initial licensure survey. |
Inspection Report
Life Safety
Deficiencies: 4
Mar 2, 2023
Visit Reason
The inspection was conducted as a fire life safety and sanitation licensure survey to assess compliance with fire and life safety standards for existing buildings licensed for seventeen or more residents and multi-story buildings.
Findings
The inspection identified several deficiencies including lack of documented testing of fire-rated doors between Assisted Living and Skilled Nursing areas, absence of audible/visible notification devices for hearing-impaired residents, use of prohibited extension cords and power taps, and incomplete documentation of emergency egress and relocation drills.
Deficiencies (4)
| Description |
|---|
| No documented testing of the doors of the 2-hour rated assembly from the Assisted Living side to the Skilled Nursing side of the building in accordance with NFPA 80; no audible, visible, or combination notification devices for hearing-impaired residents as required by NFPA 101. |
| Extension cords and multiple plug adapters are prohibited; Room 244 was using a multiple plug adapter, corrected on site 3/2/23. |
| Relocatable power taps (RPTs) are prohibited with the use of appliances; Activities room was using an RPT to supply power to an oscillating fan unit. |
| Emergency egress and relocation drills were not documented properly; drills did not document evacuation or use of designated assembly points as outlined in the emergency action plan. |
Report Facts
Percentage of hearing-impaired residents: 30
Number of emergency drills required per year: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Lori Eberharter | Administrator | Named as facility administrator. |
| Sam Burbank | Survey Team Leader | Named as survey team leader for fire life safety and sanitation licensure. |
Inspection Report
Complaint Investigation
Deficiencies: 1
Aug 11, 2022
Visit Reason
The inspection was conducted as a health care complaint investigation to assess compliance related to the facility's administration oversight.
Findings
The facility did not consistently have a licensed administrator overseeing daily operations, with the administrator present only intermittently over several months as confirmed by the operations manager.
Complaint Details
The visit was complaint-related, investigating the availability and oversight by the licensed administrator; no substantiation status was provided.
Deficiencies (1)
| Description |
|---|
| The facility did not consistently have a licensed administrator to oversee daily operations, with presence recorded as 20 days in May, 9 days in June, 13 days in July, and 3 days in August 2022. |
Report Facts
Administrator presence days: 20
Administrator presence days: 9
Administrator presence days: 13
Administrator presence days: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Timothy Nelson | Administrator | Named as the facility administrator whose presence was under review |
| Mina Ramirez | Survey Team Leader | Led the health care complaint investigation survey |
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