Inspection Report Summary
The most recent inspection on November 20, 2024, identified deficiencies related to incomplete cognitive evaluations prior to occupancy and annually, as well as service plans not being developed based on evaluations. Earlier inspections showed a recurring pattern of issues with tenant evaluations, service plans, and dementia-specific staff training. Complaint investigations mostly found unsubstantiated allegations, though some substantiated complaints involved tenant evaluations and nurse reviews. Enforcement actions included a $3,000 civil penalty in 2008, but no fines or license actions were listed in the available reports since then. The facility’s inspection history indicates ongoing challenges with evaluation and service planning requirements, with similar deficiencies noted over multiple years.
Deficiencies (last 14 years)
Deficiencies (over 14 years)
3.1 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
30% better than Iowa average
Iowa average: 4.4 deficiencies/yearDeficiencies per year
8
6
4
2
0
Census
Latest occupancy rate
63 residents
Based on a November 2024 inspection.
Census over time
Inspection Report
Renewal
Census: 63
Deficiencies: 3
Nov 20, 2024
Visit Reason
The inspection was conducted as a recertification visit to determine compliance with certification of an Assisted Living Program for People with Dementia.
Findings
The program failed to complete required cognitive evaluations prior to occupancy and annually with significant change, and failed to develop service plans based on all evaluations as required.
Deficiencies (3)
| Description |
|---|
| Evaluation prior to occupancy was not completed for Tenant #5 before signing the occupancy agreement. |
| Evaluation annually and with significant change was not completed as required for tenants reviewed. |
| Service plans were not developed based on evaluations as required. |
Report Facts
Number of tenants without cognitive impairment: 48
Number of tenants with cognitive impairment: 15
Total census: 63
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Christy Nikkel | Executive Director | Signed the Plan of Correction and is responsible for ensuring compliance with occupancy agreement and assessment completion. |
Inspection Report
Complaint Investigation
Census: 65
Deficiencies: 1
Nov 9, 2023
Visit Reason
The inspection was conducted as part of an investigation of Complaints #111295-C and #111751-C regarding regulatory insufficiencies at the assisted living program.
Findings
The program failed to evaluate a tenant's functional, cognitive, and health status as required annually and with significant change, as evidenced by incomplete documentation and lack of updated service plans for Tenant C-1. The Administrator confirmed these findings.
Complaint Details
The investigation was triggered by Complaints #111295-C and #111751-C. The findings were substantiated as the program did not meet evaluation requirements for Tenant C-1.
Deficiencies (1)
| Description |
|---|
| Failure to evaluate a tenant's functional, cognitive, and health status annually and with significant change to determine continued eligibility and service needs. |
Report Facts
Number of tenants without cognitive impairment: 55
Number of tenants with cognitive impairment: 10
Total census: 65
Number of tenants reviewed for evaluation: 3
Number of baths completed by Tenant C-1: 6
Date of speech therapy evaluation: Sep 20, 2022
Date of tenant's 90 day review: Dec 27, 2022
Date of service plan: Dec 27, 2022
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Christy Nikkel | Executive Director | Signed the Plan of Correction letter |
Inspection Report
Complaint Investigation
Census: 69
Deficiencies: 0
Aug 17, 2022
Visit Reason
The visit was conducted to investigate complaint 106447-C at the assisted living program for people with dementia.
Findings
No regulatory insufficiencies were cited during the investigation of the complaint.
Complaint Details
Complaint 106447-C was investigated and found to have no regulatory insufficiencies.
Report Facts
Number of tenants without cognitive disorder: 64
Number of tenants with cognitive disorder: 5
Total census: 69
Inspection Report
Renewal
Census: 55
Deficiencies: 7
Jan 12, 2022
Visit Reason
The inspection was conducted as a recertification visit to determine compliance with certification of an Assisted Living Program, including investigation of multiple complaints and a review of infection control.
Findings
The inspection found regulatory insufficiencies related to medication administration, tenant evaluations, service plans, nurse reviews, admission/retention criteria, and dementia-specific education for personnel. No deficiencies were cited during the infection control visit.
Complaint Details
The inspection included investigation of complaints #95310-C, #96672-C, #97579-C, #100079-C, and #100159-C.
Deficiencies (7)
| Description |
|---|
| Program failed to administer medications as ordered for 1 of 7 discharged tenants reviewed. |
| Program failed to complete required evaluations within 30 days of admission for 2 of 5 tenants reviewed. |
| Program failed to evaluate functional, cognitive, and health status as warranted by significant change for 7 of 7 former tenants and 3 of 5 current tenants reviewed. |
| Program failed to initiate discharge or waiver request when tenant exceeded level of care requiring routine two-person assistance. |
| Program failed to develop service plans based on required evaluations for 7 of 7 former tenants and 3 of 5 current tenants reviewed. |
| Program failed to ensure comprehensive nurse reviews every 90 days or as warranted for 4 of 5 tenants reviewed. |
| Program failed to provide 8 hours of dementia-specific education within 30 days of employment for 3 of 7 staff reviewed. |
Report Facts
Number of tenants without cognitive disorder: 48
Number of tenants with cognitive disorder: 7
Total census: 55
Number of discharged tenants reviewed for medication administration: 7
Number of tenants reviewed for evaluations within 30 days: 5
Number of former tenants reviewed for evaluation of significant change: 7
Number of current tenants reviewed for evaluation of significant change: 5
Number of former tenants reviewed for service plans: 7
Number of current tenants reviewed for service plans: 5
Number of tenants reviewed for nurse reviews: 5
Number of staff reviewed for dementia training: 7
Inspection Report
Routine
Census: 60
Deficiencies: 0
Sep 1, 2020
Visit Reason
The inspection was conducted as an onsite infection control survey for an Assisted Living Program for People with Dementia.
Findings
No regulatory insufficiencies were cited during the onsite infection control survey completed on 09/01/2020.
Report Facts
Number of tenants without cognitive disorder: 53
Number of tenants with cognitive disorder: 7
Total census: 60
Inspection Report
Renewal
Census: 66
Deficiencies: 3
Dec 11, 2019
Visit Reason
The recertification visit was conducted to determine compliance with certification of an Assisted Living Program for People with Dementia.
Findings
The program failed to ensure that staff received required dementia-specific education and training within specified timeframes, including initial training within 30 days of employment, annual continuing education, and hands-on dementia training. Several staff members lacked documentation of required training.
Deficiencies (3)
| Description |
|---|
| Program failed to ensure staff received eight hours of dementia-specific education within 30 days of employment for 4 of 8 staff reviewed. |
| Program failed to ensure staff received at least eight hours of annual dementia-specific continuing education for 2 of 2 staff reviewed over one year. |
| Program failed to include hands-on dementia training for 3 of 8 staff reviewed. |
Report Facts
Number of tenants without cognitive disorder: 52
Number of tenants with cognitive disorder: 14
Total census: 66
Staff reviewed for initial dementia training: 8
Staff reviewed for annual dementia training: 2
Staff reviewed for hands-on dementia training: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Named in deficiency for not completing required dementia training within 30 days | |
| Staff B | Named in deficiency for not completing required dementia training within 30 days and hands-on training | |
| Staff C | Named in deficiency for not completing required annual dementia training and hands-on training | |
| Staff D | Named in deficiency for not completing required dementia training within 30 days, annual training, and hands-on training | |
| Staff E | Named in deficiency for not completing required dementia training within 30 days | |
| Office Director | Confirmed findings on 12-10-19 and 12-11-19 |
Inspection Report
Complaint Investigation
Census: 67
Deficiencies: 0
Sep 26, 2019
Visit Reason
Investigation of Complaint #85123-C at the assisted living program for people with dementia.
Findings
No regulatory insufficiencies were cited during the complaint investigation.
Complaint Details
Investigation of Complaint #85123-C found no regulatory insufficiencies.
Report Facts
Number of tenants without cognitive disorder: 51
Number of tenants with cognitive disorder: 16
Inspection Report
Complaint Investigation
Census: 64
Deficiencies: 1
Apr 11, 2018
Visit Reason
The inspection was conducted as an investigation of Complaint #74593-C regarding tenant rights violations at the assisted living program.
Findings
The program failed to consistently ensure the privacy of tenants, specifically by staff sending private medical information via personal cell phone text messages, potentially exposing tenant information to unauthorized persons.
Complaint Details
Investigation of Complaint #74593-C found that staff sent tenant medical information via text messages using personal cell phones, risking unauthorized access to private information.
Deficiencies (1)
| Description |
|---|
| Program failed to consistently ensure the privacy of tenants by staff sending private medical information via personal cell phone text messages. |
Report Facts
Number of tenants without cognitive disorder: 52
Number of tenants with cognitive disorder: 12
Total Census of Assisted Living Program: 64
Number of tenants potentially affected: 64
Inspection Report
Complaint Investigation
Census: 66
Deficiencies: 0
Feb 8, 2018
Visit Reason
The inspection was conducted as an investigation of Complaint #73376-C at the assisted living facility.
Findings
No regulatory insufficiencies were cited during the complaint investigation.
Complaint Details
Investigation of Complaint #73376-C found no regulatory insufficiencies.
Report Facts
Number of tenants without cognitive disorder: 55
Number of tenants with cognitive disorder: 11
Total census: 66
Inspection Report
Renewal
Census: 66
Deficiencies: 3
Nov 16, 2017
Visit Reason
The inspection was conducted as a recertification visit to determine compliance with certification for an Assisted Living Program.
Findings
The inspection identified regulatory insufficiencies including failure to complete required criminal background evaluations for staff, failure to discharge a tenant who exceeded admission criteria due to unmanageable incontinence, and failure to ensure all staff received required dementia-specific education annually.
Deficiencies (3)
| Description |
|---|
| Program failed to obtain evaluation from the Department of Human Services prior to employment of an individual with a crime on their record. |
| Program failed to discharge a tenant who exceeded criteria for admission and retention due to unmanageable incontinence. |
| Program failed to ensure all staff with direct contact with tenants completed at least eight hours of dementia-specific continuing education annually. |
Report Facts
Number of tenants without cognitive disorder: 56
Number of tenants with cognitive disorder: 10
Total population of program at time of on-site: 66
Staff requiring dementia training: 3
Inspection Report
Complaint Investigation
Census: 63
Deficiencies: 2
Jun 26, 2017
Visit Reason
The inspection was conducted as an investigation of Incident #67981-C at Heritage at Northern Hills, an assisted living program, to evaluate compliance with regulatory requirements related to tenant evaluations and nurse reviews.
Findings
The program failed to ensure evaluations of tenants with possible changes in condition were completed by the Registered Nurse (RN), affecting 3 of 8 tenants reviewed. Additionally, the RN failed to conduct nurse reviews with changes in condition for 3 of 7 tenants. Documentation and assessments by the RN were missing despite Licensed Practical Nurse (LPN) notes and hospice involvement.
Complaint Details
Investigation of Incident #67981-C revealed regulatory insufficiencies related to tenant evaluation and nurse review processes. The complaint was substantiated based on record review and interviews.
Deficiencies (2)
| Description |
|---|
| Failure to complete evaluations of tenants with possible change in condition by the Registered Nurse within required timeframes. |
| Failure of the Registered Nurse to conduct nurse reviews with changes in condition for affected tenants. |
Report Facts
Number of tenants without cognitive disorder: 52
Number of tenants with cognitive disorder: 11
Total population of program at time of on-site: 63
Tenants affected by evaluation deficiency: 3
Tenants affected by nurse review deficiency: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Christy Nikkel | Executive Director | Signed Plan of Correction letter |
Inspection Report
Complaint Investigation
Census: 59
Deficiencies: 0
Mar 23, 2016
Visit Reason
The inspection was conducted as a final complaint/incident investigation following a complaint intake regarding service plans at Heritage at Northern Hills.
Findings
The investigation found that the program had assessed the tenant and developed a service plan to meet her needs, with no history of wandering or elopement prior to the incident. The tenant was diagnosed with a urinary tract infection after the incident. The program implemented a new service plan including hourly checks. The finding was unsubstantiated and no regulatory insufficiencies were identified.
Complaint Details
Allegation regarding service plans was investigated and found unsubstantiated.
Report Facts
Number of tenants without cognitive disorder: 49
Number of tenants with cognitive disorder: 10
Total Population of Program at time of on-site: 59
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Rose Boccella | Program Coordinator | Signed letter regarding complaint investigation findings |
Inspection Report
Complaint Investigation
Census: 61
Deficiencies: 1
Dec 7, 2015
Visit Reason
The inspection was conducted as a final complaint/incident investigation following an investigation by the Department of Inspections and Appeals from November 30 to December 7, 2015, regarding service plans and policies at Heritage at Northern Hills.
Findings
The investigation found the allegation regarding service plans to be unsubstantiated but identified a regulatory insufficiency related to program policies and procedures, specifically failure to follow policies regarding incident reports.
Complaint Details
The complaint allegation was related to service plans. The findings were unsubstantiated. The report noted a regulatory insufficiency in policies and procedures related to incident reporting.
Deficiencies (1)
| Description |
|---|
| Program staff failed to follow policies and procedures regarding incident reports, affecting 1 of 1 tenant identified in the investigation. |
Report Facts
Number of tenants without cognitive disorder: 51
Number of tenants with cognitive disorder: 10
Total population of program at time of on-site: 61
Total census of Assisted Living Program: 61
Days to correct regulatory insufficiency: 30
Days to submit Plan of Correction: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Rose Boccella | Program Coordinator, Adult Services Bureau | Author of the cover letter and contact person for the report |
| Certified Nurse Aide (CNA A) | Involved in assisting tenant during incident; named only by role, no full name | |
| Certified Nurse Aide (CNA B) | Assisted CNA A during incident; named only by role, no full name | |
| Executive Director | Mentioned in relation to incident report completion and staff retraining; no full name given | |
| Stephanie Johnson | Director | Facility Director addressed in the letter |
| Director of Health Services | Interviewed regarding incident report and staff training; no full name given |
Inspection Report
Recertification Monitoring Evaluation
Census: 61
Deficiencies: 1
Sep 15, 2015
Visit Reason
A recertification visit and incident investigation were conducted to determine compliance with certification for an Assisted Living Program and to investigate incident #53934-I.
Findings
The incident investigation was unsubstantiated. A regulatory insufficiency was cited in the area of Food Service due to failure to ensure consistent food safety training for staff preparing and serving meals.
Complaint Details
The incident investigated was unsubstantiated. The tenant sustained an abrasion after a fall and was transported to the emergency room. No regulatory insufficiencies were found related to the incident.
Deficiencies (1)
| Description |
|---|
| Food service personnel failed to consistently receive food safety training as required, with some staff lacking training since 2013. |
Report Facts
Number of tenants without cognitive disorder: 49
Number of tenants with cognitive disorder: 12
Total population of program at time of on-site: 61
Total census of Assisted Living Program: 61
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Stephanie Johnson | Executive Director | Named in Plan of Correction response letter and confirmed food service training status |
| Rose Boccella | Program Coordinator | Author of the Final Incident Investigation & Recertification Monitoring Evaluation Report |
Inspection Report
Complaint Investigation
Deficiencies: 4
Dec 1, 2014
Visit Reason
The inspection was conducted as a complaint/incident investigation related to tenant injury, nurse review, evaluations prior to admission, service plans, and alleged bed bugs at Northern Hills, Sioux City, Iowa.
Findings
The investigation found that tenant rights violations and complaints about nurse reviews and evaluations were not substantiated. However, regulatory insufficiencies were identified in the areas of tenant evaluation, service plans, and nurse review, including incomplete or unsigned evaluations, lack of documentation of functional evaluations, incomplete service plans, and failure to complete nurse reviews with changes in condition.
Complaint Details
Complaint #48205-C and Incident #48206-I alleged tenant rights issues related to a tenant injury; these were not substantiated. Complaint #48413-C alleged nurse review was not completed to determine if tenants exceeded admission criteria, evaluations were incomplete, service plans were not completed upon admission, and alleged bed bugs presence; the complaint was not substantiated.
Deficiencies (4)
| Description |
|---|
| Evaluations were not completed prior to admission for tenants and functional evaluations were missing or unsigned. |
| Evaluations within 30 days of occupancy and with significant change were not completed timely or properly documented. |
| Service plans did not meet identified tenant needs and were not updated following hospitalizations or significant changes. |
| Nurse reviews were not completed with changes in condition or every 90 days as required. |
Report Facts
Complaint/Incident Intake Numbers: 48413-C, 48205-C, 48206-I
Date of inspection visit: December 1 and 2, 2014
Number of tenant files reviewed: 5
Dates of admission for tenants: Tenants admitted on 5-14-14, 6-23-14, 1-2-13, etc.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Rose Boccella | Program Coordinator | Author of the complaint/incident investigation report and contact person. |
| Stephanie Johnson | Executive Director | Named in the Plan of Correction letter responding to the investigation. |
Inspection Report
Monitoring
Census: 54
Deficiencies: 0
Aug 27, 2013
Visit Reason
The visit was a Final Recertification Monitoring Evaluation conducted to review the assisted living program's compliance with Iowa Administrative Code and to evaluate the program's recertification status.
Findings
No regulatory insufficiencies were found during the evaluation. The program was accepted, and the State Fire Marshal's inspection and Facility Engineer's approval of evacuation plans were also received.
Report Facts
Total census of Assisted Living Program: 54
Number of tenants without cognitive disorder: 54
Number of tenants with cognitive disorder: 0
Number of tenants attending Tenant/Family Satisfaction meeting: 38
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Nicole Gosch | Administrator | Administrator of Northern Hills Assisted Living named in the report |
| Lori Miner | RN BSN | Monitor conducting the evaluation |
| Jim Berkley | Program Coordinator | Author of the cover letter for the report |
Inspection Report
Complaint Investigation
Census: 60
Deficiencies: 1
Mar 25, 2013
Visit Reason
The inspection was conducted as a complaint/incident investigation regarding allegations related to tenant rights and medication administration at Northern Hills Assisted Living.
Findings
The investigation found no regulatory insufficiencies related to tenant rights and incontinence supplies. However, medication administration practices did not follow accepted professional standards, including failure to cleanse hands between tenants and carrying unlabeled inhaled medication containers.
Complaint Details
The complaint alleged the program did not have incontinence briefs available for a tenant and that a Licensed Practical Nurse passed medications without knowing the medications or reasons for administration. The complaint was investigated with monitoring observations and interviews with staff and tenants.
Deficiencies (1)
| Description |
|---|
| Failure to follow accepted professional standards for medication administration, including not cleansing hands between tenants and carrying unlabeled inhaled medication containers. |
Report Facts
Number of tenants without cognitive disorder: 60
Number of tenants with cognitive disorder: 0
Total population of program at time of on-site: 60
Date of complaint/incident investigation: March 25 and 26, 2013
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Lori Miner | RN BSN | Monitor conducting the complaint/incident investigation |
Inspection Report
Monitoring
Census: 67
Deficiencies: 1
Oct 11, 2011
Visit Reason
An on-site monitoring evaluation was conducted at Northern Hills Assisted Living to review the Plan of Correction in response to a Preliminary Recertification Monitoring Evaluation Report and to assess compliance with regulatory requirements.
Findings
The report found a regulatory insufficiency related to nursing services, specifically a lack of documented registered nurse observation of staff competency in colostomy care. Tenant and family satisfaction was positive, and no regulatory insufficiencies were found during the certification period prior to this visit.
Deficiencies (1)
| Description |
|---|
| The checklist lacked documentation of registered nurse observation of each staff member's demonstration of colostomy care to determine competency. |
Report Facts
Number of tenants without cognitive disorder: 65
Number of tenants with cognitive disorder: 2
Total census of Assisted Living Program: 67
Number of tenants and family members in satisfaction meeting: 29
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Maribeth Freland | RN | Monitor conducting the evaluation |
| Lori Miner | RN BSN | Monitor conducting the evaluation |
Inspection Report
Complaint Investigation
Census: 68
Deficiencies: 0
Jul 14, 2011
Visit Reason
The visit was an on-site monitoring investigation conducted in response to an incident intake regarding a tenant elopement at Northern Hills Assisted Living.
Findings
The investigation found no regulatory insufficiencies related to the incident. The tenant eloped but was safely returned by family, and staff reported no injuries or harm. The incident was reported to the department within 24 hours and the tenant was transferred to a higher level of care.
Complaint Details
The complaint involved an allegation that Tenant #1 eloped from the program. The investigation included interviews with multiple staff members and review of documentation. The complaint was not substantiated as no regulatory insufficiencies were identified.
Report Facts
Current number of tenants without cognitive disorder: 66
Current number of tenants with cognitive disorder: 2
Total Population: 68
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Lori Miner | RN BSN | Monitor conducting the investigation |
Inspection Report
Complaint Investigation
Census: 56
Deficiencies: 6
Jun 24, 2008
Visit Reason
A complaint investigation revisit was conducted at Northern Hills assisted living program to evaluate regulatory insufficiencies related to Evaluation of Tenant, Service Plan, Medications, Nurse Review, and other areas.
Findings
The investigation found substantiated complaints in multiple areas including tenant evaluations, service plans, medication administration, nurse reviews, and record checks. The program received regulatory insufficiencies for inconsistent evaluations, incomplete service plans, medication errors, lack of nurse reviews, and incomplete implementation of the Plan of Correction.
Complaint Details
The complaint investigation was substantiated with findings in Evaluation of Tenant, Service Plan, Medications, Nurse Review, and Record Checks. The program was assessed a $3,000 civil penalty.
Deficiencies (6)
| Description |
|---|
| The program did not consistently complete functional, cognitive, and health evaluations as needed. |
| The program did not consistently develop or update individualized service plans based on evaluations. |
| The program did not consistently document medications administered and ensure medications were labeled and stored properly. |
| The program did not consistently provide registered nurse reviews at least every 90 days or after changes in condition. |
| The program did not ensure background checks were completed on all employees prior to hire. |
| The program did not completely implement the Plan of Correction submitted. |
Report Facts
Civil penalty amount: 3000
Current number of tenants without cognitive disorder: 53
Current number of tenants with cognitive disorder: 3
Total population: 56
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Michael Streepy | RN | Monitor for complaint investigation |
| Hal Chase | RN, BSN, MPH | Monitor for complaint investigation |
| Gary Troth | Administrator | Named as facility administrator in report |
| Ann Martin | Bureau Chief, Adult Services Bureau | Author of the civil penalty letter |
Inspection Report
Complaint Investigation
Census: 72
Deficiencies: 3
Oct 7, 2004
Visit Reason
A complaint investigation on-site visit was conducted at Northern Hills Assisted Living to investigate allegations related to inaccurate tenant documentation, medication administration failures, and insufficient staffing to meet tenant needs.
Findings
The investigation found regulatory insufficiencies including inaccurate documentation of an incident involving Tenant #1, failure to administer medications as per the tenant's service plan, and insufficient staffing to meet tenants' identified needs. Specific failures included incomplete meal reminders and medication cueing, leading to staff disciplinary actions.
Complaint Details
There were substantiated complaints in the areas of assessment, occupancy and transfer, services, staffing, and record checks. The complaint investigation focused on inaccurate tenant documentation, medication administration failures, and insufficient staffing.
Deficiencies (3)
| Description |
|---|
| Program did not maintain accurate documentation of the incident involving Tenant #1 on March 13, 2004. |
| Program did not provide administration of medications in accordance with applicable rules and Iowa Code. |
| Program did not provide sufficient staff to meet tenants’ identified needs at all times. |
Report Facts
Number of tenants with dementia or cognitive disorder: 7
Number of tenants without cognitive disorder: 65
Total population: 72
Number of tenant files reviewed: 5
Number of tenant files with meal reminder omissions: 4
Inspection Report
Complaint Investigation
Census: 72
Deficiencies: 6
Sep 7, 2004
Visit Reason
A complaint investigation on-site visit was conducted at Northern Hills Assisted Living to investigate allegations related to tenant evaluations, exclusion criteria, nurse reviews, service plans, staffing, and employee record checks.
Findings
The investigation found multiple regulatory insufficiencies including failure to evaluate tenants' functional and cognitive abilities, retaining tenants requiring higher levels of care, incomplete 90-day nurse reviews, outdated individualized service plans, inadequate staffing and training, and failure to complete employee criminal background checks prior to hire.
Complaint Details
There were substantiated complaints in the area of services during this certification period. The complaint investigation found multiple regulatory insufficiencies as detailed in the findings.
Deficiencies (6)
| Description |
|---|
| The program did not evaluate each tenant’s functional and cognitive abilities and health status as needed to determine the needed services. |
| The program did not transfer tenants that met the criteria for exclusion of tenants requiring a higher level of care. |
| The program RN did not conduct 90-day reviews of those tenants receiving health-related care or if there were changes in health status. |
| The program did not have an updated service plan addressing each tenant’s specific needs and expected outcomes as required. |
| The program did not provide sufficient trained staff at all times to fully meet tenant’s identified needs and ensure appropriate training. |
| The program did not complete the criminal background check prior to hire of an employee as required. |
Report Facts
Current Program Census: 72
Tenants without cognitive disorder: 65
Tenants with cognitive disorder: 7
Staffing: 2
Staff member hire date: May 20, 2004
Criminal background check date: Jun 18, 2004
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