Inspection Reports for
The Living Centre

F 0656 Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured: the facility failed to include a resident's intermittent catheterization needs in the care plan.

F 0699 Provide care or services that was trauma informed and/or culturally competent: the facility failed to provide trauma-informed care for a resident with PTSD, and the care plan did not identify triggers that upset the resident.

F 0609 Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities: the facility failed to report an alleged verbal abuse incident timely to the State Survey Agency as required.

F 0600 Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody: the facility failed to protect one resident from verbal and physical abuse by a caregiver who yelled at the resident to be quiet and pushed on the resident's injured leg causing pain.

F 0600 Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody: the facility documented multiple instances of aggressive verbal abuse by the staff member toward the resident and terminated the staff member's employment due to unsatisfactory job performance and use of profanity.

F 0609 Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities: the facility failed to report suspected abuse to the State Survey Agency for one resident despite being aware of the allegations and conducting an internal investigation.

F 0640 Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment: the facility failed to submit Death in Facility MDS assessments for two residents and Discharge MDS assessments for two residents, with delays up to 255 days overdue.

F 0636 Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months: the facility failed to update individualized fall care plans for residents #4 and #9 after multiple falls and injuries, missing opportunities to modify care plans to prevent further falls.

F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents: the facility failed to thoroughly assess and document medical evaluations after resident #9's fall, resulting in fractures, a broken tooth, head injury, and eventual death. Resident #4 also experienced multiple falls with injuries and no updated care plans or fall committee interventions.

F 0600 Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody: the facility failed to protect residents from a naked male resident entering female residents' rooms and touching one resident, causing fear and distress.

F 0609 Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities: the facility failed to report an allegation of sexual abuse involving three residents to the State Survey Agency.

F 0610 Respond appropriately to all alleged violations: the facility failed to thoroughly investigate alleged sexual abuse by a resident, lacking interviews, root cause analysis, protective actions, and follow-up documentation.

F 0623 Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights: the facility failed to complete and provide a notice of transfer for two residents.

F 0625 Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave: the facility failed to complete and provide bed hold documentation to two residents or their representatives.

F 0758 Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited: the facility failed to document the rationale for extending PRN psychotropic medication orders beyond 14 days for two residents.