Deficiencies per Year
20
15
10
5
0
Severe
High
Moderate
Unclassified
Census Over Time
Inspection Report
Follow-Up
Deficiencies: 0
Nov 4, 2024
Visit Reason
An offsite revisit survey was conducted to verify correction of all previous deficiencies cited on 2024-10-21.
Findings
All deficiencies have been corrected as of the compliance date of 2024-10-31 and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Inspection Report
Complaint Investigation
Census: 19
Deficiencies: 3
Oct 21, 2024
Visit Reason
The inspection was a resurvey with an attached complaint #189501 at the assisted living facility The Mapleton Andover, LLC, conducted on 10/21/2024.
Findings
The inspection found deficiencies related to the failure to ensure negotiated service agreements (NSA) described services based on residents' functional capacity screening, failure to name the licensed nurse responsible for healthcare service plans, and unsafe food storage practices including unlabeled and expired food items in refrigerators.
Complaint Details
The visit was a resurvey with an attached complaint #189501.
Severity Breakdown
E: 1
D: 1
F: 1
Deficiencies (3)
| Description | Severity |
|---|---|
| Failed to ensure the Negotiated Service Agreement for Residents R1 and R3 described the services they received based on their Functional Capacity Screen. | E |
| Failed to ensure the Negotiated Service Agreement for Resident R3 named the licensed nurse responsible for implementing and supervising her Healthcare Service Plan. | D |
| Failed to ensure designated staff stored food items under safe and sanitary conditions; food items lacked labels and dates, and one yogurt was expired. | F |
Report Facts
Census: 19
Days expired: 9
Days opened: 39
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Staff A | Confirmed deficiencies related to NSA and food storage. | |
| Administrative Nurse B | Confirmed deficiencies related to NSA. | |
| Dietary Staff C | Confirmed deficiencies related to food storage. |
Inspection Report
Plan of Correction
Deficiencies: 0
Oct 21, 2024
Visit Reason
The document represents the findings of a resurvey with an attached complaint #189501 conducted at the assisted living facility on 10/21/24.
Findings
This plan of correction document addresses the findings from the resurvey and complaint investigation conducted on 10/21/24 at the assisted living facility.
Complaint Details
Complaint #189501 was attached to the resurvey conducted on 10/21/24.
Inspection Report
Plan of Correction
Deficiencies: 0
Jan 16, 2024
Visit Reason
The abbreviated survey for complaint #185178 was conducted on 01/16/24 at the assisted living facility.
Findings
The survey resulted in a finding of no deficiency citations.
Complaint Details
Complaint #185178 was investigated and found to have no deficiencies.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Jan 16, 2024
Visit Reason
The abbreviated survey was conducted in response to complaint #185178 at the assisted living facility.
Findings
The survey resulted in a finding of no deficiency citations.
Complaint Details
Complaint #185178 was investigated and resulted in no deficiency citations.
Inspection Report
Complaint Investigation
Deficiencies: 0
Dec 4, 2023
Visit Reason
The inspection was conducted as a complaint investigation (179954) at the assisted living facility.
Findings
The complaint investigation conducted on 12/04/2023 resulted in no citations.
Complaint Details
Complaint investigation 179954 was conducted and found no citations.
Inspection Report
Plan of Correction
Deficiencies: 0
Nov 21, 2023
Visit Reason
The abbreviated survey for complaints #184133 was conducted on 11/21/23 at the assisted living facility.
Findings
The survey resulted in a finding of no deficiency citations.
Complaint Details
Complaint #184133 was investigated and found to have no deficiencies.
Inspection Report
Re-Inspection
Deficiencies: 17
Apr 11, 2023
Visit Reason
This report is a revisit inspection conducted to verify that previously reported deficiencies have been corrected and to document the dates such corrective actions were accomplished.
Findings
All previously cited deficiencies listed by regulation or LSC provision numbers were corrected as of the revisit dates ranging from 04/10/2023 to 04/11/2023.
Deficiencies (17)
| Description |
|---|
| Deficiency identified by regulation 26-39-103 (d) |
| Deficiency identified by regulation 26-39-102 (b) (c) |
| Deficiency identified by regulation 26-41-101 (f) (1) |
| Deficiency identified by regulation 26-41-201 (d) |
| Deficiency identified by regulation 26-41-202 (a) |
| Deficiency identified by regulation 26-41-204 (a) |
| Deficiency identified by regulation 26-41-204 (i) |
| Deficiency identified by regulation 26-41-205 (a) (2) |
| Deficiency identified by regulation 26-41-205 (g) (3) |
| Deficiency identified by regulation 26-41-205 (g) (4) |
| Deficiency identified by regulation 26-41-205 (h) |
| Deficiency identified by regulation 26-41-105 (a) |
| Deficiency identified by regulation 26-41-104 (a) |
| Deficiency identified by regulation 26-41-104 (d) |
| Deficiency identified by regulation 26-41-206 (d) |
| Deficiency identified by regulation 26-41-206 (e) (1) |
| Deficiency identified by regulation 26-41-207 (b) (5-6) (c) |
Inspection Report
Re-Inspection
Census: 19
Deficiencies: 18
Mar 14, 2023
Visit Reason
The visit was a resurvey with attached complaints at an assisted living facility conducted on 03/13/23 and 03/14/23.
Findings
The facility was found deficient in multiple areas including failure to ensure resident rights to access records, failure to validate and maintain advanced directives, neglect in skin assessment and wound care resulting in pressure ulcers, inaccurate functional capacity screening, incomplete negotiated service agreements, insufficient staffing for emergency evacuation, improper medication management, food safety violations, and non-compliance with tuberculosis screening guidelines.
Complaint Details
The visit was a resurvey with attached complaints #169382, #161662, and #161239.
Severity Breakdown
SS=F: 7
SS=D: 6
SS=E: 2
SS=G: 1
SS=J: 1
SS=F: 7
Deficiencies (18)
| Description | Severity |
|---|---|
| Failure to ensure access to residents' records for inspection and photocopying by a representative of the department. | SS=F |
| Failure to ensure validation and maintenance of advanced directives for residents. | SS=D |
| Failure to protect residents from neglect by not documenting skin assessment monitoring and interventions to prevent and treat pressure wounds. | SS=G |
| Failure to ensure each resident's functional capacity screening accurately reflected their abilities. | SS=E |
| Failure to develop negotiated service agreements that fully describe services, providers, and payment responsibilities. | SS=D |
| Failure to ensure negotiated service agreements were signed by all involved parties. | SS=D |
| Failure to provide or coordinate necessary health care services including documentation of wound assessments. | SS=D |
| Failure to ensure healthcare services were provided by qualified staff in accordance with professional standards, including assessment of bedrails use and safety. | SS=D |
| Failure to include evaluation of physical, cognitive, and functional ability in self-administration of medication assessment. | SS=D |
| Failure to ensure licensed pharmacist or nurse placed full resident names on original packages of over-the-counter medications. | SS=F |
| Failure to develop policies and procedures for receiving and identifying sample medications including all required conditions. | SS=D |
| Failure to ensure medications were not administered beyond manufacturer or pharmacy recommended expiration dates. | SS=F |
| Failure to maintain resident records in accordance with accepted professional standards and practices. | SS=F |
| Failure to provide sufficient qualified staff to safely evacuate residents requiring two-person assist in an emergency or disaster. | SS=J |
| Failure to perform an annual emergency drill including evacuation of residents to a secure location. | SS=F |
| Failure to serve food at proper temperature to residents in the unattached building. | SS=E |
| Failure to store food under safe and sanitary conditions including storing expired and uncovered food. | SS=D |
| Failure to comply with tuberculosis screening guidelines for residents and newly hired employees. | SS=F |
Report Facts
Residents census: 19
Pressure ulcer measurements: 4
Pressure ulcer measurements: 5
Tubersol vial expiration: 30
Food storage date: 10
Staffing counts: 1
Staffing counts: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Staff B | Certified Medication Aide | Named in multiple findings including medication management, staffing, and resident care. |
| Administrative Staff A | Administrator/Operator | Named in findings related to resident records, advanced directives, and staffing. |
| CMA E | Certified Medication Aide | Named in findings related to resident transfers, medication, and tuberculosis screening. |
| CMA F | Certified Medication Aide | Named in findings related to resident transfers, medication, and tuberculosis screening. |
| Licensed Nurse K | Licensed Nurse | Named in resident care and transfer findings. |
Inspection Report
Plan of Correction
Deficiencies: 0
Mar 13, 2023
Visit Reason
The document represents the findings of a resurvey with attached complaints #169382, #161662, and #161239 at the assisted living facility conducted on 03/13/23 and 03/14/23.
Findings
This plan of correction addresses the findings from the resurvey and attached complaints conducted at the facility on the specified dates.
Complaint Details
The visit was related to attached complaints #169382, #161662, and #161239.
Inspection Report
Complaint Investigation
Census: 16
Deficiencies: 9
Mar 8, 2021
Visit Reason
The inspection was conducted as a resurvey and complaint investigation covering multiple complaint investigations and resurvey visits from February 9, 2021 through March 8, 2021.
Findings
The facility was found deficient in multiple areas including failure to report allegations of abuse timely, incomplete investigations, failure to update negotiated service agreements to reflect resident needs and outside providers, inadequate coordination of health care services including falls and behavior management, improper delegation and competency documentation for blood sugar testing by medication aides, improper labeling of over-the-counter medications, unsecured medication storage, incomplete emergency management plans, lack of quarterly emergency plan reviews, and unsecured chemical storage in the laundry area.
Complaint Details
The inspection was triggered by multiple complaint investigations (#139471, #147664, #148435, #152331, #152836, #159828, #159895, #160080) and included resurvey visits.
Severity Breakdown
Level E: 7
Level F: 2
Deficiencies (9)
| Description | Severity |
|---|---|
| Failure to report allegations of sexual abuse timely and failure to conduct thorough investigations for residents #740 and #310. | Level E |
| Failure to ensure negotiated service agreements included descriptions of services and identification of providers for residents #423, #447, #730, and #818. | Level E |
| Failure to ensure licensed nurse provides or coordinates necessary health care services in accordance with functional capacity screening and negotiated service agreements for residents #231, #310, #422, #423, #447, #730, #740, and #818. | Level E |
| Failure to ensure licensed nurse oriented and instructed CMAs in blood sugar testing and documented competency for CMAs B, D, and E. | Level E |
| Failure to ensure licensed pharmacist or nurse placed full resident names on over-the-counter medications and containers for multiple residents. | Level E |
| Failure to ensure only licensed nurses and medication aides had access to stored medications and biologicals. | Level E |
| Failure to develop a detailed written emergency management plan addressing flooding, severe weather, tornado, and explosion. | Level F |
| Failure to ensure disaster and emergency preparedness by conducting quarterly reviews of the emergency management plan with staff and residents. | Level F |
| Failure to ensure laundry area had locked cabinets for storage of chemicals and supplies. | Level E |
Report Facts
Number of residents present: 16
Number of adult daycare residents: 1
Number of over-the-counter medication labeling deficiencies: 10
Number of CMAs lacking documented competency for blood sugar testing: 3
Number of falls reported for resident #818: 4
Number of incident reports of falls for resident #310: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Licensed nurse/operator G | Licensed Nurse/Operator | Named in multiple findings related to failure to report abuse, failure to update negotiated service agreements, failure to coordinate health care services, and medication management. |
| Licensed nurse F | Licensed Nurse | Named in findings related to failure to report abuse, failure to coordinate health care services, and medication management. |
| Certified Medication Aide B | Certified Medication Aide | Named in failure to report abuse and lack of documented competency for blood sugar testing. |
| Certified Medication Aide D | Certified Medication Aide | Named in failure to report abuse and lack of documented competency for blood sugar testing. |
| Certified Medication Aide E | Certified Medication Aide | Named in lack of documented competency for blood sugar testing. |
| Certified Nursing Assistant A | Certified Nursing Assistant | Named in failure to report abuse. |
| Certified Nursing Assistant Q | Certified Nursing Assistant | Named in fall incident report for resident #818. |
| Certified Medication Aide H | Certified Medication Aide | Named in failure to report abuse. |
| Certified Medication Aide J | Certified Medication Aide | Named in failure to report abuse. |
| Certified Medication Aide L | Certified Medication Aide | Named in failure to report abuse. |
| Licensed Nurse R | Medical Care Provider | Named in medical care provider visits related to resident care and behavior management. |
| Licensed Nurse S | Medical Care Provider | Named in medical care provider visits related to resident care. |
| Licensed Nurse M | Hospice Nurse | Named in hospice visits related to resident care. |
Inspection Report
Re-Inspection
Deficiencies: 2
Sep 8, 2020
Visit Reason
This is a revisit inspection conducted to verify that previously reported deficiencies have been corrected and to document the date such corrective actions were accomplished.
Findings
The report confirms that the previously cited deficiencies identified by regulation numbers 26-41-101 (f)(3) and 26-41-102 (d) have been corrected as of 09/08/2020.
Deficiencies (2)
| Description |
|---|
| Deficiency related to regulation 26-41-101 (f)(3) |
| Deficiency related to regulation 26-41-102 (d) |
Inspection Report
Complaint Investigation
Census: 10
Deficiencies: 2
Aug 11, 2020
Visit Reason
The inspection was conducted as an abbreviated survey for complaint investigations #154713 and #154736 over multiple days from 08/03/2020 to 08/11/2020.
Findings
The facility failed to properly investigate an allegation of abuse involving a resident with shaved pubic hair by not using all available video surveillance and not suspending all staff involved during the investigation. Additionally, the facility failed to have evidence of timely criminal background checks and nurse aide registry verification for three certified nursing assistants.
Complaint Details
The complaint investigation involved allegations of abuse after outside provider staff discovered a resident with shaved pubic hair. The investigation revealed failures in timely suspension of staff and incomplete use of video surveillance to identify perpetrators. The facility suspended only one staff member while others continued to work during the investigation timeframe.
Severity Breakdown
SS=F: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to use all resources (video surveillance) to establish a timeline for an abuse allegation and failure to suspend staff who provided care during the identified timeframe, placing residents at risk for abuse. | SS=F |
| Failure to have evidence of criminal background checks at time of hire for 3 certified staff and failure to verify nurse aide registry for 1 of 3 certified nurse aides. | SS=F |
Report Facts
Census: 10
Residents cognitively impaired: 8
Sampled residents: 3
Dates of complaint investigation: 08/03/2020 to 08/11/2020
Criminal background check delay: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Direct care staff A | Named in abuse investigation; suspended on 07/31/2020 after video review | |
| Direct care staff B | Named in abuse investigation; worked during investigation timeframe and not suspended | |
| Direct care staff C | Named in abuse investigation; worked during investigation timeframe and not suspended; lacked nurse aide registry verification at hire | |
| Certified medication aide D | Conducted interviews and investigation activities related to abuse allegation | |
| Operator F | Facility operator who managed investigation and suspension decisions | |
| Owner H | Owner who reviewed video footage and communicated with investigators |
Inspection Report
Abbreviated Survey
Deficiencies: 0
Jul 1, 2020
Visit Reason
The special infection control survey for COVID-19 was conducted for the facility on 2020-07-01.
Findings
The survey resulted in findings of no deficiency citations.
Inspection Report
Re-Inspection
Deficiencies: 0
Sep 25, 2018
Visit Reason
This revisit inspection was conducted to verify that previously reported deficiencies have been corrected and to confirm the date such corrective actions were accomplished.
Findings
All previously cited deficiencies identified by regulation or LSC provision numbers were corrected as of the revisit date.
Inspection Report
Re-Inspection
Census: 7
Deficiencies: 6
Aug 29, 2018
Visit Reason
The inspection was a resurvey of an assisted living facility conducted on 8/28 and 8/29/2018 to evaluate compliance with previously cited deficiencies.
Findings
The facility was found deficient in multiple areas including incomplete negotiated service agreements lacking descriptions of outside services, missing signatures, failure to document refusal of services, lack of self-administration medication assessments, improper medication administration practices, and non-compliance with tuberculosis screening guidelines for staff and residents.
Severity Breakdown
SS=E: 2
SS=D: 3
SS=F: 1
Deficiencies (6)
| Description | Severity |
|---|---|
| Failure to ensure negotiated service agreements included description of outside services, identification of providers, and responsible parties for payment for 2 of 3 residents. | SS=E |
| Negotiated service agreement lacked documentation for refusal of insulin, enoxaparin, and accu checks including potential negative outcomes and resident acceptance of risk for 1 of 3 residents. | SS=D |
| Failure to obtain signatures of all parties involved in the negotiated service agreement for 2 of 3 residents. | SS=E |
| Licensed nurse failed to perform assessment to determine resident's ability to safely self-administer insulin and enoxaparin before allowing self-administration for 1 of 3 residents. | SS=D |
| Certified staff failed to administer medications according to physician orders, manufacturer recommendations, and professional standards for 1 of 3 residents, including failure to prime insulin pen and missing medication orders on administration record. | SS=D |
| Failure to ensure compliance with tuberculosis guidelines including lack of two-step TB skin tests for 2 administrative nursing staff and incomplete TB skin test documentation for 1 resident. | SS=F |
Report Facts
Residents sampled: 3
Census: 7
Blood sugar readings: 9
Blood sugar readings: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Named in relation to failure to ensure completion and signatures of negotiated service agreements | |
| Administrative nursing staff B | Interviewed regarding negotiated service agreements, medication administration, and training | |
| Administrative nursing staff C | Observed medication administration and reviewed TB skin test records | |
| Administrative nursing staff D | Personnel record reviewed for TB skin test compliance | |
| Certified staff C | Observed administering insulin without priming pen | |
| Licensed nurse | Interviewed regarding failure to perform self-administration assessment |
Loading inspection reports...
