Inspection Reports for
The Preserve

Across the inspection history, 7 Class 3 deficiencies were cited with none in the more serious classes. The most recent visit was recorded as Deficiencies Corrected and no legal actions have been taken.

No health deficiencies were found during the inspection.

The complaint was related to Resident #2's discharge with a distended bladder, elevated WBC, and wrong medications. The grievance was not documented or investigated as required. The Director of Nursing investigated but did not document or communicate findings. The grievance was deemed unfounded but procedural requirements were not met.

The facility failed to ensure documentation of the grievance investigation, including steps taken, findings, and communication of the resolution to the complainant. Interviews confirmed the grievance was not properly logged or investigated as required by the facility's grievance policy.

The facility failed to accurately transcribe medication orders upon admission for one resident, resulting in ineffective pain control. Additionally, the facility failed to ensure medication error rates were below 5%, with two medication errors observed involving crushing medications that should not be crushed.

No health deficiencies were found during the inspection.

The investigation was triggered by complaints about inadequate wound care and pressure ulcer prevention. Resident #10's missing skin graft was substantiated with minimal harm. Resident #1 developed multiple pressure ulcers related to medical device use, substantiated with actual harm.

The facility failed to ensure proper treatment and care for residents with wounds, including failure to notify the primary care physician and interdisciplinary team of changes in skin integrity. Additionally, the facility failed to prevent pressure ulcers and properly assess and document skin conditions related to medical devices such as immobilizers and CAM boots.

The facility was found to have multiple deficiencies including inaccurate Minimum Data Set (MDS) assessments for residents' vision and behavior, inadequate assistance with activities of daily living for residents with impaired vision, improper maintenance of urinary catheters, and insufficient dietary staffing affecting meal service and dining room availability.