Inspection Report
Plan of Correction
Capacity: 35
Deficiencies: 1
Jul 20, 2023
Visit Reason
This document is a Construction Section Biennial Survey conducted to assess compliance with building and fire safety codes for an adult care home licensed for 35 beds.
Findings
The survey found deficiencies related to the building's fire safety systems, specifically holes or gaps in fire resistant rated ceilings that could allow fire and smoke to spread beyond the area of origin, including a large hole in the ceiling to the left of the kitchen hood.
Deficiencies (1)
| Description |
|---|
| Failure to maintain the building's fire safety systems in a safe condition due to holes or gaps at penetrations through fire resistant rated ceilings. |
Report Facts
Licensed bed capacity: 35
Inspection Report
Follow-Up
Deficiencies: 5
May 11, 2023
Visit Reason
The Adult Care Licensure Section conducted a follow-up survey on May 10-11, 2023 to verify correction of previous deficiencies and assess compliance with regulatory requirements.
Findings
The facility failed to ensure competency validation for licensed health professional support tasks for one personal care aide, failed to complete resident assessments within 10 days following significant change, failed to implement ordered wound care for a resident with a chronic nonhealing chest mass, failed to administer medications as ordered for hypothyroidism, iron and vitamin D deficiencies, and failed to report incident and accident reports involving emergency room evaluations to the Department of Social Services within 48 hours.
Severity Breakdown
Type B Violation: 1
Deficiencies (5)
| Description | Severity |
|---|---|
| Failed to ensure 1 of 3 personal care aides had been competency validated for licensed health professional support tasks by return demonstration including applying and removing bandages. | — |
| Failed to assure an assessment of a resident was completed within 10 days following a significant change in the resident's condition for 1 of 3 sampled residents. | — |
| Failed to implement as needed wound care as ordered by the primary care provider for 1 of 3 sampled residents who had a chronic nonhealing mass on her chest with progressive growth and a steady increase in drainage. | Type B Violation |
| Failed to administer medications including levothyroxine, iron, and vitamin D as ordered by the provider for 1 of 3 sampled residents. | — |
| Failed to ensure incident and accident reports involving emergency room evaluations after a fall for 2 of 3 sampled residents were sent to the Department of Social Services within 48 hours of the event. | — |
Report Facts
Deficiencies cited: 5
Wound size: 11.5
Wound size: 8
Wound size: 2
Levothyroxine dosage: 100
Vitamin D3 dosage: 5000
Ferrous gluconate dosage: 324
Medication tablets remaining: 9
Medication capsules remaining: 1
Medication tablets remaining: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Personal Care Aide | Named in competency validation deficiency and wound care observations |
| Resident Care Coordinator | Interviewed regarding staff competency validation, wound care, incident reporting | |
| Director of Clinical Services | Interviewed regarding staff competency validation, wound care, medication administration, incident reporting | |
| Administrator | Interviewed regarding staff competency validation, wound care, medication administration, incident reporting | |
| Hospice Nurse | Responsible for wound care and hospice orders for Resident #1 | |
| Medication Aide | Interviewed regarding wound care and medication administration for Resident #1 |
Inspection Report
Annual Inspection
Deficiencies: 9
Feb 1, 2023
Visit Reason
The Adult Care Licensure Section conducted an annual survey and complaint investigation on 02/01/23 - 02/03/23.
Findings
The facility was found deficient in maintaining water temperatures within required ranges, providing adequate supervision to residents at high risk of falls, notifying primary care providers of recurrent falls and behavioral changes, administering medications timely and accurately, ensuring quarterly pharmacy reviews, reporting incidents to local authorities, and following infection control policies including hand hygiene.
Complaint Details
Complaint investigation included issues related to water temperature, supervision of residents at risk of falls, medication administration, notification of primary care providers, resident rights including call bell response times and property misappropriation, and infection control practices.
Severity Breakdown
Type A2 Violation: 2
Type B Violation: 3
Deficiencies (9)
| Description | Severity |
|---|---|
| Water temperatures were not maintained between 100°F and 116°F at 3 of 12 water fixtures accessible to residents. | — |
| Failed to provide increased supervision for 2 of 4 sampled residents (#2, #4) with multiple recurrent falls. | Type A2 Violation |
| Failed to notify 1 of 3 sampled residents' (#2) primary care provider of recurrent falls and worsening behaviors with ineffective medication treatment. | Type B Violation |
| Failed to ensure licensed health professional support assessment for 1 of 3 sampled residents (#2) requiring physical and occupational therapy tasks. | — |
| Failed to ensure residents had reasonable response times to call bells, were treated with respect and dignity, and were free from misappropriation of property including theft of Resident #5's money and lack of privacy. | Type B Violation |
| Failed to administer medications as ordered and on time for 2 of 3 sampled residents (#2, #4) including mood disorder medications, pain medications, vitamin supplements, and nutritional supplements, resulting in medication errors and risk of adverse effects. | Type A2 Violation |
| Failed to ensure quarterly pharmacy medication reviews were completed for 2 of 3 sampled residents (#1, #3) and that recommendations were communicated to primary care providers. | — |
| Failed to report falls requiring emergency medical evaluation and treatment beyond first aid to the local Department of Social Services for 1 of 2 sampled residents (#2). | — |
| Failed to ensure infection control practices of hand hygiene were followed during medication administration and feeding assistance. | Type B Violation |
Report Facts
Medication error rate: 25
Medication administration delay: 2.5
Call bell wait time: 26
Resident falls: 6
Resident falls: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Not provided | Medication Aide | Named in medication administration and late medication findings |
| Not provided | Personal Care Aide | Named in call bell response and feeding assistance findings |
| Not provided | Director of Clinical Services | Interviewed regarding supervision, medication administration, and reporting |
| Not provided | Administrator | Interviewed regarding supervision, medication administration, call bell response, and incident investigations |
| Not provided | Regional Director | Interviewed regarding medication administration and call bell response |
| Not provided | Primary Care Provider | Interviewed regarding notification of falls, medication errors, and pharmacy reviews |
| Not provided | Pharmacist | Interviewed regarding medication administration and timing |
| Not provided | Mental Health Provider | Interviewed regarding medication timing and behavioral symptoms |
| Not provided | Adult Home Specialist | Interviewed regarding reporting of falls to DSS |
| Not provided | Business Office Manager | Interviewed regarding staffing and call bell response |
Inspection Report
Annual Inspection
Deficiencies: 1
Sep 22, 2022
Visit Reason
The Adult Care Licensure Section conducted an annual survey of the facility on 09/22/22 to assess compliance with health care regulations.
Findings
The facility failed to ensure that physician orders for weekly blood pressure checks were implemented for one of three sampled residents. Specifically, Resident #1 had an order for weekly blood pressure monitoring that was not consistently documented in the electronic medication administration record.
Deficiencies (1)
| Description |
|---|
| Failed to ensure physician orders for weekly blood pressure checks were implemented for Resident #1. |
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Resident Care Coordinator | Interviewed regarding awareness and responsibility for implementing blood pressure orders. | |
| Administrator | Interviewed regarding knowledge of blood pressure orders and pharmacy responsibilities. |
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