Inspection Report
Monitoring
Census: 71
Capacity: 108
Deficiencies: 15
Jul 7, 2025
Visit Reason
The visit was an unannounced partial inspection conducted for monitoring purposes to review compliance with licensing regulations and verify the submitted plan of correction.
Findings
The inspection identified multiple deficiencies related to safety, sanitation, food storage, medical evaluations, medication management, and documentation. The facility submitted plans of correction which were accepted and later verified as implemented.
Deficiencies (15)
| Description |
|---|
| Poisonous materials (toothpaste) were unlocked and accessible to residents in the secured dementia care unit. |
| Feces were smeared on an activity table and a nearby chair in the secured dementia care unit. |
| Food items were stored on the floor in the walk-in fridge and freezer. |
| Outdated or unlabeled food items were found in various kitchen areas. |
| Resident medical evaluations lacked documentation of health status and need for body positioning and movement stimulation. |
| Weekly menus were not posted one week in advance in the secured dementia care unit. |
| Resident medication records did not include current lists of medications or had discrepancies. |
| Medications and syringes were found unlocked and accessible in a resident's shared room. |
| Discontinued or non-current medications were found in the home's medication cart. |
| Medications were stored improperly, including punctured blister packs and expired insulin pens. |
| Unlabeled medication bottles without pharmacy labels were found in medication carts. |
| Controlled medication storage and documentation procedures were not properly followed, including missing signatures and discrepancies in inventory sheets. |
| Medication records lacked documentation of insulin units administered despite blood sugar monitoring. |
| Medication administration times were not accurately recorded; medications were marked administered when residents were absent or hospitalized. |
| The home did not consistently follow prescriber's orders, including documentation of medication refusals and administration. |
Report Facts
License Capacity: 108
Residents Served: 71
Secured Dementia Care Unit Capacity: 24
Secured Dementia Care Unit Residents Served: 20
Hospice Current Residents: 5
Residents Age 60 or Older: 71
Residents with Mobility Need: 30
Total Daily Staff: 101
Waking Staff: 76
Inspection Report
Renewal
Census: 75
Capacity: 108
Deficiencies: 25
May 7, 2025
Visit Reason
The inspection was conducted as a renewal inspection of THE RESIDENCE AT CHADDS FORD facility to assess compliance with licensing requirements.
Findings
The inspection identified multiple deficiencies related to medication administration, storage, labeling, emergency procedures, safety, resident assessments, and documentation. Plans of correction were accepted and implemented with ongoing compliance monitoring.
Deficiencies (25)
| Description |
|---|
| Medication error not reported to the Department for missed Oxycodone dose on 4/22/2025. |
| Poisonous materials (hand soap) unlocked and accessible to residents in secure dementia care unit. |
| Trash receptacle in cafe area uncovered, allowing penetration of insects and rodents. |
| Food stored on the floor in walk-in freezer and under shelf. |
| Emergency procedures lacked contact information for each resident’s designated person. |
| Obstruction of emergency egress by stop sign adhered to emergency exit door. |
| Medical evaluation for resident 1 was edited post evaluation without proper documentation. |
| Smoking area policy did not designate a safe smoking area; smoking towers improperly placed. |
| Weekly menus not posted in advance in secure dementia care unit. |
| First aid kit in transport vehicle lacked unexpired antiseptic wipes. |
| Resident 1 self-administers medications but lacks physician assessment for ability to self-administer. |
| Resident medication records incomplete or inaccurate for multiple residents. |
| Prescription medications and syringes not kept locked in resident rooms. |
| Discontinued medication (Lidocaine patch) kept in medication cart. |
| Medications stored in torn blister packs and undated insulin pen found. |
| Resident 4 had unlabeled medication bottle in room. |
| Narcotic medication sign out sheet had documentation errors and discrepancies. |
| Medication administration records missing date/time and staff initials for insulin administration. |
| Medication not administered as ordered due to expired order and delayed reorder. |
| Medication error not reported to resident or designated person for missed dose. |
| Medication administration training record incomplete for staff person B. |
| Resident mobility device use not reflected in resident support plan. |
| Resident did not sign support plan despite participation in development. |
| Directions for key-locking devices not conspicuously posted; incorrect door code posted. |
| Resident narcotic count sheet entries illegible and scribbled over. |
Report Facts
License Capacity: 108
Residents Served: 75
Secured Dementia Care Unit Capacity: 24
Residents Served in Dementia Unit: 21
Hospice Residents: 4
Total Daily Staff: 106
Waking Staff: 80
Residents with Mobility Need: 31
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff person A | Named in medication administration documentation errors and coaching. | |
| Staff person B | Named in medication administration training record deficiency and removal from duties. | |
| RCD | Resident Care Director | Named in multiple findings related to medication errors, training, and compliance monitoring. |
| ED | Executive Director | Named in multiple findings related to corrections and education. |
| RD | Registered Dietitian | Named in findings related to nutrition and safety. |
| RSS | Resident Support Specialist | Named in findings related to compliance monitoring. |
| ROD | Resident Operations Director | Named in findings related to food storage and safety. |
| Med Tech TTT | Medication Technician Trainer | Named in findings related to medication administration training and monitoring. |
| Maintenance Director | Named in findings related to environmental safety corrections. | |
| Wellness Nurse | Named in medication order follow-up and communication with physician. |
Inspection Report
Complaint Investigation
Census: 79
Capacity: 108
Deficiencies: 5
Dec 9, 2024
Visit Reason
The inspection was conducted as a complaint investigation with multiple off-site review dates from 12/09/2024 to 12/16/2024 to assess compliance with regulatory requirements.
Findings
The inspection identified multiple deficiencies related to annual medical evaluations, medication storage procedures, medication administration records, following prescriber's orders, and legibility of record entries. Plans of correction were accepted and implemented by early 2025.
Complaint Details
The inspection was triggered by a complaint, as stated under Inspection Information with reason 'Complaint'.
Deficiencies (5)
| Description |
|---|
| Resident's most recent medical evaluation did not include required medical information pertinent to diagnoses and treatment, and immunization history. |
| An error was made and not corrected in the narcotic control record entries for a prescribed medication. |
| Medication Administration Records (MAR) reflected pre-printed ranges of administration times instead of actual times for multiple medications. |
| Resident's medication was not administered as prescribed according to the MAR and staff interviews. |
| Narcotics control log showed multiple cross outs and writeovers, compromising legibility and proper documentation. |
Report Facts
License Capacity: 108
Residents Served: 79
Secured Dementia Care Unit Capacity: 24
Secured Dementia Care Unit Residents Served: 23
Total Daily Staff: 112
Waking Staff: 84
Inspection Report
Census: 81
Capacity: 108
Deficiencies: 0
Dec 4, 2024
Visit Reason
The inspection was conducted as a partial, unannounced visit due to an incident at the facility.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Report Facts
Total Daily Staff: 115
Waking Staff: 86
Residents Served: 81
License Capacity: 108
Secured Dementia Care Unit Capacity: 24
Secured Dementia Care Unit Residents Served: 23
Hospice Current Residents: 8
Residents Diagnosed with Mental Illness: 1
Residents with Mobility Need: 34
Residents 60 Years of Age or Older: 81
Residents with Physical Disability: 2
Inspection Report
Complaint Investigation
Census: 78
Capacity: 108
Deficiencies: 0
Jun 10, 2024
Visit Reason
The inspection was conducted as a complaint investigation at THE RESIDENCE AT CHADDS FORD on 06/10/2024.
Findings
No regulatory citations or deficiencies were identified as a result of this complaint inspection.
Complaint Details
The inspection was triggered by a complaint, but no deficiencies or citations were found, indicating no substantiated issues.
Report Facts
License Capacity: 108
Residents Served: 78
Memory Care Unit Capacity: 24
Memory Care Unit Residents Served: 24
Current Hospice Residents: 5
Residents Diagnosed with Mental Illness: 1
Residents Diagnosed with Intellectual Disability: 1
Residents Age 60 or Older: 78
Residents with Mobility Need: 30
Residents Receiving Supplemental Security Income: 0
Residents with Physical Disability: 0
Inspection Report
Renewal
Census: 79
Capacity: 108
Deficiencies: 7
May 8, 2024
Visit Reason
The inspection was conducted as a renewal inspection of the facility license for THE RESIDENCE AT CHADDS FORD.
Findings
The facility was found to have deficiencies related to menu posting, medication storage and accounting, and medication administration documentation. The submitted plan of correction was determined to be fully implemented as of the follow-up review.
Deficiencies (7)
| Description |
|---|
| The home's menu was not posted in a conspicuous place. |
| During medication audit, resident 1 had 29 Lorazepam syringes but the home had the count documented as 19. |
| Resident 2's glucometer did not have the correct date and time throughout April 2024, causing glucose checks to not match the Medication Administration Record. |
| Resident 2's Medication Administration Record showed a reading of 399 on 4/30/2024 which was not located in the glucometer. |
| Resident 2's glucometer showed a reading of 325 on 4/02/2024 but was documented as 385 on the Medication Administration Record. |
| On 5/7/2024, Resident 3's Narcotic Medication count Log for Zolpidem Tartrate 10 mg did not have a signature for the person administering the medication. |
| On 5/7/2024, Resident 4's Narcotic Medication count Log for Temazepam 7.5 mg capsule did not have a signature for the person administering the medication. |
Report Facts
License Capacity: 108
Residents Served: 79
Secured Dementia Care Unit Capacity: 24
Secured Dementia Care Unit Residents Served: 24
Current Hospice Residents: 4
Resident 1 Lorazepam Syringes Count: 29
Resident 1 Lorazepam Syringes Documented Count: 19
Inspection Report
Monitoring
Census: 69
Capacity: 108
Deficiencies: 11
May 4, 2023
Visit Reason
The visit was an unannounced partial inspection conducted as a monitoring review of THE RESIDENCE AT CHADDS FORD facility.
Findings
The inspection identified multiple deficiencies related to resident safety and medication management, including issues with operable bedside lamps, unlabeled leftover food, smoking policy violations, improper medication administration by family members, unsecured medications, unlabeled medications, glucometer calibration errors, and failure to follow prescriber's orders. Plans of correction were accepted and implemented by June 26, 2023.
Deficiencies (11)
| Description |
|---|
| Residents 1 and 2 did not have access to a source of light that can be turned on/off at bedside. |
| Containers of fruit salad and pudding were found without labels in the refrigerator. |
| A person was smoking near the emergency exit door where no smoking signs were posted. |
| Medication administered to Resident 3 by family members who are not licensed professionals. |
| Resident 3's medications were stored unlocked and accessible in a pill organizer on top of the refrigerator. |
| Medications for Residents 2, 5, and 8 did not have opening dates marked as required. |
| Resident 4 had discontinued 5 mg tablets still in medication cart without proper removal or destruction. |
| Resident 4 had medication bottles without pharmacy labels or resident's name. |
| OTC medications belonging to Resident 6 were not labeled with the resident's name. |
| Glucometers for Residents 1, 2, 5, 7, and 8 were not calibrated to the correct time; transcription errors in blood glucose documentation were found. |
| Failure to follow prescriber's orders including missed blood glucose readings and unavailable medication for Resident 4. |
Report Facts
Residents Served: 69
License Capacity: 108
Residents Served in Secured Dementia Care Unit: 21
Capacity of Secured Dementia Care Unit: 24
Current Hospice Residents: 2
Residents Age 60 or Older: 69
Residents with Mobility Need: 30
Inspection Report
Follow-Up
Census: 72
Capacity: 108
Deficiencies: 1
Mar 13, 2023
Visit Reason
The inspection was a partial, unannounced follow-up visit conducted due to an incident, with a focus on reviewing the submitted plan of correction.
Findings
The submitted plan of correction related to a deficiency in documenting a resident's mechanical soft diet need in the support plan was found to be fully implemented. Continued compliance is required.
Deficiencies (1)
| Description |
|---|
| The resident's support plan did not document how the need for a mechanical soft diet would be met. |
Report Facts
License Capacity: 108
Residents Served: 72
Secured Dementia Care Unit Capacity: 24
Residents Served in Dementia Care Unit: 18
Total Daily Staff: 101
Waking Staff: 76
Residents Age 60 or Older: 72
Residents with Mental Illness: 1
Residents with Mobility Need: 29
Residents with Physical Disability: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| MJ | Executive Director | Provided education on clarifying conflicting diet orders and reviewed DME for accuracy |
Inspection Report
Renewal
Census: 69
Capacity: 108
Deficiencies: 18
Mar 6, 2023
Visit Reason
The inspection was conducted as a renewal visit for the facility license, including a full unannounced inspection on 03/06/2023 and an exit conference on 03/07/2023.
Findings
The inspection identified multiple deficiencies related to medication management, sanitary conditions, emergency preparedness, food storage, fire safety, and documentation. Plans of correction were submitted and accepted, with many deficiencies marked as implemented by May or June 2023.
Deficiencies (18)
| Description |
|---|
| Failure to issue a refund within 30 days of resident discharge. |
| Criminal background checks for new staff were not completed timely. |
| Sharing of glucometers between residents and inaccurate glucose log documentation. |
| Emergency telephone numbers were not posted in resident apartments. |
| Resident did not have access to an operable lamp at bedside. |
| Uncovered and unlabeled food items found in Secure Dementia Care Unit refrigerator. |
| Accumulation of lint in dryer lint trap. |
| Fire safety inspection and fire drill not completed annually as required. |
| Fire drill records incomplete, missing exit route and resident evacuation details. |
| Medications and syringes not locked in resident room. |
| Discontinued medications present in medication carts. |
| Loose pill found in medication cart. |
| Medication label did not match the prescribed order. |
| Blood glucose readings and glucometer calibrations not properly documented. |
| PRN medications not available in the home as prescribed. |
| Medication administration records incomplete for sliding scale insulin doses. |
| Prescribed medications not administered as ordered on multiple occasions. |
| Medication not administered due to unavailability in the home. |
Report Facts
License Capacity: 108
Residents Served: 69
Secured Dementia Care Unit Capacity: 24
Secured Dementia Care Unit Residents Served: 19
Current Hospice Residents: 2
Total Daily Staff: 89
Waking Staff: 67
Inspection Report
Complaint Investigation
Census: 51
Capacity: 108
Deficiencies: 8
Apr 12, 2022
Visit Reason
The inspection was conducted as a complaint investigation to review compliance with regulations following a complaint.
Findings
The inspection identified multiple deficiencies including failure to report an incident to the Department, inadequate assistance with instrumental activities of daily living, failure to post menus and activity calendars, improper medication storage, and lack of a current activities coordinator. Plans of correction were accepted and implemented with measures to prevent recurrence.
Complaint Details
The inspection was complaint-driven as indicated by the reason for the visit and the unannounced nature of the inspection.
Deficiencies (8)
| Description |
|---|
| Failure to report an incident to the Department within 24 hours when emergency services were called for resident #1. |
| Resident #2 did not receive required verbal prompts during meal time as indicated in the resident’s assessment and support plan. |
| The home's menu for the week of 4/11/22 was not posted in the memory support area of the home. |
| A container of medicated ointment for resident #3 was improperly stored on the kitchen counter instead of in a secured medication cart. |
| The home does not have a program of activities designed to promote active involvement of residents with families and the community. |
| The home does not have a current weekly activity calendar posted in a public and conspicuous place in the home. |
| Failure to follow procedures for the delivery and management of services of planned activities for residents in the memory support unit. |
| During the week of April 11th, 2022, the home did not offer activities in memory support due to not having an activities coordinator. |
Report Facts
Residents Served: 51
License Capacity: 108
Residents in Memory Care Unit: 11
Residents in Hospice: 1
Staffing Hours per Resident: 2.9
Staffing Guideline Hours: 2
Inspection Report
Follow-Up
Census: 53
Capacity: 108
Deficiencies: 8
Mar 24, 2022
Visit Reason
The inspection was a partial, unannounced follow-up visit conducted on 03/24/2022 to review the submitted plan of correction related to an incident involving medication administration omissions and other compliance issues.
Findings
The facility failed to administer prescribed medications to residents as ordered, including a medication omission on 03/11/2022 for resident #1 and failure to administer Nuplazid to resident #2 from 03/09/22 to 03/15/22. There were also expired medications found in the medication cart and incomplete incident reports in resident records. The submitted plan of correction was determined to be fully implemented.
Deficiencies (8)
| Description |
|---|
| Failure to report an incident of medication omission within 24 hours as required. |
| Resident #1 did not receive evening medications on 03/11/22 as prescribed. |
| Resident #2 did not receive Nuplazid 34 mg from 03/09/22 to 03/15/22 due to pharmacy and insurance issues. |
| Expired medications found in medication cart for residents #1 and #2. |
| Sample prescription medications lacked required labeling information. |
| Medications were logged as administered when they were not given to resident #1 on 03/11/22. |
| Failure to follow prescriber's orders for multiple medications for resident #1 on 03/11/22 and for resident #2's Nuplazid from 03/09/22 to 03/15/22. |
| Resident records for residents #1 and #2 did not include incident reports. |
Report Facts
License Capacity: 108
Residents Served: 53
Secured Dementia Care Unit Capacity: 21
Secured Dementia Care Unit Residents Served: 13
Current Hospice Residents: 2
Medication Administration Pass Residents: 19
Medication Administration Pass Time Span: 4
Medication Administration Time per Resident: 13
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff person A | Medication Technician | Named in multiple medication administration omissions and protocol violations. |
| Mia Johnson | Signed the initial letter regarding plan of correction implementation. |
Notice
Capacity: 108
Deficiencies: 0
Sep 13, 2021
Visit Reason
The document serves as a renewal notification and issuance of a regular license for The Residence at Chadds Ford Personal Care Home, confirming receipt of the renewal application and advising of the requirement for an annual onsite inspection within the next twelve months.
Findings
No inspection findings are reported in this document; it is a licensing and renewal notification letter along with a certificate of compliance.
Report Facts
Maximum licensed capacity: 108
Secure Dementia Care Unit capacity: 24
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jamie L. Buchenauer | Deputy Secretary | Signed the renewal notification letter |
Inspection Report
Renewal
Census: 50
Capacity: 108
Deficiencies: 18
Aug 31, 2021
Visit Reason
The inspection was conducted as a renewal and incident investigation at The Residence at Chadds Ford, including multiple on-site visits from 08/31/2021 to 09/15/2021.
Findings
The inspection identified multiple deficiencies including issues with resident contracts, abuse incidents, direct care staff qualifications, staffing adequacy, medication administration errors, unsafe storage of poisonous materials, hot water temperature violations, incomplete medical evaluations, and documentation deficiencies. Plans of correction were accepted for all cited violations.
Deficiencies (18)
| Description |
|---|
| Resident contract was not reviewed timely by administrator and designee. |
| Resident neglect and verbal abuse incidents involving staff members. |
| Direct care staff member lacked required high school diploma, GED, or nurse aide registry status. |
| Staffing insufficient to meet resident needs; medication administration delayed or missed. |
| Poisonous materials were unlocked and accessible to residents not assessed as safe to handle them. |
| Hot water temperature exceeded 120°F in resident-accessible areas. |
| First aid kit missing a thermometer. |
| Food stored uncovered and undated in kitchen area. |
| Medication blister packaging was tampered with and taped shut. |
| Home lacked valid vehicle registration and insurance for transport bus. |
| Medications missing from medication cart and resident rooms. |
| Medication administration times not recorded at time of administration or not following prescriber's orders. |
| Staff member failed to complete required medication administration training and documentation. |
| Positive interventions not implemented for resident exhibiting aggressive behavior; staff physically restrained resident improperly. |
| Resident preadmission screening and assessments were incomplete or untimely. |
| Support plans not signed by residents or assessors as required. |
| Medical evaluations missing required dementia diagnosis for secured dementia care unit residents. |
| Standardized forms missing pages and incomplete documentation in resident records. |
Report Facts
Inspection dates: 5
License capacity: 108
Residents served: 50
Secured Dementia Care Unit capacity: 24
Residents in Secured Dementia Care Unit: 13
Staff total daily: 76
Waking staff: 57
Deficiency counts: 18
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff member A | Named in neglect and abuse findings; lacked required qualifications; terminated. | |
| Staff member B | Involved in restraining resident #2 and verbally abusing resident; named in abuse and positive intervention findings. | |
| Staff member C | Witnessed abuse incident; failed to complete required medication administration training. | |
| Staff member D | Reported inability to administer medications due to chaotic schedule. |
Inspection Report
Follow-Up
Census: 50
Capacity: 108
Deficiencies: 27
Aug 31, 2021
Visit Reason
The inspection was a full, unannounced renewal and incident review conducted to assess compliance with licensing regulations and to verify the implementation of previously submitted plans of correction.
Findings
The inspection identified multiple deficiencies including issues with resident contracts, abuse incidents, staff qualifications, medication administration errors, assessment and support plan documentation, and medication storage and labeling. Plans of correction were accepted and implemented with follow-up submissions verifying compliance.
Deficiencies (27)
| Description |
|---|
| Resident contract was not reviewed or signed timely by administrator and resident. |
| Resident neglect and physical restraint incidents involving staff members. |
| Direct care staff member lacked required high school diploma, GED, or nurse aide registry status. |
| Staffing insufficient to meet resident needs, resulting in missed medication administration. |
| Staff training plan incomplete and lacking required content. |
| Poisonous materials and hazardous items were unlocked and accessible to residents in secured dementia care unit. |
| Hot water temperature exceeded 120°F in resident accessible areas. |
| First aid kit missing thermometer. |
| Food stored uncovered and undated in kitchen area. |
| Outdated or spoiled food present in kitchen. |
| Resident medical evaluation form incomplete or missing pages. |
| Home lacked valid vehicle registration and insurance for transport bus. |
| Medication blister packaging compromised and taped shut. |
| Discontinued medications not destroyed properly and remained on medication cart. |
| Prescription medication labels did not match medication administration records causing confusion. |
| Over-the-counter medications not labeled with resident names. |
| Medications missing from medication carts and resident rooms. |
| Medication administration times not recorded at time of administration or not administered as scheduled. |
| Medications administered by staff who had not completed Department-approved medication administration training. |
| Positive interventions not implemented for resident exhibiting aggressive behavior; prohibited restraint used. |
| Resident preadmission screening and assessments not completed timely or missing required information. |
| Resident support plans not signed by resident or assessor. |
| Medication administration records and controlled substance records did not match; medication errors documented. |
| Direct care staff providing unsupervised ADL services without completing required training and competency testing. |
| Medication procedures lacked proper documentation and controls for receipt, administration, and error investigation. |
| Resident rights and abuse training not completed within required 40 scheduled working hours for some staff. |
| Resident medication not administered as prescribed by physician orders. |
Report Facts
License Capacity: 108
Residents Served: 50
Secured Dementia Care Unit Capacity: 24
Residents Served in Dementia Unit: 13
Staffing: 76
Waking Staff: 57
Deficiency Counts: 27
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff member A | Named in abuse and neglect findings involving resident #1. | |
| Staff member B | Named in abuse and restraint incident involving resident #2. | |
| Staff member C | Named in medication administration training deficiency and medication errors. | |
| Staff member D | Named in medication administration and staffing insufficiency findings. | |
| Staff member E | Named in direct care training deficiency. | |
| Staff member F | Named in direct care training deficiency. |
Inspection Report
Complaint Investigation
Census: 45
Capacity: 108
Deficiencies: 9
Jul 15, 2021
Visit Reason
The inspection was conducted as a complaint investigation following concerns raised about resident care and medication administration at THE RESIDENCE AT CHADDS FORD.
Findings
The inspection found multiple deficiencies including late medication administration without proper reporting, failure to follow physician orders for weight checks, inadequate incident reporting, and failure to monitor resident condition changes. Plans of correction were accepted and implemented.
Complaint Details
The visit was complaint-related, triggered by concerns about resident #1's medication administration, weight loss, falls, and lack of proper reporting and monitoring. The complaint was substantiated based on the findings.
Deficiencies (9)
| Description |
|---|
| Late administration of resident #1's medications between 4 and 7 hours without reporting the incident to the Department. |
| Resident #1 was neglected regarding assistance with meals and weight monitoring, resulting in significant weight loss and injury. |
| Resident #1's medical evaluation was not completed annually as required. |
| More than 15 hours elapsed between evening meal and breakfast on 7/15/21, violating meal timing regulations. |
| Medication changes were made without written orders from authorized prescribers. |
| Failure to follow prescriber's orders for weekly weight checks for resident #1. |
| Medication error was not reported immediately to the resident, designated person, or prescriber. |
| Resident #1's additional assessments were not updated to reflect recent falls and monitoring needs. |
| Resident #1 participated in support plan development but did not sign the support plan as required. |
Report Facts
License Capacity: 108
Residents Served: 45
Secured Dementia Care Unit Capacity: 24
Secured Dementia Care Unit Residents Served: 12
Staffing Hours - Total Daily Staff: 69
Staffing Hours - Waking Staff: 52
Weight Loss: 12
Hours Between Meals: 17.5
Inspection Report
Follow-Up
Census: 33
Capacity: 108
Deficiencies: 12
May 11, 2021
Visit Reason
The inspection was a partial, unannounced follow-up visit conducted due to an incident at the facility to verify the implementation of a submitted plan of correction.
Findings
The facility was found to have multiple deficiencies related to medication administration, documentation, and resident assessments, including failure to administer prescribed medications, failure to report medication errors and refusals, presence of discontinued medications, incomplete resident assessments, and missing signatures on support plans. The submitted plan of correction was determined to be fully implemented.
Deficiencies (12)
| Description |
|---|
| Failure to report medication incidents to the Department within 24 hours as required. |
| Resident was not administered prescribed medications as ordered, and the prescriber was not notified. |
| Discontinued medication was found in the medication cart. |
| Failure to document and timely update narcotic count sheets after medication administration. |
| Agency staff administering medication did not have access to update electronic medication administration records timely. |
| Failure to document and report resident refusal of medication to the prescriber. |
| Failure to follow prescriber's orders for medication administration and other treatments such as TED stockings. |
| Failure to immediately report medication errors to the resident, designated person, and prescriber. |
| Failure to complete initial resident assessments within 15 days of admission. |
| Failure to complete additional resident assessments annually or as required. |
| Support plans missing signatures of individuals who participated in their development. |
| Failure to complete required written cognitive preadmission screening within 72 hours prior to admission to secured dementia care unit. |
Report Facts
License Capacity: 108
Residents Served: 33
Secured Dementia Care Unit Capacity: 24
Residents Served in Dementia Unit: 11
Staffing Hours: 50
Waking Staff: 38
Medication Omission Instances: 30
Medication Refusals Not Documented: 7
Assessment Completion Deadline: 15
Preadmission Screening Timeframe: 72
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