Inspection Reports for The Terraces at Park Marino

This was an unannounced complaint investigation visit triggered by an allegation that staff did not evacuate a resident during a mandatory evacuation due to a fire near the facility.

The investigation found that at least one resident was left in their room and had to be evacuated by the fire department, confirming the allegation as substantiated. Staff began evacuation procedures but were instructed by the fire department to not re-enter the building. Some residents were evacuated by family members or unidentified individuals. The facility was destroyed by the Eaton fire, and the investigation was conducted largely via telephone and interviews.

The complaint alleged that staff did not evacuate a resident during a mandatory evacuation. The allegation was substantiated based on interviews and records showing a resident was left behind and evacuated by the fire department. The investigation included interviews with staff, residents, responsible parties, fire department personnel, and review of fire department status reports.

The inspection was a required one-year unannounced annual visit to evaluate the facility's compliance with licensing requirements.

The report outlines the licensing deficiencies and the types of deficiencies (Type A and Type B) that may be cited. It also explains the process for plans of correction, civil penalties, and appeal rights. No specific deficiencies or findings are detailed in the provided pages.

The visit was an unannounced case management follow-up on an incident report submitted on 2024-11-19 regarding an altercation between two residents resulting in injury.

The investigation found that Resident #2 exhibited aggressive behavior towards Resident #1, causing injury that required hospital transport. The facility updated care plans and implemented increased monitoring measures. No deficiencies were noted during the visit.

The complaint involved an incident where Resident #2 threw a picture frame and hit Resident #1, causing bleeding and requiring paramedic intervention. The complaint was investigated through interviews and document review, confirming the aggressive behavior history of Resident #2 and the facility's response.

An unannounced complaint investigation visit was conducted in response to allegations that facility staff did not provide information on a resident's injury and that staff were retaining residents who require a higher level of care.

The investigation found that staff responded to a resident's fall and contacted 911 as per protocol, with family notified on the same day; however, staff were unable to provide detailed information to the resident's representative. Regarding retention of residents needing higher care, the facility had three residents with dementia in assisted living awaiting openings in the dementia unit, with precautions in place to ensure their safety. Both allegations were unsubstantiated due to lack of preponderance of evidence.

The complaint investigation was unsubstantiated. Allegations included failure to provide information on a resident's injury and retaining residents requiring a higher level of care. Interviews, document reviews, and resident interviews were conducted. The investigation concluded there was insufficient evidence to prove violations.

The visit was an unannounced plan of correction (POC) inspection to follow up on a previously noted deficiency regarding storage of cleaning solutions in a resident's room.

The deficiency related to storage of cleaning solutions on a resident's nightstand was cleared during this visit after the cleaning solutions were removed and staff training and care plans were reviewed.

The visit was an unannounced plan of correction (POC) inspection conducted to follow up on deficiencies noted during an annual visit on 2024-06-06.

The inspection found that all previously noted deficiencies related to infection control, maintenance and operation, and oxygen administration were corrected by the date of the follow-up visit on 2024-07-09.

The visit was an unannounced plan of correction (POC) follow-up to verify correction of deficiencies noted during an annual visit on 2024-06-06.

The facility was found to still have cleaning solutions stored in a resident's room (#222) where a resident with dementia resides, posing an immediate health and safety risk. The deficiency related to improper storage of hazardous materials was not corrected by the due date.

An unannounced continuation annual visit was conducted as part of the annual case management inspection to evaluate compliance with regulatory requirements.

The Licensing Program Analyst reviewed multiple domains including infection control, staffing, personnel records, disaster preparedness, and residents with special health needs. No deficiencies were cited during this visit.

An unannounced annual visit was conducted using the CARE inspection tool to evaluate compliance with licensing regulations and facility standards.

The facility was generally in good repair with adequate environmental cleaning and safety measures; however, several deficiencies were noted including improper hand hygiene by staff exiting a quarantine room, water temperature issues in resident bathrooms, unsafe storage of cleaning solutions in a resident's room, lack of PPE use when caring for contagious residents, and an unsecured oxygen tank in a resident's room.

An unannounced complaint investigation visit was conducted regarding an allegation that facility staff was restricting a resident from seeing a visitor.

The investigation found that residents are aware of the visiting policy and visitations have not been restricted. Former employees are allowed to visit residents if requested by the resident. The allegation was determined to be unsubstantiated due to lack of preponderance of evidence.

The complaint alleged that facility staff was restricting a resident from seeing a visitor who was a past employee. The investigation included interviews with residents and staff, review of visitor logs and policies. The allegation was found unsubstantiated.

The inspection was an unannounced complaint investigation visit conducted in response to allegations including questionable death, staff not preventing the spread of a communicable disease, and staff not following proper hand washing.

The investigation found no sufficient evidence to substantiate the allegations. Death reports indicated residents died of natural causes, and staff and residents denied improper sanitation or hand washing practices. The facility maintained proper infection control measures and timely reporting of outbreaks.

The complaint involved allegations of questionable death related to a Covid-19 and Norovirus outbreak in March 2023, and staff failing to prevent disease spread and follow hand washing protocols. The allegations were unsubstantiated based on interviews, record reviews, and observations.

An unannounced complaint investigation visit was conducted in response to an allegation that staff do not treat residents with dignity and respect.

The investigation found that the allegation was unsubstantiated as interviews with staff, residents, and review of staff files did not provide sufficient evidence to prove the alleged violation occurred.

The allegation was that staff member S1 was rude and belittled residents. The Administrator and all interviewed staff denied the allegation. Six out of ten residents denied the allegation, while four residents did not remember S1. No disciplinary actions were found in staff files. The allegation was determined to be unsubstantiated due to lack of preponderance of evidence.

An unannounced complaint investigation visit was conducted regarding allegations that a resident developed a pressure injury due to staff neglect, facility staff did not seek timely medical attention for the resident, and staff did not notice a change in resident conditions.

The investigation substantiated that the resident developed an unstageable wound on the left heel due to staff neglect and failure to obtain timely medical care for at least two weeks. Staff were aware of the wound but lacked training in wound care and prevention. An immediate civil penalty of $500 was issued. Another allegation regarding failure to provide basic laundry services was unsubstantiated.

The complaint was substantiated regarding neglect leading to a pressure injury and failure to seek timely medical attention. The allegation about failure to provide laundry services was unsubstantiated.

An unannounced complaint investigation visit was conducted regarding allegations that residents' diapering needs were not being met, staff mismanaged residents' money, and the facility was not kept free of hazards.

The investigation found no corroborating evidence for the allegations. Staff and residents denied the claims, documentation and observations supported proper care and safety, and the police investigation found no criminal activity. Therefore, the allegations were determined to be unsubstantiated.

The complaint investigation was unannounced and focused on three allegations: unmet diapering needs, mismanagement of residents' money, and failure to maintain a hazard-free facility. Interviews with staff and residents, review of documentation, and facility observations did not support the allegations. The police investigation related to similar claims found no criminal activity. The allegations were deemed unsubstantiated due to lack of evidence.

The inspection was an unannounced complaint investigation visit conducted in response to an allegation of lack of care and supervision resulting in multiple falls and an injury.

The investigation found insufficient evidence to substantiate the allegation. Staff interviews, resident interviews, and review of records indicated that the facility had procedures in place for communication and monitoring residents, and no falls resulted in hospitalization. The allegation was determined to be unsubstantiated.

The complaint alleged that a resident (R1) suffered multiple falls between June and July 2020 due to lack of supervision and communication among staff. The investigation included interviews with staff and residents, review of resident files, incident reports, hospice records, and observation of staff to resident ratios. The allegation was found unsubstantiated due to lack of sufficient evidence.

The visit was an unannounced case management follow-up on an incident report submitted on 2023-08-28 regarding a resident not found during a morning check on 2023-08-27.

The facility failed to provide appropriate dementia care to a resident with dementia, posing an immediate risk to health and safety. Additionally, the facility did not obtain an annual physician's report appraisal as required, posing a potential risk.

The visit was triggered by a complaint incident report about a resident with dementia who was not found during a morning check and was found in another resident's room. The facility did not contact the police as required. The complaint was substantiated with noted deficiencies.

An unannounced complaint investigation visit was conducted regarding an allegation that staff allowed dental services to a resident without the resident's consent.

The investigation found that the resident in question does not reside or resided at the facility, and based on the information gathered, the allegation was deemed unfounded.

The allegation that staff allowed dental services to a resident without the resident's consent was investigated and found to be unfounded.

An unannounced case management annual continuation visit was conducted to conclude review of Personnel Records, Resident Records, and Residents with Special Health Needs.

Deficiencies were noted related to incomplete staff training on postural support and restricted health conditions, and a missing TB clearance for resident #5. Plans of correction were required to address these issues by 06/30/2023.

An unannounced annual visit was conducted using the CARE tool to evaluate the facility's compliance with licensing requirements.

The facility was found to be clean and in good repair with sufficient food supplies and proper safety measures in place. No deficiencies were noted, but a technical violation was recorded per Title 22 Regulations.

The inspection was an unannounced complaint investigation visit triggered by a complaint received on 2021-04-28 alleging lack of care and supervision resulting in multiple falls and an injury.

The investigation included interviews with staff and residents, review of resident files, and facility records. Staff and residents denied the allegations, and the facility documented and reported falls and sought timely medical attention. There was insufficient evidence to substantiate the allegation, resulting in an unsubstantiated finding.

The complaint alleged that Resident #1 suffered multiple falls between June and July 2020 due to lack of supervision and communication among staff. The allegation was found unsubstantiated based on interviews, documentation, and lack of preponderance of evidence.

Unannounced Plan of Correction visit to follow up on deficiencies identified during the annual visit on 2022-06-29.

The deficiency related to the dementia care kitchen's cabinet being unlocked was corrected; the cabinet was found locked during this visit, indicating the deficiency was cleared.

An unannounced annual visit was conducted focusing on infection control, food supplies, and medication compliance.

The facility was generally compliant with required conditions including fire safety and food supplies, but deficiencies were noted such as unlocked cleaning supplies accessible to memory care residents, missing prescribed medications for some residents, and lack of infection control hand washing signs in certain areas.

The visit was a case management follow-up to provide deficiencies related to a complaint investigation conducted on 2021-11-09 regarding a HIPAA confidentiality breach during a resident transfer.

The facility failed to safeguard resident confidentiality by providing the emergency packet of resident #2 instead of resident #1 during a hospital transfer, violating HIPAA law and endangering the resident's welfare.

The complaint investigation revealed a HIPAA violation where facility staff provided paramedics with the emergency packet for resident #2 instead of resident #1 during a hospital transfer, resulting in confidentiality breach and risk to resident welfare.

The visit was a case management visit regarding COVID-19 guidance for reporting requirements following the facility's report of COVID positive cases.

No deficiencies were given during this visit. A technical violation was provided related to timely reporting of COVID-19 breakout cases, and COVID guidance PINs were to be emailed to the administrator.

An unannounced complaint investigation visit was conducted in response to allegations that facility staff did not provide a resident's medical records to the resident's medical provider and that staff were not communicating with the resident's medical provider.

The investigation found that the facility mistakenly sent incorrect medical records to the hospital due to a receptionist error, but the facility provided training and corrected the issue. Communication with the resident's medical provider was confirmed through a medical technician, but there was no preponderance of evidence to substantiate the allegations. Therefore, the allegations were unsubstantiated.

The complaint investigation was unsubstantiated. Allegations included failure to provide correct medical records and lack of communication with the resident's medical provider. The investigation included interviews with staff and review of fax logs and hospital contacts. Despite some errors, there was insufficient evidence to prove violations occurred.

An unannounced annual visit focusing on infection control, food supplies, and medication was conducted to evaluate compliance with regulatory requirements.

The inspection found multiple deficiencies including improper storage of cleaning solutions and scissors accessible to residents, lack of a 30-day supply of medication for some residents, medications not stored in original containers, PRN medications without proper labeling, malfunctioning auditory devices in the dementia unit, and staff not properly wearing face coverings according to CDC guidelines.

The inspection was an unannounced complaint investigation triggered by an allegation that a resident's items and money were stolen while in care.

The investigation included interviews with residents and staff, and a review of records. The evidence showed that most residents did not report missing items, staff were unaware of any thefts, and no incident or police reports were found. The allegation was found to be unsubstantiated.

The complaint alleged that a resident's items and money were stolen while in care. The investigation found no substantiation for the allegation based on interviews and record reviews.