Inspection Reports for Towne Centre Assisted Living LLC
7252 ARTHUR BLVD, MERRILLVILLE, IN, 46410
Back to Facility ProfileInspection Report Summary
The most recent inspection on June 24, 2025, found no deficiencies related to the complaint investigated. Earlier inspections showed a pattern of deficiencies primarily involving medication administration, clinical documentation, service plan updates, and sanitation issues. Some investigations substantiated complaints about failure to notify physicians and families of condition changes, incomplete follow-up care, and inadequate supervision leading to resident safety concerns. Enforcement actions such as staff suspension and termination occurred in response to substantiated verbal abuse, but fines or license suspensions were not listed in the available reports. The facility’s inspection history shows some improvement with recent investigations finding no deficiencies, following a period of mixed compliance.
Deficiencies (last 4 years)
Deficiencies (over 4 years)
13.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
221% worse than Indiana average
Indiana average: 4.2 deficiencies/yearDeficiencies per year
16
12
8
4
0
Census
Latest occupancy rate
212 residents
Based on a June 2025 inspection.
Census over time
Inspection Report
Complaint Investigation
Census: 212
Deficiencies: 0
Date: Jun 24, 2025
Visit Reason
This visit was conducted for the investigation of Complaint IN00462043 at Towne Centre Assisted Living LLC.
Complaint Details
Complaint IN00462043 was investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to the allegations in Complaint IN00462043 were cited. The facility was found to be in compliance with 410 IAC 16.2-5 regarding the complaint investigation.
Report Facts
Residential Census: 212
Inspection Report
Complaint Investigation
Census: 209
Deficiencies: 8
Date: May 8, 2025
Visit Reason
This visit was for a State Residential Licensure Survey including the Investigation of Complaints IN00457194 and IN00458664.
Complaint Details
Investigation of Complaints IN00457194 and IN00458664 found no deficiencies related to the allegations.
Findings
No deficiencies were cited related to the complaints. Deficiencies were found related to medication administration, service plan documentation, food preparation, clinical records, and emergency binder completeness.
Deficiencies (8)
Failure to observe administration of chlorhexidine gluconate mouthwash to Resident 12.
Improper storage and unauthorized self-administration of fluticasone nasal spray for Resident 15.
Failure to ensure service plans were signed and updated for Residents 3, 5, 8, and 14.
Failure to ensure medications were given as ordered; Resident 13 had a missed dose of calcium carbonate.
Failure to ensure modified diets were prepared properly according to recipe; improper measuring and handling of pureed meatballs.
Failure to ensure food was prepared under sanitary conditions related to improper hand hygiene and glove use during preparation of pureed diet.
Failure to ensure clinical records were complete and accurately documented related to incomplete or lack of orders for home health, wound care, and glucose monitoring for Residents 4, 7, and 10.
Failure to ensure Emergency Binder had complete resident information including physician contact, allergies, and correct apartment numbers for Residents 2, 5, 7, 8, and 10.
Report Facts
Residential Census: 209
Deficiencies completion date: 2025
Number of residents with service plan deficiencies: 4
Number of residents with clinical record deficiencies: 3
Number of residents with emergency binder deficiencies: 5
Number of residents observed for medication administration: 5
Number of residents receiving pureed diet: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Rikki Ford | Executive Director | Signed report |
| QMA 1 | Named in medication administration deficiencies for Residents 12, 13 | |
| LPN 1 | Named in medication administration deficiencies for Resident 15 | |
| Director of Nursing | Director of Nursing | Responsible for audits, re-education, and corrective actions |
| Resident Care Coordinator | Interviewed regarding medication and service plan deficiencies | |
| Dietary Manager | Responsible for dietary staff education and food preparation audits | |
| Assisted Living Unit Manager | Interviewed regarding clinical record deficiencies | |
| Medical Records Liaison | Responsible for Emergency Binder audit and updates |
Inspection Report
Complaint Investigation
Census: 211
Deficiencies: 4
Date: Feb 25, 2025
Visit Reason
This visit was for the investigation of multiple complaints (IN00450879, IN00451374, IN00451396, IN00452221, IN00453232, IN00453712, and IN00453719) related to the facility.
Complaint Details
The investigation was triggered by multiple complaints. Some complaints resulted in deficiencies cited, while others did not. Specific complaints with deficiencies include IN00450879, IN00451396, IN00452221, and IN00453719. The facility was cited for failures related to notification, reporting, sanitation, and medication administration.
Findings
The facility was found deficient in several areas including failure to notify physician and responsible party of low blood pressure and medication not administered, failure to report a major accident within 24 hours, unsanitary dining conditions with wet silverware and food crumbs on the floor, and failure to ensure medication was administered as ordered by the physician.
Deficiencies (4)
Failed to notify a resident's physician and responsible party of low blood pressure and medication not administered for multiple days.
Failed to report a major accident to the Indiana Department of Health within 24 hours for one resident who had a fall resulting in brain swelling and death.
Failed to ensure one of two dining areas and utensils were kept clean and sanitary; food was on the floor and silverware was wet inside plastic bags.
Failed to ensure a medication was administered as ordered by the physician for one resident; blood pressure was not checked prior to administration and medication was given without required documentation.
Report Facts
Complaint numbers investigated: 7
Residential Census: 211
Dates medication not administered: 15
Dates medication administered without blood pressure check: 7
Dates medication held without blood pressure documented: 9
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Rikki Ford | Executive Director | Signed the report and involved in corrective action plans |
| Memory Care 1 Unit Manager | Interviewed regarding notification failures and medication administration | |
| Memory Care 2 Unit Manager | Interviewed regarding incident reporting timeline | |
| Administrator | Interviewed regarding incident reporting knowledge and procedures | |
| Dietary Aide 1 | Interviewed regarding wet silverware and dining room cleanliness | |
| Dietary Manager | Interviewed regarding wet silverware report and replacement | |
| CNA 2 | Interviewed regarding food on the floor in dining room |
Inspection Report
Complaint Investigation
Census: 212
Deficiencies: 1
Date: Jan 2, 2025
Visit Reason
This visit was for the investigation of multiple complaints (IN00444826, IN00445088, IN00445291, IN00445701, IN00445944, IN00447134, IN00447573, and IN00450377) at Towne Centre Assisted Living LLC.
Complaint Details
The investigation involved eight complaints, with deficiencies related only to complaints IN00445701 and IN00447134. Complaints IN00444826, IN00445088, IN00445291, IN00445944, IN00447573, and IN00450377 had no deficiencies related to the allegations. The cited deficiency involved incomplete follow-up documentation of a skin discoloration condition in Resident D.
Findings
The facility was found noncompliant in maintaining complete and accurate clinical records related to follow-up documentation of a new skin condition for one resident (Resident D). Several complaints had no deficiencies related to the allegations, but state deficiencies were cited related to complaints IN00445701 and IN00447134.
Deficiencies (1)
Failed to maintain clinical records that were complete and accurately documented related to follow up documentation of a new skin condition for 1 of 3 residents reviewed for change in condition (Resident D).
Report Facts
Residential Census: 212
Survey Dates: December 30 and 31, 2024 and January 2, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Carmella Owens | Director of Nursing | Named in interview regarding policy on skin discoloration monitoring and documentation. |
Inspection Report
Follow-Up
Census: 221
Deficiencies: 0
Date: Oct 9, 2024
Visit Reason
This visit was for the Post Survey Revisit (PSR) to the Investigation of Complaints IN00437888, IN00438307, IN00439945, IN00440596, and IN00440781 completed on August 14, 2024.
Complaint Details
This visit was a follow-up to investigate complaints IN00437888, IN00438307, IN00439945, IN00440596, and IN00440781. All complaints were found to be corrected.
Findings
Towne Centre Assisted Living LLC was found to be in compliance with 410 IAC 16.2-5 in regard to the PSR to the Investigation of Complaints. All complaints were corrected.
Report Facts
Residential Census: 221
Inspection Report
Complaint Investigation
Census: 207
Deficiencies: 0
Date: Oct 1, 2024
Visit Reason
This visit was conducted for the investigation of complaints IN00443925, IN00444102, and IN00444364 at Towne Centre Assisted Living LLC.
Complaint Details
Investigation of Complaints IN00443925, IN00444102, and IN00444364 found no deficiencies related to the allegations.
Findings
No deficiencies related to the allegations in complaints IN00443925, IN00444102, and IN00444364 were cited. The facility was found to be in compliance with 410 IAC 16.2-5 regarding these complaints.
Report Facts
Residential Census: 207
Inspection Report
Complaint Investigation
Census: 208
Deficiencies: 0
Date: Sep 11, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00441975 at Towne Centre Assisted Living LLC.
Complaint Details
Complaint IN00441975 was investigated and found to have no related deficiencies.
Findings
No deficiencies related to the allegations in Complaint IN00441975 were cited. The facility was found to be in compliance with 410 IAC 16.2-5 regarding the complaint.
Report Facts
Residential Census: 208
Inspection Report
Complaint Investigation
Census: 206
Deficiencies: 5
Date: Aug 13, 2024
Visit Reason
This visit was for the investigation of multiple complaints (IN00437888, IN00438307, IN00438703, IN00439710, IN00439842, IN00439945, IN00439960, IN00440596, and IN00440781) related to Towne Centre Assisted Living LLC.
Complaint Details
The investigation was triggered by multiple complaints alleging issues such as theft, inadequate grievance handling, resident elopement, environmental concerns, and care deficiencies. Some complaints resulted in cited deficiencies, while others did not.
Findings
The facility was found deficient in several areas including failure to implement grievance policies, inadequate supervision leading to resident elopement and injury, failure to maintain comfortable environmental temperatures, failure to update resident service plans to reflect changes in condition, and failure to provide adequate supervision and care related to falls and pressure ulcer treatments.
Deficiencies (5)
Failed to implement grievance policy for a resident with complaints of theft or missing items.
Failed to ensure a resident with dementia was free from neglect related to inadequate supervision, resulting in elopement and injury.
Failed to maintain comfortable and safe temperature levels in the Memory Care 2 activity room.
Failed to update a resident's service plan to reflect changes in physical and mental status.
Failed to ensure adequate supervision to prevent falls and failed to provide appropriate pressure ulcer treatments.
Report Facts
Complaint IDs investigated: 9
Residents present during inspection: 206
Dates of survey: 2024-08-13 to 2024-08-14
Corrective action completion dates: Sep 20, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Rikki Ford | Unknown | Laboratory Director's or Provider/Supplier Representative's signature on report |
| LPN 1 | Named in investigation related to resident elopement and failure to intervene | |
| DON | Director of Nursing | Involved in investigation findings and corrective actions related to resident elopement and care deficiencies |
| MC Unit Manager | Provided interviews regarding resident elopement and supervision | |
| CNA 4 | Provided statement related to resident falls and supervision |
Inspection Report
Complaint Investigation
Census: 219
Deficiencies: 0
Date: Jun 24, 2024
Visit Reason
This visit was conducted for the investigation of complaints IN00434657, IN00435146, IN00436748, and IN00437114 at Towne Centre Assisted Living LLC.
Complaint Details
Complaints IN00434657, IN00435146, IN00436748, and IN00437114 were investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to the allegations in any of the four complaints were cited. The facility was found to be in compliance with 410 IAC 16.2-5 regarding the investigation of these complaints.
Inspection Report
Complaint Investigation
Census: 217
Deficiencies: 0
Date: Apr 15, 2024
Visit Reason
This visit was conducted for the investigation of complaints IN00430502, IN00430604, and IN00431794 at Towne Centre Assisted Living LLC.
Complaint Details
Investigation of Complaints IN00430502, IN00430604, and IN00431794 found no deficiencies related to the allegations.
Findings
No deficiencies related to the allegations in complaints IN00430502, IN00430604, and IN00431794 were cited. The facility was found to be in compliance with 410 IAC 16.2-5 regarding these complaints.
Inspection Report
Complaint Investigation
Census: 226
Deficiencies: 11
Date: Jan 23, 2024
Visit Reason
This visit was for a State Residential Licensure Survey including the Investigation of multiple complaints (IN00416936, IN00417082, IN00417715, IN00417984, IN00418886, IN00418935, IN00419284, IN00419841, and IN00422911).
Complaint Details
The visit included investigation of complaints IN00416936, IN00417082, IN00417715, IN00417984, IN00418886, IN00418935, IN00419284, IN00419841, and IN00422911. Several complaints were substantiated with related deficiencies cited.
Findings
The facility was found deficient in multiple areas including failure to promptly notify family of significant condition changes, failure to implement grievance policies, expired CNA certification, incomplete health screenings, environmental maintenance issues, kitchen sanitation problems, incomplete resident evaluations and service plans, medication availability issues, and incomplete clinical documentation.
Deficiencies (11)
Failed to promptly notify a resident's family member of a significant change in condition related to COVID-19.
Failed to implement grievance policy for a family member related to medication refill notifications.
Failed to ensure a CNA's certificate was current and not expired while working at the facility.
Failed to ensure employee health screens were signed by a licensed nurse or physician for 2 employees.
Failed to maintain a clean and good repair environment including marred walls, holes, peeling paint, torn carpet, and leaky faucets in multiple units.
Failed to maintain kitchens clean and in good repair, including missing cabinet doors, rubber gasket issues, grease and debris, and chipped paint.
Failed to ensure food was prepared and stored under sanitary conditions, including uncovered and undated food items.
Failed to complete a self-administration of medication evaluation for a resident who self-administered medications.
Failed to update a resident's Service Plan to reflect changes in medications and treatments.
Failed to ensure medications were available for a resident with fecal impaction.
Failed to maintain complete and accurate clinical records, including documentation before and after hospitalizations, bowel movement monitoring, resident pass documentation, and incident reporting.
Report Facts
Complaint investigations: 9
Resident census: 226
Audit frequency: 4
Audit duration: 16
Audit duration: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Rikki Ford | Administrator | Signed the report and involved in plan of correction. |
| LPN 1 | Involved in an altercation with Resident D; no longer employed. | |
| Director of Nursing | Director of Nursing | Named in multiple findings related to notification failures, documentation, and staff education. |
| Human Resource Director | Interviewed regarding expired CNA certificate and health screening documentation. | |
| Dietary Supervisor 1 | Interviewed regarding kitchen sanitation deficiencies. | |
| Dietary Supervisor 2 | Interviewed regarding kitchen sanitation deficiencies. | |
| Administrator | Administrator | Involved in complaint investigations and staff education. |
Inspection Report
Complaint Investigation
Census: 217
Deficiencies: 2
Date: Aug 29, 2023
Visit Reason
This visit was for the investigation of multiple complaints (IN00414189, IN00414337, IN00415017, IN00415257, and IN00416416) concerning medication administration and care at Towne Centre Assisted Living LLC.
Complaint Details
Complaints IN00414337 and IN00415257 were substantiated with state deficiencies cited at R0241 related to medication administration errors. Complaints IN00414189, IN00415017, and IN00416416 had no deficiencies related to the allegations.
Findings
The facility failed to ensure medications were administered as ordered by the physician for 2 of 5 residents observed during a morning medication pass, including incorrect dosages and missed medication administration. Deficiencies were cited related to medication patch administration and incorrect dosage of lorazepam and omeprazole.
Deficiencies (2)
Failure to ensure medications were administered as ordered by the physician for residents in the Memory Care Unit, including incorrect dosage of lorazepam and missed administration of a scopolamine patch.
Failure to administer omeprazole as ordered with the morning medication.
Report Facts
Residential Census: 217
Deficiencies cited: 2
Medication administration times and dosages: 0.5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Rikki Ford | Administrator | Signed the report |
| LPN 1 | Prepared and administered medications incorrectly to Residents M and N | |
| RN 2 | Acknowledged wrong dose of lorazepam was administered | |
| Unit Manager | Acknowledged lorazepam dosage change |
Inspection Report
Complaint Investigation
Census: 222
Deficiencies: 0
Date: Jul 19, 2023
Visit Reason
This visit was conducted for the investigation of complaints IN00412285 and IN00413077 at Towne Centre Assisted Living LLC.
Complaint Details
Investigation of Complaints IN00412285 and IN00413077 found no deficiencies related to the allegations; facility was in compliance.
Findings
No deficiencies related to the allegations in complaints IN00412285 and IN00413077 were cited. The facility was found to be in compliance with 410 IAC 16.2-5 regarding these complaints.
Report Facts
Residential Census: 222
Inspection Report
Complaint Investigation
Census: 226
Deficiencies: 0
Date: Jul 3, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00411996 at Towne Centre Assisted Living LLC.
Complaint Details
Complaint IN00411996 was investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to the allegations in Complaint IN00411996 were cited. The facility was found to be in compliance with 410 IAC 16.2-5 regarding the complaint investigation.
Inspection Report
Complaint Investigation
Census: 220
Deficiencies: 1
Date: Jun 5, 2023
Visit Reason
This visit was conducted for the investigation of multiple complaints (IN00403733, IN00404683, IN00406236, IN00409478, and IN00409562) regarding the facility.
Complaint Details
The complaint investigation revealed that for 1 of 3 residents reviewed for abuse (Resident E), the allegation was not reported to the Indiana Department of Health as required. The resident reported staff abuse on 5/11/23, but the Executive Director did not report it until 6/5/23 after the surveyor interview. The resident declined to meet with administration for further investigation.
Findings
The investigation found state deficiencies related to complaints IN00403733, IN00409478, and IN00409562 concerning failure to report an allegation of abuse to the Indiana Department of Health for one resident. Other complaints had no deficiencies cited.
Deficiencies (1)
Failure to report an allegation of abuse to the Indiana Department of Health within 23 hours as required by facility policy and state regulations.
Report Facts
Residential Census: 220
Survey Dates: Inspection conducted on June 5 and 6, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Rikki Ford | Administrator | Named as facility administrator and signatory on the report |
Inspection Report
Complaint Investigation
Census: 222
Deficiencies: 6
Date: Mar 9, 2023
Visit Reason
This visit was for the investigation of multiple complaints (IN00394470, IN00397091, IN00397140, IN00398308, and IN00401392) at Towne Centre Assisted Living LLC.
Complaint Details
This investigation was triggered by complaints IN00394470, IN00397091, IN00397140, IN00398308, and IN00401392. Deficiencies were substantiated for complaints IN00394470, IN00397091, and IN00398308. Complaints IN00397140 and IN00401392 had no deficiencies related to the allegations.
Findings
The facility was found deficient in several areas including failure to notify a resident's physician and responsible party of a fall, failure to ensure staff awareness of call light activation due to lack of walkie talkies, failure to update service plans to reflect resident behaviors and language barriers, failure to ensure medication patches were applied as ordered, improper medication preparation practices, and failure to follow infection control guidelines during medication administration.
Deficiencies (6)
Failed to notify Resident F's physician and responsible party of a fall.
Staff were not aware of call lights activated in resident apartments due to lack of walkie talkies.
Service plan for Resident F was not updated to reflect behaviors, falls, and language barrier.
Medication patch was not located on Resident G as ordered by the physician.
Medications were pre-set for more than one scheduled administration pass and for a time when the QMA was not scheduled to work.
Facility failed to ensure infection control guidelines were followed; RN touched pills with bare hands during medication administration.
Report Facts
Residential Census: 222
Number of complaints investigated: 5
Number of residents reviewed for family and physician notification: 4
Number of residents reviewed for medication patches: 2
Number of residents reviewed for medication preparation: 7
Number of residents observed for infection control: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Rikki Ford | Executive Director | Signed the report and provided the Plan of Correction. |
| RN 1 | Named in infection control deficiency for touching pills with bare hands. | |
| Director of Nursing | Acknowledged failure to notify physician and responsible party of fall; involved in corrective actions and interviews. | |
| LPN 1 | Interviewed regarding call light activation and walkie talkie use. | |
| LPN 2 | Interviewed regarding call light activation and walkie talkie use. | |
| LPN 3 | Observed medication patch application on Resident G. | |
| CNA 1 | Interviewed regarding call light and resident language barrier. | |
| CNA 2 | Interviewed regarding call light and walkie talkie use. | |
| CNA 3 | Interviewed regarding walkie talkie use. | |
| QMA 1 | Named in medication pre-setting deficiency. |
Inspection Report
Complaint Investigation
Census: 225
Deficiencies: 2
Date: Oct 17, 2022
Visit Reason
This visit was for the investigation of complaints IN00389230, IN00390925, and IN00391642, in conjunction with post survey revisits to previous complaints and licensure surveys.
Complaint Details
Complaint IN00389230 - Substantiated with no deficiencies cited. Complaint IN00390925 - Substantiated with no deficiencies cited. Complaint IN00391642 - Substantiated with state deficiencies cited at R0041 and R0053. Previous complaints IN00377550, IN00379284, IN00381495, and IN00384290 were corrected.
Findings
The facility was substantiated for complaints related to verbal abuse involving one resident (Resident B). The facility failed to immediately notify the Administrator of the verbal abuse allegation and failed to ensure the resident was free from verbal abuse. The staff nurse involved was suspended and terminated, and corrective actions including staff education and audits were implemented.
Deficiencies (2)
Failed to implement abuse policies related to staff not immediately notifying the Administrator of an allegation of verbal abuse for 1 of 3 residents reviewed for abuse (Resident B).
Failed to ensure a resident was free from verbal abuse for 1 of 3 residents reviewed for abuse (Resident B).
Report Facts
Residential Census: 225
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Rikki Ford | Administrator | Signed the report and involved in the investigation and corrective actions. |
Inspection Report
Follow-Up
Census: 225
Deficiencies: 1
Date: Oct 17, 2022
Visit Reason
This visit was a Post Survey Revisit (PSR) to the State Residential Licensure Survey and the PSR to the Investigation of multiple complaints completed on 7/27/22. The visit was also in conjunction with the Investigation of additional complaints.
Complaint Details
Complaints IN00377550, IN00379284, IN00381495, and IN00384290 were corrected. Complaints IN00389230 and IN00390925 were substantiated with no deficiencies cited. Complaint IN00391642 was substantiated with state deficiencies cited at R0041 and R0053.
Findings
Several complaints were corrected, while three complaints were substantiated. No deficiencies were cited for two substantiated complaints, but state deficiencies related to one substantiated complaint were cited at R0041 and R0053. The facility was found to be in compliance with 410 IAC 16.2-5 regarding the PSR and complaint investigations.
Deficiencies (1)
State deficiencies related to the allegations are cited at R0041 and R0053.
Report Facts
Residential Census: 225
Inspection Report
Complaint Investigation
Census: 216
Deficiencies: 13
Date: Jul 27, 2022
Visit Reason
This visit was for a State Residential Licensure Survey including the Investigation of multiple complaints (IN00377550, IN00378152, IN00378896, IN00379284, IN00381495, IN00382665, IN00384290).
Complaint Details
This visit included investigation of complaints IN00377550, IN00378152, IN00378896, IN00379284, IN00381495, IN00382665, and IN00384290. Several complaints were substantiated with related deficiencies cited.
Findings
The facility was found deficient in multiple areas including failure to provide comprehensive nursing care for pressure ulcers, failure to notify physicians and responsible parties of changes in condition, improper visitation restrictions during COVID-19 outbreak, failure to ensure transportation for orthopedic consult, lack of posting of survey results, incomplete fall investigations, employment of unlicensed nurse aide past waiver expiration, failure to ensure resident self-medication ability, failure to provide necessary personal care, incomplete medication administration documentation, failure to follow dietitian recommendations timely, incomplete clinical records, and infection control deficiencies including improper mask and glove use and lack of COVID-19 testing and isolation protocols.
Deficiencies (13)
Failed to ensure care involving comprehensive nursing care was not provided related to wound care treatments for a large, complicated pressure ulcer resulting in deterioration.
Failed to notify physician and responsible party following change in condition related to hospital return and bruising for 2 residents.
Failed to ensure visitation was allowed on Memory Care Unit during COVID-19 outbreak.
Failed to ensure transportation arrangements were made for orthopedic consult for 1 resident.
Failed to ensure State Survey results were readily accessible and posted.
Failed to implement Fall Management policy with lack of thorough post fall investigations for 3 residents.
Failed to ensure temporary nurse aide was not working past emergency waiver expiration date.
Failed to ensure resident had ability to self-administer medications at bedside.
Failed to provide necessary personal care and assistance with activities of daily living related to wheelchair bolster and lotion application.
Failed to document medication administration properly with missing signatures on MAR.
Failed to follow Registered Dietitian recommendations timely for resident with weight loss.
Failed to maintain complete and accurate clinical records related to follow-up after hospital visits, bruising, skin tears, abrasions, and alcohol consumption.
Failed to establish and implement infection control program including proper glove and mask use, COVID-19 monitoring and testing, and isolation of unvaccinated residents upon admission.
Report Facts
Survey dates: 3
Residential Census: 216
Deficiencies cited: 13
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA 3 | Certified Nursing Assistant | Educated regarding infection control and proper glove disposal after observed wearing gloves in hallway. |
| Activity Assistant 1 | Activity Assistant | Received education on proper mask use after observed wearing mask below nose and mouth. |
| Laundry Employee 1 | Laundry Employee | Received education on proper mask use after observed not wearing mask. |
| Dietary Employee 1 | Dietary Employee | Received education on proper mask use after observed wearing gloves improperly. |
| Director of Nursing | Director of Nursing | Interviewed multiple times regarding deficiencies and corrective actions. |
| Administrator | Facility Administrator | Interviewed multiple times regarding deficiencies and corrective actions. |
| RN 1 | Registered Nurse | Interviewed regarding medication administration and clinical record deficiencies. |
| PTA 1 | Physical Therapy Assistant | Observed and educated on improper mask use. |
Viewing
Loading inspection reports...
