Deficiencies per Year
8
6
4
2
0
Unclassified
Inspection Report
Follow-Up
Deficiencies: 7
Jun 5, 2025
Visit Reason
The inspection was a health care licensure and follow-up survey conducted to verify compliance with previous deficiencies and regulatory requirements.
Findings
The facility was found to have multiple deficiencies including unsecured toxic chemicals accessible to residents, lack of assessments for self-administered medications, unavailable PRN medications, incomplete documentation of medication administration and resident care records, inconsistent documentation of resident assessments and interventions, and failure to follow standard infection control procedures.
Deficiencies (7)
| Description |
|---|
| The facility did not secure various cleaning chemicals accessible to cognitively impaired residents. |
| Resident #8 was not assessed prior to nor every 90 days to ensure safe self-administration of medications. |
| The facility did not ensure all residents' as-needed (PRN) medications were available. |
| Staff did not document reasons why residents did not receive medications as ordered. |
| Resident assessments for changes in physical and mental conditions were not consistently documented. |
| Interventions to prevent recurrence of incidents, such as falls, were not consistently documented. |
| The facility did not follow standard infection control procedures; staff administered eye drops without gloves and failed hand hygiene. |
Report Facts
Falls: 22
Dates of medication non-administration: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kindra Sagario | Administrator | Named as the facility administrator who provided statements regarding deficiencies and corrective actions. |
| Bradley Perry | Survey Team Leader | Led the health care licensure and follow-up survey. |
Inspection Report
Complaint Investigation
Deficiencies: 4
Feb 12, 2025
Visit Reason
The inspection was conducted as a health care complaint investigation triggered by allegations of abuse involving a staff member and Resident #3 at Turtle and Crane Assisted Living.
Findings
The facility failed to protect Resident #3 and other residents from abuse by a staff member who was allowed to continue working for eight days after allegations were made. The former administrator and current owner/administrator did not follow facility policies regarding abuse reporting, investigation, and resident protection, resulting in abuse with potential impact on all residents.
Complaint Details
The complaint involved allegations that Staff member B physically and verbally abused Resident #3 on 6/15/24, including rough handling and forcing medication. Staff reported the abuse to the former administrator multiple times prior to and after the incident. The former administrator was aware but did not suspend the staff member due to staffing shortages, allowing continued work until 6/26/24. Adult Protective Services and law enforcement were contacted 11 days after the initial allegation. The investigation found failures in reporting, protecting residents, and following abuse policies.
Deficiencies (4)
| Description |
|---|
| The former administrator did not ensure all facility policies were implemented, allowing a staff member accused of abuse to work for eight days pending investigation. |
| The facility nurse did not ensure residents received medications and treatments as ordered, including incorrect dosage administration for Resident #1. |
| The facility did not follow standard infection control procedures; kitchens in multiple houses had debris, dried substances, and grime. |
| The facility did not protect Resident #3 from abuse, failed to immediately notify Adult Protective Services, complete thorough investigations, and take corrective actions as required by policy. |
Report Facts
Days staff member worked after abuse allegation: 8
Resident age: 84
Number of sampled residents in abuse protection review: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kindra Sagario | Administrator | Former and current administrator involved in abuse reporting and investigation failures. |
| Jenny Walker | Survey Team Leader | Led the health care complaint investigation survey. |
Inspection Report
Original Licensing
Deficiencies: 2
Apr 11, 2024
Visit Reason
The inspection was conducted as a health care initial licensure survey combined with a complaint investigation.
Findings
The facility nurse failed to consistently conduct nursing assessments following changes in residents' health status and did not ensure medications were administered as ordered, specifically for Resident #6 who experienced multiple incidents and medication errors.
Complaint Details
The visit included a complaint investigation related to nursing assessments and medication administration errors.
Deficiencies (2)
| Description |
|---|
| The facility nurse did not consistently conduct nursing assessments when a resident experienced changes in physical or mental health status. |
| The facility nurse did not ensure residents received medications and treatments as ordered by their provider. |
Report Facts
Dates of incidents: Resident #6 had a fall on 2024-01-02, choked on food on 2024-01-09, and returned from dental surgery on 2024-01-19.
Medication order date: Resident #6 was ordered on 2024-04-01 to have medications crushed but was observed on 2024-04-09 receiving whole medication.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Michael Oldfield | Survey Team Leader | Named as the survey team leader conducting the health care initial licensure and complaint investigation. |
| Tiffany Andra | Administrator | Named as the facility administrator. |
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