Inspection Reports for Villa Capri at Varenna

The inspection was conducted as a complaint investigation following allegations that facility staff were not providing resident's medication dosage as prescribed and had not requested required medication refills.

The investigation found that resident R1's medications were provided as prescribed and medication refills were requested and received as required. There was no evidence to support the allegations, and no deficiencies were cited.

The complaint was unsubstantiated based on interviews, record reviews, and investigation findings indicating no violations occurred regarding medication administration and refill requests.

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The inspection was conducted as an unannounced complaint investigation following allegations that staff did not ensure residents' bathing needs were met and that residents did not have access to assistive devices.

The investigation found that resident R1 sometimes refused bathing, but staff offered bathing repeatedly and provided it as needed. Staff also offered assistive devices such as walkers and glasses when residents were observed without them. There was no evidence to support the allegations, and no deficiencies were cited.

The complaint was unsubstantiated based on interviews, record reviews, and observations. Allegations included failure to meet bathing needs and lack of access to assistive devices, but no violations were found.

The inspection was a Required - 1 Year unannounced visit conducted to evaluate compliance with licensing requirements, including infection control, emergency disaster preparedness, staff training, and facility safety.

The facility was found to be clean, orderly, and compliant with regulations. All resident and staff records reviewed were complete and up to date. Emergency plans, infection control, and fire safety measures were in place and drills conducted. No deficiencies were cited during this inspection.

The case management inspection was conducted to review a resident incident reported by the facility Administrator to the Department.

It was identified that staff inappropriately handled a resident (R1) when trying to provide incontinent care, and the resident reacted by screaming and kicking. Staff did not use a different approach or allow time for the resident to be agreeable to the care needed, resulting in a cited deficiency related to residents' personal rights.

An unannounced complaint investigation was conducted due to an allegation that medications were not provided to a resident as prescribed.

The investigation substantiated that resident R1 missed eight doses of a routine medication due to delayed refill orders and that a PRN medication was administered outside prescribed hours and for unapproved reasons. A violation was cited for failure to assist residents with self-administered medications as needed.

The complaint alleged that medications were not provided to the resident as prescribed. The allegation was substantiated based on record reviews, interviews, and observations. The resident missed eight doses of a routine medication and received PRN medication outside prescribed times and for unapproved indications.

An unannounced complaint investigation was conducted due to an allegation that medications were not provided to a resident as prescribed.

The investigation substantiated the allegation that medications were not provided as prescribed to resident R1. Documentation and timely ordering of medications by the responsible party were lacking, resulting in missed doses and a risk to the resident's health and safety.

The complaint was substantiated. The allegation was that medications were not provided to the resident as prescribed. The investigation found insufficient documentation and failure to notify the responsible party in a timely manner, leading to missed doses.

The visit was an unannounced Case Management - Other visit to follow up on a SOC341 report dated 7/23/24 and an incident report regarding a suspected physical abuse incident that occurred on 7/17/24 at 3am.

The facility conducted an internal investigation which was unsubstantiated. Staff training on elder abuse/mandated reporting was conducted on 7/24/24. Staff member S1 resigned due to dissatisfaction with the facility's response. No deficiencies were cited during the inspection.

The complaint involved a suspected physical abuse incident where staff member S1 pushed resident R1 during an attempt to redirect them. The facility contacted law enforcement and conducted a skin assessment with no injuries found. The internal investigation was unsubstantiated.

The inspection was a Required - 1 Year unannounced visit conducted to evaluate the facility's compliance with licensing regulations and operational plans.

The facility was found to be clean, orderly, and compliant with regulatory requirements including infection control, emergency preparedness, staff training, and medication storage. No deficiencies were cited during the visit.

The inspection was an unannounced complaint investigation conducted in response to an allegation that staff were not following physicians' orders.

The investigation found that medication orders were provided as prescribed by the physician. Although there was differing information regarding the allegation, no evidence supported a violation. The allegation was determined to be unsubstantiated and no deficiencies were cited.

The complaint alleged that staff were not following physicians' orders. The investigation included review of resident records, medication administration records, care plans, and interviews. The allegation was found unsubstantiated due to lack of evidence.

The inspection was an unannounced complaint investigation conducted due to an allegation that staff were not changing a resident timely.

The investigation substantiated the allegation that staff were not changing the resident timely. It was found that some facility caregivers stopped checking on the resident, mistakenly believing the resident's private companion was providing incontinent care, which is the responsibility of the facility staff.

The complaint alleging that staff were not changing the resident timely was substantiated based on interviews and record reviews. A citation was issued under CCR 87625 for managed incontinence care violations.

The inspection was an unannounced complaint investigation conducted due to allegations that staff were not ensuring residents received medications timely, call buttons were not operable or answered timely, and concerns about laundry services and resident safety.

The investigation substantiated that the facility failed to refill resident medications timely and did not respond promptly to resident call bells, resulting in citations and a civil penalty. Allegations regarding unsanitary laundry services, residents left in soiled items, and unsafe environment were unsubstantiated.

The complaint investigation was substantiated for allegations related to medication delays and call bell response times. The allegations regarding unsanitary laundry services, residents left in soiled items, and unsafe environment were unsubstantiated due to lack of evidence.

The inspection was an unannounced complaint investigation conducted due to allegations including staff not following physician's orders regarding medications, facility not following the Admission's Agreement, staff yelling at residents, and staff not responding to residents' requests for assistance in a timely manner.

The investigation found that the allegations regarding staff not following physician's orders and the facility not following the Admission's Agreement were unfounded. The allegation that staff yelled at residents was unsubstantiated. However, the allegation that staff did not respond to residents' requests for assistance in a timely manner was substantiated, with evidence that a resident waited approximately an hour for assistance after requesting help from staff.

The complaint investigation was triggered by multiple allegations including staff not following physician's orders, facility not following Admission's Agreement, staff yelling at residents, and staff not responding timely to residents' requests. The allegation of staff not responding timely was substantiated; others were unsubstantiated or unfounded.

Continuation of the required annual inspection visit to evaluate compliance with licensing regulations and facility operations.

The facility was generally clean and orderly with proper emergency and infection control plans in place. However, several deficiencies were cited including unlocked beauty salon with accessible poisons, hot water temperature out of regulatory range, uncovered food items, and a resident lacking an updated medical assessment.

This was an unannounced complaint investigation visit triggered by a complaint received on 2023-01-24 alleging multiple issues including improper toileting assistance, rough handling of residents, failure to follow physician orders for bathing, inappropriate speech to residents, and unmet dietary needs.

The investigation found no substantiation for the allegations after reviewing resident and staff records and conducting interviews. Residents were found to be receiving appropriate toileting, bathing, and dietary care, and staff were trained and respectful. No deficiencies were cited during the visit.

The complaint investigation was unsubstantiated, meaning there was insufficient evidence to prove the alleged violations occurred.

The inspection was an unannounced complaint investigation conducted in response to allegations that the facility did not have an acting administrator in charge and that the facility was in disrepair.

The investigation found no evidence to support the allegations. The facility had an Interim Administrator in place, and the elevator incident was addressed appropriately with repairs completed. The facility was not found to be in disrepair. The complaint was determined to be unfounded.

The complaint control number 21-AS-20230420164901 involved allegations that the facility lacked an acting administrator and was in disrepair. The investigation concluded these allegations were unfounded, meaning they were false or without reasonable basis.

The inspection was an unannounced complaint investigation triggered by an allegation that facility sink faucets do not deliver hot water.

The investigation substantiated the allegation that the facility's sink faucets did not consistently deliver hot water due to intermittent hot water issues affecting specific units. A professional plumber identified a faulty tempering valve that needs replacement, which is currently on order. The hot water temperature was found to be within regulatory limits during the inspection.

The complaint was substantiated based on interviews, record reviews, and observations. The allegation was that facility sink faucets do not deliver hot water. The facility had prior incidents in February and September 2022 and a current issue reported on October 10, 2022. The hot water issue was ongoing but being addressed with plumbing repairs.

The case management inspection was conducted to review several resident incident reports, specifically focusing on medication errors.

Two incident reports were reviewed involving medication errors where staff did not provide the correct medication dosage or medication, resulting in health and safety risks and personal rights violations to residents. A citation was issued for failure to assist residents with self-administered medications as required.

The visit was complaint-related focusing on medication errors. The citation was issued based on substantiated incidents of medication errors posing health and safety risks.

The inspection was a required 1-year unannounced visit focused on infection control procedures and practices at the facility.

The facility was generally clean, orderly, and well-supplied with hygiene products and PPE. However, deficiencies were found related to improper food storage and unsecured personal medications in the dementia care unit.

Annual required inspection focused on infection control procedures and practices at the facility.

The facility was found to be clean, orderly, and at a comfortable temperature with proper infection control measures including COVID mitigation plan, resident and staff screening, sanitizer availability, and PPE supply. No citations were issued during this inspection.

The inspection was a case management visit related to legal/non-compliance issues, continuing from prior inspections on 4/29/21 and 4/30/21, to ensure the facility's compliance with health and safety regulations and probation order terms.

The Licensing Program Analyst reviewed emergency preparedness training files for staff and disaster leaders, finding that staff had the required training. Technical assistance was provided to improve documentation and tracking of training records. No citations were issued.

The inspection was a case management legal/non-compliance visit conducted via tele-video to ensure compliance with the stipulation, waiver, and order in place related to license revocation stayed under probation conditions.

The facility was found to be generally compliant with posting requirements and emergency plans, but deficiencies were noted regarding staff lacking required emergency disaster and disaster leader training as mandated by the stipulation order. Emergency preparedness measures such as evacuation drills, emergency supplies, and communication systems were observed and reviewed.

The inspection was a case management- Legal/Non-compliance visit conducted to ensure compliance with the stipulation, waiver, and order in place related to license revocation stayed for 2 years with probation period effective 8/7/19 to 8/7/21.

The Licensing Program Analyst conducted a physical plant inspection via tele-video visit and observed no deficiencies. All fire extinguishers were charged and tagged, exits unobstructed, elevator inspected, sufficient food and water supply, hot water temperatures within range, safety features like grab bars and non-slip flooring present, evacuation chairs and generators observed, medication room and toxins securely stored. No deficiencies were cited during this inspection.

An unannounced complaint investigation was conducted due to an allegation that staff failed to properly assist a resident with medications.

The investigation found that the resident was unable to manage their own medications safely and was placed on the facility's medication program with agreement from the responsible party. The allegation was determined to be unfounded, with no deficiencies cited during the visit.

The complaint allegation that staff failed to properly assist the resident with medications was investigated and found to be unfounded.