Inspection Report
Follow-Up
Deficiencies: 0
Mar 13, 2025
Visit Reason
An offsite revisit survey was conducted to verify correction of all previous deficiencies cited on 2025-03-05.
Findings
All deficiencies have been corrected as of the compliance date of 2025-03-07, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Report Facts
Previous deficiencies cited: 1
Inspection Report
Renewal
Census: 33
Deficiencies: 2
Mar 3, 2025
Visit Reason
The inspection was a licensure resurvey conducted on 03/03/2025 and 03/04/2025 to assess compliance with medication administration and medication regimen review regulations.
Findings
The facility failed to ensure licensed nurses and certified medication aides administered medications according to physician orders and professional standards, specifically administering Chlorthalidone to a resident when blood pressure parameters indicated it should be held. Additionally, the licensed nurse failed to notify the medical care provider and seek a response within five working days regarding pharmacist recommendations for medication changes for two residents.
Severity Breakdown
SS=D: 1
SS=E: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to ensure licensed nurses and certified medication aides administered medications in accordance with medical care provider's written orders and standards of practice. | SS=D |
| Failure of licensed nurse to notify medical care provider of pharmacist recommendations and seek response within five working days. | SS=E |
Report Facts
Resident census: 33
Times medication administered below parameter: 16
Times medication administered below parameter: 21
Times medication administered below parameter: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Operator A | Interviewed confirming medication administration records and pharmacy review process | |
| Licensed Nurse B | Interviewed confirming medication administration records and failure to notify provider of pharmacist recommendations |
Inspection Report
Plan of Correction
Deficiencies: 0
Mar 3, 2025
Visit Reason
The document is a Plan of Correction submitted in response to findings from the licensure resurvey conducted on March 3 and March 4, 2025.
Findings
The Plan of Correction references citations from the licensure resurvey but does not detail specific findings or deficiencies within this document.
Inspection Report
Complaint Investigation
Deficiencies: 0
Apr 18, 2024
Visit Reason
The abbreviated survey was conducted in response to complaints #187038, 186273, 183722, and 182155 at the assisted living facility.
Findings
The survey resulted in a finding of no deficiency citations.
Complaint Details
The survey was complaint-related for complaints #187038, 186273, 183722, and 182155 and found no deficiencies.
Inspection Report
Plan of Correction
Deficiencies: 0
Apr 17, 2024
Visit Reason
The document is a plan of correction related to an abbreviated survey conducted on 04/17/24 and 04/18/24 for complaints #187038, 186273, 183722, and 182155 at an assisted living facility.
Findings
The abbreviated survey resulted in a finding of no deficiency citations.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Jul 24, 2023
Visit Reason
The abbreviated survey was conducted in response to complaints #181566 and #181412 at the assisted living facility.
Findings
The survey resulted in a finding of no deficiency citations.
Complaint Details
The survey was complaint-related for complaints #181566 and #181412 and found no deficiencies.
Inspection Report
Plan of Correction
Deficiencies: 0
Jul 24, 2023
Visit Reason
The abbreviated survey was conducted in response to complaints #181566 and #181412 on 07/24/23 and 07/25/23 at the assisted living facility.
Findings
The survey resulted in a finding of no deficiency citations.
Inspection Report
Plan of Correction
Deficiencies: 0
Jun 13, 2023
Visit Reason
An offsite revisit survey was conducted to verify correction of all previous deficiencies cited on 2023-05-24.
Findings
All deficiencies cited in the previous inspection have been corrected as of the compliance date of 2023-06-07, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Report Facts
Previous deficiencies cited: 1
Inspection Report
Re-Inspection
Census: 35
Deficiencies: 2
May 24, 2023
Visit Reason
The inspection was a resurvey with an attached complaint (#176509) at an assisted living facility to evaluate compliance with medication administration and resident record documentation requirements.
Findings
The facility failed to ensure that negotiated service agreements for residents R524 and R525 identified who was responsible for administration and management of selected medications. Additionally, licensed staff failed to document all symptoms and indications of illness, specifically regarding an open sore developed by resident R525.
Complaint Details
The inspection was conducted as a resurvey with an attached complaint #176509.
Severity Breakdown
SS=D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Negotiated Service Agreements for residents R524 and R525 did not identify who was responsible for administration and management of selected medications. | SS=D |
| Licensed staff failed to document all symptoms and indications of illness when resident R525 developed an open sore, including wound size, odor, tissue characteristics, signs of infection, actions taken, and results. | SS=D |
Report Facts
Census: 35
Residents in sample: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nurse B | Provided statements confirming deficiencies related to medication administration and documentation. | |
| Licensed Nurse B | Confirmed lack of documentation regarding resident R525's open sore. |
Inspection Report
Plan of Correction
Deficiencies: 0
May 24, 2023
Visit Reason
This document represents the findings of a resurvey with an attached complaint (#176509) conducted at the assisted living facility on 05/24/23.
Findings
The document is a plan of correction submitted in response to the findings from the resurvey and complaint investigation conducted on 05/24/23.
Complaint Details
The visit was related to complaint #176509, attached to the resurvey.
Inspection Report
Renewal
Deficiencies: 0
Oct 12, 2021
Visit Reason
The licensure resurvey with complaints (#157129, #157131, #136462, #134295, #132041) was conducted over multiple days from 10/05/21 to 10/12/21 at the assisted living facility.
Findings
The inspection resulted in a finding of no deficiency citations.
Complaint Details
The visit was complaint-related involving multiple complaint numbers; however, no deficiencies were cited.
Inspection Report
Routine
Deficiencies: 0
Jul 30, 2020
Visit Reason
The special infection control survey for COVID-19 was conducted at the facility on 07/30/2020.
Findings
The survey resulted in findings of no deficiency citations.
Inspection Report
Re-Inspection
Deficiencies: 3
Jul 24, 2018
Visit Reason
This revisit report documents the correction of deficiencies previously cited during an earlier survey, verifying that corrective actions have been completed as of the revisit date.
Findings
The report confirms that all previously identified deficiencies related to specific regulations have been corrected as of 07/24/2018.
Deficiencies (3)
| Description |
|---|
| Deficiency related to regulation 26-41-101 (f) (1) |
| Deficiency related to regulation 26-41-205 (h) |
| Deficiency related to regulation 26-41-206 (e) (1) |
Inspection Report
Complaint Investigation
Census: 37
Deficiencies: 3
Jul 5, 2018
Visit Reason
The inspection was conducted as a resurvey with complaint investigations 130395, 127870, 124609, and 121025 at the assisted living facility on 7-2-18, 7-3-18, and 7-5-18.
Findings
The facility was found deficient in multiple areas including neglect of a resident by failing to perform monthly foot assessments, improper medication storage including use of expired tuberculosis skin testing solution, and unsafe and unsanitary food storage conditions in the kitchen affecting all residents.
Complaint Details
The inspection was a resurvey with complaint investigations 130395, 127870, 124609, and 121025.
Severity Breakdown
SS=D: 1
SS=E: 1
SS=F: 1
Deficiencies (3)
| Description | Severity |
|---|---|
| Failure to ensure a resident was not subjected to neglect when the licensed nurse failed to provide monthly foot assessments as required. | SS=D |
| Failure to ensure licensed nurses and medication aides stored all medications and biologicals in accordance with manufacturer recommendations and laws, including use of expired tuberculosis skin testing solution. | SS=E |
| Failure to ensure facility staff stored all food under safe and sanitary conditions, including uncovered food, unlabeled and undated food containers, lack of thermometer in milk cooler, and no cleaning schedule. | SS=F |
Report Facts
Census: 37
Date of TB skin testing solution opening: Apr 1, 2018
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nurse B | Administrative Nurse | Interviewed regarding resident foot assessments and findings of impaired skin. |
| Administrative Nurse C | Administrative Nurse | Interviewed regarding medication storage and tuberculosis skin testing solution. |
| Administrative Staff A | Accompanied kitchen tour and confirmed food storage deficiencies. | |
| Dietary Staff B | Provided information about food storage and kitchen conditions. | |
| Licensed Staff D | Licensed Nurse | Documented wound care and dressing changes for Resident #300. |
Inspection Report
Renewal
Deficiencies: 0
Nov 17, 2016
Visit Reason
The licensure resurvey of the assisted living facility was conducted on 11-16-16 and 11-17-16 to assess compliance for renewal of licensure.
Findings
The inspection resulted in findings of no deficiency citations.
Inspection Report
Renewal
Deficiencies: 0
Nov 26, 2014
Visit Reason
The licensure resurvey was conducted as a renewal inspection of the assisted living facility Vintage Park at Stanley LLC on 11-25-14 and 11-26-14.
Findings
The inspection resulted in no deficiency citations being found during the licensure resurvey.
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