Inspection Reports for Whispering Creek Senior Living

Investigation of Incident #105263 and Complaint #105304 at Whispering Creek Senior Living MC.

No regulatory insufficiencies were cited during the investigation of Incident #105263 or Complaint #105304.

Investigation of Incident #105263 and Complaint #105304 found no regulatory insufficiencies.

The visit was a recertification inspection conducted to determine compliance with certification for an Assisted Living Program for People with Dementia.

No regulatory insufficiencies were cited during complaint investigations, but one deficiency was cited during the recertification visit related to preliminary service plans not being signed by those who developed the plan for 2 of 3 tenants reviewed.

No regulatory insufficiencies were cited during the investigation of complaints 103865-C or 103943-C.

The inspection was conducted as an investigation of Mandatory Report #98878-M related to regulatory insufficiencies in the Assisted Living Program for People with Dementia at Whispering Creek Senior Living MC.

The inspection found deficiencies including failure to follow program policies and procedures regarding incident reports, specifically a delayed incident report for bruising on a tenant, and failure to ensure dementia-specific continuing education for direct-contact personnel employed by a contracting agency.

The visit was triggered by a complaint investigation of Mandatory Report #98878-M. The findings were substantiated as confirmed by the Executive Director.

The inspection was conducted as an investigation of Incident #99172-1, related to safety and security concerns in the dementia-specific program and memory care unit.

The program failed to ensure an operating alarm system was connected to the exit door in the dementia unit, and the courtyard gate was left unlocked, allowing a tenant to elope. The facility did not maintain the courtyard off the memory care unit as safe and secure at all times.

The visit was complaint-related, investigating Incident #99172-1 involving tenant elopement through an unlocked courtyard gate. The incident was self-reported by the program, and no injuries were noted. The complaint was substantiated based on observations and interviews.

The recertification visit was conducted to determine compliance with certification requirements for the Assisted Living Program for People with Dementia.

The program failed to ensure that staff received the required eight hours of dementia-specific education within 30 days of employment for 2 of 3 staff reviewed, as evidenced by record reviews and interviews.

The inspection was conducted as a complaint investigation related to Incident 81675-I and Complaint 81275-C at Whispering Creek Assisted Living Program for People with Dementia.

No regulatory insufficiencies were cited during the complaint investigation 81275-C. However, a regulatory insufficiency was cited during the investigation of Incident 81675-I related to failure to follow policies and procedures for door alarms, resulting in a resident eloping from the memory care unit.

The complaint investigation 81275-C found no regulatory insufficiencies. The incident investigation 81675-I found the program failed to follow door alarm policies, leading to a resident eloping from the memory care unit.

The inspection was conducted as a complaint investigation related to regulatory insufficiencies cited during complaint 79696-C.

The program failed to provide services as directed by service plans for one of two reviewed tenants. Specifically, housekeeping logs were missing for Tenant #1, and the program could not provide documentation of weekly cleaning as required by the service plan and occupancy agreement.

The complaint investigation found that the program did not meet tenant rights requirements under 481-67.3(2) related to receiving adequate and appropriate care, treatment, and services.

The visit was conducted as a recertification to determine compliance with certification for an Assisted Living Program for People with Dementia.

No regulatory insufficiencies were cited during the investigation of a prior incident. However, during the recertification visit, a regulatory insufficiency was cited related to failure to obtain a Department of Human Services evaluation prior to employment for one staff member with a record of child abuse.

The visit was conducted as a recertification to determine compliance with certification for an Assisted Living Program for People with Dementia.

No regulatory insufficiencies were cited during the investigation of Incident #72660-I. However, a regulatory insufficiency was cited during the recertification visit related to record checks, specifically the failure to obtain a Department of Human Services evaluation prior to employment for one staff member.

The visit was conducted as a Final Recertification Monitoring Evaluation to determine compliance with certification for an Assisted Living Program.

No regulatory insufficiencies were found during this evaluation. The review included recertification documents, State Fire Marshal inspection report, and Facility Engineer's approval of evacuation plans.

The inspection was conducted as a complaint/incident investigation based on a monitoring visit from May 20 - 27, 2015, to evaluate allegations related to service plans at Whispering Creek Assisted Living in Sioux City, IA.

The investigation found the allegation regarding service plans to be unsubstantiated. Cognitive, functional, and health evaluations were conducted appropriately prior to and upon admission, with updates as needed. No regulatory insufficiencies were identified.

Allegation: Service Plans. Findings: Unsubstantiated. Comments: Cognitive, functional, and health evaluations were conducted prior to and upon admission. Evaluations were conducted as needed with change of condition and service plans were developed and updated appropriately.

The inspection was conducted following complaints and allegations regarding tenant rights violations, documentation alterations, and safety concerns at Whispering Creek Assisted Living. The investigation focused on incidents involving tenants in the dementia unit and general population.

The report found multiple regulatory insufficiencies related to tenant rights, evaluations, service plans, and policies and procedures. Specific incidents included inappropriate tenant interactions, failure to update service plans, inadequate documentation, and failure to follow policies on door alarms and tenant privacy.

The complaint investigation was triggered by allegations including two tenants found in bed with clothes off, sexual contact between tenants, and altered documentation related to tenant interactions. The investigation substantiated regulatory insufficiencies in tenant rights, evaluations, and service plans.

The visit was conducted as a Final Recertification Monitoring Evaluation and Incident Investigation following a survey by the Department of Inspections and Appeals (DIA) on January 23, 27, 28, and 29, 2014, to assess regulatory compliance and investigate incidents at Whispering Creek Assisted Living.

The report identified regulatory insufficiencies in the areas of Tenant Documents, Evaluations, Criteria for Admission and Retention, Service Plan, Tenant Rights, and Record Checks. Specific concerns included incomplete functional assessments, inadequate service plans, incidents of tenant aggression, and issues with staff interactions and documentation.

The visit included an incident investigation related to a staff member reported to have been verbally and possibly physically inappropriate with tenants in the dementia unit. The staff member was suspended pending investigation and subsequently terminated.

The inspection was conducted as a complaint/incident investigation regarding allegations of tenant rights violations and other concerns at Whispering Creek Assisted Living.

The investigation found that the program failed to uphold tenant rights related to two tenants who had an ongoing intimate relationship, which was disrupted when they were transferred to a secured dementia unit. Additional findings included issues related to suicidal ideations, refusal of personal care assistance, and appropriate service plans. No regulatory insufficiencies were noted in service plans.

The complaint alleged that two unrelated cognitively impaired tenants participated in an intimate relationship without consent and that tenant rights were violated when they were separated. Additional complaints included a tenant expressing suicidal ideations and refusal of personal care assistance resulting in sores.

The inspection was conducted as a complaint/incident investigation following a report that a tenant eloped from the assisted living program.

The investigation found no regulatory insufficiencies despite a deviation from rules regarding door checks documentation. The tenant elopement was investigated thoroughly with staff interviews and environmental checks, and corrective actions were taken to prevent recurrence.

The complaint involved a tenant eloping from the program on 12-25-12. The investigation included review of tenant files, staff interviews, and environmental assessments. No regulatory insufficiencies were substantiated.

The inspection was conducted as a final complaint/incident investigation following a complaint regarding medication discrepancies at Whispering Creek Assisted Living.

The investigation found no regulatory insufficiencies. The report detailed medication management issues involving tenants, including missing narcotics and medication storage concerns, but no violations were identified.

The complaint involved Tenant #1 reporting missing tablets of Oxycontin and other narcotics. Investigations revealed medication storage and administration issues, tenant confusion, and family concerns about missing pills. Despite these issues, no regulatory insufficiencies were substantiated.

The inspection was conducted as a complaint/incident investigation regarding allegations that the program's nurses did not assess tenant changes in health status, did not evaluate tenant changes in a timely manner, did not provide assistance with bathing as needed, did not follow physician's orders for medications, and staff borrowed other tenants' medications.

The investigation found regulatory insufficiencies in nurse review, evaluations, and medication administration. Specific issues included failure to complete timely nurse reviews after incidents, incomplete evaluations of tenants' health status, medication errors including failure to follow physician orders, and inadequate assistance with bathing. No deficiencies were noted related to staffing or bed linens.

The complaint investigation was substantiated with findings that the program nurses did not assess tenant changes in health status timely, did not evaluate tenants properly, did not notify family members timely, and medication errors occurred including borrowing medications from other tenants.

The visit was conducted as a Final Recertification Monitoring Evaluation for Whispering Creek Assisted Living to review recertification documents and ensure compliance with Iowa Code and Administrative Code regulations.

No regulatory insufficiencies were found during the evaluation. The program was found to be clean, safe, and sanitary, with tenant satisfaction reported as good and no regulatory insufficiencies noted during the onsite investigation.

The inspection was conducted as a final incident investigation following a complaint alleging that a staff member accepted money from a tenant and borrowed the tenant's vehicle.

The investigation found no regulatory insufficiencies. The tenant and staff member interviews revealed no evidence of misappropriation of money or funds, and local police concluded no wrongdoing occurred.

The complaint alleged that Staff Member #1 accepted money from the tenant and borrowed the tenant's vehicle. The investigation included interviews with the tenant and staff member, and a police investigation. No evidence of misappropriation or wrongdoing was found, and no regulatory insufficiencies were noted.

A complaint investigation on-site visit was conducted at Whispering Creek Assisted Living on March 23, 2011, in response to allegations including a tenant leaving the dementia unit unaccompanied and phone numbers to the Department of Inspections and Appeals not being posted.

The investigation found regulatory insufficiencies related to service plans not adequately addressing tenant needs and staffing levels insufficient to fully meet tenants' identified needs. There was no regulatory insufficiency noted regarding the posting of phone numbers to the Department of Inspections and Appeals and the long term care Ombudsman.

Complaint Allegation #33193-C involved a tenant leaving the dementia unit unaccompanied by staff with no alarms sounding, and phone numbers to the Department of Inspections and Appeals and the long term care Ombudsman not being posted. The tenant was returned to the dementia unit by staff. The complaint was substantiated with findings related to service plans and staffing but not for the phone number posting.

The visit was conducted as a Final Initial Certification and Incident Investigation at Whispering Creek Assisted Living to evaluate regulatory compliance and investigate an incident.

No regulatory insufficiencies were found during the evaluation. The program demonstrated compliance with Iowa Code and Administrative Code requirements, and the certification will continue for two years without interruption.