Three Rivers Place Senior Living

The department rescinded a $300.00 civil fine because the employee's start date did not warrant a new background check.

The facility failed to maintain a valid two-year name and date of birth background check for one staff member (Staff C), who worked 94 days past the expiration date.

The Department found that previously identified deficiencies regarding intermittent nursing services systems were corrected.

The Department found that previously identified deficiencies regarding tuberculosis testing requirements were corrected.

Facility failed to follow medical orders regarding insulin administration parameters for Resident 2, and failed to supervise oral medication self-administration for Resident 4 who failed a self-administration assessment.

Staff member observed touching nose, contaminated items, and clean dishes without washing hands or sanitizing between tasks.

Facility failed to ensure 90-day re-evaluations for delegated tasks were performed for 5 of 5 residents, and failed to ensure staff performing delegated tasks were properly trained/credentialed.

Facility failed to retain and provide access to resident records (progress notes and medication records) prior to January 2025 following an EHR system switch.

Personnel files for 3 of 5 staff reviewed did not show they received facility orientation.

Facility failed to submit background check requests within one business day for 2 of 6 staff, failed to obtain references, and allowed unsupervised work prior to results.

Facility failed to complete a Character, Competence, and Suitability (CCS) review for 3 of 3 staff with non-disqualifying background check results.

Facility failed to ensure staff were screened for tuberculosis within three days of employment for 2 of 5 staff.

Issues regarding medication technician credentials and delegation.

Missing Characteristic and background forms in employee files.

Facility failed to properly address behavioral changes in residents.

Failure to maintain/access resident information during system issues.

Inaccurate or missing TB records/timelines.

Deficiency in assessing residents for self-administration of medications.

Deficiencies in orientation and safety training documentation.

Failure to maintain required pet vaccination records for a visiting dog.

Staff failed to follow proper handwashing procedures.

Deficiencies in background check or reference verification process.

The licensee failed to submit a name and date of birth background check within one business day of hire for one staff member.

Failure to ensure nurse delegator assessed each resident receiving delegated task assistance every 90 days; failure to ensure medication administration was performed by staff trained/credentialed to perform delegated tasks.

Failure to ensure staff were screened for tuberculosis within three days of hire for one staff member.

The facility failed to follow their Intimacy assessment policy to determine each resident's ability to make an informed decision regarding sexual interactions.

The licensee failed to ensure that the registered nurse delegator assessed each resident who received delegated task assistance from staff every 90 days for five residents. Additionally, the facility failed to ensure that nurse delegated medication administration was performed by staff who were properly trained and/or credentialed.