Van Mall Retirement

The facility failed to implement safe medication systems for two residents, resulting in one resident receiving the wrong type of insulin at the wrong time, requiring overnight monitoring.

Facility failed to develop and implement systems to support safe medication services for 2 residents. One resident received wrong doses due to pharmacy/EMAR errors, and another received incorrect insulin which caused potential life-threatening complications.

Medication error occurred where resident was administered short-acting insulin instead of ordered long-acting insulin. This was a recurring deficiency.

Facility failed to ensure staff followed service plan requirements for escorting a resident to meals.

Facility failed to provide services agreed upon in the negotiated service agreement for 1 resident. The resident was not escorted to meals and remained on the floor for hours after a fall.

Facility failed to ensure staff completed or had documentation for required training (orientation, safety, mental health/dementia, nurse delegation, diabetes) for 3 of 5 sampled staff members.

Facility failed to complete TB testing within three days of hire for 3 of 3 sampled staff members.

Facility failed to complete/document a national fingerprint background check for 1 of 5 sampled staff (Staff E).

Facility failed to maintain a current resident characteristic roster (RCR) accurately documenting care needs for Resident 12.

Facility failed to complete a negotiated service agreement (NSA) within 30 days of admission for 3 of 4 sampled residents, and failed to document resident/representative involvement in care planning for 5 of 11 sampled residents.

Facility failed to document specific care and service needs in Negotiated Service Agreements (NSA) for 6 of 8 sampled residents (diets, medical devices, vision/hearing deficits, etc.).

Facility failed to complete a full assessment within 14 days of admission for 3 of 4 sampled residents (Residents 4, 6, and 11).

Facility failed to ensure 4 of 5 sampled staff completed/documented required orientation, safety, mental health, dementia, basic, or nurse delegation training.

Facility failed to ensure a Medicaid policy was completed and/or documented upon admission for 5 of 9 sampled residents.

The facility failed to provide documents requested by the department in a timely manner.

Facility failed to document medication administration (no explanation for missed doses) and allowed expired medications to remain in the medication cart.

Facility failed to maintain a current characteristic roster accurately documenting resident care needs and services for 7 of 11 sampled residents.

Failed to ensure or document required long-term care worker training for three staff members.

Failed to maintain a current resident characteristic roster (RCR) accurately documenting care needs for one resident.

Failed to develop/implement systems for safe medication services; two residents did not receive medications as ordered.

Failed to document plans for specific resident care and service needs in negotiated service agreements (NSA) for six residents.

Facility failed to provide sufficient, trained staff to furnish services and care needed by residents consistent with their negotiated service agreements.

Facility failed to provide agreed upon services regarding showers, medication management, meal escort, and meal delivery.

Missing fire drill documentation for Q1 2024; missing annual staff training on extinguishers and hood systems

No gap present in hood system filters

Failure to maintain clear width of exit near room 305

Strain protection missing on kitchen gas appliances

Break room door missing self-closure; crash bar fails to latch

Electrical cover found broken in break room

Facility failed to provide required carbon monoxide detection

Missing 5-year hydrostatic report; missing quarterly inspections; missing trim ring; excessive dust and grease on heads

Wheelchair found against heater in hallway

Failure to provide annual fire door inspection; excessive gaps found in doors throughout facility

Failure to provide annual fire resistance rated construction inspection; various holes found in ceilings and walls

Failure to maintain proper clearance around electrical panel in 3rd-floor laundry room storage

Unsecured compressed cylinder found in kitchen

Facility failed to maintain clear width of exit near room 305

Facility failed to provide annual fire door inspection that included measurement of door gaps; doors throughout found to have excessive gaps

Break room door found to have missing self-closure and crash bar fails to latch automatically

Strain protection shall be installed/reinstalled on gas appliances in kitchen

Facility failed to provide 5-year FDC hydrostatic testing report and quarterly fire sprinkler inspection; sprinkler trim ring missing in game room; fire sprinkler head by room 310 had excessive dust; kitchen sprinkler heads had grease/material build-up

Unsecured compressed gas cylinder found in kitchen

Electrical cover found broken in break room

Facility failed to provide annual fire resistance rated construction inspection; holes found in game room ceiling, kitchen ceiling, break room wall, maintenance office work shop, and storage closet ceiling

Facility failed to provide carbon monoxide detection as required

Wheelchair by room 305 found against heater in hallway

Facility failed to provide fire drill during the first quarter of 2024 for second shift; instructions on portable fire extinguishers and kitchen hood system actuation not provided to new employees

No gap shall be present in hood system filters

Facility failed to maintain proper clearance around electrical panel in laundry room, floor 3 storage