Inspection Report Summary
The most recent inspection on August 6, 2024, identified deficiencies related to incomplete evaluations after significant changes and outdated service plans for several tenants. Earlier inspections showed a pattern of issues with updating service plans, responding to door alarms, and managing tenant safety, including multiple substantiated complaints involving elopement incidents and inadequate staff responses. Main themes across reports included deficiencies in service plan updates, tenant evaluations, elopement prevention, and staff training. Several enforcement actions were noted historically, including civil penalties of $500 and $2,000 related to safety and care deficiencies, but no enforcement actions were listed in the most recent reports. The facility’s record shows ongoing challenges with compliance in key areas, with some recurring issues persisting over time.
Deficiencies (last 14 years)
Deficiencies (over 14 years)
3.4 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
23% better than Iowa average
Iowa average: 4.4 deficiencies/yearDeficiencies per year
12
9
6
3
0
Census
Latest occupancy rate
12 residents
Based on a August 2024 inspection.
This facility has shown a decline in demand based on occupancy rates.
Census over time
Inspection Report
Recertification
Census: 12
Deficiencies: 2
Date: Aug 6, 2024
Visit Reason
The recertification visit was conducted to determine compliance with certification of a Dedicated Dementia Specific Assisted Living Program.
Findings
The program failed to complete evaluations as needed with significant change for tenants, specifically related to wound care and service plans. Several tenants' service plans did not reflect current treatments or risks, and evaluations were not updated as required.
Deficiencies (2)
Program failed to complete evaluations as needed with significant change for Tenant #2 related to wound care.
Service plans were not updated to reflect current treatments, risks, or interventions for multiple tenants (#1, #2, #3, #4).
Report Facts
Number of tenants without cognitive impairment: 2
Number of tenants with cognitive impairment: 10
Total census: 12
Wound measurement: 2.3
Wound measurement: 3.3
Wound measurement: 0.02
Wound surface area: 7.59
Medication dosage: 100
Medication duration: 10
Therapy frequency: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Health and Wellness | Interviewed on 8/6/24 regarding tenant evaluations and service plans |
Inspection Report
Complaint Investigation
Census: 14
Deficiencies: 2
Date: Apr 20, 2023
Visit Reason
The inspection was conducted following investigation of Incident #112364-I involving an elopement of Tenant #1 at Keystone Cedars Memory Care.
Complaint Details
The complaint investigation was triggered by Incident #112364-I involving Tenant #1's elopement on 4/16/23. The investigation found the program did not respond properly to door alarms, delayed notification to leadership, and inadequate safety checks. The complaint was substantiated based on these findings.
Findings
The program failed to follow its policies and procedures related to missing persons and door alarms, resulting in an elopement incident. Additionally, the service plan for Tenant #1 did not reflect specific safety needs or updated interventions after multiple elopements. Door alarms were malfunctioning or not responded to timely, and staff failed to notify leadership promptly.
Deficiencies (2)
Failure to follow program policies and procedures related to missing persons and elopement prevention.
Failure to develop and update a service plan that identifies specific needs and safety interventions for a tenant with a history of elopement.
Report Facts
Census: 14
Elopement incidents: 2
Safety check frequency: 2
Door alarm reset delay: 40
Temperature: 38
Wind speed: 18
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Responded to door alarm, found Tenant #1 outside, unable to silence door alarm, involved in incident | |
| Staff B | Assisted in search for Tenant #1, notified Director of Health and Wellness, involved in incident | |
| Director of Health and Wellness | Director of Health and Wellness | Called to incident, assessed Tenant #1, provided education and training, involved in policy updates |
| Executive Director | Executive Director | Notified of elopement, reviewed incident and video footage, involved in corrective actions and policy updates |
| Staff C | Observed staff activity during incident, reported confusion due to pager issues | |
| Staff D | Provided shift report and observations related to Tenant #1 |
Inspection Report
Complaint Investigation
Census: 13
Deficiencies: 8
Date: Feb 21, 2022
Visit Reason
The inspection was conducted as a recertification visit to determine compliance with certification for a Dedicated Dementia Specific Assisted Living Program and to investigate Complaint #102204-C and Incident #102301-I.
Complaint Details
Complaint #102204-C and Incident #102301-I were investigated related to incidents involving Tenant #1 elopements and staff conduct.
Findings
The program failed to follow its policies and procedures related to incident reports and responding to door alarms, failed to treat a tenant with dignity and respect, failed to provide services according to training, failed to complete evaluations and nurse reviews as needed, failed to develop and update service plans based on evaluations, and failed to ensure staff completed required dementia-specific training within 30 days of hire.
Deficiencies (8)
Failed to follow policy and procedures related to incident reports and responding to door alarms, including multiple elopements of Tenant #1 without proper documentation or staff response.
Failed to ensure Tenant #1 was treated with consideration, respect, and dignity, including verbal abuse and inappropriate physical actions by staff.
Failed to provide services in accordance with training, including improper medication administration to Tenant #3.
Failed to complete evaluations as needed with significant change for tenants with wounds and catheters (Tenants #3 and #4).
Failed to discharge Tenant #1 who exceeded the level of care due to chronic elopement and aggressive behaviors.
Failed to develop and update service plans based on evaluations and tenant needs for all five tenants reviewed.
Failed to complete nurse reviews as needed when there was a change in tenants' health status for tenants with wounds (Tenants #3 and #5).
Failed to have staff complete eight hours of dementia-specific education within 30 days of employment for two staff members.
Report Facts
Census of Assisted Living Program for People with Dementia: 13
Number of tenants without cognitive disorder: 0
Medication dosage: 10
Medication dosage: 40
Weight loss: 11.8
Dementia training hours: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff G | Named in findings related to verbal abuse and physical mistreatment of Tenant #1 | |
| Staff E | Reported verbal abuse and physical mistreatment of Tenant #1 by Staff G | |
| Staff D | Administered medication improperly to Tenant #3 | |
| Nurse #2 | On-call nurse | Involved in investigation of staff concerns regarding Tenant #1 |
| Executive Director | Provided interviews and information about incident reports, staff training, and tenant care |
Inspection Report
Renewal
Census: 19
Deficiencies: 1
Date: Nov 27, 2018
Visit Reason
The recertification visit was conducted to determine compliance with certification for a Dedicated Dementia Specific Assisted Living Program.
Findings
The program failed to ensure staff employment background checks were completed within 30 days of hire, resulting in a regulatory insufficiency related to background check validity.
Deficiencies (1)
Program failed to ensure a staff employment background check was completed within 30 days of hire for 1 of 7 staff reviewed.
Report Facts
Number of tenants without cognitive disorder: 2
Number of tenants with cognitive disorder: 17
Total Census: 19
Staff reviewed: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Lisa Cleland | Executive Director | Signed Plan of Correction letter |
Inspection Report
Complaint Investigation
Census: 17
Deficiencies: 0
Date: Sep 19, 2018
Visit Reason
Investigation of incident #77620-I at Keystone Cedars Assisted Living Program for People with Dementia.
Complaint Details
Investigation of incident #77620-I resulted in no regulatory insufficiencies cited.
Findings
No regulatory insufficiencies were cited during the investigation of the incident.
Report Facts
Number of tenants without cognitive disorder: 4
Number of tenants with cognitive disorder: 13
Inspection Report
Renewal
Census: 80
Deficiencies: 0
Date: Nov 15, 2016
Visit Reason
Recertification visit conducted to determine compliance with certification for an Assisted Living Program.
Findings
There were no regulatory insufficiencies cited during the recertification visit.
Report Facts
Number of tenants without cognitive disorder in General Population Program: 62
Number of tenants with cognitive disorder in General Population Program: 4
Total Population of General Population Program: 66
Number of tenants without cognitive disorder in Dementia-Specific Program: 1
Number of tenants with cognitive disorder in Dementia-Specific Program: 13
Total Population of Dementia-Specific Program: 14
Total census of Assisted Living Program: 80
Inspection Report
Complaint Investigation
Census: 81
Deficiencies: 1
Date: Mar 31, 2016
Visit Reason
The inspection was conducted as a complaint/incident investigation related to Incident #58234-I, focusing on regulatory insufficiency in the area of Life Safety.
Complaint Details
The complaint investigation was substantiated with a regulatory insufficiency identified related to Incident #58234-I involving a tenant eloping from the dementia unit without the door alarm sounding.
Findings
The investigation found that the facility failed to have an operating door alarm on each exit door in the dementia-specific program, resulting in a tenant leaving the building without the alarm sounding. The tenant was safely returned, and the alarm system was in the process of being converted to an audible alarm. Staff interviews and documentation confirmed the deficiency.
Deficiencies (1)
Failure to have an operating door alarm on each exit door in a dementia-specific program, allowing a tenant to leave the building without the alarm sounding.
Report Facts
Number of tenants without cognitive disorder: 60
Number of tenants with cognitive disorder: 21
Total census: 81
Tenant age: 91
Tenant temperature: 99
Tenant pulse: 72
Tenant respirations: 18
Tenant blood pressure: 124.8
Temperature at local airport: 40
Wind speed: 6
Wind chill: 36
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Rose Boccella | Program Coordinator | Author of the complaint investigation report letter |
| Mary Jo Pipkin | Director | Named in the report letter and Plan of Correction response |
| Lisa Cleland | Executive Director | Signed the Plan of Correction response |
Inspection Report
Complaint Investigation
Census: 80
Deficiencies: 0
Date: Dec 2, 2014
Visit Reason
The inspection was conducted as a complaint/incident investigation related to staffing and a reported fall with injury at Keystone Cedars Assisted Living Program.
Complaint Details
The complaint involved staffing and an incident of a fall with injury. The investigation found no insufficiencies.
Findings
No regulatory insufficiencies were found during the investigation based on review of tenant files, incident reports, program policy, and staff interviews.
Report Facts
General Population Program tenants without cognitive disorder: 61
General Population Program tenants with cognitive disorder: 3
General Population Program total population: 64
Dementia-Specific Program tenants without cognitive disorder: 2
Dementia-Specific Program tenants with cognitive disorder: 14
Dementia-Specific Program total population: 16
Total census of Assisted Living Program: 80
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Rose Boccella | Program Coordinator | Author of the complaint/incident investigation report |
Inspection Report
Monitoring
Census: 80
Deficiencies: 2
Date: Nov 10, 2014
Visit Reason
The visit was conducted as a Final Recertification Monitoring Evaluation to assess compliance with Iowa Code chapter 231C and Iowa Administrative Code chapters 481-67 and 481-69, focusing on criminal, dependent adult abuse, and child abuse record checks.
Findings
The report found regulatory insufficiencies related to failure to conduct required criminal history and abuse record checks for staff prior to employment, as evidenced by missing or misfiled documentation for two staff members.
Deficiencies (2)
Failure to conduct criminal history and dependent adult abuse and child abuse record checks prior to employment for staff.
Failure to conduct an evaluation to determine if a criminal history warranted prohibition of employment for one staff member.
Report Facts
Total Population of Program: 80
Number of tenants without cognitive disorder: 64
Number of tenants with cognitive disorder: 16
Number of tenants without cognitive disorder: 3
Number of tenants with cognitive disorder: 13
Inspection Report
Complaint Investigation
Census: 79
Deficiencies: 0
Date: Feb 6, 2014
Visit Reason
The inspection was conducted as a complaint/incident investigation following a report that a tenant eloped from the assisted living program.
Complaint Details
The complaint involved a tenant eloping from the program. The investigation found no regulatory insufficiencies and no history of prior elopements for Tenant #1. Staff and family were involved in monitoring and responding to the incident.
Findings
The investigation found that Tenant #1 eloped but was found safe and returned to the facility without injury. There were no regulatory insufficiencies identified related to the incident, though documentation of hourly checks was inconsistent.
Report Facts
Number of tenants without cognitive disorder in General Population Program: 63
Number of tenants with cognitive disorder in General Population Program: 1
Total Population of General Population Program: 64
Number of tenants without cognitive disorder in Dementia-Specific Program: 7
Number of tenants with cognitive disorder in Dementia-Specific Program: 8
Total Population of Dementia-Specific Program: 15
Total census of Assisted Living Program: 79
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Stephanie Cummins | MA | Monitor conducting the complaint/incident investigation |
Inspection Report
Complaint Investigation
Census: 78
Deficiencies: 8
Date: Jun 12, 2013
Visit Reason
The inspection was conducted as a complaint/incident investigation regarding regulatory insufficiencies related to criteria for admission and retention, evaluation, service plans, tenant rights, and nurse review at Keystone Cedars Assisted Living.
Complaint Details
Complaint Intake #43989-C involved allegations that the facility retained a tenant who was physically and sexually abusive to staff and another tenant, failed to notify a tenant's Durable Power of Attorney after a fall, and had questionable evaluations and service plans. The complaint was substantiated with findings of regulatory insufficiencies.
Findings
The report found that the facility retained a tenant who exceeded retention criteria and was physically and sexually abusive to staff and another tenant. Multiple regulatory insufficiencies were cited, including failure to protect tenants, inadequate service plans, and violations of tenant rights.
Deficiencies (8)
Retained a tenant who exceeded criteria for retention and was physically and sexually abusive to staff and another tenant.
Failure to comply with regulatory requirements related to tenant rights and protection from abuse.
Failure to notify a tenant's Durable Power of Attorney after a fall.
Failure to complete appropriate evaluations and assessments after tenant incidents.
Inadequate staff training managing tenants with dementia.
Failure to develop and update individualized service plans based on evaluations and changes in tenant condition.
Violation of tenant rights including failure to protect from sexual abuse and physical aggression.
Inadequate nurse review and monitoring of tenants exhibiting combative and sexually inappropriate behavior.
Report Facts
Civil penalty amount: 1500
Reduced civil penalty amount: 975
Census: 78
General Population Program tenants without cognitive disorder: 63
General Population Program tenants with cognitive disorder: 1
Dementia-Specific Program tenants without cognitive disorder: 2
Dementia-Specific Program tenants with cognitive disorder: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Mary Jo Pipkin | Administrator | Administrator of Keystone Cedars Assisted Living named in report |
| Hal L. Chase | RN BSN MPH | Monitor of the complaint/incident investigation |
| Rose Boccella | Program Coordinator | Contact person for questions and payment of civil penalty |
| Jim Friberg | Acting Bureau Chief, Adult Services Bureau | Signed the demand letter |
Inspection Report
Complaint Investigation
Census: 82
Deficiencies: 1
Date: Mar 5, 2013
Visit Reason
The inspection was conducted as a complaint/incident investigation based on allegations including unauthorized posting of tenant pictures on social media, presence of animals in the program, tenants being given wrong medications, insufficient staffing during nighttime hours, and tenants requiring nursing home level of care.
Complaint Details
The complaint investigation was substantiated with findings related to staffing and training deficiencies. Other allegations such as medication errors and tenant rights violations were not substantiated.
Findings
The investigation found no regulatory insufficiencies related to medications or criteria for admission and retention. There was a regulatory insufficiency related to staffing due to lack of documentation of medication administration training for some staff and insufficient trained staff to meet tenant needs. Tenant rights were generally respected with signed consents for social media postings and no evidence of unauthorized animal interactions or forced gift giving.
Deficiencies (1)
A sufficient number of trained staff shall be available at all times to fully meet tenant's identified needs.
Report Facts
Number of tenants without cognitive disorder in General Population Program: 68
Number of tenants with cognitive disorder in General Population Program: 0
Total Population of General Population Program: 68
Number of tenants without cognitive disorder in Dementia-Specific Program: 2
Number of tenants with cognitive disorder in Dementia-Specific Program: 12
Total Population of Dementia-Specific Program: 14
TOTAL census of Assisted Living Program: 82
Number of staff personal records reviewed: 6
Number of staff members interviewed: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Mary Jo Pipkin | Administrator | Program Administrator named in complaint and investigation |
| Joyce Kix | RN | Monitor involved in complaint/incident investigation |
| Maribeth Freland | RN | Monitor involved in complaint/incident investigation |
Inspection Report
Complaint Investigation
Census: 82
Deficiencies: 0
Date: Oct 9, 2012
Visit Reason
The inspection was conducted as a complaint/incident investigation following a report that a tenant exited the dementia unit unsupervised and triggered a door alarm.
Complaint Details
The complaint involved a tenant who exited the dementia unit and triggered an alarm. The tenant was found outside near a locked exit door and was safely escorted back. Staff followed procedures, and no injuries occurred. The tenant was identified as an elopement risk and had a service plan with interventions to prevent exit seeking behaviors. The complaint was not substantiated as no regulatory insufficiencies were found.
Findings
The investigation found that Tenant #1 exited the building but was safely located and returned without injury. Staff followed policies regarding monitoring and response. No regulatory insufficiencies were identified.
Report Facts
Number of tenants without cognitive disorder in General Population Program: 69
Number of tenants with cognitive disorder in General Population Program: 0
Total population in General Population Program: 69
Number of tenants without cognitive disorder in Dementia-Specific Program: 5
Number of tenants with cognitive disorder in Dementia-Specific Program: 8
Total population in Dementia-Specific Program: 13
Total census of Assisted Living Program: 82
Temperature: 35
Wind speed: 5
Wind chill factor: 31
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Stephanie Cummins | Monitor | Named as monitor conducting the complaint/incident investigation |
| Margaret Kaltefleiter | RN MS Monitor | Named as monitor conducting the complaint/incident investigation |
| Rose Boccella | Program Coordinator | Named in cover letter regarding the complaint/incident investigation report |
Inspection Report
Complaint Investigation
Deficiencies: 5
Date: Jul 30, 2012
Visit Reason
The inspection was conducted as a final complaint/incident investigation regarding regulatory insufficiencies related to policies and procedures, program reporting to the department, and life safety at Keystone Cedars Assisted Living following a tenant elopement incident.
Complaint Details
Complaint investigation was substantiated. The tenant eloped from the dementia unit through a deactivated south exit door alarm. The program failed to report the elopement and did not complete an incident report. The door alarm was found deactivated and staff were unaware. The investigation confirmed regulatory insufficiencies in policies, reporting, and life safety.
Findings
The program failed to comply with regulatory requirements, resulting in a $500 civil penalty due to imminent danger or substantial probability of death or physical harm to a tenant who eloped through a deactivated exit door alarm. The program did not report the elopement and did not complete an incident report. The south exit door alarm was found deactivated, and staff were unaware of this. Additional regulatory insufficiencies were noted in incident reporting and alarm system procedures.
Deficiencies (5)
Failure to report tenant elopement and complete an incident report.
South exit door alarm was deactivated and not reported.
Policies and procedures on incident reports did not include all accidents or unusual occurrences affecting tenants.
Director or designee was not notified within 24 hours of tenant elopement.
Operating alarm system was not connected to each exit door in the dementia-specific program.
Report Facts
Civil penalty amount: 500
Days to submit Plan of Correction: 10
Date of complaint/incident investigation: Jul 30, 2012
Date of tenant elopement incident: Jul 12, 2012
Door alarm delay: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Mary Jo Pipkin | Administrator | Administrator involved in the tenant elopement incident and investigation. |
| Hal L. Chase | RN BSN MPH | Monitor who conducted the complaint/incident investigation. |
| Rose Boccella | Program Coordinator contact for questions regarding the report. | |
| Ann Martin | Bureau Chief, Adult Services Bureau | Signed the demand letter and report. |
Inspection Report
Monitoring
Census: 80
Deficiencies: 0
Date: May 21, 2012
Visit Reason
The visit was a Final Recertification Monitoring Evaluation to review recertification documents and conduct an on-site monitoring evaluation of Keystone Cedars Assisted Living in Cedar Rapids, IA.
Findings
No regulatory insufficiencies were found during the evaluation. Tenant satisfaction was positive, with clean and safe conditions, timely nursing services, and adequate activities offered.
Report Facts
Number of tenants without cognitive disorder: 66
Number of tenants with cognitive disorder: 0
Total Population of General Population Program: 66
Number of tenants without cognitive disorder: 5
Number of tenants with cognitive disorder: 9
Total Population of Dementia-Specific Program: 14
Total census of Assisted Living Program: 80
Number of tenants attending community meeting: 18
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Mary Jo Pipkin | Administrator | Administrator of Keystone Cedars Assisted Living named in report |
| Hal L. Chase | RN BSN MPH | Monitor conducting the evaluation |
Inspection Report
Complaint Investigation
Census: 86
Deficiencies: 0
Date: Jul 27, 2011
Visit Reason
The inspection was conducted as a complaint investigation following an allegation that the program failed to provide proper care and follow-up after an incident with injury.
Complaint Details
Complaint Allegation: It was alleged the Program failed to provide proper care and follow-up after an incident with injury. The investigation included review of three tenant incidents involving falls and injuries, staff actions, and documentation. No regulatory insufficiencies were found.
Findings
The investigation reviewed tenant incidents involving falls and injuries, staff responses, and documentation. No regulatory insufficiencies were identified during the investigation.
Report Facts
Current number of tenants without cognitive disorder: 71
Current number of tenants with cognitive disorder: 0
Total Population of GPP: 71
Total Population of DSP: 15
Total Census of ALP: 86
Number of tenant files reviewed: 3
Number of employee files reviewed: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Margaret Kaltefleiter | RN MS | Monitor conducting the complaint investigation |
Inspection Report
Monitoring
Census: 80
Deficiencies: 0
Date: Sep 22, 2010
Visit Reason
The visit was a final recertification monitoring evaluation conducted to review the assisted living program's compliance with Iowa Code and Administrative Code requirements.
Complaint Details
A complaint investigation completed on February 3 and 4, 2010 resulted in regulatory insufficiencies in the areas of Evaluation of Tenant, Service Plans and Other, with a civil penalty of $2,000 assessed.
Findings
No regulatory insufficiencies were found during this onsite recertification monitoring evaluation. Previous complaint and incident investigations had resulted in regulatory insufficiencies and civil money penalties.
Report Facts
Current number of tenants without cognitive disorder: 64
Current number of tenants with cognitive disorder: 0
Total Population of GPP: 64
Total Population of DSP: 16
Total Census of ALP: 80
Civil money penalty: 2000
Civil money penalty: 500
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Mary Jo Pipkin | Executive Director | Named as Executive Director of Keystone Cedars in the report |
| Stephanie Cummins | MA | Monitor for the evaluation |
| Joyce Kix | RN | Monitor for the evaluation |
| Rose Boccella | Program Coordinator | Signed the report letter |
Inspection Report
Complaint Investigation
Census: 74
Deficiencies: 2
Date: Feb 3, 2010
Visit Reason
A complaint investigation was conducted at Keystone Cedars Assisted Living on February 3 and 4, 2010, triggered by allegations related to tenant care, service plans, and other regulatory concerns.
Complaint Details
The complaint investigation was substantiated. It involved a tenant found outside without appropriate winter clothing who fell on ice and sustained two pubic fractures. The tenant had an elopement incident and inadequate staff response was noted.
Findings
The investigation found regulatory insufficiencies in evaluation of tenants, service plans, and other areas. A tenant was found outside without appropriate clothing and sustained two pubic fractures. The program was assessed a $2,000 civil penalty and the Plan of Correction was accepted but the request for reconsideration was denied.
Deficiencies (2)
Failure to complete evaluations with a change in condition and incomplete service plans following significant changes.
Failure to report a serious injury or elopement within the required timeframe.
Report Facts
Civil penalty amount: 2000
Reduced penalty amount: 1300
Total census: 74
General Population Program tenants: 62
Dementia Specific Program tenants: 12
Incident Investigation penalty: 500
Inspection Report
Complaint Investigation
Census: 80
Deficiencies: 1
Date: Dec 8, 2009
Visit Reason
The visit was conducted as a final incident investigation following a tenant's death due to positional asphyxiation after rolling out of bed and becoming wedged between the mattress and an assistive bed rail.
Complaint Details
The complaint involved a tenant who rolled out of bed and died due to positional asphyxiation caused by being wedged between the mattress and an assistive bed rail. Staff found the tenant unresponsive and emergency services were called. The Medical Examiner confirmed the cause of death as positional asphyxiation. The incident was investigated with interviews of staff and review of tenant records.
Findings
The investigation found that the program did not develop individualized service plans reflecting tenant needs, specifically regarding bed rail use. Staff responded to the incident but the tenant died from positional asphyxiation. No regulatory insufficiency was noted related to the incident itself, but a $500 civil penalty was assessed for regulatory insufficiencies in service plans.
Deficiencies (1)
The program did not develop individualized service plans that were individualized and indicated at a minimum the tenant’s identified needs and the tenant’s requests for assistance and expected outcomes.
Report Facts
Civil penalty amount: 500
Reduced penalty amount: 325
Census - tenants without cognitive disorder: 67
Census - tenants with cognitive disorder: 0
Census - total population of General Population Program: 67
Census - total population of Dementia Specific Program: 13
Total census of Assisted Living Program: 80
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Stephanie Cummins | Monitor | Conducted the incident investigation |
| Ann Martin | Bureau Chief, Adult Services Bureau | Signed the demand letter assessing civil penalty |
| Mary Jo Pipkin | Executive Director | Named in the report as facility executive director |
Inspection Report
Monitoring
Census: 83
Deficiencies: 9
Date: May 28, 2008
Visit Reason
An on-site monitoring evaluation was conducted at Keystone Cedars Assisted Living on May 28, 2008, to review the Plan of Correction in response to the Recertification Monitoring Evaluation Report and assess compliance with regulatory requirements.
Findings
The evaluation found multiple regulatory insufficiencies related to tenant evaluations, service plans, medication administration, nurse review, food service orientation, staffing training, dementia-specific education, and structural maintenance. The program had no regulatory insufficiencies in the past certification period but currently did not consistently meet several regulatory requirements.
Deficiencies (9)
The program did not consistently evaluate each tenant's functional, cognitive, and health status within 30 days of taking occupancy.
Service plans were not updated as needed and did not reflect activities, planned and spontaneous, for tenants.
Medication administration documentation was incomplete, with several doses not given or not signed and refusals not documented.
Nurse review was not consistently completed as needed to assess and document tenants' health status.
Staff did not have orientation on sanitation and safe food handling prior to handling food and lacked annual in-service training on food protection.
Staff did not have documented medication training, including medication management review.
The program did not consistently provide sufficient trained staff to meet tenants' identified needs.
Dementia-specific program personnel did not receive six hours of dementia-specific continuing education annually.
The program did not consistently provide a building and grounds that were well maintained, clean, safe, and sanitary.
Report Facts
Current number of tenants without cognitive disorder: 67
Current number of tenants with cognitive disorder: 1
Total Population: 68
Current number of tenants in Dementia Specific Program providing specialized care: 13
Current number of tenants without cognitive disorder in Dementia Specific Program: 2
Total Population: 15
Tenant files reviewed: 8
Staff files reviewed: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Mary Jo Pipkin | Director | Administrator and Director of Keystone Cedars Assisted Living |
| Stephanie Cummins | SW MA | Monitor |
| Lincoln Newsom | RN | Monitor |
Inspection Report
Complaint Investigation
Census: 56
Deficiencies: 4
Date: Jan 13, 2005
Visit Reason
A complaint investigation was conducted at Keystone Cedars to address allegations regarding failure to provide an updated occupancy agreement, inadequate tenant evaluations, retention of a tenant requiring a higher level of care, and insufficient staffing to meet tenant needs.
Complaint Details
The complaint investigation was initiated due to allegations that the program failed to provide an updated occupancy agreement after a tenant's transfer to a higher service level, did not properly evaluate tenants after hospitalization or condition changes, retained a tenant requiring a higher level of care who was a danger to self, and did not provide appropriate staffing and services to meet tenant needs. No substantiated complaints were noted in the certification period prior to this investigation.
Findings
The investigation found multiple regulatory insufficiencies including failure to update and obtain signatures on occupancy agreements after service level changes, inadequate evaluation of tenants' cognitive and functional status after hospitalization or condition changes, retention of a tenant who required a higher level of care and was a danger to self, and insufficiently trained staff to meet the needs of an insulin-dependent diabetic tenant.
Deficiencies (4)
The program did not provide an updated occupancy agreement signed by the tenant, tenant’s legal representative, and the program prior to tenant being transferred to the memory care unit.
The program did not evaluate each tenant appropriately with change in condition or return from hospital visit.
The program did not transfer a tenant who met the criteria for exclusion due to being a danger to self at the point the tenant was no longer able to manage diabetic needs.
The program did not have sufficiently trained staff to meet the tenant’s needs.
Report Facts
Current number of tenants without cognitive disorder in General Population Program: 40
Current number of tenants with cognitive disorder in General Population Program: 8
Total Population in General Population Program: 48
Current number of tenants in Dementia Specific Program: 7
Current number of tenants without cognitive disorder in Dementia Specific Program: 1
Total Population in Dementia Specific Program: 8
Monthly rent for tenant in general population: 3090
Monthly rent for studio apartment in memory care unit: 3550
Difference in monthly rent between general population and memory care unit: 460
Date of tenant admission to program: Sep 13, 2004
Date of tenant hospitalization: Dec 9, 2004
Date of tenant transfer to memory care unit: Dec 16, 2004
Date of tenant transfer out of program: Dec 29, 2004
Tenant blood sugar readings: 26
Tenant blood sugar reading: 31
Number of emergency room visits by tenant: 5
Inspection Report
Monitoring
Census: 40
Deficiencies: 1
Date: Sep 22, 2004
Visit Reason
An on-site monitoring evaluation was conducted at Keystone Cedars to assess compliance with assisted living program regulations and to evaluate tenant satisfaction and program operations.
Findings
The program generally met tenant satisfaction with activities, safety, and food quality. However, a regulatory insufficiency was found regarding transportation services, specifically that the program did not have an appropriately licensed driver for the program's van.
Deficiencies (1)
The program did not have an appropriately licensed driver to drive the program’s van, requiring a Class D chauffeur’s license or a Commercial Driver’s License (CDL) if the van is handicapped accessible.
Report Facts
Current number of tenants without cognitive disorder: 31
Current number of tenants with cognitive disorder: 6
Total General Population: 37
Current number of tenants in Dementia Specific Program: 3
Van passenger capacity: 12
Outings frequency per week: 2.5
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