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Inspection visit

Follow-up on corrections

PALM COURT ASSISTED LIVINGLicense 3364033664 citations on this visit
4 citations recorded

Inspector’s narrative

What the inspector wrote

Licensing Program Analsyt (LPA) Crystal Colvin was at the facility conducting an investigation on a complaint (#18-AS-20220706102318) when LPA Colvin observed the following items which were addressed: Reporting Requirements: LPA Colvin learned through record review and interviewed that one resident (R1) was physically violent to multiple residents on numerous dates. R1 punched, kicked, and spat at different residents, all of which was documented in R1's progress notes, but was not reported to Licensing. This behavior was a safety risk and personal rights violation to each resident, and had Licensing been made aware of the ongoing situation, Licensing could have reached out to assist and inquire about the issues with R1 and aided the facility in recommendations for response. Deficiency cited. Record Keeping: In addition to not reporting these incidents to Licensing, the facility staff failed to note in the multiple victims files of the abuse/violence, and therefore, this information was not relayed to the rest of the care staff, and was likely not reported the residents' responsible parties. Deficiency cited. Re-Assessment of Resident(s): R1 was observed to have a marked change in behavior, which was communicated to R1's doctor and Public Guardian, however, the facility failed to conduct an updated assessment of R1 to determine if R1 was still appropriate for their facility. Deficiency cited. Camouflaging of Medication: During LPA Colvin's investigation, LPA Colvin learned that R1 was refusing to take their medication as they "thought it was poison". This resulted in care staff camouflaging R1's medication in their morning juice. LPA Colvin clarified whether or not this was done with R1's knowledge, and it was confirmed that it was done without R1's knowledge and for the express purpose of tricking R1 into taking their medication. Deficiency cited. Based on LPA Colvin's investigation, the facility was cited and deficiencies noted on LIC809Ds. LPA Colvin conducted an exit interview with Administrator Patrick Mcadoo Morton where a copy of this report, LIC 809Ds, and appeal rights were provided. ****Due to technical issues, reports were signed with ink signatures after they were printed. Facility maintains original copy while LPA maintains a photocopy of the report.

Citations

5 citations recorded*CCLD

What does Type A vs Type B mean?

Type A. Serious citation. Imminent or substantial risk to children. The regulator requires corrective action immediately and may impose a civil penalty.

Type B. Lower-severity citation. Corrective action required, no imminent risk. The regulator monitors compliance on the next visit.

  • 87468.1(a)(2)Type A

    Personal Rights of Residents in All Facilities: (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement was not met as evidenced by: Based on record review and interview, the Licensee did not comply with the above regulation with at least one aspect of the facility. R1 was physically and verbally aggressive with multiple residents for nearly 2 months prior to the facility having R1 removed. This was an immediate safety risk to residents.

  • 87211(a)(1)(D)Type A

    Reporting Requirements: (a) Each licensee shall furnish.. reports...including...: (1) A written report shall be submitted...within seven days of the occurrence of any of the events specified...(D) Any incident which threatens the welfare, safety or health of any resident... This requirement was not met as evidenced by: Based on record review, the Licensee did not comply with the above regulation with multiple incidents. LPA Colvin observed that R1 was physically violent with other residents multiple times from 6/12/22 - 7/1/22 with only one report (7/1/22) being sent to Licensing. This was an immediate safey risk for all residents.

  • 87463(c)Type B

    Reappraisals: (c) The licensee shall arrange a meeting with the resident, the resident’s representative, if any, appropriate facility staff...when there is significant change in the resident’s condition.... This requirement was not met as evidenced by: Based on interviews and record review, the Licensee did not comply with the above regulation with one resident. R1 was observed to have a significant change in condition (behavioral) in June 2022, but the facility did not conduct a reappraisal of R1's needs. This was a potential safety risk for R1.

  • 87465(a)(5)(D)Type A

    Incidental Medical and Dental Care: (a) A plan...provide for assistance in obtaining such care...:(5) Facility staff ...may assist persons...as needed. Assistance...shall be limited to ...: (D) Assistance...does not include...hiding or camouflaging medications...without the resident's knowledge and consent... This requirement was not met by: Based on interviews conducted, the Licensee did not comply with the regulation with one resident. Staff administered R1's medication without R1's knowledge by putting it in R1's morning juice due to R1 refusing medication. This was an immediate personal rights violation of R1.

  • 87468.2(a)(4)Type B

    Additional Personal Rights of Residents...: (a) In addition to the rights listed ...residents...shall have all of the following personal rights: (4) To care, supervision, and services that meet their individual needs.... This requirement was not met as evidenced by: Based on record review and interviews, the Licensee did not comply with the above regulations for multiple residents. R1 was reported to have been violent with multiple residents, but the facility failed to document this in the other residents' file. This was a potential personal rights violation of residents.

FAQ · About this visit

Common questions about this visit

What happened during the July 14, 2022 inspection of PALM COURT ASSISTED LIVING?

This was a other inspection of PALM COURT ASSISTED LIVING on July 14, 2022. 4 citations were issued: 2 Type A (serious) and 2 Type B.

Were any citations issued to PALM COURT ASSISTED LIVING on July 14, 2022?

Yes, 4 citations were issued (2 Type A, 2 Type B). The first citation was for: "Personal Rights of Residents in All Facilities: (a) Residents in all residential care facilities for the elderly shall h..."

What type of inspection was this?

This was a other inspection. other inspections are conducted by CCLD as part of their licensing oversight.

SourceView on CCLDView original report

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Data from CCLD public records. Last updated . If you believe any information is inaccurate, report it here.