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Inspection visit

complaint

CHANTILLY LACE MANOR IILicense 3664267091 citation on this visit
1 citation recorded

Inspector’s narrative

What the inspector wrote

Licensing Program Analysts (LPAs) Anna Bueno and Michelle Echeverria conducted an unannounced visit to this facility for the purpose of initiating the investigation of and delivering findings for the above allegation. LPAs met with licensee Teresa Baddeley who was advised of the purpose of visit. The investigation consisted of records review and interviews with relevant parties. It is alleged that Resident 1 (R1) was not provided timely medical attention by facility staff. LPA Bueno conducted interviews that revealed that R1's change of condition was observed by Witness 1 (W1) who reported the change to their agency and to facility staff. Interviews further revealed R1 was not seen by any medical personnel from the outside agency providing R1 with services. Records reviewed also revealed that R1 was receiving services from an outside agency when their condition was observed by W1 and that R1 was taken to the local hospital for treatment on the same day R1's condition was observed. This allegation is therefore unsubstantiated. A finding of UNSUBSTANTIATED means although the allegations may have happened or are valid, there is no preponderance of evidence to prove the alleged violations did or did not occur. An exit interview was conducted with Licensee and a copy of this report was provided.

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.

  • 1569.695(d)Type B

    Based on observation, interview and record review, the licensee did not comply with the section cited above in maintaining a complete Emergency Disaster Plan which poses a potential health, safety or personal rights risk to persons in care.

  • 87465(c)(3)Type B

    Based on observation, the licensee did not comply with the section cited above in not maintaining a log for two different PRN medications for two different residents which poses a potential health, safety or personal rights risk to persons in care.

  • 87465(h)(4)Type B

    Based on observation and interview, the licensee did not comply with the section cited above by storing expired medication and accepting medication with altered labels which poses a potential health, safety or personal rights risk to persons in care.

  • 87470(c)(1)Type B

    Based on observation and record review, the licensee did not comply with the section cited above in submitting a complete Infection Control Plan which poses a potential health, safety or personal rights risk to persons in care.

  • 87265(d)(3)Type B

    (d) If the resident is unable to determine his/her own need for a prescription or nonprescription PRN medication, and is unable to communicate his/her symptoms clearly, facility staff designated by the licensee, shall be permitted to assist the resident with self-administration provided all of the following requirements are met: (3) The date and time the PRN medication was taken, the dosage taken, and the resident's response shall be documented and maintained in the resident's facility record. This requirement was not met as evidenced by:LPAs inspected resident medications and centralized record and found three medications not listed on the centralized record. Two of three medications appeared to have been administered, which poses a potential health and safety risk to clients in care.

FAQ · About this visit

Common questions about this visit

What happened during the January 24, 2024 inspection of CHANTILLY LACE MANOR II?

This was a complaint inspection of CHANTILLY LACE MANOR II on January 24, 2024. 1 citation were issued: 1 Type B.

Were any citations issued to CHANTILLY LACE MANOR II on January 24, 2024?

Yes, 1 citation was issued (0 Type A, 1 Type B). The first citation was for: "Based on observation, interview and record review, the licensee did not comply with the section cited above in maintaini..."

What type of inspection was this?

This was a complaint inspection. Complaint inspections are triggered when someone reports a concern about the facility to CCLD.

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.