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Page 1: dZ] } µu v Á ÇZ ] v ]o ^ À] (} Z >} } Á ] X · Provider/Facility: Hearthside Manor (699683) Intake ID(s): 3355204 License/Cert. #: AL2142 Investigator: Goulet, Michael Region/Unit:RCS

This document w

as prepared by Residential Care Services for the Locator website.

Page 2: dZ] } µu v Á ÇZ ] v ]o ^ À] (} Z >} } Á ] X · Provider/Facility: Hearthside Manor (699683) Intake ID(s): 3355204 License/Cert. #: AL2142 Investigator: Goulet, Michael Region/Unit:RCS

Residential Care Services Investigation Summary Report

Provider/Facility: Hearthside Manor (699683) Intake ID(s): 3355204

License/Cert. #: AL2142Investigator: Goulet, Michael Region/Unit: RCS Region 3/Unit A Investigation

Date(s):07/18/201707/24/2017

through

Complainant Contact Date(s): 07/20/2017, 07/26/2017Allegations:1) Resident was left on mattress in facility lobby before and after resident's death

2) Family and primary care provider were not contacted regarding resident's change in condition

Investigation Methods:Sample: 1 of 1 residents, including

named residentObservations: General environment

Residents in their roomsStaff to residentinteractionsPlace in facility whereresident was stated tohave died

Interviews: StaffPersons not associatedwith the facility

Record Reviews: Progress notesInitial assessmentAdmission assessmentFacility investigationpaperwork andcommunicationsFire Dept. reportAlert charting notesCaregivercommunications formComplainantcommunication (viaattorney)Pre-admissionassessment (MedicalCenter)Service Agreement

Page 1 of 2

This document w

as prepared by Residential Care Services for the Locator website.

Page 3: dZ] } µu v Á ÇZ ] v ]o ^ À] (} Z >} } Á ] X · Provider/Facility: Hearthside Manor (699683) Intake ID(s): 3355204 License/Cert. #: AL2142 Investigator: Goulet, Michael Region/Unit:RCS

Residential Care Services Investigation Summary Report

MedicationAdministration Record

Allegation Summary:1) Per interview and record review it was determined that facility staff did leave the resident on a mattress on the floor of acommon area of the assisted living facility memory care both prior to, and after the resident's death.

2) Per interview and record review it was determined that the assisted living facility did not contact the resident's daughterregarding a change in the resident's condition. Per staff interview, one staff member did contact the resident's physician at aMedical Center regarding a request for medication orders related to the resident's condition, but this contact was not able to besubstantiated.

Unalleged Violation(s): Yes No

Conclusion /Action:

Failed Provider Practice Identified /Citation(s) Written

Failed Provider Practice Not Identified /No Citation Written

388-78A-2640 (1a) Reporting significant change in resident's condition70.129.140 (1) Quality of Life-Rights

Page 2 of 2

This document w

as prepared by Residential Care Services for the Locator website.

Page 4: dZ] } µu v Á ÇZ ] v ]o ^ À] (} Z >} } Á ] X · Provider/Facility: Hearthside Manor (699683) Intake ID(s): 3355204 License/Cert. #: AL2142 Investigator: Goulet, Michael Region/Unit:RCS

This document w

as prepared by Residential Care Services for the Locator website.

Page 5: dZ] } µu v Á ÇZ ] v ]o ^ À] (} Z >} } Á ] X · Provider/Facility: Hearthside Manor (699683) Intake ID(s): 3355204 License/Cert. #: AL2142 Investigator: Goulet, Michael Region/Unit:RCS

This document w

as prepared by Residential Care Services for the Locator website.

Page 6: dZ] } µu v Á ÇZ ] v ]o ^ À] (} Z >} } Á ] X · Provider/Facility: Hearthside Manor (699683) Intake ID(s): 3355204 License/Cert. #: AL2142 Investigator: Goulet, Michael Region/Unit:RCS

This document w

as prepared by Residential Care Services for the Locator website.

Page 7: dZ] } µu v Á ÇZ ] v ]o ^ À] (} Z >} } Á ] X · Provider/Facility: Hearthside Manor (699683) Intake ID(s): 3355204 License/Cert. #: AL2142 Investigator: Goulet, Michael Region/Unit:RCS

This document w

as prepared by Residential Care Services for the Locator website.

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dZ] } µu v Á ÇZ ] v ]o ^ À] (} Z >} } Á ] X · Provider/Facility: Amber Waves ALF LLC (878473) Intake ID(s): 3687978 License/Cert. #: AL2324 Investigator: Webster, Brenda Region/Unit:RCS

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