6 Reports
Inspection Report — Dec 18, 2024
Complaint Investigation
Date: Dec 18, 2024
Visit Reason
The survey was conducted following a complaint inspection.
Complaint Details
The deficiencies cited involved failure to document physician-ordered treatments and inadequate staffing leading to delayed emergency call light responses.
Findings
Two deficiencies were found: the facility did not document following physician-ordered treatment on the medication administration record, and staffing was insufficient to respond promptly to emergency call lights.
Deficiencies (2)
37.106.2847-1 Medications, practitioner orders: the facility did not document following the physician's ordered treatment of a high-protein nutritional shake on the medication administration record.
37.106.2816-6 Assisted living facility staffing: the facility did not have sufficient staffing to respond promptly to emergency call lights, with recorded response times of 17 to 37 minutes.
Report Facts
response_times_minutes:
Inspection Report — Jun 13, 2023
Original Licensing
Date: Jun 13, 2023
Visit Reason
The inspection was conducted as a provisional status inspection to evaluate compliance with licensing requirements.
Findings
Three deficiencies were identified involving lack of administrator review documentation, unsecured oxygen tanks in resident rooms, and unsecured chemicals in laundry rooms.
Deficiencies (3)
37.106.2814-12 Administrator: incident reports lacked documentation of administrator review or corrective action to prevent reoccurrence; this is a repeat citation.
37.106.2853-4 Oxygen use: unsecured oxygen tanks were found in two resident rooms during the facility tour.
37.106.2865-13 Physical plant: both laundry rooms had chemicals out and not locked in storage during the facility tour.
Report Facts
incident_reports_reviewed: 10
incident_reports_with_issues: 10
Inspection Report — Jan 19, 2023
Complaint Investigation
Date: Jan 19, 2023
Visit Reason
The complaint inspection was conducted following reports of staffing shortages, medication errors, and missing incident reports.
Complaint Details
The complaint inspection cited deficiencies related to staffing shortages, delayed call light responses, medication errors including incorrect dosing and missed medications, and missing incident reports.
Findings
The facility had inadequate staffing with conflicting schedules and insufficient call light responses. Numerous medication errors and missing incident reports were found, including residents sent to the emergency room without proper documentation.
Deficiencies (9)
37.106.2814-4 Administrator: staffing schedules did not reflect actual hours worked, call light responses were delayed over 10 minutes, and multiple residents were sent to the emergency room due to inadequate staffing.
37.106.2814-12 Administrator: incident reports were missing for confirmed incidents and medication errors, and there was no documentation of review or preventative measures by the administrator.
37.106.2816-6 Assisted living facility staffing: 187 resident call response times exceeded 10 minutes, with some delays over 50 minutes.
37.106.2846-3 Medications, storage and disposal: a cabinet containing resident medications was unlocked with no key available to secure it.
37.106.2847-1 Medications, practitioner orders: medication doses were improperly altered, with sixteen doses given at half the prescribed amount, and excessive late medication administrations were documented.
37.106.2848-3 Medications, administration and preparation: medication organizers were being set up by medication technicians not authorized by law.
37.106.2848-6 Medications, administration and preparation: a resident was sent home with another resident’s insulin pen, resulting in missed medication without documentation of error or notification.
37.106.2849-2 Medications, records and documentation: a resident did not have blood sugar checked or insulin administered on time, leading to an emergency room visit without evidence of practitioner notification.
37.106.2849-5 Medications, records and documentation: there was no record of destruction for half portions of medication that were cut and discarded as instructed.
Report Facts
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Inspection Report — Feb 26, 2020
Complaint Investigation
Date: Feb 26, 2020
Visit Reason
The survey was conducted as a complaint inspection.
Complaint Details
The cited finding involved uncovered food items left out during lunch service, posing a potential food safety risk.
Findings
The facility had uncovered bowls of food left out during lunch service, which were not properly refrigerated or covered for the duration of the meal.
Deficiencies (1)
37.106.2860-1 Food service: several bowls of starters including fruit, yogurt, and lettuce were left uncovered on trays during lunch service and remained uncovered for the duration.
Inspection Report — Jan 13, 2017
Renewal
Date: Jan 13, 2017
Visit Reason
The survey was conducted as a renewal inspection to assess compliance with licensing requirements.
Findings
Two deficiencies were found related to assisted living facility staffing and resident service plans. Staff did not document reviewing individual resident service plans, and resident service plans lacked emergency contact and practitioner information.
Deficiencies (2)
37.106.2816-4 Assisted living facility staffing: there was no documentation that direct care staff signed off as having reviewed individual resident service plans.
37.106.2822-2 Resident service plan: category A: resident service plans did not include an emergency contact number or the resident’s practitioner information.
Inspection Report — Jan 8, 2016
Renewal
Date: Jan 8, 2016
Visit Reason
The survey was conducted as a renewal inspection of the facility.
Findings
Two deficiencies were identified related to resident needs assessments and construction standards. Some resident needs assessments were not dated, and certain doors did not meet life safety code requirements.
Deficiencies (2)
37.106.2821-3 Resident application and needs assessment: five of twelve resident files lacked dated resident needs assessments, preventing determination if assessments were done prior to admission.
37.106.302-2 Minimum standards of construction, general requirements: interior apartment doors were not single motion doorknobs and common bathrooms had deadbolt locks accessible to residents, violating life safety code.
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