3 Reports
Inspection Report — Dec 28, 2022
Renewal
Date: Dec 28, 2022
Visit Reason
Routine renewal inspection of the facility.
Findings
Eight deficiencies were identified including issues with locked exit doors, lack of disaster plan review documentation, missing administrator continuing education, incomplete resident weight documentation, absence of a monthly activities calendar, improper medication storage, medication record handling, and outdated fire inspection documentation.
Deficiencies (8)
37.106.302-2 Minimum standards of construction for a: two hallway doors labeled as exits had deadbolt locks requiring special knowledge or effort to open.
37.106.322-3 Minimum standards for all health care fa: there was no documentation of annual disaster plan review with staff.
37.106.2814-3 Administrator: the administrator's employee file lacked evidence of 16 contact hours of annual continued education for 2022.
37.106.2829-2 Resident file: there was no documentation that residents had weight taken on admission; this is a repeat deficiency.
37.106.2831-4 Resident activities: there was no developed or posted monthly group activities calendar or records for the past three months.
37.106.2846-1 Medications, storage and disposal: medications were pre-dispensed into portion cups ahead of time and not stored in pharmacy-dispensed containers.
37.106.2849-2 Medications, records and documentation: the administrator signed out medications for all residents and placed them in portion cups ahead of time for staff to dispense.
37.106.2866-7 Construction, building and fire codes: the facility's last documented annual fire inspection was conducted on 11/13/2020; this is a repeat deficiency.
Report Facts
date: Nov 13, 2020
date: Dec 13, 2019
integer: 16
Inspection Report — Dec 13, 2019
Renewal
Date: Dec 13, 2019
Visit Reason
Routine renewal inspection of the assisted living facility.
Findings
Ten deficiencies were identified related to policies, resident service plans, incident reporting, safety equipment, medication storage, oxygen use, housekeeping, physical plant conditions, and fire inspection documentation.
Deficiencies (10)
37.106.2815-1 Written policies and procedures: the policy and procedure manual had not been signed or dated as reviewed for any date.
37.106.2822-2 Resident service plan: category A: service plans did not indicate self-administration of medication or oxygen use and mobility aids for residents who self-administer medication and use oxygen.
37.106.2822-3 Resident service plan: category A: service plans for three residents lacked evidence of review or copies given to residents or responsible parties and were not signed by residents, responsible parties, or administrator.
37.106.2829-2 Resident file: incident reports for multiple residents did not document notification to the resident’s provider or the provider’s response.
37.106.2838-7 Resident toilets and bathing: call light strings in resident rooms and shower were wrapped or knotted, rendering the call system inoperable for individuals collapsed on the floor.
37.106.2846-3 Medications: storage and disposal: residents kept medication in unlocked and open bathroom doors and did not close or lock the room when gone.
37.106.2853-3 Oxygen use: a resident using oxygen did not have a 'No Smoking, Oxygen in Use' sign posted to the room.
37.106.2862-1 Housekeeping: the trash can in the laundry room did not have a lid.
37.106.2865-12 Physical plant: hot water temperatures in two resident rooms exceeded safe levels, measuring 130 and 126.5 degrees.
37.106.2866-7 Construction, building and fire codes: the administrator was unable to locate the 2019 fire inspection; the last documented inspection was in July 2018.
Report Facts
temperature: 130
temperature: 126.5
date: Jul 21, 2019
Inspection Report — Dec 4, 2018
Renewal
Date: Dec 4, 2018
Visit Reason
Routine renewal inspection of the assisted living facility.
Findings
Five deficiencies were identified related to employee files, resident files, furnishings, medication orders, and medication documentation.
Deficiencies (5)
37.106.2817-3 Employee files: the administrator and owner, working as direct caregivers, do not have employee files.
37.106.2829-2 Resident file: the file for a deceased resident is missing circumstances of final transfer, notice to responsible parties, and disposition of personal possessions and medications.
37.106.2836-1 Furnishings: no documentation was noted for flame resistant window treatments.
37.106.2847-1 Medications, practitioner orders: a resident did not receive scheduled 8AM medications by the time of survey, and the administrator left the facility with medication keys prior to survey.
37.106.2849-3 Medications, records and documentation: medication administration records are missing the signature page of staff members giving medications.
Viewing
Loading inspection reports...
