4 Reports
Inspection Report — Apr 18, 2018
Renewal
Date: Apr 18, 2018
Visit Reason
The survey was conducted as a renewal inspection to assess compliance with licensing requirements.
Findings
Two deficiencies were identified related to resident service plans and bathroom hygiene. The facility neglected required annual assessments for residents and had a cross-contamination risk due to shared towels in a bathroom.
Deficiencies (2)
37.106.2822-3 Resident service plan: category A: the facility failed to conduct required annual assessments and service plans for residents in 2016 and 2017.
37.106.2838-3 Resident toilets and bathing: a bathroom used by three residents had towels on shared towel bars, posing a cross-contamination risk.
Inspection Report — Apr 19, 2016
Renewal
Date: Apr 19, 2016
Visit Reason
The facility underwent a routine renewal inspection as part of its licensing requirements.
Findings
Three deficiencies were identified related to disaster planning, employee files, and resident toilets and bathing facilities. Each deficiency corresponds to a specific rule violation noted during the inspection.
Deficiencies (3)
37.106.322-1 Minimum standards for all health care facilities: disaster plan: the facility's disaster plan was incomplete and lacked procedures for staff notification during emergencies.
37.106.2817-1 Employee files: several employee files were missing required documentation such as background checks and training records.
37.106.2838-7 Resident toilets and bathing: some resident bathrooms were not maintained in a clean and safe condition, posing a risk to residents.
Inspection Report — May 5, 2015
Renewal
Date: May 5, 2015
Visit Reason
The survey was conducted as a renewal inspection to assess compliance with licensing requirements.
Findings
The facility lacked updated written policies and procedures, incomplete staff background documentation, missing resident application details, and inadequate resident service plan reviews. Medication storage and administration policies were deficient, and the physical plant maintenance program was not established with unsafe water temperatures noted.
Deficiencies (9)
37.106.2815-1 Written policies and procedures: the policy and procedure manual had no documentation of review or revision in the past four years and lacked policies on assessment processes for pre-move in, annual, and change of condition.
37.106.2816-2 Assisted living facility staffing: five direct care staff files lacked documentation of background information to ensure they do not pose a risk to resident health or safety.
37.106.2821-1 Resident application and needs assessment: two residents did not have applications in their files and three closed files lacked sex and marital status information.
37.106.2822-1 Resident service plan: category A: eleven open and three closed resident files lacked evidence of the required 60-day review of initial service plans.
37.106.2822-3 Resident service plan: category A: seven residents residing more than a year did not have their needs assessments and service plans reviewed and updated as required.
37.106.2846-5 Medications: storage and disposal: the facility had not developed or implemented a policy for lawful disposal of unused, outdated, discontinued, or recalled medications.
37.106.2848-4 Medications: administration and preparation: nine residents did not have physician orders for medications, and medication orders signed by physicians were kept by pharmacy staff and not sent to the facility.
37.106.320-1 Minimum standards for all health care facilities: the facility did not have a written maintenance program as required.
37.106.320-7 Minimum standards for all health care facilities: physical plant and equipment maintenance: water temperatures in bathroom sinks were excessively high, ranging from 123.4°F to 129°F.
Report Facts
temperature: 129
temperature: 123.4
temperature: 125.6
Inspection Report — Apr 15, 2014
Renewal
Date: Apr 15, 2014
Visit Reason
The survey was conducted as a renewal inspection of the assisted living facility.
Findings
Two deficiencies were identified: the facility lacked a policy for screening employees for risk to residents, and water temperature in a public bathroom was excessively hot at 147 degrees Fahrenheit.
Deficiencies (2)
37.106.2816-1 Assisted living facility staffing: no policy was found regarding screening, hiring, and assessing employees for risk or threat to the health, safety, or welfare of the residents.
37.106.2865-12 Physical plant: water in a public/resident bathroom was tested and found to be very hot at 147 degrees Fahrenheit, posing a safety risk.
Report Facts
temperature: 147
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