Inspection Reports for
Lake George Senior Living

19 CSR 30-86.022(14)(A) Smoking in Designated Areas & Supervised Smoking: Based on observation, interview, and record review, facility staff failed to provide non-combustible ashtrays and non-combustible receptacles to dispose cigarette butts in two areas used for smoking, and Resident #1 was observed smoking in his/her bedroom.

19 CSR 30-86.047(35) Protective Oversight: Based on observation, interview, and record review, facility staff failed to assess Resident #1 to determine if the resident could smoke safely without staff supervision and the resident's record did not contain a smoking assessment or an approval order for smoking; oxygen equipment and a lit cigarette were observed in the resident's room.

19 CSR 30-86.022(9)(C) Fire Alarm System-Test/Maintain: Based on record review and interview during a fire safety inspection on November 4, 2024, the facility failed to ensure the complete fire alarm system was tested and maintained in accordance with NFPA 72; no semi-annual inspection records were available and the deficiency affected 9 out of 9 residents.

19 CSR 30-86.047(46) Safe & Effective Medication System: Based on observations, interviews and record reviews, facility staff failed to provide a safe and effective medication administration system when staff did not notify a resident's physician of a medication error, medications were not available from the pharmacy, staff administered incorrect doses, and staff failed to document administration of a fentanyl patch.

19 CSR 30-88.047(19) TB Screen Residents & Staff: Based on record review and interview the facility failed to screen two of three sampled employees (Director of Nursing and Dietary Cook) and two of three sampled residents for tuberculosis and the DON's personnel record did not contain documentation of a required second TST.

19 CSR 30-88.047(20)(1) Personnel Record-physician statement, employ: Based on interview and record review the facility failed to ensure three newly hired employees (Director of Nursing, Certified Medication Aide and Dietary Cook A) had a written statement signed by a physician or physician's designee indicating they could work in a long-term care facility and any limitations.

19 CSR 30-88.010(4) Resident Rights-Admission/Annual Review: Based on record review and interview the facility failed to complete annual documentation of residents' rights and responsibilities for sampled residents; records for Resident #1 and Resident #2 did not contain annual documentation of residents' rights and responsibilities.

19 CSR 30-86.022(5)(D) Fire Drill Requirements, Evacuation: Based on record review and interview during the fire safety portion of the licensure inspection on October 7, 2019, the facility failed to conduct required fire drills every three months on each shift, affecting nine residents.

19 CSR 30-86.022(9)(C) Fire Alarm System-Test/Maintain: Based on record review and interview during the fire safety portion of the licensure inspection on October 7, 2019, the facility did not have documentation of required semi-annual fire alarm inspections.

19 CSR 30-86.022(9)(C) Fire Alarm System-Test/Maintain: Based on record review and interview during the fire safety portion of the licensure inspection, the facility failed to have the fire alarm system inspected semi-annually by the standards set by NFPA 72, 1999 edition and there was no documentation of a semi-annual inspection or the previous annual fire alarm inspection report.