6 Reports
Inspection Report — Nov 21, 2024
Renewal
Date: Nov 21, 2024
Visit Reason
The recertification visit was conducted to determine compliance with certification of an Assisted Living Program.
Findings
During the recertification visit, investigation #118642-C was also completed and no regulatory insufficiencies were cited as a result.
Report Facts
Number of tenants without cognitive impairment: 55
Number of tenants with cognitive impairment: 4
Inspection Report — Mar 6, 2024
Renewal
Date: Mar 6, 2024
Visit Reason
The visit was a recertification conducted to determine compliance with certification for an Assisted Living Program. The investigation of Complaint #114732-C was also conducted during this visit.
Complaint Details
Complaint #114732-C was investigated and no deficiencies were cited.
Findings
No regulatory insufficiencies were cited during the recertification visit. There were no deficiencies cited during the investigation of Complaint #114732-C.
Inspection Report — Aug 16, 2022
Renewal
Date: Aug 16, 2022
Visit Reason
The visit was a renewal (recertification) visit that also investigated Complaint #100681-C.
Complaint Details
Complaint #100681-C was investigated during the on-site visit with no regulatory insufficiencies cited.
Findings
No regulatory insufficiencies were cited during the complaint investigation.
Inspection Report — Aug 12, 2021
Renewal
Date: Aug 12, 2021
Visit Reason
The inspection was conducted as part of the recertification (renewal) of the Assisted Living Program to assess regulatory compliance.
Findings
A regulatory insufficiency was cited related to service plans: the program failed to ensure that a preliminary service plan was developed and signed prior to the tenant signing the occupancy agreement and taking occupancy. Specifically, Tenant #1's service plan was not signed before occupancy, and the occupancy agreement was signed prior to the service plan development.
Violations (1)
Failure to develop and sign a preliminary service plan prior to tenant signing occupancy agreement and taking occupancy for 1 of 3 tenants reviewed.
Report Facts
Number of tenants without cognitive disorder: 26
Number of tenants with cognitive disorder: 1
Total population of program at time of on-site: 27
Inspection Report — Jul 28, 2021
Renewal
Date: Jul 28, 2021
Visit Reason
The visit was a recertification visit to determine compliance with certification of an Assisted Living Program. The visit also included investigations of Complaint #93456-C and Complaint #94003-C, as well as an onsite infection control survey.
Complaint Details
Complaint #97534-C was investigated with no insufficiencies cited. Complaints #93456-C and #94003-C were investigated and regulatory insufficiencies were cited.
Findings
Regulatory insufficiencies were cited during the investigation of Complaints #93456-C and #94003-C and the infection control survey. No insufficiencies were cited during the recertification visit or the investigation of Complaint #97534-C.
Violations (4)
481-67.2(3) Program Policies and Procedures: The program failed to follow its policy and procedures regarding Covid-19 by not capturing and logging all visitor temperatures during the COVID restriction timeframe. Several visitor temperatures were not documented in the visitor log.
481-69.23(1)b Criteria for Admission / Retention of Tenants: The program failed to initiate a discharge or submit a waiver request when a tenant required routine two-person assistance with standing, transfer, or evacuation. Tenant #2's file showed no request for a waiver despite end of life care and increased assistance needs.
481-69.25(2) Tenant Documents: The program failed to retain records for a minimum of three years after the transfer or death of a tenant. Tenant #3's discharge records were destroyed except for nursing notes maintained on the computer.
481-69.25(1) Service Plans: The program failed to update service plans as needed. Tenant #1's service plan was not updated to reflect the need for a wheelchair, and Tenant #2's service plan was not updated based on changes in condition and increased assistance needs.
Inspection Report — Aug 26, 2020
Routine
Date: Aug 26, 2020
Visit Reason
The inspection was conducted as an onsite infection control survey of the assisted living program.
Findings
There were no regulatory insufficiencies cited during the onsite infection control survey of the program.
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