Inspection Reports for
The Cordwainer

Incident reporting: The Residence filed 36 incident reports greater than 24 hours after the occurrence of the incident during the period reviewed.

Emergency call response: In the month of September 2024 there were 25 e-call response times over the eight minutes required by the Residence policy.

Resident screening and assessment: Four records were without documentation to confirm the initial assessment was conducted by a nurse.

Quality assurance program: Documentation of Service Plan reviews for calendar years 2023 and 2024 were missing the target date for follow-up action and clear documented outcomes. Documentation of the Safety Policy and Procedures review for calendar years 2023 and 2024 were missing the target date for follow-up action and staff responsible for follow-up. The Residence was missing the follow up action for set target date, staff responsible for follow-up and clear documented outcomes in the last quarter of calendar year 2022 and for calendar years 2023 and 2024. One Resident had one PRN pharmacy filled medication bubble pack with a compromised hole punch on one date. Two Resident’s had one PRN pharmacy filled medication bubble pack with a compromised slice on one date.