Inspection Reports for
The Fremont Senior Living

19 CSR 30-86.022(7)(E) Locked Exit Doors: The facility failed to provide delayed egress locks in compliance with NFPA 101 Section 7.2.1.6.1 and failed to ensure exit door locks did not require special knowledge or a code to unlock. Observation showed a magnetically locked exit door did not activate an audible signal, required a keypad code to open, and did not release with the required force.

19 CSR 30-86.047(37) Appropriate Action & Notification: Facility staff failed to promptly notify the resident's legally authorized representative about a medication change for Resident #1, and the facility did not provide a policy regarding notifications of medication changes.

19 CSR 30-86.047(46) Safe & Effective Medication System: Facility staff requested and administered a medication that contained a drug on Resident #1's allergy list and failed to ensure a safe and effective medication system related to resident allergies.

19 CSR 30-86.047(35) Protective Oversight: Based on interview and record review, facility staff failed to provide twenty-four hour protective oversight for one resident when staff entered the facility without ensuring doors were closed allowing the resident to leave, and staff failed to consistently document monitoring of wander guard placement.

19 CSR 30-88.010(29) Dignity/Privacy: Based on interview and record review, staff failed to treat residents with consideration and respect when a staff member yelled at Resident #1 who was pushing Resident #2 in a wheelchair and CNA B threatened Resident #1; interviews and record review support the finding.

19 CSR 30-86.022(7)(D)(1 - 8) Area of Refuge Requirements: Based on observation and interview on April 6, 2022, the facility failed to provide a two-way communication system between the area of refuge and a remote/monitored area; call buttons did not operate properly during observed tests, affecting all residents.

19 CSR 30-86.022(7)(E) Locked Exit Doors: Based on observation, review and interview on April 6, 2022, the facility failed to provide delayed egress/exit door arrangements in compliance with NFPA 101; multiple exit doors and courtyard gates required special knowledge or codes to exit and lacked required emergency signage, creating a hazard.

19 CSR 30-86.022(11)(E) Sprinkler System, Res. Impaired, Multilevel: Based on observation and interview on April 6, 2022, the facility failed to maintain a complete sprinkler system in accordance with NFPA standards; several sprinkler heads were corroded or painted and may not operate as designed in the event of a fire.

19 CSR 30-86.047(35) Protective Oversight: Based on observation, interview and record review, facility staff failed to provide protective oversight for one resident (Resident #1) when the resident suffered first- and second-degree burns after hot cocoa/hot water was maintained and served at an unsafe (high) temperature.

19 CSR 30-86.022(10)(B) Combustible Materials, Unnecessary Storage Of: The surveyor observed containers of chafing fuel stored under the enclosed fire stairs, constituting storage of unnecessary combustible materials; the observation noted forty-two (42) 7.14 FL OZ containers of chafing fuel in the storage area.

19 CSR 30-86.022(10)(I) Smoke Section Partitions > than 20 beds: The facility failed to install one-hour fire-rated smoke partitions from floor-to-roof deck; smoke partitions observed in the attic were constructed of chip-board and were not one-hour fire-rated, allowing potential spread of fire and gases throughout the attic.

19 CSR 30-86.032(10) Heaters-Approved Label, Venting, No Portable: A portable electric space heater was observed behind the reception desk in the front lobby area, indicating use of a portable heater within the facility.

19 CSR 30-86.047(28)(F)(1)(C) Community Based Assessment-Significant Change: Facility staff failed to update the residents' Community Based Assessments when two residents experienced significant changes in condition.

19 CSR 30-86.047(28)(H) Individual Service Plan - Review Requirements: The facility failed to complete or timely update individualized service plans on a change of condition for two of three sampled residents.

19 CSR 30-86.047(47)(A) Physicians Orders Followed: The facility failed to ensure physician orders were complete and current and failed to transcribe physician orders related to Foley catheter care for sampled residents.