Inspection Reports for
TJ’s Assisted Living & Memory Care

R9-10-806 — The manager failed to ensure a caregiver provided current documentation of CPR training including a demonstration of ability before providing assisted living services. This posed a risk if an employee was unable to meet a resident's needs during an emergency.

36-420.01 — The facility failed to administer a fall prevention and fall recovery training program for all staff, with missing documentation for employee E2 and acknowledgment from E1 that training was not administered.

36-420.04 — The manager failed to ensure resident records contained a standardized emergency responder patient information form for residents R1, R2, and R3, with E1 acknowledging the documentation was unavailable.

Policies and procedures review — The manager failed to ensure policies and procedures were reviewed at least once every three years, with last documented review in 2020 and no further evidence of updates.

Report submission — The manager failed to submit documented reports to the governing authority as required, with no reports available and E1 admitting to not completing them.

Documentation maintenance — The manager failed to maintain documentation of caregivers' work schedules after the last date, with E3's schedule not updated and E1 acknowledging missing documentation.

R9-10-113 — The manager failed to ensure records for individuals aged 12 or older who were not residents or staff contained evidence of freedom from infectious tuberculosis, with missing documentation for O1 and O2.

Resident service plans — The manager failed to ensure service plans were reviewed and updated at least every three months for residents receiving directed care, with R1's records lacking timely updates.

R9-10-814 — The manager failed to obtain documentation that non-ambulatory residents R1 and R3 or their representatives requested to remain in the facility and that their medical needs were met per the facility's scope of services.

Medication administration policies — The manager failed to ensure policies and procedures were reviewed and approved by a medical practitioner, registered nurse, or pharmacist, with no documentation found.

Medication storage — The manager failed to ensure medications were stored in a locked area, with observation of unlocked kitchen refrigerator containing multiple medications and E1 acknowledging the issue.

Disaster plan review — The manager failed to ensure the disaster plan was reviewed at least once every 12 months, with last review documented in March 2021 and no evidence of subsequent reviews.

Disaster drills — The manager failed to ensure disaster drills were conducted on each shift at least once every three months and documented, with last drill documented in December 2023 and no further evidence.

Evacuation drills — The manager failed to ensure evacuation drills for employees and residents were conducted at least once every six months, with last drill documented in December 2023 and no additional documentation.

Smoke detector testing — The manager failed to ensure smoke detectors were tested at least once a month, with missing documentation for February and March 2024 and E1 acknowledging the lack of records.

R9-10-113 — The manager failed to establish, document, and implement tuberculosis infection control activities, with missing policies and procedures and E1 acknowledging the absence of documentation.

R9-10-113 — The manager failed to provide annual training and education on tuberculosis signs and symptoms to employees, with missing training documentation for E1 and E2 and E1 acknowledging the lack.

R9-10-113 — The manager failed to annually assess the health care institution's risk of exposure to infectious tuberculosis, with no documentation found and E1 acknowledging the absence.