Deficiencies per Year
12
9
6
3
0
Unclassified
Inspection Report
Routine
Deficiencies: 9
Sep 23, 2024
Visit Reason
The inspection was an unannounced routine inspection conducted to review compliance with assisted living facility licensing rules and regulations.
Findings
The inspection identified nine rule noncompliances related to various operational areas including medication administration, emergency disaster planning, food handlers permits, and resident evacuation plans. Several deficiencies were noted such as missing medication delegation letters, inaccurate medication administration times, incomplete evacuation plans for hospice residents, and gaps in the emergency disaster plan.
Deficiencies (9)
| Description |
|---|
| One medication technician did not have a medication delegation letter in file. |
| One medication administered had an incorrect administration time that was not updated on the medication card. |
| Three resident evacuation plans were not incorporated into their service plans and did not accurately reflect their ability. |
| Two employees did not have food handlers permits on file. |
| Water temperature in the first floor resident laundry room and lobby exceeded the required maximum temperature (123.4°F and 123°F respectively). |
| The disaster plan did not include plans for severe weather, explosion, windstorm, epidemic, or mass casualty. |
| The emergency disaster plan lacked instructions on recruiting additional help, delivery of essential care by alternate means, care if additional persons housed during emergency, and care if personnel reduced by emergency. |
| Fire drills did not include resident documentation of participants and their ability to evacuate. |
| No written policies and procedures defining the level of nursing services provided by the facility. |
Report Facts
Number of rule noncompliances: 9
Water temperature: 123.4
Water temperature: 123
Medication administration time error: 1
Missing food handlers permits: 2
Resident evacuation plans missing: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Amberly Lindsay | Individual informed of the inspection. | |
| Gordana S. Troy | Licensor | Licensor conducting the inspection. |
| Brian H. | Licensor | Licensor conducting the inspection. |
| Jared B. | Licensor | Licensor conducting the inspection. |
| Mariah W. | Licensor | Licensor conducting the inspection. |
Loading inspection reports...
