Inspection Report
Annual Inspection
Deficiencies: 3
Jun 3, 2025
Visit Reason
Annual licensure survey conducted to assess compliance with state regulations including disaster preparedness, incident and accident reporting, and health care worker background checks.
Findings
The facility was found deficient in disaster preparedness drill documentation, incident and accident reporting for serious incidents, and compliance with health care worker background check requirements. Several violations were repeated or involved multiple employees and residents.
Severity Breakdown
Type 3 Violation: 2
Type 2 Violation: 1
Deficiencies (3)
| Description | Severity |
|---|---|
| Failure to identify residents who received assistance for evacuation in written drill evaluations. | Type 3 Violation |
| Failure to report serious incidents/accidents that resulted in physical harm or injury to the Department. | Type 3 Violation |
| Failure to comply with Health Care Worker Background Check Act and Code, including lack of documentation of registry searches prior to hiring and failure to provide annual employment verification for some employees. | Type 2 Violation |
Report Facts
Residents reviewed for incident reporting: 5
Employees reviewed for background check compliance: 9
Employees with missing annual employment verification: 2
Date of incidents not reported: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| E1 | Executive Director | Confirmed findings related to disaster preparedness and background check deficiencies |
| E2 | Director of Wellness | Confirmed incidents were not reported to the Department |
| E5 | Culinary Server | Employee record showed late Health Care Worker Registry search after date of hire |
| E7 | Certified Nursing Assistant | Lacked annual employment verification until updated after audit |
| E9 | Concierge | Lacked annual employment verification until updated after audit |
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