Inspection Report
Annual Inspection
Deficiencies: 3
Sep 3, 2024
Visit Reason
Annual licensure survey conducted to assess compliance with residency requirements, service plan development, Alzheimer's and dementia program training, and other regulatory standards.
Findings
The facility was found to have multiple deficiencies including acceptance of a resident requiring extensive assistance beyond licensed services, failure to revise service plans addressing falls, oxygen use, catheter care, and failure to provide required dementia-specific staff training. These deficiencies were classified as Level 2 and Level 3 violations.
Severity Breakdown
Level 3: 2
Level 2: 1
Deficiencies (3)
| Description | Severity |
|---|---|
| Accepted a resident requiring extensive assistance with activities of daily living on hospice care beyond licensed services. | Level 3 |
| Failed to develop and mutually agree upon a comprehensive service plan addressing fall interventions, oxygen therapy, and catheter care for residents. | Level 2 |
| Failed to provide required dementia-specific orientation and ongoing training to staff, including 4 hours of dementia-specific orientation, 16 hours of on-the-job training for new direct care staff, and 12 hours of annual dementia training for existing staff. | Level 3 |
Report Facts
Residents reviewed for residency requirements: 3
Dialysis frequency: 3
Fall incident date: May 8, 2024
Newly hired employees reviewed: 6
Employees hired over a year ago reviewed: 2
Employees lacking dementia-specific orientation: 3
Newly hired direct care employees lacking on-the-job training: 3
Employees lacking annual dementia training: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| E10 | Health and Wellness Director | Named in findings related to unawareness of residency requirements and inability to explain missing service plan details and training documentation. |
| E9 | Business Office Manager | Involved in review of personnel files for dementia training compliance. |
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