Deficiencies per Year
4
3
2
1
0
High
Moderate
Unclassified
Inspection Report
Biennial Survey
Census: 8
Capacity: 10
Deficiencies: 4
Jan 27, 2025
Visit Reason
The inspection was a biennial survey to assess compliance with regulations governing Level IV Residential Care Facilities and Infection Prevention and Control.
Findings
The facility was found not in compliance with medication administration and documentation requirements, specifically related to psychotropic medication orders, documentation, and administration for one resident. There were discrepancies in medication orders, lack of timely reorders, and incorrect transcription of medication administration records.
Severity Breakdown
Classes I/II/III: 1
Class III: 1
Deficiencies (4)
| Description | Severity |
|---|---|
| Failure to use safe and acceptable methods and procedures for receiving, administering, documenting, and discontinuing psychotropic medication for one resident. | Classes I/II/III |
| Medication orders not in writing, signed, and dated within required timeframes; psychotropic medication orders not reissued every three months as required. | — |
| Lack of documented evidence of current psychotropic medication order within three months for one resident. | — |
| Medication administration records did not include all treatments and medications ordered by licensed practitioner; incorrect transcription of medication orders on MAR. | Class III |
Report Facts
Resident census: 8
Total capacity: 10
Medication order dates: Jan 27, 2024
Medication order dates: Apr 30, 2024
Medication order dates: Feb 20, 2024
Medication administration record review period: 203
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Julianne Benecke | Administrator | Named as facility administrator on report |
| Manager | Facility Manager involved in confirming findings and contacting pharmacy |
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