Inspection Report
Complaint Investigation
Capacity: 56
Deficiencies: 8
Aug 23, 2024
Visit Reason
State-compiled facility profile showing 5 inspections from 2023-05-02 to 2024-08-23 with complaint investigation and compliance findings.
Findings
Across five inspections, multiple deficiencies were cited primarily related to emergency responder documentation, medication administration compliance, service plan development, resident care documentation, and evacuation drills. Two inspections found no deficiencies.
Complaint Details
Multiple complaint investigations were conducted on 2023-05-02, 2023-09-25 to 09-27, 2024-06-13, 2024-08-14, and 2024-08-23 with deficiencies cited in four inspections and no deficiencies in one.
Deficiencies (8)
| Description |
|---|
| 36-420.04. Emergency responders; patient information; hospitals; discharge planning; patient screenings; discharge document: Failed to provide emergency responders with all required written documentation including reason for call and HIPAA release. |
| B. If an assisted living facility provides medication administration, a manager shall ensure that: 3.b. A medication administered to a resident is administered in compliance with a medication order: Failed to ensure medication was administered in compliance with the order for one resident. |
| A. Except as required in subsection (B), a manager shall ensure that a resident has a written service plan that: 2.a. Is developed with assistance and review from the resident's representative: Failed to ensure service plans were developed with assistance and review from resident representatives for six residents. |
| B. A manager of an assisted living facility authorized to provide directed care services shall not accept or retain a resident who: 1. Is confined to a bed or chair because of an inability to ambulate even with assistance; or 2. Has a stage 3 or stage 4 pressure sore: Failed to ensure current medical examinations every six months for a non-ambulatory resident. |
| C. In addition to the requirements in R9-10-808(A)(3), a manager shall ensure that the service plan for a resident receiving directed care services includes: 2. If applicable, the determination in R9-10-814(B)(2)(b)(iii): Failed to include required determination in service plan for a non-ambulatory resident. |
| E. A manager shall ensure that: 1. A bell, intercom, or other mechanical means to alert employees to a resident's needs or emergencies is available in a bedroom being used by a resident receiving directed care services: Failed to ensure call bells or mechanical alert means were available in some resident rooms. |
| B. If an assisted living facility provides medication administration, a manager shall ensure that: 3.b. A medication administered to a resident is administered in compliance with a medication order: Failed to ensure medication Metoprolol was administered in compliance with medication order. |
| A. A manager shall ensure that 5. An evacuation drill for employees and residents: a. Is conducted at least once every six months; and b. Includes all individuals on the premises except for specified exceptions: Failed to conduct and document evacuation drills at least once every six months. |
Report Facts
Inspections on page: 5
Total deficiencies: 8
Complaint Inspections: 5
Total Capacity: 56
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| E1 | Acknowledged deficiencies related to emergency responder documentation, service plans, call bells, medication administration, and evacuation drills. | |
| E2 | Confirmed medication administration issues and service plan deficiencies. | |
| Compliance Officer | Requested documentation related to emergency responder contact. |
Loading inspection reports...
