Deficiencies per Year
12
9
6
3
0
Severe
High
Moderate
Unclassified
Inspection Report
Biennial Survey
Census: 39
Capacity: 40
Deficiencies: 11
Oct 2, 2024
Visit Reason
The inspection was a biennial survey conducted to assess compliance with the Regulations Governing the Licensing and Functioning of Assisted Housing Programs: Level IV Residential Care Facilities and Infection Prevention and Control.
Findings
The facility was found non-compliant in multiple areas including medication administration errors, improper medication storage, failure to review and approve orders within required timeframes, failure to remove discontinued medications, incomplete medication administration records, untimely incident report sign-offs, water temperature exceeding allowed limits, lack of annual boiler inspections, and maintenance issues with bedroom windows.
Severity Breakdown
Class I: 1
Class II: 1
Class III: 5
Deficiencies (11)
| Description | Severity |
|---|---|
| Failed to use safe and acceptable procedures for storage and administration of a resident’s medication (Resident #4). | Class I |
| Resident received incorrect dose of prescribed medication due to failure to follow licensed practitioner orders (Resident #4). | Class II |
| Resident’s discharging licensed practitioner orders from another facility were not reviewed and approved within 72 hours (Resident #1). | — |
| Resident medications were not stored separately in locked storage with proper labeling. | Class III |
| Discontinued medication was not removed from use and properly destroyed (Resident #1). | Class III |
| Medication/treatment administration records did not include all treatments ordered by licensed practitioner (Residents #2 and #4). | Class III |
| Medications were discontinued without evidence of a stop order and incorrect medication administration documentation (Resident #4). | Class III |
| Incident reports were not initialed by the Administrator within 72 hours of the incident. | — |
| Water temperature in resident areas exceeded 120 degrees Fahrenheit. | Class III |
| Facility failed to ensure fuel boilers were tagged as inspected annually. | — |
| Facility failed to ensure bedroom windows were maintained and operable. | — |
Report Facts
Incident reports not initialed timely: 20
Water temperature: 122.5
Census: 39
Total capacity: 40
Medication administration errors: 4
Bedroom windows tested: 6
Bedroom windows not opening: 4
Bedroom windows difficult to open: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Wendy Rider | Administrator | Named as Administrator responsible for facility and confirmed findings at exit interview. |
| Employee #8 | Confirmed medication administration errors related to Resident #4. | |
| Residential Care Director | RCD | Interviewed and confirmed multiple medication and storage deficiencies. |
| Maintenance Director | Confirmed lack of annual boiler inspections and window maintenance issues. | |
| Office Manager | Participated in exit interview confirming maintenance findings. |
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