Inspection Report
Routine
Census: 8
Deficiencies: 3
Jan 5, 2023
Visit Reason
An unannounced biennial State Licensure survey was conducted at this assisted living residence to assess compliance with State Licensure requirements.
Findings
Deficiencies were identified related to the facility's licensure level and medication services. Specifically, the residence failed to retain residents according to its licensed level, did not have a limited health license, and had expired medications in the medication cart.
Deficiencies (3)
| Description |
|---|
| The residence failed to retain residents according to the level of licensure for which it has been licensed, as evidenced by 3 sample residents reviewed. |
| The residence does not have a license to provide limited health services but provided wound care and medication services inconsistent with licensure. |
| Expired medications were found in the medication cart including Antacid 750 MG, Acetaminophen 500 MG, Natural Antacid 1000 MG, and Bisac-Evac 10 MG suppository. |
Report Facts
Census: 8
Sample residents reviewed: 3
Inspection Report
Plan of Correction
Deficiencies: 4
Mar 4, 2021
Visit Reason
An unannounced biennial State Licensure survey and a complaint/incident investigation survey were conducted at the facility on 03/04/2021.
Findings
Deficiencies were identified related to management of services, resident assessments and service plans, medication administration, and medication storage and documentation. Specific issues included failure to monitor and document elevated blood pressure for a resident, incomplete nurse reviews, incomplete service plan updates, and medication errors including expired medications and discrepancies between medication orders and administration records.
Deficiencies (4)
| Description |
|---|
| Failure to provide all care and services in accordance with the prevailing community standard of care related to monitoring of blood pressure for Resident ID #1. |
| Failure to ensure nurse reviews held required components for four residents. |
| Failure to document a description of services and interventions needed including outside healthcare services for Resident ID #2. |
| Failure to ensure medication administration in accordance with physician orders and proper medication storage for Residents #1, 2, and 3. |
Report Facts
Number of residents with nurse review deficiencies: 4
Number of residents with medication storage deficiencies: 3
Date of survey completion: Mar 4, 2021
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Acknowledged Resident ID #1's elevated blood pressure was not addressed from February 2020 through March 2021; acknowledged outside services and discharge were not documented on Resident ID #2's service plan; acknowledged MAR discrepancies for Residents #1, 2, and 3. | |
| Staff A, Licensed Practical Nurse | Indicated vital signs are taken monthly and retaken if abnormal; was not aware of Resident ID #1's elevated blood pressure over the last thirteen months. | |
| Staff B, Certified Medication Technician/House Manager | Observed expired medication in medication storage cabinet. | |
| Staff C | Acknowledged discrepancies in medication labels and MARs; indicated Staff D fills pillboxes weekly. | |
| Staff D, Certified Medication Technician | Fills pillboxes weekly and administers medications. |
Inspection Report
Complaint Investigation
Deficiencies: 0
Mar 4, 2021
Visit Reason
A complaint/incident investigation survey and an unannounced biennial State Licensure survey were conducted at the facility.
Findings
No deficiencies were identified relative to the complaint investigation survey.
Complaint Details
The complaint investigation survey found no deficiencies and was unsubstantiated.
Inspection Report
Abbreviated Survey
Deficiencies: 1
Jan 7, 2021
Visit Reason
An unannounced focused survey was conducted related to COVID-19 infection control at the residence.
Findings
The facility failed to establish infection control provisions for the mutual protection of residents, employees, and the public relative to COVID-19 standards. Observations included staff not wearing facemasks properly and cloth masks being worn instead of surgical masks as required.
Deficiencies (1)
| Description |
|---|
| Failure to establish infection control provisions for mutual protection relative to COVID-19 standards, including improper mask use by staff. |
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