Deficiencies per Year
12
9
6
3
0
Unclassified
Inspection Report
Routine
Deficiencies: 12
Dec 27, 2023
Visit Reason
The inspection was an unannounced routine compliance review of the Family Tree of West Point assisted living facility to assess adherence to licensing rules and regulations.
Findings
The inspection identified 12 rule noncompliances across various regulatory areas including licensing, administrator duties, personnel qualifications, resident rights, medication administration, and emergency preparedness. Several areas were found compliant, while some deficiencies were noted and documented.
Deficiencies (12)
| Description |
|---|
| The licensee failed to implement a quality assurance program including a quality assurance committee. |
| The licensee failed to ensure employee health screening and immunization components of the personnel health program. |
| The licensee failed to ensure medications requiring refrigeration were stored at proper temperatures between 36 - 46 degrees Fahrenheit. |
| The licensee failed to ensure a type I assisted living licensee provides or contracts with a registered nurse to provide or delegate medication administration for residents who cannot self-medicate or self-direct medication management. |
| The licensee failed to ensure a type II assisted living licensee employs or contracts with a registered nurse to provide or supervise nursing services to include nursing assessments and general health monitoring. |
| The licensee failed to ensure a type II assisted living licensee with approved secure units admits residents with a diagnosis of Alzheimer's or dementia only if they can exit the facility with limited assistance from one person. |
| The licensee failed to ensure the administrator implements a quality assurance program and meets quarterly to identify and act on quality issues. |
| The licensee failed to ensure the administrator or designee annually reviews emergency procedures and conducts unannounced drills as required. |
| The licensee failed to ensure the emergency and disaster response plan addresses all required elements including evacuation procedures and assignment of personnel. |
| The licensee failed to ensure housekeeping staff are trained regarding cleaning procedures and proper handling of soiled linen and waste. |
| The licensee failed to ensure hot water temperature controls automatically regulate water temperatures between 105 - 120 degrees Fahrenheit. |
| The licensee failed to ensure medication error incident reports are completed if a medication error occurs or is identified. |
Report Facts
Number of rule noncompliances: 12
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Danielle McKissen | Licensor | One of the licensors conducting the inspection |
| Troy Knudsen | Licensor | One of the licensors conducting the inspection |
| Ken Newman | Licensor | One of the licensors conducting the inspection |
Inspection Report
Routine
Deficiencies: 12
Nov 6, 2023
Visit Reason
The inspection was a routine compliance check of the assisted living facility to assess adherence to licensing rules and regulations, including resident care, staff qualifications, safety, and facility operations.
Findings
The inspection checklist shows multiple areas assessed with compliance, non-compliance, and not assessed statuses. Several rules were marked as non-compliant, indicating deficiencies in areas such as provider duties, employee training, resident rights, medication administration, and facility safety. No specific enforcement or penalty details are provided.
Deficiencies (12)
| Description |
|---|
| Failure to ensure identification badges included required information. |
| Provider did not fully protect clients from abuse, neglect, exploitation, and mistreatment. |
| Non-compliance with policy procedures and employee training requirements. |
| Failure to maintain required staff qualifications and training. |
| Non-compliance with resident rights and admission procedures. |
| Deficiencies in resident assessments and service plans. |
| Failure to maintain accurate medication administration records and procedures. |
| Non-compliance with financial management and resident funds handling. |
| Failure to maintain adequate food service and sanitation standards. |
| Non-compliance with housekeeping, laundry, and maintenance services. |
| Failure to maintain emergency preparedness and disaster plans. |
| Non-compliance with licensing and administrative requirements. |
Report Facts
Deficiencies cited: 163
Compliance marks: 75
Not assessed: 238
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