Inspection Reports for Five Acres at Leisure Town North

The inspection was an unannounced required annual inspection conducted to evaluate compliance with licensing requirements for the Residential Care Facility for the Elderly.

The facility was found to be clean, in good repair, and compliant with safety and health regulations. No deficiencies or citations were issued during the visit. Medication storage, resident and staff records, and facility conditions met all requirements.

The inspection was conducted unannounced regarding an incident filed on 2024-05-31.

The facility was found to be clean and well-maintained, with residents well-cared for and appropriately dressed. There were no citations issued, and the staff member named in the incident report had been terminated.

Inspection was triggered by a complaint incident filed on 05/31/2024. The staff member named in the incident report was terminated. No citations were issued.

An unannounced Annual Required – 1 year inspection visit was conducted to evaluate compliance with licensing regulations and facility standards.

The facility was found to be clean, safe, and compliant with regulations including fire safety, food supply, medication security, and staff training. One technical violation was issued for a resident's medical assessment needing an update. No deficiencies were cited during the visit.

The visit was an unannounced Case Management visit to clear the Plan of Correction (POC) from the previous visit on 06/03/2024.

The Licensing Program Analyst reviewed three employee files and found that training records were complete. The administrator completed the requirements for clearing the Plan of Correction. No deficiencies were cited during this visit.

The inspection was an unannounced complaint investigation visit triggered by allegations received on 2024-03-14 regarding staff training to administer medications, resident care practices, medication security, staff background clearance, and administrator certification.

The investigation substantiated that staff were not properly trained to administer medications due to incomplete training records. Other allegations including residents being left in bed for extended periods, improper medication locking, staff background clearance, and administrator certification were found to be unsubstantiated.

The complaint investigation was substantiated for the allegation that staff were not properly trained to administer medications. Other allegations regarding residents left in bed for extended periods, medication security, staff background clearance, and administrator certification were unsubstantiated.

An unannounced Annual Required 1-year inspection visit was conducted to evaluate the facility's compliance with licensing regulations.

The facility was found to be clean, well-maintained, and in compliance with safety and health regulations. No deficiencies were cited during the visit, though technical advisories were issued regarding medication destruction training and staff annual training plans.

An unannounced annual required infection control inspection was conducted to evaluate the infection control procedures and practices of the facility.

The facility was found to be clean, with proper infection control measures in place including PPE supplies, approved Covid Mitigation plan, and secure medication storage. No deficiencies or citations were found during the inspection.

The visit was an unannounced collateral visit to review and obtain facility records concerning a former resident.

No deficiencies were cited during the visit. A walk-through of the facility was conducted and an exit interview was held with the administrator.

The visit was an unannounced collateral visit to review and obtain facility records concerning a former resident.

No deficiencies were cited during the visit. The Licensing Program Analyst met with a facility representative and discussed the report with the administrator by telephone.

The inspection was a Post Licensing unannounced visit focused on Infection Control procedures and practices of the facility.

The facility was found to have appropriate infection control measures including visitor screening, PPE supplies, staff training, and environmental cleaning. No deficiencies were cited during the visit.

The inspection was conducted as a Pre-Licensing visit to evaluate the facility prior to issuing a license.

The facility was found to be clean, organized, and in good repair with all required furnishings and safety features in place. No deficiencies were cited during the visit.

Initial licensing evaluation conducted via telephone call with the applicant/administrator to verify identity and confirm understanding of Title 22 regulations and facility operation requirements.

The applicant/administrator successfully completed Component II of the licensing process, demonstrating understanding of facility operation, staff qualifications, program policies, and application document requirements.