Inspection Report
Routine
Deficiencies: 9
May 7, 2025
Visit Reason
The inspection was an unannounced routine inspection conducted to assess compliance with assisted living facility regulations and licensing requirements.
Findings
The inspection identified nine rule noncompliances, including deficiencies in employee training, medication error reporting, emergency preparedness drills, maintenance, and documentation. Several areas such as medication administration, resident rights, and emergency plans showed gaps in compliance.
Deficiencies (9)
| Description |
|---|
| One employee did not receive documented annual in-service training in 2024. |
| The administrator did not complete the required four hours of core competency training including Alzheimer's specific training. |
| Emergency evacuation plans for two residents were not integrated into the resident's service plan. |
| No medication error reports were completed for 2025 despite medication errors occurring. |
| Missing fire drills for the prior four quarters and missing two documented disaster drills for the past year; employee participants were not included in documentation. |
| Preventative maintenance was not being maintained as required. |
| Two employees did not have the required information in DACS to initiate certification for direct patient access. |
| One employee did not have a signed BCI authorization form. |
| Medication change book with protected health information was left unattended on top of the medication cart; medication technician left the open MAR on the computer unattended. |
Report Facts
Number of rule noncompliances: 9
Missing fire drills: 4
Missing disaster drills: 2
Employees lacking DACS certification info: 2
Employees lacking signed BCI authorization: 1
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