Inspection Report
Routine
Deficiencies: 10
May 21, 2024
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 12 rule noncompliances including failure to report an abuse investigation timely, missing core competency training for employees, incomplete resident assessments, inaccuracies in service plans, staffing issues in the secure unit, and deficiencies in the emergency and disaster preparedness plan.
Deficiencies (10)
| Description |
|---|
| Did not report suspected abuse in accordance with Section 62A-3-305; one abuse investigation dated 12/25/2023 was not reported to APS until 12/28/2023. |
| Core competency training not documented in 4 employees' files. |
| Multiple employees did not have in-service trainings relevant to their jobs. |
| Two residents in the secure unit did not have memory assessed on their resident assessments. |
| One resident's assessment was not accurate at the time of assessment (diet). |
| Service plan did not include the frequency of services. |
| On May 7, 8, 13, and 19, staff working at night were not certified nurse aides; no other staff with CNA qualifications were on duty. |
| Secured unit agreement does not state that the unit is locked. |
| Three employees who worked in the memory care unit on 5/21/2024 did not have 4 hours of the required 16 hours of one-on-one training in the secure unit. |
| Did not coordinate emergency and disaster plans with state and local authorities; plan lacked instructions on recruiting additional help and delivering essential care under emergency conditions. |
Report Facts
Number of rule noncompliances: 12
Employees missing core competency training: 4
Residents without memory assessment: 2
Employees missing secure unit training: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Todd Sherratt | Executive Director | Named as the individual informed of the inspection and involved in findings related to facility management. |
| Gordana S. | Licensor | Conducted the inspection. |
| Amelinda S. | Licensor | Conducted the inspection. |
| Brian H. | Licensor | Conducted the inspection. |
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