Inspection Report
Routine
Capacity: 79
Deficiencies: 13
Oct 7, 2024
Visit Reason
Unannounced routine inspection conducted to assess compliance with assisted living facility regulations and licensing requirements.
Findings
The inspection identified 18 rule noncompliances including deficiencies in quality assurance meetings, employee orientation and training, medication administration delegation, food handler permits, fire drills, pet vaccinations, and maintenance issues such as unsecured CO2 tanks.
Deficiencies (13)
| Description |
|---|
| Quality assurance committee did not meet during the 3rd quarter of 2024 and the 4th quarter of 2023. |
| Three employees did not receive documented orientation and department-approved core competency training. |
| Five employees lacked documented in-service training relevant to their job responsibilities. |
| One administrator did not complete minimum four hours of core competency training including dementia and Alzheimer's specific training. |
| One employee was not delegated by a licensed health care professional to administer medication to residents. |
| One employee who served or prepared food did not have a current food handler's permit. |
| Missing fire drills for AM and Graveyard shifts for 2nd and 3rd quarters of 2024. |
| Facility was unable to provide vaccination records for five pets. |
| Two CO2 tanks in the kitchen were not secured. |
| Two employees did not sign a criminal background screening authorization form available for review. |
| One resident required total assistance in more than three ADLs and was not able to evacuate with limited assistance of one person. |
| Two resident assessments were not accurate at the time of assessment; one resident assessment was not completed after a significant change; one resident's service plan was not revised to include home health. |
| Scissors were found in the kitchenette on the second floor in an unsecured drawer. |
Report Facts
Number of rule noncompliances: 18
Total licensed capacity: 79
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