Deficiencies per Year
28
21
14
7
0
Unclassified
Inspection Report
Routine
Deficiencies: 26
Dec 13, 2023
Visit Reason
The inspection was an unannounced routine inspection of the Legacy House of Park Lane assisted living facility to assess compliance with licensing rules and regulations.
Findings
The inspection identified 22 rule noncompliances, including issues with employee orientation, tuberculosis screening, medication administration, housekeeping, maintenance, emergency preparedness, and resident rights. Several deficiencies were noted with corrective actions required.
Deficiencies (26)
| Description |
|---|
| 2 employees did not receive orientation within 30 days of hire including ethics, confidentiality, resident rights, abuse reporting, policies and procedures and core competency. |
| 1 employee did not have record of a tuberculosis screening in their file. |
| Resident assessment did not include information on HH for 1 resident. Resident assessment included Hospice services, including assistance with bathing and hygiene through Hospice, instead of Hospice services. |
| 1 Resident in Secure Unit had a significant change (decline) and assessment was not updated to reflect the change. |
| 2 Residents' service plans did not match resident assessment on medication administration frequency, 1 resident did not match assessment on services provided by. Assessment was not used to develop or revise the service plan. |
| This is a Type II facility. Nursing services deficiencies related to nursing care and supervision were cited. |
| 2 employees did not receive medications as ordered. |
| The QA meeting notes did not include report on the med. errors for the first and third quarter of 2023. |
| Records with resident first and last names and room numbers were accessible in the unlocked laundry room across the hall from the kitchen. |
| 3 employees did not have applications retained in their files, and 2 employees did not have core competency training retained in their files. 2 employees did not have documented their reason for leaving in their files. |
| 2 unsecured CO2 tanks observed in kitchen dry storage area. |
| 4 containers of cleaning agents and poisonous material were observed in an unlocked closet in the "Belmont Room" on the first floor. Sanitizing spray and detergent observed under unsecured kitchen sink in secure unit. The laundry room across from the kitchen was unlocked and accessible. 2 containers of cleaning agents were observed in an unlocked cabinet in a 2nd floor laundry room. |
| Fire drills do not include residents ability to evacuate. No Semi-annual disaster drills. |
| No Respite services at this time. |
| Do not offer Adult day care. |
| This facility does not manage any residents' funds. |
| Housekeeping deficiencies related to staff, cleaning schedules, odors, trash containers, and cleaning agents storage were cited. |
| Laundry services deficiencies related to laundry policy, supplies, and equipment were cited. |
| Maintenance deficiencies related to equipment, pest control, hot water temperature, and water temperature regulation were cited. |
| Emergency preparedness deficiencies related to emergency plans, staff training, drills, and emergency equipment were cited. |
| Food service deficiencies related to meal provision, menu planning, dietitian consultation, and food service sanitation were cited. |
| Pets are allowed but must be kept clean and disease-free; aggressive pets are not permitted. |
| Respite services are not currently offered. |
| DACS process deficiencies related to fingerprinting, certification, and engagement status were cited. |
| Director and staff training, incident reporting, and resident service plan documentation deficiencies were cited. |
| Medication administration deficiencies including documentation, administration, and error reporting were cited. |
Report Facts
Number of rule noncompliances: 22
Containers of cleaning agents: 4
CO2 tanks: 2
Unsecured CO2 tanks: 2
Rule noncompliances: 22
Inspection start time: 9:15
Inspection end time: 16:15
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Ryan Jensen | Individual Informed of Inspection | Named as individual informed during inspection |
| Brian Neugly | Licensor | Conducted the inspection |
| Amelinda Spek | Licensor | Conducted the inspection |
| Gordana Sabanovic | Licensor | Conducted the inspection |
| April Charsen | Licensor | Conducted the inspection |
| Ken Newman | Licensor | Conducted the inspection |
| Brian Palmer | Licensor | Conducted the inspection |
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