Deficiencies per Year
16
12
8
4
0
Unclassified
Inspection Report
Routine
Deficiencies: 16
May 6, 2024
Visit Reason
The inspection was an unannounced routine inspection conducted to review compliance with assisted living facility regulations and licensing requirements.
Findings
The inspection identified multiple rule noncompliances including deficiencies in administrator designation, employee orientation and training, maintenance issues such as non-working exit lights and fire door gaps, incomplete emergency and disaster response plans, missing documentation for resident transfers and evictions, and incomplete personnel records including background checks and fingerprinting.
Deficiencies (16)
| Description |
|---|
| Administrator did not designate in writing a competent employee to act as administrator when unavailable. |
| One employee did not have documented orientation within 30 days of hire. |
| Two new hire employees did not have documented 16 hours of one-on-one job training with a direct-care employee. |
| Four employees did not have all required annual training and core competency training. |
| At least one washing machine and clothes dryer were not made available for resident use. |
| Two exit lights were not working properly. |
| Fire doors on East and West hallways in memory care had 1/2 inch to 3/4 inch gaps with no astrical device between doors. |
| Emergency and disaster response plan did not include policies for missing residents, death of residents, and mass casualty. |
| Emergency and disaster response plan lacked assignment of personnel to specific tasks, instructions to recruit additional help, and plans for delivery of essential care under various emergency conditions. |
| One resident who was evicted did not have a signed 30-day notice on file. |
| One resident issued an eviction notice did not have documented a copy of the notice sent to the state long term care ombudsman. |
| Three resident assessments did not include memory. |
| Two resident assessments did not accurately reflect the resident's status at the time of assessment. |
| Three employees were not entered in DACS prior to hire. |
| Criminal background authorization forms were missing for seven individuals. |
| Three employees did not have fingerprints taken within 15 working days of engagement. |
Report Facts
Number of rule noncompliances: 15
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