The most recent inspection on November 12, 2024, found no deficiencies and confirmed the facility was in compliance with all regulations. Prior to that, the October 29, 2024 inspection cited multiple deficiencies related to medication administration, negotiated service agreements, and medication storage practices. Earlier inspections also noted issues with negotiated service agreements and staff certification documentation, with complaint investigations attached that were addressed through corrective plans. There were no fines, immediate jeopardy findings, or enforcement actions listed in the available reports. The facility appears to have corrected previous deficiencies promptly, showing improvement in compliance over time.
Deficiencies (last 4 years)
Deficiencies (over 4 years)1.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
An offsite revisit survey was conducted to verify correction of all previous deficiencies cited on 2024-10-30.
Findings
All deficiencies have been corrected as of the compliance date of 2024-11-05 and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Report Facts
Previous deficiencies cited: Deficiencies cited on 2024-10-30
This is a resurvey inspection conducted on 10/29/24 and 10/30/24 to evaluate compliance following a previous facility report #191381 at an assisted living community.
Findings
The inspection found multiple deficiencies including failure to develop adequate negotiated service agreements for residents, improper administration of medications not following physician orders, lack of resident names on over-the-counter medication packages, and improper medication storage practices including unlabeled and undated medication vials.
Severity Breakdown
Level D: 2Level E: 1Level F: 1
Deficiencies (4)
Description
Severity
Failure to ensure the Negotiated Service Agreement for Residents 1 and 2 described the services they received based on their service needs and preferences.
Level D
Failure to ensure facility staff administered all medications to Resident 2 in accordance with his medical care provider's orders.
Level D
Failure to ensure a licensed pharmacist or licensed nurse placed the full names of residents on the original packages of six over-the-counter medications in the memory care unit.
Level E
Failure to ensure medications and biologicals were securely and properly stored in accordance with each manufacturer's recommendations, including unlabeled and undated tuberculin vials.
Level F
Report Facts
Census: 72Residents in sample: 6Memory care residents: 33Assisted living residents: 39Medication administration errors: 13Over-the-counter medications without resident names: 6
Employees Mentioned
Name
Title
Context
Administrative Nurse B
Confirmed failure of Negotiated Service Agreements and unlabeled tuberculin vial
Administrative Nurse C
Confirmed medication administration errors for Resident 2
Certified Medication Aide D
Observed OTC medications lacking resident names and unlabeled tuberculin vial
Inspection Report Plan of CorrectionDeficiencies: 0Oct 29, 2024
Visit Reason
This document represents the provider's plan of correction following a resurvey conducted on 10/29/24 and 10/30/24 at the assisted living facility.
Findings
The plan of correction addresses findings from the resurvey linked to facility report #191381 conducted on the specified dates.
An offsite revisit survey was conducted to verify correction of all previous deficiencies cited on 2023-02-15.
Findings
All deficiencies have been corrected as of the compliance date of 2023-03-01, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
The inspection was a resurvey with attached complaints #170650 and #164234 conducted at the assisted living facility.
Findings
The facility failed to develop a negotiated service agreement for a resident based on her functional capacity screening related to medication management. Additionally, the administrator failed to ensure evidence of certification checks for three staff members was completed upon hire.
Complaint Details
The resurvey included attached complaints #170650 and #164234.
Severity Breakdown
Level D: 1Level F: 1
Deficiencies (2)
Description
Severity
Failure to develop a negotiated service agreement for Resident 217 based on her functional capacity screening regarding medication management.
Level D
Failure to ensure evidence of certification for three staff members was completed upon hire.
Level F
Report Facts
Census: 72Residents in sample: 6Employee records reviewed: 3
Employees Mentioned
Name
Title
Context
Administrative Nurse C
Administrative Nurse
Confirmed failure of negotiated service agreement for Resident 217.
Administrative Staff H
Administrative Staff
Confirmed lack of certification check dates for three staff employee records.
Inspection Report Plan of CorrectionDeficiencies: 0Feb 14, 2023
Visit Reason
This document is a plan of correction addressing findings from a resurvey with attached complaints #170650 and #164234 conducted at the assisted living facility on 02/14/23 - 02/15/23.
Findings
The plan of correction corresponds to citations identified during the resurvey and complaint investigations at the assisted living facility conducted on 02/14/23 - 02/15/23.
Complaint Details
The visit was related to complaints #170650 and #164234 attached to the resurvey.