Deficiencies per Year
24
18
12
6
0
Severe
High
Moderate
Low
Unclassified
Inspection Report
Routine
Deficiencies: 24
Nov 5, 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 26 rule noncompliances across various areas including staff training, medication administration, emergency preparedness, resident rights, and maintenance. Several deficiencies were noted such as lack of core competency training for employees, missing documentation, unsecured electrical panels, incomplete emergency and disaster plans, and failure to document resident deaths properly.
Deficiencies (24)
| Description |
|---|
| No core competency training approved by department for employees. |
| One caregiver lacked documented 16 hours of one-on-one job training. |
| Six employees did not have core competency training in their files. |
| Administrator did not complete required four hours of dementia and Alzheimer's training. |
| Two employees were not skin-tested for tuberculosis within two weeks of hire. |
| Facility did not coordinate emergency and disaster plans with state and local authorities. |
| Facility lacked a written emergency and disaster response plan. |
| Missing disaster plans for severe weather, interruption of public utilities, explosions, bomb threats, and windstorms. |
| No emergency and disaster response plan including recruitment of additional help, supplies, and equipment. |
| Electrical panels in the service entrance were unsecured and accessible. |
| Four medication errors where the registered nurse was not notified. |
| Did not ensure policies governing security and disposal of controlled substances and medication destruction were developed and implemented. |
| Two former employee files lacked required documentation after termination. |
| Eight resident deaths were not documented through written incident reports. |
| One resident assessment was completed late. |
| One resident's status was not accurate at the time of assessment. |
| Resident assessments were not used to develop service plans for three residents. |
| Did not ensure written policies and procedures defining the level of nursing services provided by the facility. |
| No certified nurse aide on duty 24 hours a day as required. |
| Two employees were not connected to DACS within five working days as required. |
| No fire drills for night shift 1st, 2nd, 3rd quarters of 2024 and 4th quarter of 2023; morning shift 2nd, 3rd quarters of 2024 and 4th quarter of 2023; afternoon shift 2nd and 3rd quarters of 2024. |
| Drills did not include resident participants or their ability to evacuate. |
| No emergency radio available in the facility. |
| First Aid Manual expired end of 2024. |
Report Facts
Number of rule noncompliances: 26
Medication errors: 4
Residents deaths not documented: 8
Employees lacking core competency training: 6
Employees not skin-tested for tuberculosis: 2
Former employee files missing documentation: 2
Fire drill shifts missing drills: 9
Employees not connected to DACS timely: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Ruth Salazar | Individual Informed of this Inspection | Named as the individual informed of the inspection. |
| Mariah | Licensor | One of the licensors conducting the inspection. |
| Brian | Licensor | One of the licensors conducting the inspection. |
| Gordana | Licensor | One of the licensors conducting the inspection. |
| Brandi Neff | OL Staff Observing Inspection | Observed the inspection. |
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