Inspection Report
Routine
Census: 128
Capacity: 52
Deficiencies: 21
Aug 19, 2024
Visit Reason
Unannounced routine inspection conducted to assess compliance with assisted living facility licensing rules and regulations.
Findings
The inspection identified 21 rule noncompliances across various areas including administrator duties, personnel training, medication administration, resident rights, emergency preparedness, and maintenance issues. Several deficiencies were noted such as lack of documented employee training, medication errors, incomplete resident assessments, and missing fire drills.
Deficiencies (21)
| Description |
|---|
| No signed job description on file for the administrator. |
| Four employees lacked documented training for ethics, confidentiality, resident rights, policy and procedures, abuse reporting, and core competency. |
| Not all required in-service trainings were conducted for all employees. |
| Four employees did not have a health inventory on file. |
| Eight residents lacked written admission agreements including legal rights and complaint filing information. |
| Three residents on hospice lacked complete evacuation plans integrated into service plans. |
| Six residents lacked completed resident assessments including required home health/hospice information. |
| One resident assessment was inaccurate at the time of assessment. |
| One resident assessment was not used to develop the service plan. |
| Facility did not ensure a certified nurse aide was on duty 24 hours per day. |
| Three employees lacked four hours of documented training in the secure unit. |
| Two residents received medications late; one resident received crushed medications without an order to do so. |
| Two residents received medications late throughout August with no medication error reports completed. |
| Medication error reports were not incorporated into the quality improvement process. |
| Tablet with EMAR and narcotic books containing PHI were left unsecured. |
| Chemicals were stored in open and accessible areas including marketing office and laundry. |
| Fire doors on second floor by room 209 were catching on carpet and would not close properly. |
| No quarterly dietary consultation completed for one resident. |
| No fire drills for day, afternoon, or night shifts for 3rd and 4th quarter of 2023; drills lacked resident participation and evacuation ability. |
| No first aid manual available in the facility. |
| No blankets available for emergency preparedness. |
Report Facts
Rule noncompliances: 21
Resident census: 128
Total licensed capacity: 52
Residents on hospice: 3
Employees lacking documented training: 4
Residents lacking admission agreement legal rights: 8
Residents lacking completed assessments: 6
Residents receiving medications late: 2
Employees lacking secure unit training: 3
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