The most recent inspection on February 18, 2025, included an enforcement action resulting in a $250 fine that has been paid in full. Earlier inspections showed repeated deficiencies primarily related to tuberculosis screening documentation and updating resident service plans after significant changes in condition. Prior reports also noted issues with medical record documentation, disaster and evacuation drills, and required practitioner documentation for bedbound residents. Complaint investigations conducted in 2023 and 2024 did not result in any deficiencies. The facility’s inspection history shows ongoing challenges with documentation and compliance, with enforcement actions occurring periodically over the past two years.
One deficiency found related to failure to ensure residents provided evidence of freedom from infectious tuberculosis during complaint and compliance inspection.
Findings
One deficiency found related to failure to ensure residents provided evidence of freedom from infectious tuberculosis during complaint and compliance inspection.
Deficiencies (1)
Description
A. Except as provided in R9-10-808(B)(2), a manager shall ensure that a resident provides evidence of freedom from infectious tuberculosis
The enforcement resulted in civil fines totaling $500 for repeat deficiencies identified during the inspection conducted on July 25-26, 2023, which were also noted in a prior inspection on August 25, 2022.
Fines & Penalties (2)
Amount
Reason
Status
$250.00
One resident's service plan was not updated after a significant change in condition (repeat deficiency).
—
$250.00
Three bedbound residents did not have a written determination from a medical practitioner (repeat deficiency).
Nine deficiencies found related to policies, tuberculosis documentation, service plan updates, medical record documentation, PCP documentation, and disaster and evacuation drills.
Findings
Nine deficiencies found related to policies, tuberculosis documentation, service plan updates, medical record documentation, PCP documentation, and disaster and evacuation drills.
Deficiencies (7)
Description
C. A manager shall ensure that policies and procedures are established, documented, and implemented to protect the health and safety of a resident
A. Except as provided in R9-10-808(B)(2), a manager shall ensure that a resident provides evidence of freedom from infectious tuberculosis
A. Except as required in subsection (B), a manager shall ensure that a resident has a written service plan that is reviewed and updated based on changes
C. A manager shall ensure that a resident's medical record contains documentation of notification of vaccination availability
B. A manager of an assisted living facility authorized to provide directed care services shall not accept or retain a resident without required PCP documentation
A. A manager shall ensure that a disaster drill for employees is conducted on each shift at least once every three months and documented
A. A manager shall ensure that an evacuation drill for employees and residents is conducted at least once every six months
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