Deficiencies per Year
8
6
4
2
0
Severe
High
Moderate
Low
Unclassified
Inspection Report
Complaint Investigation
Census: 9
Deficiencies: 5
Feb 15, 2024
Visit Reason
The Department of Social and Health Services conducted a full inspection and complaint investigation of the Royal Park Retirement Center Assisted Living Facility on 02/15/2024 due to complaints numbered 115954 and 115768.
Findings
The facility was found not in compliance with assisted living licensing requirements, with deficiencies related to maintenance and housekeeping, tuberculosis testing, staff training, CPR certification, and respirator fit testing. A follow-up inspection on 04/03/2024 found no deficiencies, indicating corrections were made.
Complaint Details
Complaint investigation referenced complaint numbers 115954 and 115768. The investigation found multiple deficiencies placing residents at risk, including failure to meet tuberculosis testing requirements, staff training, and safety maintenance. The facility was required to correct deficiencies and submit a Plan of Correction.
Deficiencies (5)
| Description |
|---|
| Failure to ensure emergency exit flooring was kept in good repair, creating a fall risk. |
| Failure to ensure staff were tested for tuberculosis as required, placing residents at risk of exposure. |
| Failure to ensure staff received two-step tuberculosis skin testing within required timeframes. |
| Failure to ensure staff completed specialty training for dementia and mental health and cardiopulmonary resuscitation and first aid. |
| Failure to ensure staff completed respirator fit testing, placing residents and staff at risk of exposure to infectious diseases. |
Report Facts
Residents reviewed: 9
Staff sampled: 6
Dates of on-site inspection: Inspection and complaint investigation conducted on 02/12/2024, 02/13/2024, 02/14/2024, and 02/15/2024.
Completion dates for correction: Various Plan of Correction completion dates ranging from 02/26/2024 to 04/10/2024.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Amy Stafford | Administrator | Signed Plan of Correction attestations related to multiple deficiencies. |
| Staff D | Certified Nursing Assistant | Named in tuberculosis testing and CPR certification deficiencies. |
| Staff B | Licensed Practical Nurse | Named in tuberculosis testing and specialty training deficiencies. |
| Staff C | Certified Medication Aide | Named in tuberculosis testing and respirator fit testing deficiencies. |
| Staff F | Certified Nursing Assistant | Named in respirator fit testing deficiency. |
| Staff H | Maintenance Director | Interviewed regarding emergency exit flooring condition. |
| Staff A | Executive Director | Interviewed regarding tuberculosis testing and specialty training records. |
| Staff G | Licensed Practical Nurse | Interviewed regarding respirator fit testing requirements. |
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