Deficiencies per Year
16
12
8
4
0
Unclassified
Inspection Report
Routine
Deficiencies: 14
Nov 29, 2023
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 14 rule noncompliances including deficiencies in employee training, medication administration records, emergency evacuation plans, health inventories, and maintenance issues such as unsecured oxygen tanks and fire door malfunctions.
Deficiencies (14)
| Description |
|---|
| Two direct care employees who were not CNAs did not receive documented 16 hours of one-on-one training. |
| Seven employees were missing some of the annual in-service trainings; an annual in-service on core competency was not done. |
| Two employees did not have health inventories in their files. |
| Assessments for four residents were not signed and dated by a licensed health care professional. |
| A resident assessment was not accurate and was not updated or revised when a significant change occurred. |
| A resident required a transfer pole and assistance with compression socks that were not assessed or included in the service plan. |
| The secured unit did not have an emergency evacuation plan that addressed the ability of the secure unit staff to evacuate residents in case of emergency. |
| The emergency evacuation plan for a hospice resident was not accurate. |
| Criminal background screening authorization forms were not completed for 3 employees and 4 employees did not submit fingerprints within 15 days of hire. |
| The licensee did not maintain an accurate medication administration record for a resident. |
| Two unsecured oxygen tanks were found in a resident room. |
| A fire door next to a resident room did not close and latch properly. |
| The electrical room entrance was open and accessible with five electrical boxes open and accessible. |
| Emergency plans were not provided that met the rule requirements. |
Report Facts
Number of rule noncompliances: 14
Employees missing annual in-service training: 7
Employees missing health inventories: 2
Employees missing criminal background screening forms: 3
Employees missing fingerprint submission: 4
Direct care employees without documented 16 hours training: 2
Residents with unsigned assessments: 4
Rule citations: 131
Rule citations compliant: 14
Rule citations non-compliant: 55
Rule citations not assessed: 1
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