Deficiencies per Year
16
12
8
4
0
Unclassified
Inspection Report
Renewal
Capacity: 39
Deficiencies: 13
Jan 22, 2025
Visit Reason
The inspection was conducted as a re-licensure renewal for an assisted living facility to ensure compliance with licensing requirements and regulations.
Findings
The inspection checklist reviewed multiple regulatory areas including incident reports, disaster drills, policies and procedures, maintenance, and administrative records. Several rules were marked as non-compliant (NC) and compliant (C) across various sections, indicating areas needing correction and areas meeting standards.
Deficiencies (13)
| Description |
|---|
| Identification badges were not properly worn or displayed by staff. |
| Providers did not fully protect clients from abuse, neglect, exploitation, and mistreatment. |
| Licensing requirements for staff qualifications and training were not fully met. |
| Administrator did not meet all qualifications including background checks and training. |
| Personnel files were incomplete or missing required documentation. |
| Resident rights were not fully protected or documented. |
| Resident assessments and service plans were incomplete or not updated. |
| Nursing services and medication administration did not meet all regulatory requirements. |
| Records and documentation were incomplete or inaccurate. |
| Food services and housekeeping did not fully comply with regulations. |
| Emergency preparedness and disaster plans were incomplete or not fully implemented. |
| Facility maintenance and safety measures were not fully compliant. |
| Resident admission and discharge procedures were not fully followed. |
Report Facts
Total licensed capacity: 39
Number of pages: 56
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