Deficiencies per Year
8
6
4
2
0
Unclassified
Inspection Report
Routine
Deficiencies: 8
Oct 4, 2023
Visit Reason
The inspection was an unannounced routine inspection conducted to assess compliance with assisted living facility regulations, including review of policies, resident care, medication administration, safety, and staff qualifications.
Findings
The inspection identified 14 rule noncompliances including issues with employee background clearance, medication administration delays, lack of medication error incident reports, unsecured chemicals, unlocked electrical panels, fire doors not latching properly, missing fire drills, and incomplete documentation of quality assurance activities.
Deficiencies (8)
| Description |
|---|
| Two citations related to employees not linked to the facility and clearance in DACS not initiated. |
| Six residents received medications late during the 8:00 AM medication pass; no medication error incident reports were completed. |
| No documentation that medication errors were reviewed during QA meetings. |
| Unsecured chemicals found in Secure Unit 1st floor Activities Closet and 1st floor Kitchen. |
| Electrical panels unlocked and accessible in health care coordinator's office. |
| Fire doors do not close completely or latch on main stairwell fire door and stairwell by room 239, leaving a gap in second floor hallway. |
| No fire drills conducted for first shift second quarter and third shift third quarter. |
| Emergency information not posted in Secure Unit on 1st or 2nd floor. |
Report Facts
Number of rule noncompliances: 14
Medication administration delay: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Nina Heck | Provider | Named as the individual informed of the inspection. |
| Gordana Sabanovic | Licensor | Conducted the inspection. |
| Amelinda Spek | Licensor | Conducted the inspection. |
| Jared Brown | Licensor | Conducted the inspection. |
| Brian Heugly | Licensor | Conducted the inspection. |
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