Deficiencies per Year
8
6
4
2
0
Moderate
Inspection Report
Annual Inspection
Deficiencies: 5
Mar 13, 2024
Visit Reason
The inspection was conducted as an annual survey to assess compliance with pharmacy services, emergency preparedness, life safety code, fire alarm system, sprinkler system, and fire drills.
Findings
The facility was found non-compliant in pharmacy services related to narcotic medication handling and record keeping, and had deficiencies in life safety code including hazardous area separation, fire alarm testing, sprinkler system maintenance, and fire drill documentation. Corrective actions and plans of correction were accepted with specified dates for compliance.
Severity Breakdown
SS-D: 4
SS-F: 1
Deficiencies (5)
| Description | Severity |
|---|---|
| Facility did not provide pharmaceutical services assuring accurate acquiring, receiving, dispensing, and administering of drugs; lacked process to destroy narcotics when not administered. | SS-D |
| Facility did not maintain hazardous areas to be fire and smoke separated in accordance with NFPA 101. | SS-D |
| Facility did not maintain the fire alarm system in accordance with NFPA 101; missed one of two required tests. | SS-D |
| Facility did not maintain the fire sprinkler system; missing required escutcheons and leaking sprinkler head. | SS-D |
| Facility failed to verify transmission of fire alarm signal during quarterly fire drills. | SS-F |
Report Facts
Deficiencies cited: 5
Date of Compliance: Mar 25, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Cole Julian | Approved Plan of Correction dated 03-27-2024 | |
| David S. Hines | Administrator | Signed inspection report on 03/20/24 and 03/22/2024 |
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