Deficiencies per Year
16
12
8
4
0
Unclassified
Inspection Report
Annual Inspection
Deficiencies: 13
Dec 7, 2023
Visit Reason
The inspection was conducted as part of the annual regulatory compliance review of a Type II assisted living facility to assess adherence to state licensing rules and regulations.
Findings
The inspection identified multiple deficiencies including incomplete resident assessments, missing emergency evacuation plans for hospice patients, lack of documentation for medication error reports, incomplete employee health inventories, unlocked electrical panels, and deficiencies in emergency and disaster preparedness plans.
Deficiencies (13)
| Description |
|---|
| Two hospice patient residents did not have emergency evacuation plans. |
| Four resident assessments were not complete. |
| Three resident assessments were not used to develop their service plans. |
| One resident's service plan did not indicate who would be providing the services. |
| No medication error reports completed for two residents; medication errors were not incorporated into the quality improvement process during multiple quarters. |
| Employee files did not contain a completed health inventory. |
| Four employee files did not include a signed criminal background screening authorization form. |
| Electrical room next to room #302 was unlocked and accessed; two electrical panels were observed to be open and accessed. |
| Emergency and disaster response plan was reviewed and did not contain policies to recruit additional help, deliver care through alternate means, or deliver care to additional persons during emergencies. |
| Fire and disaster drills did not include resident participants, problems encountered, and the ability of each resident to evacuate. |
| Emergency contact information was not prominently located throughout the facility. |
| A monthly activity calendar was not posted for residents' viewing. |
| No medication error reports provided prior to 10/27/2023; Assisted Living Director was not able to find them. |
Report Facts
Resident assessments incomplete: 4
Resident assessments not used for service plans: 3
Hospice patients without emergency evacuation plans: 2
Employee files missing criminal background screening authorization: 4
Certified nurse aide staffing ratio: 1
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