Deficiencies per Year
16
12
8
4
0
Unclassified
Inspection Report
Routine
Deficiencies: 13
Dec 4, 2023
Visit Reason
The inspection was an unannounced routine visit to review compliance with assisted living facility regulations, including review of records, policies, and facility conditions.
Findings
The inspection identified 19 rule noncompliances, with various areas reviewed including licensing, administrator qualifications, personnel, resident rights, medication administration, housekeeping, maintenance, and emergency preparedness. Some deficiencies were noted in medication administration, maintenance, and documentation.
Deficiencies (13)
| Description |
|---|
| The licensee did not have an assessment completed every 6 months for one resident. |
| Three residents had significant changes that were not addressed with corrective action in the significant change log. |
| One resident assessment did not include assistance with bathing; one service resident plan did not include the assistant wiping after toileting. |
| Four employees did not have documented orientation. |
| Four employees did not have a completed health inventory in their personnel files; two employees did not have tuberculosis tests completed within 2 weeks of initial hiring. |
| Cleaning agents and bleaches were accessible in the unlocked storage room across from the elevator control room on the first floor. |
| Electrical panels in an unlocked hallway and the elevator mechanical room were unlocked and accessible. |
| Water temperature in accessible restroom was 131.2 degrees Fahrenheit, exceeding the allowed range. |
| The provider did not have documentation that RN was notified on medication errors for November 2023. |
| The provider did not have medication error reports for 10 medications not available in November 2023. |
| Two employees did not submit fingerprints within 15 working days of the date of their hire. |
| The facility did not hold disaster drills in the previous year or during this year. Simulated disaster drills were not held during the quarter of 2022 or during the second quarter of 2023. |
| Four employees worked together, in varying pairs, during the overnight shift and did not have training in basic first aid or cardiopulmonary resuscitation. |
Report Facts
Number of rule noncompliances: 19
Water temperature: 131.2
Number of employees without documented orientation: 4
Number of medication errors not reported: 10
Number of fingerprints not submitted timely: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Sissy Williams | Individual Informed of Inspection | Named as individual informed of the inspection. |
| Brian H April | Licensor | Conducted the inspection. |
| Gordana Brian P | Licensor | Conducted the inspection. |
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