9 deficiencies cited
The agency cited 9 deficiencies concerning Personnel, Tuberculosis clearance, Residency and Residency Agreements, Medical Records, Directed Care Services, Medication Services and other requirements. Read the official report for the inspector’s evidence and scope.
Findings and correction information
- R9-10-804.1.a-e
Cited requirement:R9-10-804.1.a-e. Quality Management A manager shall ensure that: 1. A plan is established, documented, and implemented for an ongoing quality management program that, at a minimum, includes: a. A method to identify, document, and evaluate incidents; b. A method to collect data to evaluate services provided to residents; c. A method to evaluate the data collected to identify a concern about the delivery of services related to resident care; d. A method to make changes or take action as a result of the identification of a concern about the delivery of services related to resident care; and e. The frequency of submitting a documented report required in subsection (2) to the governing authority;
View provider’s plan of correction (opens a new tab)Provider-listed correction date: Apr 3, 2025. A provider’s plan does not establish agency-confirmed correction.
- PersonnelR9-10-806.A.9
Cited requirement:R9-10-806.A.9. Personnel A. A manager shall ensure that: 9. Before providing assisted living services to a resident, a caregiver or an assistant caregiver receives orientation that is specific to the duties to be performed by the caregiver or assistant caregiver; and
View provider’s plan of correction (opens a new tab)Provider-listed correction date: Apr 3, 2025. A provider’s plan does not establish agency-confirmed correction.
- Tuberculosis clearanceR9-10-807.A.1-2
Cited requirement:R9-10-807.A.1-2. Residency and Residency Agreements A. Except as provided in R9-10-808(B)(2), a manager shall ensure that a resident provides evidence of freedom from infectious tuberculosis: 1. Before or within seven calendar days after the resident's date of occupancy, and 2. As specified in R9-10-113.
View provider’s plan of correction (opens a new tab)Provider-listed correction date: Apr 4, 2025. A provider’s plan does not establish agency-confirmed correction.
- Residency and Residency AgreementsR9-10-807.B.1.a-b
Cited requirement:R9-10-807.B.1.a-b. Residency and Residency Agreements B. A manager shall ensure that before or at the time of acceptance of an individual, the individual submits documentation that is dated within 90 calendar days before the individual is accepted by an assisted living facility and: 1. If an individual is requesting or is expected to receive supervisory care services, personal care services, or directed care services: a. Includes whether the individual requires: i. Continuous medical services, ii. Continuous or intermittent nursing services, or iii. Restraints; and b. Is dated and signed by a: i. Physician, ii. Registered nurse practitioner, iii. Registered nurse, or iv. Physician assistant; and
View provider’s plan of correction (opens a new tab)Provider-listed correction date: Apr 5, 2025. A provider’s plan does not establish agency-confirmed correction.
- Medical RecordsR9-10-811.C.13.b
Cited requirement:R9-10-811.C.13.b. Medical Records C. A manager shall ensure that a resident's medical record contains: 13. Documentation of medication administered to the resident or for which the resident received assistance in the self-administration of medication that includes: b. The name, strength, dosage, and route of administration;
View provider’s plan of correction (opens a new tab)Provider-listed correction date: Apr 4, 2025. A provider’s plan does not establish agency-confirmed correction.
- Directed Care ServicesR9-10-815.F.2.a-c
Cited requirement:R9-10-815.F.2.a-c. Directed Care Services F. A manager of an assisted living facility authorized to provide directed care services shall ensure that: 2. There is a means of exiting the facility for a resident who does not have a key, special knowledge for egress, or the ability to expend increased physical effort that meets one of the following: a. Provides access to an outside area that: i. Allows the resident to be at least 30 feet away from the facility, and ii. Controls or alerts employees of the egress of a resident from the facility; b. Provides access to an outside area: i. From which a resident may exit to a location at least 30 feet away from the facility, and ii. Controls or alerts employees of the egress of a resident from the facility; or c. Uses a mechanism that meets the Special Egress-Control Devices provisions in the International Building Code incorporated by reference in R9-10-104.01; and
View provider’s plan of correction (opens a new tab)Provider-listed correction date: Jun 9, 2025. A provider’s plan does not establish agency-confirmed correction.
- Medication ServicesR9-10-816.B.3.b
Cited requirement:R9-10-816.B.3.b. Medication Services B. If an assisted living facility provides medication administration, a manager shall ensure that: 3. A medication administered to a resident: b. Is administered in compliance with a medication order, and
View provider’s plan of correction (opens a new tab)Provider-listed correction date: Apr 9, 2025. A provider’s plan does not establish agency-confirmed correction.
- Medication ServicesR9-10-816.F.1
Cited requirement:R9-10-816.F.1. Medication Services F. When medication is stored by an assisted living facility, a manager shall ensure that: 1. Medication is stored in a separate locked room, closet, cabinet, or self-contained unit used only for medication storage;
View provider’s plan of correction (opens a new tab)Provider-listed correction date: Apr 3, 2025. A provider’s plan does not establish agency-confirmed correction.
- Hazardous-material storageR9-10-819.A.11
Cited requirement:R9-10-819.A.11. Environmental Standards A. A manager shall ensure that: 11. Poisonous or toxic materials stored by the assisted living facility are maintained in labeled containers in a locked area separate from food preparation and storage, dining areas, and medications and are inaccessible to residents;
View provider’s plan of correction (opens a new tab)Provider-listed correction date: Apr 3, 2025. A provider’s plan does not establish agency-confirmed correction.