Inspection Details

Inspection #
INSP-0076384
Inspection Date(s)
5/1/2023 - 9/27/2023
Status
Complete
Inspection Type
Compliance (Annual)
Worksheet Type
Assisted Living Home
Certificate Number
AL11104H
Location Type
โ€”

Initial Comments

The following deficiencies were found during the on-site compliance inspection conducted on September 27, 2023:

Statement of Deficiency

2 deficiencies found
Deficiency #1
✓ Plan Provided
Rule
A. A manager shall ensure that: 4. A disaster drill for employees is conducted on each shift at least once every three months and documented;
Evidence
Based on documentation review and interview, the manager failed to ensure a disaster drill for employees was conducted on each shift at least once every three months. The deficient practice posed a risk if employees were unable to implement a disaster plan. Findings include: 1. A review of facility documentation revealed a staff schedule. The schedule indicated there were two shifts: -"1st shift" from 7:00 AM to 7:00 PM; and -"2nd shift" from 7:00 PM to 7:00 AM. 2. A review of facility documentation revealed disaster drills were conducted at the facility on June 3, 2023 on the first and second shifts. No other documentation of disaster drills conducted at the facility was provided for review. 3. In a joint interview, E1 and E2 acknowledged a disaster drill for employees was not conducted on each shift at least once every three months. E1 reported the facility has new management and the old management took the documentation of disaster drills for dates prior to June 2023.
Plan of Correction
Permanent Correction Date
2023-11-08
Deficiency #2
✓ Plan Provided
Rule
A. A manager shall ensure that: 5. An evacuation drill for employees and residents: a. Is conducted at least once every six months; and
Evidence
Based on documentation review and interview, the manager failed to ensure an evacuation drill for employees and residents was conducted at least once every six months. Findings include: 1. A review of facility documentation revealed a staff schedule. The schedule indicated there were two shifts: -"1st shift" from 7:00 AM to 7:00 PM; and -"2nd shift" from 7:00 PM to 7:00 AM. 2. A review of facility documentation revealed evacuation drills were conducted at the facility on June 3, 2023. No other documentation of evacuation drills conducted at the facility prior to June 2023 was provided for review. 2. In a joint interview, E1 and E2 acknowledged an evacuation drill for employees was not conducted on each shift at least once every six months. E1 reported the facility has new management and the old management took the documentation of evacuation drills for dates prior to June 2023.
Plan of Correction
Permanent Correction Date
2023-11-08