THE BLUFFS OF FLAGSTAFF

INSP-0130049

Complete

Date: 4/24/2025

Type: Complaint

Worksheet: Assisted Living Center

SOD Sent: 2025-05-13

Summary:

The following deficiencies were found during the on-site investigation of complaint 00126188 conducted on April 24, 2025:

Deficiencies Found: 5

Deficiency #1

Rule/Regulation Violated:

R9-10-808.A.3.b. Service Plans A. Except as required in subsection (B), a manager shall ensure that a resident has a written service plan that: 3. Includes the following: b. The level of service the resident is expected to receive;

Evidence/Findings:

Based on record review and interview, the manager failed to ensure a written service plan included the level of service the resident received, for four of four residents sampled. The deficient practice posed a risk as the service plan did not reinforce and clarify services to be provided to a resident. Findings include: 1. A review of R1's medical record revealed a written service plan dated January 03, 2025. The service plans did not include the level of service R1 received. 2. A review of R2's medical record revealed a written service plan dated April 24, 2025. The service plans did not include the level of service R2 received. 3. A review of R3's medical record revealed a written service plan dated October 18, 2024. The service plans did not include the level of service R3. received. 4. A review of R4's medical record revealed a written service plan dated April 24, 2025. The service plans did not include the level of service R4 received. 5. In an interview, E1 and E2 acknowledged R1's, R2's, R3's, and R4's service plans did not include the level of service the resident received.

Temporary Solution:

Manually documented in Service Plan: Residents Service Plans for Supervisory, Personal, and Directed Care updated to include Level of Care information manually typed in.

Permanent Solution:

We are currently working with the IT department to implement a new dropdown feature within the Eldermark Software. This enhancement will allow Resident Service Plans for Supervisory, Personal and Directed Care to include Level of Care information in a standardized, easily selectable format. This improvement is aimed at streamlining documentation and ensuring consistency across care planning.

Person Responsible:

Andrew Auteri, Executive Director

Deficiency #2

Rule/Regulation Violated:

R9-10-808.A.3.c. Service Plans A. Except as required in subsection (B), a manager shall ensure that a resident has a written service plan that: 3. Includes the following: c. The amount, type, and frequency of assisted living services being provided to the resident, including medication administration or assistance in the self-administration of medication;

Evidence/Findings:

Based on record review and interview, the manager failed to ensure a written service plan included the level of medication assistance, for four of four residents sampled. The deficient practice posed a risk if a resident's service plan did not include the services to be provided. Findings include: 1. A review of R1's medical record revealed a written service plan dated January 03, 2025. This service plan did not include the level of medication assistance R1 received. 2. In an interview, E2 reported that R1 received directed care services and medication administration. 3. A review of R2's medical record revealed a written service plan dated April 24, 2025. This service plan did not include the level of medication assistance R2 received. 4. In an interview, E2 reported that R2 received personal care services and medication administration. 5. A review of R3's medical record revealed a written service plan dated October 18, 2024. This service plan did not include the level of medication assistance R3 received. 6. In an interview, E2 reported that R3 received personal care services and self-administration of medication. 7. A review of R4's medical record revealed a written service plan dated April 24, 2025. This service plan did not include the level of medication assistance R4 received. 8. In an interview, E2 reported that R4 received personal care services and medication administration. 9. In an interview, E1 and E2 acknowledged R1's, R2's, R3's and R4's service plans did not include the level of medication assistance.

Temporary Solution:

Resident Service Plans for Supervisory, Personal, and Directed Care manually updated to include Medication Administration or Self-Administration.

Permanent Solution:

We are currently working with the IT department to implement an enhancement in Eldermark Software that will introduce a standardized dropdown option within the Medication Management section of the Resident Service Plan. This update will apply to Supervisor, Personal, and Directed Care levels.

The new dropdown option will reflect the following standardized language:

Staff performs Medication Management – A trained caregiver will administer, store, and re-order medications. All medications will be secured in a locked medication cart, with all narcotic medications double locked. Medications will be ordered from the preferred pharmacy and packaged in the community’s preferred format.

Residents who are Self-Administrators of medications: Resident will keep medications behind safe lock door, resident will keep narcotics behind double lock in apartment, resident will be re-evaluated per assessment schedule. Residents are educated on the importance of keeping their medication in a secure area within their apartment. Instructed to keep their door locked when they are not home. MD order for self-administration. Resident passed a self-medication assessment upon admission and will be reviewed yearly or as needed upon a change of condition.

This enhancement is designed to streamline documentation practices, promote consistency across resident care plans, and support ongoing regulatory compliance.

Person Responsible:

Andrew Auteri, Executive Director

Deficiency #3

Rule/Regulation Violated:

R9-10-808.A.3.f. Service Plans A. Except as required in subsection (B), a manager shall ensure that a resident has a written service plan that: 3. Includes the following: f. For a resident who will be storing medication in the resident's bedroom or residential unit, how the medication will be stored and controlled;

Evidence/Findings:

Based on interview and record review, the manager failed to ensure the service plans for one of one residents sampled, who stored medication in the resident's residential unit, included how the medication was stored and controlled. Findings include: 1. In an interview, E2 reported that R3 received personal care services and self-administered medication. 2. A review of R3's medical record revealed a written service plan dated October 18, 2024. This service plan did not include how the medication would be stored and controlled in R3's room. 3. In an interview, E1 and E2 acknowledged the service plan did not indicate how the medications would be stored and controlled.

Temporary Solution:

Manually documented in Service Plan: Medication stored in resident apartment to be locked when resident is NOT in apartment. Narcotics are to be behind double lock in apartment.

Permanent Solution:

Working with IT department to implement this step within the Eldermark Software to be a drop down:

Self-Administrators of medications: Resident will keep medications behind safe lock door, resident will keep narcotics behind double lock in apartment, resident will be re-evaluated per assessment schedule. Residents are educated on the importance of keeping their medication in a secure area within their apartment. Instructed to keep their door locked when they are not home. MD order for self-administration. Resident passed a self-medication assessment upon admission and will be reviewed yearly or as needed upon a change of condition.

Person Responsible:

Andrew Auteri, Executive Director

Deficiency #4

Rule/Regulation Violated:

R9-10-815.C.3. Directed Care Services C. In addition to the requirements in R9-10-808(A)(3), a manager shall ensure that the service plan for a resident receiving directed care services includes: 3. Cognitive stimulation and activities to maximize functioning;

Evidence/Findings:

Based on record review and interview, the manager failed to ensure a service plan included cognitive stimulation and activities to maximize functioning, for one of one resident sampled receiving directed care services. The deficient practice posed a risk as the service plan did not reinforce and clarify services to be provided to a resident. Findings include: 1. A review of R1's medical record revealed a written service plan dated January 03, 2025. This service plan revealed no documentation of cognitive stimulation and activities to maximize functioning. 2. In an interview, E2 reported that R1 received directed care services. 3. In an interview, E1 and E2 acknowledged R1's service plan did not include cognitive stimulation and activities to maximize functioning.

Temporary Solution:

Resident Service Plans for individuals receiving Directed Care have been manually updated to include cognitive stimulation and activities designed to maximize functioning.

Permanent Solution:

We are currently working with the IT department to implement an enhancement in Eldermark Software that will introduce a dropdown option within the Resident Service Plan for individuals receiving Directed Care. This update will include provisions for cognitive stimulation and engagement in activities designed to maximize functioning. These additions aim to support mental acuity, maintain resident independence, enhance quality of life. Service plans will now reflect specific, individualized interventions, including memory exercises and sensory stimulation. Participation in both structured and unstructured activities tailored to the resident’s unique abilities and interests. The Directed Care Activities Director will play a key role by encouraging residents to attend, explaining the nature and benefits of each activity to foster participation.

Person Responsible:

Andrew Auteri, Executive Director

Deficiency #5

Rule/Regulation Violated:

R9-10-815.C.6.a-b. Directed Care Services C. In addition to the requirements in R9-10-808(A)(3), a manager shall ensure that the service plan for a resident receiving directed care services includes: 6. Documentation: a. Of the resident's weight, or b. From a medical practitioner stating that weighing the resident is contraindicated; and

Evidence/Findings:

Based on record review and interview, the manager failed to ensure a service plan included documentation of the resident's weight or documentation from a medical practitioner stating weighing the resident was contraindicated, for one of one resident sampled receiving directed care services. The deficient practice posed a health and safety risk to the residents. Findings include: 1. A review of R1's medical record revealed a written service plan dated January 03, 2025. The service plan revealed no documentation of R1's weight. In addition, R1's record revealed no documentation of R1's weight or documentation from a medical practitioner stating weighing R1 was contraindicated. 2. In an interview, E2 reported that R1 received directed care services. 3. In an interview, E1 and E2 acknowledged R1's service plan did not include documentation of R1's weight and documentation was not available in R1's record from a medical practitioner stating weighing R1 was contraindicated.

Temporary Solution:

Resident Service Plans for individuals receiving Directed Care will be manually updated to include Resident Weight information as part of the care planning process.

Permanent Solution:

We are currently working with the IT department to implement an enhancement in Eldermark Software that will introduce a dropdown option for Weight Monitoring within the Directed Care section of the Resident Service Plan. This update will support consistent documentation and tracking of resident weight as part of overall health monitoring and individualized care planning.

Person Responsible:

Andrew Auteri, Executive Director

INSP-0115601

Complete

Date: 4/1/2025

Type: Complaint

Worksheet: Assisted Living Center

SOD Sent: 2025-05-02

Summary:

The following deficiencies were found during the on-site investigation of complaint 00124498 conducted on April 1, 2025 :

Deficiencies Found: 1

Deficiency #1

Rule/Regulation Violated:

R9-10-806.A.4.a-b. Personnel A. A manager shall ensure that: 4. A caregiver's or assistant caregiver's skills and knowledge are verified and documented: a. Before the caregiver or assistant caregiver provides physical health services or behavioral health services, and b. According to policies and procedures;

Evidence/Findings:

Based on documentation review, record review, and interview, the manager failed to ensure an assistant caregiver's skills and knowledge were verified and documented before the caregiver provided physical health services on behalf of the facility, for one of one sampled caregiver. The deficient practice posed a risk if employees did not have the skills and knowledge necessary to ensure the health and safety of residents. Findings include: 1. A review of facility documentation revealed E2 worked on January 25, 2025. 2. A review of E2's personnel record revealed E2 was hired in April 2023, as a caregiver . Review of E2's personnel record revealed no documented verification of E2's skills and knowledge. 3. In an interview, E1 acknowledged E2's personnel record did not contain documentation of verification of skills and knowledge.

Temporary Solution:

Skills and Knowledge for E2 was confirmed after CO left the community. Records show that it had been completed on 5/11/23.

Permanent Solution:

Skills and Knowledge review document to be completed for all staff within the first 6 days of employment and kept in their file.

Person Responsible:

Andrew Auteri, Executive Director

INSP-0101588

Complete

Date: 3/18/2025 - 3/19/2025

Type: Complaint;Compliance (Annual)

Worksheet: Assisted Living Center

SOD Sent: 2025-04-09

Summary:

The following deficiencies were found during the on-site compliance inspection and investigation of complaints 00121648, 00104929, 00107173, and 00106183 conducted on March 18-19, 2025.

Deficiencies Found: 3

Deficiency #1

Rule/Regulation Violated:

R9-10-810.B.1. Resident Rights B. A manager shall ensure that: 1. A resident is treated with dignity, respect, and consideration;

Evidence/Findings:

Based on observation and interview, the manager failed to ensure a resident was treated with dignity, respect, and consideration. The deficient practice posed a risk of physical and/or psychosocial harm. Findings include: 1. The Compliance Officer reviewed and listened to a video provided by the facility and observed E2 not treating R1 with dignity, respect, or consideration. E2 was belittling R1 for wetting self and having to be changed. E2 was speaking harshly to R2 while aggressively changing R2’s brief. 2. During an interview, E1 reported that E1 also reviewed the video with upper management. E1 acknowledged that E2 did not treat R1 with dignity, respect, or consideration. This is a repeat deficiency from the inspection conducted on November 3, 2023.

Permanent Solution:

1. New Hire Onboarding will continue to include Abuse, Neglect, and Exploitation training through Relias Courses.
2. Annual training on Abuse, Neglect and Exploitation through Inservice Training.
3. Reviewed Policies and Procedures with Wellness staff.

Person Responsible:

Andrew Auteri, Executive Director

Deficiency #2

Rule/Regulation Violated:

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

Evidence/Findings:

Based on record review and interview, the manager failed to ensure that assistance in the self-administration of medication provided to a resident was in compliance with an order. Findings include:1. The record for R9 contained a physician's order for Sodium Chloride tab, take 1 tab by mouth, daily.2. Record review further indicated that the medication was not given from June 10-16, 2024.3. The medication administration record (MAR) for R9 indicated that the medication had not been given due to pharmacy not delivered. 4. During an interview, E1 stated, "The medication was not given because pharmacy did not deliver. The facility contacted family due to resident had not received medication". E1 acknowledge that the medication was not given to resident as directed.

Permanent Solution:

1. Assistant Wellness Director was demoted on 8/11/24.
2. Retrained Medication Aide staff on Medication Administration via Relias Courses.
3. Reviewed Policies and Procedures with Medication Aide staff.

Person Responsible:

Andrew Auteri, Executive Director

Deficiency #3

Rule/Regulation Violated:

R9-10-818.B.1-2. Emergency and Safety Standards B. A manager shall ensure that: 1. A resident receives orientation to the exits from the assisted living facility and the route to be used when evacuating the assisted living facility within 24 hours after the resident's acceptance by the assisted living facility, 2. The resident's orientation is documented.

Evidence/Findings:

Based on record review and interview, the manager failed to ensure a resident's orientation to the assisted living facility's evacuation plan and the route to be used was documented, for nine of nine residents sampled. Findings include: 1. A record review of R1's, R2's, R3's, R4's, R5's, R6's, R7's, R8's, and R9's medical records revealed a lack of documentation indicating the residents received orientation to the exits from the assisted living facility and the route to be used when evacuating the assisted living facility within 24 hours after the resident's acceptance by the assisted living facility. 2. In an interview, E1 reported all new residents received orientation to the exits from the assisted living facility as part of their move-in process. E1 reported the orientation was conducted but was unaware that separate documentation was needed. E1 acknowledged the residents' orientation to the assisted living facility's evacuation route was not documented.

Permanent Solution:

1. All current residents and New Move-In will go through an Emergency and Evacuation Procedures checklist.
2. Document will be signed and dated for each resident.
3. Document will be signed and dated by designated trainer and ED.

Person Responsible:

Andrew Auteri, Executive Director

INSP-0090036

Complete

Date: 12/7/2023

Type: Complaint

Worksheet: Assisted Living Center

SOD Sent: 2023-12-26

Summary:

No deficiencies were found during the investigation of complaint AZ00203149 conducted on December 7, 2023.

✓ No deficiencies cited during this inspection.

INSP-0090035

Complete

Date: 11/3/2023

Type: Complaint;Compliance (Annual)

Worksheet: Assisted Living Center

SOD Sent: 2023-12-11

Summary:

The following deficiencies were found during the compliance inspection and investigation of complaint AZ00197753 conducted on November 3, 2023.

Deficiencies Found: 15

Deficiency #1

Rule/Regulation Violated:

36-420.01. Health care institutions; fall prevention and fall recovery; training programs; definition
A. Each health care institution shall develop and administer a training program for all staff regarding fall prevention and fall recovery. The training program shall include initial training and continued competency training in fall prevention and fall recovery. A health care institution may use information and training materials from the department's Arizona falls prevention coalition in developing the training program.

Evidence/Findings:

Based on record review and interview the health care institution failed to develop and administer a training program for all staff regarding fall prevention and fall recovery.

Findings include:
1. Review of the record for E4 (hired April 27, 2023), failed to reveal documentation of fall prevention and fall recovery training.
2. During an interview, E1 acknowledged that training for fall prevention and fall recovery had not been administered to all staff.

Deficiency #2

Rule/Regulation Violated:

B. A manager:
3. Except as provided in subsection (A)(6), designates, in writing, a caregiver who is:
b. Present on the assisted living facility's premises and accountable for the assisted living facility when the manager is not present on the assisted living facility premises.

Evidence/Findings:

Based on documentation review and interview, the manager failed to designate, in writing, a caregiver who was present on the assisted living facility's premises and accountable for the assisted living facility when the manager was not present.

Findings include:
1. Review of the facility delegation of authority statement revealed that E6, E7, and E8 were delegated the authority to act as the manager in the absence of E1.
2. Upon entry into the facility E1 and E6 were not present.
3. During an interview, E1 indicated that E7 and E8 were not caregivers.
4. During an interview, E1 acknowledged that documentation failed to indicate that a caregiver, who was present on the facility premises had been designated to act as manager designee when the manager is not present.

Deficiency #3

Rule/Regulation Violated:

C. A manager shall ensure that policies and procedures are:
3. Reviewed at least once every three years and updated as needed.

Evidence/Findings:

Based on documentation review and interview the manager failed to ensure that policies and procedures were reviewed at least once every three years.

Findings include:
1. Review of the facility policy and procedure manual revealed no documentation indicating that the manual had been reviewed. No additional documentation indicating that the policies and procedures had been reviewed once every three years was available.
2. During an interview, E1 acknowledged the documentation failed to indicate that the policies and procedures were reviewed at least once every three years and updated as needed.

Deficiency #4

Rule/Regulation Violated:

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;

Evidence/Findings:

Based on documentation review and interview, the manager failed to ensure that a quality management plan was established, documented, and implemented for an ongoing quality management program that includes subsections a. - e. of this rule.

Findings include:
1. Review of the facility quality management plan revealed documentation that directly reflected the information found in R9-10-804.1.a.-e. The documentation failed to reveal a quality management plan that was established and documented for the facility.
2. During an interview, E1 acknowledged the required documentation was not included in the facility quality management plan.

Deficiency #5

Rule/Regulation Violated:

A. A manager shall ensure that:
10. Before providing assisted living services to a resident, a manager or caregiver provides current documentation of first aid training and cardiopulmonary resuscitation training certification specific to adults.

Evidence/Findings:

Based on record review and interview, the manager failed to ensure for two of four records that before providing personal care services or directed care services to a resident, a manager or caregiver provides documentation of first aid training and cardiopulmonary resuscitation (CPR) training certification specific to adults.

Findings include:
1. The record for E4 (hired April 27, 2023), failed to reveal documentation of CPR and First aid certifications.
2. The record for E1 (hired October 2, 2023), contained documentation of CPR and First Aid training that expired on July 22, 2023.
3. During an interview, E1 acknowledged that the caregiver and manager provided services to residents without current documentation of first aid and CPR training certification.

Deficiency #6

Rule/Regulation Violated:

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.

Evidence/Findings:

Based on record review and interview, the manager failed to ensure that two of three sample resident records contained evidence of freedom from infectious tuberculosis (TB) as specified in R9-10-113.

Findings include:
1. The record for R2 contained no documentation of freedom from TB. Based on the resident's date of acceptance, this documentation was required.
2. The record for R3 contained no documentation of freedom from TB. Based on the resident's date of acceptance, this documentation was required.
3. During an interview, E1 acknowledged that the records did not contain evidence of freedom from TB as required.

Deficiency #7

Rule/Regulation Violated:

A. Except as required in subsection (B), a manager shall ensure that a resident has a written service plan that:
4. Is reviewed and updated based on changes in the requirements in subsections (A)(3)(a) through (f):
b. As follows:
iii. At least once every three months for a resident receiving directed care services; and

Evidence/Findings:

Based on record review and interview, the manager failed to ensure that one of one sample resident records, had a service plan that was reviewed and updated at least once every three months for a resident receiving directed care services.

Findings include:
1. The record for R5 contained a service plan that was last updated on May 2, 2023.
2. During an interview, E1 acknowledged that service plan documentation did not reflect that updates were conducted at least once every three months.

Deficiency #8

Rule/Regulation Violated:

B. A manager shall ensure that:
1. A resident is treated with dignity, respect, and consideration;

Evidence/Findings:

Based on record review and interview, the Manager failed to ensure that a resident was treated with dignity, respect and consideration.

Findings include:
1. Review of the record for R1 revealed an incident report dated July 11, 2023 that indicated E4 reacted to R1's attempt to bite them by "..hitting (R1) on the back of the head and restraining (R1) around the wrists."
2. During an interview, E1 acknowledged that striking a resident was not treating a resident with dignity, respect and consideration.

Deficiency #9

Rule/Regulation Violated:

B. A manager of an assisted living facility authorized to provide directed care services shall not accept or retain a resident who, except as provided in R9-10-814(B)(2):
1. Is confined to a bed or chair because of an inability to ambulate even with assistance; or

Evidence/Findings:

Based on record review and interview for one of one personal care resident record, the manager failed to obtain the following documentation: documentation reflecting that the resident or resident's representative requested that the resident remain in the facility and a signed and dated statement from a medical practitioner indicating that the resident's needs were being met by the facility as per their scope of services.

Findings include:
1. During an interview, E5 indicated that R2 was non-ambulatory, has not walked for more than 30 days and cannot walk even when assisted.
2. The resident's record did not contain a request from the resident or their representative to remain in the facility or a statement from the medical practitioner that the resident's needs were being met as per the facility's scope of services. Based on the resident's date of acceptance this documentation was required.
3. During an interview, E1 acknowledged that the required documentation was not in the resident's record.

Deficiency #10

Rule/Regulation Violated:

B. If an assisted living facility provides medication administration, a manager shall ensure that:
2. Policies and procedures for medication administration:
a. Are reviewed and approved by a medical practitioner, registered nurse, or pharmacist;

Evidence/Findings:

Based on documentation review and interview, the manager failed to ensure that medication administration policies and procedures were reviewed and approved by a medical practitioner, registered nurse, or pharmacist.

Findings include:
1. The facility medication administration policies and procedures failed to reveal evidence that the policies had been reviewed and approved by a medical practitioner, registered nurse, or pharmacist.
2. During an interview, E1 acknowledged that facility residents receive medication administration services.
3. During an interview, E1 acknowledged the required documentation was not available for review.

Deficiency #11

Rule/Regulation Violated:

A. A manager shall ensure that:
2. The disaster plan required in subsection (A)(1) is reviewed at least once every 12 months;

Evidence/Findings:

Based on documentation review and interview, the manager failed to ensure that the disaster plan was reviewed at least once every 12 months.

Findings include:
1. Review of facility documentation failed to reveal that the disaster plan had been reviewed at least once every 12 months.
2. During an interview, E1 acknowledged that the required documentation was not available for review.

Deficiency #12

Rule/Regulation Violated:

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/Findings:

Based on documentation review and interview, the manager failed to ensure that a disaster drill for employees was conducted on each shift at least once every three months and documented.

Findings include:
1. Facility documentation failed to reflect that disaster drills had been conducted.
2. During an interview, E1 acknowledged that no documentation of employee disaster drills was available for review.

Deficiency #13

Rule/Regulation Violated:

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/Findings:

Based on documentation review and interview, the manager failed to ensure that an evacuation drill for residents was conducted at least once every six months.

Findings include:
1. Twelve months of facility evacuation drill documentation was requested. Review of the evacuation drill documentation provided failed to reveal that resident evacuation drills had been conducted. The only evacuation drill documentation available for review was for employees only, and these drills did not involve residents.
2. During an interview, E1 acknowledged the requested documentation was not available for review.

Deficiency #14

Rule/Regulation Violated:

A. A manager shall ensure that:
6. Documentation of each evacuation drill is created, is maintained for at least 12 months after the date of the evacuation drill, and includes:
b. The amount of time taken for employees and residents to evacuate the assisted living facility;

Evidence/Findings:

Based on documentation review and interview, the manager failed to ensure that documentation of each evacuation drill was created and maintained for 12 months after the date of the evacuation drill that included the amount of time taken for employees to evacuate the assisted living facility.

Findings include:
1. Facility evacuation drill documentation for the past 12 months was reviewed. The documentation failed to reveal the amount of time taken for employees to evacuate the facility for the following dates in 2023: March 16, May 30, June 30, July 20, August 25 and September 28.
2. During an interview, E1 acknowledged the required documentation was not available for review.

Deficiency #15

Rule/Regulation Violated:

E. A manager of an assisted living center shall ensure that:
3. A fire inspection is conducted by a local fire department or the State Fire Marshal before licensing and according to the time-frame established by the local fire department or the State Fire Marshal;

Evidence/Findings:

Based on documentation review and interview, the manager failed to ensure that a fire inspection was conducted by the local fire department or the State Fire Marshal according to the time-frame established by the local fire department or the State Fire Marshal.

Findings include:
1. Facility documentation indicated the last fire inspection was conducted by the local fire department on April 27, 2022.
2. During an interview with a representative from the local Fire Department it was determined that fire inspections are required on an annual basis.
3. During an interview, E1 acknowledged that the facility did not have documentation indicating that a fire inspection had been conducted as required by the fire authority.

Facility Information

Inspection History

INSP-0134101

Summary:

Deficiencies Found: 1

Deficiency #1

Rule/Regulation Violated:

Evidence/Findings:

Permanent Solution:

Person Responsible:

INSP-0130049

Summary:

Deficiencies Found: 5

Deficiency #1

Rule/Regulation Violated:

Evidence/Findings:

Temporary Solution:

Permanent Solution:

Person Responsible:

Deficiency #2

Rule/Regulation Violated:

Evidence/Findings:

Temporary Solution:

Permanent Solution:

Person Responsible:

Deficiency #3

Rule/Regulation Violated:

Evidence/Findings:

Temporary Solution:

Permanent Solution:

Person Responsible:

Deficiency #4

Rule/Regulation Violated:

Evidence/Findings:

Temporary Solution:

Permanent Solution:

Person Responsible:

Deficiency #5

Rule/Regulation Violated:

Evidence/Findings:

Temporary Solution:

Permanent Solution:

Person Responsible:

INSP-0115601

Summary:

Deficiencies Found: 1

Deficiency #1

Rule/Regulation Violated:

Evidence/Findings:

Temporary Solution:

Permanent Solution:

Person Responsible:

INSP-0101588

Summary:

Deficiencies Found: 3

Deficiency #1

Rule/Regulation Violated:

Evidence/Findings:

Permanent Solution:

Person Responsible:

Deficiency #2

Rule/Regulation Violated:

Evidence/Findings:

Permanent Solution:

Person Responsible:

Deficiency #3

Rule/Regulation Violated:

Evidence/Findings:

Permanent Solution:

Person Responsible:

INSP-0090036

Summary:

INSP-0090035

Summary:

Deficiencies Found: 15

Deficiency #1

Rule/Regulation Violated:

Evidence/Findings:

Deficiency #2