Inspection Results
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Facility failed to meet the following Requirement(s):Corrected DateLevel of HarmResidents Affected
Exits, Stairways, and Fire Escapes. (A) Each floor of a facility shall have at least two (2) unobstructed exits remote from each other. I/II 1. For a facility whose plans were approved on or before December 31, 1987, or a facility licensed for twenty (20) or fewer beds, one (1) of the required exits from a multi-story facility shall be an outside stairway or an enclosed stairway that is separated by one- (1-) hour rated construction from each floor with an exit leading directly to the outside at grade level. Existing plaster or gypsum board of at least one-half inch (1/2") thickness may be considered equivalent to one- (1-) hour rated construction. The other required exit may be an interior stairway leading through corridors or passageways to outside or to a two- (2-) hour rated horizontal exit as defined by paragraph 3.3.61 of the 2000 edition NFPA 101. Neither of the required exits shall lead through a furnace or boiler room. Neither of the required exits shall be through a resident ' s bedroom, unless the bedroom door cannot be locked. I/II 4/24/2023   
Exits, Stairways, and Fire Escapes. (C) In residential care facilities and facilities formerly licensed as residential care facilities II, floors housing residents who require the use of a walker, wheelchair, or other assistive devices or aids, or who are blind, must have two (2) accessible exits to grade or such residents must be housed near accessible exits as specified in 19 CSR 30-86.042(33) for residential care facilities and 19 CSR 30-86.043(31) for facilities formerly licensed as residential care facilities II unless otherwise prohibited by 19 CSR 30-86.045 or 19 CSR 30-86.047, facilities equipped with a complete sprinkler system, in accordance with NFPA 13 or NFPA 13R, 1999 edition, with sprinkler coverage in attics, and smoke partitions, as defined by subsection (10)(I) of this rule, may house such residents on floors that do not have accessible exits to grade if each required exit is equipped with an area of refuge as defined and described in subsections (1)(B) and (7)(D) of this rule. I/II 4/24/2023   
Protection from Hazards. (G) All doors providing separation between floors shall have a self-closing device attached. If the doors are to be held open, electromagnetic hold-open devices shall be used that are interconnected with either an individual smoke detector or a complete fire alarm system. II 4/24/2023   
There shall be adequate storage areas for food, supplies, linen, equipment and resident ' s personal possessions. III 4/24/2023   
The facility shall screen residents and staff for tuberculosis as required for long-term care facilities by 19 CSR 20-20.100. II 4/24/2023   
The facility shall ensure that each resident being admitted or readmitted to the facility receives an admission physical examination by a licensed physician. The facility shall request documentation of the physical examination prior to admission but must have documentation of the physical examination on file no later than ten (10) days after admission. The physical examination shall contain documentation regarding the individual ' s current medical status and any special orders or procedures to be followed. If the resident is admitted directly from an acute care or another long-term care facility and is accompanied on admission by a report that reflects his or her current medical status, an admission physical shall not be required. III 4/24/2023   
The facility may admit or retain an individual for residency in an assisted living facility only if the individual does not require hospitalization or skilled nursing placement as defined in this rule, and only if the facility: (F) Completes a community based assessment conducted by an appropriately trained and qualified individual as defined in section (4) of this rule: 1. Time frame requirements for assessment shall be: B. At least semiannually; II 4/24/2023   
The facility may admit or retain an individual for residency in an assisted living facility only if the individual does not require hospitalization or skilled nursing placement as defined in this rule, and only if the facility: (G) Develops an individualized service plan (ISP), which means the planning document prepared by an assisted living facility which outlines a resident ' s needs and preferences, services to be provided, and goals expected by the resident or the resident ' s legal representative in partnership with the facility; II 4/24/2023   
The facility may admit or retain an individual for residency in an assisted living facility only if the individual does not require hospitalization or skilled nursing placement as defined in this rule, and only if the facility: (I) Includes the signatures of an authorized representative of the facility and the resident or the resident ' s legal representative in the individualized service plan to acknowledge that the service plan has been reviewed and understood by the resident or legal representative; II 4/24/2023   
Protective oversight shall be provided twenty-four (24) hours a day. For residents departing the premises on voluntary leave, the facility shall have, at a minimum, a procedure to inquire of the resident or resident ' s guardian of the resident ' s departure, of the resident ' s estimated length of absence from the facility, and of the resident ' s whereabouts while on voluntary leave. I/II 4/24/2023   
Self-control of prescription medication by a resident may be allowed only if approved in writing by the resident ' s physician and included in the resident ' s individualized service plan. A resident may be permitted to control the storage and use of nonprescription medication unless there is a physician ' s written order or facility policy to the contrary. Written approval for self-control of prescription medication shall be rewritten as needed but at least annually and after any period of hospitalization. II/III 4/24/2023   
All medication shall be safely stored at proper temperature and shall be kept in a secured location behind at least one (1) locked door or cabinet. Medication shall be accessible only to persons authorized to administer medications. II/III 4/24/2023   
The administrator shall develop and implement a safe and effective system of medication control and use, which assures that all residents ' medications are administered by personnel at least eighteen (18) years of age, in accordance with physicians ' instructions using acceptable nursing techniques. The facility shall employ a licensed nurse eight (8) hours per week for every thirty (30) residents to monitor each resident ' s condition and medication. Administration of medication shall mean delivering to a resident his or her prescription medication either in the original pharmacy container, or for internal medication, removing an individual dose from the pharmacy container and placing it in a small cup container or liquid medium for the resident to remove from the container and self-administer. External prescription medication may be applied by facility personnel if the resident is unable to do so and the resident ' s physician so authorizes. All individuals who administer medication shall be trained in medication administration and, if not a physician or a licensed nurse, shall be a certified medication technician or level I medication aide. I/II 4/24/2023   
Medication Orders. (A) No medication, treatment or diet shall be administered without an order from an individual lawfully authorized to prescribe such and the order shall be followed. II/III 4/24/2023   
Medication Orders. (B) Physician ' s written and signed orders shall include: name of medication, dosage, frequency and route of administration and the orders shall be renewed at least every three (3) months. Computer generated signatures may be used if safeguards are in place to prevent their misuse. Computer identification codes shall be accessible to and used by only the individuals whose signatures they represent. Orders that include optional doses or include pro re nata (PRN) administration frequencies shall specify a maximum frequency and the reason for administration. II/III 4/24/2023   
A physician, pharmacist or registered nurse shall review the medication regimen of each resident. This shall be done at least every other month. The review shall be performed in the facility and shall include, but shall not be limited to, indication for use, dose, possible medication interactions and medication/food interactions, contraindications, adverse reactions and a review of the medication system utilized by the facility. Irregularities and concerns shall be reported in writing to the resident ' s physician and to the administrator/manager. If after thirty (30) days, there is no action taken by a resident ' s physician and significant concerns continue regarding a resident ' s or residents ' medication order(s), the administrator shall contact or recontact the physician to determine if he or she received the information and if there are any new instructions. II/III 4/24/2023   
The facility shall maintain a record in the facility for each resident, which shall include the following: (A) Admission information including the resident ' s name; admission date; confidentiality number; previous address; birth date; sex; marital status; Social Security number; Medicare and Medicaid numbers (if applicable); name, address and telephone number of the resident ' s physician and alternate; diagnosis, name, address and telephone number of the resident ' s legally authorized representative or designee to be notified in case of emergency; and preferred dentist, pharmacist and funeral director; III 4/24/2023   
The facility shall maintain a record in the facility for each resident, which shall include the following: (B) A review monthly or more frequently, if indicated, of the resident ' s general condition and needs; a monthly review of medication consumption of any resident controlling his or her own medication, noting if prescription medications are being used in appropriate quantities; a daily record of administration of medication; a logging of the medication regimen review process; a monthly weight; a record of each referral of a resident for services from an outside service; and a record of any resident incidents including behaviors that present a reasonable likelihood of serious harm to himself or herself or others and accidents that potentially could result in injury or did result in injuries involving the resident; III 4/24/2023   
Resident records shall be maintained by the operator for at least five (5) years after a resident leaves the facility or after the resident reaches the age of twenty-one (21), whichever is longer and must include reason for discharge or transfer from the facility and cause of death, as applicable. III 4/24/2023   
Poisonous or toxic materials consist of the following categories: insecticides and rodenticides; disinfectants, sanitizer and related cleaning or drying agents; and caustics, acids, polishes and other chemicals. Each of these three (3) categories set forth shall be stored and physically located separate from each other. All poisonous or toxic materials shall be stored in locked cabinets or in a similar physically separate place used for no other purpose which is not accessible to residents. II 4/24/2023   
All floors in the facility shall be clean and shall be maintained in good repair. Floors and floor coverings of all food-preparation, food-storage and utensil-washing areas, and the floors of all walk-in refrigerating units, dressing rooms, locker rooms, toilet rooms and vestibules shall be constructed of smooth durable material such as sealed concrete, terrazzo, ceramic tile, durable grades of linoleum or plastic, or tight wood impregnated with plastic. Nothing in this section shall prohibit the use of antislip floor covering in areas where necessary for safety reasons. III 4/24/2023   
The outer clothing of all employees shall be clean and employees shall use effective hair restraints to prevent the contamination of food or food-contact surfaces. III 4/24/2023   
At all times, including while being stored, prepared, displayed, served or transported to or from the facility, food shall be protected from potential contamination, including dust, insects, rodents, unclean equipment and utensils, unnecessary handling, coughs and sneezes, flooding, drainage and overhead leakage or overhead drippage from condensation. The temperature of potentially hazardous food shall be forty-five degrees Fahrenheit (45��F) or below or one hundred forty degrees Fahrenheit (140��F) or above at all times, except as otherwise provided in this section. In the event of a fire, flood, power outage or similar event that might result in the contamination of food, or that might prevent potentially hazardous food from being held at required temperatures, the person in charge shall immediately contact the Department of Health and Senior Services (the department). Upon receiving notice of this occurrence, the department shall take whatever action that it deems necessary to protect the residents. II/III 4/24/2023   
Nonfood-contact surfaces of equipment shall be cleaned as often as is necessary to keep the equipment free of accumulation of dust, dirt, food particles and other debris. III 4/24/2023   
(8) If a resident installs and uses an electronic monitoring device, a notice to alert and inform visitors shall be posted at the entrance of the facility and resident's room. (A) The facility shall post a notice at the main entrance of the facility in large, legible type and font and display the words "Electronic Monitoring" and state: "The rooms of some residents may be monitored electronically by, or on behalf of, the residents and monitoring is not necessarily open or obvious." III 4/24/2023   
(8) If a resident installs and uses an electronic monitoring device, a notice to alert and inform visitors shall be posted at the entrance of the facility and resident's room. (B) The facility shall require the resident to post and maintain a conspicuous notice at the entrance of the resident's room stating: "This room is being monitored by an electronic monitoring device." III 4/24/2023   
(9) The facility shall require an electronic monitoring device to be installed as follows: (A) In plain view; (B) Mounted in a fixed, stationary position; (C) Directed only on the resident who initiated the installation and use of AEM device; (D) Placed for maximum protection of the privacy and dignity of the resident and the roommate; and (E) In a manner that is safe for residents, employees, or visitors who may be moving about the room. II/III 4/24/2023