2 Reports
Inspection Report — Sep 11, 2026
Routine
Date: Sep 11, 2026
Visit Reason
A health care licensure and follow-up survey was conducted to assess compliance with facility staff qualifications, service agreements, and medication distribution.
Findings
Deficiencies were found in staff training and qualifications, residents' negotiated service agreements not reflecting their needs, and medication distribution practices that did not ensure proper administration or availability of PRN medications.
Deficiencies (3)
39-3322.1 Qualifications and requirements for facility staff: the facility did not arrange for sufficiently trained staff to fully meet residents' needs, including inadequate training on transfers and use of the Sara Steady mechanical lift, resulting in multiple resident falls and unsafe transfer attempts.
39-3309.01 Negotiated service agreement: residents' NSAs did not clearly reflect their needs or describe services provided, such as missing documentation of helmet use for head protection and use of mechanical lifts with two staff members.
.310.01.f. Medication distribution: residents did not receive medications as ordered, including lack of blood glucose measurements before insulin administration and unavailability of as-needed medications for several residents.
Report Facts
: 22
: 120
Inspection Report — Mar 6, 2025
Original Licensing
Date: Mar 6, 2025
Visit Reason
Initial licensure survey conducted to evaluate compliance with health care regulations.
Findings
Two deficiencies were found related to employee background checks and failure to notify Licensing and Certification of resident incidents requiring hospital assessment and treatment.
Deficiencies (2)
.009.01 Criminal History and Background Check: one of nine employees did not have a Department Criminal History and Background Check completed, confirmed by the administrator.
.215.08.f Notification to Licensing Agency within One Business Day: the facility failed to notify Licensing and Certification within one business day for three resident incidents requiring hospital assessment and treatment; the administrator was unaware of the reporting requirement.
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