4 Reports
Inspection Report — Feb 12, 2025
Renewal
Date: Feb 12, 2025
Visit Reason
The survey was conducted as a renewal inspection to assess compliance with licensing requirements.
Findings
Five deficiencies were identified related to employee files, resident assessments, service plans, and medication documentation. Issues included missing job descriptions, delayed resident needs assessments and service plans, inconsistent updates to service plans, and incomplete medication administration records.
Deficiencies (5)
37.106.2817-2 Employee files: there was no current, initialed job description for an employee.
37.106.2821-3 Resident application and needs assessment: an initial resident needs assessment was not completed timely for a resident admitted in September 2024.
37.106.2822-1 Resident service plan: category A: a resident did not have their initial service plan developed until over a month after admission.
37.106.2822-3 Resident service plan: category A: a resident’s service plan was updated due to a condition change, but the needs assessment done earlier indicated no changes.
37.106.2849-2 Medications: records and documentation: medication administration records for all residents were missing the route on most medications.
Inspection Report — Mar 16, 2021
Renewal
Date: Mar 16, 2021
Visit Reason
The facility underwent a renewal inspection to assess compliance with licensing regulations.
Findings
One deficiency was found regarding resident unit door locks; the resident side of the door was not a single motion lock and remained locked until manually unlocked.
Deficiencies (1)
37.106.2835-2 Resident units: the resident side of the door was not a single motion lock and remained locked until manually unlocked.
Inspection Report — Jan 10, 2019
Renewal
Date: Jan 10, 2019
Visit Reason
The survey was conducted as a renewal inspection of the facility.
Findings
Four deficiencies were identified related to employee files, medication documentation, and resident service plans. Employee files were incomplete or missing, medication administration records lacked required documentation, and a resident's service plan was not updated to reflect hospice care.
Deficiencies (4)
37.106.2817-2 Employee files: one employee's file was missing signed job description, orientation to service plans, evaluations, policy overview, and documentation of orientation and ongoing training including Heimlich and basic first aid.
37.106.2817-3 Employee files: the administrator did not have a current employee file at the time of survey.
37.106.2849-2 Medications, records and documentation: medication administration records for PRN Imitrex and Tramadol lacked documentation of time, reason for administration, and follow-up for effectiveness.
37.106.2822-3 Resident service plan: category A: a resident's service plan was not updated to reflect hospice care initiated in July 2018, with the last update in May 2018 and no changes in October 2018.
Inspection Report — Feb 17, 2017
Renewal
Date: Feb 17, 2017
Visit Reason
The facility underwent a renewal inspection as part of its regular licensing process.
Findings
One deficiency was found related to medication records; the medication administration records (MARS) for three residents lacked documentation of diagnosis for each current medication.
Deficiencies (1)
37.106.2849-2 Medications: records and documentation: the medication administration records for residents 1, 2, and 3 were missing diagnosis documentation for each current medication.
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