1 Report
Inspection Report — Oct 6, 2025
Annual Inspection
Date: Oct 6, 2025
Visit Reason
Annual Licensure Survey conducted with violations cited in Disaster Preparedness, Incident and Accident Reporting, Physician's Assessment, Service Plan, Tuberculin Skin Test Procedures, and Resident Rights.
Findings
The establishment was cited for multiple violations including failure to conduct required tornado drills and orient residents timely to emergency plans, failure to report incidents within 24 hours, incomplete physician assessments prior to admission, service plans not developed and signed by a registered nurse, failure to complete two-step TB testing on admission, and failure to notify a provider timely of a resident's change in condition.
Deficiencies (6)
A2040 (295.2040 Disaster Preparedness) - The establishment failed to conduct a tornado drill on each shift during February and failed to orient residents to emergency and evacuation plans within 10 days of arrival.
A2050 (295.2050 Incident and Accident Reporting) - The establishment failed to report a serious incident involving a resident's fall and fracture within 24 hours.
A4000 (295.4000 Physician's Assessment) - The establishment failed to complete physician assessments within 120 days prior to admission for two residents.
A4010 (295.4010 Service Plan) - The establishment failed to have a registered nurse develop and sign service plans for two residents.
A4050 (295.4050 Tuberculin Skin Test Procedures) - The establishment failed to complete two-step TB testing upon admission for two residents as required by policy.
A6000 (295.6000 Resident Rights) - The establishment failed to ensure a resident was free from neglect by not notifying a provider timely of the resident's change in condition after a fall resulting in fracture.
Report Facts
Residents reviewed: 3
Residents affected: 2
Residents affected: 2
Residents affected: 1
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