1 Report
Inspection Report — Oct 6, 2025
Annual Inspection
Date: Oct 6, 2025
Visit Reason
Annual Licensure Survey conducted citing violations 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 tornado drills as required, failure to report incidents timely, incomplete physician assessments prior to admission, service plans not developed or signed by a registered nurse, incomplete tuberculosis testing, 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, creating substantial probability of harm to all residents, visitors, and employees.
A2050 (295.2050 Incident and Accident Reporting) - The establishment failed to report an incident within 24 hours for 1 of 3 residents reviewed, delaying notification of a fall with injury.
A4000 (295.4000 Physician's Assessment) - The establishment failed to complete a physician assessment within 120 days prior to admission for 2 of 3 residents reviewed.
A4010 (295.4010 Service Plan) - The establishment failed to have a registered nurse develop and sign the service plans for 2 of 3 residents reviewed.
A4050 (295.4050 Tuberculin Skin Test Procedures) - The establishment failed to comply with tuberculosis screening requirements by not completing a two-step TB test for 2 of 3 residents reviewed upon admission.
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 delayed x-ray and treatment.
Report Facts
Residents reviewed: 3
Residents affected: 1
Residents affected: 2
Residents affected: 2
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