5 Reports
Inspection Report — Oct 3, 2025
Renewal
Date: Oct 3, 2025
Visit Reason
The facility underwent a renewal inspection as part of its regular licensing process.
Findings
The inspection identified that the basement door leading to resident rooms and the front door exit did not open with a single motion, which is required for safety compliance.
Deficiencies (1)
37.106.2866-4 Construction, building and fire codes: the basement door to resident rooms and the front door exit did not open with a single motion, posing an egress safety issue.
Inspection Report — Aug 2, 2018
Renewal
Date: Aug 2, 2018
Visit Reason
The survey was conducted as a renewal inspection of the facility.
Findings
Three deficiencies were identified related to resident file documentation, resident unit features, and resident bathroom call system functionality.
Deficiencies (3)
37.106.2829-2 Resident file: there was no documentation of the disposition of a resident's personal possessions.
37.106.2835-2 Resident units: no resident rooms were equipped with single motion door knobs.
37.106.2838-7 Resident toilets and bathing: the call system in a resident bathroom was loosely fixed and did not activate when the call cord was pulled.
Inspection Report — Sep 20, 2016
Renewal
Date: Sep 20, 2016
Visit Reason
The survey was conducted as a renewal inspection to assess compliance with licensing requirements.
Findings
Deficiencies were found in resident service plans not reflecting recent significant changes, missing weight documentation in resident files, lack of physician notification in incident reports, and incomplete resident-specific health care plans.
Deficiencies (4)
37.106.2822-3 Resident service plan: category A: the service plan and resident needs assessment were not updated to reflect a resident's recent significant change after starting hospice care.
37.106.2829-2 Resident file: two residents' files did not have weights listed.
37.106.2829-1 Resident file: incident reports lacked physician notification for all reviewed incidents, including falls with injuries and complaints of pain.
37.106.2875-2 Resident health care plan: category B: a resident's health care plan was not resident specific and was missing multiple required health and functional status elements.
Inspection Report — Apr 16, 2015
Complaint Investigation
Date: Apr 16, 2015
Visit Reason
The inspection was conducted following a complaint investigation.
Complaint Details
The complaint investigation identified deficiencies related to resident service plan updates, resident activities, call system accessibility in bathrooms, and oxygen use signage.
Findings
Deficiencies were found in resident service plan reviews, lack of an activity calendar, absence of a fixed call system in resident bathrooms, and improper oxygen use signage in resident rooms.
Deficiencies (4)
37.106.2822-3 Resident service plan: category A: the resident needs assessment and service plan had not been reviewed and updated annually as required.
37.106.2831-4 Resident activities: an activity calendar was not found in the facility, and staff reported using a book to plan activities instead.
37.106.2838-7 Resident toilets and bathing: the facility did not have a fixed call system in resident bathrooms, and call cords in employee and shower bathrooms were too short to be accessible from the floor.
37.106.2853-4 Oxygen use: oxygen concentrators were running in two rooms without residents present, and required oxygen use signs were not posted in those rooms.
Inspection Report — Aug 29, 2014
Renewal
Date: Aug 29, 2014
Visit Reason
The survey was conducted as a renewal inspection of the facility.
Findings
The survey identified deficiencies in policy documentation, employee training, medication storage, and infection control practices.
Deficiencies (5)
37.106.330-1 Minimum standards for all health care fa: the policy and procedure manual lacks written documentation of review.
37.106.2817-1 Employee files: four employee files lacked documentation of Heimlich maneuver training, and one employee's job description incorrectly stated supervisory roles.
37.106.2817-3 Employee files: four employee files lacked documentation of Heimlich maneuver training, and one employee's job description incorrectly stated supervisory roles.
37.106.2846-5 Medications, storage and disposal: multiple medications in storage were outdated or improperly stored, including expired aspirin and missing bottle caps.
37.106.2855-1 Infection control: an aide was observed not removing or changing gloves and failing to wash hands between resident cares.
Report Facts
medication_count: 25
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