Deficiencies per Year
12
9
6
3
0
Severe
High
Moderate
Low
Unclassified
Inspection Report
Complaint Investigation
Census: 70
Capacity: 70
Deficiencies: 9
Feb 21, 2025
Visit Reason
State-compiled facility profile showing 14 inspections from 2023-02 to 2025-02 with deficiency history and complaint investigations.
Findings
Across multiple inspections, the facility had mostly complaint investigations with no deficiencies cited, except for two inspections in 2023 and 2024 where multiple deficiencies were found related to staffing documentation, oxygen administration, medication monitoring, care planning, chemical and food storage safety.
Complaint Details
Multiple complaint investigations were conducted between 2023 and 2025, with most resulting in no deficiencies cited. Two inspections combined complaint and compliance (annual) surveys that identified deficiencies.
Deficiencies (9)
| Description |
|---|
| R9-10-412.B.4.d. — Failed to ensure accurate and complete daily staff postings for nursing personnel hours worked, resulting in staffing discrepancies and resident complaints of understaffing. |
| R9-10-419.2.a. — Failed to administer oxygen as ordered to resident #510, with multiple observations confirming no oxygen was provided despite active physician orders. |
| R9-10-403.C.2.b. — Failed to provide treatment and care in accordance with professional standards for resident #215 receiving vancomycin, including failure to notify provider of critical lab results. |
| §483.21(b) — Failed to develop and implement a comprehensive care plan for bathing for resident #17, risking skin issues and poor hygiene. |
| §483.25(d) — Failed to ensure chemicals were safely stored in the kitchen, with hazardous chemicals observed on open shelves accessible during kitchen door open times. |
| §483.60(i) — Failed to properly store food in the kitchen, including uncovered or unsealed items risking contamination and loss of freshness. |
| R9-10-414.B.1. — Failed to develop and implement a care plan for bathing for resident #17 within seven days of assessment. |
| R9-10-423.A.3.b. — Failed to ensure food was stored, refrigerated, and reheated properly to meet dietary needs. |
| R9-10-425.A.11. — Failed to maintain poisonous or toxic materials in labeled containers in a locked area separate from food and medications. |
Report Facts
Inspections on page: 14
Total deficiencies: 10
Complaint inspections: 12
Facility capacity: 70
Census: 70
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| BRET KING | Administrator | Named in staffing deficiency interview and oversight |
| Staff #39 | CNA | Interviewed regarding staffing levels and workload |
| Staff #31 | Staffing Coordinator | Interviewed regarding staffing discrepancies and hours worked |
| Staff #83 | Administrator | Interviewed jointly with staffing coordinator about staffing issues |
| Staff #61 | Certified Nursing Assistant (CNA) | Interviewed about oxygen administration process |
| Staff #113 | Licensed Practical Nurse (LPN) | Interviewed about oxygen administration and physician orders |
| Staff #76 | Assistant Director of Nursing (ADON) | Interviewed about oxygen administration expectations |
| Staff #60 | Licensed Practical Nurse (LPN) | Interviewed about vancomycin trough monitoring and notification process |
| Staff #102 | Assistant Director of Nursing (ADON) | Interviewed about vancomycin monitoring and pharmacy communication |
| Staff #12 | Director of Nursing (DON) | Interviewed about vancomycin monitoring and care planning |
| Staff #7 | MDS Coordinator | Interviewed about care plan requirements for bathing |
| Staff #11 | Dietary Supervisor | Interviewed about chemical and food storage practices |
| Staff #188 | Administrator | Interviewed about chemical and food storage policies and practices |
| Staff #84 | Staff | Written up for failure to verify lab values before medication administration |
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