The most recent inspection on September 20, 2024, found no deficiencies during the on-site compliance review. Earlier inspections showed some challenges, including multiple deficiencies in late 2022 related to fall prevention training, policy implementation, caregiver skills verification, orientation, personnel records, service plan reviews, and resident acceptance criteria. Enforcement actions in early 2023 resulted in fines totaling $2,500 for issues with CPR training policies, caregiver skill verification, and personnel record maintenance, which were paid in full. Complaint investigations since then were unsubstantiated or found no deficiencies, except for one substantiated personnel record issue in late 2022. The inspection history indicates improvement, with recent inspections showing no deficiencies following prior citations and enforcement actions.
Deficiencies (last 3 years)
Deficiencies (over 3 years)2.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
The facility was found non-compliant in multiple areas including CPR policy implementation, caregiver skill verification, and personnel record maintenance, resulting in civil fines totaling $1250.
Fines & Penalties (3)
Amount
Reason
Status
$500.00
Failure to ensure policies and procedures were established, documented, and implemented to protect health and safety of a resident including CPR training and documentation.
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$250.00
Failure to ensure caregiver's or assistant caregiver's skills and knowledge were verified and documented before providing physical health services.
—
$500.00
Failure to ensure personnel record for each employee included documentation of CPR and first aid training.
Seven deficiencies were found related to fall prevention training, policy implementation, caregiver skills verification, orientation, personnel records, service plan reviews, and resident acceptance criteria.
Findings
Seven deficiencies were found related to fall prevention training, policy implementation, caregiver skills verification, orientation, personnel records, service plan reviews, and resident acceptance criteria.
Deficiencies (7)
Description
36-420.01 — Fall prevention and training programs
C. — Policies and procedures establishment and implementation
