Inspection Report Summary
The most recent inspection on November 8, 2024, found the facility in compliance with state residential licensure requirements and cited no deficiencies. Earlier inspections showed a mix of results, including a June 21, 2023 survey that identified deficiencies related to fire and disaster preparedness, CPR and First Aid staffing, medication administration and storage, and infection control practices. Complaint investigations in December 2023 and June 2023 were unsubstantiated, with no deficiencies related to the complaint allegations. No fines, immediate jeopardy findings, or enforcement actions were listed in the available reports. The facility’s inspection history suggests improvement, with the most recent survey showing no deficiencies after prior issues were noted.
Deficiencies (last 2 years)
Deficiencies are regulatory violations found during state inspections.
Deficiencies per year
Census
Based on a November 2024 inspection.
Census over time
| Description |
|---|
| Failed to ensure fire drills were held in conjunction with the local fire department at least every six months. |
| Failed to ensure staff met CPR and First Aid certification requirements for 8 of 42 shifts reviewed. |
| Failed to ensure medication was administered as ordered for 1 of 5 residents reviewed (Resident 14). |
| Failed to ensure proper medication storage, disposal, and controlled substance count verification in medication rooms and carts. |
| Failed to ensure insulin medications had pharmacy labels including physician name, prescription number, date of issuance, and pharmacy name for 1 of 3 medication carts reviewed. |
| Failed to establish infection control procedures for cleaning and disinfecting blood glucose meters, resulting in shared glucometers without proper cleaning for 3 of 12 residents monitored. |
| Name | Title | Context |
|---|---|---|
| James Kesler | Executive Director | Interviewed regarding fire drills, CPR/First Aid staffing, medication policies, and infection control. |
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