17 CMS Surveys
Inspection Report — Jan 20, 2026
Complaint Investigation
Date: Jan 20, 2026
Visit Reason
Investigation of a complaint received on 2025-12-15 about improper bed mobility and resident fall.
Complaint Details
Improper bed mobility and positioning causing resident fall: established.
Findings
A violation was established for failure to ensure proper positioning and bed mobility, resulting in a resident falling out of bed and being transferred to the hospital.
Deficiencies (1)
F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents: the facility failed to ensure proper positioning and bed mobility for resident R701, resulting in a fall from bed and transfer to hospital.
Inspection Report — Oct 24, 2025
Complaint Investigation
Date: Oct 24, 2025
Visit Reason
Investigation of a complaint received on 2025-10-21 about failure to notify responsible party of a fall, medication administration, staffing shortages, and infection control.
Complaint Details
Failure to notify responsible party of fall and hospital transfer: established. Missed medication administration for two residents: established. Insufficient staffing causing delays in resident care: established. Failure to implement infection control precautions for ESBL infection: established.
Findings
Four rule violations were established related to failure to notify responsible party of a fall, missed medication administration, insufficient staffing, and inadequate infection prevention and control.
Deficiencies (4)
F 0580 Failure to notify responsible party: Licensed Practical Nurse 'A' failed to notify the resident's responsible party of a fall and hospital transfer.
F 0684 Medication administration: The facility failed to ensure medications were available and administered per physician orders for two residents, resulting in missed doses.
F 0725 Staffing levels: The facility failed to provide sufficient nursing staff to meet resident needs, resulting in delays in care and residents being left wet for extended periods.
F 0880 Infection prevention and control: The facility failed to implement enhanced barrier precautions for a resident with an ESBL infection and PICC line, resulting in lack of PPE use and signage.
Inspection Report — Jul 31, 2025
Complaint Investigation
Date: Jul 31, 2025
Visit Reason
Investigation of complaints received about neglect, abuse, medication administration, falls, infection control, and pest control.
Complaint Details
Dignified dining experience: established. Equipment maintenance: established. Reporting neglect and injury: established. Investigation of injury: established. Bathing assistance: established. Wound care and medication administration: established. Safe bed mobility: established. Infection control program: established. Pest control program: established.
Findings
Multiple deficiencies were found including failure to ensure dignified dining experience, equipment maintenance, timely reporting and investigation of injuries, provision of bathing assistance, wound care, medication administration, safe bed mobility, infection control, and pest control.
Deficiencies (9)
F 0550 Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights: facility failed to ensure a dignified dining experience for one resident (R14) with delayed meal service and presence of flies in dining areas.
F 0584 Honor the resident's right to a safe, clean, comfortable and homelike environment: facility failed to maintain resident equipment in good repair; wheelchair for resident R8 had missing armrest and worn wheels.
F 0609 Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities: facility failed to report an allegation of neglect and injury of unknown origin for residents R138 and R141; no investigation or reporting to State Agency was done.
F 0610 Respond appropriately to all alleged violations: facility failed to complete and document a thorough investigation into an injury of unknown origin for resident R138; investigation steps and documentation were incomplete.
F 0677 Provide care and assistance to perform activities of daily living: facility failed to consistently provide bathing assistance for resident R63, who reported missed showers despite documentation indicating showers were given.
F 0684 Provide appropriate treatment and care according to orders, resident's preferences and goals: facility failed to assess and treat a skin impairment on resident R55 in a timely manner, resulting in infection and delayed healing; also failed to administer wound care treatments consistently; failed to provide medications from back-up supply for resident R139.
F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents: resident R105 fell out of bed when rolled away from the wall, causing injury; staff failed to follow safe bed mobility practices.
F 0880 Provide and implement an infection prevention and control program: facility failed to ensure consistent infection control practices, failed to follow county health department guidance for legionella surveillance, and failed to identify and test residents meeting criteria for enhanced legionella testing.
F 0925 Make sure there is a pest control program to prevent/deal with mice, insects, or other pests: facility failed to maintain an effective pest control program; flying insects observed throughout the facility including resident rooms and dining areas; pest control visits not documented since March 2025.
Inspection Report — Jul 31, 2025
Renewal
Date: Jul 31, 2025
Visit Reason
Renewal inspection of the adult foster care family home license.
Findings
The facility was found to have multiple deficiencies including failure to timely assess and treat skin impairments, failure to ensure safe medication administration and storage, failure to maintain accurate medical records, failure to provide adequate bathing and bed mobility assistance, failure to ensure infection control standards and surveillance, failure to monitor antibiotic use effectively, failure to ensure pest control, and failure to properly explain binding arbitration agreements to residents.
Deficiencies (14)
Failure to timely assess and treat skin impairments resulted in an infected wound on R55's arm that was not treated for over two months and was not properly documented or followed up by nursing staff.
R49's right leg skin impairment with blistering and drainage was not treated until after identification, with delayed initiation of treatment orders.
Medications for R139 were not pulled from the back-up medication supply and administered timely, resulting in missed doses of cardiac medications after hospital admission.
R105 fell out of bed when a CNA rolled her over without realizing the bed was away from the wall, causing injury to her foot; staff failed to follow safe bed mobility practices.
Binding Arbitration agreements were not clearly explained to residents R84 and R80, who did not understand the legal implications of signing and their rights to rescind the agreement.
The facility failed to identify and implement plans to address systemic issues in infection control and pest control, including failure to follow county health department guidance on legionella surveillance and presence of flying insects throughout the facility.
Infection control practices were inconsistently followed, including improper use of personal protective equipment by staff.
The facility failed to ensure an effective system to monitor antibiotic use, with multiple residents prescribed potentially unnecessary antibiotics without documented review or physician response.
Medication carts and storage rooms were not properly cleaned or maintained; expired insulin products and sticky residues were observed, posing risks to medication safety.
Food storage and preparation practices were not in accordance with professional standards, including undated and uncovered food items in refrigerators and dirty kitchen equipment.
Medical records for resident R96 were incomplete and inaccurate, including a progress note falsely indicating a guardian that did not exist and questionable authorship of the note.
R30's Minimum Data Set assessment was inaccurate regarding hospice care status, indicating a lack of proper assessment and documentation.
R63 did not consistently receive bathing assistance as scheduled, with documented showers not actually provided as reported by the resident.
R30's anxiety disorder care plan was not developed or implemented, despite medication orders for anxiety, indicating a failure to provide comprehensive resident-centered care.
Inspection Report — May 15, 2025
Complaint Investigation
Date: May 15, 2025
Visit Reason
Investigation of a complaint received on 2025-05-15 about failure to address resident grievances.
Complaint Details
Failure to address resident grievances: violation established.
Findings
The facility failed to address grievances for one resident, resulting in verbalized frustrations with quality of care.
Inspection Report — Apr 10, 2025
Complaint Investigation
Date: Apr 10, 2025
Visit Reason
Investigation of a complaint received on 2025-04-05 about misappropriation of property, falls, and medication storage.
Complaint Details
Misappropriation of property: violation established. Multiple falls with inadequate investigation and supervision: violation established. Improper medication storage and expired medications: violation established.
Findings
Three deficiencies were found related to failure to report alleged misappropriation of property, inadequate investigation and supervision to prevent resident falls, and improper medication storage and handling.
Deficiencies (3)
F 0609 Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities: the facility failed to report an allegation of misappropriation of property to the Administrator and/or State Survey Agency for one resident.
F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents: the facility failed to thoroughly investigate multiple falls and implement effective interventions including adequate supervision for one resident who had repeated falls resulting in injury.
F 0761 Ensure drugs and biologicals used in the facility are labeled and stored properly: the facility failed to ensure medications were stored properly and discarded by the expiration date for two medication carts reviewed.
Inspection Report — Mar 6, 2025
Complaint Investigation
Date: Mar 6, 2025
Visit Reason
Investigation of a complaint received on 2025-01-06 about failure to provide regularly scheduled bathing.
Complaint Details
Failure to provide regularly scheduled bathing for resident R902: established.
Findings
The facility failed to ensure regularly scheduled bathing was provided for one resident (R902) as ordered. Past noncompliance was cited but the facility demonstrated corrective actions and maintained compliance after the discharge of the resident.
Deficiencies (1)
F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable: the facility failed to ensure regularly scheduled bathing was provided for one resident (R902) as ordered on 1/2/25 and from 1/14/25 through 1/22/25.
Inspection Report — Oct 28, 2024
Complaint Investigation
Date: Oct 28, 2024
Visit Reason
Investigation of a complaint received on 2024-10-12 about physical and verbal abuse by a staff member.
Complaint Details
Physical and verbal abuse by CNA C: established. Delay in reporting abuse to authorities: established.
Findings
Two violations were established related to physical and verbal abuse of resident R901 by Certified Nursing Assistant C (CNA C) on 10/12/24, including punching, kicking, grabbing the neck, and verbal insults. The facility failed to timely report the abuse to the abuse coordinator and State Agency, resulting in delayed notification.
Deficiencies (2)
F 0600 Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody: CNA C physically and verbally abused resident R901 by punching, kicking, grabbing the neck, and calling her a b**** on 10/12/24.
F 0609 Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities: The facility delayed notification of the abuse allegation to the abuse coordinator and State Agency after the incident on 10/12/24.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA C | Certified Nursing Assistant | Named in the physical and verbal abuse findings against resident R901. |
Inspection Report — Sep 17, 2024
Complaint Investigation
Date: Sep 17, 2024
Visit Reason
Investigation of multiple complaints received on 2024-09-06 about resident care deficiencies including failure to protect from abuse, inadequate feeding assistance, insufficient nursing staff, and failure to provide food and drink per individualized care plans.
Complaint Details
Resident-to-resident physical abuse: established. Failure to provide one-to-one feeding assistance: established. Insufficient nursing staff to meet resident needs: established. Failure to provide food and drink per individualized care plan: established. Failure to update facility-wide assessment to reflect current resident needs and staffing: established.
Findings
The facility failed to protect residents from physical abuse, provide required one-to-one feeding assistance, maintain sufficient nursing staff to meet resident needs, provide food and drink in accordance with individualized care plans, and conduct a facility-wide assessment reflecting current resident acuity and staffing needs. Multiple residents were affected, including R803, R804, R805, and R806.
Deficiencies (5)
F 0600 Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody: the facility failed to protect resident R803 from physical abuse by resident R804 resulting in injury and fear.
F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable: the facility failed to provide one-to-one feeding assistance as ordered for resident R806, who was observed without required assistance and left with food on clothing.
F 0725 Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift: the facility failed to maintain sufficient nursing staff to meet resident needs, with multiple shifts understaffed and agency staff unaware of care requirements.
F 0805 Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs: the facility failed to provide resident R806 with drink and adaptive utensils per plan of care, including use of straws despite orders prohibiting them.
F 0838 Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies: the facility failed to update the facility assessment to reflect changes in resident acuity, staffing needs, and administrative staff, resulting in insufficient resources to provide care.
Inspection Report — Jul 17, 2024
Renewal
Date: Jul 17, 2024
Visit Reason
Renewal inspection of the adult foster care family home license.
Findings
Multiple deficiencies were cited related to resident care, infection control, medication administration, food service, and facility maintenance. The facility was found to be out of compliance with infection control protocols, medication regimen reviews, timely medication administration, food preferences and meal service, pressure ulcer care, and pest control.
Deficiencies (18)
F 0578 Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive: conflicting documentation and failure to ensure accurate advance directive information for resident R83.
F 0600 Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody: failure to protect resident R26 from resident-to-resident verbal and physical abuse by R67, and failure to implement behavioral management plan.
F 0644 Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed: failure to complete an annual OBRA Level I evaluation and submit required PASRR documentation for resident R31.
F 0656 Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured: failure to develop and implement care plans for oxygen use and transmission-based precautions for resident R18.
F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable: failure to provide showers as requested for resident R349.
F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing: failure to implement physician treatment orders timely for pressure ulcers for resident R28 and failure to assess and prevent pressure ulcer development for resident R355.
F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents: failure to ensure resident R26 was transferred appropriately with two-person assist using mechanical lift, resulting in skin abrasion and lack of incident report.
F 0756 Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures: failure to ensure monthly medication regimen reviews were conducted by the consultant pharmacist for resident R18.
F 0760 Ensure that residents are free from significant medication errors: failure to ensure timely administration of seizure medications and timely physician notification for residents R18 and R88, resulting in increased seizure risk.
F 0773 Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results: failure to timely notify physician of abnormal laboratory results for resident R26.
F 0802 Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service: failure to ensure adequate kitchen staffing resulting in late and incorrect meals, cold food, and resident dissatisfaction affecting multiple residents including R5, R28, and R64.
F 0806 Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options: failure to honor resident food preferences and provide appealing food options for residents R28, R36, R49, R56, R72, R74, and R78, resulting in verbalized complaints and dissatisfaction.
F 0809 Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests: failure to provide timely meals resulting in late meal times outside of resident preferences and needs affecting residents on the 2nd floor and resident council.
F 0812 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards: failure to maintain a sanitary kitchen, maintain equipment in good repair, safely store and handle food, and maintain proper dishwashing sanitizer levels, resulting in increased risk of foodborne illness affecting all residents.
F 0868 Have the Quality Assessment and Assurance group have the required members and meet at least quarterly: failure to ensure the Infection Control Preventionist attended QAPI meetings at least quarterly, risking lack of coordination of resident care policies.
F 0880 Provide and implement an infection prevention and control program: failure to ensure staff followed proper infection control practices and protocols including transmission-based and enhanced barrier precautions for residents R7, R18, R49, R63, and R298.
F 0881 Implement a program that monitors antibiotic use: failure to implement an antibiotic stewardship program that consistently identified signs and symptoms of infection and failed to provide clinical justification for antibiotic use, including incomplete documentation and delayed availability of criteria.
F 0925 Make sure there is a pest control program to prevent/deal with mice, insects, or other pests: failure to eliminate pest harborage conditions resulting in presence of flying pests (gnats) in multiple kitchen and dining areas affecting all residents.
Inspection Report — Jul 17, 2024
Complaint Investigation
Date: Jul 17, 2024
Visit Reason
Investigation of complaints received about resident abuse, inadequate care, food service deficiencies, infection control, and antibiotic stewardship.
Complaint Details
Resident-to-resident abuse: established. Failure to provide showers: established. Unsafe transfers causing injury: established. Inadequate food service staffing and failure to honor food preferences: established. Poor infection control practices including PPE and hand hygiene failures: established. Inadequate antibiotic stewardship program: established.
Findings
Multiple deficiencies were found including failure to protect residents from abuse, inadequate assistance with activities of daily living, insufficient supervision to prevent accidents, inadequate food service staffing and failure to honor resident food preferences, poor infection prevention and control practices, and failure to implement an effective antibiotic stewardship program.
Deficiencies (7)
F 0600 Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody: the facility failed to protect one resident (R26) from resident-to-resident verbal and physical abuse by another resident (R67), and failed to implement behavioral management interventions to prevent recurrence.
F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable: the facility failed to provide a shower for one resident (R349) despite requests and documented need.
F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents: the facility failed to ensure a resident (R26) was transferred safely using a two-person assist mechanical lift, resulting in a skin abrasion and lack of incident reporting.
F 0802 Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service: the facility failed to ensure adequate kitchen staffing, resulting in late, incorrect, and cold meals affecting multiple residents including R5, R28, and R64.
F 0806 Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options: the facility failed to honor food preferences and provide adequate meal choices for multiple residents (R28, R36, R49, R56, R72, R74, R78), resulting in dissatisfaction and complaints.
F 0880 Provide and implement an infection prevention and control program: the facility failed to ensure staff compliance with transmission-based and enhanced barrier precautions for residents (R7, R18, R49, R63, R298), including lack of PPE availability, failure to don/doff PPE, and inadequate hand hygiene.
F 0881 Implement a program that monitors antibiotic use: the facility failed to implement an effective antibiotic stewardship program, including inconsistent identification of infection signs and symptoms, lack of clinical justification for antibiotic use, and incomplete documentation of McGeer criteria.
Inspection Report — Jun 3, 2024
Complaint Investigation
Date: Jun 3, 2024
Visit Reason
Investigation of a complaint received on 2024-06-03 about failure to document follow-up and address resident concerns regarding food service and communication.
Complaint Details
Resident food preferences not honored and overcooked food: established. Facility staff not answering phones after hours causing communication issues: established.
Findings
The facility failed to document follow-up and address concerns per the facility's Concern/Complaint Policy and Procedure for two residents regarding food service and communication issues.
Deficiencies (1)
F 0585 Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances: the facility failed to document follow-up and address concerns for two residents regarding food service and communication as required by policy.
Inspection Report — Apr 30, 2024
Complaint Investigation
Date: Apr 30, 2024
Visit Reason
Investigation of a complaint received on 2024-04-29 about environmental cleanliness, abuse reporting, and infection control.
Complaint Details
Environmental cleanliness issues: established. Failure to timely report suspected abuse: established. Failure to follow infection control protocols: established.
Findings
Three deficiencies were found related to environmental cleanliness, failure to timely report suspected abuse, and failure to follow infection control protocols.
Deficiencies (3)
F 0584 Honor the resident's right to a safe, clean, comfortable and homelike environment: the facility had offensive odors, soiled floors, walls, trash/debris in dining rooms, uncovered condiments, and exposed sharp metal edges on a nursing desk.
F 0609 Timely report suspected abuse, neglect, or theft: the facility failed to report an allegation of abuse by CNA T in a timely manner and did not follow proper investigation procedures.
F 0880 Provide and implement an infection prevention and control program: staff failed to perform hand hygiene when exiting the room of a resident on enhanced barrier precautions, and staff were uncertain about PPE use requirements.
Inspection Report — Sep 7, 2023
Complaint Investigation
Date: Sep 7, 2023
Visit Reason
Investigation of a complaint received on 2022-10-27 about failure to monitor change in condition and timely transfer of a resident with congestive heart failure.
Complaint Details
Failure to monitor change in condition and weight gain: established. Failure to timely start diuretics per cardiology consult: established. Failure to communicate with guardian about condition and x-ray results: established.
Findings
The facility failed to consistently monitor the change in condition for Resident R905, failed to communicate and follow up on specialist orders timely, resulting in significant weight gain, difficulty breathing, and death in the facility.
Deficiencies (1)
F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals: the facility failed to monitor Resident R905's significant weight gain of 9.4 lbs in 4 days, failed to timely start diuretics as recommended by the cardiologist, and failed to communicate critical findings to the guardian, resulting in delayed treatment and death.
Inspection Report — Jul 20, 2023
Complaint Investigation
Date: Jul 20, 2023
Visit Reason
Investigation of a complaint received about multiple care and safety concerns including dignity, environment, abuse reporting, care planning, transfers, nutrition, medication monitoring, and staff competencies.
Complaint Details
Resident dignity violations: established. Unsafe environment and maintenance issues: established. Failure to report abuse allegation: established. Inadequate care planning for contracture: established. Failure to assist with ADLs: established. Failure to follow up on change of condition: established. Improper transfer and unsecured sharps container: established. Failure to provide eating assistance and monitor weight loss: established. Missing CNA competency evaluations: established. Inadequate monitoring and documentation of PRN psychotropic medication: established.
Findings
Multiple deficiencies were found including failure to ensure resident dignity and privacy, inadequate care planning and follow-up for contractures and weight loss, improper transfers, failure to provide timely assistance with activities of daily living, failure to report abuse allegations timely, unsecured sharps containers, lack of documentation for PRN psychotropic medication use, and missing annual CNA competency evaluations.
Deficiencies (10)
F 0550 Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights: facility failed to ensure resident dignity for 10 residents including improper feeding assistance and lack of privacy during transfers.
F 0584 Honor the resident's right to a safe, clean, comfortable and homelike environment: facility failed to maintain clean dining room floors, repair lighting in resident rooms, and maintain wheelchair armrests in good condition.
F 0609 Timely report suspected abuse, neglect, or theft: facility failed to report an allegation of abuse to the Abuse Coordinator and/or State Agency for one resident (R86).
F 0657 Develop the complete care plan within 7 days of the comprehensive assessment: facility failed to ensure an updated care plan for a resident's (R38) left hand contracture.
F 0677 Provide care and assistance to perform activities of daily living: facility failed to provide timely and appropriate assistance with activities of daily living for two residents (R6 and R8), including nail care and assistance to get out of bed.
F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals: facility failed to follow up timely with the physician and/or transfer a resident (R355) with a change of condition to an acute care setting.
F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents: facility failed to properly transfer one resident (R6) requiring a mechanical lift and failed to ensure sharps containers were locked and secured on medication carts.
F 0692 Provide enough food/fluids to maintain a resident's health: facility failed to ensure assistance with eating was provided to one resident (R60) and failed to ensure assessment and monitoring of significant weight loss for one resident (R306).
F 0730 Observe each nurse aide's job performance and give regular training: facility failed to ensure annual competencies/performance reviews for five Certified Nurse Aides.
F 0758 Implement gradual dose reductions and non-pharmacological interventions prior to initiating or continuing psychotropic medication: facility failed to ensure a resident (R5) prescribed PRN psychotropic medication had adequate behavior monitoring and documentation of non-pharmacological interventions prior to medication administration.
Inspection Report — Jun 29, 2023
Complaint Investigation
Date: Jun 29, 2023
Visit Reason
Investigation of complaints received about pressure ulcer care, fall risk and mechanical lift use, and infection prevention and control related to Legionellosis.
Complaint Details
Pressure ulcer care deficiencies for R806: established. Fall risk assessment and mechanical lift use deficiencies for R808: established. Infection prevention and control deficiencies related to Legionellosis cases R810 and R811: established.
Findings
Three deficiencies were found: 1) Failure to ensure accurate skin assessments and timely preventive interventions for pressure ulcers. 2) Failure to ensure accurate fall risk assessment, proper use and training on mechanical lift devices, resulting in a resident fall with injury. 3) Failure to maintain an active water management plan and effective infection surveillance program, resulting in Legionella contamination and inadequate testing and investigation of cases.
Deficiencies (3)
F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing: the facility failed to ensure accurate skin assessments and timely preventive interventions for one resident (R806).
F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents: the facility failed to complete accurate fall risk assessments, failed to follow policy on mechanical lifts, and failed to train staff properly, resulting in a resident fall with a T12 vertebral fracture.
F 0880 Provide and implement an infection prevention and control program: the facility failed to maintain an active water management plan and consistent infection surveillance, resulting in Legionella contamination and failure to test and investigate all residents with symptoms.
Inspection Report — Mar 16, 2023
Complaint Investigation
Date: Mar 16, 2023
Visit Reason
Investigation of complaints received regarding resident transfers, elopement, diagnostic testing, and food service.
Complaint Details
Unsafe resident transfer causing fall and fracture: established. Resident elopement due to unsecured exit door: established. Failure to complete ordered x-ray: established. Food service complaints about temperature and timeliness: not established.
Findings
Three rule violations were established related to unsafe resident transfer, failure to prevent elopement, and failure to complete physician-ordered x-rays. Food service issues were noted but not cited as violations.
Deficiencies (3)
F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents: a CNA failed to use the proper one-person assist lift for resident R703, resulting in a fall with fracture to the resident's right clavicle.
F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents: the facility failed to prevent resident R705 from eloping through an unsecured exit door during a power outage.
F 0777 Provide or obtain x-rays/tests when ordered and promptly tell the ordering practitioner of the results: the facility failed to ensure a physician ordered STAT x-ray of resident R702's right hand was completed as ordered.
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