5 Reports
Inspection Report — Jun 4, 2025
Routine CMS
Date: Jun 4, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, medication administration, infection control, and data transmission for a nursing home facility.
Findings
The facility was found deficient in timely transmission of Minimum Data Set discharge assessments, failure to provide appropriate mobility aids and respiratory care signage, medication errors exceeding 5%, and inadequate implementation of enhanced barrier precautions for infection control.
Deficiencies (5)
F0640: The facility failed to electronically transmit accurate and complete Minimum Data Set discharge assessments within 14 days for 2 residents discharged in January 2025.
F0688: The facility failed to provide appropriate services and equipment to maintain or improve mobility for 2 residents with limited mobility, including failure to provide ordered hand rolls and orthotic devices.
F0695: The facility failed to provide safe respiratory care by not placing oxygen-in-use signage outside the rooms of 2 residents receiving oxygen therapy.
F0759: The facility failed to maintain a medication error rate below 5%, with 2 medication errors out of 37 opportunities, including omissions of prescribed eye and antidepressant medications.
F0880: The facility failed to implement its infection control program by not placing enhanced barrier precaution signage and PPE outside the rooms of 2 residents with wounds requiring such precautions.
Report Facts
Medication error rate: 5.26
Medication errors: 2
Medication administration opportunities: 37
Residents reviewed for mobility: 3
Residents affected by mobility deficiency: 2
Residents reviewed for oxygen: 2
Residents affected by oxygen signage deficiency: 2
Residents affected by infection control deficiency: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| S2 Director of Nursing | Director of Nursing | Confirmed deficiencies related to hand roll placement, oxygen signage, medication errors, and infection control signage |
| S3 Licensed Practical Nurse | Licensed Practical Nurse | Observed medication administration and confirmed hand roll placement issues |
| S4 Licensed Practical Nurse | Licensed Practical Nurse | Observed medication administration and oxygen signage absence |
| S5 Occupational Therapist | Occupational Therapist | Recommended palm protector for resident's hand which was not implemented |
| S6 Certified Nursing Assistant | Certified Nursing Assistant | Reported no order for palm protector use |
Inspection Report — Aug 14, 2024
Complaint Investigation CMS
Date: Aug 14, 2024
Visit Reason
The inspection was conducted in response to complaints regarding long call light response times and inadequate pressure ulcer care at the facility.
Complaint Details
The complaint investigation substantiated that resident #2 experienced long call light response times and resident #3 did not receive proper pressure ulcer care as per physician orders.
Findings
The facility failed to ensure timely response to a resident's call light, with a maximum wait time of over 32 minutes. Additionally, the facility failed to provide appropriate pressure ulcer care by not covering a resident's sacral wound as ordered by the physician.
Deficiencies (2)
F 0557: The facility failed to ensure resident #2's call light was answered in a timely manner, resulting in a maximum response time of 32 minutes and 34 seconds on 08/11/2024.
F 0686: The facility failed to provide appropriate pressure ulcer care for resident #3 by not covering the sacral wound with a dressing as ordered, leaving the wound open and exposed with feces inside.
Report Facts
Maximum call light response time (minutes:seconds): 32.34
Number of residents sampled for pressure ulcers: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| S5 LPN | Licensed Practical Nurse | Named in relation to pressure ulcer dressing finding for resident #3 |
| S3 Wound Care Nurse | Wound Care Nurse | Named in relation to pressure ulcer dressing finding for resident #3 |
| S4 CNA | Certified Nursing Assistant | Observed resident #3 without dressing and notified nurse |
| S1 Administrator | Administrator | Notified of both call light response and pressure ulcer care findings |
| S2 Assistant Administrator | Assistant Administrator | Notified of pressure ulcer care findings |
Inspection Report — May 30, 2024
Routine CMS
Date: May 30, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, medication management, food service, equipment safety, and overall facility operations.
Findings
The facility was found deficient in providing adequate assistance with activities of daily living, ensuring psychotropic medications were properly managed, accommodating resident food preferences, maintaining food service safety standards, and keeping essential kitchen equipment in safe working condition.
Deficiencies (5)
F 0677: The facility failed to provide necessary nail care to resident #5, who had long and dirty fingernails despite requests for assistance.
F 0758: The facility failed to ensure psychotropic medications were used appropriately for residents #24 and #219, including missing lab work and lack of documented diagnosis.
F 0806: The facility failed to provide condiments with meals to 5 residents, including #4, #17, #22, #39, and #47, despite their dietary orders and preferences.
F 0812: The facility failed to ensure dietary staff properly tested sanitizer levels in the dishwashing process and prevented contamination of food by serving utensils during meal service.
F 0908: The facility failed to maintain the deep fryer in safe operating condition due to a large buildup of grease in the internal compartment.
Report Facts
Residents receiving meals: 72
Residents affected by nail care deficiency: 1
Residents reviewed for psychotropic medication: 5
Residents affected by psychotropic medication deficiency: 2
Residents affected by food condiment deficiency: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| S2 Director of Nurses | Director of Nursing | Confirmed nail care deficiency and medication management issues. |
| S4 Dietary Manager | Dietary Manager | Provided information on residents served meals and confirmed food service safety deficiencies. |
| S5 Dietary Worker | Dietary Worker | Observed improperly handling serving utensils and sanitizer testing. |
| S6 Dietary Worker | Dietary Worker | Observed and interviewed regarding sanitizer testing procedures. |
| S7 Dietary Worker | Dietary Worker | Observed placing tong handles in contact with food. |
| S8 Assistant Director of Nursing | Assistant Director of Nursing | Confirmed lack of documented diagnosis for psychotropic medication use. |
| S1 Administrator | Administrator | Notified of food service and equipment safety observations. |
| S9 Administrator-In-Training | Administrator-In-Training | Notified of food service and equipment safety observations. |
| S3 Licensed Practical Nurse | Licensed Practical Nurse | Confirmed resident #5 needed nail care. |
Inspection Report — Nov 1, 2023
Complaint Investigation CMS
Date: Nov 1, 2023
Visit Reason
The inspection was conducted due to allegations of abuse reported by residents and concerns about infection prevention and control practices during pericare procedures.
Complaint Details
The complaint involved allegations of abuse by Resident #1 against a former employee who reportedly pulled on her left arm causing pain. The allegation was not immediately reported to the administrator as required. The complaint was substantiated with findings confirming delayed reporting.
Findings
The facility failed to immediately report an allegation of abuse involving Resident #1 to the administrator. Additionally, staff failed to perform proper hand hygiene during pericare for Residents #1 and #2, risking cross contamination.
Deficiencies (2)
F 0609: The facility failed to ensure that an allegation of abuse related to Resident #1 was reported immediately to the administrator by an employee who was made aware of the allegation.
F 0880: The facility failed to maintain an infection prevention and control program as staff did not perform proper hand hygiene after providing pericare for Residents #1 and #2, risking cross contamination.
Report Facts
Residents involved in abuse allegation: 1
Residents observed during pericare: 2
Inspection Report — May 17, 2023
Complaint Investigation CMS
Date: May 17, 2023
Visit Reason
The inspection was conducted based on a complaint regarding the facility's failure to provide timely meal assistance and adequate grooming care to a resident.
Complaint Details
The complaint investigation found substantiated deficiencies related to failure to provide timely meal assistance and grooming care for resident #52.
Findings
The facility failed to provide resident #52 with timely meal assistance while other residents at the table were served. Additionally, the facility did not ensure the resident received necessary grooming care, as evidenced by unshaved facial hair.
Deficiencies (2)
F 0550: The facility failed to treat resident #52 with respect and dignity by not providing timely meal assistance while other residents were served.
F 0677: The facility failed to provide necessary grooming care for resident #52, who had unkempt facial hair in need of shaving.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse | Confirmed resident #52 waited without his meal and that facial hair needed shaving. | |
| Director of Nursing | Confirmed resident #52 should have been provided his meal at the same time as other residents and that facial hair needed shaving. |
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