4 CMS Surveys
Inspection Report — Aug 7, 2025
Date: Aug 7, 2025
Visit Reason
No specific visit type named in the Initial Comment block; the document states no health deficiencies found.
Findings
The establishment was found in compliance with no health deficiencies cited.
Inspection Report — Jun 13, 2024
Complaint Investigation
Date: Jun 13, 2024
Visit Reason
Complaint investigation regarding allegations of abuse involving resident R70, including failure to timely report and investigate the abuse allegation.
Complaint Details
Complaint involving resident R70 regarding abuse allegations; failure to timely report and investigate abuse; no other complaints listed.
Findings
The facility failed to timely report an allegation of abuse to the State Survey Agency, failed to initiate an investigation promptly, and failed to develop and implement a comprehensive person-centered care plan for abuse for resident R70. Additionally, the facility failed to properly label and store food items, risking contamination for all 77 residents.
Deficiencies (4)
F0609 (Timely report suspected abuse) - The facility failed to report an allegation of abuse to the State Survey Agency within 24 hours of being made aware of a potential abuse allegation from resident R70.
F0610 (Respond appropriately to all alleged violations) - The facility failed to initiate an investigation in a timely manner for an allegation of abuse for resident R70.
F0656 (Develop and implement a complete care plan) - The facility failed to develop and implement a comprehensive person-centered care plan for abuse for resident R70.
F0812 (Procure food from approved sources and store properly) - The facility failed to follow policy by not properly labeling and storing food, including expired items and unlabeled products, affecting all 77 residents.
Report Facts
Residents affected: 1
Residents affected: 35
Residents affected: 77
Inspection Report — Aug 4, 2023
Annual Inspection
Date: Aug 4, 2023
Visit Reason
Annual Licensure Survey
Findings
The facility was found to have multiple deficiencies including failure to provide dignity during feeding, improper use of physical restraints, incorrect use of pressure relieving mattresses, failure to post nurse staffing information, failure to follow controlled substance policies, and failure to follow infection prevention and control policies.
Deficiencies (6)
F0550 (295.2050 Resident Rights) - The facility failed to provide dignity during meal time by standing over a resident while feeding, affecting one resident.
F0604 (295.2060 Restraints) - The facility failed to ensure that two residents were free from physical restraints, as they were seated in a manner restricting movement.
F0686 (295.2086 Pressure Ulcers) - The facility failed to correctly use pressure relieving mattresses for three of four residents at risk for skin alteration.
F0732 (295.2132 Nurse Staffing) - The facility failed to post complete nurse staffing data in a prominent place accessible to residents and visitors, affecting all 81 residents.
F0755 (295.2155 Pharmaceutical Services) - The facility failed to follow controlled substance policy by not storing controlled substances in a locked refrigerator and failing to accurately document controlled drug counts, affecting five residents.
F0880 (295.2180 Infection Control) - The facility failed to follow its standard precaution policy when a staff member did not perform hand hygiene after picking up a resident's fruit cup from the floor.
Report Facts
Residents affected: 1
Residents affected: 2
Residents affected: 3
Residents affected: 81
Residents affected: 5
Residents affected: 1
Inspection Report — May 2, 2023
Complaint Investigation
Date: May 2, 2023
Visit Reason
Complaint investigation regarding failure to complete a thorough investigation of injury of unknown origin for resident R2 and failure to follow professional standards of practice after a resident fall for resident R6.
Findings
The facility failed to complete a thorough investigation of an injury of unknown origin for one resident (R2) and failed to follow professional standards of practice after a resident fall, resulting in a right femur fracture for resident R6. The facility also failed to have effective fall prevention interventions and adequate supervision for R6 and failed to properly assist R2 during repositioning, causing bruises and a femoral fracture.
Deficiencies (3)
F0610 (Complaint Investigation) - The facility failed to complete a thorough investigation of injury of unknown origin affecting one resident (R2).
F0658 (Complaint Investigation) - The facility failed to follow professional standards of practice after a resident fall by not immobilizing the suspected area of injury and allowing the resident (R6) to continue weight bearing activity.
F0689 (Complaint Investigation) - The facility failed to have effective fall prevention interventions and adequate supervision for resident R6, resulting in a fall with injury, and failed to properly assist resident R2 during repositioning, causing bruises and a femoral fracture.
Report Facts
Residents affected: 1
Residents affected: 1
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