Inspection Report
Re-Inspection
Deficiencies: 4
Jul 7, 2025
Visit Reason
A Revisit Survey was conducted on 07/07/2025 based upon implementation of the acceptable Plan of Correction to verify compliance.
Findings
The facility was deemed to be in compliance on 06/30/2025 based on the acceptable Plan of Correction. The prior deficiencies related to misappropriation of resident property and abuse, neglect, or misappropriation were addressed with corrective actions including staff education, policy reviews, and monitoring procedures.
Complaint Details
The revisit survey was conducted following a complaint investigation related to allegations of abuse, neglect, and misappropriation of resident property involving multiple residents and staff. The investigation included interviews, record reviews, and policy assessments. The facility implemented corrective actions including staff education, policy revisions, monitoring, and forensic accounting to address the issues.
Severity Breakdown
Level D: 4
Deficiencies (4)
| Description | Severity |
|---|---|
| Failure to be free from abuse, neglect, misappropriation of resident property, and exploitation as evidenced by misappropriation of resident property for 3 of 3 residents reviewed. | Level D |
| Failure to ensure employees were not found guilty of abuse, neglect, exploitation, or misappropriation of property or mistreatment by a court of law. | Level D |
| Failure to investigate, prevent, and correct alleged violations of abuse, neglect, exploitation, or misappropriation of resident property. | Level D |
| Failure to ensure quality of care including skin integrity and accident prevention. | Level D |
Report Facts
Survey Census: 104
Sample Size: 24
Number of residents reviewed for misappropriation: 3
Weight loss percentage: 5.5
Weight record months: 6
Skin assessments: 10
Sabina Lift transfers per week: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Slate Registered Nurse | SRNA 36 | Identified as the suspect in fraudulent charges and terminated from employment |
| Resident 45 | Resident involved in misappropriation investigation and assisted with communications to cancel debit and charge cards | |
| Resident 158 | Resident involved in misappropriation investigation with fraudulent charges reversed | |
| Resident 10 | Resident involved in misappropriation investigation and assisted with cancelling debit card | |
| Administrator | Conducted investigations, coordinated corrective actions, and provided education and monitoring | |
| Accounts Receivable Bookkeeper | Received education on reporting allegations and suspicions of theft, fraud, or misappropriation | |
| Chief HR Officer | Reviewed criminal background checks and hiring process for SRNA 36 | |
| PTGC | Part-Time General Counsel | Reviewed background check and hiring process for SRNA 36 |
| Director of Nursing | DON | Conducted educational in-services and monitored skin assessments |
| Nurse Consultant | Provided education regarding reporting requirements | |
| Staff Development Coordinator | Provided education and training on reporting requirements | |
| Vice President of Operations | Provided education and training on reporting requirements |
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