Deficiencies per Year
12
9
6
3
0
Severe
High
Moderate
Low
Unclassified
Inspection Report
Complaint Investigation
Capacity: 82
Deficiencies: 11
Oct 27, 2025
Visit Reason
State-compiled facility profile showing 10 inspections from 2021 to 2025 with deficiency history and licensing violations.
Findings
Across multiple inspections, the facility exhibited deficiencies related to discharge planning, quality of care, medication administration errors, environmental cleanliness, catheter care, and safety interventions. Several deficiencies were noted as not corrected at follow-up visits, indicating ongoing compliance challenges.
Deficiencies (11)
| Description |
|---|
| F0000 - INITIAL COMMENTS |
| M0000 - Initial Comments |
| F0584 - Safe/Clean/Comfortable/Homelike Environment: Failed to ensure a homelike environment for 1 of 2 resident rooms (Room #29) with stained and uncleanable recliner chair. |
| F0660 - Discharge Planning Process: Failed to ensure safe discharge for 1 of 2 sampled residents (#210), including lack of family notification and education on catheter care and medications. |
| F0689 - Free of Accident Hazards/Supervision/Devices: Failed to ensure fall prevention safety interventions were followed for 1 of 4 residents (#26). |
| F0690 - Bowel/Bladder Incontinence, Catheter, UTI: Failed to follow catheter care orders for 1 of 1 resident (#53). |
| F0812 - Food Procurement,Store/Prepare/Serve-Sanitary: Failed to ensure food and beverages were labeled and stored properly to minimize spoilage and cross contamination in kitchen. |
| F0661 - Discharge Summary: Failed to complete discharge summary for 1 of 3 sampled residents (#1). |
| F0684 - Quality of Care: Failed to follow physician orders for bowel care and respiratory care for multiple residents (#1, #3, #4, #7). |
| F0760 - Residents are Free of Significant Med Errors: Failed to administer Warfarin as ordered resulting in significant medication error for 1 of 3 sampled residents (#1). |
| F0661 - Discharge Summary: Failed to complete discharge summary for 1 of 3 sampled residents (#1). |
Report Facts
Inspections on page: 10
Total deficiencies: 11
Total surveys: 10
Licensing violations: 10
Abuse violations: 0
Notices: 0
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff 1 | Administrator | Named in multiple findings including discharge planning, catheter care, kitchen sanitation, medication administration, and fall prevention |
| Staff 2 | DNS | Named in findings related to discharge planning, catheter care, medication administration, and fall prevention |
| Staff 3 | Infection Preventionist / LPN | Named in findings related to environment cleanliness and fall prevention |
| Staff 4 | Social Services Director | Named in discharge summary deficiency |
| Staff 13 | CNA | Named in fall prevention and discharge planning findings |
| Staff 15 | RNCM | Named in discharge planning findings |
| Staff 18 | RN | Named in catheter care deficiency |
| Staff 19 | LPN | Named in catheter care deficiency |
| Staff 20 | RCM/LPN | Named in catheter care deficiency |
| Staff 14 | Dietary Manager | Named in kitchen sanitation deficiency |
| Staff 16 | Physical Therapy Assistant | Named in discharge planning findings |
| Staff 7 | LPN (Former) | Named in medication error and heat pack application findings |
| Staff 5 | Social Services | Named in discharge planning findings |
| Staff 4 | RN (Former) | Named in medication error and discharge summary findings |
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