Deficiencies per Year
8
6
4
2
0
Severe
High
Moderate
Low
Unclassified
Census Over Time
Inspection Report
Complaint Investigation
Deficiencies: 0
Oct 15, 2025
Visit Reason
An investigation for facility reported incidents #2617233-I and 2633555-I was conducted from October 13, 2025 to October 15, 2025.
Findings
The facility was found to be in substantial compliance following the investigation.
Complaint Details
Investigation was related to two facility reported incidents (#2617233-I and 2633555-I).
Inspection Report
Complaint Investigation
Deficiencies: 0
Aug 21, 2025
Visit Reason
A complaint investigation was conducted for complaints #1742004-C, #1742013-C, and #2591233-C from August 19, 2025 to August 21, 2025.
Findings
The facility was found to be in substantial compliance with no deficiencies cited.
Complaint Details
Complaint investigation for complaints #1742004-C, #1742013-C, and #2591233-C resulted in a finding of substantial compliance.
Inspection Report
Complaint Investigation
Deficiencies: 0
Apr 3, 2025
Visit Reason
A complaint investigation for complaints #125995-C, #12624-C, #126364-C, and #127483-C was conducted from April 1, 2025 to April 3, 2025.
Findings
The facility was found to be in substantial compliance.
Complaint Details
Investigation involved multiple complaints identified by numbers #125995-C, #12624-C, #126364-C, and #127483-C. The facility was found to be in substantial compliance.
Inspection Report
Annual Inspection
Census: 86
Deficiencies: 1
Jan 15, 2025
Visit Reason
The inspection was conducted as part of the facility's annual recertification survey and included investigation of two complaints (#125109-C and #125385-C). Both complaints were found not substantiated.
Findings
The facility failed to accurately indicate mental health diagnoses on the Preadmission Screening and Resident Review (PASARR) for 2 of 2 residents reviewed. Specifically, diagnoses such as bipolar disorder and psychotic disorder were omitted from PASARR documentation, contrary to facility policy and regulatory requirements.
Complaint Details
Two complaints (#125109-C and #125385-C) were investigated during the survey period. Both complaints were not substantiated.
Severity Breakdown
SS=E: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to accurately indicate mental health diagnoses on PASARR for Resident #80 and Resident #84. | SS=E |
Report Facts
Census: 86
Complaint count: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Stated the facility should have submitted a Level II PASARR upon admission or by the first care conference and expects PASARR to reflect current mental health diagnoses. |
| Social Worker | Social Worker | Responsible for reviewing and completing residents' PASARR; unaware of Resident #80's mental health diagnosis and confirmed diagnoses should be on PASARR. |
Inspection Report
Plan of Correction
Deficiencies: 0
Nov 13, 2024
Visit Reason
The document is a Plan of Correction related to a Complaint Survey that ended on 2024-10-17, addressing the facility's compliance status.
Findings
The facility was found to be in substantial compliance based on the credible allegation and Plan of Correction, resulting in certification effective 2024-11-08.
Complaint Details
The Plan of Correction follows a Complaint Survey ending on 2024-10-17, indicating the facility's compliance was substantiated.
Inspection Report
Complaint Investigation
Census: 89
Deficiencies: 2
Oct 17, 2024
Visit Reason
The inspection was conducted as a result of investigation of complaints #121116-C, #121466-C, #121689-C, #121819-C, and #123936-C. Complaints #121466-C and #121689-C were substantiated.
Findings
The facility failed to provide sufficient nursing staff to respond to call lights timely for multiple residents, and failed to maintain an effective infection prevention and control program, including appropriate use of Enhanced Barrier Precautions for residents with indwelling catheters.
Complaint Details
Investigation of complaints #121116-C, #121466-C, #121689-C, #121819-C, and #123936-C. Complaints #121466-C and #121689-C were substantiated.
Deficiencies (2)
| Description |
|---|
| Failure to have sufficient nursing staff to respond to call lights within 15 minutes for 4 of 6 residents reviewed. |
| Failure to establish and maintain an infection prevention and control program including appropriate use of Enhanced Barrier Precautions for residents with indwelling catheters. |
Report Facts
Resident census: 89
Residents reviewed for call light response: 6
Residents with Enhanced Barrier Precautions reviewed: 10
Audits frequency: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Certified Nursing Assistant (CNA) | Stated resident call lights were on for longer than 15 minutes at least 10 times a week |
| Staff C | Certified Nursing Assistant (CNA) | Stated resident call lights were on for longer than 15 minutes maybe 3 times a week |
| Staff D | Licensed Practical Nursing (LPN) | Stated resident call lights were on for longer than 15 minutes maybe twice a week |
| Staff E | Registered Nurse (RN) | Stated it was rare for a resident's call light to go unanswered for over 15 minutes |
| Staff A | Certified Nursing Assistant (CNA) | Observed cleaning catheter without wearing a gown |
| Staff F | Registered Nurse (RN), Clinical Care Leader | Stated staff are to wear gown and gloves at minimum when residents have Enhanced Barrier Precautions |
| Staff G | RN and Infection Preventionist | Stated staff were educated on Enhanced Barrier Precautions and gown/glove use |
| Administrator | Stated no concerns raised about call lights at recent Resident Council meetings |
Inspection Report
Plan of Correction
Deficiencies: 0
May 17, 2024
Visit Reason
The document serves as a Plan of Correction following acceptance of a credible allegation of substantial compliance by the facility.
Findings
The facility was certified in compliance effective May 17, 2024, based on acceptance of the Plan of Correction and credible allegation of substantial compliance.
Inspection Report
Complaint Investigation
Census: 87
Deficiencies: 2
Apr 25, 2024
Visit Reason
The inspection was conducted as a result of complaints #119783-C, #120112-C, #120234-C, and #120268-C from April 18, 2024 to April 25, 2024, with substantiation of complaints #120112-C and #120268-C.
Findings
The facility failed to provide adequate personal hygiene services including bathing and incontinence care for dependent residents, and failed to provide an activities program based on residents' individual interests. Observations and record reviews showed residents did not receive scheduled bathing opportunities and lacked planned activities.
Complaint Details
Complaints #120112-C and #120268-C were substantiated.
Deficiencies (2)
| Description |
|---|
| Facility failed to ensure residents received at least two bathing opportunities per week and adequate incontinence care for residents unable to carry out activities independently. |
| Facility failed to provide an activities program based on a resident's individual interests for 1 of 2 residents reviewed. |
Report Facts
Residents reviewed: 4
Bathing opportunities missed: 4
Bathing opportunities missed: 2
Bathing opportunities missed: 6
Facility reported census: 87
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff F | Activities Supervisor | Interviewed regarding lack of individual activities planned for Resident #1 |
Inspection Report
Plan of Correction
Deficiencies: 0
Apr 14, 2024
Visit Reason
The document reflects acceptance of a credible allegation of substantial compliance and the facility's Plan of Correction, leading to certification in compliance.
Findings
The facility was found to be in substantial compliance based on the accepted Plan of Correction, resulting in certification effective April 14, 2024.
Inspection Report
Annual Inspection
Census: 82
Deficiencies: 6
Mar 14, 2024
Visit Reason
The inspection was conducted as an annual Recertification Survey and investigation of multiple complaints and facility-reported incidents at Good Samaritan Society - Davenport.
Findings
The facility was found to have multiple deficiencies including failure to provide required Medicaid/Medicare coverage notices, failure to report alleged abuse timely, failure to notify the Ombudsman of resident transfers, improper management of indwelling catheters, food safety violations, and lack of attendance at Quality Assurance meetings by the Director of Nursing. Several residents were affected by these deficient practices.
Complaint Details
Complaint #118537-C was substantiated based on findings related to failure to provide Medicaid/Medicare notices and failure to report alleged abuse timely.
Deficiencies (6)
| Description |
|---|
| Failure to provide required Medicaid/Medicare coverage/liability notice to residents. |
| Failure to report alleged abuse within required timeframes. |
| Failure to notify Ombudsman of resident transfers to hospital. |
| Failure to ensure indwelling catheter bags and tubing were positioned off the floor. |
| Failure to serve meals under sanitary conditions. |
| Failure of Director of Nursing to attend quarterly Quality Assurance and Assurance Committee meetings. |
Report Facts
Census: 82
Residents affected: 1
Residents affected: 3
Residents affected: 3
Residents affected: 4
Inspection Report
Plan of Correction
Deficiencies: 0
Oct 3, 2023
Visit Reason
The document is a Plan of Correction submitted following a survey, indicating acceptance of credible allegation of substantial compliance and certification of the facility.
Findings
The facility was found to be in substantial compliance based on the credible allegation and Plan of Correction, resulting in certification effective September 30, 2023.
Inspection Report
Complaint Investigation
Census: 90
Deficiencies: 1
Sep 14, 2023
Visit Reason
The inspection was conducted as a COVID-19 Focused Infection Control Survey and included an investigation of complaints #112989-C, #115303-C, and #115474-C, with complaint #115474-C substantiated.
Findings
The facility was found in compliance with COVID-19 infection control practices but had deficiencies related to resident self-administration of medications, including lack of self-medication assessments and physician orders for residents to self-administer medications.
Complaint Details
The investigation of complaints #112989-C, #115303-C, and #115474-C was conducted from September 12 to September 14, 2023. Complaint #115474-C was substantiated.
Severity Breakdown
SS=E: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility failed to complete self-medication assessments and obtain physician orders for self-medication for 4 of 6 residents in the sample. | SS=E |
Report Facts
Total residents: 90
Residents with incomplete self-medication assessments: 4
Residents in sample: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A, Registered Nurse | Administered medications and observed resident #11 during medication administration | |
| Staff B, Licensed Practical Nurse | Observed by resident #11 regarding medication administration | |
| Director of Nursing (DON) | Provided statements about facility policies and resident self-administration assessments |
Inspection Report
Plan of Correction
Deficiencies: 0
Apr 20, 2023
Visit Reason
The document is a plan of correction submitted following a survey to address deficiencies and certify compliance.
Findings
The facility was found to be in compliance based on acceptance of the credible allegation of compliance and plan of correction effective April 20, 2023.
Inspection Report
Complaint Investigation
Census: 90
Deficiencies: 4
Apr 10, 2023
Visit Reason
The inspection was conducted as a Recertification Survey and investigation of multiple complaints and a facility self-reported incident from April 3, 2023 to April 10, 2023.
Findings
The facility was found deficient in addressing advance directives for residents, including failure to include residents in care plan participation, failure to prepare and serve food under sanitary conditions, and failure to maintain a clean kitchen free of pests and rodents. Specific issues included missing advance directives documentation, lack of resident notification for care plan meetings, contaminated kitchen equipment, and evidence of rodent infestation.
Complaint Details
The visit was complaint-related, investigating Complaints #108774-C, #109152-C, #110216-C, #111892-C and Facility Self-Reported Incident #110358-I.
Severity Breakdown
Level D: 2
Level E: 2
Deficiencies (4)
| Description | Severity |
|---|---|
| The facility failed to address advanced directives (legal documents that provide instructions for medical care when a person is unable to communicate their wishes) on admission for 1 of 24 residents reviewed (Resident #292). | Level D |
| The facility failed to include residents in the participation of developing a care plan, provide residents with a copy of the care plan developed, nor notify residents or resident representatives of scheduled care conference meetings for 1 of 18 residents reviewed (Resident #81). | Level D |
| The facility failed to prepare and serve food under sanitary conditions, including contaminated kitchen equipment and lack of temperature logs. | Level E |
| The facility failed to maintain a clean kitchen free of rodents and other insects, with evidence of rodent excrement and pest infestation. | Level E |
Report Facts
Residents reviewed for advance directives: 24
Residents reviewed for care plan participation: 18
Facility census: 90
Deficiency counts: 4
Inspection Report
Plan of Correction
Deficiencies: 0
Oct 25, 2022
Visit Reason
The document reflects acceptance of the facility's credible allegation of compliance and plan of correction following a prior denial of payment for new Medicare and Medicaid admissions.
Findings
The facility will be certified in compliance effective October 25, 2022, with a Denial of Payment for new Medicare and Medicaid Admissions imposed from August 9, 2022 to October 24, 2022.
Report Facts
Denial of Payment period: Denial of Payment for new Medicare and Medicaid Admissions from August 9, 2022 to October 24, 2022
Inspection Report
Complaint Investigation
Census: 82
Deficiencies: 2
Oct 13, 2022
Visit Reason
The inspection was conducted as an onsite revisit of the survey ending August 30, 2022, and the investigation of multiple complaints (#107389-C, #107430-C, #107806-C, and #107825-C) from October 4 to October 13, 2022. Complaint #107806-C was substantiated.
Findings
The facility failed to complete an assessment and implement interventions after a possible injury occurred when a resident's wheelchair became unsecured and tipped during transport in the facility van. The resident hit his head but was not immediately assessed or monitored properly. Additionally, the facility failed to ensure resident safety by improperly securing the wheelchair in the van, attaching tie downs to the wheelchair caster wheels instead of the frame, contrary to facility policy and manufacturer instructions.
Complaint Details
Complaint #107806-C was substantiated. The investigation revealed failures related to assessment and safety during resident transport in the facility van.
Severity Breakdown
SS=D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to complete an assessment and implement interventions after a possible injury during transport in the facility van for Resident #7. | SS=D |
| Failed to ensure resident safety by improperly securing a wheelchair in the facility van while transporting Resident #7. | SS=D |
Report Facts
Resident census: 82
Residents reviewed: 3
Years of experience: 15
Date of incident: Sep 8, 2022
Date of MDS assessment: Aug 26, 2022
Date of Care Plan: Jul 27, 2022
Date of Physical Therapy Plan of Care: Jul 28, 2022
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Unit Secretary/Back-Up Van Driver | Named in findings related to improper securing of wheelchair and failure to report incident immediately |
| Staff C | Licensed Practical Nurse (LPN) | Named in findings related to medication pass and incomplete assessment after incident |
| Staff D | Licensed Practical Nurse (LPN) | Named in findings related to being informed of incident but not documenting it |
| Staff E | Certified Medication Assistant (CMA) | Named in findings related to delayed knowledge of incident |
| Director of Nursing Services | DNS | Named in findings related to assessment after incident and policy review |
| Staff B | Van Driver | Named in findings related to training and proper wheelchair securement procedures |
Inspection Report
Complaint Investigation
Census: 82
Deficiencies: 2
Oct 13, 2022
Visit Reason
The inspection was conducted as an onsite revisit of the survey ending August 30, 2022, and the investigation of complaints #107389-C, #107430-C, #107806-C, and #107825-C between October 4 and October 13, 2022.
Findings
The facility failed to complete an assessment and implement interventions after a possible injury occurred during transport of a resident in the facility van and failed to ensure resident safety by improperly securing a wheelchair in the facility van. Complaint #107806-C was substantiated.
Complaint Details
Complaint #107806-C was substantiated.
Severity Breakdown
D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| The facility failed to complete an assessment and implement any interventions needed after a possible injury occurred while a resident was transported in the facility van for 1 of 3 residents reviewed (Resident #7). | D |
| The facility failed to ensure resident safety by improperly securing a wheelchair in the facility van while transporting a resident for 1 of 1 residents (Resident #7). | D |
Report Facts
Census: 82
Residents reviewed: 3
Residents reviewed: 1
Compliance date: Oct 25, 2022
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Unit Secretary/Back-Up Van Driver | Named in incident progress notes and transport of resident in wheelchair van |
| Staff C | Licensed Practical Nurse (LPN) | Named in medication administration and assessment findings |
| Staff D | Licensed Practical Nurse (LPN) | Named in reporting and documentation of incident |
| Staff E | Certified Medication Assistant (CMA) | Named in medication administration and incident knowledge |
| Staff B | Van Driver | Named in interview regarding wheelchair securing procedures |
| Director of Nursing Services (DNS) | Named in interview regarding incident and resident assessment |
Inspection Report
Re-Inspection
Census: 89
Deficiencies: 4
Aug 30, 2022
Visit Reason
The inspection was a revisit following the survey ending July 12, 2022, and an investigation of Complaints #105290-C and #105399-C conducted from August 22, 2022 to August 30, 2022.
Findings
The facility failed to implement abuse and neglect policies, failed to report incidents of possible abuse to the state agency, failed to investigate reported incidents of abuse, and failed to provide necessary treatment and services to prevent pressure ulcers for several residents. The facility reported a census of 89 residents.
Complaint Details
Complaint #105399-C was substantiated. Complaint #105290-C was not substantiated.
Severity Breakdown
SS=D: 4
Deficiencies (4)
| Description | Severity |
|---|---|
| The facility failed to implement their abuse and neglect policy to protect residents from possible abuse for one of three residents (Resident #4) reviewed for dignity. | SS=D |
| The facility failed to report an incident of possible abuse to the state agency for one of three residents (Resident #4) reviewed for dignity. | SS=D |
| The facility failed to investigate a reported incident of possible abuse for one of three residents (Resident #4) reviewed for dignity. | SS=D |
| The facility failed to provide necessary treatment and services to promote healing and prevent infection of pressure ulcers for one to four residents (Resident #1) reviewed for pressure ulcer prevention and treatment. | SS=D |
Report Facts
Census: 89
Complaint investigation dates: 9
Staff working hours: 2
Staff working hours: 2
Compliance dates: Sep 28, 2022
Compliance dates: Sep 16, 2022
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Letha Dolph | Administrator | Named in relation to abuse and neglect findings and plan of correction |
| Gail Dierks | Region Clinical Director | Provided education and signed letter regarding abuse and neglect investigation |
| Staff A | Certified Nursing Assistant (CNA) | Involved in abuse incident with Resident #4 |
| Staff B | Certified Nursing Assistant (CNA) | Interviewed regarding abuse training and pressure ulcer care |
| Staff E | Registered Nurse (RN) | Interviewed regarding abuse incident and pressure ulcer care |
| Staff F | Certified Nursing Assistant (CNA) | Interviewed regarding abuse reporting procedures |
| Staff C | Certified Nursing Assistant (CNA) | Interviewed regarding Staff A's behavior and training |
| Staff D | RN/Facility Wound Care Nurse | Responsible for wound care and pressure ulcer dressing changes |
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding abuse reporting and wound care expectations |
Inspection Report
Complaint Investigation
Census: 89
Deficiencies: 4
Aug 30, 2022
Visit Reason
The inspection was conducted as a revisit following a survey ending July 12, 2022, and investigation of Complaints #105290-C and #105399-C between August 22 and August 30, 2022. Complaint #105399-C was substantiated, and #105290-C was not substantiated.
Findings
The facility failed to implement abuse and neglect policies to protect residents, failed to report and investigate an incident of possible abuse involving Resident #4, and failed to provide necessary treatment and services to promote healing and prevent infection of pressure ulcers for Resident #1. The facility reported a census of 89 residents.
Complaint Details
Complaint #105399-C was substantiated. Complaint #105290-C was not substantiated. The complaint investigation focused on allegations of abuse and neglect involving Resident #4, including failure to report, investigate, and prevent abuse.
Severity Breakdown
SS=D: 4
Deficiencies (4)
| Description | Severity |
|---|---|
| Failed to implement abuse and neglect policy to protect residents from possible abuse for Resident #4. | SS=D |
| Failed to report an incident of possible abuse to the state agency for Resident #4. | SS=D |
| Failed to investigate a reported incident of possible abuse for Resident #4. | SS=D |
| Failed to provide necessary treatment and services to promote healing and prevent infection of pressure ulcers for Resident #1. | SS=D |
Report Facts
Census: 89
BIMS score: 10
BIMS score: 0
Deficiencies cited: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Certified Nursing Assistant (CNA) | Named in abuse and neglect findings related to rough transfers and failure to report abuse. |
| Staff B | Certified Nursing Assistant (CNA) | Interviewed regarding abuse reporting training and incontinence care. |
| Staff E | Registered Nurse (RN) | Charge Nurse involved in interviews and investigations related to abuse allegations. |
| Staff F | Certified Nursing Assistant (CNA) | Provided information about abuse reporting training and procedures. |
| Staff C | Certified Nursing Assistant (CNA) | Reported concerns about Staff A's unsafe transfers and lack of skills. |
| Staff D | RN/Facility Wound Care Nurse | Responsible for wound care and dressing changes; interviewed about wound care documentation. |
| Director of Nursing | Director of Nursing (DON) | Provided expectations for wound care and hand hygiene practices. |
| Administrator | Facility Administrator | Involved in abuse allegation reporting, investigation decisions, and staff suspension. |
Inspection Report
Complaint Investigation
Census: 98
Deficiencies: 4
Jul 12, 2022
Visit Reason
The inspection was conducted as a result of investigations into multiple complaints (#100264-C, #101460-C, #101721-C, #102767-C, #103572-C, #103633-C, #104001-C, #104487-C, #104613-C, #105133-C, and #105154-C) with substantiated deficiencies.
Findings
The facility was found deficient in multiple areas including failure to implement appropriate infection control during corticosteroid inhalation medication administration, inadequate incontinence care and personal hygiene assistance, failure to provide appropriate dental care resulting in hospitalization, and failure to implement pressure sore prevention interventions leading to unstageable pressure sores.
Complaint Details
The visit was complaint-related, investigating multiple complaints with some substantiated and resulting in deficiencies. Complaint #100264-C was substantiated from a previous investigation. Complaints #101721-C, #102767-C, #103572-C, #104001-C, #104487-C, #104613-C, and #105154-C were substantiated with deficiencies. Complaint #105133-C was substantiated but did not result in a deficiency.
Severity Breakdown
SS = D: 3
SS = G: 1
Deficiencies (4)
| Description | Severity |
|---|---|
| Failed to implement appropriate infection control and standards of nursing practices during corticosteroid inhalation medication administrations for 2 residents. | SS = D |
| Failed to provide appropriate incontinence care, grooming/personal hygiene assistance, and baths/showers at appropriate intervals for sampled residents. | SS = D |
| Failed to implement appropriate interventions for a resident's identified dental problems that resulted in hospitalization with surgery required. | SS = D |
| Failed to implement appropriate pressure sore prevention interventions, complete regular skin assessments and documentation, resulting in unstageable pressure sore and subsequent developments. | SS = G |
Report Facts
Census: 98
Residents reviewed: 12
Residents reviewed: 3
Residents sampled: 3
Residents observed: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Registered Nurse (RN), Director of Nursing (DON) | Interviewed regarding medication administration and infection control |
| Staff B | Licensed Practical Nurse (LPN) | Observed administering medications and involved in dental care findings |
| Staff C | Licensed Practical Nurse (LPN) | Observed administering medications during corticosteroid inhalation |
| Staff E | Certified Nursing Assistant (CNA) | Observed providing incontinence care |
| Staff G | Registered Nurse (RN), Director of Nursing (DON) | Interviewed regarding nursing staff expectations |
| Staff D | Unit Secretary | Involved in dental care documentation and interviews |
| Staff F | Certified Nursing Assistant (CNA) | Assisted in resident care observations |
| Staff H | Administrator, previous Director of Nursing (DON) | Interviewed regarding resident shower/bathing issues |
| Staff I | Registered Nurse (RN) | Involved in dental care and new orders |
| Staff J | Nurse Practitioner (NP) | Notified and assessed resident for dental abscess |
Inspection Report
Annual Inspection
Census: 101
Deficiencies: 8
Dec 30, 2021
Visit Reason
The annual recertification health survey was conducted from December 27-30, 2021, to assess compliance with Medicare and Medicaid regulations.
Findings
The survey identified multiple deficiencies related to Medicaid/Medicare coverage notices, bed hold policies, PASRR assessments, baseline care plans, bowel/bladder incontinence care, respiratory care, food safety, and infection prevention and control. The facility failed to provide required notices, complete assessments timely, and ensure proper care and documentation for residents.
Deficiencies (8)
| Description |
|---|
| Failure to provide complete notices of discontinuation of Medicare Part A covered skilled services within required timeframes for 3 residents. |
| Failure to provide Bed Hold notices to residents or their representatives for 4 of 8 residents transferred to hospital. |
| Failure to coordinate PASRR assessments and address specialized service needs for 1 resident. |
| Failure to complete baseline care plans within 48 hours of admission for 2 of 15 residents. |
| Failure to provide adequate catheter care for 1 of 2 residents requiring catheter care. |
| Failure to provide proper respiratory/tracheostomy care and suctioning for residents requiring oxygen therapy. |
| Failure to ensure food safety practices including proper labeling and storage of food items. |
| Failure to establish and maintain an infection prevention and control program including hand hygiene and glove use during wound care. |
Report Facts
Census: 101
Residents reviewed for discontinuation notices: 3
Residents transferred to hospital: 8
Residents reviewed for PASRR: 1
Residents reviewed for baseline care plans: 15
Residents reviewed for catheter care: 2
Residents reviewed for respiratory care: 4
Residents reviewed for food safety: 101
Residents reviewed for infection control: 90
Inspection Report
Complaint Investigation
Census: 102
Deficiencies: 2
Oct 19, 2021
Visit Reason
The inspection was conducted from 9/29/21 to 10/19/21 investigating multiple complaints (#97115, #98125, #98315, #99780, #100076, #100113, and #100133). Complaint #100076 was substantiated.
Findings
The facility failed to maintain pharmacy procedures and consultation on all aspects of pharmacy services, resulting in irregular staff actions related to medication orders for residents. Additionally, the facility failed to provide a medication regimen free from unnecessary psychotropic medications, leading to resident confusion, physical decline, and repeated falls.
Complaint Details
Complaint #100076 was substantiated based on findings related to pharmacy services and psychotropic medication use.
Severity Breakdown
Level D: 1
Level G: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to maintain pharmacy procedures and consultation on all aspects of pharmacy services, including accurate drug record reconciliation and medication order continuity for residents. | Level D |
| Failure to provide a medication regimen free from unnecessary psychotropic medications, resulting in resident confusion, physical decline, repeated falls, and inability to participate in therapy. | Level G |
Report Facts
Resident census: 102
Residents reviewed: 9
Medication doses unaccounted: 17
Medication doses dispensed: 58
Medication doses administered: 34
Psychotropic medication review dates: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff S | Registered Nurse (RN) | Signed off on discontinued Trazodone order |
| Staff H | Licensed Practical Nurse (LPN) | Wrote medication requests and acknowledged pharmacy fax form |
| Staff D | Registered Nurse (RN) | Checked off medications on Pharmacy Packing Slip and provided statements about unaccounted doses |
| Staff Q | Registered Pharmacist (RPh) | Reported receipt of fax requesting Trazodone and medication dispensing details |
| Staff F | Certified Medication Aide (CMA) | Administered medications and provided statements about medication documentation |
| Staff A | Licensed Practical Nurse (LPN) | Assisted with medication cart exchange and provided statements about medication orders |
| Staff T | Registered Nurse (RN) | Reported on medication notification to physician and resident appointments |
| Staff N | Neurosurgeon | Provided prognosis for resident at hospital discharge |
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding pharmacy fax form, medication procedures, and education provided |
Inspection Report
Complaint Investigation
Census: 90
Deficiencies: 1
Jan 28, 2021
Visit Reason
A COVID-19 Focused Infection Control Survey and an investigation of multiple complaints (#90569, #92827, #93318, #93411, #95042) and a Facility Self-Reported Incident (#91400) were conducted by the Department of Inspections and Appeals from 1/5/21 to 1/28/21.
Findings
The facility was found to be in compliance with CMS and CDC recommended COVID-19 practices except for complaint #93318 which was substantiated, resulting in a deficiency related to failure to permit compassionate care visitation during a resident's significant decline that resulted in death.
Complaint Details
Complaint #93318 was substantiated and resulted in the cited deficiency.
Deficiencies (1)
| Description |
|---|
| The facility failed to permit compassionate care visitation during a resident's significant decline in condition that resulted in death for 1 of 5 closed resident records reviewed (Resident #12). |
Report Facts
Facility Census: 90
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Certified Nursing Assistant (CNA) | Stated she cared for Residents #11 and #12 during the day shift and provided information about visitation and care. |
| Staff B | Registered Nurse (RN) | Reported Resident #11 tested positive for COVID and was transferred to the COVID unit. |
| Staff C | Registered Nurse (RN) | Worked on the day shift on 9/13/20 and was assigned to Resident #12 when he died; called Nursing Director regarding visitation. |
| Director of Nursing | Director of Nursing (DON) | Stated she contacted Corporate Consultant Nurse to request visitation permission for Resident #11 to visit Resident #12. |
Inspection Report
Routine
Census: 81
Deficiencies: 0
Dec 2, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the Department of Inspections and Appeals from 12/01/20 to 12/02/20 to assess compliance with CMS and CDC recommended practices for COVID-19 preparation.
Findings
The facility was found to be in compliance with CMS and CDC recommended practices to prepare for COVID-19.
Inspection Report
Abbreviated Survey
Census: 113
Deficiencies: 0
Jun 11, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the Department of Inspections and Appeals on 6/11/20 to assess the facility's compliance with CMS and CDC recommended practices for COVID-19 preparation.
Findings
The facility was found to be in compliance with CMS and CDC recommended practices to prepare for COVID-19.
Report Facts
Total residents: 113
Inspection Report
Complaint Investigation
Deficiencies: 0
Jan 23, 2020
Visit Reason
The inspection was conducted to investigate complaints #86000 and #87022 at the facility.
Findings
The complaints investigated on 1/22/20-1/23/20 were not substantiated according to the Code of Federal Regulations (42 CFR), Part 483, Subpart B-C.
Complaint Details
Complaints #86000 and #87022 were investigated and found to be not substantiated.
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