Inspection Report
Abbreviated Survey
Census: 123
Deficiencies: 7
Aug 1, 2025
Visit Reason
A Recertification and Abbreviated Survey was conducted from 07/29/2025 to 08/01/2025 to investigate compliance with 42 CFR 483 subpart B.
Findings
The facility was found not to be in substantial compliance with 42 CFR 483 subpart B. Regulatory deficiencies were identified related to accuracy of assessments, comprehensive care plans, medication storage, infection control, and environmental safety.
Severity Breakdown
Level D: 5
Level E: 2
Deficiencies (7)
| Description | Severity |
|---|---|
| Accuracy of Assessments - Registered nurse must sign and certify assessments; penalty for falsification; discrepancies found in MDS assessments. | Level D |
| Develop and Implement Comprehensive Care Plan - Care plans lacked documentation of resident and family participation; no evidence of care plan meetings for some residents. | Level D |
| Storage of Drugs and Biologicals - Expired medications found in medication room refrigerator and hall medication refrigerator. | Level D |
| Food that accommodates resident allergies, intolerances, and preferences - Facility failed to ensure residents received food accommodating allergies and preferences. | Level D |
| Infection Prevention and Control - Facility failed to maintain infection prevention program; staff failed to use appropriate PPE and follow hygiene procedures. | Level D |
| Resident Call System - Call lights malfunctioning; some residents unable to use call system properly. | Level E |
| Environmental Safety - Water damage and ceiling issues in resident rooms; mold and discolored areas noted. | Level E |
Report Facts
Survey Census: 123
Sample Size: 28
Supplemental Residents: 6
Deficiencies cited: 7
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