Inspection Report
Annual Inspection
Deficiencies: 6
Oct 6, 2025
Visit Reason
Annual Licensure Survey conducted to assess compliance with state regulations including disaster preparedness, incident and accident reporting, physician's assessment, service plan, tuberculin skin test procedures, and resident rights.
Findings
The facility was cited for multiple violations including failure to conduct required tornado drills, failure to orient residents to emergency plans within 10 days of arrival, failure to report incidents within 24 hours, lack of physician assessments prior to admission for some residents, service plans not developed or signed by a registered nurse, failure to complete required two-step TB testing, and failure to ensure resident rights by timely notifying providers of changes in resident condition.
Severity Breakdown
Type 2 Violation: 2
Type 3 Violation: 4
Deficiencies (6)
| Description | Severity |
|---|---|
| Failure to conduct tornado drills on each shift during February and failure to orient residents to emergency and evacuation plans within 10 days of arrival. | Type 2 Violation |
| Failure to report a serious incident or accident within 24 hours to the Department of Public Health. | Type 3 Violation |
| Failure to complete a physician assessment within 120 days prior to admission for residents. | Type 3 Violation |
| Failure to have a registered nurse develop and sign residents' service plans. | Type 3 Violation |
| Failure to comply with Tuberculosis Code by not completing two-step TB testing for residents upon admission. | Type 3 Violation |
| Failure to ensure resident rights by not timely notifying provider of resident's change in condition after a fall. | Type 2 Violation |
Report Facts
Incident reporting delay: 2
Number of residents reviewed for incident/accident reporting: 3
Number of residents reviewed for physician assessment: 3
Number of residents reviewed for service plans: 3
Number of residents reviewed for TB testing: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| E1 | Director | Interviewed regarding tornado drills and incident reporting |
| E5 | Nurse Manager | Interviewed regarding physician assessments, service plans, and TB testing |
| E3 | Licensed Practical Nurse (LPN) | Provided information about resident pain and incident reporting |
| E4 | Licensed Practical Nurse (LPN) | Reported notifying Nurse Practitioner about resident's condition and x-ray |
| Z1 | Nurse Practitioner (NP) | Interviewed about notification timing and x-ray orders related to resident fall |
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