Inspection Report Summary
The most recent inspection on September 9, 2025, resulted in no deficiencies. Earlier inspections showed a pattern of deficiencies primarily related to resident care coordination, especially in negotiated service agreements, and safety measures during resident transfers. Complaint investigations substantiated issues including neglect during mechanical sling lifts and failures in health care service provision, as well as prior concerns about infection control and emergency preparedness. Enforcement actions such as fines or license suspensions were not listed in the available reports. The facility appears to have addressed previous deficiencies successfully, with recent inspections showing improvement and no new citations.
Deficiencies (last 9 years)
Deficiencies are regulatory violations found during state inspections.
Deficiencies per year
Census
Based on a February 2024 inspection.
Census over time
| Description |
|---|
| Deficiency related to regulation 26-41-101 (f)(1) |
| Deficiency related to regulation 26-41-204 (a) |
| Description | Severity |
|---|---|
| Failure to protect Resident 1 from neglect by not ensuring two-person assist during mechanical sling lift transfers, resulting in injury. | G |
| Failure to ensure a licensed nurse provided necessary health care services for Resident 5 by not including a bed assist device in the negotiated service agreement for transfers. | D |
| Name | Title | Context |
|---|---|---|
| CNA C | Certified Nurse Aide | Named in the finding related to improper transfer of Resident 1 using mechanical sling lift alone. |
| APRN D | Advanced Practice Registered Nurse | Documented Resident 1's fracture of left distal tibia. |
| Administrative Staff A | Confirmed CNA C used mechanical sling lift alone and confirmed Resident 5's use of bed assist device. | |
| Administrative Nurse B | Confirmed Resident 5's negotiated service agreement lacked documentation of bed assist device use. |
| Description | Severity |
|---|---|
| Failure to ensure designated staff completed the Negotiated Service Agreement/Health Care Service Plan to include a description of the services the resident will receive and identification of the provider of each service. | SS=E |
| Failure to ensure disaster and emergency preparedness by ensuring quarterly review of the facility's emergency management plan with residents. | SS=F |
| Failure to ensure staff implemented procedures to prevent the spread of infections, including improper handling of glasses and coffee cups by dietary staff. | SS=E |
| Failure to ensure proper paperwork was completed for the use of video surveillance in residents' rooms as required by state regulations. | — |
| Name | Title | Context |
|---|---|---|
| Administrative Staff A | Confirmed details about Functional Capacity Screen, Negotiated Service Agreement, and electronic monitoring paperwork. | |
| Administrative Staff E | Confirmed resident conditions and assisted with observations related to tube feeding. | |
| Certified Medication Aide D | Observed assisting resident R823 with medications and tube feeding. | |
| Maintenance Staff C | Reported not reviewing emergency management plan with residents. | |
| Dietary Staff F | Observed improperly handling glasses and coffee cups, contributing to infection control deficiency. | |
| Dietary Staff G | Reported proper procedures for handling cups and glasses. | |
| Activity Staff B | Reported Maintenance Staff C's activities with residents regarding emergency management plan. |
| Description |
|---|
| Findings of a resurvey with complaint investigations #161997, #167190, #167224 |
| Description |
|---|
| Deficiency related to regulation 26-41-202 (h) |
| Deficiency related to regulation 26-41-204 (d) |
| Deficiency related to regulation 26-41-206 (a)(b) |
| Description | Severity |
|---|---|
| Failure to ensure signatures on negotiated service agreements and provision of copies to residents or legal representatives. | F |
| Negotiated service agreements lacked description of health care services and name of licensed nurse responsible for implementation and supervision. | F |
| Failure to have medical care provider's order on file and prepare mechanically altered diet according to instructions for resident #312. | D |
| Name | Title | Context |
|---|---|---|
| Operator #A | Interviewed regarding NSA signatures and dietary recipe book. | |
| Licensed Nurse #B | Interviewed regarding NSA signatures and distribution of Functional Capacity Screen. | |
| Dietary Staff #C | Interviewed regarding preparation of mechanical soft diet. |
| Description | Severity |
|---|---|
| Failure to provide health care services to resident #923 by qualified staff in accordance with acceptable standards of practice, including not providing the ordered mechanical soft diet. | SS=D |
| Description |
|---|
| Deficiency under regulation 26-41-101 (f) (1) corrected |
| Description | Severity |
|---|---|
| Failure to ensure no resident was subjected to neglect when the licensed nurse failed to provide or coordinate health care services necessary to address the cognitively impaired resident's risk for elopement, and failure to enforce the policy for sign in and sign out when residents were leaving the building. | SS=J |
| Name | Title | Context |
|---|---|---|
| Administrative Nurse A | Interviewed and confirmed failures in monitoring sign out register and resident supervision | |
| Licensed Nurse A | Confirmed failure to read hospital reports and assess resident's elopement risk | |
| Administrative Staff B | Participated in search and monitoring of resident sign out | |
| Sitter #1 | Provided care and supervision to resident, confirmed resident required accompaniment when outside facility | |
| Operator | Interviewed regarding facility policies and search efforts |
| Description |
|---|
| Deficiency related to regulation 26-41-205 (h) |
| Description | Severity |
|---|---|
| Licensed nurses and medication aides failed to ensure insulin pens were stored in accordance with manufacturer's recommendations, with open and in use pens improperly stored in the refrigerator. | SS=F |
| Name | Title | Context |
|---|---|---|
| Resident Care Coordinator (RCC)/Registered Nurse (RN) | Confirmed insulin pens inside the basket were open and in use and reviewed manufacturer's storage instructions. | |
| Operator | Stated nurses administer insulin to residents. |
| Description |
|---|
| Deficiency under regulation 26-41-204(a) |
| Deficiency under regulation 26-41-205(d)(1-2) |
| Deficiency under regulation 28-39-255 |
| Description | Severity |
|---|---|
| Failure to ensure licensed nurse accurately assessed and coordinated necessary health care services to prevent elopement of a cognitively impaired resident, resulting in injury and hospitalization. | Level J |
| Failure to administer medications in accordance with medical provider's orders and standards of practice, including administration of medication at incorrect times and lack of communication regarding medication availability. | Level D |
| Failure to maintain sanitary conditions in dietary areas, including dust accumulation, dead bugs, water damage, and lack of cleaning schedule. | Level F |
| Name | Title | Context |
|---|---|---|
| Licensed nurse #A | Documented resident wandering and placed wanderguard on resident's ankle | |
| Licensed nurse #B | Failed to assess resident prior to medication administration and did not respond to door alarms | |
| Certified Medication Aide #C | Administered clonazepam at incorrect time and documented resident behavior | |
| Certified Medication Aide #E | Observed resident trying to exit building and redirected resident | |
| Certified Nursing Assistant #D | Reset door alarm without checking outside and provided care during elopement incident | |
| Resident Care Coordinator | Provided statements regarding medication administration and resident care | |
| Dietary Manager | Acknowledged lack of cleaning schedule in kitchen | |
| Office Manager | Reviewed video recordings and confirmed kitchen needed cleaning |
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