4 Reports
Inspection Report — Aug 28, 2024
Complaint Investigation State
Date: Aug 28, 2024
Visit Reason
State-compiled facility profile showing 10 inspections from June 2022 to May 2026 with citation and complaint history.
Complaint Details
The state logged 103 complaints about this facility; 7 led to on-site inspections.
Findings
Across 10 inspections, 6 resulted in citations totaling 33, including 24 standard health and 9 life safety code citations. The facility had 103 complaints with 7 on-site inspections and no formal enforcement actions.
Citations (28)
Standard Health Citation — quality of care: Baseline Care Plan deficiencies noted.
Standard Health Citation — quality of care: Failure to develop and implement a comprehensive care plan.
Standard Health Citation — quality of care: Issues with increasing or preventing decrease in range of motion/mobility.
Standard Health Citation — quality of care: Infection prevention and control deficiencies.
Standard Health Citation — quality of care: Posted nurse staffing information not properly maintained.
Standard Health Citation — quality of care: Reporting of alleged violations was inadequate.
Standard Health Citation — quality of care: Respect, dignity, and right to have personal property issues.
Life Safety Code Citation — NFPA requirements: Corridor doors did not meet code requirements.
Life Safety Code Citation — NFPA requirements: Electrical systems essential electric system deficiencies.
Life Safety Code Citation — NFPA requirements: Stairways and smokeproof enclosures deficiencies.
Standard Health Citation — quality of care: Reporting to National Health Safety Network was deficient.
Standard Health Citation — quality of care: Requirements before submitting a request for were not met.
Standard Health Citation — quality of care: Requirements before submitting a request for were not met.
Standard Health Citation — quality of care: Requirements before submitting a request for were not met.
Standard Health Citation — quality of care: Accuracy of assessments was deficient.
Standard Health Citation — quality of care: Baseline care plan deficiencies noted.
Standard Health Citation — quality of care: Care plan timing and revision issues.
Standard Health Citation — quality of care: Food procurement, storage, preparation, and sanitary issues.
Standard Health Citation — quality of care: Facility was not free of accident hazards and lacked supervision/devices.
Standard Health Citation — quality of care: Failure to notify of changes such as injury, decline, or room changes.
Standard Health Citation — quality of care: Pharmacy services, procedures, pharmacist, and records deficiencies.
Standard Health Citation — quality of care: Quality of care issues noted.
Standard Health Citation — quality of care: Reporting of alleged violations was inadequate.
Standard Health Citation — quality of care: Right to be free from physical restraints was violated.
Standard Health Citation — quality of care: Safe, clean, comfortable, homelike environment was not maintained.
Life Safety Code Citation — NFPA requirements: Electrical systems essential electric system deficiencies.
Life Safety Code Citation — NFPA requirements: Sprinkler system installation deficiencies.
Life Safety Code Citation — NFPA requirements: Sprinkler system maintenance and testing deficiencies.
Report Facts
Inspections on page: 10
Total violations/deficiencies cited: 33
Inspections with violations: 6
Inspections without violations: 4
Complaints total: 103
On-site complaint inspections: 7
Citations from complaints: 11
Citations by category - Standard Health: 24
Citations by category - Life Safety Code: 9
Inspection Report — Aug 28, 2024
Annual Inspection CMS
Date: Aug 28, 2024
Visit Reason
The inspection was a Recertification Survey conducted from 08/21/2024 to 08/28/2024 to assess compliance with regulatory requirements for nursing home care.
Findings
The facility was found deficient in multiple areas including failure to maintain resident dignity regarding catheter privacy, failure to provide and sign baseline care plans, lack of comprehensive care plans for oxygen therapy, failure to ensure use of prescribed splints, inadequate posting of nurse staffing information, and lapses in infection control related to oxygen tubing changes.
Citations (6)
Resident #3's Foley catheter bag and tubing were not covered with a privacy bag as required by facility policy.
Resident #78 was not provided a written summary of their baseline care plan and no signed copy was available to verify receipt.
Resident #75 was receiving oxygen therapy but a comprehensive care plan addressing oxygen use was not created.
Resident #3 with left hand weakness was observed multiple times without the ordered left-hand splint, which could not be located.
Nurse staffing information was posted in a location not readily accessible to residents and visitors and did not include actual hours worked or resident census.
Resident #9 and Resident #29's oxygen tubing was not changed weekly as per protocol; tubing was either undated or dated over two weeks prior.
Report Facts
Residents reviewed: 25
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #1 | Interviewed regarding catheter bag privacy and oxygen tubing change protocol | |
| Certified Nursing Assistant #5 | Interviewed regarding missing catheter privacy bag | |
| Director of Nursing | Interviewed regarding catheter privacy bag policy, baseline care plan signing, oxygen care plan responsibility, and staffing posting | |
| Director of Social Work | Interviewed regarding baseline care plan signing and family receipt | |
| Registered Nurse Supervisor #1 | Interviewed regarding baseline care plan process, oxygen care plan responsibility, and oxygen tubing change protocol | |
| Registered Nurse #6 | Interviewed regarding oxygen care plan creation responsibility | |
| Registered Nurse #3 | Interviewed regarding oxygen tubing change and splint observation | |
| Certified Nursing Assistant #6 | Interviewed regarding absence of Resident #3's left-hand splint | |
| Director of Physical Therapy | Interviewed regarding splint compliance and assessments | |
| Staff Development Coordinator | Interviewed regarding nurse staffing information posting location and content | |
| Administrator | Interviewed regarding staffing posting responsibility and awareness | |
| Licensed Practical Nurse #2 | Interviewed regarding oxygen tubing change schedule | |
| Infection Preventionist | Interviewed regarding oxygen tubing change protocol and monitoring |
Inspection Report — Oct 18, 2022
Annual Inspection CMS
Date: Oct 18, 2022
Visit Reason
The inspection was a Recertification and Complaint survey conducted from 10/12/2022 to 10/18/2022 to assess compliance with federal regulations regarding resident care, medication management, care planning, and food safety.
Complaint Details
The complaint investigation included allegations of delayed medication administration for Resident #257 and inaccurate resident assessments. The complaint was substantiated based on findings of delayed medication delivery and inaccurate MDS documentation.
Findings
The facility was found deficient in multiple areas including improper use of physical restraints, inaccurate resident assessments, failure to provide baseline care plans to residents or their representatives, lack of resident participation in care plan meetings, expired medications in storage, and delays and errors in medication administration for certain residents.
Citations (7)
Use of physical restraints by placing pillows under fitted sheets to prevent resident from getting out of bed without physician order.
Minimum Data Set (MDS) assessments did not accurately reflect residents' medication use, including anticoagulants, antidepressants, and insulin injections.
Resident and/or representative were not provided with a written summary of the baseline care plan within 48 hours of admission.
Resident was not offered the opportunity to participate in the development of their comprehensive care plan during quarterly care plan meetings.
Expired medications were found in the medication storage room, including aspirin with expiration date 07/2022.
Resident #257 did not receive ordered medications Clozapine and Trulance timely upon admission due to delayed pharmacy delivery and lack of lab work, with no documented physician orders to hold medications.
Expired liquid nutritional supplements, thickened juice, and thickened water were observed in the kitchen's Emergency Food Storage Room.
Report Facts
Residents reviewed for restraints: 2
Residents reviewed for MDS accuracy: 28
Residents reviewed for care plan baseline: 3
Residents reviewed for care plan meetings: 2
Expired aspirin tablets: 2
Medication doses missed: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant #4 | CNA | Interviewed regarding use of pillows as restraint for Resident #25. |
| Licensed Practical Nurse #1 | LPN | Interviewed regarding nursing judgment on pillow placement for Resident #25. |
| Registered Nurse #1 | RN | Interviewed regarding physical restraint policies and rounds. |
| Director of Nursing | DON | Interviewed multiple times regarding restraint use, care plan distribution, medication issues, and expired medications. |
| Physical Therapist Assistant | PTA | Interviewed regarding Resident #25's mobility and pillow placement. |
| Nurse Practitioner | NP | Interviewed regarding medication delays and lab requirements for Resident #257. |
| Pharmacy Consultant | PC | Interviewed regarding medication storage inspections and expired medications. |
| Pharmacy Technician | Pharmacy Technician | Interviewed regarding medication order processing and clarifications. |
| Food Service Manager | FSM | Interviewed regarding food storage and rotation practices. |
| Food Service Department Supervisor | FSDS | Interviewed regarding food storage checks. |
| Registered Nurse #1 | RN | Interviewed regarding baseline care plan creation and distribution responsibilities. |
| Care Manager/Social Worker | CM/SW | Interviewed regarding baseline care plan responsibilities. |
| Director of Social Work | DSW | Interviewed regarding baseline care plan distribution responsibilities. |
| Social Worker | SW | Interviewed regarding resident participation in care plan meetings. |
Inspection Report — Nov 14, 2019
Abbreviated Survey CMS
Date: Nov 14, 2019
Visit Reason
The inspection was conducted as a recertification and abbreviated survey to assess compliance with infection prevention and control practices during wound care.
Findings
The facility failed to ensure proper infection control practices during a wound dressing change, specifically allowing a nurse to cover open wounds with a soiled diaper without cleaning the resident first, posing a risk of contamination and infection.
Citations (1)
Failure to provide and implement an infection prevention and control program during wound care, including improper handling of soiled dressings and diapers.
Report Facts
Residents Affected: 2
Stage 4 Pressure Ulcers: 3
Observation time: 9.13
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN #1) | Conducted wound dressing change and admitted to improper infection control practice | |
| Registered Nurse (RN #1) | Assisted with positioning during wound care and interviewed about standards of practice | |
| Director of Nursing (DNS #1) | Interviewed regarding staff training and infection control protocols |
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