5 CMS Surveys
Inspection Report — Apr 2, 2025
Complaint Investigation
Date: Apr 2, 2025
Visit Reason
Investigation of a complaint received on 2025-03-04 about pain management for a resident.
Complaint Details
Failure to properly assess and manage pain for resident R901: established.
Findings
The facility failed to properly assess and ensure pain was effectively managed for one resident following a fall with injury, resulting in actual harm.
Deficiencies (1)
F 0697 Provide safe, appropriate pain management for a resident who requires such services: the facility failed to update the care plan after a fall with injury and did not implement scheduled medication to manage pain, only administering medications as needed without documented effectiveness after administration.
Inspection Report — Dec 17, 2024
Complaint Investigation
Date: Dec 17, 2024
Visit Reason
Investigation of a complaint received on 2024-12-17 about resident care and accommodation.
Complaint Details
Failure to provide a mattress in a timely manner: established. Failure to provide nail care for two dependent residents: established.
Findings
Two deficiencies were found related to resident care: failure to provide a mattress in a timely manner for one resident and failure to provide nail care for two dependent residents.
Deficiencies (2)
F 0558 Reasonably accommodate the needs and preferences of each resident: the facility failed to provide a mattress in a timely manner for one resident, resulting in disturbed sleep and back pain.
F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable: the facility failed to provide nail care for two dependent residents, resulting in unmet care needs.
Inspection Report — Feb 14, 2024
Complaint Investigation
Date: Feb 14, 2024
Visit Reason
Investigation of a complaint received regarding resident dignity, privacy violations, and infection control concerns.
Complaint Details
Resident dignity not maintained: established. Privacy violation via social media video: established. Infection control failures including hand hygiene and ice scooper storage: established.
Findings
Three deficiencies were established related to failure to maintain resident dignity, failure to maintain resident privacy, and failure to implement proper infection prevention and control practices.
Deficiencies (3)
F 0550 Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights: the facility failed to maintain the dignity of five residents who were not properly dressed for breakfast in the dining room, causing resident frustration and discomfort.
F 0583 Keep residents' personal and medical records private and confidential: the facility failed to maintain privacy for one resident by allowing a staff member to post a video of the resident on social media without consent.
F 0880 Provide and implement an infection prevention and control program: staff failed to perform proper hand hygiene and failed to properly store the ice scooper, risking contamination and spread of microorganisms.
Inspection Report — Feb 14, 2024
Complaint Investigation
Date: Feb 14, 2024
Visit Reason
Investigation of a complaint received regarding resident dignity and privacy violations.
Complaint Details
Failure to maintain resident dignity: established. Privacy violation via social media posting: established.
Findings
Two rule violations were established: failure to maintain resident dignity for multiple residents and failure to maintain privacy for one resident resulting in exposure on social media.
Deficiencies (2)
F 0550 Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights: the facility failed to maintain the dignity of five residents who were not properly dressed for breakfast and expressed frustration and discomfort.
F 0583 Keep residents' personal and medical records private and confidential: the facility failed to maintain privacy for one resident when a staff member posted a video of the resident on social media without consent.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA L | Certified Nursing Assistant | Named in the privacy violation finding for posting a video of resident R66 on social media. |
Inspection Report — Feb 8, 2023
Plan of Correction
Date: Feb 8, 2023
Visit Reason
An acceptable corrective action plan has been received.
Findings
This document lists deficiencies identified during the survey but is a plan of correction letter referencing those deficiencies; no new violations are cited here.
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