6 CMS Surveys
Inspection Report — Jul 31, 2025
Complaint Investigation
Date: Jul 31, 2025
Visit Reason
Investigation of a complaint received on 2025-07-31 about failure to meet resident care and safety standards.
Complaint Details
Call lights not accessible for residents R5 and R20: established. Failure to notify representative of fall with injury for resident R2: established. Failure to implement fall care plan interventions for resident R2: established. Incorrect labeling of tube feeding for resident R69: established. Failure to provide ordered nebulizer treatments and clean equipment for resident R1: established. Inaccurate narcotic administration documentation for resident R4: established. Food safety violations in kitchen: established. Lack of active infection control plan for legionella risk: established.
Findings
Seven deficiencies were found related to resident care, notification, care planning, medication administration, respiratory care, food safety, and infection control.
Deficiencies (8)
F 0558 Reasonably accommodate the needs and preferences of each resident: the facility failed to ensure call lights were in reach for 2 dependent residents (R5 and R20).
F 0580 Immediately tell the resident, the resident's doctor, and a family member of situations that affect the resident: the facility failed to notify the resident's representative of a fall with injury for resident R2.
F 0656 Develop and implement a complete care plan that meets all the resident's needs: the facility failed to implement care planned fall interventions for resident R2, as grip strips were missing in the bathroom.
F 0693 Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube: the facility failed to correctly label an ordered tube feeding for resident R69.
F 0695 Provide safe and appropriate respiratory care for a resident when needed: the facility failed to offer ordered nebulizer treatments and adequately clean nebulizer equipment for resident R1.
F 0755 Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist: the facility failed to accurately document narcotic administration for resident R4.
F 0812 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards: the facility failed to maintain best practices in the kitchen, including improper drain line installation and misuse of handwashing sink.
F 0880 Provide and implement an infection prevention and control program: the facility failed to have an active plan for reducing the risk of legionella and other opportunistic pathogens of premise plumbing.
Inspection Report — Aug 28, 2024
Complaint Investigation
Date: Aug 28, 2024
Visit Reason
Investigation of a complaint received about infection control, feeding tube care, smoking supervision, and immunizations.
Complaint Details
Smoking supervision failures for Residents #25, #1, #27, #26, and #13: established. Feeding tube medication administration errors for Resident #61: established. Infection control lapses including lack of contact isolation and improper hand hygiene for Residents #21, #64, and #217: established. Failure to document immunizations for Resident #29: established.
Findings
The facility failed to ensure proper smoking supervision, feeding tube care, infection prevention and control practices including contact isolation for C. difficile, and administration of pneumococcal and influenza vaccinations, resulting in increased risk of harm to residents.
Deficiencies (4)
F 0689 Smoking supervision: Residents #25, #1, #27, #26, and #13 were observed smoking unsupervised without staff, family, or visitors present, contrary to facility policy requiring direct supervision.
F 0693 Feeding tube care: Registered Nurse H administered medication via Resident #61's peg tube by pushing the syringe plunger without assessing tube placement or gastric residual, and did not use gravity flow as required by facility policy and nursing standards.
F 0880 Infection prevention and control: Resident #21 was not placed in contact isolation for suspected C. difficile infection; signage did not reflect contact precautions; staff failed to wash hands with soap and water; Resident #64 required enhanced barrier precautions but lacked physician orders and proper signage; Resident #217 was in contact precautions but staff used hand sanitizer instead of soap and water.
F 0883 Immunizations: Resident #29's medical record lacked documentation of administration or refusal of pneumococcal and influenza vaccines despite POA consent and physician orders.
Inspection Report — Dec 6, 2023
Complaint Investigation
Date: Dec 6, 2023
Visit Reason
Investigation of a complaint received on 2023-12-06 about pressure ulcer care and prevention.
Complaint Details
Pressure ulcer care and prevention: violation established.
Findings
The facility failed to prevent the development and worsening of pressure ulcers for one resident. Multiple deficiencies in skin care and wound management were identified, including lack of timely documentation, inadequate investigation of wound causes, and incomplete care planning.
Deficiencies (1)
F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing: the facility failed to prevent worsening pressure ulcers for Resident #5, with delayed documentation, inadequate investigation of wound causes, and incomplete care planning for pressure ulcer prevention and treatment.
Inspection Report — Aug 25, 2023
Complaint Investigation
Date: Aug 25, 2023
Visit Reason
Investigation of a complaint received about medication administration and food safety practices.
Complaint Details
Medication administration outside ordered parameters for Residents #7 and #13: established. Kitchen plumbing leaks and improper food cooling: established.
Findings
Two deficiencies were found related to medication administration outside physician orders and failure to maintain kitchen plumbing and properly cool potentially hazardous food.
Deficiencies (2)
F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals: the facility failed to ensure medications were administered according to physician orders for Residents #7 and #13, including administering medications when heart rate was below ordered parameters and giving insulin without coordinating with meals or snacks.
F 0812 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards: the facility failed to maintain kitchen plumbing with water leaking from the dish machine and failed to properly cool potentially hazardous food, risking contamination.
Inspection Report — Aug 25, 2023
Complaint Investigation
Date: Aug 25, 2023
Visit Reason
Investigation of a complaint received about medication administration and food safety practices.
Findings
Two deficiencies were established related to medication administration outside physician orders and failure to maintain kitchen plumbing and properly cool potentially hazardous food.
Deficiencies (2)
F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals: the facility failed to ensure medications were administered according to physician orders for Residents #7 and #13, including administering medications when heart rate was below ordered parameters and giving insulin without coordinating with meals or snacks.
F 0812 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards: the facility failed to maintain kitchen plumbing with water leaking under the dish machine and failed to properly cool potentially hazardous food, risking contamination.
Inspection Report — Feb 8, 2023
Complaint Investigation
Date: Feb 8, 2023
Visit Reason
Investigation of a complaint received on 2023-02-08 about failure to follow resident care plan resulting in a fall.
Complaint Details
Failure to follow resident care plan for toileting assistance: violation established.
Findings
The facility failed to prevent a fall by not following a resident's care plan for toileting assistance for 1 of 3 residents, resulting in the resident falling and sustaining two skin tears.
Deficiencies (1)
F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents: CNA C did not follow R3's care plan requiring two-person assistance for toileting and transferring, resulting in R3 falling and sustaining skin tears.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA C | Certified Nursing Assistant | Named in the finding for not following resident R3's care plan for transfers and toileting. |
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