Inspection Report Summary
The most recent inspection on September 25, 2025, found the facility in substantial compliance with no deficiencies noted. Earlier inspections also showed no deficiencies, indicating consistent adherence to regulatory standards. There were no complaint investigations or enforcement actions listed in the available reports. The facility has maintained compliance across all surveys. This suggests a stable pattern of meeting required regulations over time.
Deficiencies (last 3 years)
Deficiencies are regulatory violations found during state inspections.
Deficiencies per year
Census
Based on a September 2025 inspection.
Census over time
Inspection Report
Plan of CorrectionInspection Report
RenewalInspection Report
Complaint Investigation| Name | Title | Context |
|---|---|---|
| Assistant Director of Nursing | Assistant Director of Nursing (ADON) | Responsible for wound care but not certified; stated she did not implement care plan for R66 |
| Director of Nursing | Director of Nursing (DON) | Responsible for care plan implementation oversight; stated MDS Coordinator responsible for care plans |
| Administrator | Administrator | Expected all residents to have comprehensive care plans and staff to follow policies |
| Licensed Practical Nurse #8 | Licensed Practical Nurse (LPN8) | Assessed R66's wound on 05/14/2024; notified wound care nurse and surgeon's office |
| Registered Nurse #1 | Registered Nurse (RN1) | Agency nurse; described care plan responsibilities and wound care protocols |
| Podiatric Surgeon | Podiatric Surgeon | Provided wound care orders on 05/03/2024; saw R66 on 05/15/2024 and admitted her to hospital |
| Signature Care Consultant | Signature Care Consultant | Stated wound care nurse had no formal wound care certification |
| Licensed Practical Nurse #3 | Licensed Practical Nurse (LPN3) | Night shift nurse; admitted to charting wound care without assessment |
| Minimum Data Set Coordinator | MDS Coordinator | Responsible for care plan development; developed enhanced barrier precaution care plan on 05/07/2024 |
| Medical Director | Medical Director | Expected staff to follow orders and clarify deviations |
Inspection Report
Annual Inspection| Name | Title | Context |
|---|---|---|
| Dietary Worker #1 | Stated containers should always have a label and date and should have been discarded. | |
| Dietary Manager | Expected all food to be labeled and dated and staff should not use food or liquids after discard date. | |
| Administrator | Stated dietary department responsible for food control; expected food to be dated, labeled, covered, and not used past discard date; expected staff to follow policies regarding biohazard materials and pest control. | |
| Special Projects Director of Nursing | Observed Resident #74's wound care and biohazard storage. | |
| DON | Director of Nursing | Stated clean supplies and biohazard materials should never be stored together. |
| Regional DON | Stated clean supplies and biohazard materials should never be stored together. |
Inspection Report
Routine| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant #6 | CNA | Observed failing to pull privacy curtain and called resident a feeder |
| Director of Nursing | DON | Interviewed regarding privacy, care conferences, catheter care, and infection control |
| Licensed Practical Nurse #2 | LPN | Facility wound nurse who did not notify physician of wound worsening |
| Certified Nursing Assistant #4 | CNA | Acknowledged resident required cueing for oral care |
| Registered Nurse #3 | RN | Crushed delayed release medication for resident |
| Registered Nurse #7 | RN | Crushed enteric-coated medication for resident |
| Laundry Attendant | LA | Observed improper gown use in laundry |
| Certified Nursing Assistant #1 | CNA | Observed not encouraging handwashing before meals |
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