Inspection Report Summary
The most recent inspection on October 10, 2023, identified several deficiencies including missing background check documentation for a substitute caregiver, incomplete medication orders and records, inadequate special diet menus, and lack of fire drill documentation during certain shifts. Earlier inspections also noted deficiencies, such as unsecured medications and missing documentation of care plan reviews and dental exams. The main themes across reports involved medication management, documentation practices, and safety procedures. No fines, enforcement actions, or substantiated complaints were listed in the available reports. The pattern of deficiencies suggests ongoing challenges in maintaining complete records and procedural compliance over time.
Deficiencies (last 2 years)
Deficiencies are regulatory violations found during state inspections.
Deficiencies per year
| Description |
|---|
| No documentation of background check (fingerprint) clearance for substitute caregiver #1. |
| No special diet menu available to accommodate residents' special diet orders. |
| No physician order for certain medications noted in the medication administration record (MAR) for Resident #1. |
| Medications were not initialed as given, held, or refused by Resident #1 on MAR. |
| Physician order for medication was not recorded on the MAR for Resident #1. |
| Telephone and verbal medication orders were obtained but not recorded on the physician's order sheet or confirmed in writing within required timeframe. |
| Progress notes did not document indication for holding doses of medication for Resident #1. |
| Fire drills were not conducted during the 3rd or night shift from October 2022 to September 2023. |
| Alteration in hydration care plan was not updated to reflect medication changes for Resident #1. |
| Description |
|---|
| Unlabeled medications or treatments found unsecured in residents' rooms (Bedroom #3 and Bedroom #4). |
| No documentation that SCG #1 reviewed and acknowledged the RN case manager care plan for resident #1. |
| No documentation of resident #1 having an annual dental exam completed, refused, or dentist stating an annual exam is not warranted. |
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