Inspection Report
Complaint Investigation
Census: 64
Capacity: 78
Deficiencies: 26
Feb 15, 2024
Visit Reason
State-compiled facility profile showing 5 inspections from 2021 to 2024 with detailed deficiency history and enforcement actions.
Findings
Across multiple inspections, the facility was found to have numerous deficiencies including failure to ensure safe medication administration, inadequate staffing, poor resident rights protections, insufficient infection control, and incomplete documentation of physician orders and training. Several deficiencies were repeated and plans of correction were documented but not always fully implemented.
Complaint Details
The most recent complaint investigation on 2024-02-07 found failures in medication administration for a resident unable to self-administer insulin, resulting in hospitalization. Multiple staff acknowledged findings during interviews.
Deficiencies (26)
| Description |
|---|
| C0270 - Change of Condition and Monitoring: Failed to ensure safe medication system for a resident unable to self-administer insulin. |
| C0325 - Systems: Self-Administration of Meds: Failed to ensure safe medication system for a resident unable to self-administer insulin. |
| C0150 - Facility Administration: Operation |
| C0154 - Facility Administration: Policy & Procedure |
| C0155 - Facility Administration: Records |
| C0200 - Resident Rights and Protection - General |
| C0231 - Reporting & Investigating Abuse-Other Action |
| C0243 - Resident Services: Adls |
| C0260 - Service Plan: General |
| C0290 - Res Hlth Srvc: On- and Off-Site Health Srvc |
| C0295 - Infection Prevention & Control |
| C0300 - Systems: Medications and Treatments |
| C0301 - Systems: Medication Administration |
| C0302 - Systems: Tracking Control Substances |
| C0303 - Systems: Treatment Orders |
| C0360 - Staffing Requirements and Training: Staffing |
| C0361 - Acuity-Based Staffing Tool |
| C0370 - Staffing Requirements and Training – Pre-Serv |
| C0374 - Annual and Biennial Inservice For All Staff |
| C0422 - Fire and Life Safety: Training For Residents |
| C0450 - Inspections and Investigations |
| C0610 - General Building Exterior |
| C0613 - General Building: Doors-Walls, Cleanable |
| C0655 - Call System |
| C0160 - Reasonable Precautions |
| C0000 - Comment |
Report Facts
Inspections on page: 5
Total deficiencies: 40
Total surveys: 5
Licensing violations: 20
Abuse violations: 0
Notices: 1
Licensed beds: 78
Census: 64
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff 1 | Executive Director | Named in multiple findings including medication errors, resident rights violations, staffing deficiencies, and acknowledged findings during interviews |
| Staff 2 | LPN | Named in medication administration and coordination of care findings, acknowledged findings during interviews |
| Staff 3 | Regional Operations Director | Acknowledged findings related to medication administration |
| Staff 4 | RN | Involved in medication administration findings and acknowledged findings during interviews |
| Staff 7 | Maintenance Director | Acknowledged findings related to fire and life safety training and building maintenance |
| Staff 29 | Interim Executive Director | Acknowledged findings during revisit surveys |
| Staff 26 | Director of Operations | Acknowledged findings related to resident rights and medication administration |
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