Deficiencies per Year
12
9
6
3
0
Severe
High
Moderate
Low
Unclassified
Census Over Time
Census
Capacity
Inspection Report
Complaint Investigation
Census: 87
Capacity: 100
Deficiencies: 0
Dec 18, 2025
Visit Reason
The State Agency conducted a complaint investigation related to accidents/incidents regarding elopement at the facility.
Findings
The facility was found to be in compliance with Medicare and Medicaid requirements and no deficiencies were cited during the investigation.
Complaint Details
Complaint Investigation (CI), MS #2688841, related to accidents/incidents regarding elopement. No deficiencies were cited.
Report Facts
Licensed beds: 100
Census: 87
Inspection Report
Complaint Investigation
Deficiencies: 0
Dec 18, 2025
Visit Reason
The State Agency conducted a Complaint Investigation (CI), MS #2688841, related to accidents/incidents regarding elopement at the facility.
Findings
The facility was found to be in compliance with the Minimum Standards for Institutions for the Aged or Infirm, state licensure requirements. There were no deficiencies cited.
Complaint Details
Complaint Investigation MS #2688841 was related to accidents/incidents regarding elopement. The complaint was investigated and found to be unsubstantiated as no deficiencies were cited.
Inspection Report
Complaint Investigation
Census: 86
Capacity: 100
Deficiencies: 1
Dec 4, 2025
Visit Reason
The State Agency conducted seven complaint investigations at the facility from 12/01/2025 to 12/04/2025, including investigations for quality of care, resident abuse, misappropriation of property, and accident hazards. The visit focused on a complaint investigation related to accident hazards and supervision following an elopement incident involving Resident #9.
Findings
The facility failed to provide adequate supervision to prevent the elopement of Resident #9, who was found 0.4 miles from the facility unsupervised. This failure placed the resident and others at risk of serious injury or death. Immediate Jeopardy was identified but removed after corrective actions were implemented. The facility conducted audits, staff in-services, elopement drills, and updated care plans and monitoring procedures to address the deficiencies.
Complaint Details
The complaint investigations included multiple allegations such as quality of care, resident abuse, and accident hazards. The specific complaint related to accident hazards involved Resident #9 eloping from the facility unsupervised on 11/28/2025, which led to an Immediate Jeopardy determination that was later removed after corrective actions.
Severity Breakdown
SQC-J: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to provide adequate supervision and a secure environment to prevent the elopement of Resident #9. | SQC-J |
Report Facts
Complaint Investigations conducted: 7
Distance Resident #9 eloped: 0.4
Temperature at time of elopement: 51
Facility licensed capacity: 100
Facility census: 86
BIMS score for Resident #9: 9
Number of vehicles observed: 125
Number of elopement drills: 4
Duration of elopement drill program: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Nursing Home Administrator | Administrator | Described understanding of elopement incident and corrective actions |
| Physical Therapist Assistant | PTA | Observed Resident #9 exiting facility and held door open, assumed nurse was accompanying resident |
| Registered Nurse #1 | RN | Last saw Resident #9 at 10:37 AM and assessed resident after return |
| Social Worker #1 | Social Worker | Participated in search and interview of Resident #9 after elopement |
| Certified Nursing Assistant #1 | CNA | Last saw Resident #9 at 10:00 AM before elopement |
| Maintenance Director | Maintenance Director | Conducted elopement drills and audits on doors and windows |
| Assistant Director of Nursing | ADON | Completed staff in-services on elopement and emergency procedures |
Inspection Report
Complaint Investigation
Deficiencies: 1
Dec 4, 2025
Visit Reason
The State Agency conducted a Complaint Investigation at Pleasant Hills Com Liv Center from 2025-12-01 to 2025-12-04 involving multiple complaint investigations related to quality of care, resident abuse, misappropriation of property, and accidents, specifically investigating an elopement incident involving Resident #9.
Findings
The facility failed to provide adequate supervision to prevent the elopement of Resident #9, who was found 0.4 miles from the facility unsupervised, placing the resident and others at risk of serious injury or death. An Immediate Jeopardy was identified but later removed after corrective actions were implemented. The facility conducted staff in-services, elopement drills, audits, and updated care plans and monitoring procedures to prevent recurrence.
Complaint Details
The complaint investigation involved multiple complaint investigations (CI MS #2638894, #2681269, #2664970, #2651812, #2648248, #2681255, and #2683513). The elopement incident of Resident #9 was substantiated, with Immediate Jeopardy and Substandard Quality of Care identified and later removed after corrective actions.
Severity Breakdown
Level IV: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to provide adequate supervision and a secure environment to prevent the elopement of Resident #9. | Level IV |
Report Facts
Distance Resident #9 eloped: 0.4
Temperature at time of elopement: 51
Vehicles counted: 125
BIMS score: 9
Number of sampled residents: 10
Time Resident #9 was unsupervised outside: 22
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Nursing Home Administrator (LNHA) | Described understanding of the elopement incident involving Resident #9 | |
| Physical Therapist Assistant (PTA) #1 | Observed Resident #9 exiting the facility and assisted in locating the resident | |
| Registered Nurse (RN) #1 | Last saw Resident #9 before elopement and assessed resident upon return | |
| Social Worker #1 | Participated in search and care of Resident #9 after elopement | |
| Certified Nursing Assistant (CNA) #1 | Last saw Resident #9 at 10:00 AM on day of incident | |
| Maintenance Director | Conducted elopement drills on all shifts | |
| Assistant Director of Nursing (ADON) | Completed staff in-services on elopement and emergency procedures | |
| On-Call Nurse Practitioner (NP) #1 | Notified and provided new order for psychiatric evaluation |
Inspection Report
Complaint Investigation
Census: 82
Capacity: 100
Deficiencies: 0
Oct 24, 2025
Visit Reason
The State Agency conducted a Complaint Investigation related to resident-on-resident abuse at the facility from 10/23/2025 through 10/24/2025.
Findings
During the survey, the State Agency determined the facility was in compliance with Medicare and Medicaid requirements and no deficiencies were cited.
Complaint Details
Complaint Investigation (CI) 2630994 and 2632180 were investigated regarding resident-on-resident abuse; no deficiencies were found.
Report Facts
Licensed beds: 100
Census: 82
Inspection Report
Complaint Investigation
Deficiencies: 0
Oct 24, 2025
Visit Reason
The State Agency conducted a Complaint Investigation related to resident-on-resident abuse at the facility from 10/23/2025 through 10/24/2025.
Findings
The facility was found to be in compliance with the Minimum Standards for Institutions for the Aged or Infirm, state licensure requirements, and no deficiencies were cited.
Complaint Details
Complaint Investigation numbers 2630994 and 2632180 were related to resident-on-resident abuse. Both complaints were investigated and found to have no deficiencies.
Inspection Report
Follow-Up
Census: 80
Capacity: 100
Deficiencies: 0
Jul 29, 2025
Visit Reason
The State Agency conducted a follow-up revisit at the facility on 7/29/25 related to a complaint survey conducted from 6/17/25 through 6/24/25.
Findings
The State Agency determined the facility was in compliance with the requirements of participation in Medicare and Medicaid and recommends the facility be placed back in compliance effective 7/18/25.
Complaint Details
The follow-up revisit was related to a complaint survey conducted from 6/17/25 through 6/24/25.
Report Facts
Licensed beds: 100
Census: 80
Inspection Report
Follow-Up
Deficiencies: 0
Jul 29, 2025
Visit Reason
The State Agency conducted a follow-up revisit at the facility on 7/29/25 related to a complaint survey conducted from 6/17/25 through 6/24/25.
Findings
The State Agency determined the facility was in compliance with the Minimum Standards for Institutions for the Aged or Infirm, state licensure requirements, and recommends the facility be placed back into compliance effective 7/18/25.
Complaint Details
The visit was related to a complaint survey conducted from 6/17/25 through 6/24/25. The facility was found to be in compliance upon follow-up.
Report Facts
Survey completion date: Jul 29, 2025
Complaint survey period: 7
Inspection Report
Complaint Investigation
Census: 80
Capacity: 100
Deficiencies: 0
Jul 28, 2025
Visit Reason
The State Agency conducted complaint investigations related to abuse/neglect, misappropriation, physical environment (pests), resident rights, and safety at the facility.
Findings
The facility was found to be in compliance with Medicare and Medicaid requirements, and no deficiencies were cited during the complaint investigations.
Complaint Details
Complaint investigations MS #475778 and MS #2573239 were conducted. MS #475778 investigated abuse/neglect, misappropriation, and physical environment (pests). MS #2573239 investigated resident rights and safety. No deficiencies were cited.
Report Facts
Licensed beds: 100
Census: 80
Inspection Report
Complaint Investigation
Census: 80
Capacity: 100
Deficiencies: 0
Jul 28, 2025
Visit Reason
The State Agency conducted complaint investigations related to abuse/neglect, misappropriation, physical environment (pests), resident rights, and safety at the facility.
Findings
The facility was found to be in compliance with the Minimum Standards for Institutions for the Aged or Infirm and state licensure requirements. No deficiencies were cited.
Complaint Details
Complaint investigations MS #475778 and MS #2573239 were conducted. MS #475778 involved abuse/neglect, misappropriation, and physical environment (pests). MS #2573239 involved resident rights and safety. No deficiencies were cited.
Report Facts
Licensed beds: 100
Resident census: 80
Inspection Report
Complaint Investigation
Census: 81
Deficiencies: 4
Jun 24, 2025
Visit Reason
The State Agency conducted multiple complaint investigations at Pleasant Hills Com Liv Center from 2025-06-17 through 2025-06-24, triggered by numerous allegations including abuse, neglect, resident safety, medication issues, staffing, and quality of care.
Findings
The facility was found non-compliant with Minimum Standards for Institutions for the Aged or Infirm, citing multiple deficiencies including failure to prevent resident-to-resident abuse, failure to maintain resident dignity, inadequate accommodation of resident needs, unsafe and uncomfortable environment, lack of clean linens causing care postponement, failure to provide personal hygiene care, failure to assess a resident after a fall, and unsafe medication storage.
Complaint Details
The complaint investigations involved multiple allegations including falls, abuse, neglect, resident safety, medication errors, staffing shortages, falsification of records, insufficient supplies, and quality of care issues. Several allegations were substantiated resulting in citations; others were investigated but did not result in deficiencies.
Severity Breakdown
Level II: 4
Deficiencies (4)
| Description | Severity |
|---|---|
| Failed to prevent repeated resident-to-resident physical aggression and failed to ensure respectful, dignified care including failure to cover indwelling catheter bag and provide adequate linens and accommodations for residents' needs. | Level II |
| Failed to provide personal hygiene, specifically fingernail and toenail care during activities of daily living for two residents. | Level II |
| Failed to evaluate and analyze hazards and risks and failed to assess a resident following a documented fall. | Level II |
| Failed to safely and securely store medications for one resident, with medications left unsecured in the resident's room without physician order. | Level II |
Report Facts
Number of residents sampled: 30
Number of residents with cited deficiencies: 8
Facility census: 81
Number of disposable dry washcloths: 850
Number of bottles of body wash: 78
Number of gallons of cleanser: 2
Length of fingernails: 0.1875
Length of fingernails: 0.3333
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Reported awareness of resident-to-resident abuse and fall incident |
| Social Services Director | Social Services Director | Grievance Officer involved in abuse referrals and discharge planning |
| RN #3 | Registered Nurse | Reported witnessing abuse incident and notifying staff |
| CNA #5 | Certified Nursing Assistant | Witnessed resident-to-resident abuse and reported incident |
| CNA #4 | Certified Nursing Assistant | Witnessed resident-to-resident abuse and intervened |
| Director of Nursing | Director of Nursing | Provided information on abuse incidents, resident care concerns, and medication storage |
| Administrator | Facility Administrator | Acknowledged ongoing resident abuse incidents and supply concerns |
| Housekeeping Supervisor | Housekeeping Supervisor | Reported on linen supply issues and miscommunication |
| RN #1 | Registered Nurse | Reported linen shortages and confirmed wheelchair armrest condition |
| CNA #1 | Certified Nursing Assistant | Reported wheelchair armrest breakage during transfer |
| Occupational Therapist Assistant #1 | Occupational Therapist Assistant | Inspected wheelchair and notified repair company |
| Staffing Coordinator | Staffing Coordinator | Reported no recall of fall incident |
Inspection Report
Complaint Investigation
Census: 81
Capacity: 100
Deficiencies: 9
Jun 24, 2025
Visit Reason
The State Agency conducted twenty-four complaint investigations at the facility from 6/17/25 through 6/24/25 due to multiple complaints including falls, abuse, neglect, resident safety, insufficient supplies, and quality of care.
Findings
The facility was found not in compliance with Medicare and Medicaid participation requirements, with deficiencies including failure to ensure resident dignity, reasonable accommodations, safe environment, freedom from abuse, proper reporting of abuse, adequate activities of daily living care, accident prevention, medication storage, and facility assessment.
Complaint Details
The complaint investigation included multiple allegations such as falls, abuse, neglect, insufficient supplies, and resident safety. Specific substantiated abuse involved repeated resident-to-resident physical aggression between Resident #1 and Resident #2, resulting in injury to Resident #1.
Severity Breakdown
SS=D: 8
SS=G: 1
Deficiencies (9)
| Description | Severity |
|---|---|
| Failed to ensure resident's right to respectful, dignified care by not applying catheter bag cover, leaving contents visible. | SS=D |
| Failed to provide reasonable accommodation by discontinuing disposable premoistened cleansing cloths for incontinent residents with wounds. | SS=D |
| Failed to provide a safe and comfortable environment including torn wheelchair armrests and lack of clean linens causing postponed resident care. | SS=D |
| Failed to ensure resident's right to be free from abuse; repeated resident-to-resident physical aggression resulted in injury requiring pain medication. | SS=G |
| Failed to report an allegation of resident-on-resident physical abuse to the State Agency within required timeframe. | SS=D |
| Failed to provide personal hygiene care, specifically fingernail and toenail care for two residents. | SS=D |
| Failed to evaluate and analyze hazards and risks and failed to assess a resident following a documented fall. | SS=D |
| Failed to safely and securely store medications for one resident with medications unsecured in room. | SS=D |
| Failed to conduct and document a facility-wide assessment to determine resources necessary to care for residents, including staffing and equipment needs. | SS=D |
Report Facts
Complaint investigations conducted: 24
Facility licensed capacity: 100
Facility census: 81
Residents sampled: 30
Residents with disposable cloths discontinued: 4
Residents with long fingernails: 2
Functional lifts: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Reported witnessing resident-to-resident abuse and involved in abuse investigation |
| CNA #5 | Certified Nursing Assistant | Witnessed resident-to-resident abuse and reported incident |
| Director of Nursing | Director of Nursing | Interviewed regarding multiple deficiencies including catheter care, disposable cloths, abuse incidents, and medication storage |
| Social Services Director | Social Services Director | Grievance Officer involved in abuse case management and resident referrals |
| Administrator | Facility Administrator | Interviewed regarding awareness of abuse incidents, staffing, and facility assessment |
| RN #1 | Registered Nurse | Confirmed wheelchair armrest condition and lack of linens |
| CNA #1 | Certified Nursing Assistant | Reported wheelchair armrest breakage during transfer |
| Staff Development Coordinator | Staff Development Coordinator | Responsible for staffing and scheduling, acknowledged lack of acuity-based staffing |
Inspection Report
Complaint Investigation
Deficiencies: 0
May 14, 2025
Visit Reason
The State Agency conducted eight complaint investigations at the facility from 5/12/25 through 5/14/25 related to supplies and infection control, staffing and neglect, resident safety, and misappropriation of residents' personal property.
Findings
During the survey, the facility was found to be in compliance with the Minimum Standards for Institutions for the Aged or Infirm and state licensure requirements. No deficiencies were cited.
Complaint Details
Eight complaint investigations were conducted covering issues such as supplies and infection control, staffing and neglect, resident dignity and respect, resident safety related to falls, residents left wet or soiled, and misappropriation of residents' personal property. The complaints were not substantiated as no deficiencies were cited.
Report Facts
Number of complaint investigations: 8
Inspection Report
Complaint Investigation
Census: 82
Capacity: 100
Deficiencies: 0
May 14, 2025
Visit Reason
The State Agency conducted eight complaint investigations at the facility from 2025-05-12 through 2025-05-14 related to supplies and infection control, staffing and neglect, resident safety, and misappropriation of residents' personal property.
Findings
The facility was found to be in compliance with Medicare and Medicaid participation requirements, and no deficiencies were cited during the complaint investigations.
Complaint Details
Eight complaint investigations were conducted covering issues such as supplies and infection control, staffing and neglect, resident safety related to falls, residents left soiled or wet, dignity and respect concerns, and misappropriation of residents' personal property. No deficiencies were cited.
Report Facts
Number of complaint investigations: 8
Licensed bed capacity: 100
Census: 82
Inspection Report
Complaint Investigation
Census: 83
Capacity: 100
Deficiencies: 0
Mar 25, 2025
Visit Reason
The State Agency conducted two complaint investigations related to staffing and dietary services, and resident care issues including being left wet for extended periods, inappropriate incontinence care, and lack of supplies.
Findings
The facility was found to be in compliance with Medicare and Medicaid requirements, and no deficiencies were cited during the complaint investigations.
Complaint Details
Two complaint investigations (CI MS #27981 and CI MS #27935) were conducted. CI MS #27981 addressed staffing and dietary services, while CI MS #27935 addressed resident care concerns. Both complaints were investigated and found to be unsubstantiated with no deficiencies cited.
Report Facts
Licensed beds: 100
Resident census: 83
Inspection Report
Complaint Investigation
Census: 83
Capacity: 100
Deficiencies: 0
Mar 25, 2025
Visit Reason
The State Agency conducted two complaint investigations related to staffing and dietary services, and resident care issues including being left wet for extended periods, inappropriate incontinence care, and lack of supplies.
Findings
The facility was found to be in compliance with the Minimum Standards for Institutions for the Aged or Infirm and state licensure requirements. No deficiencies were cited.
Complaint Details
Two complaint investigations (CI MS #27981 and CI MS #27935) were conducted. CI MS #27981 concerned staffing and dietary services, and CI MS #27935 concerned resident care issues. Both complaints were investigated and found to be unsubstantiated as no deficiencies were cited.
Report Facts
Licensed beds: 100
Census: 83
Inspection Report
Follow-Up
Census: 84
Capacity: 100
Deficiencies: 0
Jan 8, 2025
Visit Reason
The State Agency conducted a follow-up revisit at the facility on 1/8/25 related to an annual recertification survey conducted from 12/10/24 through 12/12/24.
Findings
The State Agency found the facility to be in compliance with the requirements of participation in Medicare and Medicaid and recommends the facility be placed back in compliance effective 1/6/25.
Inspection Report
Follow-Up
Deficiencies: 0
Jan 8, 2025
Visit Reason
The State Agency conducted a follow-up revisit at the facility on 1/8/25 related to an annual recertification survey conducted from 12/10/24 through 12/12/24.
Findings
The State Agency determined the facility was in compliance with the Minimum Standards for Institutions for the Aged or Infirm, state licensure requirements, and recommends the facility be placed back in compliance effective 1/6/25.
Inspection Report
Follow-Up
Census: 84
Capacity: 100
Deficiencies: 0
Jan 8, 2025
Visit Reason
The State Agency conducted a follow-up revisit at the facility on 1/8/25 related to an annual recertification survey conducted from 12/10/24 through 12/12/24.
Findings
The State Agency found the facility to be in compliance with the requirements of participation in Medicare and Medicaid and recommends the facility be placed back in compliance effective 1/6/25.
Inspection Report
Follow-Up
Deficiencies: 0
Jan 8, 2025
Visit Reason
The State Agency conducted a follow-up revisit at the facility on 1/8/25 related to an annual recertification survey conducted 12/10/24 through 12/12/24.
Findings
The State Agency determined the facility was in compliance with the Minimum Standards for Institutions for the Aged or Infirm, state licensure requirements, and recommends the facility be placed back in compliance effective 1/6/25.
Inspection Report
Complaint Investigation
Census: 84
Capacity: 100
Deficiencies: 0
Jan 7, 2025
Visit Reason
The State Agency conducted a complaint investigation related to facility staffing, food not palatable, insufficient supplies, and roaches in the facility.
Findings
The facility was found to be in compliance with Medicare and Medicaid participation requirements, with no deficiencies cited during this complaint investigation. However, the facility remains out of compliance for the annual survey conducted on 12/12/2024.
Complaint Details
Complaint investigation (CI MS #27440) related to staffing, food quality, supplies, and pest issues; no deficiencies were cited and the facility was found compliant during this investigation.
Report Facts
Resident census: 84
Total licensed capacity: 100
Inspection Report
Complaint Investigation
Deficiencies: 0
Jan 7, 2025
Visit Reason
The State Agency conducted a complaint investigation related to facility staffing, food not palatable, insufficient supplies, and roaches in the facility.
Findings
The facility was found to be in compliance with the Minimum Standards for Institutions for the Aged or Infirm and state licensure requirements, with no deficiencies cited during this complaint investigation. However, the facility remains out of compliance for the annual survey conducted on 12/12/2024.
Complaint Details
Complaint MS #27440 was investigated and found to be unsubstantiated as no deficiencies were cited.
Report Facts
Complaint number: 27440
Annual survey date: Dec 12, 2024
Inspection Report
Annual Inspection
Census: 84
Capacity: 100
Deficiencies: 2
Dec 12, 2024
Visit Reason
The State Agency conducted an Annual Recertification survey along with two Complaint Investigations related to resident rights at the facility from 12/10/2024 through 12/12/2024.
Findings
The facility was found not in compliance with Medicare and Medicaid participation requirements, citing deficiencies related to resident rights and dignity. Specific issues included a CNA attempting to check a resident for incontinence against his wishes in a hallway and failure to have a privacy cover on a urinary drainage bag for another resident.
Complaint Details
Two complaint investigations (CI MS #27141 and CI MS #27015) were conducted related to resident rights. One complaint involved Resident #7 alleging inappropriate incontinence care by a CNA, which was substantiated and corrective actions were taken including reassigning the CNA and contacting the District Ombudsman.
Severity Breakdown
SS=D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to ensure residents' rights related to respect and dignity when a CNA attempted to check a resident for incontinence in the hallway against his wishes. | SS=D |
| Failed to ensure a privacy cover on a urinary drainage bag for a resident. | SS=D |
Report Facts
Census: 84
Total licensed capacity: 100
Number of sampled residents: 19
BIMS score: 15
BIMS score: 15
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| CNA #1 | Certified Nurse Aide | Named in finding related to inappropriate incontinence care against resident's wishes |
| Licensed Practical Nurse #3 | LPN | Confirmed resident declined care during incident |
| Licensed Practical Nurse #4 | LPN | Stated catheter drainage bags should be kept in privacy bags |
| Assistant Director of Nursing | ADON | Conducted assessments of residents and ensured corrective actions |
| Director of Nursing | DON | Confirmed privacy bag policy and participated in staff in-service and audits |
| Licensed Nursing Home Administrator | LNHA | Corroborated incident details regarding Resident #7 |
Inspection Report
Annual Inspection
Deficiencies: 2
Dec 12, 2024
Visit Reason
The State Agency conducted an annual recertification survey along with complaint investigations at the facility from 2024-12-10 through 2024-12-12 to assess compliance with Minimum Standards for Institutions for the Aged or Infirm and state licensure requirements.
Findings
The facility was found not in compliance with residents' rights related to respect and dignity. Specifically, a Certified Nurse Aide (CNA) attempted to check Resident #7 for incontinence in the hallway against his wishes, and the facility failed to ensure a privacy cover on a urinary drainage bag for Resident #79. Corrective actions and staff in-services were implemented to address these issues.
Complaint Details
The visit included complaint investigations MS #27141 and MS #27015. Resident #7 filed a grievance alleging the CNA attempted to check him for incontinence in the hallway against his wishes. Corrective action included reassigning the CNA and contacting the District Ombudsman.
Deficiencies (2)
| Description |
|---|
| Failed to ensure residents' rights related to respect and dignity when a CNA attempted to check Resident #7 for incontinence in the hallway against his wishes. |
| Failed to ensure a privacy cover on a urinary drainage bag for Resident #79. |
Report Facts
Number of sampled residents with privacy cover issue: 2
Dates of survey: Survey conducted from 2024-12-10 through 2024-12-12.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| CNA #1 | Certified Nurse Aide | Named in finding related to attempting to check Resident #7 for incontinence against his wishes. |
| Assistant Director of Nursing | Assistant Director of Nursing (ADON) | Conducted assessments of Residents #7 and #79 and involved in corrective actions. |
| Licensed Practical Nurse #3 | Licensed Practical Nurse (LPN) | Confirmed Resident #7 declined care when CNA #1 attempted to assist. |
| Licensed Practical Nurse #4 | Licensed Practical Nurse (LPN) | Stated catheter drainage bags should always be in a privacy bag. |
| Director of Nursing | Director of Nursing (DON) | Confirmed urine drainage bags should be kept in privacy bags and involved in staff in-service. |
| Licensed Nursing Home Administrator | Licensed Nursing Home Administrator (LNHA) | Corroborated CNA #1 attempted to assist Resident #7 against his wishes. |
Inspection Report
Annual Inspection
Census: 84
Capacity: 100
Deficiencies: 2
Dec 12, 2024
Visit Reason
The State Agency conducted an Annual Recertification survey along with two Complaint Investigations related to resident rights at the facility from 12/10/2024 through 12/12/2024.
Findings
The facility was found not in compliance with Medicare and Medicaid participation requirements, citing deficiencies related to resident rights, dignity, privacy, and medication storage and administration. Specific issues included failure to respect resident rights during care, lack of privacy covers on urinary drainage bags, unsecured medication and treatment carts, and medications left unattended at a resident's bedside.
Complaint Details
Two complaint investigations (CI MS #27141 and CI MS #27015) were conducted related to resident rights. One complaint involved a CNA attempting to check Resident #7 for incontinence against his wishes in the hallway. The grievance resulted in the CNA no longer being assigned to the resident and the District Ombudsman being contacted.
Severity Breakdown
SS=D: 1
SS=E: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to ensure residents' rights related to respect and dignity when a CNA attempted to check a resident for incontinence against his wishes and failed to have a privacy cover on a urinary drainage bag for two residents. | SS=D |
| Failed to ensure medications were secured when a medication cart and treatment cart were left unlocked and unattended and failed to ensure medications were not left at a resident's bedside. | SS=E |
Report Facts
Census: 84
Total licensed capacity: 100
Deficiency completion date: Jan 6, 2025
Residents sampled: 19
Medications administered: 18
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| CNA #1 | Certified Nurse Aide | Involved in resident rights deficiency for attempting to check Resident #7 against his wishes |
| Assistant Director of Nursing | Assistant Director of Nursing (ADON) | Assessed residents and ensured corrective actions for privacy cover and dignity issues |
| Director of Nursing | Director of Nursing (DON) | Assessed residents, verified medication orders, and involved in corrective actions and staff in-service |
| Licensed Practical Nurse #3 | LPN | Confirmed Resident #7 declined care at the time of CNA attempt |
| Licensed Practical Nurse #4 | LPN | Confirmed catheter drainage bags should be kept in privacy bags |
| Licensed Practical Nurse #5 | LPN | Admitted leaving medications unattended at Resident #71's bedside |
| Licensed Practical Nurse #1 | LPN | Acknowledged medication cart was left unlocked |
| Registered Nurse #1 | Wound Care Nurse | Left treatment cart unlocked during wound care |
| Licensed Nursing Home Administrator | Administrator | Corroborated CNA #1's actions and involved in staff in-service |
Inspection Report
Annual Inspection
Deficiencies: 2
Dec 12, 2024
Visit Reason
The State Agency conducted an annual recertification survey along with complaint investigations at the facility from 12/10/2024 through 12/12/2024 to assess compliance with Minimum Standards for Institutions for the Aged or Infirm and state licensure requirements.
Findings
The facility was found not in compliance with residents' rights related to respect and dignity. Specifically, a Certified Nurse Aide (CNA) attempted to check a resident for incontinence in the hallway against his wishes, and the facility failed to ensure a privacy cover on a urinary drainage bag for another resident. Corrective actions and staff in-services were implemented to address these issues.
Complaint Details
The visit included complaint investigations MS #27141 and MS #27015. Resident #7 filed a grievance alleging the CNA attempted to check him for incontinence in the hallway against his wishes. The CNA acknowledged the inappropriate action. Corrective action included reassigning the CNA and contacting the District Ombudsman.
Deficiencies (2)
| Description |
|---|
| Failed to ensure residents' rights related to respect and dignity when a CNA attempted to check a resident for incontinence in the hallway against his wishes. |
| Failed to ensure a privacy cover on a urinary drainage bag for a resident. |
Report Facts
Survey period: 3
Sampled residents with privacy cover issue: 2
BIMS score: 15
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| CNA #1 | Certified Nurse Aide | Named in finding related to attempting to check Resident #7 for incontinence against his wishes |
| Assistant Director of Nursing | Assistant Director of Nursing (ADON) | Assessed residents and ensured corrective actions related to privacy covers and dignity |
| Director of Nursing | Director of Nursing (DON) | Conducted audits and in-serviced staff on dignity and respect related to residents' rights |
| Licensed Practical Nurse #3 | Licensed Practical Nurse (LPN) | Confirmed Resident #7 declined care at time of CNA attempt |
| Licensed Practical Nurse #4 | Licensed Practical Nurse (LPN) | Stated catheter drainage bags should always be in a privacy bag |
| Licensed Nursing Home Administrator | Licensed Nursing Home Administrator (LNHA) | Corroborated CNA #1 attempted to assist Resident #7 against his wishes |
Inspection Report
Deficiencies: 0
Dec 11, 2024
Visit Reason
The survey was conducted to assess the facility's compliance with Federal, State, and local emergency preparedness requirements.
Findings
The facility met all applicable emergency preparedness requirements with no deficiencies cited.
Inspection Report
Life Safety
Deficiencies: 0
Dec 11, 2024
Visit Reason
The inspection was conducted to assess compliance with the 2012 Edition of the Life Safety Code (LSC) of the National Fire Protection Association (NFPA).
Findings
The facility met the applicable provisions of the 2012 Edition of the Life Safety Code, and no LSC deficiencies were cited during this survey.
Inspection Report
Re-Inspection
Deficiencies: 0
Sep 16, 2024
Visit Reason
The State Agency conducted a Life Safety Code (LSC) revisit survey to verify information related to a Comparative Federal Monitoring Survey conducted on 08/08/24.
Findings
Although the facility confirmed corrective measures effective 09/09/24, it remains out of compliance with the 2012 Edition of the Life Safety Code due to deficiencies cited in the 07/11/24 health survey.
Report Facts
Survey dates: Aug 8, 2024
Survey dates: Jul 11, 2024
Inspection Report
Follow-Up
Census: 86
Capacity: 100
Deficiencies: 0
Sep 16, 2024
Visit Reason
The State Agency conducted a follow-up revisit at the facility on 9/16/24 related to an annual recertification survey conducted from 7/8/24 through 7/11/24.
Findings
The State Agency found the facility to be in compliance with the requirements of participation in Medicare and Medicaid and recommends the facility be placed back in compliance effective 8/6/24.
Inspection Report
Follow-Up
Deficiencies: 0
Sep 16, 2024
Visit Reason
The State Agency conducted a follow-up revisit survey on 2024-09-16 at the facility for the annual recertification survey that was conducted from 2024-07-08 through 2024-07-11.
Findings
The State Agency determined the facility was in compliance with the Minimum Standards for Institutions for the Aged or Infirm, state licensure requirement and recommends the facility be placed back in compliance effective 2024-08-06.
Inspection Report
Complaint Investigation
Census: 86
Capacity: 100
Deficiencies: 0
Aug 6, 2024
Visit Reason
The State Agency conducted two complaint investigations related to resident abuse at the facility on 08/06/2024.
Findings
During the survey, the facility was found to be in compliance with Medicare and Medicaid requirements with no deficiencies cited; however, the facility remains out of compliance due to deficiencies cited on the prior 07/11/2024 survey.
Complaint Details
Two complaint investigations (CI MS #26062 and CI MS #26099) related to resident abuse were conducted; no deficiencies were cited during this visit.
Report Facts
Licensed beds: 100
Census: 86
Inspection Report
Complaint Investigation
Deficiencies: 0
Aug 6, 2024
Visit Reason
The State Agency conducted two complaint investigations related to resident abuse at the facility on 08/06/2024.
Findings
During the survey, the facility was found to be in compliance with the Minimum Standards for Institutions for the Aged or Infirm and state licensure requirements. No deficiencies were cited during this investigation, but the facility remains out of compliance due to deficiencies cited on the 07/11/2024 survey.
Complaint Details
Two complaint investigations (CI MS #26062 and CI MS #26099) related to resident abuse were conducted. The facility was found compliant with no deficiencies cited during this investigation.
Inspection Report
Annual Inspection
Census: 83
Capacity: 100
Deficiencies: 4
Jul 11, 2024
Visit Reason
The State Agency conducted an Annual Recertification survey and six Complaint Investigations at the facility from 7/8/24 through 7/11/24 to assess compliance with Medicare and Medicaid participation requirements and investigate specific complaints.
Findings
The facility was found not in compliance with Medicare and Medicaid participation requirements, with citations issued for care plan timing and revision, accident hazards and supervision, bowel/bladder incontinence and catheter care, and tube feeding management. No citations were related to the complaint investigations.
Complaint Details
Six complaint investigations were conducted related to nursing services, misappropriation of property, facility staffing and resident rights, resident elopement, and allegations of neglect. No citations were issued related to these complaints.
Severity Breakdown
SS=D: 3
SS=E: 1
Deficiencies (4)
| Description | Severity |
|---|---|
| Failed to revise a comprehensive care plan intervention when an order changed related to accuchecks for one resident. | SS=D |
| Failed to conduct a safety smoking assessment for a resident to safeguard against potential hazards for burns and/or fires. | SS=D |
| Failed to ensure indwelling catheter tubing was secured to prevent complications for one resident. | SS=D |
| Failed to properly label and date enteral feeding bags for three of four observations for a resident with enteral feedings. | SS=E |
Report Facts
Licensed beds: 100
Resident census: 83
Complaint investigations: 6
Deficiency citations: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Named in relation to care plan revision expectation and smoking assessment completion |
| Licensed Practical Nurse #2 | Licensed Practical Nurse | Interviewed regarding care plan revision and smoking assessment |
| Assistant Director of Nursing | Assistant Director of Nursing | Assessed residents and ensured corrective actions for catheter care and enteral feeding |
| Medical Records Nurse | Medical Records Nurse | Conducted audits and participated in care plan and catheter care corrective actions |
| Registered Nurse Supervisor | Registered Nurse Supervisor | Conducted audits and in-serviced staff on catheter care and enteral feeding procedures |
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Interviewed regarding enteral feeding bag labeling |
Inspection Report
Annual Inspection
Deficiencies: 3
Jul 11, 2024
Visit Reason
The State Agency conducted an annual recertification survey and multiple complaint investigations at the facility from 7/8/24 through 7/11/24, investigating several complaint investigations related to nursing services, misappropriation of property, staffing, resident rights, elopement, and neglect.
Findings
The facility was found not in compliance with state licensure requirements and cited for deficiencies related to urinary incontinence catheter care, gastric feeding labeling, and accident prevention regarding smoking safety assessments. No citations were related to the complaint investigations. Corrective actions and audits were implemented to address the deficiencies.
Complaint Details
The complaint investigations included issues related to nursing services, misappropriation of property, facility staffing and resident rights, resident elopement, and allegations of neglect. There were no citations related to these complaint investigations.
Severity Breakdown
Level II: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Failed to ensure indwelling catheter leg tubing was secured to prevent complications for one resident with an indwelling catheter. | Level II |
| Failed to properly label and date enteral feeding bags for three of four observations for a resident with enteral feedings. | Level II |
| Failed to conduct a safety smoking assessment for a resident to safeguard against potential hazards for burns and/or fires. | Level II |
Report Facts
Complaint Investigations investigated: 6
Residents reviewed for accidents and hazards: 3
Observations of enteral feeding bags: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Assistant Director of Nursing | Assistant Director of Nursing (ADON) | Assessed Resident #3 and Resident #24; involved in audits and staff in-service on catheter care and enteral feeding procedures |
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding catheter care, feeding procedures, and smoking assessments; conducted audits and in-serviced staff |
| Licensed Practical Nurse #1 | Licensed Practical Nurse (LPN) | Confirmed lack of catheter leg strap and unlabeled feeding bags during observations |
| Licensed Practical Nurse #2 | Licensed Practical Nurse (LPN)/MDS nurse | Confirmed Resident #1 had not been assessed for smoking since 2021 |
| Certified Nurse Aide #1 | Certified Nurse Aide (CNA) | Confirmed Resident #3 did not have catheter leg strap in place |
| Administrator | Administrator | Interviewed regarding expectations for quality care and involved in QAPI meetings |
Inspection Report
Life Safety
Deficiencies: 0
Jul 11, 2024
Visit Reason
The survey was conducted to assess compliance with the 2012 Edition of the Life Safety Code (LSC) of the National Fire Protection Association (NFPA).
Findings
The facility met the applicable provisions of the 2012 Life Safety Code, and no LSC deficiencies were cited during this survey.
Inspection Report
Deficiencies: 0
Jul 11, 2024
Visit Reason
The survey was conducted to assess the facility's compliance with Federal, State, and local emergency preparedness requirements.
Findings
The facility met all applicable emergency preparedness requirements with no deficiencies cited.
Inspection Report
Follow-Up
Deficiencies: 1
May 1, 2024
Visit Reason
The State Agency conducted a follow-up revisit at the facility on 5/01/24 related to a recertification survey conducted on 2/14/24 and a complaint survey conducted from 4/8/24 in which the facility was re-cited for Resident Rights.
Findings
During the follow-up revisit, the State Agency determined the facility had achieved compliance with the Minimum Standards for Institutions for the Aged or Infirm, state licensure requirements, and recommends the facility be placed back in compliance effective 4/23/24.
Complaint Details
The follow-up revisit was related to a complaint survey conducted from 4/8/24 in which the facility was re-cited for Resident Rights.
Deficiencies (1)
| Description |
|---|
| Facility was re-cited F550 related to Resident Rights |
Inspection Report
Follow-Up
Census: 88
Capacity: 100
Deficiencies: 0
May 1, 2024
Visit Reason
The State Agency conducted a follow-up revisit related to a recertification survey conducted on 2024-02-14 and a complaint survey conducted on 2024-04-08 in which the facility was re-cited for Resident Rights.
Findings
During the follow-up revisit, the State Agency determined the facility had achieved compliance with Medicare and Medicaid participation requirements and recommended the facility be placed back in compliance effective 2024-04-23.
Complaint Details
The complaint survey conducted on 2024-04-08 resulted in a re-citation for Resident Rights (F550).
Report Facts
Licensed beds: 100
Census: 88
Inspection Report
Follow-Up
Deficiencies: 1
May 1, 2024
Visit Reason
The State Agency conducted a follow-up revisit at the facility on 5/01/24 related to a recertification survey conducted on 2/14/24 and a complaint survey conducted from 4/8/24 in which the facility was re-cited for Resident Rights violations.
Findings
During the follow-up revisit, the State Agency determined the facility had achieved compliance with the Minimum Standards for Institutions for the Aged or Infirm and state licensure requirements, recommending the facility be placed back in compliance effective 4/23/24.
Complaint Details
The visit was related to a complaint survey conducted from 4/8/24. The facility was re-cited for Resident Rights violations. The follow-up determined compliance was achieved.
Deficiencies (1)
| Description |
|---|
| Facility was re-cited F550 related to Resident Rights during prior complaint survey. |
Inspection Report
Follow-Up
Census: 88
Capacity: 100
Deficiencies: 1
May 1, 2024
Visit Reason
The State Agency conducted a follow-up revisit related to a recertification survey conducted on 2024-02-14 and a complaint survey conducted from 2024-04-08, focusing on a re-cited deficiency related to Resident Rights.
Findings
During the follow-up revisit, the facility was determined to have achieved compliance with Medicare and Medicaid participation requirements and is recommended to be placed back in compliance effective 2024-04-23.
Complaint Details
The follow-up revisit was related to a complaint survey conducted from 2024-04-08 involving Resident Rights.
Deficiencies (1)
| Description |
|---|
| Re-cited F550 related to Resident Rights |
Report Facts
Licensed beds: 100
Census: 88
Inspection Report
Complaint Investigation
Census: 87
Capacity: 100
Deficiencies: 0
Apr 30, 2024
Visit Reason
The State Agency conducted a complaint investigation (MS #24936) related to Nursing Services at the facility on 04/30/2024.
Findings
No deficiencies were cited during the complaint investigation; however, the facility remains out of compliance with Medicare and Medicaid participation requirements due to deficiencies cited in prior surveys on 02/14/2024 and 04/08/2024.
Complaint Details
Complaint investigation MS #24936 related to Nursing Services was conducted and found no deficiencies.
Report Facts
Licensed beds: 100
Census: 87
Inspection Report
Complaint Investigation
Census: 87
Capacity: 100
Deficiencies: 0
Apr 30, 2024
Visit Reason
The State Agency conducted a Complaint Investigation (CI), MS #24936, related to Nursing Services at the facility on 4/30/24.
Findings
No deficiencies were cited during the complaint investigation; however, the facility remains out of compliance with Medicare and Medicaid participation requirements due to deficiencies cited on prior surveys dated 02/14/24 and 04/08/24.
Complaint Details
Complaint Investigation MS #24936 related to Nursing Services; no deficiencies cited during this investigation.
Report Facts
Licensed beds: 100
Census: 87
Inspection Report
Complaint Investigation
Deficiencies: 0
Apr 30, 2024
Visit Reason
The State Agency conducted a Complaint Investigation (CI), MS #24936 at the facility related to Nursing Services.
Findings
No deficiencies were cited during the complaint investigation; however, the facility remains out of compliance with state licensure requirements due to deficiencies cited on the 02/14/24 and 04/08/24 surveys.
Complaint Details
Complaint Investigation MS #24936 related to Nursing Services was conducted and found no deficiencies.
Report Facts
Complaint Investigation Number: 24936
Previous survey dates: Deficiencies cited on 02/14/24 and 04/08/24 surveys
Inspection Report
Complaint Investigation
Deficiencies: 1
Apr 8, 2024
Visit Reason
The State Survey Agency conducted a Revisit Survey and a Complaint Survey triggered by complaint investigation number 24695 to determine compliance with state licensure requirements and resident rights.
Findings
The facility was found out of compliance with resident respect and dignity standards. Specifically, Licensed Practical Nurse (LPN) #1 was reported and observed to speak to residents in a loud, rude, and aggressive manner, which was corroborated by resident, family, and staff interviews. The facility had previously issued verbal warnings to LPN #1 and initiated corrective actions including staff in-service training and resident interviews to address grievances.
Complaint Details
The complaint investigation (CI MS #24695) substantiated that LPN #1 routinely spoke to residents in a loud, rude, and aggressive manner, including yelling orders and refusing requests, as reported by residents, family members, and staff.
Severity Breakdown
Level II: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure residents were treated and spoken to in a dignified and respectful manner, specifically involving LPN #1's rude and aggressive behavior toward residents. | Level II |
Report Facts
Resident interviews: 4
Staff members interviewed weekly: 2
Residents interviewed weekly: 4
Monitoring period: 6
BIMS score: 15
BIMS score: 12
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Named in findings related to rude, loud, and aggressive behavior toward residents |
| Director of Nurses | Director of Nursing | Signed corrective coaching and witness statement regarding LPN #1's behavior |
| Assistant Director of Nursing | Assistant Director of Nursing | Provided interview about in-service training and ongoing investigation of LPN #1 |
| Social Services Director | Social Services Director | Received grievances and directed them to appropriate department heads |
| Staffing Coordinator | Staffing Coordinator | Reported complaints about LPN #1's communication style |
Inspection Report
Complaint Investigation
Census: 83
Capacity: 100
Deficiencies: 1
Apr 8, 2024
Visit Reason
The State Survey Agency conducted a Revisit Survey and a Complaint Survey triggered by complaint investigation number 24695. The revisit survey verified correction of a previous deficiency, while the complaint survey was conducted due to allegations of resident disrespect and dignity violations.
Findings
The facility was found out of compliance with regulation F550 related to resident respect and dignity. Multiple residents and family members reported that Licensed Practical Nurse (LPN) #1 spoke to residents in a loud, rude, and aggressive manner, including yelling orders and being disrespectful. The facility had initiated corrective actions including staff in-service training and resident interviews to address grievances.
Complaint Details
The complaint investigation found substantiated allegations that LPN #1 routinely spoke to residents in a loud, rude, and aggressive manner, including yelling at residents to go to bed or their rooms and refusing to respond to call lights. Multiple interviews with residents, family members, and staff confirmed these behaviors. The facility was actively investigating the issue and considering termination of LPN #1's employment due to repeated coaching and verbal warnings.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure residents were treated and spoken to in a dignified and respectful manner for two of four sampled residents. | SS=D |
Report Facts
Licensed beds: 100
Resident census: 83
BIMS score: 15
BIMS score: 12
Date of verbal warning: Mar 13, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Named in multiple findings related to rude and disrespectful behavior toward residents |
| Director of Nursing | Director of Nursing | Signed corrective coaching and involved in corrective actions |
| Assistant Director of Nursing | Assistant Director of Nursing | Provided information about training and investigation of LPN #1 |
| Social Worker | Social Worker | Conducted resident interviews regarding grievances |
| Administrator | Administrator | Held resident council meeting and involved in QAPI meetings |
| Staffing Coordinator | Staffing Coordinator | Reported complaints about LPN #1's behavior |
| Social Services Director | Social Services Director | Received grievances and directed them to appropriate department heads |
Inspection Report
Complaint Investigation
Deficiencies: 1
Apr 8, 2024
Visit Reason
The inspection was conducted as a Revisit Survey and a Complaint Survey (CI MS #24695) to determine compliance with Minimum Standards for Institutions for the Aged or Infirm and state licensure requirements, specifically related to resident respect and dignity.
Findings
The facility was found out of compliance with resident rights related to respect and dignity. Multiple residents and family members reported that Licensed Practical Nurse (LPN) #1 spoke to residents in a loud, rude, and aggressive manner. The facility had previously issued verbal warnings and coaching to LPN #1. The facility conducted interviews with residents and staff, provided in-service training on resident rights and employee behavior, and implemented a Quality Assurance Performance Improvement (QAPI) plan to monitor and address concerns.
Complaint Details
The complaint investigation was triggered by reports from residents and family members that LPN #1 routinely spoke to residents in a loud, rude, and aggressive manner, including yelling orders and refusing requests. The facility confirmed receipt of grievances and was investigating the allegations, which could result in termination of LPN #1's employment.
Severity Breakdown
Level II: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure residents were treated and spoken to in a dignified and respectful manner, specifically by LPN #1 who was reported to be loud, rude, and aggressive. | Level II |
Report Facts
Resident sample size: 4
Resident interviews: 2
QAPI monitoring period: 6
QAPI weekly interviews: 4
BIMS score Resident #1: 15
BIMS score Resident #2: 12
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Named in findings related to rude, loud, and aggressive behavior toward residents. |
| Director of Nursing | Director of Nursing | Signed corrective coaching document and involved in corrective actions. |
| Assistant Director of Nursing | Assistant Director of Nursing | Provided interviews and described in-service training and investigation status. |
| Staffing Coordinator | Staffing Coordinator | Reported complaints about LPN #1's communication style. |
| Social Services Director | Social Services Director | Received grievances and directed them to appropriate departments. |
Inspection Report
Complaint Investigation
Census: 83
Capacity: 100
Deficiencies: 1
Apr 8, 2024
Visit Reason
The State Survey Agency conducted a Revisit Survey and a Complaint Survey triggered by complaint investigation number 24695. The revisit survey verified correction of a prior deficiency, while the complaint survey was conducted due to allegations of disrespectful and undignified treatment of residents.
Findings
The facility was found out of substantial compliance related to resident respect and dignity due to failure to ensure residents were treated and spoken to in a dignified and respectful manner. Multiple residents and family members reported that Licensed Practical Nurse (LPN) #1 spoke to residents in a loud, rude, and aggressive manner. The facility implemented corrective actions including staff in-service training and resident interviews to address grievances.
Complaint Details
The complaint investigation was substantiated with findings that LPN #1 routinely spoke to residents in a loud, rude, and aggressive manner, including yelling orders and refusing to respond to call lights appropriately. Multiple residents, family members, and staff reported these behaviors. The facility was out of substantial compliance with Medicare and Medicaid requirements related to resident dignity and respect.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure residents were treated and spoken to in a dignified and respectful manner, specifically involving LPN #1's rude and aggressive communication with residents. | SS=D |
Report Facts
Licensed beds: 100
Resident census: 83
Resident sample size: 4
Residents affected: 2
BIMS score Resident #1: 15
BIMS score Resident #2: 12
Corrective action period: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Named in findings related to rude and disrespectful behavior toward residents |
| Director of Nursing | Director of Nursing (DON) | Signed corrective coaching and involved in corrective actions |
| Assistant Director of Nursing | Assistant Director of Nursing (ADON) | Provided information on in-service training and investigation of LPN #1 |
| Social Worker | Conducted resident interviews regarding grievances | |
| Staffing Coordinator | Reported complaints about LPN #1's communication style | |
| Social Services Director | Social Services Director (SSD) | Received grievances and directed them to appropriate department heads |
Inspection Report
Complaint Investigation
Census: 86
Capacity: 100
Deficiencies: 1
Mar 21, 2024
Visit Reason
The State Agency conducted an investigation for a Facility Reported Incident related to an elopement from 3/14/24 through 3/15/24 and extended the survey from 3/20/24 through 3/21/24 to assess compliance.
Findings
The facility failed to provide adequate supervision to prevent Resident #1, a vulnerable resident, from leaving the facility unnoticed and unsupervised, resulting in an Immediate Jeopardy and Substandard Quality of Care. Corrective actions were implemented on 3/9/24, and the facility was found in compliance at the time of survey.
Complaint Details
Investigation was triggered by a complaint related to an elopement incident involving Resident #1 who left the facility unsupervised for approximately 6 to 8 hours, was found 12 miles away by police, and admitted to hospital for Acute Kidney Injury and Rhabdomyolysis. Immediate Jeopardy was identified but removed after corrective actions.
Severity Breakdown
Severity J: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to provide adequate supervision to prevent Resident #1 from exiting the facility unnoticed and unsupervised. | Severity J |
Report Facts
Facility licensed beds: 100
Resident census: 86
Distance resident found from facility (miles): 12
Duration resident unsupervised (hours): 6
Date of incident: Mar 9, 2024
Date survey completed: Mar 21, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Aide #1 | CNA | Last staff to see Resident #1 in bed at 1:15 AM and reported resident missing at 3:15 AM. |
| Licensed Practical Nurse #1 | LPN | Notified of resident missing and involved in search and notifications. |
| Director of Nurses | DON | Notified of incident, assessed resident at police station and hospital, involved in corrective actions and audits. |
| Administrator in Training | AIT | Notified of incident and involved in corrective actions. |
| Maintenance Supervisor | Maintenance Supervisor | Checked all doors and windows, conducted perimeter searches, implemented door alarms and keypad covers. |
| Social Services Director | SSD | Assessed resident at police station, audited elopement books, and notified resident's family. |
Inspection Report
Complaint Investigation
Census: 86
Capacity: 100
Deficiencies: 1
Mar 14, 2024
Visit Reason
The State Agency conducted a Complaint Investigation related to an elopement incident involving Resident #1 from 3/14/24 through 3/15/24, with an extended survey from 3/20/24 through 3/21/24.
Findings
The facility failed to provide adequate supervision to prevent Resident #1, a vulnerable resident, from leaving the facility unnoticed by kicking open an entrance door. Resident #1 was off the facility grounds for approximately 6 to 8 hours and was found 12 miles away by police, admitted to hospital for Acute Kidney Injury and Rhabdomyolysis. The situation was initially an Immediate Jeopardy but was resolved prior to the survey entrance. The facility implemented corrective actions including staff in-service, audits, door alarms, and elopement drills.
Complaint Details
The complaint investigation was triggered by an elopement incident where Resident #1 left the facility unnoticed for approximately 6 to 8 hours, resulting in hospitalization. The Immediate Jeopardy and Substandard Quality of Care were identified but removed after corrective actions on 3/9/24.
Severity Breakdown
Level IV: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility failed to provide adequate supervision to prevent Resident #1 from exiting the facility unnoticed and unsupervised. | Level IV |
Report Facts
Facility licensed beds: 100
Resident census: 86
Duration resident off premises: 6
Distance resident found from facility: 12
Date of incident: Mar 9, 2024
Date survey completed: Mar 21, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Aide #1 | CNA | Last staff to see Resident #1 in bed at 1:15 AM and reported resident missing at 3:15 AM |
| Licensed Practical Nurse #1 | LPN | Notified by CNA #1 of missing resident and involved in search and notifications |
| Director of Nurses | DON | Notified of missing resident, assessed resident at police station and hospital, led audits and corrective actions |
| Maintenance Supervisor | Maintenance Supervisor | Checked all exit doors and windows, placed door alarms, changed door codes |
| Social Services Director | SSD | Assessed resident at police station, audited elopement books, notified resident's family, and initiated discharge planning |
Inspection Report
Annual Inspection
Deficiencies: 1
Feb 14, 2024
Visit Reason
The State Agency conducted an annual recertification survey at Pleasant Hills Community Living Center from 2/11/2024 to 2/14/2024 to determine compliance with Minimum Standards of Operation for Institutions for the Aged or Infirm and state licensure requirements.
Findings
The facility was found not in compliance with residents' rights policies, specifically failing to consistently ensure call lights were answered in a timely manner for multiple residents. This deficiency affected at least four residents and was substantiated through interviews, record reviews, and grievance logs.
Severity Breakdown
Level II: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to treat residents with dignity and respect by failing to consistently ensure call lights were answered in a timely manner for residents #1, #32, #45, and #80. | Level II |
Report Facts
Number of sampled residents with call light issues: 3
Number of unsampled residents with call light issues: 1
BIMS scores: 14
BIMS scores: 15
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Social Worker | Conducted resident interviews and staff in-service on call light response | |
| Director of Nurses (DON) | Confirmed awareness of complaints and conducted staff in-service on call light response | |
| Activity Director (AD) | Reported grievance about call lights to DON and Administrator | |
| Social Service Director (SSD) | Confirmed complaints and staff in-service on call light response | |
| Administrator | Confirmed resident complaints and conducted multiple in-services on call light response | |
| Assistant Administrator (AA) | Spoken to by Ombudsman regarding complaints |
Inspection Report
Annual Inspection
Census: 84
Capacity: 100
Deficiencies: 2
Feb 14, 2024
Visit Reason
The State Agency conducted an annual recertification survey at the facility from 2/11/24 through 2/14/24 to assess compliance with Medicare and Medicaid Requirements for participation.
Findings
The facility was found not in compliance with Medicare and Medicaid requirements, citing deficiencies related to resident rights and bedrails. Specifically, the facility failed to ensure timely response to call lights for several residents and failed to obtain informed consent for bedrail use for multiple residents.
Severity Breakdown
SS=D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to treat residents with dignity and respect by not consistently ensuring call lights were answered in a timely manner for residents #1, #32, #45, and #80. | SS=D |
| Failure to obtain informed consent for the use of bed rails for seven residents (#1, #14, #24, #31, #45, #81, and #142). | SS=D |
Report Facts
Licensed beds: 100
Census: 84
Residents reviewed for bedrails: 18
Residents without informed consent for bedrails: 7
Residents sampled for call light issues: 31
Residents with call light response issues: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nurses | Director of Nurses (DON) | Confirmed call light evaluation and audit, provided staff training on call light response, and acknowledged lack of bedrail consent forms |
| Social Worker | Social Worker (SW) | Conducted resident interviews, provided staff in-service on residents' rights related to call lights, and performed call light evaluations and audits |
| Regional Nurse Consultant | Regional Nurse Consultant (RNC) | Completed audit on bed rail orders, care plans, and assessment forms |
| Administrator | Administrator | Confirmed resident complaints about call lights, conducted staff in-services on call light response and customer service |
| Activity Director | Activity Director (AD) | Reported grievance related to call lights not being answered timely |
| Social Service Director | Social Service Director (SSD) | Confirmed complaints during resident council about call light response and staff in-service |
| Maintenance Director | Maintenance Director | Conducts routine bed and bed rail quality checks |
| Minimum Data Set Nurse | Minimum Data Set Nurse (MDS Nurse) | Reviewed care plans for accuracy related to bedrails |
| Maintenance Supervisor | Maintenance Supervisor | Completed side rail inspections and will perform monthly inspections |
Inspection Report
Life Safety
Deficiencies: 0
Feb 14, 2024
Visit Reason
The survey was conducted to assess compliance with the 2012 Edition of the Life Safety Code (LSC) of the National Fire Protection Association (NFPA).
Findings
The facility met the applicable provisions of the 2012 Edition of the Life Safety Code, and no LSC deficiencies were cited during this survey.
Inspection Report
Life Safety
Deficiencies: 0
Feb 14, 2024
Visit Reason
The survey was conducted to assess the facility's compliance with Federal, State, and local emergency preparedness requirements.
Findings
The facility met all applicable emergency preparedness requirements with no Life Safety Code deficiencies cited during the survey.
Inspection Report
Complaint Investigation
Deficiencies: 0
Jan 25, 2024
Visit Reason
The State Agency conducted a Complaint Investigation at the facility related to resident neglect.
Findings
The facility was found to be in compliance with the Minimum Standards for Institutions for the Aged or Infirm, state licensure requirement. No deficiencies were cited.
Complaint Details
Complaint Investigation MS #23927 related to resident neglect; no deficiencies cited.
Inspection Report
Complaint Investigation
Census: 87
Capacity: 100
Deficiencies: 0
Jan 25, 2024
Visit Reason
The State Agency conducted a complaint investigation related to resident neglect at the facility on 2024-01-25.
Findings
The facility was found to be in compliance with Medicare and Medicaid requirements, and no deficiencies were cited related to the complaint.
Complaint Details
Complaint investigation (CI MS #23927) related to resident neglect; no deficiencies were cited.
Report Facts
Licensed beds: 100
Resident census: 87
Inspection Report
Complaint Investigation
Deficiencies: 1
Dec 12, 2023
Visit Reason
The State Agency conducted a Complaint Investigation at Pleasant Hills Com Liv Center on 12/12/2023 related to a Facility Reported Incident concerning a violation of resident rights.
Findings
The facility was found to have failed to treat a resident with respect and dignity during care for one of four residents reviewed. The deficiency was determined to be Past Non-Compliance and was corrected prior to the survey date. The facility conducted an immediate investigation, held a QAPI meeting, provided in-services on resident rights and abuse/neglect, suspended the employee involved, and reported the incident to the State Agency and Attorney General Office.
Complaint Details
The complaint investigation (MS #23596) was triggered by a Facility Reported Incident involving a Certified Nursing Assistant (CNA #1) who was overheard speaking to Resident #1 in an abrasive tone and language, including telling the resident "I don't care." The facility investigated and confirmed the incident. The CNA admitted to the behavior. The resident had moderate cognitive impairment. The facility took corrective actions including in-services, suspension of the employee, and reporting to the State Agency and Attorney General Office.
Severity Breakdown
Level II: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failed to treat a resident with respect and dignity during care for one of four residents reviewed. | Level II |
Report Facts
Number of residents reviewed: 4
BIMS summary score: 9
Date of facility admission: Dec 7, 2023
Date of facility investigation: Dec 9, 2023
Date of QAPI meeting: Dec 9, 2023
Date deficiency corrected: Dec 10, 2023
Date of in-service training start: Dec 9, 2023
Date CNA training acknowledgment: May 15, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| CNA #1 | Certified Nursing Assistant | Named in finding for disrespectful behavior toward Resident #1 |
| Administrator | Interviewed and confirmed CNA #1's behavior and facility corrective actions | |
| Director of Nurses (DON) | Interviewed and confirmed CNA #1's disrespectful behavior and facility policies |
Inspection Report
Complaint Investigation
Census: 82
Capacity: 100
Deficiencies: 1
Dec 12, 2023
Visit Reason
The State Agency conducted a complaint investigation related to a Facility Reported Incident concerning a violation of resident rights at the facility on 12/12/2023.
Findings
The facility failed to treat a resident with respect and dignity during care for one of four residents reviewed. The deficiency was determined to be past non-compliance and was corrected prior to the survey date through corrective actions including staff in-services, suspension of the employee, and a QAPI meeting.
Complaint Details
The complaint investigation was triggered by reports that a Certified Nursing Assistant (CNA #1) spoke to Resident #1 in an abrasive tone and language, telling the resident "I don't care." The facility investigated, confirmed the incident, and took corrective actions including in-services and suspension of the employee. The facility reported the abuse to the State Agency and Attorney General Office on 12/9/2023.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to treat a resident with respect and dignity during care. | SS=D |
Report Facts
Licensed beds: 100
Resident census: 82
BIMS score: 9
Date of incident: Dec 9, 2023
Date deficiency corrected: Dec 10, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| CNA #1 | Certified Nursing Assistant | Named in the finding for disrespectful treatment of Resident #1 |
| Administrator | Confirmed the incident and corrective actions taken | |
| Director of Nurses | Director of Nurses | Confirmed disrespectful behavior by CNA #1 and facility policies |
Inspection Report
Follow-Up
Deficiencies: 0
Nov 7, 2023
Visit Reason
The State Agency conducted a follow-up revisit at the facility from 11/06/23 through 11/07/23 related to a recertification survey along with a complaint survey conducted from 9/25/23 through 9/29/23.
Findings
The State Agency determined the facility was in compliance with the Minimum Standards for Institutions for the Aged or Infirm, state licensure requirements, and recommends the facility be placed back in compliance effective 10/19/23.
Report Facts
Survey dates: Complaint survey conducted from 2023-09-25 through 2023-09-29
Survey dates: Follow-up revisit conducted from 2023-11-06 through 2023-11-07
Inspection Report
Follow-Up
Census: 83
Capacity: 120
Deficiencies: 0
Nov 7, 2023
Visit Reason
The State Agency conducted a follow-up revisit at the facility from 11/06/23 through 11/07/23 related to a recertification survey along with a complaint survey conducted 9/25/23 through 9/29/23.
Findings
The State Agency found the facility to be in compliance with the requirements of participation in Medicare and Medicaid and recommends the facility be placed back in compliance effective 10/19/23.
Complaint Details
The visit was related to a complaint survey conducted 9/25/23 through 9/29/23; no substantiation status is stated.
Inspection Report
Follow-Up
Census: 83
Capacity: 120
Deficiencies: 0
Nov 7, 2023
Visit Reason
The State Agency conducted a follow-up revisit at the facility from 11/06/23 through 11/07/23 related to a recertification survey along with a complaint survey that was conducted 9/25/23 through 9/29/23.
Findings
The State Agency found the facility to be in compliance with the requirements of participation in Medicare and Medicaid and recommends the facility be placed back in compliance effective 10/19/23.
Complaint Details
The visit was related to a complaint survey conducted 9/25/23 through 9/29/23; the facility was found in compliance upon follow-up.
Report Facts
Licensed beds: 120
Resident census: 83
Inspection Report
Annual Inspection
Census: 81
Capacity: 120
Deficiencies: 8
Sep 29, 2023
Visit Reason
The State Agency conducted an annual recertification survey and two complaint investigations related to facility staffing and quality of care from 09/25/23 through 09/29/23.
Findings
The facility was found not in compliance with Medicare and Medicaid participation requirements, citing multiple deficiencies including failure to timely report and investigate an injury of unknown source, failure to provide written bed hold policy notifications, failure to implement comprehensive care plans, inadequate supervision to prevent accidents, insufficient nursing staff, failure to have RN coverage for 8 consecutive hours, and lapses in infection prevention and control procedures.
Complaint Details
The complaint investigations (CI MS #22690 and CI MS #22934) were related to facility staffing and quality of care. The facility was cited for failure to have sufficient staff and failure to provide incontinent care on the night shift.
Severity Breakdown
SS=G: 4
SS=D: 2
SS=F: 2
Deficiencies (8)
| Description | Severity |
|---|---|
| Failure to report within two hours an injury of unknown source resulting in intracerebral hemorrhage for Resident #38. | SS=G |
| Failure to thoroughly investigate an injury of unknown source resulting in intracerebral hemorrhage for Resident #38. | SS=G |
| Failure to provide written notification of bed hold policy at time of transfer for Residents #4 and #39. | SS=D |
| Failure to implement comprehensive care plans for Residents #38 and #55. | SS=G |
| Failure to adequately supervise and implement interventions to prevent accidents for Residents #38 and #55. | SS=G |
| Failure to have sufficient nursing staff to meet resident needs, including inadequate staffing on night shift for Residents #8 and #41. | SS=F |
| Failure to have a Registered Nurse for at least 8 consecutive hours a day for 7 days a week on multiple days. | SS=F |
| Failure to consistently implement infection control measures to prevent infection transmission for Residents #180 and #181. | SS=D |
Report Facts
Licensed beds: 120
Resident census: 81
Deficiency counts: 8
RN coverage days less than 8 hours: 8
Staff on night shift: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Observed Resident #38 on floor and involved in incident reporting. |
| Director of Nursing | Director of Nursing | Confirmed incidents, staffing issues, and care plan deficiencies. |
| Administrator | Administrator | Confirmed awareness of incidents, staffing shortages, and reporting failures. |
| Licensed Practical Nurse #4 | Licensed Practical Nurse | Observed infection control lapses during PEG tube care. |
| Registered Nurse #2 | Registered Nurse / Wound Care Nurse | Observed infection control lapses during wound care. |
| Licensed Practical Nurse #3 | Care Plan Nurse | Responsible for writing and reviewing resident care plans. |
| Licensed Practical Nurse #2 | Licensed Practical Nurse | Reported staffing shortages and lack of backup plan. |
| Certified Nursing Assistant #2 | Certified Nursing Assistant | Assisted Resident #38 after fall and reported bed issues. |
| Nurse Practitioner | Nurse Practitioner | Confirmed Resident #38's major head injury and follow-up care. |
| Assistant Director of Nursing | Assistant Director of Nursing | Removed razor from Resident #55 and educated resident on safety. |
Inspection Report
Complaint Investigation
Deficiencies: 2
Sep 29, 2023
Visit Reason
The inspection was conducted in response to a complaint (MS #22934) alleging insufficient staffing on the night shift to provide incontinent care for residents.
Findings
The facility failed to maintain adequate staffing levels to meet resident needs, resulting in two residents not receiving timely care. Additionally, the facility failed to adequately supervise residents to prevent accidents, including a resident fall resulting in a major head injury and another resident shaving unsupervised with a razor, posing safety risks.
Complaint Details
Complaint MS #22934 alleged insufficient staffing on the night shift to provide incontinent care. The complaint was substantiated based on interviews and record review showing inadequate staffing and care delays for residents #8 and #41.
Severity Breakdown
Level II: 1
Level III: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to have sufficient staff to meet the needs of residents, specifically on the night shift for incontinent care. | Level II |
| Failed to adequately supervise and implement interventions to prevent accidents, resulting in a resident fall with major head injury and another resident shaving unsupervised with a razor. | Level III |
Report Facts
Residents sampled: 19
Residents affected: 2
Residents on North Hall: 60
CNAs scheduled: 5
CNAs left shift: 3
CNAs remaining: 2
Resident fall date: Sep 8, 2023
Incident report date: Oct 19, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #1 | LPN | Assessed resident #38 after fall and documented incident |
| Licensed Practical Nurse #2 | LPN | Confirmed staffing shortages and CNA departures on night shift 9/28/23 |
| Director of Nursing | DON | Confirmed staffing issues, fall incident, and supervised staff education |
| Assistant Director of Nursing | ADON | Removed razor from resident #55 and educated resident on shaving risks |
| Administrator | Administrator | Acknowledged staffing shortages and resident fall incident |
| Certified Nursing Assistant #2 | CNA | Witnessed resident #38 fall and reported bed malfunction |
| Certified Nursing Assistant #1 | CNA | Reported resident #55 shaving unsupervised |
| Nurse Practitioner | NP | Confirmed major head injury of resident #38 after fall |
Inspection Report
Annual Inspection
Census: 81
Capacity: 120
Deficiencies: 2
Sep 29, 2023
Visit Reason
The State Agency conducted an annual recertification survey and two complaint investigations related to facility staffing and quality of care from 09/25/2023 through 09/29/2023.
Findings
The facility was found not in compliance with Medicare and Medicaid participation requirements, citing multiple deficiencies including insufficient nursing staff and failure to have a registered nurse for at least 8 consecutive hours on several days. Staffing shortages impacted resident care, with specific complaints from residents about inadequate assistance during night shifts.
Complaint Details
Two complaint investigations (CI MS #22690 and CI MS #22934) were conducted related to facility staffing and quality of care. The complaint MS #22934 alleged insufficient night shift staff to provide incontinent care. The complaints were substantiated with findings of staffing shortages.
Severity Breakdown
SS=F: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Facility failed to have sufficient nursing staff to meet resident needs for two of 19 sampled residents, including inadequate night shift staffing for incontinent care. | SS=F |
| Facility failed to have a Registered Nurse for at least 8 consecutive hours a day for 7 out of 20 days reviewed. | SS=F |
Report Facts
Licensed beds: 120
Resident census: 81
Days without 8 consecutive RN hours: 7
CNAs scheduled on night of 9/28/23: 5
CNAs working on night of 9/28/23: 2
Residents on North Hall night shift: 60
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #2 | LPN | Confirmed staffing shortages and lack of backup plan for CNA absences |
| Director of Nursing | DON | Confirmed staffing shortages, attempts to hire staff, and lack of RN coverage for 8 consecutive hours |
| Administrator | Acknowledged staffing shortages and efforts to resolve them |
Inspection Report
Annual Inspection
Capacity: 180
Deficiencies: 3
Sep 29, 2023
Visit Reason
The State Agency conducted an annual recertification survey and complaint investigations related to facility staffing and quality of care from 09/25/23 through 09/29/23.
Findings
The facility was found non-compliant with staffing requirements, accident prevention, and infection control standards. Deficiencies included inadequate staffing leading to unmet resident care needs, failure to prevent resident falls and unsafe shaving practices, and improper infection control procedures during wound care and PEG tube care.
Complaint Details
Complaint investigations MS #22690 and MS #22934 were conducted related to facility staffing and quality of care. The complaint MS #22934 alleged insufficient night shift staff to provide incontinent care.
Severity Breakdown
Level II: 2
Level III: 1
Deficiencies (3)
| Description | Severity |
|---|---|
| Failed to have sufficient nursing staff to meet resident needs, affecting 2 of 19 sampled residents. | Level II |
| Failed to adequately supervise and implement interventions to prevent accidents, resulting in a resident fall with major head injury and unsafe shaving practices for another resident. | Level III |
| Failed to consistently implement infection control measures during wound care and PEG tube care, risking infection transmission for 2 residents. | Level II |
Report Facts
Number of sampled residents affected by staffing deficiency: 2
Number of beds in facility: 180
Number of CNAs scheduled on North Hall night shift: 5
Number of CNAs working on North Hall night shift after 3 left: 2
Number of residents on North Hall night shift: 60
Number of residents reviewed for accidents: 4
BIMS score: 15
BIMS score: 2
Date range of survey: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #2 | LPN | Confirmed staffing shortages and CNA turnover on night shift |
| Director of Nursing | DON | Confirmed staffing shortages, attempts to hire staff, and unsafe long shifts worked by staff |
| Administrator | Administrator | Confirmed awareness of staffing shortages and efforts to resolve them |
| Licensed Practical Nurse #1 | LPN | Assessed resident after fall and documented incident |
| Assistant Director of Nursing | ADON | Removed razor from resident and educated resident on shaving risk |
| CNA #2 | Certified Nurse Aide | Witnessed resident fall and reported bed malfunction |
| Registered Nurse #2 | RN/Wound Care Nurse | Performed wound care with improper hand hygiene |
| Licensed Practical Nurse #4 | LPN | Performed PEG tube care with improper hand hygiene |
| Registered Nurse #1 | RN/Infection Preventionist | Confirmed improper infection control practices by staff |
Inspection Report
Life Safety
Deficiencies: 0
Sep 28, 2023
Visit Reason
The inspection was conducted to assess compliance with the 2012 Edition of the Life Safety Code (LSC) of the National Fire Protection Association (NFPA).
Findings
The facility met the applicable provisions of the 2012 Edition of the Life Safety Code with no deficiencies cited during this survey.
Inspection Report
Deficiencies: 0
Sep 28, 2023
Visit Reason
The survey was conducted to assess the facility's compliance with Federal, State, and local emergency preparedness requirements.
Findings
The facility met all applicable emergency preparedness requirements with no deficiencies cited.
Inspection Report
Complaint Investigation
Deficiencies: 0
Aug 21, 2023
Visit Reason
The State Agency conducted a complaint investigation related to allegations that the Business Office Manager was rude and unprofessional to residents when they asked for funds from their trust accounts.
Findings
The facility was found to be in compliance with the Minimum Standards for Institutions for the Aged or Infirm and state licensure requirements. No deficiencies were cited.
Complaint Details
Complaint investigation MS #22285 regarding Business Office Manager behavior was substantiated as no deficiencies were found.
Inspection Report
Complaint Investigation
Census: 77
Capacity: 100
Deficiencies: 0
Aug 21, 2023
Visit Reason
The State Agency conducted a complaint investigation related to allegations that the Business Office Manager was rude and unprofessional to residents when they asked for personal funds from their Trust Account.
Findings
The facility was found to be in compliance with Medicare and Medicaid requirements, and no deficiencies were cited during the investigation.
Complaint Details
Complaint MS #22285 was investigated regarding the Business Office Manager's rude and unprofessional behavior towards residents requesting personal funds from their Trust Account. The complaint was not substantiated as no deficiencies were cited.
Report Facts
Licensed beds: 100
Census: 77
Inspection Report
Complaint Investigation
Census: 77
Capacity: 120
Deficiencies: 0
Aug 2, 2023
Visit Reason
The State Agency conducted a complaint investigation at the facility for one complaint (MS #22106) related to physical environment issues such as pests and offensive odors, and quality of care concerns including staffing, pressure sore prevention, routine turning/repositioning of dependent residents, and feeding assistance.
Findings
The facility was found to be in compliance with Medicare and Medicaid requirements, and no deficiencies were cited related to the complaint.
Complaint Details
Complaint MS #22106 investigated for physical environment issues (pests and offensive odors) and quality of care concerns (staffing, pressure sore prevention, turning/repositioning, feeding assistance); no deficiencies were cited.
Report Facts
Licensed beds: 120
Resident census: 77
Inspection Report
Complaint Investigation
Deficiencies: 0
Aug 2, 2023
Visit Reason
The State Agency conducted a Complaint Investigation at the facility for one complaint (MS #22106) related to physical environment issues such as pests and offensive odors, and quality of care concerns including staffing, pressure sore prevention, routine turning/repositioning of dependent residents, and feeding assistance.
Findings
The facility was found to be in compliance with the Mississippi Regulations for Minimum Standards for Institutions for the Aged or Infirm, and no deficiencies were cited.
Complaint Details
Complaint MS #22106 investigated for physical environment issues (pests and offensive odors) and quality of care issues (staffing, pressure sore prevention, turning/repositioning, feeding assistance); no deficiencies were cited.
Inspection Report
Complaint Investigation
Deficiencies: 0
Apr 25, 2023
Visit Reason
The State Agency conducted a complaint investigation at the facility for two complaints, MS #21344 related to accidents involving a fall with injury, and MS #21297 related to nursing services allegations of nursing staff use of illegal substances during duty.
Findings
No deficiencies were cited related to the complaints investigated; however, the facility remains out of compliance due to deficiencies cited on the 2023-04-06 annual survey.
Complaint Details
The complaint investigation involved two complaints: MS #21344 for accidents related to a fall with injury, and MS #19492 for nursing services related to allegations of nursing staff use of illegal substances during duty. No deficiencies were cited from these investigations.
Inspection Report
Complaint Investigation
Deficiencies: 0
Apr 25, 2023
Visit Reason
The State Agency conducted a complaint investigation at the facility for two complaints, MS #21344 and MS #21297, on 4/25/23. The investigation focused on accidents related to a fall with injury and allegations of nursing staff use of illegal substances during duty.
Findings
No deficiencies were cited related to the complaints investigated; however, the facility remains out of compliance due to deficiencies cited on the 4/6/23 annual survey.
Complaint Details
The complaint investigation involved two complaints: MS #21344 regarding accidents related to a fall with injury, and MS #19492 regarding nursing staff use of illegal substances during duty. No deficiencies were cited from these investigations.
Inspection Report
Complaint Investigation
Census: 70
Capacity: 100
Deficiencies: 0
Apr 25, 2023
Visit Reason
The State Agency conducted a complaint investigation at the facility for two complaints, MS #21344 related to accidents from a fall with injury, and MS #21297 related to nursing staff use of illegal substances during duty.
Findings
No deficiencies were cited related to the complaints investigated; however, the facility remains out of compliance due to deficiencies cited on the 2023-04-06 recertification survey.
Complaint Details
The complaint investigation involved two complaints: MS #21344 for accidents related to a fall with injury, and MS #19492 for nursing services allegations of nursing staff use of illegal substances during duty. No deficiencies were cited from these complaints.
Report Facts
Licensed beds: 100
Resident census: 70
Inspection Report
Annual Inspection
Census: 70
Deficiencies: 2
Apr 6, 2023
Visit Reason
The State Agency conducted an annual re-certification survey at the facility from 4/4/23 through 4/6/23 to assess compliance with Minimum Standards for Institutions for the Aged or Infirm and state licensure requirements.
Findings
The facility was found not in compliance with standards related to Activities of Daily Living (ADL) care and Range of Motion (ROM) treatment. Specifically, two residents had inadequate nail care with brown substances under fingernails, and one resident did not have ordered hand rolls in place to prevent contractures.
Severity Breakdown
Level II: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to provide Activities of Daily Living (ADL) nail care for two residents, evidenced by long fingernails with brown substance under nails. | Level II |
| Failed to provide appropriate treatment and services to prevent possible decrease in Range of Motion (ROM) for one resident, evidenced by absence of ordered hand rolls. | Level II |
Report Facts
Residents reviewed for ADL: 70
Residents reviewed for ROM: 22
Residents with ADL deficiency: 2
Resident with ROM deficiency: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Assistant Director of Nursing | ADON | Provided nail care for Residents #20 and #27; observed residents for nail care and splinting devices; responsible for weekly and monthly rounds |
| Director of Nursing | DON | In-serviced nursing staff on ADL and splinting care; confirmed responsibility for nail care and splinting devices; assessed Resident #39 |
| Certified Nurse Assistant #1 | CNA | Confirmed responsibility for nail care of Resident #20 |
| Certified Nurse Assistant #2 | CNA | Confirmed responsibility for nail care of Resident #27 |
| Licensed Practical Nurse #7 | LPN | Confirmed CNA responsibility for Resident #27's nail care |
| Licensed Practical Nurse #1 | LPN | Confirmed Resident #39 was supposed to have hand towels placed in hands |
| Registered Nurse #1 | RN | Confirmed Resident #39 had physician's order for hand rolls |
Inspection Report
Annual Inspection
Census: 70
Capacity: 120
Deficiencies: 7
Apr 6, 2023
Visit Reason
The State Agency conducted an annual re-certification survey at the facility from 4/4/23 through 4/6/23 to determine compliance with Medicare and Medicaid participation requirements.
Findings
The facility was found not in compliance with multiple requirements including comprehensive care plans, ADL care, range of motion maintenance, respiratory care, medication storage and administration, food preferences, and quality assurance program effectiveness.
Severity Breakdown
SS=E: 2
SS=D: 4
SS=F: 1
Deficiencies (7)
| Description | Severity |
|---|---|
| Failed to develop and implement comprehensive care plans for residents needing nail care and hand rolls. | SS=E |
| Failed to provide necessary ADL care for dependent residents as evidenced by long fingernails with brown substance. | SS=D |
| Failed to provide appropriate treatment and services to prevent decrease in range of motion for a resident. | SS=D |
| Failed to properly store oxygen tubing, nebulizer equipment, and post oxygen safety signs. | SS=D |
| Failed to ensure medications were under direct observation during administration. | SS=E |
| Failed to honor resident requests for warming food and food preferences. | SS=D |
| Failed to sustain an effective Quality Assurance and Performance Improvement (QAPI) program as evidenced by repeat deficiencies. | SS=F |
Report Facts
Residents reviewed for care plans: 22
Residents reviewed for ADL care: 70
Residents reviewed for oxygen therapy: 7
Residents reviewed for medication administration: 3
Residents interviewed for food preferences: 22
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #2 | LPN | Named in medication administration deficiency for leaving medications unattended. |
| Director of Nursing | DON | Involved in multiple findings including care plan deficiencies, respiratory care, medication administration, and food warming policies. |
| Assistant Director of Nursing | ADON | Provided nail care and observed residents for nail care and splinting devices. |
| Regional Director of Operations | RDO | In-serviced Administrator on QAPI process and reviewed repeat deficiencies. |
| Dietary Manager | DM | Met with residents to update food preferences and updated tray ticket system. |
Inspection Report
Life Safety
Deficiencies: 0
Apr 5, 2023
Visit Reason
The survey was conducted to assess compliance with the 2012 Edition of the Life Safety Code (LSC) of the National Fire Protection Association (NFPA).
Findings
The facility met the applicable provisions of the 2012 Edition of the Life Safety Code with no deficiencies cited during this survey.
Inspection Report
Routine
Deficiencies: 0
Apr 5, 2023
Visit Reason
The survey was conducted to assess the facility's compliance with applicable Federal, State, and local emergency preparedness requirements.
Findings
The facility met all applicable emergency preparedness requirements with no deficiencies cited.
Inspection Report
Complaint Investigation
Census: 73
Capacity: 100
Deficiencies: 0
Feb 7, 2023
Visit Reason
The State Agency conducted a complaint investigation related to hydration, infection control, rehabilitative services, pressure sores, resident grooming, and residents being left soiled for extended periods.
Findings
The facility was found to be in compliance with Medicare and Medicaid requirements, and no deficiencies were cited during the survey.
Complaint Details
Complaint investigation MS #20593 was substantiated with no deficiencies cited.
Report Facts
Licensed beds: 100
Resident census: 73
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