Deficiencies per Year
12
9
6
3
0
Unclassified
Inspection Report
Annual Inspection
Deficiencies: 11
Jan 11, 2024
Visit Reason
A recertification survey was conducted from 01/08/2024 to 01/11/2024 to assess compliance with 42 CFR Part 483, Subpart B, for Long Term Care Facilities.
Findings
The facility was found not to be in substantial compliance with federal regulations, with deficiencies cited in areas including resident self-administration of medications, comprehensive care planning, ADL care, tube feeding management, respiratory care, emergency preparedness, and life safety code compliance.
Deficiencies (11)
| Description |
|---|
| Resident self-administration of medications was not properly assessed or supported, with failure to ensure safe storage and monitoring of inhalers. |
| Failure to develop and implement comprehensive care plans for residents, including those on respiratory ventilators. |
| Failure to provide adequate ADL care, including nail care for dependent residents. |
| Failure to properly manage tube feeding, including labeling and administration according to orders. |
| Failure to provide appropriate respiratory care and tracheostomy management for residents. |
| Failure to develop and maintain a comprehensive emergency preparedness program, including annual testing and drills. |
| Failure to maintain fire/smoke doors with self-closing devices and conduct required fire drills. |
| Failure to maintain emergency lighting and conduct monthly testing. |
| Failure to maintain hazardous areas and enclosures in accordance with fire safety codes. |
| Failure to maintain portable fire extinguishers and conduct monthly inspections. |
| Failure to maintain electrical equipment, including power cords and extension cords, in compliance with safety standards. |
Report Facts
Deficiencies cited: 11
Dates of survey: Jan 8, 2024
Dates of survey: Jan 11, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Cole Julian | Executive Director | Signed plan of correction approval on 01/30/2024 |
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