25 Reports
Inspection Report — May 3, 2026
Annual Inspection
Date: May 3, 2026
Visit Reason
On-site annual compliance inspection of a Nursing Care Institution conducted on 3 May 2026.
Findings
Four deficiencies were cited, but no evidence text was provided for any of them.
Deficiencies (4)
R9-10-403 — No evidence text provided for the administrator's failure to ensure policies and procedures for physical and behavioral health services were established, documented, and implemented.
R9-10-413 — No evidence text provided for the medical director's failure to ensure residents were assisted in obtaining needed physical therapy services not provided by the institution.
R9-10-414 — No evidence text provided for the administrator's failure to ensure behavioral health professional review of residents' comprehensive assessments and care plans when indicated.
R9-10-423 — No evidence text provided for the registered dietitian or director of food services failing to ensure tableware, utensils, equipment, and food-contact surfaces were clean and in good repair.
Report Facts
Deficiencies cited: 4
Inspection Report — Mar 20, 2026
Annual Inspection
Date: Mar 20, 2026
Visit Reason
Annual compliance inspection of Nursing Care Institution conducted 17-20 March 2026, including investigation of complaint intake 00161848.
Complaint Details
The recertification and complaint survey was conducted on March 17-20, 2026, in conjunction with investigation of intake: 00161848 and federal intake 2802367.
Findings
The inspection found four deficiencies related to resident screening, provision of specialized rehab services, behavioral health services, and food safety. Plans of correction were provided for all deficiencies.
Deficiencies (4)
R9-10-403 — The facility failed to ensure that the Level I PASRR screening was accurately completed and updated for two residents (#13 and #63).
R9-10-413 — The facility failed to ensure one resident (#25) was provided specialized rehab services to meet their needs and achieve the highest practicable level of function.
R9-10-414 — The facility failed to ensure provision and implementation of necessary behavioral health services for one resident (#5) with identified mental health needs.
R9-10-423 — The facility failed to ensure that food was stored in accordance with professional standards for food safety.
Report Facts
Deficiencies cited: 4
Complaints investigated: 1
Inspection Report — Sep 24, 2025
Date: Sep 24, 2025
Visit Reason
On-site inspection of type Other at a Nursing Care Institution conducted 24 September 2025.
Findings
Two deficiencies were found. One deficiency lacked evidence text, and the other involved failure to conduct all required fire drills per NFPA 101.
Deficiencies (2)
No evidence text provided for the deficiency related to corridor doors and fire protection requirements.
Fire Drills — The facility failed to provide all required fire drills per NFPA 101, not conducting one per shift per quarter to familiarize staff with emergency conditions.
Report Facts
Deficiencies cited: 2
Inspection Report — Aug 20, 2025
Complaint Investigation
Date: Aug 20, 2025
Visit Reason
On-site complaint investigation of multiple complaints including AZ00202130, AZ00221753, AZ00201996, AZ00201997, AZ00214730, AZ00214731, and others at a Nursing Care Institution, conducted 19-20 August 2025.
Complaint Details
The state complaint survey was conducted on August 19, 2025, through August 20, 2025, of numerous complaint numbers including 2274302 (AZ00202130), 2274334 (AZ00221753), 2274300 (AZ00201996), 227301 (AZ00201997), 2274332 (AZ00214730), 2274333 (AZ00214731), 2274364, 00130258, 2274338 (AZ00215318), 2274337 (AZ00215315), 2274327 (AZ00213857), 2274328 (AZ00213855), 2274318 (AZ00210870), 2274317 (AZ00210867), 2274298 (AZ00201925), 2583520, 00138952, 2274363 (AZ00224419), 00129231, 2274402 (AZ00224414), 2274151 (AZ00214752), 2274323 (AZ00212121), 2274324 (AZ00212123), 2274315 (AZ00208811), 2274316 (AZ00208812), 2274303 (AZ00202131), 227299 (AZ00201926), 2274296 (AZ00201415), and 2274297 (AZ00201416). There were no deficiencies cited.
Findings
This inspection found no deficiencies.
Inspection Report — Jun 19, 2025
Complaint Investigation
Date: Jun 19, 2025
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On-site complaint investigation of complaints SF00133171, AZ00206721, AZ00206705, AZ00224837, and AZ00206720 at a Nursing Care Institution, conducted 19 June 2025.
Complaint Details
The investigation of complaints SF00133171, AZ00206721, AZ00206705, AZ00224837, and AZ00206720 were conducted on June 19, 2025. No deficiencies were noted.
Findings
No deficiencies were found during this complaint investigation.
Report Facts
Complaints investigated: 5
Inspection Report — Jun 10, 2025
Complaint Investigation
Date: Jun 10, 2025
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On-site complaint investigation of intakes AZ00224790, SF00132763, AZ00224768, SF00132607, AZ00200709, AZ00200710, AZ00200821, AZ00224800, and SF00132892 at a Nursing Care Institution, conducted 9 through 10 June 2025.
Complaint Details
Investigation of intakes # AZ00224790, SF00132763, AZ00224768, SF00132607, AZ00200709, AZ00200710, AZ00200821, AZ00224800, SF00132892 was conducted on June 9, 2025 through June 10, 2025. No deficiencies were cited.
Findings
No deficiencies were cited during this complaint investigation.
Report Facts
Complaints investigated: 9
Inspection Report — May 22, 2025
Complaint Investigation
Date: May 22, 2025
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On-site complaint investigation of intakes SF00130923, SF00130749, SF00130781, AZ00224556, AZ00224529, and AZ00224534 at a Nursing Care Institution, conducted 22 May 2025.
Complaint Details
An onsite complaint survey was conducted on May 22, 2025 for the investigation of intakes #SF00130923, #SF00130749, and #SF00130781. An onsite complaint survey was conducted on May 22, 2025 for the investigation of intakes #AZ00224556, #AZ00224529, and AZ00224534.
Findings
This inspection found no deficiencies.
Inspection Report — May 9, 2025
Complaint Investigation
Date: May 9, 2025
Visit Reason
The inspection was conducted due to concerns about the facility's failure to provide adequate supervision to a resident at risk for elopement and wandering, following a complaint or incident involving resident #3 eloping from the facility.
Complaint Details
The complaint investigation found that resident #3, who had severely impaired cognition and was an elopement risk, eloped from the facility on April 24, 2025. The resident was found at a bus stop unharmed. Staff interviews revealed inadequate supervision and failure to move the resident to a secured unit despite known risks. The resident's family later approved placement on a secured unit.
Findings
The facility failed to ensure adequate supervision of resident #3, who was identified as an elopement risk and exhibited wandering and agitation behaviors. The resident eloped from the facility, was found at a bus stop, and the facility did not initially place her in a secured unit despite known risks. Interviews with staff confirmed lapses in supervision and delayed response to the resident's elopement risk.
Deficiencies (1)
Failure to ensure adequate supervision to prevent accidents and elopement for resident #3 who was an elopement risk and wandered frequently.
Report Facts
Date of survey completion: May 9, 2025
Resident #3 BIMS score: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Assistant Director of Nursing | LPN | Reported on management response to elopement and search efforts |
| Licensed Practical Nurse | LPN | Described staff procedures for residents attempting to wander and specific behaviors of resident #3 |
| Director of Nursing | DON | Provided background on resident #3 and expectations for elopement prevention |
Inspection Report — May 9, 2025
Date: May 9, 2025
Visit Reason
The inspection was conducted to investigate the facility's compliance with ensuring adequate supervision and safety to prevent accidents, specifically focusing on a resident (#3) who eloped from the facility.
Findings
The facility failed to provide adequate supervision to resident #3, who was identified as an elopement risk and exhibited wandering and agitation behaviors. Despite multiple staff interviews and documented behavioral notes indicating the resident's risk and attempts to leave, the resident eloped from the facility and was found at a bus stop. The facility did not move the resident to a secured unit until after the elopement incident.
Deficiencies (1)
Failure to ensure adequate supervision to prevent elopement of resident #3 who was an identified elopement risk and exhibited wandering behaviors.
Report Facts
Residents Affected: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Assistant Director of Nursing | LPN | Interviewed regarding the elopement incident and facility response |
| Licensed Practical Nurse | LPN | Interviewed about resident wandering and staff interventions |
| Certified Nursing Assistant | CNA | Two CNAs interviewed about resident behaviors and supervision |
| Director of Nursing | DON | Current and prior DONs interviewed about resident history and facility policies |
| Receptionist | Interviewed about front door monitoring and resident elopement |
Inspection Report — Mar 3, 2025
Complaint Investigation
Date: Mar 3, 2025
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On-site complaint investigation of intakes 00115456, 00109270, AZ00223496, and AZ00223473 at a Nursing Care Institution, conducted 3 March 2025.
Complaint Details
An onsite complaint survey was conducted on March 03, 2025 for the investigation of intake # 00115456, 00109270. There were no deficiencies cited. An onsite complaint survey was conducted on March 03, 2025 for the investigation of intake # AZ00223496, AZ00223473. There were no deficiencies cited.
Findings
This inspection resulted in no deficiencies cited.
Report Facts
Complaints investigated: 4
Inspection Report — Feb 14, 2025
Complaint Investigation
Date: Feb 14, 2025
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On-site complaint investigation of intakes AZ00223308, AZ00223315, AZ00223191, AZ00223421, and AZ00223307 at a Nursing Care Institution, conducted 14 February 2025.
Complaint Details
An onsite complaint survey was conducted on February 14, 2025 for the investigation of intake # AZ00223308, AZ00223315, AZ00223191, AZ00223421, AZ00223307, and AZ00223315. There were no deficiencies cited.
Findings
This inspection resulted in no deficiencies cited or citations.
Report Facts
Complaints investigated: 6
Inspection Report — Feb 4, 2025
Complaint Investigation
Date: Feb 4, 2025
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On-site complaint investigation of intake #AZ00222971 and #AZ00222963 at a Nursing Care Institution, conducted 4 February 2025.
Complaint Details
An onsite complaint survey was conducted on February 4, 2025 for the investigation of intake #AZ00222971 and intake #AZ00222963. There were no deficiencies cited.
Findings
No deficiencies were cited during this complaint investigation.
Inspection Report — Jan 7, 2025
Complaint Investigation
Date: Jan 7, 2025
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On-site complaint investigation of intakes AZ00221535, AZ00221506, and AZ00221532 at a Nursing Care Institution, conducted 7 January 2025.
Complaint Details
An onsite complaint survey was conducted on January 7, 2025 for the investigation of intake # AZ00221535, AZ00221506, and AZ00221532. There were no deficiencies cited.
Findings
This inspection resulted in no deficiencies or citations.
Inspection Report — Dec 4, 2024
Complaint Investigation
Date: Dec 4, 2024
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On-site complaint investigation of intakes AZ00203735, AZ00206322, AZ00206763, AZ00219255, AZ00203734, AZ00206319, AZ00206760, and AZ00219255 at a Nursing Care Institution, conducted 4 December 2024.
Complaint Details
An onsite complaint survey was conducted on December 4, 2024 for the investigation of intakes #AZ00203735, AZ00206322, AZ00206763, and AZ00219255. Federal comments note investigation of intakes #AZ00203734, AZ00206319, AZ00206760, and AZ00219255. No deficiencies were cited.
Findings
No deficiencies were cited during this complaint investigation.
Inspection Report — Oct 29, 2024
Date: Oct 29, 2024
Visit Reason
On-site other inspection using the Nursing Care Institution worksheet at Sandstone Estates Rehab Centre conducted 29 October 2024.
Findings
Two deficiencies were found related to fire/smoke barrier penetrations and improper mounting of light switches in oxygen storage rooms. Plans of correction were provided and accepted.
Deficiencies (2)
Subdivision of Building Spaces - Smoke Barrier Construction — The facility failed to properly fill penetrations, holes, and openings in multiple smoke barrier areas, including drywall patches above smoke doors and ceiling tiles near room 210, allowing potential smoke and heat penetration during a fire.
Gas Equipment - Cylinder and Container Storage — The facility failed to have light switches mounted at least 5 feet above the finished floor in oxygen storage rooms across from rooms 109 and 209, risking damage to electrical devices and patient safety.
Report Facts
Deficiencies cited: 2
Inspection Report — Oct 25, 2024
Complaint Investigation
Date: Oct 25, 2024
Visit Reason
The inspection was conducted due to complaints and allegations of narcotic diversion, abuse, neglect, and failure to report and investigate abuse incidents at Sandstone Estates Rehab Centre.
Complaint Details
The complaint investigation was substantiated regarding narcotic diversion by an LPN (Staff #220) who was terminated. Multiple allegations of abuse and neglect were investigated for residents #11, #13, and #33, with findings of failure to report and protect residents. The facility failed to report allegations timely to the state and other authorities. The investigation revealed multiple failures in abuse prevention, reporting, and investigation.
Findings
The facility failed to prevent narcotic diversion by an LPN, failed to implement and report allegations of abuse timely for multiple residents, failed to protect residents from further abuse during investigations, failed to follow physician orders properly, failed to ensure medication error rates were below 5%, failed to provide timely hygiene care, failed to ensure expired medications were discarded, failed to prevent unnecessary medications, failed to ensure medication administration infection control, and failed to provide palatable and safe food temperatures.
Deficiencies (12)
Failure to prevent narcotic diversion by an LPN who falsified prescriptions and diverted medications.
Failure to implement policies and procedures to prevent abuse, neglect, and theft for residents #11 and #13.
Failure to timely report suspected abuse and neglect to the state agency and other mandated entities for residents #11 and #13.
Failure to respond appropriately to all alleged violations of abuse for residents #11 and #13, including failure to protect residents from further abuse during investigations.
Failure to ensure physician orders were followed according to professional standards for residents #24 and #29.
Failure to ensure medication error rates were below 5%, with errors observed for residents #43 and #21.
Failure to provide timely shower and dressing assistance to resident #12.
Failure to ensure expired medications were appropriately disposed of and not available for resident use.
Failure to ensure residents were free from unnecessary medications, with resident #24 receiving duplicate insulin orders.
Failure to ensure resident #43 was free from significant medication errors by administering discontinued medication.
Failure to ensure food was palatable and served at safe and appetizing temperatures, with multiple residents reporting cold and unappetizing food.
Failure to ensure proper hand hygiene during medication administration, risking contamination of medications.
Report Facts
Medication error rate: 7.41
Number of narcotic orders started and discontinued in same shift: 34
Number of residents affected by abuse reporting failures: 3
Number of showers missed or refused for Resident #12: Resident #12 frequently missed scheduled showers, especially Fridays.
Expired medication date: 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff #220 | Licensed Practical Nurse (LPN) | Named in narcotic diversion and termination. |
| Staff #55 | Director of Nursing (DON) | Named as supervisor during narcotic diversion investigation and complaint filer. |
| Staff #82 | Administrator | Filed self-report for narcotic diversion and interviewed about incident. |
| Staff #640 | Assistant Director of Nursing (ADON) | Interviewed regarding abuse reporting and investigations. |
| Staff #618 | Director of Nursing (DON) | Interviewed regarding abuse investigations, medication administration, and policy. |
| Staff #672 | Social Services Director | Interviewed regarding knowledge of abuse incidents. |
| Staff #644 | Registered Nurse (RN) | Interviewed regarding medication administration and physician notification. |
| Staff #710 | Licensed Practical Nurse (LPN) | Observed administering expired medication and interviewed. |
| Staff #700 | Registered Nurse (RN) | Observed medication administration and interviewed. |
| Staff #669 | Dietary Manager | Interviewed regarding food temperature complaints. |
| Staff #684 | Certified Nursing Assistant (CNA) | Interviewed regarding bathing schedule and staffing. |
| Staff #622 | Certified Nursing Assistant (CNA) | Interviewed regarding bathing schedule and risks. |
| Staff #657 | Certified Nursing Assistant (CNA) | Interviewed regarding bathing schedule and risks. |
Inspection Report — Oct 25, 2024
Annual Inspection
Date: Oct 25, 2024
Visit Reason
On-site complaint investigation and annual recertification survey conducted 21-25 October 2024 at Sandstone Estates Rehab Centre, including investigation of complaints AZ00200102, AZ00200100, AZ00196959, AZ00196858, AZ00191370, AZ00191302, AZ00191195, AZ00200101, AZ00200099, AZ00196958, AZ00196857, AZ00191369, AZ00191301 and AZ00191195.
Complaint Details
The recertification survey was conducted 10/21/2024 through 10/24/2024 in conjunction with the investigation of complaints AZ00200102, AZ00200100, AZ00196959, AZ00196858, AZ00191370, AZ00191302, AZ00191195, AZ00200101, AZ00200099, AZ00196958, AZ00196857, AZ00191369, AZ00191301 and AZ00191195.
Findings
The inspection found multiple deficiencies including failure to report and investigate abuse allegations timely, medication errors, improper medication administration, failure to protect residents from misappropriation, inadequate hygiene care, and food served at unsafe temperatures. A total of 12 deficiencies were cited.
Deficiencies (12)
R9-10-403 — The facility failed to ensure all allegations of abuse were reported to the state agency and mandated entities within the required timeframe for two sampled residents (#11 and #13).
R9-10-403 — The facility failed to ensure thorough investigations of abuse allegations were completed and residents were protected from further abuse during investigations for two sampled residents (#11 and #13).
R9-10-403 — The facility failed to implement written policies and procedures to prohibit and prevent abuse for two sampled residents (#11 and #13).
R9-10-410 — The facility failed to ensure one resident (#420) was free from misappropriation of medications, including narcotic diversion by an LPN (Staff #220).
R9-10-412 — The facility failed to ensure one resident (#24) was not administered an unnecessary medication due to duplicate insulin glargine orders without clarification.
R9-10-414 — The facility failed to provide timely shower and dressing care to one resident (#12), resulting in missed scheduled baths and inadequate hygiene.
R9-10-421 — The facility failed to ensure one resident (#43) was free from significant medication errors, including administration of discontinued medication.
R9-10-421 — The facility failed to ensure medication was administered only as prescribed for one resident (#29), including failure to notify physician of high blood glucose as ordered.
R9-10-421 — The facility failed to maintain medication error rate below 5% by administering medications incorrectly for two residents (#43 and #21), including expired medication use.
R9-10-421 — The facility failed to establish and implement policies to protect residents by properly storing, inventorying, and dispensing controlled substances, including expired medications.
R9-10-422 — The facility failed to ensure proper hand hygiene was conducted during medication administration by staff (RN/Staff #700).
R9-10-423 — The facility failed to ensure food was palatable and served at safe temperatures, with multiple residents reporting cold and unappetizing meals.
Report Facts
Deficiencies cited: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff #621 | Licensed Practical Nurse | Received message to have visitors leave and informed visitors to leave Resident #11's room. |
| Staff #618 | Director of Nursing | Investigated abuse allegation for Resident #11 and communicated with resident and family. |
| Staff #640 | Assistant Director of Nursing | Interviewed regarding abuse reporting policies and expectations. |
| Staff #220 | Licensed Practical Nurse | Involved in narcotic diversion and medication misappropriation for Resident #420. |
| Staff #644 | Registered Nurse | Interviewed regarding duplicate insulin orders for Resident #24. |
| Staff #700 | Registered Nurse | Observed administering discontinued medication to Resident #43 and improper hand hygiene. |
| Staff #685 | Licensed Practical Nurse | Interviewed about medication administration procedures. |
| Staff #710 | Licensed Practical Nurse | Observed administering expired medication and improper medication handling. |
| Staff #672 | Social Services Director | Interviewed regarding knowledge of abuse incident. |
| Staff #684 | Certified Nursing Assistant | Interviewed about staffing and bathing schedule issues. |
| Staff #622 | Certified Nursing Assistant | Interviewed about shower scheduling and risks of missed showers. |
| Staff #657 | Certified Nursing Assistant | Interviewed about shower procedures and documentation of refusals. |
| Staff #669 | Dietary Manager | Interviewed about food temperature complaints and corrective actions. |
Inspection Report — Sep 23, 2024
Complaint Investigation
Date: Sep 23, 2024
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On-site complaint investigation of intakes AZ00216208, AZ00216015, AZ00216207, and AZ00216014 at a Nursing Care Institution, conducted 23 September 2024.
Complaint Details
An onsite complaint survey was conducted on September 23, 2024 for the investigation of intake #s: AZ00216208, AZ00216015, AZ00216207, and AZ00216014. No deficiencies were cited.
Findings
No deficiencies were cited during this complaint investigation.
Inspection Report — Aug 7, 2024
Complaint Investigation
Date: Aug 7, 2024
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On-site complaint investigation of intakes AZ00213992 and AZ00214005 at a Nursing Care Institution, conducted 7 August 2024.
Complaint Details
An onsite complaint survey was conducted on August 7, 2024 for the investigation of intake # AZ00213992, AZ00214005. There were no deficiencies cited. Federal comments also note investigation of intake # AZ00213991, AZ00214005 with no deficiencies cited.
Findings
This inspection resulted in no deficiencies cited.
Inspection Report — Jul 26, 2024
Complaint Investigation
Date: Jul 26, 2024
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On-site complaint investigation of intake AZ00213636 and AZ00213635 at a Nursing Care Institution, conducted 25-26 July 2024.
Complaint Details
An onsite complaint survey was conducted on July 25, 2024 through July 26, 2024 for the investigation of intake # AZ00213636. Federal comments note a similar onsite complaint survey for intake # AZ00213635. There were no deficiencies cited.
Findings
This inspection found no deficiencies.
Inspection Report — Apr 11, 2024
Complaint Investigation
Date: Apr 11, 2024
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On-site complaint investigation of intake numbers AZ00208490 and AZ00208487 at a Nursing Care Institution, conducted 11 April 2024.
Complaint Details
An onsite complaint survey was conducted on April 11, 2024 for the investigation of intake # AZ00208490 and intake # AZ00208487. There were no deficiencies cited.
Findings
This inspection resulted in no deficiencies cited.
Inspection Report — Nov 7, 2023
Complaint Investigation
Date: Nov 7, 2023
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On-site complaint investigation of complaints AZ00202397, AZ00202428, and AZ00202427 at a Nursing Care Institution, conducted 7 November 2023.
Complaint Details
A complaint investigation was conducted on November 7, 2023. The following complaints were investigated: AZ00202397, AZ00202428, AZ00202427. No deficiencies were cited.
Findings
No deficiencies were cited during this complaint investigation.
Report Facts
Complaints investigated: 3
Inspection Report — May 5, 2023
Complaint Investigation
Date: May 5, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to ensure a resident (#55) was free from neglect and received appropriate treatment and care according to professional standards.
Complaint Details
The complaint investigation found substantiated neglect related to delayed notification of low blood pressure and delayed treatment for resident #55, who developed severe sepsis and expired. The facility failed to monitor and communicate significant changes in condition timely.
Findings
The facility failed to timely notify the physician of the resident's low blood pressure and delayed interventions, resulting in the resident developing severe sepsis and ultimately expiring. Documentation gaps and delayed communication were noted, along with failure to monitor and treat the resident's condition promptly.
Deficiencies (2)
Failed to ensure resident #55 was free from neglect by not acting timely on life-threatening signs and symptoms.
Failed to provide appropriate treatment and care according to orders and professional standards for resident #55.
Report Facts
Blood pressure readings: 94
Blood pressure readings: 55
Blood pressure readings: 71
Blood pressure readings: 43
Heart rate: 108
Oxygen flow rate: 4
Hospital admission time: 15.45
Resident expiration time: Resident #55 expired on an unspecified date at 3:23 p.m.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant (CNA) staff #104 | Certified Nursing Assistant | Interviewed regarding reporting low blood pressure and vital signs documentation |
| Licensed Practical Nurse (LPN) staff #23 | Licensed Practical Nurse | Interviewed regarding delayed response to low blood pressure and documentation |
| Director of Nursing (DON) staff #98 | Director of Nursing | Interviewed regarding expectations for nurse assessments and notification of physician |
Inspection Report — Jan 26, 2023
Routine
Date: Jan 26, 2023
Visit Reason
The inspection was conducted as a routine survey to assess compliance with regulatory requirements related to resident care, treatment, safety, and facility operations.
Findings
The facility was found deficient in multiple areas including failure to complete significant change assessments, incomplete care plans for pressure ulcers, inadequate treatment and monitoring of skin conditions, failure to maintain accurate and timely weight monitoring, medication management issues including expired medications and unsecured medications at bedside, failure to ensure RN coverage for 8 consecutive hours daily, and incomplete clinical documentation.
Deficiencies (11)
Failed to ensure a significant change MDS assessment was completed for one resident within the required timeframe.
Failed to develop and implement a complete care plan for treatment and care of pressure ulcer for one resident.
Failed to develop the complete care plan within 7 days of the comprehensive assessment and revise it by a team of health professionals for one resident.
Failed to provide treatment and services in accordance with professional standards for one resident with skin conditions.
Failed to provide appropriate pressure ulcer care and prevent new ulcers from developing for one resident.
Failed to ensure resident environment was free from accident hazards and provide adequate supervision to prevent accidents and medication accidents.
Failed to ensure medications were not left unsecured at bedside and failed to have physician orders for self-administration of medications.
Failed to ensure weight was obtained as ordered and maintained acceptable nutritional status for one resident.
Failed to have a registered nurse on duty for at least 8 consecutive hours a day, 7 days a week.
Failed to discard expired medications and ensure expired medications were not available for administration.
Failed to ensure clinical record was accurately documented in accordance with accepted professional standards.
Report Facts
Sample size: 23
Weight loss percentage: 7.36
Weight loss percentage: 17.07
Expired medications count: 17
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff #85 | Registered Dietician Nutritionist | Interviewed regarding failure to identify and notify weight loss for resident #4 |
| Staff #8 | Director of Nursing | Interviewed regarding weight monitoring, care plan expectations, RN staffing, and treatment expectations |
| Staff #33 | Licensed Practical Nurse / Wound Nurse | Interviewed regarding wound care and skin assessments |
| Staff #12 | Certified Nursing Assistant | Interviewed regarding bed and picture safety hazard |
| Staff #141 | Certified Nursing Assistant | Interviewed regarding bed safety and maintenance communication |
| Staff #45 | Licensed Practical Nurse | Observed medication pass and interviewed regarding expired medications and medication storage |
| Staff #109 | Licensed Practical Nurse | Interviewed regarding expired medications and medication cart maintenance |
Inspection Report — Dec 6, 2021
Routine
Date: Dec 6, 2021
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, medication administration, infection control, and other facility operations.
Findings
The facility was found deficient in multiple areas including failure to obtain psychotropic medication consents timely, incomplete advance directive documentation, failure to provide timely Medicaid/Medicare notices, incomplete resident assessments, inadequate care planning for dialysis, unsafe discharge medication practices, inadequate assistance with activities of daily living, inconsistent fall prevention interventions, dialysis care deficiencies, medication availability issues, improper medication administration outside ordered parameters, improper storage and labeling of medications and glucose solutions, food safety violations, and lapses in infection control practices including PPE use.
Deficiencies (15)
Failure to ensure residents and/or representatives were informed of risks and benefits of psychotropic medications prior to administration.
Failure to maintain current advance directives and ensure resident wishes were followed.
Failure to timely provide Skilled Nursing Facility Advanced Beneficiary Notice and Notice of Medicare Non-Coverage.
Failure to complete comprehensive resident assessments within required timeframes.
Failure to develop and implement a comprehensive care plan for resident receiving dialysis.
Failure to ensure safe discharge medication practices including documentation and timely delivery of prescriptions.
Failure to provide timely and adequate assistance with activities of daily living including bathing and nail care.
Failure to consistently implement fall interventions and develop new interventions after multiple falls.
Failure to provide dialysis care consistent with professional standards including monitoring of fistula site.
Failure to ensure routine medications were consistently available and administered as ordered.
Failure to ensure residents did not receive unnecessary medications, including failure to hold medications per parameters.
Failure to consistently monitor for effectiveness and side effects of psychotropic medication.
Failure to label and date opened medications and glucose control solutions and store them properly.
Failure to store food properly with appropriate labeling and failure to wear hair restraints and avoid snacking in food prep areas.
Failure to maintain infection control standards including proper PPE use by staff, visitors, and transportation personnel for residents on isolation precautions.
Report Facts
Sample size: 20
Sample size: 6
Sample size: 5
Medication unavailable days: 10
Medication unavailable days: 12
Medication unavailable days: 4
Psychotropic medication monitoring missing days: 17
Psychotropic medication monitoring missing days: 21
Psychotropic medication monitoring missing days: 16
Psychotropic medication effectiveness monitoring missing days: 14
Psychotropic medication effectiveness monitoring missing days: 13
Psychotropic medication effectiveness monitoring missing days: 13
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff #44 | Registered Nurse Unit Manager | Interviewed regarding psychotropic medication consent, medication availability, medication monitoring, fall interventions, and infection control |
| Staff #134 | Director of Nursing | Interviewed regarding psychotropic medication consent, medication availability, medication monitoring, dialysis care, discharge practices, infection control, and staff expectations |
| Staff #101 | Food Service Manager | Interviewed regarding food safety and kitchen hygiene |
| Staff #150 | Certified Nursing Assistant | Interviewed regarding bathing and ADL assistance |
| Staff #82 | Licensed Practical Nurse | Interviewed regarding medication administration and holding medications per parameters |
| Staff #106 | Licensed Practical Nurse | Interviewed regarding dialysis care and medication administration |
| Staff #9 | Licensed Practical Nurse | Interviewed regarding discharge medication practices |
| Staff #24 | Social Services Director/Assistant | Interviewed regarding discharge medication practices and advanced directives |
6 CMS Surveys
CMS Survey — May 5, 2023
May 5, 2023
CMS Survey — Oct 25, 2024
Oct 25, 2024
CMS Survey — May 9, 2025
May 9, 2025
CMS Survey — Dec 6, 2021
Dec 6, 2021
CMS Survey — Jan 26, 2023
Jan 26, 2023
CMS Survey — Oct 25, 2024
Oct 25, 2024
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