Deficiencies per Year
24
18
12
6
0
Unclassified
Inspection Report
Complaint Investigation
Capacity: 30
Deficiencies: 23
Apr 3, 2025
Visit Reason
State-compiled facility profile showing 17 inspections from 2023-03-23 to 2025-04-03 with deficiency history and complaint investigations.
Findings
Across multiple complaint investigations from 2023 to 2025, the facility had several deficiencies related to resident care plans, medication administration, fall prevention, abuse reporting, emergency preparedness, and life safety code compliance. Some inspections found no deficiencies, while others cited multiple violations including failure to prevent falls, failure to report abuse, and unsafe water temperatures.
Complaint Details
Multiple complaint investigations were conducted from 2023 through 2025 involving allegations of abuse, falls, medication errors, and failure to provide required notices and documentation. Some complaints resulted in deficiencies while others found no deficiencies.
Deficiencies (23)
| Description |
|---|
| R9-10-414.B.3.b. Assist the resident in maintaining the resident's highest practicable well-being according to the resident's comprehensive assessment. Failed to ensure adequate supervision to prevent resident to resident altercations involving residents #6 and #7. |
| R9-10-414.B.3.b. Assist the resident in maintaining the resident's highest practicable well-being according to the resident's comprehensive assessment. Failed to ensure one resident (#1) was free from preventable falls. |
| §483.25(d) Accidents. Failed to ensure fall safety measures were in place to prevent a fall with major injury for resident #19. |
| R9-10-425.A.1.b. Free from a condition or situation that may cause a resident or an individual to suffer physical injury; Failed to ensure fall safety measures were in place to prevent a fall with major injury for resident #19. |
| R9-10-421.B.3.a. A medication administered to a resident is administered in compliance with an order. Failed to ensure medications were administered as ordered for residents #525, #575, and #550. |
| R9-10-403.C.2.a. Policies and procedures for physical health services and behavioral health services are established, documented, and implemented. Failed to provide written notice of bed-hold policy to resident #423. |
| §483.15(c) Transfer and discharge. Failed to ensure discharge/transfer paperwork was completed for resident #423. |
| §483.15(d)(1) Notice before transfer. Failed to provide written notice of bed-hold policy and implications to resident #423. |
| §483.21(b)(3) Comprehensive Care Plans. Failed to notify physician of low blood pressure readings for resident #423. |
| §483.25(d) Accidents. Failed to ensure safety measures to prevent a fall resulting in fracture for resident #73 and failed to ensure water temperatures were within safe range. |
| R9-10-411.C.19. Transfer documentation. Failed to ensure discharge/transfer paperwork was completed for resident #423. |
| R9-10-414.B.3.b. Assist the resident in maintaining the resident's highest practicable well-being according to the resident's comprehensive assessment. Failed to notify physician of low blood pressure readings for resident #423. |
| R9-10-425.A.1.b. Free from a condition or situation that may cause a resident or an individual to suffer physical injury; Failed to ensure fall safety measures for resident #73 who suffered a fracture. |
| [(a) Emergency Plan.] Failed to develop emergency preparedness plan based on community risk assessments. |
| [(c) Emergency preparedness communication plan.] Failed to include method for sharing patient information in emergency preparedness communication plan. |
| Egress Doors. Failed to maintain two special locking exit doors to meet Life Safety Code requirements. |
| Electrical Equipment - Power Cords and Extension Cords. Failed to ensure staff did not use daisy chain power strips creating electrical hazard. |
| §483.25(b) Skin Integrity. Failed to provide care and services related to pressure ulcers for resident #1 resulting in wound worsening. |
| R9-10-414.B.3.b. Assist the resident in maintaining the resident's highest practicable well-being according to the resident's comprehensive assessment. Failed to assist resident #1 with pressure ulcer care. |
| R9-10-403.F.2.a. Report suspected abuse immediately. Failed to report allegation of abuse involving resident #7 to State Agency as required. |
| §483.12(a)(1) Freedom from abuse. Failed to ensure resident #7 was free from abuse by another resident. |
| §483.12(c)(1) Ensure alleged violations involving abuse are reported immediately. Failed to report allegation of abuse involving resident #7 to State Agency as required. |
| R9-10-410.B.3.a. A resident is not subjected to abuse. Failed to ensure resident #7 was not subjected to abuse. |
Report Facts
Inspections on page: 17
Total deficiencies: 24
Complaint inspections: 16
Total capacity: 30
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| EMILY DAWSON | Administrator | Named as Administrator of the facility |
| Staff #43 | Licensed Practical Nurse (LPN) | Interviewed regarding resident to resident altercation and supervision |
| Staff #3 | Certified Nursing Assistant (CNA) | Interviewed regarding fall prevention interventions |
| Staff #8 | Licensed Practical Nurse (LPN) | Interviewed regarding fall risk assessments and interventions |
| Staff #5 | Director of Nursing (DON) | Interviewed regarding fall prevention and care plan oversight |
| Staff #1 | Registered Nurse (RN) | Interviewed regarding fall interventions |
| Staff #4 | Certified Nursing Assistant (CNA) | Interviewed regarding fall safety measures |
| Staff #56 | Maintenance Director | Interviewed regarding water temperature measurements |
| Staff #62 | Director of Nursing (DON) | Interviewed regarding water temperature safety and fall care |
| Staff #271 | Administrator | Interviewed regarding water temperature safety and plan of correction |
| Staff #16 | Licensed Practical Nurse (LPN) | Interviewed regarding transfer/discharge orders and abuse reporting |
| Staff #19 | Social Services Director (SSD) | Interviewed regarding bed-hold policy and consent |
| Staff #4 | Director of Nursing (DON) | Interviewed regarding abuse incident and reporting |
| Staff #2 | Certified Nursing Assistant (CNA) | Interviewed regarding abuse incident involving residents #7 and #8 |
| Staff #35 | Administrator | Interviewed regarding abuse incident and reporting decisions |
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