Inspection Report
Abbreviated Survey
Census: 127
Deficiencies: 1
Apr 18, 2025
Visit Reason
A Standard Recertification and Abbreviated Survey was conducted to investigate multiple survey IDs and assess compliance with 42 CFR 483 subpart B.
Findings
The facility was found not to be in substantial compliance and was cited with deficiencies at the highest Scope and Severity level of 'F'. The investigation included review of resident rights, consent for physical contact, and care planning, with findings of failure to ensure informed consent and participation in treatment.
Severity Breakdown
F: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure residents' right to be informed and participate in treatment, including lack of consent for physical contact for two residents. | F |
Report Facts
Survey Census: 127
Sample Size: 26
Supplemental Residents: 9
Date Survey Completed: Apr 18, 2025
Date of Compliance: Apr 29, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Signature Care Consultant | Consultant | Conducted review of events and educated staff on policies and procedures related to residents' rights and informed consent |
| Director of Nursing | Director of Nursing | Educated on State Operational Manual and involved in corrective action plan |
| Staff Development Coordinator | Staff Development Coordinator | Participated in education and training on residents' rights and consent policies |
| Assistant Director of Nursing | Assistant Director of Nursing | Participated in education and training on residents' rights and consent policies |
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