Inspection Report
Complaint Investigation
Deficiencies: 4
Apr 24, 2025
Visit Reason
An unannounced complaint/incident investigation survey was conducted from 4/23/2025 to 4/24/2025 to determine compliance with state regulations at the facility.
Findings
Deficiencies were identified related to management of services, resident records, wound care, and notification of responsible parties regarding incidents such as falls and injuries. The facility failed to provide timely notification and documentation of physician orders and wound care treatments for several residents.
Complaint Details
The investigation was initiated due to complaints and incident reports referencing multiple residents with falls, wounds, and lack of timely physician orders and notifications. The complaint was substantiated by findings of deficient care and documentation.
Deficiencies (4)
| Description |
|---|
| Failure to provide care and services in accordance with prevailing community standards, including notification of responsible party for resident falls and injuries. |
| Failure to maintain complete and accurate resident records including physician orders and wound care documentation. |
| Failure to obtain and follow physician orders for physical therapy, occupational therapy, and wound care treatments in a timely manner. |
| Failure to notify responsible parties of incidents involving residents such as falls and skin tears. |
Report Facts
Dates of investigation: Investigation conducted from 4/23/2025 to 4/24/2025
Number of residents reviewed: 6
Dates of incidents: Resident #1 fall on 3/25/2025; incident reports dated 3/7/2025, 4/15/2025, 4/23/2025
Inspection Report
Complaint Investigation
Deficiencies: 0
Nov 13, 2024
Visit Reason
An unannounced complaint/incident investigation survey was conducted at the residence on 11/13/2024 to determine compliance with state regulations.
Findings
No deficiencies were identified during the investigation.
Complaint Details
The investigation was related to complaint reference numbers 98053 and 98161. No deficiencies were found.
Inspection Report
Complaint Investigation
Deficiencies: 0
Sep 20, 2024
Visit Reason
An unannounced complaint/incident investigation survey was conducted to determine compliance with state regulations.
Findings
No deficiencies were identified during the investigation.
Complaint Details
The investigation was related to complaint reference number 94796 and was unannounced.
Inspection Report
Complaint Investigation
Deficiencies: 0
Sep 5, 2024
Visit Reason
An unannounced complaint/incident investigation survey was conducted at this residence.
Findings
No deficiencies were identified during the investigation.
Complaint Details
The investigation was unannounced and no deficiencies were found, indicating no substantiated issues.
Inspection Report
Complaint Investigation
Deficiencies: 3
Jan 26, 2024
Visit Reason
An unannounced biennial State Licensure survey and a complaint/incident investigation survey were conducted at the residence to assess compliance with state licensure requirements.
Findings
Deficiencies were identified related to failure to complete nurse reviews every 90 days for three of four sampled residents, failure to review and update service plans at required intervals, and medication storage and labeling issues including expired and unlabeled medications.
Complaint Details
The visit included a complaint/incident investigation. The Executive Director was unable to provide evidence that nurse reviews were completed every 90 days as required for Residents #1, #3, and #4.
Deficiencies (3)
| Description |
|---|
| Failure to complete nurse reviews every 90 days for Residents #1, #3, and #4 as required. |
| Failure to review and update service plans at intervals not to exceed twelve months and failure to accurately reflect outside services for Residents #1 and #3. |
| Failure to ensure medications were stored securely and properly labeled, including expired medications and medications without directions for use or resident identifiers. |
Report Facts
Sample residents reviewed: 4
Nurse review intervals: 90
Service plan review interval: 12
Medication cart observation date: Jan 25, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Observed medications without directions for use and resident identifier during medication cart observation. | |
| Executive Director | Executive Director | Interviewed and unable to provide evidence of required nurse reviews and service plan updates. |
| Registered Nurse Program Director | Registered Nurse Program Director | Present during medication cart observation and acknowledged medication storage deficiencies. |
| Certified Medication Technician | Certified Medication Technician | Present during medication cart observation where medications lacked directions and resident identifiers. |
Inspection Report
Complaint Investigation
Deficiencies: 0
Feb 10, 2022
Visit Reason
An unannounced complaint investigation survey and a biennial State licensure survey were conducted at this residence on 02/10/2022.
Findings
No deficiencies were identified relative to the complaint investigation.
Complaint Details
The complaint investigation found no deficiencies.
Inspection Report
Complaint Investigation
Deficiencies: 1
Feb 10, 2022
Visit Reason
An unannounced biennial State Licensure survey and a complaint/incident investigation survey were conducted at the residence on 02/10/2022.
Findings
The residence failed to store medications in the original pharmacy-dispensed containers with proper labeling and secure storage, leading to potential medication errors. Multiple medication carts contained bottles without resident identifiers or instructions for use.
Complaint Details
The complaint investigation found that medications in three medication carts lacked resident identifiers or instructions for use, which could lead to medication errors. The Director of Wellness acknowledged these issues during an interview on 02/10/2022.
Deficiencies (1)
| Description |
|---|
| Medications were not stored with proper labeling, securely, or in original pharmacy-dispensed containers, leading to potential medication errors. |
Report Facts
Medication carts reviewed: 3
Audit frequency: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Wellness | Acknowledged medication labeling deficiencies during interview on 02/10/2022. |
Inspection Report
Complaint Investigation
Deficiencies: 0
Nov 26, 2021
Visit Reason
An unannounced complaint/incident investigation survey was conducted at this residence.
Findings
No deficiencies were identified during the investigation.
Complaint Details
Unannounced complaint/incident investigation survey with no deficiencies identified.
Inspection Report
Complaint Investigation
Deficiencies: 0
Jan 7, 2021
Visit Reason
A complaint investigation survey and unannounced focused survey was conducted related to COVID19 infection control at the residence.
Findings
No deficiencies were identified during the complaint investigation and focused survey.
Complaint Details
Complaint investigation survey related to COVID19 infection control; no deficiencies identified.
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