Deficiencies per Year
12
9
6
3
0
Severe
High
Moderate
Low
Unclassified
Census Over Time
Inspection Report
Complaint Investigation
Deficiencies: 0
Nov 6, 2025
Visit Reason
A complaint investigation was conducted for complaints #2657352-C, #2657893-C, #2657915-C and facility reported incidents #2657934-I from November 4, 2025 to November 6, 2025.
Findings
The facility was found to be in substantial compliance.
Complaint Details
Investigation involved multiple complaints and facility reported incidents; facility found in substantial compliance.
Inspection Report
Complaint Investigation
Deficiencies: 0
Oct 16, 2025
Visit Reason
A complaint investigation for complaints #2602348-C and #2629938-C was conducted from October 14, 2025 to October 16, 2025.
Findings
The facility was found to be in substantial compliance following the complaint investigation.
Complaint Details
Complaint investigation for complaints #2602348-C and #2629938-C; facility found to be in substantial compliance.
Inspection Report
Plan of Correction
Deficiencies: 0
Jul 25, 2025
Visit Reason
The document is a statement of deficiencies and plan of correction related to the facility's compliance status, indicating acceptance of a credible allegation of substantial compliance and plan of correction.
Findings
The facility was certified in compliance effective July 25, 2025, based on acceptance of the credible allegation of substantial compliance and plan of correction. No specific deficiencies are detailed in the report.
Inspection Report
Complaint Investigation
Census: 86
Deficiencies: 4
Jul 2, 2025
Visit Reason
The inspection was conducted as a result of investigations into multiple complaints (#128324-C, #128580-C, #128730-C, #128767-C, #128908-C, #129017-C, #129659-C) and facility reported incidents between June 23, 2025 and July 2, 2025.
Findings
The facility was found deficient in ensuring residents' rights and dignity, particularly related to malfunctioning stand lifts and battery issues causing delays and safety concerns. Additionally, the facility failed to meet professional standards in following physician orders for oxygen administration and maintaining accurate medical records for residents requiring oxygen therapy.
Complaint Details
The investigation was triggered by multiple complaints alleging noncompliance with resident rights and care standards. The complaints were substantiated as deficiencies were found related to resident dignity, equipment maintenance, and oxygen therapy management.
Deficiencies (4)
| Description |
|---|
| Failure to ensure dignity and respect for residents due to malfunctioning stand lifts and battery issues causing delays in toileting and transfers. |
| Failure to follow physician orders for oxygen administration for multiple residents, including lack of documentation and improper oxygen flow rates. |
| Failure to maintain accurate and complete medical records, including documentation of oxygen administration and discharge planning. |
| Failure to maintain mechanical and electrical patient care equipment in safe operating condition, specifically stand lifts with battery issues. |
Report Facts
Census: 86
Number of residents reviewed for oxygen orders: 3
Number of residents with oxygen saturation below 90%: 2
Number of residents with documented oxygen therapy issues: 3
Number of residents reviewed for dignity and equipment issues: 2
Number of residents reviewed for medical record deficiencies: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff D | Certified Nurse Aide (CNA) | Involved in resident transfers and battery issues with stand lifts |
| Staff E | Certified Medication Aide (CMA)/CNA | Assisted with resident transfers and reported battery issues |
| Chief Nursing Officer (CNO) | Licensed Nursing Home Administrator (LNHA) | Acknowledged concerns regarding battery issues and resident dignity |
| Director of Nursing (DON) | Acknowledged concerns regarding battery issues and resident dignity | |
| Director of Operations | Verified issues with batteries and chargers on facility lifts | |
| Staff A | Licensed Practical Nurse (LPN) | Documented oxygen saturation and administration for Resident #2 |
| Staff B | Certified Medication Aide (CMA) | Checked oxygen saturation and administered oxygen for Resident #2 |
| Staff C | Certified Nurse Aide (CNA) | Reported Resident #8's oxygen use behavior |
| Staff F | Licensed Practical Nurse (LPN) | Explained lab order process and oxygen administration documentation |
| Staff G | Certified Nurse Aide (CNA) | Acknowledged oxygen setting issues for Resident #9 |
| Staff H | Certified Nurse Aide (CNA) | Provided personal care and reported bed issues for Resident #7 |
| Staff I | Certified Nurse Aide (CNA) | Acknowledged Resident #7's bed not working |
| Staff J | Certified Medication Aide (CMA) | Acknowledged Resident #7's bed not working |
| Staff K | Certified Nurse Aide (CNA) | Explained mechanical lift behavior during transfers |
| Staff L | Maintenance | Reported first work order regarding Resident #7's bed |
Inspection Report
Plan of Correction
Deficiencies: 0
May 13, 2025
Visit Reason
The document serves as a Plan of Correction following a survey, indicating acceptance of the facility's credible allegation of substantial compliance.
Findings
The facility was found to be in substantial compliance based on the credible allegation and Plan of Correction, leading to certification effective May 13, 2025.
Inspection Report
Complaint Investigation
Census: 82
Deficiencies: 1
Apr 24, 2025
Visit Reason
The inspection was conducted as a complaint investigation based on Facility Reported Incident #128061-1 and Complaints #127784-C and #128063-C, with Complaint #128063-C substantiated.
Findings
The facility failed to clarify a medication order for a resident admitted on 4/3/25, delaying medication administration until 4/7/25. Deficiencies included inadequate pharmacy services, unclear medication orders, and failure to maintain accurate drug records and reconciliation.
Complaint Details
Complaint #128063-C was substantiated.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to clarify a medication order resulting in delayed medication administration for a resident. | SS=D |
Report Facts
Census: 82
Correction date: May 13, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Drett Yarmin | Administrator | Signed the statement of deficiencies |
Inspection Report
Plan of Correction
Deficiencies: 0
Mar 14, 2025
Visit Reason
The document serves as a Plan of Correction following acceptance of the facility's credible allegation of substantial compliance.
Findings
The facility was found to be in substantial compliance and will be certified in compliance effective March 14, 2025.
Inspection Report
Annual Inspection
Census: 82
Deficiencies: 5
Feb 13, 2025
Visit Reason
The inspection was conducted as part of the facility's Annual Recertification Survey and included investigation of substantiated complaints and a facility reported incident.
Findings
The facility was found deficient in maintaining a safe, clean, and homelike environment, following physician's orders for medication administration, ensuring adequate supervision to prevent accidents, providing necessary respiratory care, and managing psychotropic medications appropriately. Several residents' care plans and medication administration records showed lapses in compliance with professional standards.
Complaint Details
Complaint #125495-C was substantiated. Facility reported incident #126585-I was also substantiated.
Severity Breakdown
SS=D: 5
Deficiencies (5)
| Description | Severity |
|---|---|
| Failure to maintain a safe, clean, comfortable, and homelike environment, including odor control and carpet cleaning. | SS=D |
| Failure to meet professional standards in services provided, including following physician's orders and medication administration. | SS=D |
| Failure to ensure the resident environment is free of accident hazards and provide adequate supervision to prevent accidents. | SS=D |
| Failure to provide necessary respiratory care and follow-up with medical equipment orders. | SS=D |
| Failure to ensure residents do not receive unnecessary psychotropic medications and to perform gradual dose reductions as required. | SS=D |
Report Facts
Resident census: 82
Resident census: 59
Residents reviewed: 20
Residents reviewed: 5
Residents reviewed: 2
Residents reviewed: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Tasha Stauffer | Signed the initial comments section of the report on 3-19-25 | |
| Staff A | Registered Nurse (RN) | Documented medication administration issues for Calcium Carbonate |
| Staff B | Licensed Practical Nurse (LPN) | Described medication cart stock checking and notification procedures |
| Staff C | Central Supply (CS) | Stated lack of method to check stock medications in October |
| Director of Nursing (DON) | Director of Nursing | Provided statements on medication administration and supervision |
| Staff E | Registered Nurse (RN) | Described medication administration and refusal documentation |
| Staff G | Housekeeping | Discussed carpet cleaning procedures and frequency |
| Staff H | Housekeeping | Explained resident room cleaning procedures |
| Staff I | Certified Nursing Assistant | Interviewed regarding resident assistance levels |
| Staff J | Licensed Practical Nurse | Interviewed regarding resident assistance levels |
| Staff L | Licensed Practical Nurse | Interviewed regarding resident assistance levels |
| Staff M | Registered Nurse | Interviewed regarding CPAP machine use |
| Staff N | Registered Nurse | Confirmed presence of CPAP machine during overnight shift |
| Staff O | Registered Nurse | Acknowledged presence of CPAP machine on bedside nightstand |
| Staff F | Licensed Practical Nurse | Stated TAR documentation for resident target behaviors |
Inspection Report
Complaint Investigation
Deficiencies: 0
Dec 17, 2024
Visit Reason
A complaint investigation for complaint #124912-C and facility reported incident #125249-I was conducted from December 16, 2024 to December 17, 2024.
Findings
The facility was found to be in substantial compliance.
Complaint Details
Investigation was related to complaint #124912-C and facility reported incident #125249-I; facility found in substantial compliance.
Inspection Report
Plan of Correction
Deficiencies: 0
Sep 20, 2024
Visit Reason
The document is a Plan of Correction submitted following a prior inspection, indicating acceptance of credible allegation of substantial compliance and certification of the facility in compliance effective September 20, 2024.
Findings
The facility was found to be in substantial compliance based on the accepted Plan of Correction, resulting in certification of compliance effective September 20, 2024.
Inspection Report
Complaint Investigation
Census: 82
Deficiencies: 6
Aug 20, 2024
Visit Reason
The inspection resulted from investigation of Complaints #122711-C, #122668-C, and Facility Reported Incidents #122134-I conducted from August 13, 2024 to August 20, 2024. Complaints #122711-C and #122668-C were substantiated.
Findings
The facility failed to meet professional standards of quality in care and services, including failure to provide weight monitoring for Resident #5, bathing assistance for Resident #1, neurological assessments after incidents for Resident #2, adequate supervision to prevent accidents, and proper urinary output monitoring for catheterized residents. Multiple deficiencies were identified related to care planning, documentation, and staff education.
Complaint Details
Investigation of Complaints #122711-C and #122668-C were substantiated. The deficiencies resulted from these complaints and facility reported incidents #122134-I.
Severity Breakdown
SS=D: 5
SS=INFECTION PREVENTION & CONTROL: 1
Deficiencies (6)
| Description | Severity |
|---|---|
| Failure to provide care and services according to accepted standards for weight monitoring of Resident #5. | SS=D |
| Failure to provide bathing assistance for Resident #1. | SS=D |
| Failure to complete and document neurological assessments after a reported head injury for Resident #2. | SS=D |
| Failure to provide adequate supervision and assistance to prevent accidents for Resident #2. | SS=D |
| Failure to monitor and document urinary output appropriately for catheterized residents. | SS=D |
| Failure to establish and maintain an infection prevention and control program. | SS=INFECTION PREVENTION & CONTROL |
Report Facts
Resident census: 82
Correction date: Sep 20, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Tasha Stauffer | Administrator | Signed the initial comments on the Statement of Deficiencies |
Inspection Report
Plan of Correction
Deficiencies: 0
Jul 17, 2024
Visit Reason
The visit was conducted to evaluate the facility's compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities based on a credible allegation of compliance and plan of correction.
Findings
The Sunny View Care Center was found to be in substantial compliance effective 6/27/24, with no specific deficiencies cited in this report.
Inspection Report
Complaint Investigation
Census: 88
Deficiencies: 5
Jun 5, 2024
Visit Reason
The inspection was conducted due to an investigation of multiple complaint intakes (#121000-M, #119718-C, #120038-C, #120098-C, and #120615-C) from May 21, 2024 to June 5, 2024. Several complaints were substantiated.
Findings
The facility was found non-compliant with several federal requirements including failure to maintain comprehensive care plans, failure to follow physician medication orders, improper medication administration, inadequate perineal care for dependent residents, failure to assess and intervene after a resident fall, and insufficient nursing staff leading to delayed response to resident call lights.
Complaint Details
The investigation was triggered by multiple complaint intakes (#119718, #120038, #120098, and #120615), all of which were substantiated. The facility reported incident #121000-M will be addressed separately.
Severity Breakdown
SS=D: 3
SS=E: 2
Deficiencies (5)
| Description | Severity |
|---|---|
| Failed to maintain a complete and accurate Care Plan for Resident #2, specifically not addressing continence status. | SS=D |
| Failed to follow physician's orders and properly administer medications for Residents #11, #12, and #13. | SS=D |
| Failed to properly provide perineal care for Residents #2 and #3. | SS=E |
| Failed to assess and implement interventions following a fall for Resident #3. | SS=D |
| Failed to have sufficient nursing staff to respond to resident call lights within 15 minutes for Residents #2 and #5. | SS=E |
Report Facts
Residents: 88
Medication administration audit time delay: 168
Call light response time: 30
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff G | Certified Medication Aide (CMA) | Named in medication administration delay for Resident #13 |
| Staff F | Licensed Practical Nurse (LPN) | Observed leaving medications unattended for Resident #12 |
| Staff H | Certified Nursing Assistant (CNA) | Reported frequent leaving of medications unattended |
| Staff I | Certified Nursing Assistant (CNA) | Confirmed witnessing residents left unattended with medications |
| Staff J | Certified Nursing Assistant (CNA) | Confirmed failure to answer resident call lights timely |
| Staff A | Certified Nursing Assistant (CNA) | Involved in perineal care deficiencies for Resident #2 and #3 |
| Staff B | Assistant Director of Nursing (ADON) | Involved in perineal care deficiency observation and responsible for ongoing compliance |
| Director of Clinical Services | Confirmed care plan and medication administration deficiencies | |
| Director of Nursing | Responsible for ongoing compliance and staff re-education | |
| Assistant Director of Nursing | Responsible for ongoing compliance and staff re-education |
Inspection Report
Plan of Correction
Deficiencies: 0
Apr 8, 2024
Visit Reason
The document serves as a Plan of Correction following acceptance of the facility's credible allegation of substantial compliance.
Findings
The facility was certified in compliance effective April 8, 2024, based on acceptance of the credible allegation of substantial compliance and Plan of Correction.
Inspection Report
Annual Inspection
Census: 85
Deficiencies: 10
Mar 11, 2024
Visit Reason
The inspection was conducted as part of the facility's annual recertification survey and investigation of complaints #117117-C, #117950-C, #118700-C, #119300-C, and facility reported incident #118435-I.
Findings
The facility was found to have multiple deficiencies related to notification of changes, care plan timing and revision, services provided meeting professional standards, assistance with activities of daily living, free of accident hazards, sufficient nursing staff, storage of drugs and biologicals, and infection prevention and control. The facility reported a census of 85 residents during the survey.
Complaint Details
Complaint #117117-C, #118700-C, and #119300-C were substantiated. Facility reported incident #118435-I was substantiated.
Deficiencies (10)
| Description |
|---|
| Failed to notify resident families of falls for 1 of 3 residents reviewed for falls (Resident #40). |
| Failed to update comprehensive care plans when a resident had a change in advanced directives for 1 of 24 residents reviewed (Resident #10). |
| Failed to meet professional standards of quality in transcription of physician orders for 3 of 85 residents reviewed (#10, #22, #74). |
| Failed to assist a dependent resident with feeding for 1 of 3 residents reviewed. |
| Failed to provide adequate supervision and assistance devices to prevent accidents for 1 of 4 residents at risk for choking (Resident #40) and failed to ensure a resident's bed was in the lowest position for 1 of 4 residents reviewed (Resident #10). |
| Failed to follow professional standards to ensure physician orders were transcribed accurately for 3 of 3 residents reviewed (#22, #10, #74). |
| Failed to administer medications as ordered and failed to transcribe orders correctly for Resident #74. |
| Failed to provide sufficient nursing staff to assure resident safety and maintain highest practicable well-being. |
| Failed to ensure medication cart remained locked in a resident care area when not under staff supervision. |
| Failed to maintain an infection prevention and control program to provide a safe, sanitary, and comfortable environment and prevent communicable diseases and infections. |
Report Facts
Census: 85
Residents reviewed for falls: 3
Residents reviewed for care plan updates: 24
Residents reviewed for transcription accuracy: 3
Residents reviewed for feeding assistance: 3
Residents reviewed for choking risk: 4
Residents reviewed for medication order transcription: 3
Residents reviewed for medication administration: 1
Residents reviewed for nursing staff sufficiency: 85
Inspection Report
Complaint Investigation
Census: 86
Deficiencies: 3
Nov 7, 2023
Visit Reason
The inspection was conducted as a result of investigations of multiple complaints and facility self-reported incidents between October 18, 2023 and November 7, 2023. Several complaints were substantiated.
Findings
The facility was found not in substantial compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities. Deficiencies included failure to return resident belongings post-discharge, inadequate assistance with activities of daily living such as oral care, toileting, and dining, and failure to properly assess and document skin conditions and injuries for residents.
Complaint Details
The visit was triggered by investigations of complaints #111942-C, #112666-C, #113637-C, #114457-C, #114458-C, #114516-C, #115029-C, #115050-C, #116063-C, #116200-C, #116233-C, #116582-C, #116673-C and facility self-reported incidents #115715-I and #116068-I. The following complaints were substantiated: #112666-C, #115050-C, #116063-C, #116200-C, #116233-C, and #116673-C.
Severity Breakdown
SS=D: 2
SS=E: 1
Deficiencies (3)
| Description | Severity |
|---|---|
| Failure to assure resident belongings were returned post discharge, including missing personal items such as a teddy bear. | SS=D |
| Failure to properly provide perineal care, oral care, dining assistance, and toileting assistance to multiple residents. | SS=E |
| Failure to provide necessary assessments and documentation for a resident with skin conditions and injuries, including bruising and fractures. | SS=D |
Report Facts
Total Residents: 86
Number of substantiated complaints: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Certified Nursing Assistant (CNA), Certified Medication Aide (CMA) | Mentioned in relation to failure to provide oral care and perineal care |
| Staff B | Certified Nursing Assistant (CNA), Certified Medication Aide (CMA), Human Resources | Observed feeding assistance and toileting care |
| Staff C | Registered Nurse (RN) | Interviewed regarding oral care deficiencies |
| Staff E | Certified Nursing Assistant (CNA) | Involved in toileting and perineal care observations |
| Staff F | Certified Nursing Assistant (CNA) | Involved in toileting and perineal care observations |
| Staff G | Registered Nurse (RN) | Confirmed observations of inadequate oral care |
| Staff H | Registered Nurse (RN) | Confirmed observations of inadequate oral care |
| Administrator | Confirmed facility policies and discussed missing resident belongings | |
| Staff D | Housekeeping | Confirmed cleaning of resident's room and disposal of flowers |
| Activity Director | Recalled missing teddy bear in resident's belongings |
Inspection Report
Plan of Correction
Deficiencies: 0
Apr 13, 2023
Visit Reason
The document is a plan of correction submitted following a survey to address deficiencies and certify compliance.
Findings
The facility was found to be in compliance based on acceptance of the credible allegation of compliance and plan of correction effective April 12, 2023.
Inspection Report
Annual Inspection
Census: 81
Deficiencies: 5
Mar 16, 2023
Visit Reason
The inspection was conducted as part of the facility's annual recertification survey and included investigation of two complaints, one substantiated and one not substantiated.
Findings
The facility was found deficient in multiple areas including failure to ensure staff completed required abuse training, failure to notify the Ombudsman of resident transfers, failure to follow physician's orders, inadequate infection prevention and control practices, and failure to ensure nurse aides completed required in-service training.
Complaint Details
Complaint #111276-C was substantiated. Complaint #111099-C was not substantiated.
Severity Breakdown
SS=D: 3
SS=E: 2
Deficiencies (5)
| Description | Severity |
|---|---|
| Failed to ensure 1 of 5 staff members completed the two hour Dependent Adult Abuse training within 6 months of hire date. | SS=D |
| Failed to notify the Ombudsman of residents transferring to the hospital for 1 of 1 residents reviewed. | SS=D |
| Failed to follow physician's orders for 1 of 12 residents reviewed related to medication administration delay. | SS=D |
| Failed to follow infection control practices including signage, PPE use, mask changing, and hand hygiene during a COVID-19 outbreak. | SS=E |
| Failed to ensure 5 of 5 Certified Nurse Aide staff completed the required 12 hours of in-service training annually. | SS=E |
Report Facts
Census: 81
Staff members reviewed for abuse training: 5
Residents reviewed for physician order compliance: 12
Certified Nurse Aides reviewed for in-service training: 5
In-service attendance: 6
In-service attendance: 10
In-service attendance: 11
In-service attendance: 0
In-service attendance: 0
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff F | Certified Nursing Assistant | Named in deficiency for failure to complete Dependent Adult Abuse training |
| Staff G | Certified Nursing Assistant | Observed during infection control deficiencies |
| Staff H | Certified Nursing Assistant | Observed during infection control deficiencies |
| Staff I | Hospice Certified Nursing Assistant | Observed during infection control deficiencies |
| Staff J | Certified Medication Aide | Observed during infection control deficiencies |
| Staff A | Certified Nursing Assistant | Named in deficiency for failure to complete required in-service training |
| Staff B | Certified Nursing Assistant | Named in deficiency for failure to complete required in-service training |
| Staff C | Certified Nursing Assistant | Named in deficiency for failure to complete required in-service training |
| Staff D | Certified Nursing Assistant | Named in deficiency for failure to complete required in-service training |
| Staff E | Certified Nursing Assistant | Named in deficiency for failure to complete required in-service training |
| Administrator | Provided multiple interviews regarding facility policies and deficiencies | |
| Director of Nursing | Director of Nursing | Provided multiple interviews regarding facility policies and deficiencies |
Inspection Report
Complaint Investigation
Deficiencies: 0
Jan 25, 2023
Visit Reason
The inspection was conducted to investigate Complaint 109062-C and a facility reported incident 110441-I.
Findings
The complaint and reported incident were investigated and found to be not substantiated during the visit from January 17-25, 2023.
Complaint Details
Complaint 109062-C and facility reported incident 110441-I were investigated and not substantiated.
Inspection Report
Complaint Investigation
Deficiencies: 0
Nov 3, 2022
Visit Reason
Complaint 108633-C was investigated from October 31 to November 3, 2022.
Findings
The complaint investigation was not substantiated and no deficiencies were identified at the time of the investigation.
Complaint Details
Complaint 108633-C was investigated and found not substantiated.
Inspection Report
Plan of Correction
Deficiencies: 0
Oct 12, 2022
Visit Reason
The document reports acceptance of the facility's credible allegation of compliance and plan of correction following an investigation ending September 21, 2022.
Findings
The facility was certified in compliance effective October 12, 2022, based on acceptance of the plan of correction and credible allegation of compliance.
Inspection Report
Complaint Investigation
Census: 80
Deficiencies: 3
Sep 21, 2022
Visit Reason
The inspection was conducted as a result of complaints 106559-C and 107427-C, which were substantiated. The visit aimed to investigate these complaints regarding resident care and notification of changes.
Findings
The facility failed to notify a resident or responsible party/physician of significant changes in condition, including injury and decline. Deficiencies were found in medication administration documentation, notification processes, and professional standards of care related to apical pulse monitoring and pressure ulcer prevention and treatment. The facility reported a census of 80 residents at the time of investigation.
Complaint Details
The investigation was triggered by complaints 106559-C and 107427-C, both of which were substantiated.
Severity Breakdown
SS=D: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Failure to notify resident, responsible party, or physician of significant changes in condition including injury or decline. | SS=D |
| Failure to meet professional standards of quality including obtaining apical pulse before administering beta blocker medication. | SS=D |
| Failure to provide treatment and services to prevent and heal pressure ulcers consistent with professional standards. | SS=D |
Report Facts
Resident census: 80
Medication administration documentation: 23
Medication quantity: 62
Pressure ulcer assessments: 3
Inspection Report
Plan of Correction
Deficiencies: 0
Jul 20, 2022
Visit Reason
The document serves as a statement of deficiencies and plan of correction for Sunny View Care Center, certifying the facility as in compliance based on acceptance of a credible allegation of compliance and plan of correction.
Findings
The facility was found to be in compliance effective July 20, 2022, based on acceptance of the credible allegation of compliance and plan of correction. No specific deficiencies or severity levels are detailed in the report.
Inspection Report
Complaint Investigation
Census: 80
Deficiencies: 2
Jul 19, 2022
Visit Reason
The inspection was conducted as an investigation of complaints #104983-C and facility reported incidents #105411-I and #103991-I from July 11-19, 2022.
Findings
The facility failed to follow physician orders for medication administration for 4 residents, resulting in significant medication errors including an overdose incident. The facility reported a census of 80 residents and identified multiple deficiencies related to medication administration and care plan compliance.
Complaint Details
Complaint #104983-C was investigated and found not substantiated. Facility reported incident #105411-I was substantiated. Complaint #103991-I and facility reported incident #103991-I were not substantiated.
Severity Breakdown
SS=E: 1
SS=D: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Facility failed to follow physician orders for 4 residents reviewed, resulting in missed or incorrect administration of medications. | SS=E |
| Residents are not free from significant medication errors; one resident received 1,750 mg more Vancomycin than ordered. | SS=D |
Report Facts
Residents reviewed: 4
Census: 80
Medication overdose amount: 1750
Medication overdose total dose: 2750
Inspection Report
Annual Inspection
Census: 71
Deficiencies: 7
Sep 30, 2021
Visit Reason
The inspection was conducted as the facility's annual health survey and included investigations of several complaints and facility-reported incidents.
Findings
The facility was found deficient in multiple areas including documentation of advanced directives, Medicaid/Medicare coverage notices, development and implementation of comprehensive care plans, quality of care including skin assessments and fall prevention, bed rail usage, and infection prevention and control. Several complaints and incidents were substantiated.
Complaint Details
Complaints #93100-C, #93813-C, and facility-reported incidents #95229-I, #99746-I, and #100074-I were substantiated. Complaints #89493-C and #90856-C did not result in deficiency.
Deficiencies (7)
| Description |
|---|
| Facility failed to document an accurate code status for one out of 24 residents reviewed for advanced directives. |
| Facility failed to comply with all applicable Federal Regulations regarding Medicare requirements governing billing practices for three residents reviewed for liability and appeal notices. |
| Facility failed to develop a care plan to address the resident need for oxygen and hospice care for one of 20 sampled residents reviewed for comprehensive care plans. |
| Facility failed to assess and document follow-up skin assessments for one of three residents reviewed. |
| Facility failed to provide adequate supervision to prevent falls and provide a safe environment for two of five residents reviewed for falls. |
| Facility failed to ensure proper use and maintenance of bed rails for four residents reviewed. |
| Facility failed to establish and maintain an infection prevention and control program including proper COVID-19 specimen collection and infection control practices. |
Report Facts
Residents reviewed for advanced directives: 24
Facility census: 71
Residents reviewed for comprehensive care plans: 20
Residents reviewed for skin assessments: 3
Residents reviewed for fall prevention: 5
Residents reviewed for bed rail usage: 4
Residents reviewed for infection control: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff C | Licensed Practical Nurse (LPN) | Reported reviewing IPOST in resident's chart to verify code status. |
| Staff D | Licensed Practical Nurse (LPN) | Reported reviewing IPOST in resident's chart. |
| Corporate Nurse | Reported checking IPOST, EHR, and purple dot system for resident code status. | |
| Staff H | Director of Clinical Services | Reported on hospice services and oxygen use for Resident #10. |
| Staff J | MDS Coordinator | Reported on oxygen and hospice care plans and policy compliance. |
| Staff E | Registered Nurse (RN) | Reported facility followed directives in RAI to complete MDS assessments. |
| Staff M | Registered Nurse (RN) | Reported on fall interventions and care plans for Resident #79. |
| Staff O | Certified Nursing Assistant (CNA) | Documented last visual of Resident #79 before fall. |
| Staff P | Licensed Practical Nurse (LPN) | Received coaching regarding failure to place intervention on Bio sheet. |
| Staff R | Certified Medication Assistant (CMA) | Reported on side rail use for Resident #79. |
| Staff A | Certified Nursing Assistant (CNA) | Reported on fall interventions and use of Bio sheets. |
| Staff Q | Certified Nursing Assistant (CNA) | Reported on care interventions and side rail use for Resident #79. |
| Staff L | Licensed Practical Nurse (LPN) | Completed report on environmental concerns and side rail use. |
| Staff F | Performed COVID-19 antigen testing and specimen collection. | |
| Staff K | Certified Nursing Assistant (CNA) | Reported on fall and care interventions for Resident #40. |
Inspection Report
Routine
Census: 71
Deficiencies: 0
Jul 6, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the Department of Inspection and Appeals from 2020-06-23 to 2020-07-06 to assess compliance with CMS and CDC recommended practices for COVID-19 preparation.
Findings
The facility was found to be in compliance with CMS and CDC recommended practices to prepare for COVID-19. Additionally, an investigation into Complaint #89873-C was not substantiated.
Complaint Details
Investigation into Complaint #89873-C was not substantiated.
Report Facts
Total residents: 71
Inspection Report
Annual Inspection
Census: 81
Deficiencies: 5
Feb 6, 2020
Visit Reason
The inspection was conducted as part of the facility's annual health survey and included review of incident #87241 and complaint #87108, which was not substantiated.
Findings
The facility failed to notify the Ombudsman of hospital transfers for 2 residents, failed to resubmit PASRR after diagnosis changes for 4 residents, failed to update care plans timely for one resident, failed to ensure treatment was completed as ordered for one resident, and failed to secure wheelchair armrests for one resident, posing safety risks.
Complaint Details
Complaint #87108 was investigated and found not substantiated.
Deficiencies (5)
| Description |
|---|
| Failed to notify Ombudsman of hospital transfers for 2 residents. |
| Failed to resubmit PASARR after change in diagnosis for 4 residents. |
| Failed to update care plan timely for one resident. |
| Failed to ensure treatment to skin tear was completed as ordered for one resident. |
| Wheelchair armrest could be unlatched, posing accident hazard for one resident. |
Report Facts
Resident census: 81
Hospital transfers not notified: 2
Residents with PASRR resubmission failure: 4
Residents reviewed for care plan update: 19
Residents with care plan update failure: 1
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