Inspection Report Summary
The most recent inspection on November 29, 2023, found no deficiencies. Earlier inspections showed a mix of findings, including issues with medication security, resident care, and maintenance. Deficiencies primarily involved medication management, resident supervision, and documentation of adverse changes in condition. Complaint investigations were mostly unsubstantiated, with one substantiated case in 2021 involving missing narcotics and another in 2019 related to inadequate supervision and resident abuse, which led to staff termination. The facility’s inspection history shows improvement over time, with recent investigations consistently finding no violations.
Deficiencies (last 7 years)
Deficiencies are regulatory violations found during state inspections.
Deficiencies per year
Inspection Report
Complaint InvestigationInspection Report
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Complaint Investigation| Name | Title | Context |
|---|---|---|
| Staff A | Interviewed regarding fire extinguisher service plan and Resident #1 incident reporting. | |
| Staff I | Care staff who observed Resident #1's facial discoloration but failed to report and complete incident report. |
Inspection Report
Complaint Investigation| Name | Title | Context |
|---|---|---|
| Staff A | Interviewed regarding medication checks and missing narcotics | |
| Staff B | Interviewed regarding medication aide responsibilities and narcotic counts |
Inspection Report
Complaint InvestigationInspection Report
Complaint InvestigationInspection Report
MonitoringInspection Report
Complaint InvestigationInspection Report
Complaint InvestigationInspection Report
Complaint Investigation| Name | Title | Context |
|---|---|---|
| Staff B | Interviewed regarding broken chair and medication found. | |
| Staff A | Interviewed regarding unknown how medication got into Resident #3's room. |
Inspection Report
Complaint Investigation| Name | Title | Context |
|---|---|---|
| Staff C | Reported and assisted Resident #1 during fall incident; worked overnight shift | |
| Staff I | Assisted Resident #1 during fall incident; reported family concerns about rough handling | |
| Staff K | Terminated for misconduct related to rough handling and pushing Resident #4 | |
| Staff E | Reported Resident #1 required 3-person assist with transfers | |
| Staff D | Received call about Resident #1 fall and called 911 | |
| Staff H | Reported family concerns about Staff K and confirmed termination | |
| BB | Facility staff who reported staffing shortages and concerns about Resident #1 transfer | |
| Staff M | Assisted Staff C with Resident #1 fall incident |
Inspection Report
Complaint InvestigationInspection Report
Complaint InvestigationInspection Report
Annual Inspection| Name | Title | Context |
|---|---|---|
| Staff E | Staff member who did not receive required first aid and CPR training within 60 days | |
| Staff A | Interviewed staff who stated Staff E was scheduled for training | |
| Staff G | Interviewed staff who stated the valve assembly for hot water would be fixed | |
| Staff D | Interviewed staff who stated PRN medications for Resident #4 were expired and new prescriptions were needed |
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