Deficiencies per Year
12
9
6
3
0
Severe
High
Moderate
Low
Unclassified
Census Over Time
Inspection Report
Annual Inspection
Census: 72
Deficiencies: 12
May 20, 2025
Visit Reason
An unannounced Annual and Complaint survey was conducted at the facility from May 12, 2025, through May 20, 2025, based on interviews, record review, and other facility documentation.
Findings
The survey identified multiple deficiencies related to resident rights, abuse reporting, comprehensive care plans, medication management, infection control, and quality of care. The facility failed to ensure residents were treated with respect and dignity, timely reporting of abuse allegations, and proper implementation of care plans and medication protocols.
Complaint Details
The complaint investigation was substantiated with findings including failure to report abuse allegations timely and failure to protect residents from abuse and neglect.
Severity Breakdown
Level 2: 12
Deficiencies (12)
| Description | Severity |
|---|---|
| Failure to treat residents with respect and dignity, including staff entering rooms without knocking or waiting for permission. | Level 2 |
| Failure to ensure a responsible party was involved in code status decisions for a cognitively impaired resident. | Level 2 |
| Failure to offer residents the opportunity to formulate an advance directive. | Level 2 |
| Failure to report allegations of abuse to the State Agency within required timeframes. | Level 2 |
| Failure to develop a comprehensive person-centered care plan for an identified care area. | Level 2 |
| Failure to provide services that meet professional standards, including admission assessments by Licensed Practical Nurses. | Level 2 |
| Failure to follow physician's orders related to blood pressure management. | Level 2 |
| Failure to provide individualized bowel and bladder continence care and antibiotic therapy for residents with urinary catheters. | Level 2 |
| Failure to limit psychotropic medication to 14 days and provide proper stop dates for PRN medications. | Level 2 |
| Failure to promptly notify ordering practitioners of laboratory results outside clinical reference ranges. | Level 2 |
| Failure to use enhanced barrier precautions consistently for a resident with a central line. | Level 2 |
| Failure to establish and maintain an infection prevention and control program that includes required elements. | Level 2 |
Report Facts
Residents present: 72
Survey sample size: 29
Deficiency completion dates: 7
BIMS score: 5
Medication stop date: 14
Audit sample size: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| E14 | PTA | Observed entering resident rooms without waiting for permission |
| E15 | RN | Observed entering resident rooms without waiting for permission |
| E1 | Executive Director | Reviewed findings with surveyors and involved in corrective action plans |
| E2 | Director of Nursing | Reviewed findings with surveyors and involved in corrective action plans |
| E5 | NP | Interviewed regarding cognitive assessments and medication orders |
| E13 | LPN | Observed medication administration and admission assessments |
| E17 | Housekeeping | Observed entering resident rooms without waiting for permission |
| E78 | Resident | Subject of abuse allegation and medication review |
Inspection Report
Annual Inspection
Census: 69
Deficiencies: 5
Jun 13, 2024
Visit Reason
An unannounced annual and complaint survey was conducted from June 6, 2024 through June 13, 2024, including an Emergency Preparedness survey, to assess compliance with federal and state regulations.
Findings
The facility had multiple deficiencies including failure to maintain complete personnel records with mandatory screenings for some employees, failure to develop a person-centered care plan for a resident, inadequate nail care for residents, failure to provide respiratory care consistent with professional standards, and failure to ensure proper monitoring and documentation of psychotropic medication use.
Severity Breakdown
F 656: 1
F 677: 1
F 695: 1
F 758: 1
Deficiencies (5)
| Description | Severity |
|---|---|
| Personnel records lacked evidence of mandatory tuberculosis screening, criminal background check, drug testing, and adult abuse registry check for one employee. | — |
| Facility failed to develop a person-centered care plan for a resident to address wax buildup in the ears. | F 656 |
| Facility failed to provide nail care to residents, resulting in long fingernails with dark encrusted debris. | F 677 |
| Facility failed to provide respiratory care consistent with professional standards for a resident requiring oxygen therapy. | F 695 |
| Facility failed to ensure adequate monitoring and documentation of psychotropic medication use, including AIMS assessments and PRN orders. | F 758 |
Report Facts
Facility census: 69
Investigative sample: 45
Employees reviewed: 8
Residents reviewed for care plans: 45
Residents reviewed for ADL: 3
Residents reviewed for respiratory care: 1
Residents reviewed for psychotropic medication: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| E1 | Nursing Home Administrator (NHA) | Interviewed regarding personnel records and findings |
| E2 | Director of Nursing (DON) | Interviewed and involved in exit conference and audit plans |
| E4 | Human Resources Director | Interviewed regarding personnel records and audits |
| E19 | Registered Nurse (RN), Unit Manager (UM) | Interviewed regarding care plans and medication administration |
| E20 | Certified Nursing Assistant (CNA) | Observed providing care and interviewed regarding resident care |
| R3 | Resident | Subject of nail care deficiency |
| R46 | Resident | Subject of care plan and ear wax buildup deficiency |
| R51 | Resident | Subject of respiratory care deficiency |
| R40 | Resident | Subject of psychotropic medication monitoring deficiency |
Inspection Report
Annual Inspection
Census: 58
Deficiencies: 1
Jun 23, 2023
Visit Reason
An unannounced annual and complaint survey was conducted at the facility from June 20, 2023 through June 23, 2023, including an Emergency Preparedness survey as required by 42 CFR 483.73.
Findings
The facility was found deficient in assisting residents in obtaining routine and 24-hour emergency dental care, specifically failing to promptly refer a resident with lost dentures for dental services within the required three days. No Emergency Preparedness deficiencies were found.
Deficiencies (1)
| Description |
|---|
| Failure to assist residents in obtaining routine and emergency dental care, including timely referral for lost dentures within three days. |
Report Facts
Facility census: 58
Sample size: 30
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| E1 (Executive Director) | Participated in exit conference and confirmed facility response to lost dentures | |
| E2 (Director of Nursing) | Participated in exit conference and confirmed facility response to lost dentures |
Inspection Report
Complaint Investigation
Census: 55
Deficiencies: 8
Nov 19, 2021
Visit Reason
An unannounced complaint survey was conducted at the facility from November 4, 2021 through November 19, 2021 to investigate complaints and assess compliance with regulatory requirements.
Findings
The survey identified multiple deficiencies based on observations, interviews, and clinical record reviews, including failures in notification of changes, discharge planning, medication administration, nutrition, laboratory services, and medical record maintenance. The facility failed to notify the resident's Power of Attorney of significant medical changes, failed to provide required discharge notices, and lacked effective systems for medication and nutrition management.
Complaint Details
The visit was triggered by a complaint and was an unannounced complaint survey conducted from November 4, 2021 through November 19, 2021. The deficiencies were based on observations, interviews, and clinical record reviews. The facility census on the first day was 55 residents.
Deficiencies (8)
| Description |
|---|
| Failure to notify resident's Power of Attorney of significant medical changes. |
| Failure to provide Notice to Medicare Provider Non-Coverage (NOMNC) before terminating services. |
| Failure to provide comprehensive care plan goals and discharge summaries to receiving providers. |
| Failure to provide accurate discharge summaries and post-discharge plans of care. |
| Failure to maintain effective nutrition and hydration status maintenance. |
| Failure to provide routine medication administration and pharmacy consultation. |
| Failure to provide timely and adequate laboratory services. |
| Failure to maintain complete, accurate, and confidential medical records. |
Report Facts
Facility census: 55
Survey sample size: 4
Inspection Report
Annual Inspection
Census: 62
Deficiencies: 11
Aug 13, 2021
Visit Reason
An unannounced annual and complaint survey was conducted at the facility beginning August 5, 2021 and ending August 13, 2021.
Findings
The report details multiple deficiencies based on observations, interviews, and review of residents' clinical records and other facility documentation. Deficiencies include emergency preparedness training, resident rights and grievance procedures, discharge planning, care plan revisions, pressure ulcer care, medication management, infection control, and abuse prevention training.
Complaint Details
The survey included complaint investigation components related to resident rights, grievance procedures, discharge planning, and abuse prevention training. Specific findings included residents unaware of the ombudsman program and grievance process, and staff lacking required abuse training.
Deficiencies (11)
| Description |
|---|
| Facility failed to provide emergency preparedness training at least annually to staff. |
| Facility failed to ensure residents were informed of the ombudsman program and their right to file a grievance/complaint. |
| Facility failed to provide safe and orderly discharge for one resident. |
| Facility failed to ensure care plans were revised to reflect residents' interventions. |
| Facility failed to provide appropriate care for pressure ulcers and off-loading of heels. |
| Facility failed to provide monthly drug regimen review for one resident. |
| Facility failed to store and maintain drugs and biologicals properly, including insulin pens. |
| Facility failed to maintain confidentiality and proper medical records. |
| Facility failed to conduct quality assessment and assurance committee meetings as required. |
| Facility failed to maintain infection prevention and control program and practices. |
| Facility failed to provide abuse, neglect, and exploitation training to staff. |
Report Facts
Facility census: 62
Investigative sample size: 22
Staff sample for emergency preparedness training: 15
Residents sampled for care plan review: 22
Residents sampled for abuse training review: 15
Meals reviewed: 543
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