Inspection Report Summary
The most recent inspection on December 26, 2025, found deficiencies related to maintaining a safe, clean, and homelike environment in one of three shower rooms, with visible mold and mildew. Earlier inspections showed a pattern of deficiencies involving resident care, medication management, infection control, and environmental cleanliness. Complaint investigations substantiated issues such as neglect, delayed medical care, improper wound care, and medication errors, but enforcement actions or fines were not listed in the available reports. The facility has repeatedly been cited for problems with hygiene, care planning, and safety hazards, including a resident fall resulting in a fracture. While deficiencies continue to appear, some recent inspections suggest ongoing efforts to address environmental concerns.
Deficiencies (last 3 years)
Deficiencies (over 3 years)
20 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
326% worse than Pennsylvania average
Pennsylvania average: 4.7 deficiencies/yearDeficiencies per year
20
15
10
5
0
Census
Latest occupancy rate
38 residents
Based on a November 2023 inspection.
This facility has shown a decline in demand based on occupancy rates.
Occupancy over time
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Dec 26, 2025
Visit Reason
The inspection was conducted due to concerns raised about the cleanliness and safety of one of the shower rooms in the facility.
Complaint Details
The visit was complaint-related based on resident concerns about the shower room being dirty and containing mold. The complaint was substantiated by observations and interviews.
Findings
The facility failed to maintain a safe, clean, and homelike environment in one of three shower rooms observed, with visible mold and mildew substances and a strong foul odor. Interviews with residents confirmed concerns about the shower room's condition, and the Nursing Home Administrator acknowledged the issue and committed to immediate cleaning.
Deficiencies (1)
Failure to maintain a safe, clean, comfortable and homelike environment in one of three shower rooms, including presence of mold and mildew.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nursing Home Administrator | Interviewed regarding the shower room cleanliness and committed to immediate cleaning. |
Inspection Report
Annual Inspection
Deficiencies: 8
Date: Aug 7, 2025
Visit Reason
The inspection was conducted as an annual survey to assess the facility's compliance with regulatory requirements and standards of care.
Findings
The facility was found deficient in multiple areas including failure to ensure call light accessibility for residents, improper use and documentation of psychotropic medications, inaccurate resident assessments, incomplete care plan revisions, inadequate provision of care and services, failure to maintain appropriate range of motion and mobility services, failure to act on pharmacy recommendations, and improper kitchen equipment use and monitoring.
Deficiencies (8)
Failed to ensure the call system is within reach of the resident for one of 35 residents reviewed (Resident 155).
Failed to ensure that a resident's medication regimen was free from unnecessary psychotropic medications for one of seven residents reviewed (Resident 8).
Failed to ensure the resident assessment accurately reflected the resident status for three of 35 residents reviewed (Residents 5, 51, and 85).
Failed to review and revise the resident plan of care for one of 35 residents reviewed (Resident 8).
Failed to ensure care and services are provided in accordance with professional standards of practice for four of 35 residents reviewed (Residents 43, 82, 128, and 141).
Failed to provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility for one of one residents reviewed (Resident 17).
Failed to ensure pharmacy recommendations were acted on appropriately for two of 35 residents reviewed (Residents 25 and 51).
Failed to utilize kitchen equipment in accordance with professional standards for food service safety in the main kitchen.
Report Facts
Residents reviewed: 35
Residents affected: 1
Residents affected: 7
Residents affected: 3
Residents affected: 4
Residents affected: 1
Residents affected: 2
Dish machine rinse temperature: 93
Dish machine rinse temperature: 96
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Employee 2 | Regional Director of Clinical Services | Interviewed regarding medication order issues, care plan revisions, and pharmacy recommendations |
| Employee 3 | Registered Nurse | Interviewed regarding medication administration and resident 141's medication spill incident |
| Employee 4 | Nurse Aide | Interviewed regarding medication spill incident with Resident 141 |
| Employee 6 | Dietary Employee | Interviewed regarding dish machine temperature issues |
| Employee 7 | Interviewed regarding Resident 5's helmet use and assessment | |
| Director of Nursing | Director of Nursing (DON) | Interviewed multiple times regarding various deficiencies including call light accessibility, medication orders, care plans, and pharmacy recommendations |
| Nursing Home Administrator | Nursing Home Administrator (NHA) | Interviewed regarding multiple deficiencies including care plans, medication administration, and kitchen equipment |
Inspection Report
Annual Inspection
Deficiencies: 11
Date: Sep 26, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements including resident assessments, care planning, medication management, infection control, and other aspects of nursing home operations.
Findings
The facility was found deficient in multiple areas including inaccurate resident assessments, incomplete and untimely care plan revisions, failure to implement physician orders, inadequate infection control practices, missing documentation related to dialysis care, failure to monitor side effects of psychotropic medications, unsafe food storage and handling practices, and lack of annual performance evaluations for nurse aides.
Deficiencies (11)
Facility failed to ensure resident assessments accurately reflected resident status for 11 of 38 residents reviewed.
Facility failed to ensure care plans were reviewed and revised timely and residents were given opportunity to participate in care planning.
Facility failed to implement care plans and physician orders for residents including failure to revise care plans for new diagnoses and treatments.
Facility failed to provide appropriate pressure ulcer care and prevent new ulcers for one resident.
Facility failed to ensure adequate supervision and assistance to prevent accidents for one resident.
Facility failed to monitor weight and nutritional status adequately for one resident.
Facility failed to provide safe and appropriate dialysis care and maintain accurate dialysis records for one resident.
Facility failed to ensure residents were free of unnecessary psychotropic medications and monitor for side effects.
Facility failed to store food and utilize equipment in accordance with professional standards for food service safety in the main kitchen and pantries.
Facility failed to ensure adequate infection prevention and control practices including use of enhanced barrier precautions and PPE.
Facility failed to complete annual performance evaluations for nurse aides.
Report Facts
Residents reviewed: 38
Residents affected: 11
Residents affected: 7
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Employees affected: 4
Blood pressures documented in left arm: 73
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Employee 1 | Regional Director of Clinical Services | Confirmed multiple MDS coding errors and care plan deficiencies; unable to locate dialysis documentation |
| Employee 3 | Licensed Practical Nurse | Unaware of trauma triggers for Resident 43 |
| Employee 4 | Registered Nurse | Provided immediate education after Resident 63 fall incident |
| Employee 5 | Social Worker | Revealed missed social service assessment for Resident 43 |
| Employee 7 | Registered Nurse Assessment Coordinator | Confirmed MDS coding errors for Resident 43 and 142 |
| Employee 8 | Nurse Aide | Involved in Resident 63 fall incident |
| Employee 10 | Nurse Aide | Assisted in Resident 63 fall incident |
| Employee 11 | Nurse Aide | Missing annual performance evaluation |
| Employee 12 | Nurse Aide | Missing annual performance evaluation |
| Employee 13 | Nurse Aide | Missing annual performance evaluation |
| Employee 15 | Nurse Aide | Missing annual performance evaluation |
| Employee 16 | Failed to don gown during wound care for Resident 32 | |
| Employee 17 | Failed to don gown during wound care for Resident 32 | |
| Employee 2 | Food Service Director | Observed expired sanitizer test strips and food safety issues |
| Nursing Home Administrator | NHA | Confirmed multiple deficiencies and provided interviews |
Inspection Report
Annual Inspection
Deficiencies: 2
Date: Sep 26, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, including monitoring of resident weight and nurse aide training.
Findings
The facility failed to ensure proper monitoring of weight for one resident who experienced significant weight loss and failed to provide required annual in-service training for three nurse aides, including dementia management and abuse prevention training.
Deficiencies (2)
Failure to monitor one resident's weight adequately, resulting in a 34-pound weight loss without proper documentation or care planning for refusals.
Failure to provide required annual in-service training including dementia management and abuse prevention for three nurse aides.
Report Facts
Residents reviewed for weight monitoring: 38
Weight loss: 34
Weight loss percentage: 15.32
Nurse aide employee records reviewed: 5
Nurse aides lacking required training: 3
Inspection Report
Routine
Deficiencies: 1
Date: Jul 10, 2024
Visit Reason
The inspection was conducted to assess the facility's compliance with regulations regarding maintaining a safe, clean, comfortable, and homelike environment, specifically focusing on air conditioning and temperature control on the 1300 nursing unit.
Findings
The facility failed to ensure a safe, comfortable, homelike interior environment on the 1300 unit due to problems with air conditioning, resulting in elevated room temperatures and resident complaints of excessive heat. Maintenance was monitoring temperatures and portable air conditioning units were used, but one resident's air conditioning unit was not functioning properly.
Deficiencies (1)
Failure to ensure a safe, comfortable, homelike interior environment on the 1300 nursing unit due to inadequate air conditioning and elevated temperatures.
Report Facts
Room temperature: 83
Room temperature: 86
Room temperature: 83
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nursing Home Administrator | Interviewed regarding air conditioning issues and corrective steps | |
| Maintenance Director | Conducted temperature measurements and reported malfunctioning air conditioning unit |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: May 23, 2024
Visit Reason
The inspection was conducted to investigate complaints related to the facility's failure to provide appropriate treatment and care according to orders and professional standards, specifically regarding delayed CT scan after a resident's fall and delayed wound vac treatment for a pressure ulcer.
Complaint Details
The complaint investigation focused on delays in obtaining a CT scan for Resident 4 after a fall and delays in wound vac treatment for Resident 1's pressure ulcer. The CT scan was initially scheduled more than a month after the fall and only performed after the order was changed to stat. The wound vac treatment was delayed due to difficulty obtaining supplies, with the wound vac not applied until May 6, 2024.
Findings
The facility failed to ensure timely medical care for Resident 4 by delaying a CT scan ordered after a fall, which was initially scheduled over a month later and only completed after being changed to stat. Additionally, the facility failed to provide timely wound vac treatment for Resident 1's unstageable pressure ulcer due to supply issues, resulting in a delay of several days before treatment was applied.
Deficiencies (2)
Failure to provide timely CT scan after Resident 4's fall, resulting in delayed diagnostic imaging.
Failure to provide appropriate pressure ulcer care and prevent new ulcers from developing for Resident 1 due to delayed wound vac application caused by supply issues.
Report Facts
Date of Resident 4 fall: May 13, 2024
Date CT scan ordered: May 15, 2024
Date CT scan performed: May 22, 2024
Date wound vac applied: May 6, 2024
Dates wound vac supply awaited: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nursing Home Administrator | NHA | Interviewed regarding delays in CT scan scheduling and wound vac supply issues |
| Employee 1 | Interviewed regarding difficulty obtaining wound vac supplies |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Feb 22, 2024
Visit Reason
The inspection was conducted based on complaints alleging neglect and inadequate catheter care at the facility.
Complaint Details
The complaint investigation found substantiated neglect related to Resident 4 not being changed in a timely manner and substantiated failure to provide catheter care and follow-up for Resident 2, resulting in infection and complications.
Findings
The facility failed to ensure residents were free from neglect, specifically Resident 4 was left in wet briefs for hours. Additionally, the facility failed to provide appropriate suprapubic catheter care and monitoring for Resident 2, resulting in an infection and failure to follow urology specialist recommendations.
Deficiencies (2)
Failure to protect residents from neglect, as Resident 4 was left sitting in wet briefs for hours.
Failure to provide appropriate suprapubic catheter care and monitoring for Resident 2, resulting in actual harm due to infection and failure to implement urology recommendations.
Report Facts
Residents reviewed: 4
Nurse Aids on 800/900 hall: 4
Date of catheter care order: Oct 27, 2023
Date of urology consultation: Feb 15, 2024
Bladder scan volume: 296
Antibiotic treatment duration: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Employee 1 | Registered Nurse | Named in neglect finding for Resident 4 |
| Employee 2 | Licensed Practical Nurse | Named in catheter care deficiency for Resident 2 |
| Director of Nursing | Director of Nursing | Interviewed regarding neglect and catheter care findings |
| Nursing Home Administrator | Nursing Home Administrator | Interviewed regarding neglect and catheter care findings |
Inspection Report
Deficiencies: 1
Date: Jan 29, 2024
Visit Reason
The inspection was conducted to assess compliance with professional standards related to pressure ulcer care and prevention at the nursing home.
Findings
The facility failed to ensure appropriate pressure ulcer care for one of six residents reviewed, specifically Resident 1. Observations revealed multiple breaches in proper dressing change procedures, including failure to establish a clean field, improper handling and disposal of soiled dressings, inadequate hand hygiene, and failure to clean the overbed table after the procedure.
Deficiencies (1)
Failure to provide appropriate pressure ulcer care and prevent new ulcers from developing for Resident 1.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Employee 1 | Registered Nurse | Named in findings related to improper dressing change procedures for Resident 1. |
Inspection Report
Routine
Deficiencies: 1
Date: Jan 11, 2024
Visit Reason
The inspection was conducted to assess the facility's compliance with maintaining a safe, clean, comfortable, and homelike environment for residents, based on observations and staff interviews.
Findings
The facility failed to maintain a safe, clean, and homelike environment in four resident rooms, with observations of food crumbs, broken furniture, stains, and unclean floors. Housekeeping was noted to have missed cleaning some rooms, and some stains were persistent despite cleaning efforts.
Deficiencies (1)
Failure to maintain a safe, clean, comfortable, and homelike environment in four resident rooms, including presence of food crumbs, broken furniture, stains, and unclean floors.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse | Interviewed regarding condition of Resident 2's room | |
| Nursing Home Administrator (NHA) | Interviewed and observed conditions in multiple resident rooms and discussed housekeeping follow-up | |
| Housekeeper | Interviewed regarding cleaning of Resident 3 and 4's rooms |
Inspection Report
Routine
Census: 38
Deficiencies: 2
Date: Nov 16, 2023
Visit Reason
The inspection was conducted to assess the facility's compliance with regulations regarding maintaining a safe, clean, comfortable, and homelike environment and providing assistance with activities of daily living for dependent residents.
Findings
The facility failed to maintain a clean and homelike environment for five of 38 residents observed, with issues such as soiled wheelchairs, missing protective molding, and broken bedside stands. Additionally, the facility failed to provide scheduled showers or bed baths to six of 33 dependent residents reviewed, as documented by missing bathing records and resident interviews.
Deficiencies (2)
Facility failed to maintain a clean, comfortable, and homelike environment for five residents, including soiled wheelchairs and broken furniture.
Facility failed to provide assistance with activities of daily living, specifically showers or bed baths, for six dependent residents as scheduled.
Report Facts
Residents observed: 38
Residents reviewed: 33
Residents affected: 5
Residents affected: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nursing Home Administrator (NHA) | Interviewed regarding cleanliness and bathing deficiencies | |
| Director of Nursing (DON) | Interviewed regarding cleanliness and bathing deficiencies |
Inspection Report
Routine
Deficiencies: 17
Date: Nov 16, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements including resident rights, safety, care quality, infection control, medication management, and other aspects of facility operations.
Findings
The facility was found deficient in multiple areas including failure to honor resident rights related to advance directives, maintain a clean and homelike environment, conduct timely abuse investigations, complete significant change assessments, ensure accurate resident assessments, revise care plans timely, provide care according to professional standards, assist with activities of daily living, provide appropriate pressure ulcer care, maintain adequate nutrition, provide safe respiratory care, perform timely medication regimen reviews, ensure medication error rates below 5%, properly document controlled substance disposition, assist with dental services, and implement effective infection prevention and control practices.
Deficiencies (17)
Failed to offer option to formulate advance directives and document resident choices for 3 of 38 records; failed to document correct code status matching POLST for 1 of 38 residents.
Failed to maintain a clean, comfortable, and homelike environment for 5 of 38 residents observed.
Failed to conduct timely and thorough investigation to rule out abuse, neglect, or mistreatment following an unwitnessed fall for 1 of 12 residents reviewed for falls.
Failed to complete significant change assessment for hospice status for 1 of 38 residents reviewed.
Failed to ensure resident assessment accurately reflected status for 6 of 39 residents reviewed.
Failed to review and revise resident care plans timely for 4 of 38 residents reviewed.
Failed to ensure care and services were provided in accordance with professional standards for 1 of 38 residents reviewed.
Failed to provide assistance with activities of daily living for dependent residents for 6 of 33 residents reviewed.
Failed to provide care and services to promote healing and prevent worsening of pressure ulcers for 1 of 4 residents reviewed for pressure ulcers.
Failed to answer dietary consult in response to weight loss to maintain adequate nutritional status for 1 of 38 residents reviewed.
Failed to provide respiratory care consistent with professional standards for 1 of 39 residents reviewed.
Failed to ensure medication regimen reviews were completed by a consultant pharmacist and responded to timely by attending physician for 4 of 39 residents reviewed.
Failed to ensure medication error rate was below 5%, with 2 errors out of 31 opportunities (6.45%).
Failed to ensure documentation of controlled medication disposition and reason for 1 of 3 closed records reviewed.
Failed to assist residents in obtaining routine and emergency dental services for 1 of 39 residents reviewed.
Failed to ensure residents were free from unnecessary antipsychotic medication for 1 of 5 residents reviewed.
Failed to implement infection control practices to prevent transmission of infectious disease for 1 of 1 resident reviewed for transmission based precautions; failed to maintain data collection system for 3 of 12 months; failed to maintain effective infection control related to medication preparation and administration for 1 of 3 residents observed.
Report Facts
Medication error rate: 6.45
Residents reviewed: 38
Residents observed: 33
Residents affected: 5
Residents affected: 6
Residents affected: 4
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Employee 1 | Licensed Practical Nurse | Named in medication error finding for improper inhaler administration and topical medication measurement |
| Nursing Home Administrator | Interviewed multiple times regarding deficiencies and findings | |
| Director of Nursing | Interviewed multiple times regarding deficiencies and findings | |
| Employee 2 | Registered Nurse Assessment Coordinator | Named in inaccurate MDS coding findings |
| Employee 3 | Medical Doctor | Named in dietary consult order and communication |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Oct 26, 2023
Visit Reason
The inspection was conducted due to concerns about the facility's failure to provide appropriate care and services to heal and prevent infection of pressure ulcers for two residents.
Complaint Details
The complaint investigation found substantiated failures in wound care practices, including improper glove use and instrument cleaning, confirmed by direct observation and staff interviews.
Findings
The facility failed to follow proper wound care procedures, including inadequate hand hygiene, failure to change gloves between tasks, and not cleaning instruments used during dressing changes, which posed a risk of infection to residents with stage IV pressure injuries.
Deficiencies (2)
Failure to change gloves and perform hand hygiene between removing old dressing, cleansing wound, and applying new dressing for Residents 1 and 2.
Failure to clean scissors before and after use during wound dressing changes.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Employee 1 | Observed failing to follow proper wound care procedures including glove changes and instrument cleaning. | |
| Director of Nursing | Director of Nursing (DON) | Interviewed and confirmed facility expectations regarding wound care procedures and instrument cleaning. |
Inspection Report
Deficiencies: 1
Date: Sep 8, 2023
Visit Reason
The inspection was conducted to assess compliance with regulations regarding providing residents with a written notice of their rights, services, and rules prior to or upon admission.
Findings
The facility failed to ensure that three of six residents reviewed were provided a written notice of rights, services, and rules prior to or upon admission. Admission agreements were missing or unsigned for Residents 1 and 4, while Resident 6's agreement was signed. The Nursing Home Administrator indicated gaps in the admissions process and follow-up.
Deficiencies (1)
Failure to provide residents with a written notice of rights, rules, services, and charges prior to or upon admission for three of six residents reviewed.
Report Facts
Residents affected: 3
Timeframe for admission agreement review: 48
Inspection Report
Routine
Census: 100
Deficiencies: 5
Date: Aug 9, 2023
Visit Reason
The inspection was conducted to assess the facility's compliance with regulations regarding resident environment, personal hygiene, respiratory care, food safety, and dietary services.
Findings
The facility failed to maintain a safe, clean, and homelike environment in multiple resident rooms, shower rooms, and dining rooms. There were deficiencies in personal hygiene care for residents dependent on staff, respiratory care equipment maintenance, food temperature safety during meals, and accommodation of resident food preferences.
Deficiencies (5)
Facility failed to maintain a safe, clean, and homelike environment in six resident rooms, one shower room, and two dining rooms, including presence of dried blood, dirty PTAC units, and unclean shower grout.
Facility failed to maintain adequate personal hygiene and grooming for residents dependent on staff for assistance with activities of daily living (Residents 3 and 5).
Facility failed to provide safe and appropriate respiratory care; oxygen concentrator filters were dirty for Residents 8 and 9.
Facility failed to provide food at a safe temperature; turkey served at 129°F, below acceptable temperature during lunch meal on 500 unit.
Facility failed to provide food that accommodates resident preferences; Resident 3 was served one slice of turkey despite meal ticket indicating double portions.
Report Facts
Residents present: 100
Residents affected: 6
Residents affected: 2
Residents affected: 2
Residents affected: 1
Food temperature: 129
Food temperature: 178
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nursing Home Administrator | Interviewed regarding bed changing, housekeeping, bathing expectations, oxygen concentrator filter cleaning, and food service issues | |
| Employee 1 | Food Service Director | Conducted test tray temperature measurements and interviewed about food temperature and resident food requests |
Inspection Report
Deficiencies: 1
Date: Jul 27, 2023
Visit Reason
The inspection was conducted to evaluate the facility's compliance with pharmaceutical services regulations, specifically assessing the procedures for acquiring, receiving, dispensing, and administering medications to residents.
Findings
The facility failed to have an adequate procedure for pharmacy services, resulting in medication delivery delays and administration errors for one resident. The Director of Nursing confirmed the facility does not have a designated back-up pharmacy for medication delivery.
Deficiencies (1)
Failure to have a procedure for provision of pharmacy services ensuring accurate acquiring, receiving, dispensing, and administering of drugs for residents.
Report Facts
Medication administration delay: 159
Residents reviewed: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Interviewed regarding back-up pharmacy services |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: May 16, 2023
Visit Reason
The inspection was conducted following a complaint investigation regarding a resident fall resulting in a right hip fracture due to a wet floor hazard in the nursing home.
Complaint Details
The investigation was triggered by a fall incident involving Resident 2 on May 11, 2023, where the resident slipped on a freshly mopped wet floor without verbal notification of the hazard. The fall resulted in a right hip fracture. Resident 2 had no prior fall history. The facility's housekeeping staff placed a wet floor sign at the doorway but did not notify the resident verbally as he was asleep.
Findings
The facility failed to ensure the resident environment was free from accident hazards, specifically a wet floor that caused Resident 2 to slip and sustain a right hip fracture. The wet floor was freshly mopped with a wet floor sign placed only at the doorway, and the resident was not verbally notified of the hazard while asleep.
Deficiencies (1)
Failure to ensure the resident environment was free from accident hazards resulting in a right hip fracture due to a wet floor.
Report Facts
Residents reviewed: 6
Brief Interview for Mental Status score: 13
Deficiencies cited: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse 1 | Registered Nurse | Entered progress note documenting the fall and condition of Resident 2 |
| Housekeeper 1 | Witnessed Resident 2 on the floor and placed wet floor sign | |
| Director of Nursing | Director of Nursing | Confirmed no prior fall history and housekeeping notification practices |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Apr 24, 2023
Visit Reason
The inspection was conducted based on a complaint investigation to determine if the facility ensured residents' drug regimens were free from unnecessary psychotropic medications.
Complaint Details
The complaint investigation found that Resident 2 received Haldol 5 mg twice daily instead of the prescribed 0.5 mg twice daily due to a transcription error not identified by the facility.
Findings
The facility failed to ensure one of three residents reviewed was free from unnecessary psychotropic medications due to a transcription error that resulted in a resident receiving a tenfold higher dose of Haldol than prescribed without a physician's order.
Deficiencies (1)
Facility failed to ensure one resident was free from unnecessary psychotropic medications due to a transcription error resulting in a tenfold increase in Haldol dosage without physician order.
Report Facts
Medication doses administered: 14
Medication dose discrepancy: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Interviewed regarding the transcription error of Resident 2's Haldol medication order. |
Inspection Report
Deficiencies: 1
Date: Apr 10, 2023
Visit Reason
The inspection was conducted to assess compliance with housekeeping standards and to ensure a safe, clean, and comfortable environment for residents, specifically reviewing the sanitation of resident rooms.
Findings
The facility failed to maintain sanitary housekeeping services in one of four resident rooms reviewed, with observations of a large yellow dried stain, sticky and wet streaked floors in Resident 3's room. Interviews confirmed these issues and plans for correction were stated.
Deficiencies (1)
Failure to ensure housekeeping services necessary to maintain a sanitary and comfortable interior for Resident 3's room, including presence of a large yellow dried stain and sticky floor areas.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Housekeeping Manager | Interviewed regarding housekeeping issues in Resident 3's room | |
| Housekeeper | Responsible for Resident 3's room, does not usually work that assignment | |
| Nursing Home Administrator | Interviewed and stated cleaning process concerns will be corrected |
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