6 CMS Surveys
Inspection Report — Sep 4, 2025
Date: Sep 4, 2025
Visit Reason
Not determinable from the provided text; the Initial Comment block is missing or unreadable.
Findings
The document is an inspection report with deficiencies related to wound care and skin treatment for residents R2 and R4, but the Initial Comment block is not present to classify the visit type or provide a summary.
Deficiencies (1)
F0684 - The facility failed to provide needed care and services in accordance with resident's plan of care as ordered by physician, facility's protocol, and professional standard of practice, affecting two residents (R2 and R4) reviewed for quality of care.
Report Facts
Residents affected: 2
Inspection Report — May 8, 2025
Annual Inspection
Date: May 8, 2025
Visit Reason
Annual Licensure Survey
Findings
The facility was found to have deficiencies related to failure to conduct PASARR screenings for residents with mental disorders and failure to provide appropriate pressure ulcer care for one resident. The facility did not have a policy regarding PASARR screening and failed to assess and treat a stage 4 pressure ulcer in a timely manner.
Deficiencies (2)
F0645 (PASARR screening for Mental disorders or Intellectual Disabilities) - The facility failed to conduct PASARR screenings for 4 of 6 residents reviewed and did not ensure appropriate evaluation and care for residents with mental disorders.
F0686 (Provide appropriate pressure ulcer care and prevent new ulcers from developing) - The facility failed to assess and provide appropriate care for a stage 4 pressure ulcer for 1 of 4 residents reviewed, resulting in worsening condition and hospital transfer.
Report Facts
Residents affected: 4
Residents affected: 1
Inspection Report — Oct 12, 2024
Date: Oct 12, 2024
Visit Reason
The document does not contain an A 000 Initial Comment block specifying the visit type; therefore, inspection_type is set to 'other'.
Findings
The facility failed to ensure proper infection prevention and control practices, including handling soiled linens and incontinence care for one resident, which could lead to skin breakdown and contamination.
Deficiencies (1)
F0880 (Infection Prevention and Control) - The facility failed to ensure soiled linens were handled to prevent cross contamination and failed to provide proper incontinence care for one of three residents reviewed.
Report Facts
Residents affected: 1
Inspection Report — Jun 7, 2024
Date: Jun 7, 2024
Visit Reason
The document does not contain an A 000 Initial Comment block specifying the visit type; therefore, inspection_type is set to 'other'.
Findings
The facility was found to have deficiencies related to resident privacy and food safety practices, including failure to maintain resident privacy and improper food labeling and sanitizing procedures.
Deficiencies (2)
F0583 (Statement of Resident Rights) - The facility failed to maintain resident privacy when a resident was left exposed with bare chest and legs visible from the hallway, affecting one resident.
F0812 (Kitchen Policy) - The facility failed to label and date food items properly and did not follow sanitizer manufacturer instructions for immersing blender items, potentially affecting 131 residents on oral diet and 13 residents on puree diet.
Report Facts
Residents affected: 1
Residents affected: 131
Residents affected: 13
Inspection Report — Jun 1, 2023
Date: Jun 1, 2023
Visit Reason
The document does not contain an A 000 Initial Comment block specifying the visit type; therefore, inspection_type is set to 'other'.
Findings
The facility failed to protect residents from physical abuse by another resident, resulting in injury to one resident and hospitalization. The investigation revealed conflicting witness reports and concerns about supervision adequacy.
Deficiencies (1)
F0600 (Protect each resident from all types of abuse) - The facility failed to keep a resident free from physical abuse by another resident, resulting in injury and hospitalization of one resident and scratch marks on another.
Report Facts
Residents affected: 2
Inspection Report — May 18, 2023
Date: May 18, 2023
Visit Reason
The document does not contain an A 000 Initial Comment block specifying the visit type; therefore, inspection_type is set to 'other'.
Findings
The facility was found to have multiple deficiencies related to pressure ulcer care, pain management, pharmaceutical services, and medication storage and labeling.
Deficiencies (4)
F0686 (Pressure Ulcer Care) - The facility failed to prevent or identify the formation of a pressure injury and failed to follow physician's orders and facility skin care policy for one resident (R49), resulting in a stage 4 pressure ulcer.
F0697 (Pain Management) - The facility failed to perform comprehensive pain assessments as scheduled, failed to administer pain medication as requested or needed, and failed to follow pain policy for two residents (R115, R129), resulting in periods of unbearable pain for R115.
F0755 (Pharmaceutical Services) - The facility failed to maintain an accurate count of schedule II controlled pain medication for one resident (R129), creating a discrepancy with potential to affect all 133 residents.
F0761 (Medication Storage and Labeling) - The facility failed to follow pharmacy medication storage and labeling policy and medication pass policy by not noting and implementing open date labels and failing to refrigerate new medications requiring refrigeration for six residents (R22, R27, R61, R70, R76, R121).
Report Facts
Residents affected: 1
Residents affected: 2
Residents affected: 133
Residents affected: 6
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