Inspection Report
Routine
Deficiencies: 14
Mar 14, 2024
Visit Reason
State-compiled facility profile showing multiple inspections from 2016 to 2024 with deficiency history and compliance findings.
Findings
Across multiple inspections from 2016 to 2024, the facility had several Class 3 deficiencies primarily related to staff training, resident records, medication management, and staffing standards. Recent inspections in 2023 and 2024 showed no deficiencies.
Complaint Details
Multiple complaint investigations are included from 2017 through 2023, with some resulting in Class 3 deficiencies related to training, records, and medication management.
Severity Breakdown
Class 3: 14
Unclassified: 1
Deficiencies (14)
| Description | Severity |
|---|---|
| A0086 — TRAINING - ADRD: Facilities must ensure staff receive Alzheimer’s Disease and Related Disorders training as required. | Class 3 |
| A0162 — RECORDS - RESIDENT: Resident records must be maintained on premises with required demographic and health information. | Class 3 |
| A0078 — STAFFING STANDARDS - STAFF: Newly hired staff must submit health care provider statements regarding communicable diseases within 30 days of employment. | Class 3 |
| A0081 — TRAINING - STAFF IN-SERVICE: New employees must attend preservice orientation covering responsible care topics. | Class 3 |
| A0090 — TRAINING - DO NOT RESUSCITATE ORDERS: Staff must receive training on facility policies regarding DNROs. | Class 3 |
| A0160 — RECORDS - FACILITY: Facility must maintain required records readily available for review. | Class 3 |
| CZ814 — BACKGROUND SCREENING CLEARINGHOUSE: Compliance with background screening requirements for employees. | Unclassified |
| A0054 — MEDICATION - RECORDS: Facility must maintain medication records including prescription details and daily observation. | Class 3 |
| A0052 — MEDICATION - ASSISTANCE WITH SELF-ADMIN: Unlicensed persons assisting with medication must be trained and meet age requirements. | Class 3 |
| A0056 — MEDICATION - LABELING AND ORDERS: Prescription drugs must be properly labeled and dispensed according to regulations. | Class 3 |
| AN277 — LNS - RESIDENT CARE STANDARDS: Facility must employ sufficient qualified staff to meet limited nursing service needs. | Class 3 |
| A0030 — RESIDENT CARE - RIGHTS & FACILITY PROCEDURES: Facility must post Resident Bill of Rights and have grievance procedures. | Class 3 |
| A0082 — TRAINING - HIV/AIDS: Facility employees must complete one-time education on HIV/AIDS topics. | Class 3 |
| A0161 — RECORDS - STAFF: Personnel records must document background screening, training compliance, and licenses. | Class 3 |
Report Facts
Inspections on page: 31
Inspection Report
Deficiencies: 0
Mar 14, 2024
Visit Reason
State-compiled facility profile showing multiple inspections from 2016 to 2024 with deficiency history and inspection statuses.
Findings
Across the inspections, the facility had periods with no deficiencies, cited deficiencies, and corrected deficiencies. Deficiencies were cited in various complaint, standard, and monitor inspections, with some later corrected.
Report Facts
Inspections on page: 38
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