Inspection Report Summary
The most recent inspection on October 9, 2024, found no deficiencies at the facility. Earlier inspections showed some issues, including missed annual performance reviews and in-service education for Licensed Nurse Assistants in August 2023, and substantiated complaints in June 2022 related to incomplete documentation of residents’ code status and inconsistent allergy records. Inspectors cited deficiencies mainly in staff performance management and medical record documentation. Complaint investigations were substantiated in one case involving emergency care policies and allergy documentation, while no enforcement actions or fines were listed in the available reports. The inspection history suggests improvement over time, with the latest review showing compliance after prior identified issues.
Deficiencies (last 3 years)
Deficiencies are regulatory violations found during state inspections.
Deficiencies per year
Inspection Report
Annual InspectionInspection Report
Plan of Correction| Name | Title | Context |
|---|---|---|
| Administrator | Confirmed that the facility had not conducted the required performance reviews for the LNAs |
Inspection Report
Complaint Investigation| Name | Title | Context |
|---|---|---|
| Registered Nurse (RN) | Interviewed regarding Resident #2's code status and documentation | |
| Director of Nursing (DON) | Interviewed regarding resident code status documentation and Full code list | |
| Medical Director | Interviewed regarding Resident #2's lack of completed COLST form | |
| Director of Social Services | Interviewed regarding responsibility for entering code status into medical records |
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