Inspection Report
Complaint Investigation
Census: 55
Deficiencies: 1
May 1, 2025
Visit Reason
A recertification and complaint survey was conducted from 04/29/2025 to 05/01/2025 to assess compliance with 42 CFR 483 Subpart B.
Findings
The facility was found not to be in substantial compliance due to failure to follow infection control precautions related to peripheral inserted central catheters for three residents. No deficiencies were issued for other listed residents. The facility implemented corrective actions including education, policy review, and monitoring plans.
Complaint Details
The survey was complaint-related and the facility was found not in substantial compliance with infection prevention and control requirements. The complaint was substantiated based on observations and interviews regarding infection control practices.
Severity Breakdown
SS=E: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to follow infection control precautions for three residents with peripheral inserted central catheters, specifically not placing protective caps on catheter hubs. | SS=E |
Report Facts
Survey Census: 55
Survey Dates: From 2025-04-29 to 2025-05-01
Sample Size: 55
Number of residents with catheter issues: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Acting Infection Preventionist | Interviewed on 04/30/2025 regarding catheter hub caps |
| Registered Nurse 2 | RN | Interviewed on 05/01/2025 about catheter cleaning practices |
| Assistant Director of Nursing | Assistant Director of Nursing | Interviewed on 05/01/2025 about nursing cleaning procedures |
| Director of Health Services | Director of Health Services | Completed comprehensive reviews and involved in corrective actions |
| Assistant Director of Health Services | Assistant Director of Health Services | Completed comprehensive reviews and involved in corrective actions |
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