3 Reports
Inspection Report — Jun 26, 2025
CMS
Date: Jun 26, 2025
Visit Reason
The inspection was conducted to evaluate the facility's compliance with staffing requirements for the food and nutrition service, specifically regarding employment of a qualified dietician or certified dietary manager.
Findings
The facility failed to employ a full-time Certified Dietary Manager for 38 residents receiving meals from the kitchen, placing residents at risk of inadequate nutrition. Dietary staff was not certified but was in the process of certification.
Deficiencies (1)
F 0801: The facility failed to employ a full-time Certified Dietary Manager for 38 residents who receive meals from the kitchen, risking inadequate nutrition. Dietary staff stated they were not certified but were pursuing certification.
Report Facts
Residents affected: 38
Sample size: 13
Inspection Report — Oct 30, 2023
Annual Inspection CMS
Date: Oct 30, 2023
Visit Reason
The inspection was conducted as an annual survey to assess compliance with regulatory standards in medication storage, dietary management, food sanitation, and infection prevention.
Findings
The facility had multiple deficiencies including unsafe medication storage practices, failure to employ a full-time Certified Dietary Manager, inadequate hairnet use by dietary staff, and failure to implement a water management program for Legionella disease, placing residents at risk for medication errors, inadequate nutrition, food borne illness, and infectious disease.
Deficiencies (4)
F 0761: The facility failed to store medications safely when a Certified Medication Aide dispensed medications into unlabeled, uncovered plastic cups left in the medication cart, risking medication errors.
F 0801: The facility failed to employ a full-time Certified Dietary Manager to supervise meal preparation and sanitation, risking inadequate nutrition or food borne illness.
F 0812: The facility failed to ensure dietary staff wore complete hairnet coverage, including mustaches and sideburns, risking food borne illness.
F 0880: The facility failed to implement a water management program for Legionella disease, risking residents contracting Legionella pneumonia.
Report Facts
Sample size: 12
Number of unlabeled medication cups observed: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CMA R | Certified Medication Aide | Named in medication storage deficiency for dispensing medications into unlabeled cups |
| Administrative Staff A | Verified medication storage incident and dietary manager policy | |
| Dietary Staff BB | Dietary Staff | Observed assisting with meal preparation without dietary manager certification |
| Dietary Staff CC | Dietary Staff | Observed not wearing complete hairnet coverage during food preparation |
| Dietary Staff DD | Dietary Staff | Observed not wearing beard net while preparing drinks and desserts |
Inspection Report — Apr 5, 2022
Routine CMS
Date: Apr 5, 2022
Visit Reason
The inspection was a routine survey to assess compliance with regulatory requirements related to resident dignity, accommodation of needs, fall prevention, and medication administration.
Findings
The facility was found to have multiple deficiencies including failure to provide privacy during gastrostomy care, failure to accommodate a resident's wheelchair needs for self-propelling, inadequate supervision leading to a resident fall, and failure to check blood pressure prior to administering medication.
Deficiencies (4)
F 0550: The facility failed to treat Resident 16 with respect and dignity by not providing privacy during gastrostomy tube care, leaving the door open and curtain unpulled.
F 0558: The facility failed to reasonably accommodate Resident 34's needs by placing him in a wheelchair without foot pedals, preventing him from self-propelling and maintaining independence.
F 0689: The facility failed to provide adequate supervision to prevent a fall for Resident 15 and failed to properly transfer her from wheelchair to shower chair, resulting in skin tears and a head bump.
F 0760: The facility failed to check Resident 3's blood pressure prior to administering Metoprolol Tartrate 100 mg, placing the resident at risk for side effects from low blood pressure.
Report Facts
Residents in sample: 13
Skin tear size: 0.1
Metoprolol dosage: 100
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nurse D | Administrative Nurse | Verified privacy issues during gastrostomy care, supervision failures, and medication administration concerns |
| Licensed Nurse G | Licensed Nurse | Observed failing to provide privacy during gastrostomy care and commented on wheelchair adjustments |
| Certified Nurse Aide O | Certified Nurse Aide | Involved in fall incident with Resident 15 and provided statements about the event |
| Certified Medication Aide R | Certified Medication Aide | Administered Metoprolol to Resident 3 without checking blood pressure |
| Physical Therapy Consultant HH | Physical Therapy Consultant | Evaluated Resident 34's wheelchair and noted adjustments |
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