Deficiencies per Year
20
15
10
5
0
Severe
High
Moderate
Low
Unclassified
Inspection Report
Re-Inspection
Capacity: 62
Deficiencies: 17
Oct 17, 2024
Visit Reason
State-compiled facility profile showing 7 inspections from 2021 to 2024 with deficiency history and enforcement actions
Findings
Across multiple inspections, the facility demonstrated numerous deficiencies including failure to properly monitor and assess residents' changes of condition, incomplete medication administration records, inadequate staff training, failure to update staffing plans, and insufficient fire and life safety training for residents. Some deficiencies were corrected while others remained uncorrected as of the latest inspection.
Complaint Details
The complaint investigation conducted on 6/25/2024 found failures in medication administration system and training program for direct care staff, with findings acknowledged by facility staff.
Deficiencies (17)
| Description |
|---|
| C0270 - Change of Condition and Monitoring: Failed to ensure changes of condition were evaluated, referred to RN, documented, and communicated to staff with weekly progress notes for sampled residents experiencing severe weight loss and other conditions |
| C0280 - Resident Health Services: Failed to ensure RN completed timely significant change of condition assessments for residents with severe weight loss and weight gain |
| C0310 - Systems: Medication Administration: Failed to maintain accurate Medication Administration Records (MAR) including documentation of pain ratings for PRN medications |
| C0325 - Systems: Self-Administration of Meds: Failed to evaluate residents for safe self-administration and obtain physician orders for self-administration of medications |
| C0363 - Acuity Based Staffing Tool - Updates & Staffing Plan: Failed to update posted staffing plan to match Acuity-Based Staffing Tool (ABST) results |
| C0372 - Training Within 30 Days of Hire – Direct Care Staff: Failed to ensure newly hired staff demonstrated competency in assigned duties within 30 days |
| C0374 - Annual and Biennial Inservice for All Staff: Failed to ensure required annual in-service training hours and infectious disease training were completed by staff |
| C0422 - Fire and Life Safety: Training for Residents: Failed to ensure residents received annual fire and life safety training with proper documentation |
| C0000 - Comment: Kitchen inspections documented findings of compliance and non-compliance with food sanitation rules |
| C0240 - Resident Services Meals, Food Sanitation Rule: Failed to maintain kitchen in good repair and sanitary manner with multiple sanitation and maintenance issues |
| C0303 - Systems: Treatment Orders: Failed to ensure safe medication administration system due to medication unavailability |
| C0365 - Staffing Rqmt and Training: Training Rqmts: Failed to have training program including competency evaluation for direct care staff |
| C0010 - Licensing Complaint Investigation: Findings from complaint investigation related to compliance with state and local laws |
| C0360 - Staffing Requirements and Training: Staffing: Failed to have enough staff to meet residents' scheduled and unscheduled needs with delayed call light responses |
| C0361 - Acuity-Based Staffing Tool: Failed to fully implement and update acuity-based staffing tool and maintain accurate posted staffing plan |
| C0270 - Change of Condition and Monitoring (2021): Failed to monitor residents consistent with evaluated needs and service plan, including thorough fall investigations and intervention monitoring |
| C0640 - Heating and Ventilation: Failed to ensure wall heater covers did not exceed 120 degrees Fahrenheit in resident areas |
Report Facts
Inspections on page: 7
Total deficiencies: 15
Total surveys: 7
Licensing violations: 10
Abuse violations: 0
Notices: 0
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Becky Johnson | Administrator | Named in multiple findings and plan of correction discussions |
| Staff 1 | Administrator | Named in multiple findings and plan of correction discussions |
| Staff 2 | Regional Director of Wellness/RN | Named in multiple findings and plan of correction discussions |
| Staff 4 | Regional Care Coordinator (RCC) | Named in multiple findings and plan of correction discussions |
| Staff 5 | Regional Care Coordinator (RCC) | Named in multiple findings and plan of correction discussions |
| Staff 9 | Medication Technician (MT) | Named in medication administration findings |
| Staff 17 | Caregiver (CG) | Named in training deficiency findings |
| Staff 18 | Caregiver (CG) | Named in training deficiency findings |
| Staff 19 | Cook | Named in annual training deficiency findings |
| Staff 20 | Housekeeper | Named in annual training deficiency findings |
| Staff 3 | Medication Technician (MT) | Named in complaint investigation findings |
| Staff 6 | Regional Care Coordinator (RCC) | Named in fall investigation findings |
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