Deficiencies per Year
12
9
6
3
0
Unclassified
Inspection Report
Follow-Up
Census: 12
Deficiencies: 11
Feb 24, 2025
Visit Reason
The visit was a partial, announced inspection conducted as a follow-up to verify the correction of previously identified deficiencies and review the submitted plan of correction.
Findings
The inspection found multiple deficiencies related to record confidentiality, resident personal equipment, sanitary conditions, lighting, surfaces, exterior hazards, food storage, refrigerator/freezer temperatures, fire drill records, designated meeting places during fire drills, and menu postings. All deficiencies had plans of correction accepted and were implemented by April 18, 2025.
Deficiencies (11)
| Description |
|---|
| Blue binders containing residents' files including protected health information were unlocked, unattended, and accessible in an unlocked closet in the unlocked doctor's office. |
| Resident's bedside mobility device was not properly secured to the bed frame, moving approximately 6 inches side to side and obstructing the bed from completely lowering. |
| A cookie, cardboard boxes, papers and tissues were jammed behind a dresser in the PC family lounge. |
| The light above the toilet and the light in the shower in the bathroom near a resident's room were not working, causing poor visibility. |
| Wallpaper peeling from the ceiling and a fist-sized circular area of cracked plaster and paint on walls near resident rooms. |
| Concrete ramp outside the activities area was eroding, creating divots and areas with loose stone. |
| A case of water and crate of milk were stored on the floor in the basement. |
| Basement freezer temperature was elevated at 9-10 degrees Fahrenheit, above the required 0°F or below. |
| Fire drill record did not include the number of residents evacuated during the drill. |
| During the fire drill, residents did not evacuate to a designated meeting place away from the building or within the fire-safe area; residents remained in rooms behind fire-rated doors. |
| The home's menu for the week was posted, but the next week's menu was not posted. |
Report Facts
Residents served: 12
Staff total daily: 18
Waking staff: 14
Residents diagnosed with mental illness: 1
Residents with mobility need: 6
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