Inspection Reports for
Zearing Health Care, LLC

The facility failed to obtain informed consent for psychotropic medications for 5 residents, did not develop comprehensive care plans reflecting residents' behaviors related to falls for 3 residents, and failed to use gloves correctly in the kitchen to prevent cross contamination. The facility lacked a policy on informed consents for psychotropic drug use and did not provide requested care plan policy prior to exit.

The complaint investigation involved Resident #1 who was verbally abused by Staff A during a meal, with Staff A using profane language and inappropriate behavior. Staff B witnessed the incident but did not immediately act to remove Staff A. The facility later instructed Staff A to leave after the incident was reported. The investigation also included concerns about wheelchair safety and failure to follow abuse prevention policies.

The facility failed to treat residents with dignity and respect during assistance with activities of daily living for 2 of 5 residents reviewed, and failed to separate residents from an alleged perpetrator of verbal abuse in a timely manner. Staff used inappropriate language and behavior while assisting residents, and proper protocols for wheelchair safety and abuse reporting were not followed.

The investigation of complaints #2576768-C and #2582101-C resulted in deficiencies. Staff A was suspended on 7/30/25 due to allegations of abuse. Interviewed residents and staff confirmed verbal abuse and unprofessional behavior. The facility failed to separate the alleged perpetrator from the resident promptly. A self-report was submitted to the State Survey Agency. The investigation is ongoing with corrective actions planned.

The facility was found not in compliance with 42 CFR Part 483 requirements related to resident rights and abuse prevention. Staff A was suspended for verbal abuse, and the facility failed to separate the alleged perpetrator from the resident in a timely manner. Multiple interviews and reviews revealed staff used profane language and failed to treat residents with dignity.

The facility will be certified in compliance effective September 26, 2025, based on the acceptance of the Plan of Correction.

The visit was complaint-related due to a medication error incident on 5/3/25. The error was substantiated as Staff A, a Registered Nurse, administered the wrong medications to Resident #1. The facility followed protocol by notifying the administrative staff, on-call provider, Resident #1's family, and pharmacy. Resident #1 was assessed multiple times with vital signs monitored and no adverse effects noted.

The facility failed to follow the 5 rights of medication administration and physician orders, resulting in a medication error with minimal harm or potential for actual harm affecting a few residents. Resident #1 was monitored closely with no adverse reactions noted, and the facility followed protocol including notifying the provider, family, and pharmacy.

Complaint #128449-C resulted in a deficiency related to medication administration errors. The complaint was substantiated by observation, clinical record review, staff interviews, and policy review.

The facility was found not in compliance with 42 CFR Part 483 requirements related to medication administration and physician orders. A medication error occurred when a Registered Nurse administered medications to the wrong resident, and the facility failed to follow the five rights of medication administration.

Facility reported incident #126019-I was substantiated. The complaint investigation found failure to report abuse timely and failure to separate the alleged abuser from the resident. The facility reported a census of 35 residents during the investigation.

The facility failed to report an allegation of abuse timely for one resident and did not separate the alleged abuser from the resident for approximately 7 days after the incident. Staff interviews and policy reviews revealed multiple failures in reporting and preventing abuse. The facility implemented corrective actions including staff training and separation of the alleged abuser.

The complaint involved an allegation of abuse against Resident #1 on 1/3/25. The facility staff who witnessed the alleged abuse failed to report it timely to the administration or the Department of Inspections, Appeals, and Licensing. The Administrator first learned of the allegation on 1/10/25, about 7 days after the incident, allowing the alleged abuser to continue working with residents during that time.

The facility failed to timely report an allegation of abuse for Resident #1 and failed to separate the alleged abuser from the resident for approximately 7 days after the incident. Staff interviews, policy review, and timecard details confirmed these failures. The facility census was 35 residents at the time.

Complaint #100142-C was substantiated. Complaint #105180-C was not substantiated.

The facility was found to have multiple deficiencies including failure to provide timely notification of changes for residents, incomplete comprehensive assessments after significant changes, failure to notify residents of charges in a timely manner, incomplete PASARR assessments, and failure to properly manage psychotropic drug orders and medication cart security.

Complaint #91969-C was substantiated based on observations, staff interviews, and record reviews indicating multiple deficiencies in resident care and facility operations.

The facility failed to maintain a safe, clean, comfortable, and homelike environment for residents, including issues with odors, sticky floors, and unclean furniture in Resident #23's room. The facility also failed to notify the Ombudsman of transfers for Residents #14 and #26, and did not complete required PASARR screenings for residents with mental disorders. Additionally, care plans lacked necessary details and interventions, and medication administration protocols were not properly followed.

Complaint #91279-C was investigated and found not substantiated. The facility was cited for deficient infection prevention and control practices.

The facility failed to ensure staff followed proper infection control practices for 2 of 3 residents observed, including failure to wash or sanitize hands during wound care and improper glove use. The complaint was not substantiated, but deficiencies in infection prevention and control were identified.