Inspection Report Summary
The most recent inspection on November 15, 2024, found no deficiencies after a revisit survey confirmed correction of prior issues. Earlier inspections in 2024 identified deficiencies primarily related to fire safety, including self-closing doors that did not latch properly and sprinkler system maintenance, as well as resident care concerns involving urinary catheter dignity, care plan implementation, and oxygen therapy administration. Complaint investigations during this period were mostly unsubstantiated, with one substantiated complaint in 2022 involving improper technique during resident care that resulted in a fall and injury. No fines, immediate jeopardy findings, or license actions were listed in the available reports. The facility appears to be addressing past deficiencies, as recent follow-up surveys have verified corrections and the latest inspection was free of citations.
Deficiencies (last 8 years)
Deficiencies are regulatory violations found during state inspections.
Deficiencies per year
Census
Based on a November 2024 inspection.
Census over time
Inspection Report
Inspection Report
Re-InspectionInspection Report
Follow-Up| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed the findings of doors not latching upon closing during the tour of the facility. |
Inspection Report
Life Safety| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed findings related to door latch failures and wiring attached to sprinkler piping during facility tour |
Inspection Report
Annual Inspection| Name | Title | Context |
|---|---|---|
| BB | Licensed Practical Nurse (LPN) | Confirmed that urinary catheter drainage bags for residents R71 and R94 were uncovered and later covered. |
| AA | Assistant Director of Nursing (ADON) | Revealed that all residents with urinary catheters should have the drainage bag in a privacy bag. |
Inspection Report
Routine| Name | Title | Context |
|---|---|---|
| BB | Licensed Practical Nurse (LPN) | Confirmed urinary catheter drainage bags were uncovered and oxygen flow rates were incorrect for residents R71, R94, and R66 |
| AA | Assistant Director of Nursing (ADON) | Stated expectations for urinary catheter privacy bags and oxygen flow rate monitoring |
| CC | Licensed Practical Nurse (LPN) | Verified and adjusted oxygen flow rate for resident R66 |
| FF | MDS Coordinator | Stated nursing staff responsibility for ensuring resident care plans were followed |
Inspection Report
Follow-UpInspection Report
Plan of CorrectionInspection Report
Re-InspectionInspection Report
Follow-Up| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed findings regarding lack of door inspection documentation during facility tour. |
Inspection Report
Life Safety| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed multiple findings during facility tour on 4/27/2023 |
Inspection Report
Annual InspectionInspection Report
Complaint Investigation| Name | Title | Context |
|---|---|---|
| EE | Licensed Practical Nurse (LPN) | Responsible for maintenance and cleaning of oxygen equipment for resident #159; mentioned resident refused assistance and care orders changed to PRN. |
| AA | Assistant Director of Nursing (ADON) | Confirmed oxygen equipment was lying on the floor and not properly stored. |
| DON | Director of Nursing | Confirmed nurse assigned to resident's hall responsible for oxygen equipment maintenance and cleaning; confirmed no qualified Infection Preventionist nurse. |
| Administrator | Confirmed no policy for storing respiratory equipment; confirmed no qualified Infection Preventionist nurse after previous nurse resigned on 4/18/2023. |
Inspection Report
Plan of CorrectionInspection Report
Re-InspectionInspection Report
Abbreviated SurveyInspection Report
Abbreviated SurveyInspection Report
Complaint Investigation| Name | Title | Context |
|---|---|---|
| CNA EE | Certified Nursing Assistant | Named in fall incident for improper technique during ADL care |
| LPN KK | Licensed Practical Nurse | Present during fall incident, documented and reported events |
| Assistant Director of Nursing | Assistant Director of Nursing | Provided statement regarding the fall incident |
Inspection Report
Abbreviated SurveyInspection Report
RenewalInspection Report
RenewalInspection Report
RoutineInspection Report
Life SafetyInspection Report
RoutineInspection Report
RoutineInspection Report
RoutineInspection Report
Abbreviated SurveyInspection Report
RoutineInspection Report
RoutineInspection Report
Abbreviated SurveyInspection Report
Re-InspectionInspection Report
Life SafetyInspection Report
Abbreviated SurveyInspection Report
Follow-UpInspection Report
Annual InspectionInspection Report
Life Safety| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed findings during facility tour and staff interviews |
Inspection Report
Abbreviated SurveyInspection Report
Abbreviated SurveyInspection Report
Abbreviated SurveyInspection Report
RoutineInspection Report
Life SafetyInspection Report
Abbreviated SurveyInspection Report
Complaint InvestigationReport
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