Inspection Report Summary
The most recent inspection on October 23, 2025, found the facility to be in substantial compliance following a complaint investigation with no deficiencies cited. Earlier inspections showed a mixed record, including a 2023 substantiated complaint involving staff abuse and insufficient nursing staff, as well as a 2024 citation for failure to safeguard resident-identifiable information. Prior deficiencies primarily involved resident care issues such as abuse prevention, staffing levels, and documentation, along with some infection control and privacy concerns. Complaint investigations were mostly unsubstantiated except for the 2023 abuse-related case, which led to staff termination and corrective actions. The facility’s inspection history shows improvement over time, with recent surveys indicating compliance and no enforcement actions listed in the available reports.
Deficiencies (last 6 years)
Deficiencies are regulatory violations found during state inspections.
Deficiencies per year
Census
Based on a September 2024 inspection.
Census over time
Inspection Report
Complaint InvestigationInspection Report
Annual InspectionInspection Report
Complaint InvestigationInspection Report
Plan of CorrectionInspection Report
Annual Inspection| Name | Title | Context |
|---|---|---|
| Staff A | Registered Nurse (RN) | Interviewed regarding laptop screen locking procedures |
| Director of Nursing | Stated staff should lock computer screen when leaving medication cart |
Inspection Report
Complaint InvestigationInspection Report
Annual InspectionInspection Report
Re-InspectionInspection Report
Complaint Investigation| Name | Title | Context |
|---|---|---|
| Staff D | Named in abuse video incident and termination | |
| Staff E | Reported video incident to Assistant Administrator | |
| Staff C | Nurse | Witnessed video incident and reported management response |
| Assistant Administrator | Informed about video incident and involved in termination decision | |
| Director of Nursing | DON | Reported abuse investigation and staff training |
| Social Service Director | SSD | Provided family pamphlets and interviewed residents |
| Staff A | Aide | Witnessed and reported on video incident |
| Staff B | Aide | Reported hearing about video incident |
| Staff F | Aide | Reported training on abuse and phone use |
| Staff G | Aide | Reported training on abuse and phone use |
Inspection Report
Plan of CorrectionInspection Report
Annual Inspection| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Confirmed failure to report bruise and suicide attempt; discussed wound care order confusion and oxygen order adherence |
| Staff B | Registered Nurse | Reported wound dressing frequency for Resident #271 |
| Staff A | Licensed Practical Nurse | Observed performing wound dressing change for Resident #271 |
Inspection Report
Annual InspectionInspection Report
Abbreviated SurveyInspection Report
RoutineInspection Report
Abbreviated Survey| Name | Title | Context |
|---|---|---|
| Gary Joe Routh | Administrator | Signed the report and plan of correction. |
| Staff A | Certified Nursing Assistant | Observed failing to follow proper hand hygiene and glove use during resident care. |
Report
Report
Report
Report
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