Inspection Report Summary
The most recent inspection on March 21, 2025, cited deficiencies related to professional standards of care, fall prevention, medication and respiratory supply storage, and the facility’s water management plan for Legionella risks. Earlier inspections showed a pattern of issues with medication administration, care planning, infection control, and communication, with several substantiated complaints over time. Prior reports noted deficiencies in medication management, resident supervision, infection prevention, and documentation, including some related to respiratory care and emergency communication. Complaint investigations were mostly substantiated when deficiencies were found, including a notable case involving inadequate respiratory suctioning that contributed to a resident’s death. The facility’s inspection history shows ongoing challenges with clinical care and safety practices, with recent findings continuing some previously identified themes.
Deficiencies (last 6 years)
Deficiencies are regulatory violations found during state inspections.
Deficiencies per year
Census
Based on a March 2025 inspection.
Census over time
Inspection Report
Annual Inspection| Name | Title | Context |
|---|---|---|
| Faith Epperson | Director of Nursing | Named in plan of correction and interviews related to blood sugar monitoring and fall prevention |
| Registered Nurse 1 | Observed blood sugar check and insulin administration for resident R21 | |
| License Practical Nurse 1 | Checked blood sugar and administered insulin for resident R21 | |
| Advanced Registered Nurse Practitioner | Interviewed regarding physician notifications and resident care | |
| Certified Medication Aide 1 | Observed administering medications to residents R12 and R10 | |
| Administrator | Conducted audits and education related to care plans, medication administration, and infection control | |
| Vice President | Corporate Compliance | Interviewed regarding medication self-administration assessments |
Inspection Report
Annual InspectionInspection Report
RecertificationInspection Report
Complaint InvestigationInspection Report
Plan of CorrectionInspection Report
Complaint Investigation| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing (DON) | Stated on 4/17/24 that she would look into medication availability issues and confirmed medication ordering procedures |
Inspection Report
Plan of CorrectionInspection Report
Plan of CorrectionInspection Report
Complaint Investigation| Name | Title | Context |
|---|---|---|
| Staff G | Registered Nurse (RN) | Stated resident was very tired but alert and able to answer questions |
| Staff F | Certified Nursing Assistant (CNA) | Reported resident was cognitive and could answer questions |
| Staff E | Certified Nursing Assistant/Certified Medication Aide (CNA/CMA) | Documented administering medication and resident's responses |
| Staff H | Certified Nursing Assistant (CNA) | Worked overnight shifts and reported resident complaints and care |
| Staff D | Certified Nursing Assistant (CNA) | Worked specific days and reported resident behavior and care |
| Staff C | Registered Nurse (RN) | Interviewed CNA and reported on resident's condition and care |
| Staff B | Registered Nurse (RN) | Reported on resident's pain and medication administration issues |
Inspection Report
Annual Inspection| Name | Title | Context |
|---|---|---|
| Staff A | MDS Coordinator | Acknowledged and verified MDS assessment inaccuracies and care plan deficiencies |
| Director of Nursing | Director of Nursing | Acknowledged missing transfer documentation, care plan expectations, and hand hygiene standards |
| Staff B | Certified Nurse Aide | Observed failing to perform proper hand hygiene and infection control during resident care |
| Staff C | Non-Certified Aide | Observed failing to perform proper hand hygiene and infection control during resident care |
| Staff D | Certified Nurse Aide | Observed failing to perform proper hand hygiene and infection control during resident care |
Inspection Report
Plan of CorrectionInspection Report
Complaint Investigation| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing (DON) | Reported completion of facility investigations and narcotic count discrepancies. |
| Staff A | Registered Nurse (RN) | Documented medication administration and provided a typed recount statement regarding narcotic counts. |
| Staff B | Certified Medication Aide (CMA) | Administered tramadol and involved in medication discrepancy. |
| Staff C | Certified Medication Aide (CMA) | Reported on narcotic count practices and shift procedures. |
| Staff D | Licensed Practical Nurse (LPN) | Reported narcotic count concerns and interactions with DON. |
| Staff E | Licensed Practical Nurse (LPN) | Reported narcotic count practices and verification issues. |
| Assistant Director of Nursing | Assistant Director of Nursing (ADON) | Reported on narcotic count completion and observations. |
Inspection Report
Re-InspectionInspection Report
Complaint Investigation| Name | Title | Context |
|---|---|---|
| Jennifer Blair | Administrator | Signed the Plan of Correction on 03/22/2023 |
| Staff A | LPN (licensed practical nurse) | Interviewed and confirmed Resident #2's communication and suctioning needs |
| Staff B | CMA/CNA (certified medication aide/certified nursing assistant) | Interviewed and confirmed Resident #2's suctioning needs |
| Staff C | RN (registered nurse) | Interviewed and confirmed Resident #2's suctioning needs and procedure |
| Staff D | CNA | Interviewed and described Resident #2's condition and suctioning needs |
| Staff E | CNA | Interviewed and confirmed Resident #2's communication about suctioning needs |
| Staff F | CNA | Interviewed and described Resident #2's condition and suctioning needs |
| Staff G | LPN | Interviewed and described events around Resident #2's decline and suctioning |
| Staff H | CMA/CNA | Interviewed and confirmed Resident #2's communication about suctioning needs |
| Staff I | ADON (assistant director of nursing) | Interviewed and confirmed nursing expectations for suctioning Resident #2 |
| Staff J | RN | Interviewed and confirmed Resident #2's suctioning needs and availability of suction machine |
Inspection Report
Plan of CorrectionInspection Report
Annual Inspection| Name | Title | Context |
|---|---|---|
| Staff K | Registered Nurse (RN) | Administered medications and tube feeding to Resident #145 and provided statements regarding tracheostomy care. |
| Staff I | Licensed Practical Nurse (LPN) | Confirmed admission MDS for Resident #145 had not been completed. |
| Staff C | Certified Nursing Assistant (CNA) | Observed transferring Resident #39 using Sit-To-Stand lift and assisted with resident care. |
| Staff J | Registered Nurse (RN) | Removed old dressing and applied new dressing for Resident #6 and #11. |
| Staff A | Activities Director | Observed not wearing gloves and failing to use sanitizer during COVID-19 outbreak. |
| Staff B | Certified Medication Aide (CMA) | Failed to perform hand hygiene during medication administration. |
| Staff D | Housekeeping Staff | Not wearing gown or gloves while cleaning resident rooms. |
| Staff E | Registered Nurse (RN) | Handled oxygen tubing for Resident #17 without gloves or gown. |
| Staff F | Certified Nursing Assistant (CNA) | Assisted Resident #19 who tested positive for COVID-19. |
| Staff G | Certified Nursing Assistant (CNA) | Assisted Resident #19 who tested positive for COVID-19. |
| Director of Nursing | Director of Nursing | Commented on improper positioning of resident during Sit-To-Stand transfer. |
| Administrator | Administrator | Provided statements regarding MDS completion, care plans, vaccination refusals, and COVID-19 infection control. |
| Regional Nurse Consultant | Regional Nurse Consultant | Confirmed lack of RN coverage and vaccination status for residents. |
| Dietary Manager | Dietary Manager | Provided statements regarding food temperatures, sanitation, and meal service. |
| Staff J | Registered Nurse (RN) | Removed old dressing and applied new dressing for Resident #6 and #11. |
Inspection Report
Plan of CorrectionInspection Report
Complaint InvestigationInspection Report
Complaint InvestigationInspection Report
Annual Inspection| Name | Title | Context |
|---|---|---|
| Administrator | Interviewed on January 28, 2021 regarding staff communication with residents |
Inspection Report
Complaint InvestigationInspection Report
RoutineReport
Report
Report
Report
Report
Report
Report
Report
Loading inspection reports...



