Inspection Report Summary
The most recent inspection on November 25, 2025, found the facility in compliance with no specific deficiencies detailed. Earlier inspections showed some deficiencies primarily related to resident transfers and accident prevention, with citations for failure to follow care plans resulting in residents being lowered to the floor during transfers, though no injuries were reported. Prior reports also noted issues with resident rights violations, food safety, infection control, and maintaining a safe environment, including a substantiated complaint about unauthorized video recording of a resident. Complaint investigations were mostly unsubstantiated except for a few substantiated cases involving resident dignity and abuse concerns. The facility appears to have addressed many prior deficiencies, showing improvement in recent inspections, although transfer-related issues persisted until the latest survey.
Deficiencies (last 6 years)
Deficiencies are regulatory violations found during state inspections.
Deficiencies per year
Census
Based on a November 2025 inspection.
Census over time
Inspection Report
Complaint Investigation| Name | Title | Context |
|---|---|---|
| Staff A | Certified Nursing Assistant (CNA) | Used Ez-stand for all transfers of Resident #3 |
| Staff B | Registered Nurse (RN) | Reported CNAs do not use pocket care plans and described Therapy Communication Binder |
| Staff C | Certified Nursing Assistant (CNA) | Lowered Resident #3 to floor during transfer and failed to review Therapy Communication Binder |
| Staff D | Licensed Practical Nurse (LPN) | Reported transfer status change was an intervention, not by Physical Therapy |
Inspection Report
Plan of CorrectionInspection Report
Plan of CorrectionInspection Report
Plan of CorrectionInspection Report
Routine| Name | Title | Context |
|---|---|---|
| Staff A | Certified Nurse Aide (CNA) | Assisted Resident #27 during fall incident and moved shower chair |
| Staff B | Licensed Practical Nurse (LPN) | Authored incident note and witnessed the fall |
| Staff C | Certified Nurse Aide (CNA) | Observed walking Resident #27 without using gait belt |
| Director of Nursing | Stated staff should always use gait belts for transfers and ambulation |
Inspection Report
Annual Inspection| Name | Title | Context |
|---|---|---|
| Staff A | Certified Nurse Aide (CNA) | Witnessed and involved in the fall incident with Resident #27 |
| Staff B | Licensed Practical Nurse (LPN) | Authored incident note documenting the fall of Resident #27 |
| Staff C | Certified Nurse Aide (CNA) | Observed walking Resident #27 without using a gait belt during ambulation/transfer |
| Director of Nursing | Director of Nursing | Stated staff should always use gait belts for transfers and ambulation |
Inspection Report
Complaint InvestigationInspection Report
Complaint InvestigationInspection Report
Plan of CorrectionInspection Report
Complaint Investigation| Name | Title | Context |
|---|---|---|
| Staff G | Certified Nursing Assistant | Named in abuse finding for posting video of resident on social media; terminated |
| Staff H | Certified Nursing Assistant | Reported the video to nursing staff and administration |
| Staff D | Licensed Practical Nurse | Received report of video and notified Director of Nursing |
| Staff A | Registered Nurse, Director of Nursing | Observed infection control deficiencies during blood glucose testing |
| Staff B | Certified Nursing Assistant | Provided information about cell phone policy and past incidents |
| Staff I | Director of Nursing | Notified about video incident and involved in response |
| Administrator | Administrator | Reported incident, completed investigation, terminated employee, and implemented training |
Inspection Report
Complaint Investigation| Name | Title | Context |
|---|---|---|
| Staff G | Certified Nursing Assistant (CNA) | Named in abuse finding for posting resident video on social media; terminated |
| Staff H | Certified Nursing Assistant (CNA) | Reported the video to nursing staff and administration |
| Staff D | Licensed Practical Nurse (LPN) | Received report of video and notified Director of Nursing |
| Staff B | Certified Nursing Assistant (CNA) | Interviewed regarding cell phone policy and hallway clutter |
| Staff A | Registered Nurse (RN), Director of Nursing (DON) | Observed blood glucose testing and improper lancet disposal |
| Staff E | Cook | Observed preparing and serving meals, including pureed food |
| Staff F | Dietary Aide | Assisted in serving meals |
| Staff K | Executive Chef | Provided information on food portioning and menu review |
| Administrator | Facility Administrator | Provided statements on incident reporting, training, and policies |
| DON | Director of Nursing | Stated expectation for nurse accountability regarding CNA conduct |
Inspection Report
Annual Inspection| Name | Title | Context |
|---|---|---|
| Staff G | Certified Nursing Assistant (CNA) | Named in abuse finding for recording and posting resident video on social media; terminated immediately. |
| Staff H | Certified Nursing Assistant (CNA) | Interviewed regarding the video incident and awareness of cell phone policy. |
| Staff D | Licensed Practical Nurse (LPN) | Interviewed regarding the video incident and reporting. |
| Staff I | Director of Nursing (DON) | Interviewed regarding the video incident and facility response. |
| Staff E | Cook | Observed during meal preparation with noted deficiencies in food handling. |
| Staff F | Dietary Aide | Observed during meal service with noted deficiencies. |
| Staff K | Executive Chef | Interviewed about menu preparation and serving sizes. |
| Staff A | Registered Nurse (RN), Director of Nursing (DON) | Observed blood glucose testing and infection control deficiencies. |
Inspection Report
Plan of CorrectionInspection Report
Complaint Investigation| Name | Title | Context |
|---|---|---|
| Staff D | Certified Nurse Aide (CNA) | Named in rude behavior toward Resident #2 |
| Staff E | Certified Nurse Aide (CNA) | Named in rude behavior and rushed care toward Resident #5 |
| Staff A | Certified Nurse Aide (CNA) | Involved in interaction with Resident #9; acknowledged by Director of Nursing |
| Staff B | Licensed Practical Nurse (LPN) | Spoke about expectations for resident dignity and reporting |
| Staff C | Anonymous employee | Reported witnessing rude behavior by staff |
| Director of Nursing | Director of Nursing (DON) | Spoke about expectations for dignity and facility policies |
Inspection Report
Complaint Investigation| Name | Title | Context |
|---|---|---|
| Staff D | Certified Nurse Aide (CNA) | Named in findings for rude behavior and loud voice toward Resident #2 |
| Staff E | Certified Nurse Aide (CNA) | Named in findings for rude behavior and disrespectful tone to residents |
| Staff F | Certified Nurse Aide (CNA) | Named in findings for rude behavior and disrespectful tone to residents |
| Staff A | Certified Nurse Aide (CNA) | Observed interacting with Resident #9 and mentioned in dignity findings |
| Staff B | Licensed Practical Nurse (LPN) | Interviewed regarding resident dignity and care |
| Staff C | Anonymous employee | Reported witnessing rude behavior by staff to residents |
| Director of Nursing | Director of Nursing (DON) | Provided statements regarding expectations for resident dignity and staff interactions |
Inspection Report
Plan of CorrectionInspection Report
RoutineInspection Report
Annual Inspection| Name | Title | Context |
|---|---|---|
| Staff A | Certified Nurse Aide (CNA) | Named in infection control deficiency related to improper catheter care |
| Staff B | Certified Nurse Aide (CNA) | Named in infection control deficiency related to improper catheter care |
| Dietary Manager | Responsible for performing random audits of food service and food items for dating | |
| Director of Nursing | Director of Nursing | Provided immediate education to staff and will complete random audits of catheter care |
Inspection Report
Plan of CorrectionInspection Report
Annual Inspection| Name | Title | Context |
|---|---|---|
| Staff A | Licensed Practical Nurse (LPN) | Named in infection control deficiency related to improper wound care technique. |
| Pam Harned | Administrator | Signed the report and acknowledged deficiencies. |
Inspection Report
Complaint InvestigationInspection Report
Annual Inspection| Name | Title | Context |
|---|---|---|
| Pam Harned | Administrator | Signed the plan of correction |
| Staff D | Registered Nurse | Observed improperly handling syringe and medication discrepancies |
| Staff E | Registered Nurse | Reported on syringe safety and medication administration |
| Assistant Director of Nursing | ADON | Provided education and oversight on medication administration and narcotic counts |
| Staff A | Dietary Manager | Revealed information about evening snack preparation and distribution |
| Staff C | Dietary Aide | Interviewed about food storage and snack preparation |
| Staff B | Cook | Interviewed about snack preparation and distribution |
Inspection Report
Abbreviated SurveyInspection Report
Abbreviated SurveyInspection Report
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