Inspection Report Summary
The most recent inspection on March 25, 2025, found no deficiencies related to the complaint investigated. Earlier inspections showed a mixed pattern with several deficiencies noted, particularly in emergency preparedness, life safety code compliance, resident care including medication management and skin condition monitoring, and documentation. A substantiated complaint in December 2023 involved staff abuse and failure to timely report, resulting in federal and state deficiencies cited under abuse-related regulations. Other complaint investigations were mostly unsubstantiated or found no related deficiencies. The facility’s recent inspections indicate some improvement in compliance, especially with no deficiencies cited in the latest complaint investigations and follow-up surveys.
Deficiencies (last 4 years)
Deficiencies are regulatory violations found during state inspections.
Deficiencies per year
Census
Based on a March 2025 inspection.
Census over time
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Life Safety| Name | Title | Context |
|---|---|---|
| Max Jones | Administrator | Named in relation to review of findings and exit conference |
| Director of Environmental Services | Interviewed and acknowledged generator testing deficiencies and exit door lock issues |
Inspection Report
Renewal| Name | Title | Context |
|---|---|---|
| Max Jones | Administrator | Signed the inspection report |
| Director of Nursing | Interviewed regarding medication self-administration and wound care | |
| Assistant Director of Nursing | Interviewed regarding nurse staffing posting and infection control | |
| RN 1 | Interviewed regarding fall prevention and wheelchair Dycem | |
| LPN 1 | Interviewed regarding enhanced barrier precautions | |
| Maintenance Director | Interviewed regarding fire drill invitations |
Inspection Report
Complaint InvestigationInspection Report
Complaint Investigation| Name | Title | Context |
|---|---|---|
| Max Wayern Jones | Administrator | Signed report and referenced in findings |
| Terminated Employee 1 | Staff member substantiated for abuse of Resident B | |
| Employee 2 | Witnessed and reported abuse incident | |
| Employee 3 | Interviewed resident and reported incident to ADON | |
| Employee 4 | Witnessed yelling and water on floor near Nurses' Station | |
| Assistant Director of Nursing | ADON | Interviewed and involved in investigation and reporting |
Inspection Report
Life SafetyInspection Report
Life Safety| Name | Title | Context |
|---|---|---|
| Maintenance Technician #1 | Interviewed and acknowledged deficiencies related to fire suppression system, sprinkler system, ceiling construction, sprinkler heads, and door latching. |
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