Inspection Report Summary
The most recent inspection on October 30, 2025 found the facility in substantial compliance after correcting deficiencies cited in the prior October 2, 2025 survey, which included issues related to abuse prevention, dialysis care, food safety, quality assurance, and infection control. Earlier inspections showed a pattern of deficiencies involving resident dignity and respect, care planning, medication management, infection prevention, and staff supervision, with some substantiated complaints of neglect and abuse. Enforcement actions such as immediate jeopardy related to medication errors were noted in the September 2024 inspection, but no fines or license suspensions were listed in the available reports. Complaint investigations were mixed, with several substantiated cases involving abuse and neglect, while others were unsubstantiated. The facility appears to have made improvements recently by correcting cited deficiencies promptly, though prior inspections revealed ongoing challenges in multiple care and safety areas.
Deficiencies (last 6 years)
Deficiencies are regulatory violations found during state inspections.
Deficiencies per year
Census
Based on a October 2025 inspection.
Census over time
Inspection Report
Plan of CorrectionInspection Report
Annual Inspection| Name | Title | Context |
|---|---|---|
| Staff Q | Certified Nursing Assistant (CNA) | Named in abuse and neglect deficiency related to resident #64. |
| Staff L | Certified Nurse Aide (CNA) | Interviewed regarding abuse incident involving resident #64. |
| Staff P | Licensed Practical Nurse (LPN) | Reported on abuse incident involving resident #64. |
| Staff N | Registered Nurse (RN) | Involved in abuse incident investigation and dialysis care deficiency. |
| Director of Nursing | Provided statements regarding abuse incident and dialysis care. | |
| Staff K | Registered Nurse (RN) | Observed performing tube feeding and infection control deficiency. |
| Staff F | Executive Chef | Named in food safety deficiency. |
| Staff H | Dietary Aide | Named in food safety deficiency. |
Inspection Report
Plan of CorrectionInspection Report
Complaint Investigation| Name | Title | Context |
|---|---|---|
| Staff B | Certified Nursing Assistant (CNA) | Observed feeding Resident #5 and then walking away |
| Staff D | Certified Nursing Assistant (CNA) | Observed feeding Resident #5 and then walking away |
| Staff C | Certified Nursing Assistant (CNA) | Observed feeding Resident #5 with a spoon and repositioning Resident #6 |
| Director of Nursing | Interviewed and stated expectations for staff interaction during meals |
Inspection Report
Re-InspectionInspection Report
Annual Inspection| Name | Title | Context |
|---|---|---|
| Brent R. Fullmore | Administrator | Signed the initial comments and plan of correction on 10/24/24. |
| Staff A | Certified Nursing Assistant (CNA) | Involved in assisting Resident #5 in a Broda chair during observation. |
| Staff O | Certified Nursing Assistant (CNA) | Interviewed regarding proper use of Broda chair and resident transport. |
| Assistant Director of Nursing (ADON) | Interviewed about resident transport and care plan revisions. | |
| Staff J | Registered Nurse (RN) | Interviewed about care planning and baseline care plan completion. |
| Director of Nursing (DON) | Interviewed about care plan revisions, hospice notifications, and medication administration. | |
| Staff F | Registered Nurse (RN) | Interviewed about resident care, tracheostomy care, and medication administration. |
| Staff B | Cook | Interviewed about food temperature and food handling practices. |
| Staff C | Licensed Practical Nurse (LPN) | Observed wearing PPE and interviewed about infection control practices. |
| Staff D | Certified Nursing Aide (CNA) | Observed wearing PPE and interviewed about infection control practices. |
| Staff H | Physical Therapist Assistant | Observed entering resident room without goggles. |
| Staff K | Medical Assistant | Interviewed about anticoagulation clinic and medication administration. |
| Staff L | Former Director of Nursing (DON) | Interviewed about computer access and medication order entry. |
| Staff M | Licensed Practical Nurse (LPN) | Interviewed about medication order entry and clinic procedures. |
| Staff N | Hospice Case Manager | Interviewed about hospice notifications and resident hospitalizations. |
| Staff G | Licensed Practical Nurse (LPN) | Interviewed about wound care and isolation gown use. |
Inspection Report
Re-InspectionInspection Report
Complaint Investigation| Name | Title | Context |
|---|---|---|
| Brent R. Fillmore | Administrator | Signed the report and plan of correction |
| Staff C | Registered Nurse (RN) | Involved in resident search and assessment during elopement incident |
| Staff D | Certified Nursing Assistant (CNA) | Reported observations during night shift and resident search |
| Staff E | Licensed Practical Nurse (LPN) | Reported observations during night shift and resident search |
| Staff G | Licensed Practical Nurse (LPN) | Reported observations during night shift and resident search |
| Staff H | Support Services Coordinator | Checked door alarms and reported issues |
| Director of Nursing (DON) | Provided statements regarding staff education and incident response |
Inspection Report
Plan of CorrectionInspection Report
Annual Inspection| Name | Title | Context |
|---|---|---|
| Staff Q | Re-educated about not referring to residents as 'feeders' and dignity policy. | |
| Staff M | Nurse | Failed to complete mandatory reporter abuse training within required timeframe. |
| Staff C | Re-educated on insulin pen administration per manufacturer guidelines. | |
| Staff D | Re-educated on medication crushing and pantoprazole administration. | |
| Staff B | Re-educated regarding ADL performance including perineal care and dining assistance. | |
| Staff P | Re-educated on C-diff precautions and infection control practices. | |
| Staff L | Registered Nurse | Reviewed for current licensure and re-educated on new hire process. |
| Staff F | Educated regarding safe wheelchair pushing and fall prevention. | |
| Staff A | Re-educated regarding hair net use and hygiene practices. | |
| Staff R | Re-educated regarding hair net use and hygiene practices. | |
| Staff O | Re-educated on C-diff precautions and infection control practices. | |
| Staff J | Re-educated on C-diff precautions and infection control practices. |
Inspection Report
Complaint InvestigationInspection Report
Complaint Investigation| Name | Title | Context |
|---|---|---|
| Staff S | Certified Nursing Assistant (CNA) | Named in findings related to failure to respond to call lights and resident assistance |
| Staff BB | Licensed Practical Nurse (LPN) | Named in abuse investigation and re-education on abuse policy |
| Staff Z | Licensed Practical Nurse (LPN) | Named in abuse investigation and re-education on abuse policy |
| Director of Nursing (DON) | Director of Nursing | Named in interviews regarding abuse investigation and facility policies |
| Staff F | Certified Nursing Assistant (CNA) | Named in observations and interviews related to resident care and call light response |
| Staff T | Licensed Practical Nurse (LPN) | Named in medication administration and resident care findings |
| Staff Q | Licensed Practical Nurse (LPN) | Named in medication administration and resident care findings |
| Staff AA | Registered Nurse (RN) | Named in staffing and medication administration findings |
| Staff X | Registered Nurse (RN) | Named in medication administration and resident care findings |
Inspection Report
Plan of CorrectionInspection Report
Plan of CorrectionInspection Report
Annual Inspection| Name | Title | Context |
|---|---|---|
| Staff L | Certified Nurse Aide (CNA) | Named in dignity violation for charging resident $10 for call light use |
| Staff M | Certified Nurse Aide (CNA) | Reported Staff L's statement about charging resident for call light |
| Administrator | Administrator | Reported Staff L no longer worked at the facility and stated expectation of dignity and respect |
| Mrs. Dash | Dietary staff | Responsible for meal options and resident meal trays |
| Staff D | Dietary Server | Reported issues with meal tickets and food service |
| Staff J | Certified Nurse Assistant (CNA) | Reported issues with menu slips and food service |
| Staff K | Licensed Practical Nurse (LPN) | Reported responsibility for delivering menus to residents |
| DON | Director of Nursing | Re-educated staff on bed hold policy and meal service |
| Staff C | Licensed Practical Nurse/Administration Nurse | Reported inability to find bed hold notice for resident |
| Assistant Director of Nursing (ADON) | Assistant Director of Nursing | Reported on menu slip process and care plan policy |
| Staff A | Registered Nurse (RN) | Observed administering medications and thickened liquids |
| Staff E | Dietary Cook | Failed to properly wash and sanitize food preparation equipment |
| Staff F | Dietary Cook | Failed to properly wash and sanitize food preparation equipment |
| Staff G | Certified Nursing Assistant (CNA) | Returned pudding to kitchen and reported resident could not drink cranberry juice |
| Staff I | Dietary Staff | Re-educated on cleaning dishes and fan removal |
| Staff T | Certified Nursing Assistant (CNA) | Returned pudding to kitchen and reported resident could not drink cranberry juice |
| Culinary Manager | Culinary Manager | Reported training on food temperatures and food safety |
| Registered Dietitian Consultant | Registered Dietitian Consultant | Re-educated on proper storage of thick-it scoop and handling items |
Inspection Report
Complaint InvestigationInspection Report
Abbreviated SurveyInspection Report
RoutineInspection Report
RoutineInspection Report
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