Inspection Report Summary
The most recent inspection on January 24, 2025 found no deficiencies and substantiated no complaints. Prior inspections showed a pattern of deficiencies primarily related to fire safety code compliance and medication and food safety practices, with issues such as unsecured hazardous materials, incomplete medication audits, and fire alarm and sprinkler system maintenance. Earlier complaint investigations were mostly unsubstantiated, though a substantiated abuse allegation in early 2023 resulted in a cited deficiency for failure to protect a resident and timely report the incident. Enforcement actions such as fines or license suspensions were not listed in the available reports. The facility has demonstrated improvement over time, correcting prior deficiencies noted in medication management and fire safety during subsequent revisit surveys.
Deficiencies (last 9 years)
Deficiencies are regulatory violations found during state inspections.
Deficiencies per year
Census
Based on a January 2025 inspection.
Census over time
Inspection Report
Annual Inspection| Name | Title | Context |
|---|---|---|
| GG | Certified Nursing Assistant (CNA) | Mentioned in relation to communication attempts with resident R84 |
| FF | Licensed Practical Nurse (LPN) | Mentioned in relation to communication methods with resident R84 |
| EE | Unit Manager (UM) | Discussed communication interventions and care plan updates for resident R84 |
| Social Services Director | Discussed communication assessments and TTY device for resident R84 | |
| MDS Director | Responsible for updating care plan for resident R84 | |
| Administrator | Provided statements regarding care plan updates and infection control expectations | |
| Director of Education and Infection Prevention | Discussed infection prevention policies and responsibilities for labeling and bagging urinals | |
| Maintenance Director | Confirmed unlabeled and unbagged urinals in shared bathrooms | |
| Maintenance Supervisor | Confirmed unlabeled and unbagged urinals in shared bathrooms |
Inspection Report
Complaint Investigation| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Completed investigation regarding resident R6's leg pain and fracture; conducted interviews with staff |
| Administrator | Administrator and Abuse and Neglect Coordinator | Reported all allegations to the state and participated in the investigation team |
| Social Services Director | Social Services Director | Part of the investigation team and responsible for typing the investigation summary |
Inspection Report
Abbreviated SurveyInspection Report
Plan of CorrectionInspection Report
Re-InspectionInspection Report
Life Safety| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed findings during facility tour and staff interviews |
Inspection Report
Complaint InvestigationInspection Report
Annual Inspection| Name | Title | Context |
|---|---|---|
| LPN AA | Licensed Practical Nurse | Verified missing signatures on narcotic count sheets and explained CMA limitations. |
| Director of Nursing | Verified missing signatures on Controlled Drug Shift Audit sheets and suggested staffing issues. | |
| Environmental Services Director | Reported lack of key for janitorial room and confirmed hazard for dementia residents. | |
| LPN CC | Licensed Practical Nurse | Confirmed Dakin solution was left in resident's room and should not be stored bedside. |
| Cook DD | Cook | Observed preparing food without hairnet and beard restraint; confirmed in-service training on labeling and storage. |
| Kitchen Director | Confirmed responsibility for checking expiration dates and discarding expired food. | |
| District Manager | Confirmed cleaning and inventory schedule and Kitchen Director's responsibilities. |
Inspection Report
Routine| Name | Title | Context |
|---|---|---|
| CC | Licensed Practical Nurse (LPN) | Confirmed Dakin solution was left in resident's room and should not be stored at bedside |
| BB | Licensed Practical Nurse (LPN)/Unit Manager | Verified oxygen concentrator filter condition and cleaning schedule |
| AA | Licensed Practical Nurse (LPN) | Verified missing signatures on narcotic count sheets and explained CMA limitations |
| Director of Nursing (DON) | Director of Nursing | Verified missing signatures on Controlled Drug Shift Audit sheets and commented on possible staffing issues |
| DD | Kitchen staff | Observed preparing food without hairnet and beard restraint; confirmed in-service training on labeling and storage |
| KD | Kitchen Director | Confirmed responsibility for checking expiration dates and discarding expired food |
| DM | District Manager | Confirmed cleaning and inventory schedule and responsibilities |
| Environmental Services Director | Environmental Services Director | Confirmed janitorial room key situation and accident hazard potential |
Inspection Report
Routine| Name | Title | Context |
|---|---|---|
| CC | Licensed Practical Nurse (LPN) | Confirmed Dakin solution was left in resident's room and should not be stored at bedside |
| BB | Licensed Practical Nurse (LPN)/Unit Manager | Verified oxygen concentrator filter was covered with white-gray fuzzy substance and described cleaning schedule |
| AA | Licensed Practical Nurse (LPN) | Verified missing signatures on narcotic count sheets and explained CMA limitations |
| Director of Nursing (DON) | Director of Nursing | Verified missing signatures on Controlled Drug Shift Audit sheets and commented on possible staffing issues |
| KD | Kitchen Director | Confirmed responsibility for checking expiration dates, discarded expired food, and confirmed cleaning schedule |
| DM | District Manager | Confirmed cleaning and inventory schedule and responsibility for labeling, storing, and discarding food |
| DD | Kitchen staff | Observed preparing food without hairnet and beard restraint; confirmed in-service training on labeling and storage |
| Environmental Services Director | Confirmed janitorial room key situation and accident hazard potential |
Inspection Report
Routine| Name | Title | Context |
|---|---|---|
| CC | Licensed Practical Nurse (LPN) | Confirmed Dakin solution was left in resident's room and should not be stored bedside. |
| BB | Licensed Practical Nurse (LPN)/Unit Manager | Verified oxygen concentrator filter was covered with white-gray fuzzy substance. |
| AA | Licensed Practical Nurse (LPN) | Verified missing signatures on narcotic count sheets. |
| Director of Nursing | Director of Nursing (DON) | Verified missing signatures on Controlled Drug Shift Audit sheets and noted possible staffing issues. |
| DD | Cook | Observed preparing food without hairnet and beard restraint; confirmed in-service on labeling and storage but admitted lapses. |
| KD | Kitchen Director | Confirmed responsibility for checking expiration dates and discarding expired food items. |
| DM | District Manager | Confirmed cleaning and inventory conducted twice weekly and responsibility of Kitchen Director. |
Inspection Report
Abbreviated SurveyInspection Report
RoutineInspection Report
Annual InspectionInspection Report
Abbreviated SurveyInspection Report
Plan of CorrectionInspection Report
Plan of CorrectionInspection Report
Complaint Investigation| Name | Title | Context |
|---|---|---|
| LPN #2 | Licensed Practical Nurse | Reported the abuse allegation to the Director of Social Work after delay due to busy holiday shift. |
| LPN #4 | Unit Manager | Received abuse allegation report from LPN #2 and reported to the Director of Nursing. |
| Director of Nursing | DON | Interviewed resident and family, reported abuse to State Agency and police, and expected immediate reporting of abuse allegations. |
| Administrator | Facility Administrator | Emphasized importance of resident care and timely reporting of incidents. |
Inspection Report
Complaint Investigation| Name | Title | Context |
|---|---|---|
| CNA#1 | Certified Nursing Assistant | Alleged perpetrator of physical abuse against resident R#1 |
| LPN#2 | Licensed Practical Nurse | Received abuse report from R#1 and attempted to report to Director of Social Work |
| LPN#4 | Unit Manager | Reported the abuse allegation to the Director of Nursing |
| DON | Director of Nursing | Interviewed resident R#1, reported abuse to State Agency and police, and oversaw investigation |
| Administrator | Facility Administrator | Oversaw facility compliance and reporting expectations |
| Director of Social Work | Abuse Coordinator | Responsible for abuse reporting and training department heads on reporting requirements |
Inspection Report
Complaint Investigation| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant (CNA#1) | Alleged perpetrator of physical abuse against Resident #1; agency CNA placed on 'do not return' list | |
| Licensed Practical Nurse (LPN#2) | Received abuse allegation report from Resident #1 and attempted to report to Director of Social Work | |
| Unit Manager (LPN#4) | Informed about abuse allegation and reported to Director of Nursing | |
| Director of Nursing (DON) | Interviewed Resident #1, family, and staff; reported abuse to State Agency and police | |
| Abuse Coordinator (Director of Social Work) | Responsible for reporting abuse allegations to State Agency within required timeframe | |
| Administrator | Oversight of facility compliance and reporting expectations |
Inspection Report
Plan of CorrectionInspection Report
Re-InspectionInspection Report
Follow-UpInspection Report
Abbreviated Survey| Name | Title | Context |
|---|---|---|
| R#270 | Resident | Resident involved in sexual abuse incidents |
| R#23 | Resident | Resident victim of sexual abuse by R#270 |
| R#58 | Resident | Resident exposed to sexual abuse by R#270 |
| Police Detective WWW | Investigated sexual abuse allegations involving R#270 | |
| Administrator | Facility Administrator involved in sexual abuse investigation and COVID-19 outbreak management | |
| Director of Nursing | Involved in sexual abuse investigation and COVID-19 outbreak management | |
| Social Worker VVV | Provided insight on sexual abuse assessment and trauma | |
| Director of Clinical Services | Involved in sexual abuse investigation and COVID-19 outbreak management | |
| LPN AAA | Licensed Practical Nurse | Provided care and documentation related to falls and splint use |
| CNA RR | Certified Nursing Assistant | Documented splint application incorrectly |
| CNA BBB | Certified Nursing Assistant | Documented splint application incorrectly |
| CNA CCC | Certified Nursing Assistant | Documented splint application incorrectly |
| LPN QQ | Licensed Practical Nurse | Unaware of splint use for resident R#20 |
| MDS Coordinator RN DDD | Registered Nurse | Responsible for MDS assessment and documentation |
Inspection Report
Renewal| Name | Title | Context |
|---|---|---|
| CNA RR | Certified Nurse Assistant | Interviewed regarding screening and PPE use; noted not fit-tested for N95 mask. |
| CNA MM | Certified Nurse Assistant | Interviewed about screening, PPE use, and outbreak protocols; noted wearing mask for which he was fit-tested. |
| CNA VV | Certified Nurse Assistant | Interviewed about screening and PPE use; acknowledged not wearing mask for which she was fit-tested. |
| Activity Assistant CC | Observed entering facility without mask or screening; acknowledged failure to self-screen. | |
| RN WW | Registered Nurse | Interviewed about screening and PPE requirements for COVID hall staff. |
| CNA XX | Certified Nurse Assistant | Interviewed about screening and mask use; stated not all staff were screened. |
| RN BB | Director of Nursing | Observed not wearing eye protection at nursing station. |
| LPN QQ | Licensed Practical Nurse | Interviewed about PPE encouragement; acknowledged not wearing eye protection. |
Inspection Report
Abbreviated Survey| Name | Title | Context |
|---|---|---|
| R#270 | Resident | Resident involved in sexual abuse incidents. |
| CNA SSS | Certified Nursing Assistant | Witnessed sexual abuse and exposure by R#270. |
| Police Detective WWW | Investigated sexual abuse allegations involving R#270. | |
| Administrator | Informed of immediate jeopardy and involved in abuse and COVID-19 outbreak response. | |
| Director of Nursing (DON) | Involved in abuse investigation and COVID-19 outbreak response. | |
| Director of Clinical Services (DCS) | Involved in abuse investigation and COVID-19 outbreak response. | |
| ICP DD | Infection Control Preventionist | Responsible for COVID-19 testing and infection control program. |
Inspection Report
Complaint Investigation| Name | Title | Context |
|---|---|---|
| CNA SSS | Certified Nursing Assistant | Observed resident R#270 exposing himself to resident R#58 |
| Police Detective WWW | Investigated sexual abuse allegations involving resident R#270 | |
| Director of Nursing (DON) | Director of Nursing | Provided statements regarding handling of sexual abuse and infection control |
| Administrator | Facility Administrator | Provided statements regarding sexual abuse investigation and COVID-19 outbreak |
| Social Worker VVV | Social Worker | Provided statements regarding assessment of sexual abuse victims |
| ICP DD | Infection Control Preventionist | Provided statements regarding COVID-19 testing and outbreak management |
Inspection Report
Renewal| Name | Title | Context |
|---|---|---|
| CNA RR | Certified Nurse Assistant | Interviewed regarding screening process and PPE use; noted not fit-tested for N95 mask. |
| CNA MM | Certified Nurse Assistant | Interviewed about screening, PPE use, and outbreak protocols; noted wearing fit-tested mask but no eye protection. |
| CNA VV | Certified Nurse Assistant | Interviewed about screening and PPE; admitted not wearing fit-tested mask or eye protection. |
| Activity Assistant CC | Activity Assistant | Observed entering facility without screening or mask; acknowledged failure to self-screen. |
| RN WW | Registered Nurse | Stated staff dedicated to COVID hall required to wear N95 mask and goggles. |
| RN BB | Director of Nursing | Observed not wearing eye protection at nursing station. |
| LPN KK | Licensed Practical Nurse | Observed serving lunch without eye protection. |
| CNA LL | Certified Nurse Assistant | Observed serving lunch without eye protection. |
| CNA MM | Certified Nurse Assistant | Observed serving lunch without eye protection. |
| Dietitian JJ | Dietitian | Observed working in dining room without eye protection. |
| Director of Dining Services II | Director of Dining Services | Observed working in dining room without eye protection. |
| Physical Therapy Assistant GGG | Physical Therapy Assistant | Observed wearing N95 mask improperly and no eye protection. |
| Certified Occupational Therapy Assistant TT | Certified Occupational Therapy Assistant | Observed with mask under chin. |
| Certified Occupational Therapy Assistant HHH | Certified Occupational Therapy Assistant | Observed wearing mask inappropriately and no eye protection. |
| Volunteer D | Volunteer | Observed not wearing eye protection while giving communion. |
Inspection Report
Life Safety| Name | Title | Context |
|---|---|---|
| Maintenance manager | Interviewed regarding lack of documentation of daily inspections | |
| Staff M | Confirmed findings during facility tour |
Inspection Report
Abbreviated SurveyInspection Report
Abbreviated SurveyInspection Report
RoutineInspection Report
RoutineInspection Report
Abbreviated SurveyInspection Report
RoutineInspection Report
Abbreviated SurveyInspection Report
Re-InspectionInspection Report
Follow-UpInspection Report
Life Safety| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed findings during facility tour and observations. |
Inspection Report
Complaint InvestigationInspection Report
Complaint InvestigationInspection Report
Follow-UpInspection Report
Follow-Up| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed findings during the follow-up POC tour. |
Inspection Report
Complaint InvestigationInspection Report
Annual InspectionInspection Report
Life Safety| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed findings during facility tour |
Inspection Report
Complaint InvestigationInspection Report
Follow-UpInspection Report
RoutineInspection Report
Life Safety| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed findings during facility tour and staff interviews |
Inspection Report
Abbreviated SurveyInspection Report
Abbreviated SurveyInspection Report
Abbreviated SurveyLoading inspection reports...



