Inspection Report Summary
The most recent inspection on August 27, 2025, found no deficiencies during a desk audit verifying compliance. Earlier inspections showed a pattern of some deficiencies primarily related to medical record documentation, resident safety, and infection control practices, with several issues corrected in follow-up reviews. Complaint investigations were mostly unsubstantiated, though a few substantiated cases involved verbal abuse and lapses in resident care, including one substantiated abuse incident in 2019 that led to staff termination. No fines, immediate jeopardy findings, or license actions were listed in the available reports. The facility’s record shows improvement over time, with recent inspections indicating compliance and resolution of prior deficiencies.
Deficiencies (last 6 years)
Deficiencies are regulatory violations found during state inspections.
Deficiencies per year
Census
Based on a October 2024 inspection.
Census over time
Inspection Report
Renewal| Name | Title | Context |
|---|---|---|
| Peter Showstead | Administrator | Personnel contacted during the inspection |
| Linda M. Gagnon | Surveyor | Surveyor conducting the inspection |
Inspection Report
Follow-Up| Name | Title | Context |
|---|---|---|
| Peter Showstead | Administrator | Notified by telephone on 10/17/24 at 10:30 AM that all violations were corrected |
Inspection Report
Plan of Correction| Name | Title | Context |
|---|---|---|
| Maureen Golas-Markure | Supervising Nurse Consultant | Signed letter as Supervising Nurse Consultant from Facility Licensing and Investigations Section. |
| Peter Showstead | Administrator | Named as facility administrator in relation to the plan of correction. |
| Social Worker #1 | Interviewed regarding failure to document follow-up visit notes after abuse allegation. | |
| DNS | Director of Nursing Services interviewed regarding social worker documentation. |
Inspection Report
Renewal| Name | Title | Context |
|---|---|---|
| Peter Shon Hwang | Administrator | Personnel contacted during inspection on 7/30/24 at 1:30 PM |
Inspection Report
Plan of Correction| Name | Title | Context |
|---|---|---|
| Lynn Lyon | DNA | Personnel contacted during inspection on 2024-04-12 |
| Allison Benson | FLIS staff who signed the report and submitted it |
Inspection Report
Complaint Investigation| Name | Title | Context |
|---|---|---|
| Lynn Lyon | Director of Nursing | Personnel contacted during the inspection. |
| Peter Showstead | Administrator | Personnel contacted during the inspection. |
Inspection Report
Complaint Investigation| Name | Title | Context |
|---|---|---|
| Lynn Lyon | Director of Nursing | Personnel contacted during the inspection |
| Peter Showstead | Administrator | Personnel contacted during the inspection |
Inspection Report
Follow-Up| Name | Title | Context |
|---|---|---|
| Peter Showstead | Administrator | Personnel contacted on 04/27/2022 at 3:30pm during the inspection. |
| James Tan | RN, Nurse Consultant | Signature of DHSR Staff and report submitter. |
Inspection Report
Renewal| Name | Title | Context |
|---|---|---|
| Peter Shownstead | ADM | Personnel contacted during inspection |
Inspection Report
Renewal| Name | Title | Context |
|---|---|---|
| Norma Schuberth | Supervising Nurse Consultant | Signed letter regarding notice of noncompliance and plan of correction instructions |
Inspection Report
Complaint Investigation| Name | Title | Context |
|---|---|---|
| Peter Showstead | Administrator | Personnel contacted during inspection |
| Lynn Lyon | Director of Nursing Services (DNS) | Personnel contacted during inspection |
Inspection Report
Plan of Correction| Name | Title | Context |
|---|---|---|
| Connie Greene | Supervising Nurse Consultant | Signed the notice letter and involved in the complaint investigation. |
| Peter Showstead | Administrator | Named as recipient of the notice and plan of correction. |
Inspection Report
Complaint Investigation| Name | Title | Context |
|---|---|---|
| NA #1 | Nurse Aide | Assigned nurse aide for Resident #1 who provided care and reported no additional bed rail padding required |
| NA #2 | Nurse Aide | Reported blood on Resident #1's pillow and notified nursing staff |
| LPN #1 | Licensed Practical Nurse | Administered Tylenol for Resident #1's restlessness and reported no other incidents |
| LPN #2 | Licensed Practical Nurse | Assigned nurse for 11-7 A.M. shift on 9/11/20, reported blood on Resident #1's head and pillow |
| Director of Nursing | Director of Nursing | Conducted interviews, assessed Resident #1, and identified care plan deficiencies |
| Director of Rehabilitation | Director of Rehabilitation | Evaluated Resident #1 post-incident and noted lack of documentation for side rail padding |
Inspection Report
Abbreviated SurveyInspection Report
Plan of Correction| Name | Title | Context |
|---|---|---|
| Norma Schuberth | Supervising Nurse Consultant | Author of the plan of correction notice |
Inspection Report
Plan of Correction| Name | Title | Context |
|---|---|---|
| Norma Schuberth | Supervising Nurse Consultant | Signed letter as Supervising Nurse Consultant for Facility Licensing and Investigations Section |
Inspection Report
Plan of Correction| Name | Title | Context |
|---|---|---|
| Norma Schuberth | Supervising Nurse Consultant | Signed letter regarding the inspection and plan of correction instructions |
Inspection Report
Abbreviated SurveyInspection Report
Complaint InvestigationInspection Report
Plan of Correction| Name | Title | Context |
|---|---|---|
| Norma Schuberth | Supervising Nurse Consultant | Signed letter regarding violations and plan of correction instructions |
| Peter Showstead | Administrator | Named in relation to grievance investigation and plan of correction |
Inspection Report
Complaint Investigation| Name | Title | Context |
|---|---|---|
| Peter Showstead | Administrator | Personnel contacted during inspection. |
| Lynn Lyon | Director of Nursing Services | Interviewed regarding care procedures and staff education. |
| Alice Martinez | Supervising Nurse Consultant | Author of the notice letter regarding violations and plan of correction. |
Inspection Report
Plan of Correction| Name | Title | Context |
|---|---|---|
| Alice Martinez | Supervising Nurse Consultant | Signed the notice letter from Facility Licensing and Investigations Section |
| Peter Showstead | Administrator | Facility administrator addressed in the report |
Inspection Report
RoutineInspection Report
RoutineInspection Report
Abbreviated SurveyInspection Report
Renewal| Name | Title | Context |
|---|---|---|
| Peter Shurtleff | Personnel contacted during inspection | |
| Lynn Lyon | DMS | Personnel contacted during inspection |
| Laurie Knowles | ADNS | Personnel contacted during inspection |
Inspection Report
Renewal| Name | Title | Context |
|---|---|---|
| Peter Shustack | Personnel contacted during inspection | |
| Lynn Lyon | Personnel contacted during inspection | |
| Laura Knowles | ADNS | Personnel contacted during inspection |
Inspection Report
Plan of Correction| Name | Title | Context |
|---|---|---|
| Norma Schuberth | Supervising Nurse Consultant | Signed the letter and directed the plan of correction submission. |
| Peter Showstead | Administrator | Named as recipient of the letter and involved in incident discussions. |
| RN #1 | Witnessed verbal abuse incident, sent email to Administrator and DON, failed to immediately remove NA #2 from assignment. | |
| NA #2 | Staff member who verbally abused Resident #63 and was terminated. | |
| RN #4 | Completed admission for Resident #133 and was educated on timely ordering of medications. | |
| APRN #1 | Interviewed regarding medication administration for Resident #133. | |
| Pharmacy Director | Interviewed regarding pharmacy delivery schedules and medication orders. | |
| DNS | Director of Nursing Services, responsible for monitoring plan of correction. |
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