Inspection Report Summary
The most recent inspection on December 12, 2024 found the facility to be in substantial compliance with no deficiencies cited. Earlier inspections showed a mixed record, with prior annual surveys noting deficiencies related to care plan timing and revision, resident assessments, and infection control. Complaint investigations were mostly unsubstantiated, except for a substantiated case in September 2022 involving inadequate wound care that resulted in a resident’s death. No fines, immediate jeopardy findings, or license actions were listed in the available reports. The facility’s inspection history suggests improvement over time, with recent surveys showing compliance following earlier issues.
Deficiencies (last 6 years)
Deficiencies are regulatory violations found during state inspections.
Deficiencies per year
Census
Based on a August 2024 inspection.
Census over time
Inspection Report
Complaint InvestigationInspection Report
Annual InspectionInspection Report
Annual InspectionInspection Report
Complaint InvestigationInspection Report
Complaint InvestigationInspection Report
Plan of CorrectionInspection Report
Annual Inspection| Name | Title | Context |
|---|---|---|
| Richard Curley | Administrator | Signed the initial comments on the statement of deficiencies |
| Director of Nursing (DON) | Stated plans for resident hearing aids and care plan expectations | |
| RAI Coordinator | Confirmed hearing aid placement and care plan documentation issues |
Inspection Report
Annual Inspection| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing (DON) | Reported expectations for Care Plan content and confirmed deficiencies |
| RAI Coordinator | Resident Assessment Instrument Coordinator | Confirmed hearing aid placement not documented and stated expectations for pain-related Care Plan documentation |
| Administrator | Administrator | Stated expectations for documentation of pain and related Care Plans |
Inspection Report
Plan of CorrectionInspection Report
Annual Inspection| Name | Title | Context |
|---|---|---|
| Staff A | Registered Nurse (RN) | Observed administering medication and performing hand hygiene incorrectly |
| Staff B | Registered Nurse (RN) | Observed performing blood glucose monitoring with improper glove use |
| Staff C | Registered Nurse (RN) | Reported use of isolation bin and failure to wear gown during PICC line care |
| Staff D | Certified Nurse Aide (CNA) | Interviewed regarding incident recall |
| Staff E | Certified Nurse Aide (CNA) | Interviewed regarding resident pills incident |
| Director of Nursing (DON) | Director of Nursing | Interviewed regarding policies and expectations for MDS accuracy and care plans |
| Staff F | Registered Nurse (RN) | Re-educated on assessment and reporting requirements and provided late medication error report |
| Staff nurse | Requires additional training on glucometer use and hand hygiene/gloving per corrective action plan |
Inspection Report
Annual Inspection| Name | Title | Context |
|---|---|---|
| Staff A | Registered Nurse (RN) | Named in gastric tube feeding observation and interview regarding tube placement |
| Staff C | Registered Nurse (RN) | Named in observation of failure to wear gown during PICC line care |
| Staff F | Registered Nurse (RN) | Documented behavior note regarding Resident #17 medication incident |
| Staff B | Registered Nurse (RN) | Observed performing blood glucose check and sanitizing meter without changing gloves |
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding expectations for care plan accuracy and infection control practices |
| Administrator | Facility Administrator | Interviewed regarding facility policies and procedures |
| MDS Coordinator | MDS Coordinator | Interviewed regarding MDS assessment accuracy |
Inspection Report
Re-InspectionInspection Report
Complaint Investigation| Name | Title | Context |
|---|---|---|
| Staff A | Registered Nurse (RN) | Named in wound assessment and documentation deficiencies |
| Staff B | Registered Nurse (RN) | Completed Re-Admission Skin Assessment and notified provider and family |
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding wound assessment and documentation |
| Medical Director | Medical Director (MD) | Interviewed regarding wound care expectations and resident condition |
| Physical Therapist | Physical Therapist (PT) | Confirmed open area on resident's left elbow |
| Orthopedic Surgeon | Orthopedic Surgeon | Provided medical opinion on wound and surgery |
| MDS Coordinator | MDS Coordinator | Confirmed wound assessment and documentation deficiencies |
Inspection Report
RenewalInspection Report
Abbreviated SurveyInspection Report
RoutineInspection Report
Abbreviated SurveyLoading inspection reports...



