Inspection Report Summary
The most recent inspection on May 7, 2025, found no deficiencies related to the complaint investigated. Earlier inspections showed a pattern of deficiencies primarily involving infection control, supervision and fall prevention, emergency preparedness, and care plan implementation. Complaint investigations were mostly unsubstantiated, though some substantiated complaints involved inadequate supervision leading to resident elopement, failure to prevent falls, and incomplete care according to physician orders. Enforcement actions such as fines or license suspensions were not listed in the available reports. The facility’s record shows some improvement over time, with recent inspections citing fewer issues compared to earlier surveys.
Deficiencies (last 4 years)
Deficiencies are regulatory violations found during state inspections.
Deficiencies per year
Census
Based on a May 2025 inspection.
Census over time
Inspection Report
Complaint InvestigationInspection Report
Complaint InvestigationInspection Report
Complaint InvestigationInspection Report
Complaint Investigation| Name | Title | Context |
|---|---|---|
| Jennie Deyne | Executive Director | Signed the report |
| CNA 7 | Named in infection control deficiency related to hand hygiene and care practices | |
| RN 4 | Registered Nurse | Named in infection control deficiency related to hand hygiene and glove disposal |
| Director of Nursing | Director of Nursing | Provided facility policy on hand hygiene |
| Director of Health Services | Director of Health Services (DHS) | Responsible for staff education and audits related to infection control corrective actions |
Inspection Report
Complaint InvestigationInspection Report
Life SafetyInspection Report
Re-Inspection| Name | Title | Context |
|---|---|---|
| Jennie Deyne | Executive Director | Signed report and educated Director of Plant Operations on corrective actions |
| Director of Plant Operations | Interviewed regarding door deficiency and responsible for corrective actions |
Inspection Report
RenewalInspection Report
Life Safety| Name | Title | Context |
|---|---|---|
| Jennie Deyne | Executive Director | Named in relation to emergency preparedness and life safety findings and plan of correction |
| Director of Plant Operations | Involved in emergency preparedness, sprinkler system, fire drills, and electrical equipment findings and corrective actions | |
| Facility Maintenance Support | Involved in emergency preparedness and sprinkler system findings |
Inspection Report
Annual Inspection| Name | Title | Context |
|---|---|---|
| Jennie Deyne | Executive Director | Signed report and involved in corrective action plans |
| CNA 48 | Certified Nurse Aide | Observed providing incontinence care with infection control deficiencies |
| CNA 56 | Certified Nurse Aide | Observed providing incontinence care with infection control deficiencies |
| Cook 17 | Reported dishwasher rinse temperature issues | |
| Dietary Manager | Provided policies and interview regarding food safety and dishwasher maintenance | |
| Social Service Director | SSD | Responsible for care plan conference completion and education |
| Director of Nursing | DON | Provided interview on hand hygiene expectations |
| Maintenance Director | Responsible for fire drill coordination and maintenance issues |
Inspection Report
Complaint InvestigationInspection Report
Plan of CorrectionInspection Report
Complaint InvestigationInspection Report
Re-InspectionInspection Report
Complaint InvestigationInspection Report
Complaint Investigation| Name | Title | Context |
|---|---|---|
| Jessica West | Executive Director | Signed report as facility representative |
| LPN 7 | Licensed Practical Nurse | Provided CNA Assignment Form and interview regarding Resident B |
| QMA 3 | Qualified Medication Aide | Observed failing to assist Resident B with walker and gait belt |
| CNA 9 | Certified Nurse Aide | Interviewed regarding Resident B's assistance level |
| QMA 5 | Qualified Medication Aide | Interviewed about fall interventions for Resident B |
| CNA 11 | Certified Nurse Aide | Interviewed about Resident B's transfer assistance and fall interventions |
Inspection Report
Life Safety| Name | Title | Context |
|---|---|---|
| Jessica West | Executive Director | Named in exit conference and education related to deficiencies |
| Director of Plant Operations | Named in multiple findings including fire door issues, egress door issues, smoke detector placement, sprinkler system inspection, boiler inspection, GFCI receptacle, and fire drill documentation |
Inspection Report
Complaint Investigation| Name | Title | Context |
|---|---|---|
| Jessica West | Executive Director | Signed report and involved in administrative oversight |
| LPN 25 | Licensed Practical Nurse | Interviewed regarding Resident 199 dignity and discharge plans |
| LPN 23 | Licensed Practical Nurse | Interviewed regarding DNR orders and code status |
| QMA 15 | Qualified Medication Aide | Interviewed regarding DNR orders and respiratory equipment |
| RN 21 | Registered Nurse | Interviewed regarding QMA authorization for PRN medications |
| Administrator | Provided multiple interviews regarding policies, staffing, and deficiencies | |
| Regional Consultant | Provided interviews regarding policies and findings | |
| Infection Preventionist | Interviewed regarding hand hygiene and infection control practices | |
| CNA 3 | Certified Nurse Aide | Observed during care of Resident 15 and Resident G |
| CNA 6 | Certified Nurse Aide | Observed during care of Resident 15 and Resident G |
Inspection Report
Plan of CorrectionInspection Report
Complaint InvestigationInspection Report
Complaint InvestigationInspection Report
Complaint Investigation| Name | Title | Context |
|---|---|---|
| Registered Nurse (RN) 3 | Indicated dressings on Resident B's right forearm should have been changed on 9/6/22 but had not been changed since 9/3. |
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