5 Reports
Inspection Report — Jun 3, 2026
Routine
Date: Jun 3, 2026
Visit Reason
A health care licensure and follow-up survey was conducted to assess compliance with regulations and identify deficient practices.
Findings
The facility failed to assess residents' maladaptive behaviors before prescribing psychotropic medications and did not develop behavior plans with specific interventions. Residents' Negotiated Service Agreements were outdated and incomplete, nursing assessments were not completed prior to admission, non-drug interventions were not attempted before medication, and the Certified Food Protection Manager's certificate had expired.
Deficiencies (6)
.330.06.a. Additional Resident Records: the facility did not ensure residents' maladaptive behaviors were assessed prior to prescribing psychotropic medications (previously cited 12/13/2023).
.330.06.b. Additional Resident Records: the facility did not develop behavior plans with specific interventions for residents' maladaptive behaviors (previously cited 12/13/2023).
.320.01. Use of NSA: residents' Negotiated Service Agreements did not clearly reflect their needs or describe services to be provided, including missing updates for home health and hospice services.
.319.03. Nursing Assessment: nursing assessments were not completed prior to admission for several residents as required.
.310.04.a. Behavior Modifying Medication: the facility did not attempt non-drug interventions prior to requesting medications to address maladaptive behaviors.
.450. REQUIREMENTS FOR FOOD AND NUTRITIONAL CARE SERVICES: the Certified Food Protection Manager's certificate had expired and was in the process of renewal.
Report Facts
date: Dec 13, 2023
date: Dec 13, 2023
date: Jan 29, 2026
date: May 16, 2026
date: Apr 3, 2025
date: May 24, 2024
Inspection Report — Nov 4, 2024
Life Safety
Date: Nov 4, 2024
Visit Reason
A fire life safety and sanitation licensure survey was conducted to assess compliance with fire safety and electrical equipment regulations.
Findings
Six deficiencies were identified related to fire and life safety records, fire suppression system maintenance, and prohibited electrical equipment use.
Deficiencies (4)
.330.15.a.ii. Fire and Life Safety Records: facility could not provide documentation of testing sensitivity of smoke detectors within the last five years.
.403. Fire and life safety standards for existing buildings: facility failed to maintain visual inspection of fire suppression wet pressure gauges monthly, semi-annual testing of vane-type fire suppression systems, maintenance of components and valves including gauge calibration and internal valve inspections, and the Post Indicator Valve (PIV) was damaged and its status could not be determined.
.405.01.a. Electrical Installations and Equipment: a multi-plug adapter was in use in room #15 supplying power to an oxygen concentrator, which is prohibited.
.405.02.a. Prohibited Applications: a relocatable power tab (RPT) was in use in room #12 supplying power to an oxygen concentrator, which is prohibited.
Inspection Report — Dec 13, 2023
Routine
Date: Dec 13, 2023
Visit Reason
A health care licensure and follow-up survey was conducted to assess compliance with regulatory requirements.
Findings
Ten deficiencies were identified related to incomplete background checks, inadequate abuse/neglect policies, failure to conduct timely investigations and notifications, plumbing issues, missing psychotropic medication reviews, outdated negotiated service agreements, and insufficient resident care and behavior documentation.
Deficiencies (10)
.009.01 Criminal history and background check: the facility did not complete background checks for all employees with direct resident access; one of four staff reviewed lacked a fingerprint and FBI check.
.215.01 Administrator responsibility: the abuse/neglect/exploitation policy lacked required elements including education, reporting procedures, documentation storage, and interventions to prevent further abuse (previous technical assistance provided 6/30/22).
.215.08.b Investigation within thirty days: the administrator did not conduct investigations within 30 days for multiple incidents involving Resident #3 grabbing or attempting to kiss other residents; cameras were reviewed but investigations incomplete.
.215.08.f Notification to licensing agency within one business day: the facility failed to notify Licensing and Certification within one business day of two residents' falls causing injuries requiring medical treatment; the administrator was unaware of reporting requirements.
.250.09 Plumbing: hot water temperatures were not consistently maintained between 105 and 120 degrees F, with readings of 128 degrees F in rooms #1 and #3; administrator was unaware and planned to adjust (previous technical assistance provided 6/30/22).
.310.04.e Psychotropic or behavior modifying medication: six-month psychotropic medication reviews were not completed for two residents taking such medications; no reviews since May 2022.
.320 Negotiated service agreement (NSA) requirements: four residents' NSAs were not updated to reflect current needs, missing instructions for equipment use, catheter care, behavior documentation, and other pertinent information (previous technical assistance provided 6/30/22).
.330.04.c.vi Resident care records: staff did not notify the nurse of multiple symptoms and conditions experienced by residents including vomiting, diarrhea, headaches, pain, dizziness, and eye injections.
.330.06.a Behavior documentation: the facility did not assess residents' maladaptive behaviors, including seven unsolicited sexual advances by Resident #3 between September and December 2023.
.330.06.b Behavior documentation: the facility did not develop a behavior plan with specific interventions for Resident #3's behaviors as required.
Report Facts
date: Sep 14, 2023
date: Oct 12, 2023
date: Dec 4, 2023
date: Sep 18, 2023
date: Sep 19, 2023
temperature_fahrenheit: 128
date: May 1, 2023
count: 7
Inspection Report — Sep 22, 2022
Life Safety
Date: Sep 22, 2022
Visit Reason
A fire life safety and sanitation licensure survey was conducted to assess compliance with emergency actions, fire drills, and HVAC safety standards.
Findings
Two deficiencies were found related to emergency fire drills not being performed bimonthly and the natural gas fireplace lacking an adequate safety barrier.
Deficiencies (2)
.410 Requirements for emergency actions and fire drills: the facility failed to perform emergency egress and relocation drills bimonthly, with drills only documented in March, May, June 2022, and September and December 2021.
.250.10.b Heating, ventilation, and air-conditioning (HVAC): the natural gas fireplace screen did not prevent the glass from being touched and there was no other safety barrier present.
Inspection Report — Jun 30, 2022
Original Licensing
Date: Jun 30, 2022
Visit Reason
Initial licensure survey conducted to assess compliance with health care regulations.
Findings
Four deficiencies were found related to incomplete criminal history and background checks for staff, and nursing assessment and delegation failures by the facility nurse.
Deficiencies (4)
.009.05 New criminal history and background check: two of four staff members did not have a current criminal history and background check completed after the facility's change of ownership.
.009.06.a Use of previous criminal history and background check: two of four staff members did not have the required State Police background check completed after the facility's change of ownership.
.300.01 Licensed Registered Nurse (RN): the facility nurse did not complete comprehensive nursing assessments for two residents and did not delegate medication technicians prior to assisting residents with medications; the nurse was not available for interview.
.300.02 Licensed Nurse: the facility nurse did not complete change of condition assessments when residents had pressure injuries or surgical site infections; the nurse was not available for interview.
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