4 Reports
Inspection Report — Apr 30, 2026
Complaint Investigation
Date: Apr 30, 2026
Visit Reason
A complaint investigation was conducted regarding medication administration and resident care practices.
Complaint Details
The complaint investigation focused on medication administration errors and resident care deficiencies; these issues were substantiated.
Findings
The facility failed to administer medications as ordered, maintain proper medication destruction logs, update negotiated service agreements to reflect residents' current needs, keep current provider orders, and schedule sufficient staff to meet residents' needs. Several issues were previously cited on 7/2/25.
Deficiencies (5)
.305.02.b. Quarterly Nursing Assessments: residents did not receive medications as ordered, including incorrect dosages and schedules for escitalopram and Miralax (previously cited 7/2/2025).
.310.02. Discontinued and Expired Prescriptions: medication destruction logs lacked required components such as reason, method, and two witnesses, especially in the memory care unit from October 2025 to February 2026.
.320.08. Periodic Review: negotiated service agreements for residents #1, #4, and #7 were not updated to reflect significant changes in health status and care needs.
.330.04.c.ii. Resident Care Records: the facility did not maintain current written and signed provider orders; discrepancies existed between orders and medication administration records for Resident #1.
.600.04.a. Sufficient Personnel: the facility did not schedule enough staff to meet residents' needs, resulting in inadequate supervision and care, including failure to implement two-hour safety checks for Resident #7 after a fall (previously cited 7/2/2025).
Report Facts
date: Apr 2, 2026
date: Apr 13, 2026
date_range: 2025-10 to 2026-02
date: Feb 7, 2026
date: 2026-04-28 to 2026-04-29
date: Dec 1, 2025
date: Dec 11, 2025
Inspection Report — Jul 2, 2025
Complaint Investigation
Date: Jul 2, 2025
Visit Reason
A health care complaint investigation survey was conducted due to concerns about resident care and facility practices.
Complaint Details
The complaint investigation focused on concerns about resident care, including activity engagement, medication administration, health assessments, infection control, meal provision, staffing levels, resident rights, and administrative oversight. The complaint was substantiated with multiple deficiencies found.
Findings
Multiple deficiencies were found related to activity engagement, medication orders, resident health assessments, infection control, menu posting, meal frequency, disposable items, staffing, resident rights, and administrator qualifications.
Deficiencies (10)
.151. Activity requirements: residents in the memory care unit were not consistently engaged in scheduled activities, with many left sitting without encouragement to participate; the administrator acknowledged the lack of activities needed to be addressed.
.305.02.b. Current medication orders and treatment orders: the facility did not ensure residents received diets as ordered; Resident #4 was observed drinking thin liquids instead of prescribed thickened liquids, risking aspiration.
.305.03. Resident health status: the facility nurse did not assess residents after changes in mental or health status, including injuries from altercations and falls; the previous nurse was behind on assessments.
.335.02. Standard precautions: staff were observed not changing gloves between handling food items and not practicing hand hygiene between medication passes; additional infection control training was needed.
.451.01.c. Menu: the facility's menu was not posted for residents in the memory care unit and the assisted living menu was outdated; the administrator was unaware if current menus were posted.
.460.02.d. Frequency of meals: residents were not consistently offered snacks and fluids between meals; for example, Resident #1 drank salsa from a cup due to lack of fluids and snacks were not offered to residents in rooms or not in common areas (previously cited 4/19/24).
.460.04. Disposable items: single-use cups were used in the memory care dining room due to lack of clean cups available.
.600.04.a. Sufficient personnel: the facility did not provide care as required in residents' negotiated service agreements; Resident #3 did not receive toileting and showers as required, Resident #2 was observed in soiled clothing, and the facility had been short staffed for months.
39-3316 Resident Rights (1) a. Resident records: the facility did not provide immediate access to resident records or copies within two business days; Resident #3's POA experienced delays due to administrator turnover.
39-3321.4. Qualifications and requirements of administrator: the former administrator failed to implement corrective actions after incidents of resident altercations causing injury; the current administrator stated the aggressive resident should have been discharged immediately after the first incident.
Report Facts
: 11
: 7
: Array
: 7/2/2025
Inspection Report — Apr 19, 2024
Routine
Date: Apr 19, 2024
Visit Reason
A health care licensure and follow-up survey with complaint investigation was conducted to assess compliance with state regulations and investigate reported deficiencies.
Complaint Details
Complaint investigation was conducted alongside routine licensure survey; deficiencies were substantiated in areas including investigations, notifications, and resident care.
Findings
The facility was found deficient in multiple areas including incomplete criminal background checks, inadequate investigation procedures, failure to notify Adult Protective Services of abuse allegations, insufficient corrective actions for resident falls, incomplete nursing assessments, medication management issues, incomplete resident care documentation, and inadequate behavior documentation and meal frequency in the memory care unit.
Deficiencies (19)
.009.01 Criminal History and Background Check: one of ten employees did not have a Department Criminal History and Background Check completed (previously cited 1/6/2023).
.009.06.c Use of Previous Criminal History and Background Check: one of five employees did not have the state police background check completed prior to working alone with residents (previously cited 1/6/2023).
.215.01 Administrator Responsibility: the administrator did not ensure all policies and procedures for investigations of incidents were completed, including interviews with all relevant staff and witnesses, and did not conduct investigations on multiple incidents involving residents.
.215.07 Notification to Adult Protection and Law Enforcement: the administrator failed to report all allegations of abuse, neglect, and exploitation to Adult Protective Services for incidents involving residents on multiple dates.
.215.08.e Corrective Action: the facility administrator did not consistently implement adequate corrective actions to prevent recurrence of residents' falls, including multiple falls by Resident #4, #10, and #17.
.215.08.g Identify and Monitor Patterns: the administrator did not have a process to monitor patterns of incidents and accidents to develop interventions to prevent recurrences, despite multiple falls by residents.
.300.01 Licensed Registered Nurse (RN): the facility RN did not complete all residents' initial and quarterly nursing assessments; many were completed by the LPN instead.
.310.01.c Medication Distribution System: medication refrigerator temperatures were not monitored and documented daily, with multiple missed recordings and temperatures below 38 degrees F in the memory care unit (previously cited 1/6/2023).
.310.04.e Psychotropic or Behavior Modifying Medication: residents taking psychotropic medications for longer than six months did not have required six-month medication reviews completed.
.319 Comprehensive Assessment Requirements: several residents were admitted without completed demographics, nursing, and maladaptive behavior assessments prior to admission.
.320.01 Use of NSA: residents' Negotiated Service Agreements did not clearly reflect needs, describe services provided, nor ensure care needs were completed; some NSAs lacked hospice or private duty companion service details (previously cited 1/6/2023).
.320.02 Key Elements of the NSA: NSAs for 8 of 10 sampled residents did not include all required components such as medication management, supervision, and night needs.
.320.03 Signature, Date, and Approval of Agreement: NSAs were not signed and dated by residents or their legal guardians for several residents; facility was behind on obtaining signatures.
.330.04 Resident Care Records: resident care records lacked documentation by caregivers of unusual events, medical issues, and calls to nurse and administrator; medication technicians documented on behalf of caregivers.
.330.04.c.vii Resident Care Records: assessments of residents' conditions were not consistently documented, including incidents of nosebleed and shortness of breath.
.330.06.a Behavior Documentation: the facility did not evaluate residents' maladaptive behaviors in a timely manner, including yelling, cussing, sexual tendencies, physical aggression, and refusals of care.
.330.06.b Behavior Documentation: the facility did not develop sufficient behavior plans with specific interventions for residents with maladaptive behaviors; staff lacked beneficial behavior plans.
.330.06.c Behavior Documentation: the facility did not document times, dates, interventions, and effectiveness of behaviors such as physical aggression and sexual inappropriateness; documentation by care staff was inconsistent.
.460.02.d Frequency of Meals: residents in the memory care unit were not consistently offered snacks and fluids during the day; requests for snacks were repeatedly denied outside of designated snack times.
Report Facts
date: Jan 6, 2023
date: Apr 18, 2024
date: Sep 8, 2023
date: Jan 11, 2023
date: Apr 13, 2024
count: 10
count: 9
count: 19
count: 23
count: 23
date: Mar 3, 2024
date: Mar 1, 2024
date: Mar 5, 2024
date: Mar 27, 2024
date: Jul 26, 2023
date: Feb 7, 2024
date: Dec 31, 2023
date: Apr 16, 2024
date: Mar 30, 2024
date: Nov 3, 2023
date: Mar 4, 2024
date: Apr 16, 2024
date: Apr 17, 2024
Inspection Report — Jan 6, 2023
Original Licensing
Date: Jan 6, 2023
Visit Reason
An initial licensure survey combined with a complaint investigation was conducted to assess compliance with health care regulations and investigate complaint allegations.
Complaint Details
The complaint investigation was combined with the initial licensure survey; specific complaint details were not stated in the report.
Findings
Multiple deficiencies were found including incomplete criminal background checks, medication administration issues, inadequate documentation, insufficient staff training, and staffing shortages affecting resident care and safety.
Deficiencies (11)
.009.01 Criminal History and Background Check: one of eight employees did not have a Department Criminal History and Background Check, and the administrator stated the background checks were not completed.
.009.06.c Use of Previous Criminal History and Background Check: three of eight employees who required a state police background check did not have one completed; the administrator stated the employees had applied but had not received results.
.305.02.b Current Medication Orders and Treatment Orders: the facility nurse did not ensure all residents received medications, specialized diets, and treatments as ordered, including low-sodium diets not consistently provided or communicated, missed medications for Resident #3, and insufficient portable oxygen for Resident #6 during outings.
.310.01.c Medication Distribution System: medication refrigerator temperatures were not monitored or documented daily, with missing documentation for December 2022 and temperatures below 38 degrees F on several occasions in January 2023.
.320.01 Use of NSA: residents' Negotiated Service Agreements did not clearly reflect needs or services, and care needs were inconsistently met, including unclear toileting needs, missed housekeeping, lack of walker documentation, and unmet laundry services due to staffing shortages.
.330.04 Resident Care Records: documentation by caregivers was lacking for unusual events, medical issues, and assessments; wounds and condition changes were assessed but not consistently documented.
.330.13.e Personnel Records: eight of eight staff did not have documentation of completing 16 hours of orientation; the administrator stated orientation was provided but not documented.
.450 REQUIREMENTS FOR FOOD AND NUTRITIONAL CARE SERVICES: the facility did not have a Certified Food Protection Manager as the kitchen manager's certification had expired.
.600.04 Personnel Management: insufficient staffing was scheduled to meet resident needs, resulting in unmet laundry, housekeeping, and shower needs; overnight units were left unsupervised without certified staff, and some staff lacked current CPR/First aid certifications.
.625.03.k Content for Training: eight of eight employees did not receive infection control training; the administrator stated the training was not completed.
.630 TRAINING REQUIREMENTS FOR FACILITIES ADMITTING RESIDENTS WITH A DIAGNOSIS OF DEMENTIA, MENTAL ILLNESS, DEVELOPMENTAL DISABILITY, OR TRAUMATIC BRAIN INJURY: eight of eight staff did not have evidence of specialized training for caring for residents with mental illness and developmental disability; the administrator confirmed no such training was provided despite current residents with these conditions.
Report Facts
staff_count: 8
staff_count: 3
resident_count: 3
date: Jan 5, 2023
date_range: Array
hours: 16
staff_count: 3
staff_count: 8
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