Inspection Report
Complaint Investigation
Census: 81
Capacity: 120
Deficiencies: 8
Jun 19, 2025
Visit Reason
State-compiled facility profile showing 7 inspections from 2023-10 to 2025-06 with complaint investigations and deficiency history.
Findings
Across multiple complaint investigations and recertification surveys, the facility had several inspections with no deficiencies cited, but some inspections identified deficiencies related to resident care, staff training, personnel records, and life safety code violations.
Complaint Details
Multiple complaint investigations were conducted on 2025-06-18 to 2025-06-19, 2025-05-14, 2025-02-04, 2024-10-09 to 2024-10-10, 2023-10-19 to 2023-10-20, and 2023-10-10 to 2023-10-13, with some resulting in deficiencies and others with none cited.
Deficiencies (8)
| Description |
|---|
| R9-10-414.B.3.b. — Failed to ensure that a resident received adequate supervision and care during perineal care to prevent accidents, including lack of 2-person assist for a resident with morbid obesity. |
| R9-10-403.C.1.a. — Failed to ensure that personnel received required in-service training to maintain continuing competence, including CNA and RN missing dementia and communication training. |
| R9-10-406.E.2. — Failed to provide evidence that two employees were free from infectious tuberculosis. |
| R9-10-406.F.3.c. — Failed to maintain documentation of fingerprint clearance cards for two employees, including one terminated RN. |
| §483.95(g) — Failed to ensure required in-service training for nurse aides, including dementia management and resident abuse prevention training. |
| Cooking Facilities — Failed to have a kitchen hood system and fire suppression system for a deep fat fryer in the kitchen, increasing fire risk. |
| Corridor - Doors — Failed to maintain rated fire doors, including damaged door and missing latching hardware, risking smoke and heat transfer. |
| HVAC — Failed to inspect and maintain facility smoke dampers or fusible links, with last documented inspection in January 2017. |
Report Facts
Inspections on page: 7
Total deficiencies: 8
Complaint inspections: 6
Census: 81
Total capacity: 120
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff #87 | Certified Nursing Assistant (CNA) | Named in resident care deficiency related to peri care and fall |
| Staff #106 | Director of Nursing (DON) | Named in multiple deficiencies related to staff training and oversight |
| Staff #33 | Registered Nurse (RN) | Named in deficiencies related to training and fingerprint clearance |
| Staff #119 | Licensed Practical Nurse (LPN) | Named in deficiency related to tuberculosis screening |
| Staff #83 | Licensed Practical Nurse (LPN) | Named in deficiency related to tuberculosis screening |
| Staff #64 | Registered Nurse (RN) | Interviewed regarding resident fall incident |
| Staff #12 | Director of Nursing (DON) | Interviewed regarding multiple deficiencies and staff training |
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