Inspection Report
Complaint Investigation
Capacity: 91
Deficiencies: 40
Dec 3, 2025
Visit Reason
State-compiled facility profile showing 10 inspections from 2023-2025 with detailed deficiency history and enforcement actions.
Findings
Across multiple inspections from 2023 to 2025, the facility exhibited numerous deficiencies including failure to maintain adequate staffing, unresolved grievances, inadequate care plan revisions, failure to prevent abuse and neglect, infection control lapses, and issues with environmental safety and nutrition. Several deficiencies were corrected while others remained uncorrected at the time of inspections.
Complaint Details
Multiple complaint investigations are included in the inspections, with findings of abuse, neglect, grievance failures, and inadequate investigations of alleged violations.
Deficiencies (40)
| Description |
|---|
| F0000 - INITIAL COMMENTS |
| M0000 - Initial Comments |
| F0584 - Safe/Clean/Comfortable/Homelike Environment: Failed to maintain appropriate room and water temperatures and facility environment issues |
| F0609 - Reporting of Alleged Violations: Failed to report allegations of verbal abuse and staff misconduct |
| F0610 - Investigate/Prevent/Correct Alleged Violation: Failed to investigate allegations of verbal abuse |
| F0657 - Care Plan Timing and Revision: Failed to revise care plans to reflect current resident needs |
| F0677 - ADL Care Provided for Dependent Residents: Failed to provide oral/dental care as required |
| F0679 - Activities Meet Interest/Needs Each Resident: Failed to provide adequate activities and assessments |
| F0689 - Free of Accident Hazards/Supervision/Devices: Failed to maintain fall prevention measures and safe environment |
| F0692 - Nutrition/Hydration Status Maintenance: Failed to maintain nutritional status and timely interventions |
| F0697 - Pain Management: Failed to document and follow up on pain management requests |
| F0761 - Label/Store Drugs and Biologicals: Failed to properly store medications and biologicals |
| F0791 - Routine/Emergency Dental Srvcs in NFs: Delayed dental care and follow up for residents |
| F0880 - Infection Prevention & Control: Failed to follow infection control protocols including PPE use and hand hygiene |
| M0183 - Nursing Services: Minimum CNA Staffing: Failed to maintain minimum CNA staffing levels |
| F0550 - Resident Rights/Exercise of Rights: Failed to treat residents with dignity and respect |
| F0557 - Respect, Dignity/Right to have Prsnl Property: Failed to treat residents with respect and dignity |
| F0565 - Resident/Family Group and Response: Failed to address resident council grievances timely |
| F0585 - Grievances: Failed to resolve grievances and follow up |
| F0600 - Free from Abuse and Neglect: Failed to protect residents from abuse and neglect |
| F0637 - Comprehensive Assessment After Signifcant Chg: Failed to complete significant change assessments |
| F0684 - Quality of Care: Failed to provide adequate medication monitoring and wound care |
| F0692 - Nutrition/Hydration Status Maintenance: Failed to maintain nutritional status and monitor weight loss |
| F0698 - Dialysis: Failed to ensure communication with dialysis center |
| F0725 - Sufficient Nursing Staff: Failed to maintain adequate nursing staff to meet resident needs |
| F0732 - Posted Nurse Staffing Information: Failed to post accurate staffing information |
| F0755 - Pharmacy Srvcs/Procedures/Pharmacist/Records: Failed to ensure medication availability and administration |
| F0758 - Free from Unnec Psychotropic Meds/PRN Use: Failed to assess residents prior to psychotropic medication use |
| F0759 - Free of Medication Error Rts 5 Prcnt or More: Medication error rate exceeded 5% |
| F0803 - Menus Meet Resident Nds/Prep in Adv/Followed: Failed to follow menus and meet resident food preferences |
| F0810 - Assistive Devices - Eating Equipment/Utensils: Failed to provide assistive eating devices |
| F0812 - Food Procurement,Store/Prepare/Serve-Sanitary: Failed to maintain sanitary food handling and storage |
| F0842 - Resident Records - Identifiable Information: Failed to maintain accurate and complete resident records |
| F0881 - Antibiotic Stewardship Program: Failed to monitor antibiotic use appropriately |
| M0141 - Employees Reference Checks and Verifications: Failed to complete reference checks for new staff |
| M0143 - Employees: Criminal Record Checks: Failed to complete background checks for new staff |
| M0320 - Dietary Services: Diets and Menus: Failed to provide on-site Registered Dietician visits |
| F0680 - Qualifications of Activity Professional: Failed to provide qualified activities professional |
| F0655 - Baseline Care Plan: Failed to develop baseline care plan reflective of mobility needs |
| F0919 - Resident Call System: Failed to ensure functioning and audible call light system |
Report Facts
Inspections on page: 10
Total deficiencies: 59
Total surveys: 10
Licensing violations: 20
Notices: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff 1 | Administrator | Named in multiple findings related to complaint investigations, reporting failures, and staff education |
| Staff 2 | Director of Nursing Services (DNS) | Named in multiple findings related to complaint investigations, care plan revisions, and staff education |
| Staff 4 | Social Services Director | Named in findings related to grievance handling and dental care follow-up |
| Staff 15 | LPN-Resident Care Manager | Named in findings related to wound care, medication administration, and staffing |
| Staff 16 | Activity Director | Named in findings related to activities program qualifications and resident engagement |
| Staff 18 | LPN | Named in medication storage and infection control findings |
| Staff 19 | LPN Unit Manager / Infection Preventionist | Named in infection control and care plan findings |
| Staff 22 | Scheduling Coordinator | Named in staffing deficiency findings |
| Staff 26 | LPN | Named in abuse and grievance findings |
| Staff 27 | Resident Care Manager LPN | Named in multiple care plan and nutrition findings |
| Staff 31 | LPN / Dietary Aide | Named in infection control and food handling findings |
| Staff 32 | CNA / Kitchen Manager | Named in infection control and dietary findings |
| Staff 33 | Registered Dietitian | Named in dietary services findings |
| Staff 37 | HR and Payroll | Named in background check findings |
| Staff 45 | LPN | Named in medication administration findings |
Loading inspection reports...
