Inspection Report Summary
The most recent inspection on October 21, 2025, found the facility to be in substantial compliance with no deficiencies noted. Earlier inspections also showed no deficiencies, indicating consistent adherence to regulatory standards. There were no complaint investigations reported in the available records. Enforcement actions such as fines or license suspensions were not listed in the available reports. This pattern suggests the facility has maintained compliance over time.
Deficiencies (last 4 years)
Deficiencies are regulatory violations found during state inspections.
Deficiencies per year
Inspection Report
Abbreviated SurveyInspection Report
Annual Inspection| Name | Title | Context |
|---|---|---|
| MDS Coordinator | Confirmed lack of SCSA MDS completion for Resident (R) 4 | |
| Director of Nursing | Director of Nursing | Stated expectation for timely assessments and responding to medication irregularities |
| Administrator | Administrator | Aware of SCSA MDS requirement but unaware MDS Coordinator did not know the rule |
| Pharmacist 7 | Pharmacist | Reported no response to pharmacy recommendations for Resident (R) 6 |
| R6's primary physician | Physician | Stated possible miscommunication regarding response to pharmacy recommendation |
Inspection Report
Complaint Investigation| Name | Title | Context |
|---|---|---|
| CNA 1 | Certified Nursing Assistant | Witnessed R2 hit R1 on the cheek and intervened |
| Director of Nursing | Director of Nursing | Interviewed regarding incident response and care plan revision |
| Administrator | Administrator | Interviewed regarding incident and facility response |
| Assistant Director of Nursing | Assistant Director of Nursing | Interviewed regarding care plan revision responsibilities |
| MDS Coordinator | MDS Coordinator | Interviewed regarding care plan development and revision |
Inspection Report
Complaint Investigation| Name | Title | Context |
|---|---|---|
| Regional Business Office Manager | Regional Business Office Manager | Conducted investigation, provided education, and interviewed during survey |
| Administrator | Administrator | Interviewed regarding discovery and investigation of misappropriation |
| Detective #2 | Lead Investigating Officer | Interviewed regarding law enforcement investigation and expected indictment |
| Former Business Office Manager | Business Office Manager | Former employee who misappropriated resident funds |
| Director of Nursing | Director of Nursing | Provided staff education on abuse policy and misappropriation |
Inspection Report
Inspection Report
Routine| Name | Title | Context |
|---|---|---|
| RN #1 | Registered Nurse | Named in wound care deficiency for failing to cleanse wound and improper infection control |
| Assistant Director of Nursing | Infection Control Nurse | Interviewed regarding wound care policy and staff training |
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding expectations for wound care and staffing postings |
| Licensed Practical Nurse #1 | Licensed Practical Nurse (LPN) | Interviewed regarding staffing posting responsibilities and training |
| Facility Administrator | Administrator | Interviewed regarding staffing posting policies and issues |
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