Inspection Report Summary
The most recent inspection on December 3, 2025 found the facility to be in substantial compliance with no deficiencies noted. Earlier inspections showed some deficiencies primarily related to medication administration, resident assessments, immunizations, catheter care, and documentation of advance directives. Complaint investigations during this period were consistently found to be unsubstantiated or resulted in findings of substantial compliance. There were no fines, immediate jeopardy findings, or enforcement actions listed in the available reports. The facility’s inspection history indicates improvement over time, with recent surveys showing compliance after addressing prior issues.
Deficiencies (last 6 years)
Deficiencies are regulatory violations found during state inspections.
Deficiencies per year
Census
Based on a October 2024 inspection.
Census over time
Inspection Report
Annual InspectionInspection Report
Annual InspectionInspection Report
Complaint InvestigationInspection Report
Plan of CorrectionInspection Report
Annual Inspection| Name | Title | Context |
|---|---|---|
| Staff B | Certified Nursing Assistant (CNA) | Explained alarm placement for Resident #16 |
| Staff D | Certified Nursing Assistant (CNA) | Explained alarms started after resident falls |
| Director of Nursing | Director of Nursing (DON) | Explained fall interventions and medication policies |
| MDS Coordinator | MDS Coordinator | Responsible for Care Plan and MDS updates |
| Staff E | Licensed Practical Nurse (LPN) | Administered crushed medications to Resident #31 |
| Assistant Director of Nursing | Assistant Director of Nursing (ADON) | Informed about immunization registry checks |
Inspection Report
Annual Inspection| Name | Title | Context |
|---|---|---|
| Staff B | Certified Nursing Assistant (CNA) | Explained alarm placement on Resident #16's chair |
| Staff D | Certified Nursing Assistant (CNA) | Explained alarms started after Resident #16's falls |
| Staff E | Licensed Practical Nurse (LPN) | Observed crushing of medications for Resident #31 |
| Director of Nursing | DON | Explained prior fall interventions and medication policies |
| Assistant Director of Nursing | ADON | Informed about immunization registry checks |
Inspection Report
Complaint InvestigationInspection Report
Complaint InvestigationInspection Report
Plan of CorrectionInspection Report
Routine| Name | Title | Context |
|---|---|---|
| Staff E | Certified Nurse Aide (CNA) | Reported on dignity cover for catheter drainage bag |
| Staff B | Licensed Practical Nurse (LPN) | Reported on catheter drainage bag changes and dignity covers |
| Director of Nursing (DON) | Director of Nursing | Reported expectations for catheter bag dignity covers and medication administration |
| Staff D | Certified Nurse Aide (CNA) | Explained staff procedures for advance directives and catheter care |
| Staff A | Certified Medication Aide (CMA) | Reported on medication administration timing |
| Staff F | Licensed Practical Nurse (LPN) | Explained medication administration timing |
| Staff C | Cook | Observed during meal tray service and food handling |
| Dietary Supervisor | Dietary Supervisor | Reported expectations for food coverage and hand hygiene |
Inspection Report
Annual Inspection| Name | Title | Context |
|---|---|---|
| Staff E | Certified Nurse Aide (CNA) | Revealed catheter drainage bag came with dignity cover attached and explained cover use. |
| Staff B | Licensed Practical Nurse (LPN) | Reported catheter drainage bags are changed weekly and dignity covers are attached but sometimes not replaced. |
| Staff F | Licensed Practical Nurse (LPN) | Explained administration of levothyroxine medication and timing expectations. |
| Staff A | Certified Medication Aide (CMA) | Reported not giving Resident #302 her medications yet and completed passing medications after 10 AM. |
| Staff D | Certified Nurse Aide (CNA) | Reported keeping Resident #46's catheter drainage bag in wire basket to keep off floor. |
| Staff C | Cook | Observed dropping menu tickets on floor and failure to complete hand hygiene. |
| Dietary Supervisor | Prepared room trays without covering drinks and side dishes; confirmed expectation for covering food and drinks during room tray delivery. | |
| Director of Nursing | Director of Nursing (DON) | Reported expectations for catheter bag coverage and medication administration timing; verified inaccuracies in code status documentation. |
Inspection Report
Annual InspectionInspection Report
Complaint InvestigationInspection Report
Plan of CorrectionInspection Report
Annual Inspection| Name | Title | Context |
|---|---|---|
| Director of Nursing | Interviewed on 6/16/22 regarding care plan expectations and medication administration |
Inspection Report
Complaint InvestigationInspection Report
Complaint Investigation| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Reported expectations for nursing staff to use gait belts and catheter care procedures |
| Staff A | Certified Nurses Aid (CNA) | Observed assisting Resident #30 during transfers |
| Staff B | Certified Nurses Aid (CNA) | Observed assisting Resident #30 and performing catheter care |
| Staff C | Certified Nurses Aid (CNA) | Reported catheter care procedures and hand hygiene practices |
Inspection Report
Abbreviated SurveyInspection Report
Abbreviated SurveyLoading inspection reports...



