Inspection Report
Complaint Investigation
Capacity: 230
Deficiencies: 16
Aug 29, 2025
Visit Reason
State-compiled facility profile showing 22 complaint inspections from 2022 to 2025 with deficiency history and compliance findings.
Findings
Across multiple complaint investigations from 2022 through 2025, the facility was cited for numerous deficiencies primarily related to failure to protect residents from abuse, inadequate medication administration, failure to complete timely assessments, and issues with facility safety and emergency preparedness. Several inspections found no deficiencies, but multiple complaint surveys identified serious concerns including resident-to-resident abuse and lapses in care.
Complaint Details
Multiple complaint investigations were conducted between 2023 and 2025, with many resulting in no deficiencies cited. Several complaint surveys identified failures to protect residents from abuse and other care deficiencies.
Deficiencies (16)
| Description |
|---|
| R9-10-403.C. An administrator shall ensure that: R9-10-403.C.2.d. Cover storing, dispensing, administering, and disposing of medication; - Failed to ensure physician orders were followed as written. |
| §483.12 Freedom from Abuse, Neglect, and Exploitation - Failed to ensure that residents were free from abuse by other residents. |
| §483.45 Pharmacy Services - Failed to ensure medications were administered as ordered by the physician for one resident (#10). |
| R9-10-410.B.3.a. Abuse - Failed to ensure residents were not subjected to abuse. |
| R9-10-425.A.1.b. Free from a condition or situation that may cause a resident or an individual to suffer physical injury - Failed to ensure residents did not elope from the facility. |
| §483.20(c) Quarterly Review Assessment - Failed to complete quarterly Minimum Data Set (MDS) assessment within required timeframe for one resident (#47). |
| §483.21(b)(3) Comprehensive Care Plans - Failed to ensure controlled medications were provided and accounted for in accordance with professional standards for 4 residents (#52, #358, #27). |
| §483.25(d) Accidents - Failed to ensure one resident (#124) was free from accident hazards related to medication self-administration. |
| §483.25(l) Dialysis - Failed to ensure one resident (#84) received safe monitoring of vital signs, including weights. |
| R9-10-414.A.4. - Failed to develop and complete quarterly MDS assessment within required timeframe for one resident (#47). |
| R9-10-414.B.3.b. - Failed to ensure controlled medications were provided and accounted for in accordance with professional standards for 4 residents (#52, #358, #27). |
| R9-10-417 - Failed to ensure dialysis services were provided in compliance with requirements for one resident (#84). |
| [(a) Emergency Plan] - Failed to maintain Emergency Preparedness Plan based on community risk assessments. |
| Egress Doors - Failed to maintain special locking exit doors to ensure correct force needed to release doors. |
| Corridor - Doors - Failed to maintain several doors to prevent transfer of heat or smoke. |
| HVAC - Failed to inspect and maintain fire/smoke dampers or fusible links as required. |
Report Facts
Inspections on page: 22
Total deficiencies: 26
Complaint inspections: 20
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