Deficiencies per Year
24
18
12
6
0
Severe
High
Moderate
Low
Unclassified
Inspection Report
Complaint Investigation
Capacity: 80
Deficiencies: 23
Jun 27, 2025
Visit Reason
State-compiled facility profile showing 10 inspections from 2021 to 2025 with deficiency history and enforcement actions
Findings
Across multiple inspections from 2021 to 2025, the facility exhibited deficiencies in areas including medication management, infection prevention, care planning, pain management, staffing, and resident safety. Several deficiencies were corrected while others remained uncorrected, indicating ongoing challenges in compliance and quality of care.
Complaint Details
Multiple inspections include complaint investigations related to licensure complaints and abuse allegations, with findings of verbal abuse, neglect, medication mismanagement, and failure to follow care plans.
Deficiencies (23)
| Description |
|---|
| F0000 - INITIAL COMMENTS |
| F0580 - Notify of Changes (Injury/Decline/Room, etc.): Failed to notify physician of resident discharge to hospital for 1 of 1 sampled resident (#39) |
| F0584 - Safe/Clean/Comfortable/Homelike Environment: Failed to protect resident property from loss or theft for 1 of 2 sampled residents (#38) |
| F0628 - Discharge Process: Failed to ensure appropriate information was communicated to receiving health care institution prior to resident transfer for 1 of 1 sampled resident (#39) |
| F0636 - Comprehensive Assessments & Timing: Failed to complete timely MDS assessments for 4 of 8 sampled residents (#s 20, 21, 32, 33) |
| F0637 - Comprehensive Assessment After Significant Change: Failed to complete Significant Change MDS assessment within required 14 days for 1 of 1 sampled resident (#39) |
| F0655 - Baseline Care Plan: Failed to complete baseline care plan within 48 hours of admission for 1 of 1 sampled resident (#32) |
| F0684 - Quality of Care: Failed to follow physician orders for weights and medications for sampled residents (#33, #38, #14) |
| F0684 - Quality of Care: Failed to follow physician orders and care plan for medications and ADLs for 3 of 8 sampled residents (#s 2, 28, 33) |
| F0686 - Treatment/Services to Prevent/Heal Pressure Ulcer: Failed to prevent pressure ulcer development and provide accurate wound care for 1 of 1 sampled resident (#35) |
| F0730 - Nurse Aide Performance Review: Failed to complete annual performance reviews for 5 of 5 sampled CNA staff (#s 17, 18, 19, 20, 21) |
| F0755 - Pharmacy Services/Procedures/Pharmacist/Records: Failed to ensure narcotic records were reconciled for 3 of 3 halls |
| F0760 - Residents are Free of Significant Medication Errors: Failed to prevent significant medication errors for 7 of 17 residents (#s 12, 15, 16, 19, 22, 29, 30) |
| F0761 - Label/Store Drugs and Biologicals: Failed to store narcotic pain medications safely |
| F0801 - Qualified Dietary Staff: Dietary manager certification expired |
| F0804 - Nutritive Value/Appear, Palatable/Prefer Temp: Failed to provide palatable food for 1 kitchen and 2 of 4 residents (#4, 33) |
| F0880 - Infection Prevention & Control: Failed to follow infection control standards for 1 hall and 1 resident (#28) |
| F0884 - Reporting - National Health Safety Network: Failed to report complete COVID-19 information to CDC NHSN during required period |
| F0600 - Free from Abuse and Neglect: Failed to ensure residents free from abuse for 3 of 5 sampled residents (#s 9, 20, 2) |
| F0657 - Care Plan Timing and Revision: Failed to revise care plan for 1 of 1 sampled resident (#15) for dental concerns |
| F0658 - Services Provided Meet Professional Standards: Failed to ensure professional standards for medication administration and nursing care for sampled residents |
| F0689 - Free of Accident Hazards/Supervision/Devices: Failed to provide supervision for swallowing safety for 1 of 2 residents (#3), resulting in immediate jeopardy |
| F0602 - Free from Misappropriation/Exploitation: Failed to ensure resident pain medication was not misappropriated for 1 of 3 sampled residents (#3) |
Report Facts
Inspections on page: 10
Total deficiencies: 36
Total surveys: 10
Licensing violations: 20
Abuse violations: 0
Notices: 0
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff 1 | Administrator | Named in multiple findings including medication errors, infection control, and abuse investigations |
| Staff 2 | Director of Nursing (DNS) | Named in multiple findings including medication management, abuse investigations, and infection control |
| Staff 3 | LPN Care Manager / RNCM | Named in wound care and abuse investigation findings |
| Staff 5 | MDS Coordinator / Social Services Director | Named in MDS assessment and care plan deficiencies |
| Staff 12 | Agency LPN | Named in infection control and medication administration findings |
| Staff 14 | LPN / Housekeeper | Named in infection control and abuse findings |
| Staff 20 | LPN / CNA | Named in medication administration and abuse findings |
| Staff 26 | RN / Infection Preventionist | Named in infection prevention findings |
| Staff 27 | LPN / CNA | Named in abuse and grievance findings |
| Staff 29 | CNA | Named in infection control and abuse findings |
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