Deficiencies per Year
12
9
6
3
0
Severe
High
Moderate
Low
Unclassified
Inspection Report
Complaint Investigation
Capacity: 312
Deficiencies: 9
Nov 24, 2025
Visit Reason
State-compiled facility profile showing multiple complaint investigations from 2022 to 2025 with deficiency history and inspection summaries.
Findings
Across multiple complaint investigations, the facility was found to have several deficiencies primarily related to resident abuse, safety hazards, and failure to maintain premises and equipment. Many inspections found no deficiencies, but some investigations cited abuse incidents and life safety code violations.
Complaint Details
Multiple complaint investigations were conducted from 2022 through 2025, with many inspections finding no deficiencies. Some complaint investigations cited deficiencies related to resident abuse, safety hazards, and care planning failures.
Deficiencies (9)
| Description |
|---|
| §483.12 Freedom from Abuse, Neglect, and Exploitation The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. §483.12(a) The facility must- §483.12(a)(1) Not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion; Based on review of clinical record, facility policy and procedure, and interviews, the facility failed to ensure one resident (#26) was not abused by another resident (#50). The deficient practice could lead to residents suffering from physical and psychosocial harm. |
| §483.25(d) Accidents. The facility must ensure that - §483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and §483.25(d)(2)Each resident receives adequate supervision and assistance devices to prevent accidents. Based on the clinical record, staff interviews, facility policy and facility records, the facility failed to ensure that 1 resident (#33) was safe. Failure to ensure the resident's safety could lead to resident harm. |
| R9-10-410.B. An administrator shall ensure that: R9-10-410.B.3. A resident is not subjected to: R9-10-410.B.3.a. Abuse; Based on review of clinical record, facility policy and procedure, and interviews, the facility failed to ensure one resident (#26) was not abused by another resident (#50). |
| R9-10-425.A. An administrator shall ensure that: R9-10-425.A.1. A nursing care institution's premises and equipment are: R9-10-425.A.1.b. Free from a condition or situation that may cause a resident or an individual to suffer physical injury; Based on the clinical record, staff interviews, facility policy and facility records, the facility failed to ensure that 1 resident (#33) was safe. |
| R9-10-410.B. An administrator shall ensure that: R9-10-410.B.3. A resident is not subjected to: R9-10-410.B.3.a. Abuse; Based on staff interviews, clinical record review, facility documents and facility policy, the facility failed to ensure that three residents (#33, #24, #11) were not abused. |
| R9-10-414.B. An administrator shall ensure that a care plan for a resident: R9-10-414.B.3. Ensures that a resident is provided nursing care institution services that: R9-10-414.B.3.b. Assist the resident in maintaining the resident's highest practicable well-being according to the resident's comprehensive assessment. Based on clinical record review, staff and resident interviews, facility records and facility policy the facility failed to ensure that one resident (#24) is free from preventable falls. |
| Egress Doors Doors in a required means of egress shall not be equipped with a latch or a lock that requires the use of a tool or key from the egress side unless using one of the following special locking arrangements: CLINICAL NEEDS OR SECURITY THREAT LOCKING Where special locking arrangements for the clinical security needs of the patient are used, only one locking device shall be permitted on each door and provisions shall be made for the rapid removal of occupants by: remote control of locks; keying of all locks or keys carried by staff at all times; or other such reliable means available to the staff at all times. 18.2.2.2.5.1, 18.2.2.2.6, 19.2.2.2.5.1, 19.2.2.2.6 SPECIAL NEEDS LOCKING ARRANGEMENTS Where special locking arrangements for the safety needs of the patient are used, all of the Clinical or Security Locking requirements are being met. In addition, the locks must be electrical locks that fail safely so as to release upon loss of power to the device; the building is protected by a supervised automatic sprinkler system and the locked space is protected by a complete smoke detection system (or is constantly monitored at an attended location within the locked space); and both the sprinkler and detection systems are arranged to unlock the doors upon activation. 18.2.2.2.5.2, 19.2.2.2.5.2, TIA 12-4 DELAYED-EGRESS LOCKING ARRANGEMENTS Approved, listed delayed-egress locking systems installed in accordance with 7.2.1.6.1 shall be permitted on door assemblies serving low and ordinary hazard contents in buildings protected throughout by an approved, supervised automatic fire detection system or an approved, supervised automatic sprinkler system. 18.2.2.2.4, 19.2.2.2.4 ACCESS-CONTROLLED EGRESS LOCKING ARRANGEMENTS Access-Controlled Egress Door assemblies installed in accordance with 7.2.1.6.2 shall be permitted. 18.2.2.2.4, 19.2.2.2.4 ELEVATOR LOBBY EXIT ACCESS LOCKING ARRANGEMENTS Elevator lobby exit access door locking in accordance with Based on observation the facility failed to maintain several special locking exit doors located in the facility. Failing to ensure the correct amount of force needed to release of the exit doors could cause harm to patients and/or staff in an emergency |
| Fire Alarm System - Initiation Initiation of the fire alarm system is by manual means and by any required sprinkler system alarm, detection device, or detection system. Manual alarm boxes are provided in the path of egress near each required exit. Manual alarm boxes in patient sleeping areas shall not be required at exits if manual alarm boxes are located at all nurse's stations or other continuously attended staff location, provided alarm boxes are visible, continuously accessible, and 200' travel distance is not exceeded. 18.3.4.2.1, 18.3.4.2.2, 19.3.4.2.1, 19.3.4.2.2, 9.6.2.5 Based on observation the facility failed to prevent the fire alarm pull station to be accessible and unobstructed. Obscuring the fire alarm pull stations from view may prevent or delay the initiating of the fire alarm system in an emergency and this has potential harm to the patients during a fire. |
| Corridor - Doors Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas resist the passage of smoke and are made of 1 3/4 inch solid-bonded core wood or other material capable of resisting fire for at least 20 minutes. Doors in fully sprinklered smoke compartments are only required to resist the passage of smoke. Corridor doors and doors to rooms containing flammable or combustible materials have positive latching hardware. Roller latches are prohibited by CMS regulation. These requirements do not apply to auxiliary spaces that do not contain flammable or combustible material. Clearance between bottom of door and floor covering is not exceeding 1 inch. Powered doors complying with 7.2.1.9 are permissible if provided with a device capable of keeping the door closed when a force of 5 lbf is applied. There is no impediment to the closing of the doors. Hold open devices that release when the door is pushed or pulled are permitted. Nonrated protective plates of unlimited height are permitted. Dutch doors meeting 19.3.6.3.6 are permitted. Door frames shall be labeled and made of steel or other materials in compliance with 8.3, unless the smoke compartment is sprinklered. Fixed fire window assemblies are allowed per 8.3. In sprinklered compartments there are no restrictions in area or fire resistance of glass or frames in window assemblies. 19.3.6.3, 42 CFR Parts 403, 418, 460, 482, 483, and 485 Show in REMARKS details of doors such as fire protection ratings, automatics closing devices, etc. Based on observation the facility failed to maintain several doors in the building. Failing to maintain doors in the facility could allow heat and/or smoke to transfer which will cause harm to the patients and/or staff. |
Report Facts
Inspections on page: 22
Total deficiencies: 10
Complaint inspections: 21
Total capacity: 312
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