Inspection Report Summary
Most inspections found no deficiencies, with the facility generally clean, well-maintained, and residents expressing satisfaction with care. Some complaint investigations were substantiated, including one in February 2024 where staff improperly restrained a resident and limited visits, and another in October 2024 involving insufficient supervision and delayed emergency response after a resident’s fall resulting in serious injury. Other complaints about medication management, feeding, and verbal abuse were unsubstantiated. The most recent report from October 7, 2025, was perfect with no deficiencies noted during the pre-licensing inspection. Overall, the facility shows improvement with no recent issues, though past concerns involved resident rights and care supervision.
Deficiencies per Year
4
3
2
1
0
High
Moderate
Census Over Time
Census
Capacity
Inspection Report
Original Licensing
Census: 5
Capacity: 6
Deficiencies: 0
Oct 7, 2025
Visit Reason
The purpose of the visit was to conduct a pre-licensing inspection for change of ownership.
Findings
There were no deficiencies noted during the inspection.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kevin Mknelly | Licensing Program Analyst | Met with Administrator during the inspection visit. |
| Jessica Rocas | Administrator | Facility Administrator met during the inspection. |
Inspection Report
Annual Inspection
Census: 3
Capacity: 6
Deficiencies: 1
Apr 3, 2025
Visit Reason
The inspection was an unannounced annual inspection conducted to ensure compliance with health and safety regulations at the facility.
Findings
The facility was generally clean and residents expressed satisfaction with care. No immediate health, safety, or personal rights violations were observed except for water temperature exceeding the regulatory range in two bathroom locations, which posed a potential risk.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Water temperature exceeded regulation range, measured above 130 degrees Fahrenheit in two bathroom locations, posing a potential health, safety, or personal rights risk to persons in care. | Type B |
Report Facts
Capacity: 6
Census: 3
Plan of Correction Due Date: Apr 4, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kevin Mknelly | Licensing Program Analyst | Conducted the inspection and signed the report |
| Abigaila Budac | Administrator | Facility administrator present during inspection and exit interview |
Inspection Report
Census: 3
Capacity: 6
Deficiencies: 0
Jan 28, 2025
Visit Reason
The inspection was a case management visit conducted to perform a health and safety check at the facility.
Findings
The facility was found to be clean and orderly with sufficient staffing to attend to resident care needs. Medications and chemicals were secured, food supplies met requirements, and the home was at a comfortable temperature. No deficiencies were noted during the inspection.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kevin Mknelly | Licensing Program Analyst | Conducted the case management visit and health and safety check. |
| Abigaila Budac | Administrator | Facility administrator met with the Licensing Program Analyst during the visit. |
Inspection Report
Complaint Investigation
Census: 3
Capacity: 6
Deficiencies: 2
Oct 1, 2024
Visit Reason
An unannounced complaint investigation was conducted following a complaint received on 2024-08-05 regarding insufficient care and supervision of a resident and delayed medical treatment after a fall incident on 2024-08-04.
Findings
The investigation substantiated that staff did not provide sufficient care and supervision to resident R1, who required assistance with ambulation, resulting in a fall and serious injury. Staff delayed calling 9-1-1, instead contacting Hospice and the Administrator, causing a delay of approximately 1 hour and 40 minutes before emergency care was received. Another allegation regarding food quality was found unsubstantiated.
Complaint Details
The complaint was substantiated. Staff failed to ensure sufficient care and supervision for resident R1, who fell and sustained serious injuries. Staff delayed seeking timely medical treatment by not calling 9-1-1 immediately, instead contacting Hospice and the Administrator first. The delay was approximately 1 hour and 40 minutes before R1 was admitted to the emergency room. Another complaint about food quality was unsubstantiated.
Severity Breakdown
Type A: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to regularly observe residents for changes in physical, mental, emotional and social functioning and provide appropriate assistance, resulting in a fall due to lack of physical assistance while ambulating. | Type A |
| Failure to immediately telephone emergency response (9-1-1) for a terminally ill resident receiving hospice services during a medical emergency not related to the expected course of the resident’s terminal illness, causing delayed emergency response. | Type A |
Report Facts
Capacity: 6
Census: 3
Civil penalty: 500
Time lapse: 100
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kevin Mknelly | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Abigail Budac | Administrator | Facility administrator interviewed during investigation |
| S1 | Caregiver | Caregiver involved in the incident with resident R1 |
| Maribeth Senty | Licensing Program Manager | Oversaw the complaint investigation |
Inspection Report
Complaint Investigation
Census: 5
Capacity: 6
Deficiencies: 0
May 9, 2024
Visit Reason
The visit was a case management inspection conducted to deliver complaint findings related to an incident report of a resident's fall with injury.
Findings
The fall did not appear to be due to lack of supervision and the resident received timely medical care. No deficiencies were noted as a result of the inspection.
Complaint Details
The complaint involved an incident report of resident R1's fall with injury. The complaint was investigated and found not substantiated as the fall was not due to lack of supervision and medical care was timely.
Report Facts
Capacity: 6
Census: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kevin Mknelly | Licensing Program Analyst | Conducted the case management visit and delivered complaint findings |
| Abigaila Budac | Administrator | Named as facility administrator, but was unavailable during the visit |
Inspection Report
Annual Inspection
Census: 4
Capacity: 6
Deficiencies: 0
Mar 27, 2024
Visit Reason
The inspection was an unannounced annual inspection conducted to evaluate the facility's compliance with health and safety regulations using the CARE inspection tool.
Findings
No deficiencies were cited during the inspection. The facility was found to be very clean, with no immediate health, safety, or personal rights violations observed. Resident files and staff files were complete.
Report Facts
Capacity: 6
Census: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Abigaila Budac | Administrator | Present to assist during the inspection and discussed hospice care plan levels of detail |
| Kevin Mknelly | Licensing Program Analyst | Conducted the annual inspection |
| Maribeth Senty | Licensing Program Manager | Named in the report header |
Inspection Report
Complaint Investigation
Census: 4
Capacity: 6
Deficiencies: 2
Feb 21, 2024
Visit Reason
An unannounced complaint investigation visit was conducted in response to allegations received on 2024-01-16 regarding staff restraining a resident and prohibiting resident visits, as well as allegations of medication mismanagement and inadequate feeding.
Findings
The investigation substantiated that staff restrained a resident using a weighted blanket tied in place and that visits were at times discouraged or limited by appointment, posing immediate and potential risks to resident rights. Allegations regarding medication mismanagement and inadequate feeding were found unsubstantiated due to lack of evidence.
Complaint Details
The complaint investigation was substantiated for allegations that staff restrained a resident and prohibited resident visits. The allegations of medication mismanagement and inadequate feeding were unsubstantiated.
Severity Breakdown
Type A: 1
Type B: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Use of a weighted blanket tied and tucked to limit resident's movements constituted a restraint, violating postural support regulations. | Type A |
| Visits were discouraged or limited by appointment, violating residents' personal rights to receive visitors. | Type B |
Report Facts
Facility capacity: 6
Census: 4
Deficiencies cited: 2
Plan of Correction due dates: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kevin Mknelly | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Abigaila Budac | Administrator | Facility administrator present during investigation and exit interview |
| Ildiko Soropan | Lead Caregiver | Met with Licensing Program Analyst during investigation and involved in findings |
| Maribeth Senty | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
Inspection Report
Complaint Investigation
Census: 5
Capacity: 6
Deficiencies: 0
Dec 5, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by an allegation that staff were verbally abusive toward residents.
Findings
The investigation found that the facility met Title 22 requirements, was clean and well staffed, and that residents and families were very happy with care and interactions. The complaint was determined to be unfounded and dismissed.
Complaint Details
The complaint alleged verbal abuse by staff toward residents. The complaint was investigated and found to be unfounded, meaning the allegation was false or without reasonable basis.
Report Facts
Capacity: 6
Census: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kevin Mknelly | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Abigaila Budoc | Administrator | Met with Licensing Program Analyst during investigation |
Inspection Report
Annual Inspection
Census: 5
Capacity: 6
Deficiencies: 0
Apr 26, 2023
Visit Reason
An unannounced visit was conducted to perform the required annual inspection of the facility.
Findings
The inspection found the facility to be operating within the scope of its license with no deficiencies observed or cited. The facility was clean, well-maintained, and compliant with safety and care standards.
Report Facts
Hospice residents: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kevin Mknelly | Licensing Program Analyst | Conducted the inspection visit |
| Abigaila Budac | Administrator | Facility administrator contacted during inspection |
| Maribeth Senty | Licensing Program Manager | Named in report header |
Inspection Report
Annual Inspection
Census: 6
Capacity: 6
Deficiencies: 0
Mar 18, 2022
Visit Reason
The inspection was a Required-1 Year unannounced visit to conduct an annual inspection focusing on infection control compliance.
Findings
The facility was found to be in substantial compliance with no immediate health, safety, or personal rights violations observed. No deficiencies were cited as a result of the inspection.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kevin Mknelly | Licensing Program Analyst | Conducted the inspection and authored the report. |
| Abigaila Budac | Administrator | Facility administrator mentioned in the report. |
Inspection Report
Annual Inspection
Census: 5
Capacity: 6
Deficiencies: 0
Aug 26, 2021
Visit Reason
The inspection was an unannounced Required-1 Year Inspection focusing on infection control to ensure compliance with health and safety regulations.
Findings
The facility was found to be in substantial compliance with no immediate health, safety, or personal rights violations observed. No deficiencies were cited as a result of the inspection.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kevin Mknelly | Licensing Program Analyst | Conducted the Required-1 Year Inspection and authored the report. |
| Abigaila Budac | Administrator | Facility Administrator present during the inspection. |
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