Inspection Report Summary
The most recent inspection on October 20, 2025, identified several deficiencies related to fire drills, CPR-certified staff availability, physician assessments, and electronic monitoring consent. Earlier inspections, including the December 30, 2024 survey, found the facility in compliance with applicable regulations. The main themes of deficiencies involved emergency preparedness, staff training, resident assessments, and privacy documentation. No complaint investigations or enforcement actions were listed in the available reports. The record shows new issues appearing in the latest inspection after a previously clean survey, indicating some recent challenges in maintaining compliance.
Deficiencies (last 2 years)
Deficiencies are regulatory violations found during state inspections.
Deficiencies per year
| Description | Severity |
|---|---|
| Technical infraction for failure to address use of electronic monitoring in residents' rooms and failure to have representative complete consent form. | Technical Infraction |
| Failure to perform fire drills on a bi-monthly basis as required, with drills only conducted quarterly. | Type 2 Violation |
| Failure to have at least one direct care staff person on duty 24 hours a day with CPR certification including demonstration of ability to perform CPR. | Type 2 Violation |
| Failure to have an annual physician's assessment completed by a physician for one resident in the sample reviewed. | Type 3 Violation |
| Name | Title | Context |
|---|---|---|
| E2 | Director of Nursing (DON) | Provided information regarding fire drills, CPR certification, and physician assessments. |
| E1 | Executive Director | Mentioned as conducting fire drills. |
| E3 | Caregiver | Scheduled for shifts without CPR certification including demonstration. |
| E4 | Caregiver | Scheduled for shifts without CPR certification including demonstration. |
| E5 | Caregiver | Scheduled for shifts without CPR certification including demonstration. |
| Z1 | Nurse Practitioner (NP) | Signed physician assessment for resident R2 instead of a physician. |
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