4 Reports
Inspection Report — Feb 3, 2025
Original Licensing State
Date: Feb 3, 2025
Visit Reason
State-compiled facility profile showing 11 inspections from June 2022 to May 2026 with citation and enforcement history.
Complaint Details
The state logged 37 complaints about this facility; 11 led to on-site inspections. No citations resulted from those complaints during the reporting period.
Findings
Across 11 inspections, 6 resulted in citations totaling 55 deficiencies primarily related to standard health and Life Safety Code issues. The facility had 3 enforcement actions with fines totaling $12,000 and 37 complaints with 11 on-site inspections.
Citations (31)
Standard Health Citation — quality of care: Failed to develop and implement a comprehensive care plan.
Standard Health Citation — quality of care: Inadequate facility assessment.
Standard Health Citation — quality of care: Unsanitary food procurement, storage, preparation, or serving.
Standard Health Citation — quality of care: Improper labeling or storage of drugs and biologicals.
Standard Health Citation — quality of care: Ineffective pest control program.
Standard Health Citation — quality of care: Nutritive value, appearance, palatability, or temperature issues with food.
Standard Health Citation — quality of care: Inadequate PASARR screening for mental and intellectual disabilities.
Standard Health Citation — quality of care: Insufficient treatment or services to prevent or heal pressure ulcers.
Life Safety Code Citation — NFPA requirements: Hazardous areas not properly enclosed.
Life Safety Code Citation — NFPA requirements: Improper subdivision of building spaces with smoke barriers.
Standard Health Citation — quality of care: Failure to report to National Health Safety Network.
Standard Health Citation — quality of care: Food procurement, storage, preparation, or serving unsanitary.
Standard Health Citation — quality of care: Nutrition and hydration status maintenance inadequate.
Standard Health Citation — quality of care: Physician visits frequency, timeliness, or alternate NPP inadequate.
Standard Health Citation — quality of care: Resident's care not supervised by a physician.
Standard Health Citation — quality of care: Respiratory/tracheostomy care and suctioning inadequate.
Life Safety Code Citation — NFPA requirements: Discharge from exits not compliant.
Life Safety Code Citation — NFPA requirements: Doors without self-closing devices.
Life Safety Code Citation — NFPA requirements: Exit signage inadequate.
Life Safety Code Citation — NFPA requirements: Hazardous areas enclosure issues.
Life Safety Code Citation — NFPA requirements: Other health care facilities code violations.
Life Safety Code Citation — NFPA requirements: Means of egress general issues.
Life Safety Code Citation — NFPA requirements: Physical environment issues.
Life Safety Code Citation — NFPA requirements: Portable fire extinguishers not compliant.
Life Safety Code Citation — NFPA requirements: Portable space heaters not compliant.
Life Safety Code Citation — NFPA requirements: Sprinkler system installation issues.
Life Safety Code Citation — NFPA requirements: Sprinkler system maintenance and testing inadequate.
Life Safety Code Citation — NFPA requirements: Stairways and smokeproof enclosures issues.
Life Safety Code Citation — NFPA requirements: Standards of construction for new and existing nursing homes.
Life Safety Code Citation — NFPA requirements: Subdivision of building spaces with smoke barriers issues.
Life Safety Code Citation — NFPA requirements: Subdivision of building spaces with smoke compartments issues.
Report Facts
Inspections on page: 11
Total violations/deficiencies cited: 55
Inspections with violations: 6
Inspections without violations: 5
Total complaints: 37
On-site complaint inspections: 11
Enforcement actions: 3
Total fines: 12000
Citations issued: 3
Inspection Report — Feb 3, 2025
Annual Inspection CMS
Date: Feb 3, 2025
Visit Reason
The Recertification Survey was initiated on 1/28/2025 and completed on 2/3/2025 to assess compliance with regulatory requirements for nursing home operations and resident care.
Findings
The facility was found deficient in multiple areas including incomplete PASARR screening for mental disorders, failure to implement comprehensive care plans, inadequate pressure ulcer care, improper medication storage and labeling, serving food at unsafe temperatures, inadequate dishmachine sanitization, incomplete facility staffing assessment, and ineffective pest control program.
Citations (8)
Incomplete PASARR screening for mental disorders or intellectual disabilities for Resident #69, missing screener identification number.
Failure to implement a comprehensive person-centered care plan for Resident #337, specifically not ensuring physician-ordered heel booties were worn.
Inadequate pressure ulcer care for Residents #26 and #38, including failure to provide air mattress as ordered and improper air mattress weight calibration.
Medications and biologicals not stored properly; Albuterol Sulfate inhaler found unlabeled in Resident #35's room without nurse supervision or physician order.
Food served to residents was not palatable, attractive, or at safe and appetizing temperatures; hot foods served below 135°F and cold foods above 41°F.
Dishmachine rinse temperature was below manufacturer recommendations (100°F observed vs 180°F required), and temperature logs showed inconsistent monitoring.
Facility assessment did not include contracted nursing staff agencies used to meet staffing needs.
Ineffective pest control program with cockroach sightings at Unit 2 South nursing station and resident reports of cockroaches throughout the facility.
Report Facts
Residents reviewed for PASARR: 37
Residents reviewed for Pressure Ulcers: 3
Residents affected by deficiencies: 1
Residents affected by deficiencies: 1
Residents affected by deficiencies: 2
Residents affected by deficiencies: 1
Residents affected by deficiencies: 10
Dishmachine rinse temperature range: 100
Dishmachine rinse temperature range: 166
Resident #38 weight: 150
Air mattress weight setting: 290
Food temperature: 100
Food temperature: 112
Food temperature: 108
Food temperature: 73
Food temperature: 70
Food temperature: 60
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Admission Coordinator | Stated the PASARR screen should have been reviewed for accuracy and completion | |
| Director of Admissions | Responsible for reviewing admission documents including PASARR screening | |
| Administrator | Stated PASARR screening should be reviewed prior to admission | |
| Registered Nurse #3 | Registered Nurse | Observed Resident #337 and applied heel booties |
| Certified Nursing Assistant #1 | Certified Nursing Assistant | Assigned to Resident #337 and unaware heel booties should be worn at all times |
| Certified Nursing Assistant #2 | Certified Nursing Assistant | Float CNA assigned to Resident #337 and did not put on heel booties during day |
| Registered Nurse Supervisor #1 | Registered Nurse Supervisor | Stated CNAs are responsible for checking nursing care instructions |
| Director of Nursing Services | Stated CNAs expected to review nursing care profile and provide care as per plan | |
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Checked wound care and confirmed air mattress needed for Resident #26 |
| Licensed Practical Nurse #2 | Licensed Practical Nurse | Signed Treatment Administration Record for air mattress presence |
| Wound Care Registered Nurse #1 | Wound Care Registered Nurse | Evaluated Resident #26 and confirmed need for air mattress |
| Licensed Practical Nurse #4 | Licensed Practical Nurse | Adjusted air mattress weight setting for Resident #38 improperly |
| Licensed Practical Nurse #3 | Licensed Practical Nurse | Unit Manager who stated mattress becomes firm at 290 pounds setting |
| Director of Housekeeping | Stated housekeeping does not calibrate air mattress weight setting | |
| Wound Care Nurse #1 | Wound Care Nurse | Stated nurses responsible for monitoring air mattress weight settings |
| Licensed Practical Nurse #5 | Licensed Practical Nurse | Unaware of Albuterol inhaler in Resident #35's room |
| Food Service Director | Acknowledged food temperature complaints and dishmachine issues | |
| Dietary Aide #1 | Dietary Aide | Present during food temperature testing on Unit 3 North |
| Dietary Aide #2 | Dietary Aide | Operated dishmachine and unaware of low rinse temperature |
| Dietary Aide #3 | Dietary Aide | Did not check or record dishmachine temperatures |
| Maintenance Director | Responsible for pest control program | |
| Ombudsman | Reported resident complaints about food temperatures |
Inspection Report — Apr 11, 2023
Annual Inspection CMS
Date: Apr 11, 2023
Visit Reason
The inspection was a Recertification Survey conducted from 4/3/2023 to 4/11/2023 to assess compliance with regulatory requirements for nursing home care.
Findings
The facility was found deficient in multiple areas including failure to maintain residents' nutritional and hydration status, inadequate respiratory care, lack of timely physician supervision and visits, and improper food storage practices. Specific deficiencies involved significant unaddressed weight loss in residents, oxygen therapy not administered as ordered, delayed physician documentation, and perishable food left unrefrigerated outside the facility.
Citations (5)
Failure to ensure residents maintained acceptable nutritional and hydration status, including unaddressed significant weight loss for Resident #156 and Resident #142.
Failure to provide safe and appropriate respiratory care, including Resident #176 observed without oxygen as ordered and improper oxygen tubing management.
Failure to ensure medical care was supervised by a physician, including unaddressed significant weight loss and lack of timely physician follow-up for Resident #156.
Failure to ensure residents were seen by a physician at least once every 30 days for the first 90 days after admission, specifically Resident #156.
Failure to procure food from approved sources and store, prepare, distribute, and serve food in accordance with professional standards, including 12 unopened boxes of perishable food left outside unrefrigerated.
Report Facts
Weight loss percentage: 7
Weight loss in pounds: 12.7
Weight loss in pounds: 8.4
Weight loss percentage: 5.8
Weight loss percentage: 8
Temperature: 50
Temperature: 53
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RD #1 | Registered Dietitian | Interviewed regarding weight monitoring and interventions for residents. |
| RD #2 | Regional Registered Dietitian | Interviewed regarding weight change communication and interventions. |
| RD #3 | Former Registered Dietitian | Interviewed regarding failure to document significant weight loss and communication. |
| DNS | Director of Nursing Services | Interviewed regarding responsibilities for weight change notifications and communication. |
| Physician #1 | Medical Director | Interviewed regarding physician notification and expectations for resident care. |
| Physician #2 | Primary Care Physician | Interviewed regarding documentation and awareness of resident weight loss and visits. |
| LPN #1 | Licensed Practical Nurse | Interviewed regarding oxygen tubing labeling and resident oxygen therapy. |
| RN #1 | Registered Nurse Supervisor | Interviewed regarding oxygen tubing change policy and observations. |
| FSW #1 | Food Service Worker | Interviewed regarding food storage outside and freezer rental. |
| FSD | Food Service Director | Interviewed regarding food delivery, storage, and freezer rental. |
| Administrator | Facility Administrator | Interviewed regarding food storage outside and freezer rental. |
| ADNS | Assistant Director of Nursing Services | Interviewed regarding oxygen tubing change policy. |
Inspection Report — Sep 15, 2020
Annual Inspection CMS
Date: Sep 15, 2020
Visit Reason
The inspection was a Recertification Survey conducted to assess compliance with professional standards for foodservice safety and infection prevention and control in the nursing home.
Findings
The facility was found deficient in food handling practices where Certified Nursing Assistants were observed handling resident food with bare hands, and in infection control where a Licensed Practical Nurse wore a mask below his nose while interacting closely with a resident without a mask.
Citations (2)
Food was served in a manner that did not comply with professional standards; CNAs handled resident food with bare hands during meal service.
Infection prevention and control program was not properly maintained; an LPN was observed wearing a facial mask below his nose while less than 6 feet from a resident without a mask.
Report Facts
Residents affected: 2
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #1 | Certified Nursing Assistant | Observed handling food with bare hands during breakfast for Resident #14 |
| CNA #2 | Certified Nursing Assistant | Observed handling food with bare hands during lunch for Resident #78 |
| LPN #1 | Licensed Practical Nurse | Observed wearing mask below nose while interacting with Resident #78 |
| Director of Nursing Services | Director of Nursing Services | Interviewed regarding proper food handling and mask use policies |
| Infection Control Registered Nurse | Registered Nurse | Interviewed regarding proper mask wearing |
| Registered Nurse unit supervisor | Registered Nurse | Interviewed regarding food handling practices |
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