Deficiencies per Year
16
12
8
4
0
Unclassified
Census Over Time
Census
Capacity
Notice
Capacity: 125
Deficiencies: 0
Jul 17, 2025
Visit Reason
The document serves to notify the facility of the approval of a revised license reflecting an increase in the home's capacity from 108/24 to 125/24.
Findings
The document does not report any inspection findings or deficiencies; it confirms the approval of the revised license capacity with no violations noted in the attached self-inspection form.
Report Facts
Capacity change: 125
Previous capacity: 108
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Juliet Marsala | Deputy Secretary | Signed the approval letter for the revised license. |
Inspection Report
Complaint Investigation
Census: 95
Capacity: 108
Deficiencies: 9
Mar 25, 2025
Visit Reason
The inspection was an unannounced partial inspection conducted due to a complaint and incident involving the facility.
Findings
The inspection identified multiple violations including abuse and neglect of residents, failure to report incidents timely, inadequate personal hygiene assistance, medication errors, failure to follow prescriber's orders, and incomplete resident assessments. The facility submitted plans of correction which were accepted and later implemented.
Complaint Details
The inspection was triggered by a complaint and incident involving alleged abuse by a staff person who physically blocked and restrained a resident in a wheelchair, causing distress. The facility failed to immediately suspend the staff and report the incident timely.
Deficiencies (9)
| Description |
|---|
| Failure to immediately develop and implement a plan of supervision or suspend a staff person involved in an alleged abuse incident. |
| Failure to report a resident fall resulting in fracture to the Department within 24 hours. |
| Resident did not receive the required number of showers as per assessment and support plan. |
| Staff person did not receive required training within 40 hours on resident rights, emergency medical plan, mandatory abuse reporting, and reporting of incidents. |
| Resident's medical evaluation was not obtained annually in a timely manner. |
| Medication administration record missing diagnosis or purpose for medications. |
| Failure to follow prescriber's orders resulting in medication errors and incorrect dosing. |
| Use of chemical restraint for controlling behavior without proper justification. |
| Resident assessment did not include updated mobility and ambulation changes after a hip fracture. |
Report Facts
License Capacity: 108
Residents Served: 95
Secured Dementia Care Unit Capacity: 24
Secured Dementia Care Unit Residents Served: 20
Current Hospice Residents: 5
Total Daily Staff: 129
Waking Staff: 97
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff Person B | Named in abuse incident, failure to receive required training, and terminated following investigation. | |
| Staff Person C | Counseled for failure to timely report allegations of abuse. | |
| Staff Person D | Counseled for medication error involving resident. | |
| Staff Person E | Counseled for administering medications for behavior without proper documentation. | |
| Staff Person F | Counseled for administering medications for behavior without proper documentation. | |
| Administrator Designee | Suspended and terminated Staff Person B; involved in corrective actions. | |
| Assistant Health Care Director | Involved in suspension and termination of Staff Person B and education of staff. | |
| Healthcare Director | Responsible for audits, education, and corrective actions related to medical evaluations, medication records, and staff training. |
Inspection Report
Renewal
Census: 97
Capacity: 108
Deficiencies: 14
Nov 19, 2024
Visit Reason
The inspection was conducted as a renewal and complaint investigation of the facility to assess compliance with licensing and regulatory requirements.
Findings
The inspection identified multiple deficiencies including failure to post current license and inspection summaries, inadequate first aid/CPR trained staff during overnight shifts, incomplete staff orientation and training, improper food storage, lint accumulation in dryers, overdue fire extinguisher inspections, medication storage and labeling issues, failure to follow prescriber's orders, and incomplete resident assessments and support plans. Plans of correction were accepted and implemented by the facility.
Complaint Details
The inspection included a complaint investigation component as indicated by the reason for visit being 'Renewal, Complaint'. Specific substantiation status is not stated.
Deficiencies (14)
| Description |
|---|
| Failure to post current violation reports and licensing inspection summaries in a conspicuous and public place. |
| Insufficient number of staff certified in First Aid and CPR present during overnight shifts with 96 residents. |
| New staff did not receive required orientation on fire safety and emergency preparedness topics on first day. |
| New staff did not complete orientation training on resident rights, emergency medical plan, and mandatory abuse reporting within 40 scheduled hours. |
| Food items stored on the floor in the dry food storage room. |
| Approximately 2-inch lint accumulation in the lint trap of a commercial dryer. |
| Two fire extinguishers in the main kitchen had not been inspected by a fire safety expert since 7/2023 and 8/2023. |
| Loose pills and pill fragments found in medication carts and medication room. |
| Pharmacy labels for several residents' medications did not reflect recent dosage changes. |
| Discrepancies between blood glucose readings documented in MAR and resident's glucometer readings. |
| Resident refusals to take prescribed medications were not documented or reported to prescribers. |
| Medications were not administered as prescribed to several residents on specific dates. |
| Initial assessment was not completed for a resident within 15 days of admission. |
| Initial support plan was not completed for a resident within 30 days of admission. |
Report Facts
Residents served: 97
License capacity: 108
Residents in secured dementia care unit: 20
Capacity of secured dementia care unit: 24
Current hospice residents: 6
Staff certified in First Aid/CPR overnight: 1
Lint accumulation: 2
Dates of medication refusal: 6
Inspection Report
Follow-Up
Census: 91
Capacity: 108
Deficiencies: 4
Jul 11, 2024
Visit Reason
The inspection was a partial, unannounced visit conducted on 07/11/2024 for complaint and monitoring purposes, including a follow-up on a previously submitted plan of correction.
Findings
The inspection found multiple medication-related deficiencies including improper medication storage, missing medications leading to missed doses, incomplete medication records lacking diagnosis or purpose, and failure to follow prescriber's orders. The submitted plan of correction was determined to be fully implemented.
Complaint Details
The inspection was complaint-related and monitoring in nature. The plan of correction submitted in response to prior deficiencies was reviewed and found to be fully implemented.
Deficiencies (4)
| Description |
|---|
| Loose pills found on the floor and in medication carts indicating improper medication storage. |
| Medications prescribed to residents were not available in the home, resulting in missed doses. |
| Medication Administration Records (MAR) lacked diagnosis or purpose for several prescribed medications. |
| Failure to administer prescribed medications as ordered by the prescriber on multiple occasions. |
Report Facts
License Capacity: 108
Residents Served: 91
Secured Dementia Care Unit Capacity: 24
Secured Dementia Care Unit Residents Served: 21
Current Hospice Residents: 2
Total Daily Staff: 117
Waking Staff: 88
Residents with Mobility Need: 26
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Healthcare Director | Named in relation to medication audit, re-education of staff, and oversight of medication management and plan of correction implementation. | |
| Assistant Healthcare Director | Involved in discarding identified medications and conducting medication cart audits. |
Inspection Report
Follow-Up
Census: 91
Capacity: 108
Deficiencies: 7
May 21, 2024
Visit Reason
The inspection visit on 05/21/2024 was a partial, unannounced follow-up review to verify the implementation of a previously submitted plan of correction related to an incident.
Findings
The inspection found multiple deficiencies including delayed access to resident records, failure to report incidents timely, resident abuse and neglect, restricted access to bedrooms, inaccurate resident support plans, untimely preadmission cognitive screenings, and incomplete resident record entries. Corrective actions and retraining were implemented with ongoing monitoring planned.
Deficiencies (7)
| Description |
|---|
| Delayed provision of resident complete records to inspectors until 2:05pm despite requests at 9:30am and 1:15pm. |
| Failure to report incidents and conditions to the Department within 24 hours as required. |
| Resident left unsupervised for approximately ten minutes resulting in inappropriate sexual behavior witnessed in the Secure Dementia Care Unit. |
| Frequent locking of resident bedroom doors in the Secure Dementia Care Unit, restricting access. |
| Resident support plans contained inaccurate mobility assessments inconsistent with medical evaluations. |
| Written cognitive preadmission screenings for residents admitted to the Secure Dementia Care Unit were not completed within 72 hours prior to admission. |
| Resident record entries were not permanent, legible, dated, or signed by the staff person making the entry. |
Report Facts
Residents Served: 91
License Capacity: 108
Residents Served in Secured Dementia Care Unit: 19
Capacity of Secured Dementia Care Unit: 24
Current Hospice Residents: 2
Residents Age 60 or Older: 90
Residents with Mobility Need: 27
Total Daily Staff: 118
Waking Staff: 89
Inspection Report
Complaint Investigation
Census: 89
Capacity: 108
Deficiencies: 15
Apr 30, 2024
Visit Reason
The inspection was conducted as a complaint investigation with an unannounced partial inspection on 04/30/2024 and 05/01/2024 to review compliance and follow-up on a plan of correction submission.
Findings
The inspection identified multiple deficiencies related to staffing hours, medication management, medication storage, labeling, record keeping, and resident assessments. The facility submitted plans of correction which were accepted and later determined to be fully implemented.
Complaint Details
The inspection was complaint-driven as indicated by the inspection reason and was conducted as a partial unannounced inspection with follow-up on plan of correction submissions.
Deficiencies (15)
| Description |
|---|
| Direct care staff hours were insufficient to meet the minimum required 2 hours per day for residents with mobility needs on multiple dates. |
| Less than 75% of personal care service hours were provided during waking hours on multiple dates. |
| Prescription medications, OTC medications, CAM and syringes were not kept locked; medication cart was found unlocked and unattended. |
| A bottle of Gabapentin 300 mg tablets was found without a current order at that dosage. |
| Blister card for a resident's medication had a torn backing exposing tablets. |
| Discontinued, expired, or no longer needed medications were improperly disposed of in a waste can instead of according to regulations. |
| Pharmacy labels on medications had incorrect dosage instructions. |
| Over-the-counter medications and CAM were not labeled with the resident's name. |
| Medication was not available in the home for a prescribed period, indicating a supply lapse. |
| Locks on medication carts were not operable, allowing unauthorized access to medications including controlled substances. |
| Medication administration records (MARs) lacked diagnosis or purpose for prescribed medications for multiple residents. |
| Medication was not administered as prescribed because it had been disposed of prior to administration. |
| Resident's preadmission screening form was incomplete and undated, lacking required determinations. |
| Resident's initial assessment did not accurately reflect care needs compared to preadmission screening. |
| Confidential resident information was improperly posted and accessible in the facility lobby. |
Report Facts
Residents served: 89
License capacity: 108
Residents with mobility needs: 25
Direct care hours required: 114
Direct care hours provided: 109.5
Direct care hours provided: 86.5
Direct care hours provided: 71
Waking hours provided: 82
Waking hours provided: 61
Waking hours provided: 71
Inspection Report
Renewal
Census: 81
Capacity: 108
Deficiencies: 9
Jan 3, 2024
Visit Reason
The inspection was conducted as a renewal inspection of the facility's license, including a full unannounced review on 01/03/2024 and 01/04/2024.
Findings
The inspection found multiple deficiencies including cleanliness issues in the kitchen, lint accumulation in dryers, incomplete or untimely medical evaluations for residents, medication storage and administration discrepancies, and failure to follow prescriber's orders. Plans of correction were accepted and implemented by mid-January 2024.
Deficiencies (9)
| Description |
|---|
| Food debris observed on several kitchen surfaces and floors including pushcarts, storage containers, steam tables, and fryer area. |
| Approximately 1-inch accumulation of lint in the lint trap of dryer 2 on the second floor. |
| Initial medical evaluations (DME) for several residents were not completed within the specified timeframe relative to admission. |
| Medications prescribed to residents were not available in the home at the time of inspection. |
| Discrepancies found between resident glucometer readings and medication administration record (MAR) entries. |
| Medication administration records did not indicate dosage of medication administered on a sliding scale for a resident. |
| Medication administration records lacked initials of staff who administered medications on specific dates and times. |
| Medications prescribed to residents were not administered as ordered on specific dates and times. |
| Resident admitted to Secure Dementia Care Unit had medical evaluation completed outside the required timeframe prior to admission. |
Report Facts
License Capacity: 108
Residents Served: 81
Secured Dementia Care Unit Capacity: 24
Residents Served in Secured Dementia Care Unit: 21
Hospice Residents: 6
Total Daily Staff: 102
Waking Staff: 77
Inspection Report
Follow-Up
Capacity: 24
Deficiencies: 3
Sep 26, 2023
Visit Reason
The inspection was a follow-up review conducted on 09/26/2023 to verify that the previously submitted plan of correction was fully implemented at the facility.
Findings
The facility was found to have fully implemented the plan of correction related to prior deficiencies, including proper labeling of poisonous materials, removal and securing of heat sources, and monitoring of refrigerator temperatures. Continued compliance is required.
Deficiencies (3)
| Description |
|---|
| A 24 ounce clear spray bottle containing a blue liquid substance was observed without a manufacturer's label in the housekeeping closet. |
| A steam table in the Secured Dementia Care Unit's kitchen lacked protective guards to prevent resident contact. |
| The temperature in the cinema's refrigerator was above the required 40°F, measuring 44°F and 48°F at different times. |
Report Facts
License Capacity: 24
Census: 0
Temperature readings: 44
Temperature readings: 48
Plan of Correction Completion Date: Oct 6, 2023
Plan of Correction Completion Date: Oct 25, 2023
Plan of Correction Completion Date: Sep 28, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Residence Director | Provided education and training related to deficiencies and plan of correction | |
| Maintenance Director | Applied proper chemical labels, conducted audits, placed thermometer, and monitored temperature logs | |
| Housekeeper | Participated in internal audit of cleaning supplies and chemicals |
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