Inspection Report
Complaint Investigation
Capacity: 223
Deficiencies: 10
Jul 11, 2025
Visit Reason
State-compiled facility profile showing 17 inspections from 2023-02 to 2025-07 with complaint investigation and other inspection types including deficiencies and no deficiencies cited.
Findings
Across multiple complaint investigations and other inspections, most inspections found no deficiencies. Several complaint inspections cited deficiencies related to abuse prevention, notification of changes, and staffing. The 2023 inspections included life safety and compliance deficiencies related to fire safety, door maintenance, and administrative policies.
Complaint Details
Multiple complaint investigations were conducted between 2023 and 2025, investigating numerous intake numbers. Most complaint inspections found no deficiencies, except for several that cited deficiencies related to abuse prevention, notification of changes, and staffing.
Deficiencies (10)
| Description |
|---|
| R9-10-412.B. A director of nursing shall ensure that: R9-10-412.B.2. Sufficient nursing personnel, as determined by the method in subsection (B)(1), are on the nursing care institution premises to meet the needs of a resident for nursing services; |
| 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 documentation, staff interviews, and the facility policy and procedures, the facility failed to ensure that residents are free from abuse from other residents. Detailed findings describe resident altercations and substantiated abuse. |
| §483.10(g)(14) Notification of Changes. Facility failed to ensure the physician was notified of a change of condition for one resident (#5), potentially resulting in delayed treatment. |
| R9-10-412.B. A director of nursing shall ensure that: R9-10-412.B.6. As soon as possible but not more than 24 hours after one of the following events occur, a nurse notifies a resident's attending physician and, if applicable, the resident's representative, if the resident: R9-10-412.B.6.c. Has a significant change in condition; and Facility failed to ensure physician notification of significant change of condition for resident #5. |
| 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 special locking arrangements. Facility failed to maintain two special locking exit doors causing potential harm in emergency. |
| Cooking Facilities - Cooking equipment is protected in accordance with NFPA 96. Facility failed to inspect and clean kitchen hood baffles; rags found on gas line and floor, increasing fire risk. |
| Corridor - Doors protecting corridor openings resist passage of smoke and have positive latching hardware. Facility failed to maintain several doors which failed to latch securely, risking smoke/heat transfer. |
| Utilities - Gas and Electric - Equipment using gas or related piping complies with NFPA 54 and electrical wiring with NFPA 70. Facility failed to ensure protected covering over exposed wires under kitchen disposal. |
| R9-10-403.C. An administrator shall ensure that: R9-10-403.C.2. Policies and procedures for physical health services and behavioral health services are established, documented, and implemented to protect the health and safety of a resident. Facility failed to refer resident #92 for PASRR Level II evaluation despite escalated behaviors and diagnoses. |
| §483.20(k) Preadmission Screening for individuals with a mental disorder and individuals with intellectual disability. Facility failed to refer resident #92 for required PASRR Level II evaluation despite diagnoses and medication orders. |
Report Facts
Inspections on page: 17
Total deficiencies: 10
Complaint inspections: 15
Total capacity: 223
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| KIMBERLY A TROTTA | Administrator | Named as facility administrator in facility information |
| Social Service Director (staff #99) | Social Service Director | Interviewed regarding PASRR Level II evaluation for resident #92 |
| Director of Nursing (DON/staff #1) | Director of Nursing | Interviewed regarding abuse investigation and substantiation |
| licensed practical nurse (LPN/staff #23) | Licensed Practical Nurse | Interviewed regarding abuse definitions and resident supervision |
| licensed practical nurse (LPN/staff #85) | Licensed Practical Nurse | Interviewed regarding notification procedures after resident falls |
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