Deficiencies per Year
20
15
10
5
0
Severe
High
Moderate
Low
Unclassified
Inspection Report
Complaint Investigation
Capacity: 50
Deficiencies: 20
Oct 28, 2025
Visit Reason
State-compiled facility profile showing 10 inspections from 2022-2025 with deficiency history and licensing violations.
Findings
Across multiple inspections, the facility exhibited deficiencies in areas including infection prevention, resident care assessments, medication administration, abuse reporting and investigation, and staff training. Several deficiencies were not corrected at follow-up visits, indicating ongoing compliance challenges.
Complaint Details
Multiple inspections included complaint investigations related to licensure complaints, abuse allegations, and infection control concerns. Notably, failures in abuse reporting and investigation were documented, including a sexual abuse allegation not reported to the State Agency.
Deficiencies (20)
| Description |
|---|
| F0000 - INITIAL COMMENTS |
| M0000 - Initial Comments |
| F0637 - Comprehensive Assessment After Signifcant Chg: Failed to identify in a timely manner a resident who experienced a significant change in status for 1 of 2 sampled residents (#18). |
| F0689 - Free of Accident Hazards/Supervision/Devices: Failed to ensure care plan interventions to prevent falls for 1 of 2 sampled residents (#18). |
| F0730 - Nurse Aide Peform Review-12 hr/yr In-Service: Failed to ensure CNA staff annual performance reviews were completed for 3 of 3 sampled CNA staff (#s 7, 8, 9). |
| F0791 - Routine/Emergency Dental Srvcs in NFs: Failed to ensure dental services were provided for 1 of 2 sampled residents (#19). |
| F0812 - Food Procurement,Store/Prepare/Serve-Sanitary: Failed to ensure kitchen staff wore appropriate hair restraints during meal preparation. |
| F0880 - Infection Prevention & Control: Failed to implement enhanced barrier precautions for residents with diabetic wounds for 1 of 3 sampled residents (#2). |
| F0554 - Resident Self-Admin Meds-Clinically Approp: Failed to assess a resident for safe self-administration of medication for 1 of 1 sampled resident (#26). |
| F0582 - Medicaid/Medicare Coverage/Liability Notice: Failed to ensure residents received Advance Beneficiary Notification information for 1 of 3 sampled residents (#22). |
| F0684 - Quality of Care: Failed to implement bowel care and follow physician orders timely for 2 of 5 sampled residents (#s 20 and 21). |
| F0687 - Foot Care: Failed to provide appropriate foot care for 1 of 1 sampled resident (#26). |
| F0698 - Dialysis: Failed to ensure dialysis treatment and care was in place including physician orders and communication with dialysis provider for 1 of 1 sampled resident (#1). |
| F0732 - Posted Nurse Staffing Information: Failed to ensure Direct Care Staff Daily Report postings were accurate for 9 of 30 days reviewed. |
| F0759 - Free of Medication Error Rts 5 Prcnt or More: Failed to ensure medication error rate less than 5% for 1 of 6 sampled residents (#240); facility medication error rate was 8%. |
| F0947 - Required In-Service Training for Nurse Aides: Failed to ensure CNA staff received 12 hours of in-service training annually for 2 of 5 randomly selected staff members (#s 11 and 13). |
| F0602 - Free from Misappropriation/Exploitation: Failed to ensure a resident was free from misappropriation of property for 1 of 1 sampled resident (#4). |
| F0609 - Reporting of Alleged Violations: Failed to notify State Agency of misappropriation of resident property for 1 of 1 sampled resident (#4). |
| F0610 - Investigate/Prevent/Correct Alleged Violation: Failed to conduct thorough investigation of alleged sexual abuse for 1 of 1 sampled resident (#1). |
| F0884 - Reporting - National Health Safety Network: Failed to report complete COVID-19 information to CDC's NHSN during required seven-day period. |
Report Facts
Inspections on page: 10
Total deficiencies: 19
Total surveys: 10
Licensed beds: 50
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff 1 | Administrator | Named in findings related to misappropriation, abuse reporting, and staffing postings |
| Staff 2 | DNS (Director of Nursing Services) | Named in multiple findings related to infection control, medication administration, abuse reporting, and staff training |
| Staff 3 | RNCM | Named in medication error and abuse investigation findings |
| Staff 4 | Social Service Director | Named in findings related to dental services and foot care |
| Staff 5 | Staffing Coordinator | Named in staffing posting deficiency |
| Staff 7 | CNA/LPN | Named in medication self-administration and bowel care findings |
| Staff 8 | CNA | Named in annual performance review deficiency |
| Staff 9 | CNA | Named in annual performance review deficiency |
| Staff 10 | CMA/Dietary Manager | Named in medication error and food sanitation deficiencies |
| Staff 11 | CNA | Named in significant change assessment and in-service training deficiencies |
| Staff 12 | CNA | Named in fall prevention deficiency |
| Staff 13 | CNA | Named in significant change assessment and in-service training deficiencies |
| Staff 14 | LPN/Resident Care Manager | Named in significant change assessment and fall prevention deficiencies |
| Staff 15 | LPN | Named in dental services deficiency |
| Staff 16 | LPN | Named in foot care deficiency |
| Staff 17 | LPN | Named in foot care deficiency |
| Staff 18 | LPN | Named in bowel care deficiency |
| Staff 19 | RN | Named in dialysis deficiency |
| Staff 240 | Resident | Named in medication error deficiency |
| Staff 4 | Agency CNA | Identified as perpetrator in misappropriation of resident property |
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