Inspection Report
Complaint Investigation
Capacity: 222
Deficiencies: 7
May 5, 2025
Visit Reason
State-compiled facility profile showing multiple complaint inspections from 2022 to 2025 with deficiency history.
Findings
Across multiple complaint inspections from 2022 to 2025, the facility had mostly no deficiencies cited, with a few inspections identifying deficiencies related to laboratory services, personnel qualifications, nursing care, and life safety door maintenance.
Complaint Details
Multiple complaint investigations were conducted from 2022 through 2025, with most resulting in no deficiencies cited. Some complaint investigations were combined with recertification or compliance surveys.
Deficiencies (7)
| Description |
|---|
| §483.50(a) Laboratory Services. §483.50(a)(1) The facility must provide or obtain laboratory services to meet the needs of its residents. The facility is responsible for the quality and timeliness of the services. (i) If the facility provides its own laboratory services, the services must meet the applicable requirements for laboratories specified in part 493 of this chapter. |
| R9-10-413.B. A medical director shall ensure that: R9-10-413.B.6. If the any of the following services are not provided by the nursing care institution and needed by a resident, the resident is assisted in obtaining, at the resident's expense: R9-10-413.B.6.d. Clinical laboratory services from a laboratory that holds a certificate of accreditation or certificate of compliance issued by the United States Department of Health and Human Services under the 1988 amendments to the Clinical Laboratories Improvement Act of 1967; |
| R9-10-406.B. An administrator shall ensure that:R9-10-406.B.2. A personnel member's skills and knowledge are verified and documented:R9-10-406.B.2.a. Before the personnel member provides physical health services or behavioral health services, and |
| R9-10-406.B. An administrator shall ensure that:R9-10-406.B.3. Sufficient personnel members are present on a nursing care institution's premises with the qualifications, skills, and knowledge necessary to:R9-10-406.B.3.a. Provide the services in the nursing care institution's scope of services, |
| R9-10-412.B. A director of nursing shall ensure that:R9-10-412.B.7. An unnecessary drug is not administered to a resident. |
| R9-10-414.B. An administrator shall ensure that a care plan for a resident:R9-10-414.B.3. Ensures that a resident is provided nursing care institution services that:R9-10-414.B.3.b. Assist the resident in maintaining the resident's highest practicable well-being according to the resident's comprehensive assessment. |
| Corridor - Doors Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas resist the passage of smoke and are made of 1 3/4 inch solid-bonded core wood or other material capable of resisting fire for at least 20 minutes. Doors in fully sprinklered smoke compartments are only required to resist the passage of smoke. Corridor doors and doors to rooms containing flammable or combustible materials have positive latching hardware. Roller latches are prohibited by CMS regulation. These requirements do not apply to auxiliary spaces that do not contain flammable or combustible material. Clearance between bottom of door and floor covering is not exceeding 1 inch. Powered doors complying with 7.2.1.9 are permissible if provided with a device capable of keeping the door closed when a force of 5 lbf is applied. There is no impediment to the closing of the doors. Hold open devices that release when the door is pushed or pulled are permitted. Nonrated protective plates of unlimited height are permitted. Dutch doors meeting 19.3.6.3.6 are permitted. Door frames shall be labeled and made of steel or other materials in compliance with 8.3, unless the smoke compartment is sprinklered. Fixed fire window assemblies are allowed per 8.3. In sprinklered compartments there are no restrictions in area or fire resistance of glass or frames in window assemblies.19.3.6.3, 42 CFR Parts 403, 418, 460, 482, 483, and 485 Show in REMARKS details of doors such as fire protection ratings, automatics closing devices, etc. |
Report Facts
Inspections on page: 35
Total deficiencies: 7
Complaint inspections: 33
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