Inspection Report
Re-Inspection
Capacity: 74
Deficiencies: 29
Oct 31, 2025
Visit Reason
State-compiled facility profile showing multiple inspections from 2021 to 2025 with detailed deficiency history and enforcement actions.
Findings
Across multiple inspections from 2021 to 2025, the facility exhibited numerous deficiencies including failures in informed consent, abuse prevention, infection control, care planning, medication administration, environmental safety, and staffing. Several deficiencies were corrected while others remained uncorrected at the time of inspections.
Complaint Details
Multiple complaint investigations included allegations of abuse, neglect, failure to report incidents timely, failure to investigate falls, and failure to maintain adequate staffing and care standards.
Deficiencies (29)
| Description |
|---|
| M0000 - Initial Comments |
| F0552 - Right to be Informed/Make Treatment Decisions: Failure to obtain informed consent for psychotropic medications. |
| F0600 - Free from Abuse and Neglect: Abuse and neglect incidents involving multiple residents and staff. |
| F0609 - Reporting of Alleged Violations: Failure to timely report alleged abuse and neglect incidents to the State Agency. |
| F0628 - Discharge Process: Failure to provide written notice of bed hold policy and notify Ombudsman upon resident transfer. |
| F0684 - Quality of Care: Missed medication doses and inadequate bowel management. |
| F0689 - Free of Accident Hazards/Supervision/Devices: Unsafe water temperatures and inadequate supervision leading to resident elopement risk. |
| F0812 - Food Procurement,Store/Prepare/Serve-Sanitary: Failure to follow proper hand hygiene and food handling practices. |
| F0880 - Infection Prevention & Control: Failure to follow PPE protocols and infection control practices. |
| M0180 - Nursing Services: Daily Staff Public Posting: Census not documented on multiple night shifts. |
| M0182 - Nursing Services: Minimum Licensed Nurse Staff: Failure to maintain minimum RN coverage for consecutive hours on multiple days. |
| F0580 - Notify of Changes (Injury/Decline/Room, etc.): Failure to notify resident representative of change of condition. |
| F0657 - Care Plan Timing and Revision: Failure to revise care plans timely for residents with fluid restrictions and medical devices. |
| F0658 - Services Provided Meet Professional Standards: Failure to follow infection control standards for wound care and diabetic testing. |
| F0659 - Qualified Persons: LPNs performing wound assessments outside their scope of practice. |
| F0677 - ADL Care Provided for Dependent Residents: Failure to provide required assistance with ADLs for dependent residents. |
| F0686 - Treatment/Svcs to Prevent/Heal Pressure Ulcer: Failure to follow physician orders and provide care to promote healing of pressure ulcers. |
| F0687 - Foot Care: Failure to provide appropriate foot care for residents with compromised mobility. |
| F0726 - Competent Nursing Staff: Failure to verify nursing staff competency and orientation. |
| F0803 - Menus Meet Resident Nds/Prep in Adv/Followed: Failure to provide therapeutic diets as ordered. |
| F0804 - Nutritive Value/Appear, Palatable/Prefer Temp: Failure to ensure meals were palatable, attractive, and served at appropriate temperatures. |
| F0806 - Resident Allergies, Preferences, Substitutes: Failure to honor resident food preferences. |
| F0812 - Food Procurement,Store/Prepare/Serve-Sanitary: Failure to ensure beard restraints worn during meal preparation. |
| F0883 - Influenza and Pneumococcal Immunizations: Failure to provide immunizations to eligible residents. |
| F0921 - Safe/Functional/Sanitary/Comfortable Environ: Unsafe and unsanitary laundry room conditions. |
| M0143 - Employees: Criminal Record Checks: Failure to complete background checks for newly hired staff. |
| F0610 - Investigate/Prevent/Correct Alleged Violation: Failure to thoroughly investigate unwitnessed fall with major injury and rule out abuse. |
| F0689 - Free of Accident Hazards/Supervision/Devices: Failure to ensure environment free of accident hazards (e.g., unsecured toilet). |
| M0183 - Nursing Services: Minimum CNA Staffing: Failure to maintain minimum CNA staffing requirements on multiple days. |
Report Facts
Inspections on page: 10
Total deficiencies: 49
Licensing violations: 17
Notices: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff 1 | Administrator | Named in multiple findings related to abuse investigations, reporting failures, and oversight |
| Staff 2 | Director of Nursing Services (DNS) | Named in multiple findings related to abuse investigations, staffing, reporting, and care planning |
| Staff 11 | Regional Director of Clinical Operations | Acknowledged failures in informed consent and abuse reporting |
| Staff 14 | Assistant Director of Nursing Services | Acknowledged informed consent and medication administration issues |
| Staff 15 | Regional Vice President | Acknowledged abuse reporting failures |
| Staff 17 | Staffing Coordinator | Confirmed staffing deficiencies |
| Staff 26 | Dietary Manager | Named in food handling and infection control deficiencies |
| Staff 12 | Registered Nurse (RN) | Named in infection control and competency deficiencies |
| Staff 50 | Licensed Practical Nurse (LPN) | Named in background check deficiency |
| Crystal Snarr | Regional Director of Clinical Operations | Provided education related to reporting and compliance |
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