Inspection Report Summary
The most recent inspection on May 20, 2025, identified a deficiency related to incomplete and unsigned service plans for some residents upon admission. Earlier inspections showed a pattern of mixed results, with prior deficiencies involving medication management, care planning, and life safety code compliance. Main themes of deficiencies included medication reconciliation, authorization for PRN medications, service plan documentation, and some life safety code issues such as maintenance and egress door locking. Several complaint investigations were conducted, most of which were unsubstantiated, though a few substantiated complaints led to citations related to resident care and infection control. The facility’s inspection history shows some ongoing challenges with regulatory compliance, but recent efforts such as audits and staff education have been implemented to address these issues.
Deficiencies (last 4 years)
Deficiencies are regulatory violations found during state inspections.
Deficiencies per year
Census
Based on a May 2025 inspection.
Occupancy over time
Inspection Report
Complaint Investigation| Name | Title | Context |
|---|---|---|
| Holly Snyder | Executive Director | Signed the report |
| Assistant Director of Nursing (ADON) | Interviewed regarding service plan completion and policy |
Inspection Report
Complaint InvestigationInspection Report
Complaint InvestigationInspection Report
Re-InspectionInspection Report
Complaint InvestigationInspection Report
Complaint InvestigationInspection Report
Life Safety| Name | Title | Context |
|---|---|---|
| Holly Snyder | Executive Director | Signed report and involved in plan of correction |
| Director of Plant Operations | Responsible for inspection, testing, documentation, and education regarding PCREE | |
| Senior Director of Plant Operations | Interviewed during survey and acknowledged findings | |
| Corporate Support Representative | Interviewed during survey and acknowledged findings |
Inspection Report
Renewal| Name | Title | Context |
|---|---|---|
| Holly Snyder | HFA | Facility representative signing the report |
| RN 6 | Accompanied medication cart observations and provided information about narcotic count procedures | |
| LPN 7 | Accompanied medication cart observation for Noble Hall cart | |
| QMA 3 | Qualified Medication Assistant | Administered PRN medications without documented nurse or physician authorization |
| QMA 4 | Qualified Medication Assistant | Administered PRN medication without documented nurse or physician authorization |
| QMA 5 | Qualified Medication Assistant | Provided interview about PRN medication administration process |
| DON | Director of Nursing | Provided interviews regarding narcotic count procedures and PRN medication authorization |
Inspection Report
Annual InspectionInspection Report
Complaint InvestigationInspection Report
Complaint InvestigationInspection Report
Complaint InvestigationInspection Report
Complaint InvestigationInspection Report
Complaint InvestigationInspection Report
Complaint InvestigationInspection Report
Life SafetyInspection Report
Renewal| Name | Title | Context |
|---|---|---|
| Rebeccah Garza | RN Clinical Support | Signed the report |
| DON | Director of Nursing | Provided interviews regarding fluid restriction, insulin administration, narcotic reconciliation, pharmacy recommendations, and elopement incident |
| Environmental Services Director | Witnessed resident elopement and completed statement of witness form | |
| Corporate Nurse Consultant | Interviewed regarding facility policy on pharmacy recommendations | |
| Dementia Unit Director | Interviewed about patio door alarm and courtyard gate | |
| Resident 56's spouse | Provided information about resident's history of elopement | |
| IDT Social Services Director | Interviewed regarding pharmacy recommendation documentation |
Inspection Report
Annual InspectionInspection Report
Complaint InvestigationInspection Report
Complaint InvestigationInspection Report
Complaint InvestigationInspection Report
Life SafetyInspection Report
Complaint InvestigationInspection Report
Complaint Investigation| Name | Title | Context |
|---|---|---|
| Stacy Mevzek | Executive Director | Signed the report |
| CNA 1 | Certified Nursing Aide | Named in deficiency for transferring resident without assistance |
| RN 2 | Registered Nurse | Interviewed regarding CNA 1 not following proper transfer protocol |
| RN 3 | Registered Nurse | Interviewed regarding resident's fearfulness and transfer requirements |
Inspection Report
Life Safety| Name | Title | Context |
|---|---|---|
| Stacy Mevzek | Executive Director | Signed report and involved in exit conference |
| Plant Operations Director | Acknowledged deficiencies related to egress door and sprinkler system | |
| Assistant Plant Operations Director | Acknowledged deficiencies related to egress door and sprinkler system | |
| Corporate Facilities Management Support Representative | Acknowledged deficiencies related to egress door and sprinkler system |
Inspection Report
Annual InspectionInspection Report
Recertification| Name | Title | Context |
|---|---|---|
| Jenny McCurdy | RN, Clinical support nurse | Signed report |
| LPN 7 | Observed entering isolation room with improper PPE use | |
| Housekeeper 8 | Observed wearing N95 over surgical mask in isolation room | |
| QMA 9 | Qualified Medication Aide | Observed improper handling of eye drop medication in isolation room |
| RN 3 | Registered Nurse | Observed improper mask use entering isolation room |
| NP Student 4 | Nurse Practitioner Student | Observed improper mask use entering isolation room |
| CNA 6 | Certified Nurse's Aide | Reported staffing shortages and shower delays |
Inspection Report
Complaint InvestigationLoading inspection reports...



