3 Reports · 1 Summary
Inspection Summary
3 inspections covered, Jun 2022 – May 2026.
Inspection Reports Summary
Visit Reason
State-compiled facility profile showing 3 inspections from June 2022 to May 2026 with deficiency history and enforcement actions.
Complaint Details
The facility received 110 complaints with 3 on-site inspections conducted. No citations resulted from complaints during the reporting period.
Findings
Across 3 inspections, 2 had no citations while 1 inspection resulted in 6 citations including 4 standard health and 2 life safety code violations. The facility had 110 complaints with 3 on-site inspections and 1 enforcement action totaling $2,000 in fines.
Citations (6)
Standard Health Citation — quality of care: Activities did not meet interests or needs of each resident.
Standard Health Citation — quality of care: Failed to increase or prevent decrease in range of motion/mobility.
Standard Health Citation — quality of care: Inadequate PASARR screening for mental and intellectual disabilities.
Standard Health Citation — quality of care: Failed to provide right to survey results and advocate agency information.
Life Safety Code Citation — NFPA requirements: Electrical systems essential electric system deficiencies.
Life Safety Code Citation — NFPA requirements: Stairways and smokeproof enclosures deficiencies.
Report Facts
Inspections on page: 3
Total violations/deficiencies cited: 6
Inspections with violations: 1
Inspections without violations: 2
Total complaints: 110
On-site complaint inspections: 3
Total enforcement actions: 1
Total fines: 2000
Individual Reports
One document per inspection visit.
Inspection Report — Mar 21, 2024
Annual Inspection
Date: Mar 21, 2024
Visit Reason
The inspection was conducted as a Recertification survey from 03/14/2024 to 03/21/2024 to assess compliance with state and federal regulations for nursing home operations.
Findings
The facility was found deficient in multiple areas including failure to post survey results in an accessible manner, incomplete PASARR screening documentation for mental disorders, inadequate activities programming for residents with cognitive impairments, and failure to provide ordered hand splints and handrolls to a resident with limited range of motion.
Citations (4)
Survey results were not posted in a place readily accessible to residents and visitors, with the binder placed inside the front desk and not visible to wheelchair users.
Incomplete preadmission screening for mental disorders; SCREEN DOH 695 form was incomplete and Level II services determination was not documented for Resident #244.
Lack of ongoing activities program meeting the interests and needs of Resident #53 with severely impaired cognition; no activity plan or documented 1:1 visits were provided.
Resident #218 with limited range of motion was not provided with ordered hand splints and handrolls; devices were observed unused and staff were unaware or inconsistent in applying them.
Report Facts
Residents sampled: 38
Residents affected: 1
Residents affected: 1
Residents affected: 1
Resident Council meeting attendees: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse Manager #2 | Interviewed regarding Resident #244's behavior and PASARR screening responsibility | |
| Acting Director of Social Services | Interviewed regarding PASARR screening process and documentation for Resident #244 | |
| Certified Nurse Aide #7 | Interviewed about activities provided to Resident #53 | |
| Recreation Leader | Interviewed about activities and 1:1 visits for Resident #53 | |
| Registered Nurse Manager #1 | Interviewed regarding application of hand splints and handrolls for Resident #218 | |
| Certified Nursing Assistant #1 | Interviewed about care provided to Resident #218 including splint application | |
| Occupational Therapist #1 | Interviewed about hand splint orders and staff education for Resident #218 | |
| Director of Nursing | Interviewed about responsibilities for ensuring device application and care plans |
Inspection Report — Feb 4, 2022
Complaint Investigation
Date: Feb 4, 2022
Visit Reason
The inspection was conducted as a recertification survey and complaint investigation related to privacy breaches, timely reporting of abuse, proper garbage disposal, and infection control practices.
Complaint Details
The complaint investigation revealed that the facility failed to report incidents of abuse involving residents #19, #415, and #416 within the required 2-hour timeframe. Incidents included physical altercations resulting in injury and delayed reporting to the State Survey Agency.
Findings
The facility failed to maintain resident privacy by leaving electronic medical records and medication blister packs unattended, did not report alleged abuse incidents within the required 2-hour timeframe, improperly disposed of garbage without covers, and did not follow infection control guidelines for handling linens.
Citations (4)
Left an open laptop logged into a resident's electronic medical record and medication blister packs unattended, exposing personal health information.
Did not report alleged abuse incidents within 2 hours as required by regulations.
Garbage container was transported without a cover, contrary to facility policy.
Facility staff did not follow infection control guidelines while handling clean and soiled linen, including linens contacting staff uniforms and returning linens to the clean linen cart.
Report Facts
Residents reviewed for privacy: 4
Units reviewed for privacy: 5
Residents reviewed for abuse: 6
Hours late reporting incident on 01/30/2020: 25.5
Hours late reporting incident on 03/30/2021: 14.62
Date of survey completion: Feb 4, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Left laptop open logged into EMR and discarded medication blister packs with resident information in trash |
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding EMR handling and abuse reporting policies |
| Regional Director of Nursing | Regional Director of Nursing (RDON) | Interviewed regarding EMR and medication blister pack handling |
| LPN #5 | Licensed Practical Nurse | Witnessed and reported resident altercation incident |
| RN Supervisor | Registered Nurse Supervisor | Notified of abuse incidents and interviewed |
| LPN #4 | Licensed Practical Nurse | Witnessed resident altercation and reported incident |
| LPN #6 | Licensed Practical Nurse | Notified RN Supervisor and Administrator about abuse incident |
| CNA #1 | Certified Nursing Assistant | Observed mishandling linens during care |
| Food Service Director | Food Service Director (FSD) | Interviewed regarding garbage disposal practices |
| Infection Control Nurse | Infection Control Nurse (ICN) | Interviewed regarding infection control and linen handling policies |
Inspection Report — Jun 27, 2019
Re-Inspection
Date: Jun 27, 2019
Visit Reason
The inspection was conducted as a re-certification survey to assess compliance with federal regulations, including accuracy of resident assessments and infection prevention and control practices.
Findings
The facility was found deficient in ensuring accurate Minimum Data Set (MDS) assessments, specifically misreporting a diagnosis of Schizophrenia for one resident without medical record support. Additionally, infection control practices were inadequate as a housekeeper failed to wear proper personal protective equipment (PPE) and used the same mop for rooms with and without contact precautions, risking transmission of Acinetobacter Baumannii.
Citations (2)
Failure to ensure the Minimum Data Set (MDS) accurately reflected the resident's status, with incorrect documentation of Schizophrenia diagnosis for Resident #212.
Failure to provide and implement an infection prevention and control program, evidenced by a housekeeper not wearing proper PPE and using the same mop for contact precaution and non-contact precaution rooms.
Report Facts
Residents sampled: 35
MDS documents miscoded: 3
Residents affected: 1
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| MDS coordinator #1 | Interviewed regarding coding of Schizophrenia and correction of MDS records | |
| MDS coordinator #2 | Admitted to incorrectly coding three MDS records for Resident #212 | |
| RN #1 | Registered Nurse | Interviewed and stated Resident #212 does not have Schizophrenia |
| Psychiatrist #1 | Psychiatrist | Interviewed and stated Resident #212 was never diagnosed with Schizophrenia |
| Director of Housekeeping | Interviewed regarding infection control policies and housekeeper PPE use | |
| Housekeeper | Observed not wearing proper PPE and using same mop for contact precaution and non-contact precaution rooms |
3 CMS Surveys
CMS Survey — Jun 27, 2019
Jun 27, 2019
CMS Survey — Feb 4, 2022
Feb 4, 2022
CMS Survey — Mar 21, 2024
Mar 21, 2024
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