Inspection Report Summary
The most recent inspection on September 30, 2025, showed the facility was certified in compliance based on acceptance of a credible allegation of compliance and plan of correction, with no specific deficiencies detailed. Prior inspections had identified various deficiencies related mainly to resident care practices, including safe transfer techniques and infection control, as well as medication administration and documentation issues. Complaint investigations included a substantiated case in May 2022 where the facility failed to provide adequate supervision during a mechanical lift transfer, resulting in staff suspension; most other complaints were unsubstantiated or found the facility in substantial compliance. Enforcement actions such as fines or license suspensions were not listed in the available reports. The inspection history shows some recurring themes around care and infection control, but recent corrective actions suggest improvement over time.
Deficiencies (last 6 years)
Deficiencies are regulatory violations found during state inspections.
Deficiencies per year
Census
Based on a September 2025 inspection.
Census over time
Inspection Report
Plan of CorrectionInspection Report
Annual Inspection| Name | Title | Context |
|---|---|---|
| Chris Schenkelberg | Healthcare Administrator | Submitted the Plan of Correction |
| Staff E | Certified Medication Aide (CMA) | Involved in deficient transfer technique with Resident #46 |
| Staff F | CNA in training | Involved in deficient transfer technique with Resident #46 |
| Staff H | Certified Nursing Assistant (CNA) | Failed to perform proper hand hygiene after resident care |
| Staff I | Registered Nurse, Unit Manager | Reported hand hygiene deficiencies |
| Staff C | Registered Nurse (RN) | Observed resident transfer issues |
| Staff D | CNA | Reported resident transfer difficulties |
| Director of Nursing | Director of Nursing (DON) | Provided statements on transfer practices and conducted staff education |
Inspection Report
Plan of CorrectionInspection Report
Annual InspectionInspection Report
Complaint InvestigationInspection Report
Plan of CorrectionInspection Report
Annual Inspection| Name | Title | Context |
|---|---|---|
| Chris Schenkelberg | Healthcare Administrator | Signed the inspection report and plan of correction |
| Staff F | Certified Nurse Aide | Reported on wheelchair headrest condition and reporting procedures |
| Staff G | Certified Nurse Aide | Reported on wheelchair repair procedures and communication |
| Staff H | Licensed Practical Nurse | Reported on headrest tear awareness and replacement procedures |
| Staff D | Registered Nurse Manager | Provided information on care plan expectations and wheelchair headrest replacement |
| Staff L | Registered Nurse | Reported on oxygen tubing change orders |
| Staff A | Certified Nurse Assistant | Reported on call light response expectations and pager system |
| Staff B | Registered Nurse | Reported on call light response expectations |
| Staff C | Dietary Aide | Observed serving food without proper hand hygiene |
| Director of Nursing | Provided multiple statements on facility policies and expectations regarding care plans, oxygen tubing, call light response, and medication administration |
Inspection Report
Plan of CorrectionInspection Report
Renewal| Name | Title | Context |
|---|---|---|
| Chris Schenkelberg | Administrator | Confirmed discharge MDS assessment was not done and signed the plan of correction |
| Staff D | Nurse Manager | Interviewed regarding the missed discharge MDS assessment |
| Director of Nursing | Explained Nurse Managers' responsibility for discharge MDS assessments and impact of non-completion | |
| Certified Dietary Manager | CDM | Observed soap dispenser empty and discarded outdated food |
| Registered Dietitian | Stated soap should have been replaced promptly | |
| Staff C | Dietary Aide | Stated she cleaned the kitchen including steam table and juice machine after meals |
Inspection Report
Plan of CorrectionInspection Report
Complaint InvestigationInspection Report
Annual Inspection| Name | Title | Context |
|---|---|---|
| Staff E | Unit Manager | Stated order for weekly weights was not followed; confirmed CPAP cleaning policy; stated expectation for following physician orders |
| Staff D | Licensed Practical Nurse (LPN) | Observed improper perineal care; assisted resident with morning care without placing prescribed boot |
| Staff F | Certified Nursing Assistant (CNA) | Assisted resident with morning care; observed during perineal care |
| Staff H | Registered Nurse (RN) Unit Manager | Confirmed missed INR test for Resident #50; described new INR monitoring process |
| Staff I | Registered Nurse (RN) | Changed dressing on Resident #50; attempted INR test with difficulty |
| Staff A | Dietary Aide | Served inappropriate portions of pureed pork and baked potato |
| Staff G | Cook | Prepared pureed foods with improper glove use and hand hygiene |
| Staff M | Licensed Practical Nurse (LPN) | Dropped medication box on floor and did not sanitize before use |
| Staff N | Certified Nursing Assistant (CNA) | Provided incontinence care without changing gloves or sanitizing hands |
| Staff O | Licensed Practical Nurse (LPN) | Handled wound care supplies placed on floor and did not follow infection control practices |
| Staff C | Certified Nursing Assistant (CNA) | Handled soiled linens improperly during resident care |
| Staff B | Licensed Practical Nurse (LPN) | Handled bread with bare hands during food preparation |
| Staff D | Licensed Practical Nurse (LPN) | Handled eye drop bag improperly during medication administration |
Inspection Report
Abbreviated SurveyInspection Report
Abbreviated Survey| Name | Title | Context |
|---|---|---|
| Chris Schenkelberg | Healthcare Administrator | Signed the statement of deficiencies and plan of correction |
Inspection Report
Abbreviated Survey| Name | Title | Context |
|---|---|---|
| Chris Schenkelberg | Healthcare Administrator | Named in the plan of correction |
Inspection Report
Abbreviated Survey| Name | Title | Context |
|---|---|---|
| Staff A | Home Health Care Aide | Observed not wearing face mask properly while assisting Resident #7 |
| Staff B | Registered Nurse (RN) | Provided statements about PPE expectations for Staff A |
| Staff C | Certified Nurses' Aide (CNA) | Reported never seeing Staff A without a face mask |
| Staff D | Reported never seeing Staff A without a face mask | |
| Staff E | Licensed Practical Nurse (LPN) | Reported Staff A did not wear a shield but always a mask |
| Chris Schenkelberg | Administrator | Signed the report and provided statements about Staff A's mask use |
| Director of Nursing (DON) | Director of Nursing | Explained facility did not employ Staff A and discussed mask policies |
Inspection Report
Abbreviated Survey| Name | Title | Context |
|---|---|---|
| Staff D | Licensed Practical Nurse (LPN) | Observed adjusting mask improperly and sanitizing hands after handling dirty dishes |
| Staff G | Dietary Aide | Reported kiosk symptom screening procedures |
| Staff E | Housekeeping | Reported kiosk symptom screening procedures |
| Staff I | Certified Nurses' Aide (CNA) | Observed giving new staff a tour with improper mask use |
| Staff J | Observed wearing mask improperly and sanitizing hands after handling resident's toy | |
| Staff L | Certified Nurses' Aide (CNA) | Observed wearing N95 mask and face shield improperly, lowering mask below nose and mouth |
| Director of Nursing | Director of Nursing (DON) | Reported additional staff member tested positive for COVID-19 |
| Administrator | Reported COVID-19 cases and infection control challenges | |
| Staff B | Licensed Practical Nurse (LPN) | Reported resident returned to floor with bad cough |
| Staff F | Certified Nurses' Aide (CNA) | Reported working with resident before illness and mask use issues |
| Staff K | Unit Manager | Reported resident testing and staff positive COVID-19 cases |
Inspection Report
Complaint Investigation| Name | Title | Context |
|---|---|---|
| Chris Schenkelberg | Administrator | Signed the report and plan of correction |
| Staff B RN | Registered Nurse | Interviewed regarding resident condition and communication with physician |
| Director of Nursing | Director of Nursing | Interviewed regarding nursing assessments and expectations |
Inspection Report
RoutineLoading inspection reports...



