Inspection Report — Mar 13, 2026
Complaint Investigation
Citations: 13
Date: Mar 13, 2026
Visit Reason
State-compiled facility profile showing 5 inspections from 2022 to 2026 with citation and complaint history, enforcement actions, and deficiency details.
Complaint Details
The state logged 71 complaints about this facility; 5 led to on-site inspections.
Findings
Across 5 inspections, 3 resulted in citations totaling 24 deficiencies split between standard health and life safety code issues. The facility had 71 complaints with 5 on-site inspections and 2 enforcement actions with fines totaling $4,000.
Citations (13)
Medicaid/medicare Coverage/liability Notice: Standard Health Citation — quality of care with pattern scope.
Reporting Of Alleged Violations: Standard Health Citation — quality of care with isolated scope.
Resident Records - Identifiable Information: Standard Health Citation — quality of care with isolated scope.
Residents Are Free Of Significant Med Errors: Standard Health Citation — quality of care with pattern scope.
Respiratory/tracheostomy Care And Suctioning: Standard Health Citation — quality of care with isolated scope.
Electrical Equipment - Power Cords And Extens: Life Safety Code Citation — NFPA requirements with isolated scope.
Electrical Equipment - Testing And Maintenanc: Life Safety Code Citation — NFPA requirements with pattern scope.
Horizontal Sliding Doors: Life Safety Code Citation — NFPA requirements with isolated scope.
Portable Fire Extinguishers: Life Safety Code Citation — NFPA requirements with pattern scope.
Payroll Based Journal: Standard Health Citation — quality of care with widespread scope.
Infection Prevention & Control: Standard Health Citation — quality of care with isolated scope.
Hazardous Areas - Enclosure: Life Safety Code Citation — NFPA requirements with pattern scope.
Sprinkler System - Maintenance And Testing: Life Safety Code Citation — NFPA requirements with isolated scope.
Report Facts
Inspections on page: 5
Total violations/deficiencies cited: 24
Inspections with violations: 3
Inspections without violations: 2
Total complaints: 71
On-site complaint inspections: 5
Enforcement actions: 2
Total fines: 4000
Citations from complaints: 6
Inspection Report — Dec 1, 2023
Annual Inspection
Citations: 1
Date: Dec 1, 2023
Visit Reason
The inspection was conducted as a recertification survey to evaluate the facility's compliance with infection prevention and control requirements.
Findings
The facility failed to ensure proper infection control practices on one of five resident units, specifically by not disinfecting blood pressure cuffs between resident uses. Staff were reeducated and policies reinforced to address this issue.
Citations (1)
F 0880: The facility did not ensure blood pressure cuffs were disinfected between resident use on Unit 6, violating infection prevention protocols. Licensed Practical Nurse #1 was observed not sanitizing the BP cuff between residents.
Report Facts
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN) #1 | Observed not sanitizing BP cuff between resident uses | |
| Director of Nursing (DON) | Interviewed regarding infection control policies and staff reeducation |
Inspection Report — Sep 10, 2021
Complaint Investigation
Citations: 10
Date: Sep 10, 2021
Visit Reason
The inspection was conducted as a Recertification and Complaint Survey to investigate complaints and assess compliance with regulatory requirements.
Complaint Details
The complaint investigation revealed failures in notification of resident representatives, care planning, diabetes management, medication administration, activities programming, pressure ulcer prevention, range of motion device use, physician oversight, and infection control.
Findings
The facility was found deficient in multiple areas including failure to notify residents' representatives of significant changes, incomplete care plans, inadequate management of diabetes and medication administration, insufficient activities programming, improper pressure ulcer care, failure to maintain range of motion devices, and lapses in infection control related to oxygen tubing.
Citations (10)
F 0580: The facility failed to immediately notify a resident's representative about scheduled medical consultations and procedures, violating notification of changes requirements.
F 0656: The facility did not develop or implement a comprehensive care plan for a resident's oxygen therapy, omitting necessary interventions and equipment maintenance.
F 0658: Licensed nurses failed to inform the physician or nurse practitioner about elevated blood glucose readings and resident's refusal of treatment for diabetes management.
F 0679: The facility did not provide an ongoing activities program meeting the interests and psychosocial needs of a resident with severe cognitive impairment.
F 0684: A resident's frequent refusals of medication, finger sticks, and elevated blood glucose levels were not addressed by the care team to prevent complications associated with diabetes.
F 0686: The facility failed to provide pressure ulcer prevention services, including failure to apply ordered heel booties and turning and positioning as per care plan.
F 0688: A resident was not provided with ordered hand roll and hand splint devices consistently, risking further decline in range of motion and mobility.
F 0711: The physician did not review or address a resident's consistently high blood sugars and non-compliance with diabetic management at each required visit.
F 0759: The facility failed to administer six prescribed medications to a resident during medication administration observations, resulting in a medication error rate of 20.69%.
F 0880: The facility did not ensure proper infection control practices for oxygen therapy; oxygen tubing was not labeled and there was no documentation of tubing changes as required.
Report Facts
Medication error rate: 20.69
Fingerstick monitoring opportunities: 93
Fingerstick monitoring documented values: 18
Hemoglobin A1c: 12.4
Hemoglobin A1c: 13.4
Glucose level: 446
Glucose level: 374
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #6 | Licensed Practical Nurse | Observed medication administration and failed to administer six prescribed medications to Resident #86. |
| NP #4 | Nurse Practitioner | Interviewed and acknowledged elevated FSBS results for Resident #9 should have been addressed. |
| Attending Physician #10 | Physician | Interviewed and acknowledged Resident #9's elevated FSBS and medication refusals; made medication changes. |
| LPN #5 | Licensed Practical Nurse | Interviewed regarding medication administration and consult scheduling. |
| Director of Nursing | Director of Nursing | Interviewed regarding notification policies, medication ordering, and infection control practices. |
| Assistant Director of Nursing / Educator | Assistant Director of Nursing / Educator | Interviewed regarding staff education and documentation practices. |
| Certified Nursing Assistant #1 | Certified Nursing Assistant | Interviewed regarding application of hand roll and splint devices. |
| Certified Nursing Assistant #2 | Certified Nursing Assistant | Interviewed regarding resident activities and pressure ulcer prevention care. |
| Licensed Practical Nurse #7 | Licensed Practical Nurse | Interviewed regarding oxygen tubing change and labeling. |
| Licensed Practical Nurse #8 | Licensed Practical Nurse | Interviewed regarding oxygen tubing change and labeling. |
| Registered Nurse Supervisor #2 | Registered Nurse Supervisor | Interviewed regarding oxygen tubing change and labeling. |
Inspection Report — Feb 22, 2019
Annual Inspection
Citations: 2
Date: Feb 22, 2019
Visit Reason
The inspection was conducted as a Recertification survey to assess compliance with regulatory requirements for the nursing home facility.
Findings
The facility was found deficient in properly managing residents' personal funds by not providing quarterly financial statements to cognitively intact residents. Additionally, infection control practices were inadequate as a wound vac machine and tubing were observed on the floor, posing a risk to resident safety.
Citations (2)
F 0568: The facility did not ensure that individual financial records were available to residents through quarterly statements. Two cognitively intact residents with personal funds held by the facility did not receive quarterly statements as required by policy.
F 0880: The facility failed to maintain infection control practices by allowing a wound vac machine and tubing to rest on the floor on multiple occasions, which is against protocol and poses a risk of infection.
Report Facts
Residents reviewed for Personal Funds: 38
Residents affected: 2
Residents reviewed in Infection Control sample: 38
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Employee #1 | In charge of accounting and maintenance of resident's personal funds; described policy for quarterly statements | |
| Licensed Practical Nurse (LPN) | Observed wound vac machine on floor and did not remove it; did not educate resident | |
| Nurse Practitioner | Acknowledged wound vac machine and tubing should not be on floor | |
| RN Supervisor | Observed wound vac machine on floor and was informed | |
| Assistant Director of Nursing/Infection Preventionist | Conducted infection control inservice and stated wound vac machine should not be placed on floor |
Viewing
Loading inspection reports...
