Deficiencies per Year
80
60
40
20
0
Severe
High
Moderate
Low
Unclassified
Inspection Report
Complaint Investigation
Deficiencies: 44
Jan 29, 2025
Visit Reason
State-compiled facility profile showing multiple complaint surveys and Covid-19 surveys from 2021 through 2025 with deficiency and enforcement history.
Findings
Across multiple inspections from 2021 to 2025, the facility received numerous Level 2 deficiencies primarily related to quality of care and life safety code issues, with one Level 3 deficiency indicating actual harm. Most deficiencies were corrected by follow-up dates. Enforcement actions included fines related to quality of care violations.
Complaint Details
The facility received 23 complaints from November 1, 2021 to October 31, 2025, with 27 complaint-related on-site inspections and 33 complaint-related citations during this period.
Severity Breakdown
Level 2: 53
Level 3: 1
Deficiencies (44)
| Description | Severity |
|---|---|
| Accounting and records of personal funds — Standard Health Inspection Citation: pertains to quality of care, e.g., resident care, staff/resident interaction, environment, and record-keeping. | Level 2 |
| Choose/be notified of room/roommate change — Standard Health Inspection Citation: pertains to quality of care, e.g., resident care, staff/resident interaction, environment, and record-keeping. | Level 2 |
| Develop/implement comprehensive care plan — Standard Health Inspection Citation: pertains to quality of care, e.g., resident care, staff/resident interaction, environment, and record-keeping. | Level 2 |
| Dispose garbage and refuse properly — Standard Health Inspection Citation: pertains to quality of care, e.g., resident care, staff/resident interaction, environment, and record-keeping. | Level 2 |
| Food procurement,store/prepare/serve-sanitary — Standard Health Inspection Citation: pertains to quality of care, e.g., resident care, staff/resident interaction, environment, and record-keeping. | Level 2 |
| Infection prevention & control — Standard Health Inspection Citation: pertains to quality of care, e.g., resident care, staff/resident interaction, environment, and record-keeping. | Level 2 |
| Label/store drugs and biologicals — Standard Health Inspection Citation: pertains to quality of care, e.g., resident care, staff/resident interaction, environment, and record-keeping. | Level 2 |
| Nurse aide peform review-12 hr/yr in-service — Standard Health Inspection Citation: pertains to quality of care, e.g., resident care, staff/resident interaction, environment, and record-keeping. | Level 2 |
| Protection/management of personal funds — Standard Health Inspection Citation: pertains to quality of care, e.g., resident care, staff/resident interaction, environment, and record-keeping. | Level 2 |
| Quality of care — Standard Health Inspection Citation: pertains to quality of care, e.g., resident care, staff/resident interaction, environment, and record-keeping. | Level 2 |
| Reasonable accommodations needs/preferences — Standard Health Inspection Citation: pertains to quality of care, e.g., resident care, staff/resident interaction, environment, and record-keeping. | Level 2 |
| Required in-service training for nurse aides — Standard Health Inspection Citation: pertains to quality of care, e.g., resident care, staff/resident interaction, environment, and record-keeping. | Level 2 |
| Resident rights/exercise of rights — Standard Health Inspection Citation: pertains to quality of care, e.g., resident care, staff/resident interaction, environment, and record-keeping. | Level 2 |
| Respiratory/tracheostomy care and suctioning — Standard Health Inspection Citation: pertains to quality of care, e.g., resident care, staff/resident interaction, environment, and record-keeping. | Level 2 |
| Right to be informed/make treatment decisions — Standard Health Inspection Citation: pertains to quality of care, e.g., resident care, staff/resident interaction, environment, and record-keeping. | Level 2 |
| Right to survey results/advocate agency info — Standard Health Inspection Citation: pertains to quality of care, e.g., resident care, staff/resident interaction, environment, and record-keeping. | Level 2 |
| Sufficient nursing staff — Standard Health Inspection Citation: pertains to quality of care, e.g., resident care, staff/resident interaction, environment, and record-keeping. | Level 2 |
| Surety bond-security of personal funds — Standard Health Inspection Citation: pertains to quality of care, e.g., resident care, staff/resident interaction, environment, and record-keeping. | Level 2 |
| Free of accident hazards/supervision/devices — Standard Health Inspection Citation: pertains to quality of care, e.g., resident care, staff/resident interaction, environment, and record-keeping. | Level 2 |
| Care plan timing and revision — Standard Health Inspection Citation: pertains to quality of care, e.g., resident care, staff/resident interaction, environment, and record-keeping. | Level 2 |
| Free from abuse and neglect — Standard Health Inspection Citation: pertains to quality of care, e.g., resident care, staff/resident interaction, environment, and record-keeping. | Level 2 |
| Investigate/prevent/correct alleged violation — Standard Health Inspection Citation: pertains to quality of care, e.g., resident care, staff/resident interaction, environment, and record-keeping. | Level 2 |
| Reporting - national health safety network — Standard Health Inspection Citation: pertains to quality of care, e.g., resident care, staff/resident interaction, environment, and record-keeping. | Level 2 |
| Accuracy of assessments — Standard Health Inspection Citation: pertains to quality of care, e.g., resident care, staff/resident interaction, environment, and record-keeping. | Level 2 |
| Behavioral health services — Standard Health Inspection Citation: pertains to quality of care, e.g., resident care, staff/resident interaction, environment, and record-keeping. | Level 2 |
| Free from abuse and neglect — Standard Health Inspection Citation: pertains to quality of care, e.g., resident care, staff/resident interaction, environment, and record-keeping. | Level 3 |
| Increase/prevent decrease in rom/mobility — Standard Health Inspection Citation: pertains to quality of care, e.g., resident care, staff/resident interaction, environment, and record-keeping. | Level 2 |
| Residents are free of significant med errors — Standard Health Inspection Citation: pertains to quality of care, e.g., resident care, staff/resident interaction, environment, and record-keeping. | Level 2 |
| Services provided meet professional standards — Standard Health Inspection Citation: pertains to quality of care, e.g., resident care, staff/resident interaction, environment, and record-keeping. | Level 2 |
| Treatment/svcs to prevent/heal pressure ulcer — Standard Health Inspection Citation: pertains to quality of care, e.g., resident care, staff/resident interaction, environment, and record-keeping. | Level 2 |
| Electrical systems - essential electric syste — Standard Life Safety Code Citation: pertains to a wide range of life safety code requirements as established by the National Fire Protection Agency (NFPA), including construction, protection and operational features designed to provide safety from fire, smoke, and panic. | Level 2 |
| Fire alarm system - testing and maintenance — Standard Life Safety Code Citation: pertains to a wide range of life safety code requirements as established by the National Fire Protection Agency (NFPA), including construction, protection and operational features designed to provide safety from fire, smoke, and panic. | Level 2 |
| Fire drills — Standard Life Safety Code Citation: pertains to a wide range of life safety code requirements as established by the National Fire Protection Agency (NFPA), including construction, protection and operational features designed to provide safety from fire, smoke, and panic. | Level 2 |
| Hazardous areas - enclosure — Standard Life Safety Code Citation: pertains to a wide range of life safety code requirements as established by the National Fire Protection Agency (NFPA), including construction, protection and operational features designed to provide safety from fire, smoke, and panic. | Level 2 |
| Sprinkler system - maintenance and testing — Standard Life Safety Code Citation: pertains to a wide range of life safety code requirements as established by the National Fire Protection Agency (NFPA), including construction, protection and operational features designed to provide safety from fire, smoke, and panic. | Level 2 |
| Corridor - doors — Standard Life Safety Code Citation: pertains to a wide range of life safety code requirements as established by the National Fire Protection Agency (NFPA), including construction, protection and operational features designed to provide safety from fire, smoke, and panic. | Level 2 |
| Corridors - construction of walls — Standard Life Safety Code Citation: pertains to a wide range of life safety code requirements as established by the National Fire Protection Agency (NFPA), including construction, protection and operational features designed to provide safety from fire, smoke, and panic. | Level 2 |
| Electrical equipment - power cords and extens — Standard Life Safety Code Citation: pertains to a wide range of life safety code requirements as established by the National Fire Protection Agency (NFPA), including construction, protection and operational features designed to provide safety from fire, smoke, and panic. | Level 2 |
| Electrical systems - maintenance and testing — Standard Life Safety Code Citation: pertains to a wide range of life safety code requirements as established by the National Fire Protection Agency (NFPA), including construction, protection and operational features designed to provide safety from fire, smoke, and panic. | Level 2 |
| Horizontal sliding doors — Standard Life Safety Code Citation: pertains to a wide range of life safety code requirements as established by the National Fire Protection Agency (NFPA), including construction, protection and operational features designed to provide safety from fire, smoke, and panic. | Level 2 |
| Maintenance, inspection & testing - doors — Standard Life Safety Code Citation: pertains to a wide range of life safety code requirements as established by the National Fire Protection Agency (NFPA), including construction, protection and operational features designed to provide safety from fire, smoke, and panic. | Level 2 |
| Physical environment — Standard Life Safety Code Citation: pertains to a wide range of life safety code requirements as established by the National Fire Protection Agency (NFPA), including construction, protection and operational features designed to provide safety from fire, smoke, and panic. | Level 2 |
| Sprinkler system - installation — Standard Life Safety Code Citation: pertains to a wide range of life safety code requirements as established by the National Fire Protection Agency (NFPA), including construction, protection and operational features designed to provide safety from fire, smoke, and panic. | Level 2 |
| Standards of construction for new existing nh — Standard Life Safety Code Citation: pertains to a wide range of life safety code requirements as established by the National Fire Protection Agency (NFPA), including construction, protection and operational features designed to provide safety from fire, smoke, and panic. | Level 2 |
Report Facts
Inspections on page: 17
Date range of inspections: From December 27, 2021 through January 29, 2025
Total citations: 37
Total complaints: 23
Complaint-related citations: 33
Complaint-related inspections: 27
Total fines: 30000
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