Inspection Report — Dec 4, 2025
Complaint Investigation
Citations: 31
Date: Dec 4, 2025
Visit Reason
State-compiled facility profile showing 15 inspections from 2022 to 2025 with deficiency and enforcement history.
Complaint Details
The state logged 124 complaints about this facility; 17 led to on-site inspections.
Findings
Across 15 inspections, 13 resulted in citations totaling 42 deficiencies primarily related to standard health and life safety code issues. The facility had 2 enforcement actions with fines totaling $30,000 and multiple complaints leading to on-site inspections.
Citations (31)
Notify Of Changes (injury/decline/room, Etc.): Failed to properly notify changes affecting residents.
Accounting And Records Of Personal Funds: Inadequate management of residents' personal funds.
Choose/be Notified Of Room/roommate Change: Residents were not properly notified or allowed to choose room changes.
Develop/implement Comprehensive Care Plan: Care plans were not adequately developed or implemented.
Dispose Garbage And Refuse Properly: Improper disposal of garbage and refuse noted.
Food Procurement,store/prepare/serve-sanitary: Sanitary issues in food procurement, storage, preparation, or service.
Infection Prevention & Control: Infection control protocols were insufficient.
Label/store Drugs And Biologicals: Medication labeling and storage were inadequate.
Nurse Aide Peform Review-12 Hr/yr In-service: Nurse aide training and performance reviews were deficient.
Protection/management Of Personal Funds: Personal funds were not properly protected or managed.
Quality Of Care: Quality of care standards were not fully met.
Reasonable Accommodations Needs/preferences: Reasonable accommodations for resident needs and preferences were lacking.
Required In-service Training For Nurse Aides: Required in-service training for nurse aides was incomplete.
Resident Rights/exercise Of Rights: Residents' rights were not fully respected or exercised.
Respiratory/tracheostomy Care And Suctioning: Deficiencies in respiratory and tracheostomy care and suctioning.
Right To Be Informed/make Treatment Decisions: Residents were not adequately informed to make treatment decisions.
Right To Survey Results/advocate Agency Info: Residents were not properly informed about survey results or advocacy information.
Sufficient Nursing Staff: Nursing staff levels were insufficient.
Surety Bond-security Of Personal Funds: Surety bond security for personal funds was inadequate.
Electrical Systems - Essential Electric Syste: Essential electrical systems did not meet NFPA requirements.
Fire Alarm System - Testing And Maintenance: Fire alarm system testing and maintenance were deficient.
Fire Drills: Fire drills were not conducted according to NFPA requirements.
Hazardous Areas - Enclosure: Hazardous areas were not properly enclosed.
Sprinkler System - Maintenance And Testing: Sprinkler system maintenance and testing were inadequate.
Free Of Accident Hazards/supervision/devices: Facility was not free of accident hazards or lacked proper supervision/devices.
Pain Management: Pain management practices were insufficient.
Right To Participate In Planning Care: Residents were not adequately involved in care planning.
Care Plan Timing And Revision: Care plans were not timely revised or updated.
Free From Abuse And Neglect: Residents were not fully protected from abuse and neglect.
Investigate/prevent/correct Alleged Violation: Alleged violations were not properly investigated, prevented, or corrected.
Reporting - National Health Safety Network: Failed to properly report to the National Health Safety Network.
Report Facts
Inspections on page: 15
Total violations/deficiencies cited: 42
Inspections with violations: 13
Inspections without violations: 2
Complaints total: 124
Complaints leading to on-site inspections: 17
Enforcement actions: 2
Total fines: 30000
Citations from complaints: 19
Inspection Report — Oct 21, 2025
Abbreviated Survey
Citations: 1
Date: Oct 21, 2025
Visit Reason
The abbreviated survey was conducted to review compliance related to resident abuse and notification policies following an incident involving Resident #1 on 09/27/2025.
Complaint Details
The investigation was complaint-related, triggered by the resident's family grievance that they were not notified timely about the incident on 09/27/2025. The complaint was substantiated, resulting in counseling and reeducation of the nursing supervisor.
Findings
The facility failed to ensure timely notification of the resident's representative regarding an incident involving Resident #1, who had an aggressive altercation requiring psychiatric evaluation. The family was only informed by the resident during a visit, leading to a grievance and subsequent counseling and reeducation of the nursing supervisor.
Citations (1)
Failure to timely notify the resident's representative of an incident involving Resident #1.
Report Facts
Residents reviewed for abuse: 3
Residents affected: 1
Incident date: Sep 27, 2025
Survey dates: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse Supervisor #7 | Registered Nurse Supervisor | Informed family about Resident #1 swinging a chair and hitting the wall |
| Certified Nurse #1 | Certified Nurse | Asked by Resident #1 to keep the door open during the incident |
| Certified Nurse Aide #1 | Certified Nurse Aide | Denied Resident #1's request to keep the door open and was sitting outside Resident #1's room during the incident |
| Registered Nurse Supervisor #2 | Registered Nurse Supervisor | Observed the incident aftermath and reported on family notification attempts |
| Registered Nurse #3 | Medication Nurse | Asked Registered Nurse Supervisor #2 to come to unit 2 during the incident |
| Assistant Director of Nursing | Assistant Director of Nursing | Attended family meeting and addressed concerns about notification |
| Social Worker #6 | Social Worker | Aware of family meeting and grievance regarding the incident |
| Administrator | Administrator | Attended interdisciplinary meeting and initiated grievance regarding family notification |
Inspection Report — Jan 29, 2025
Annual Inspection
Citations: 16
Date: Jan 29, 2025
Visit Reason
The inspection was a Recertification and Abbreviated survey conducted from 01/22/2025 to 01/29/2025 to assess compliance with regulatory requirements for nursing home operations and resident care.
Findings
The facility was found deficient in multiple areas including resident dignity during feeding, resident rights regarding treatment and room changes, financial management, care planning, medication administration, respiratory care, staffing adequacy, nurse aide training and performance reviews, medication storage, food safety, infection control, and waste disposal.
Citations (16)
Facility staff were observed standing over residents while assisting with meals, not ensuring a dignified dining experience.
Facility administered Donepezil to a resident despite the representative's request to withhold the medication.
Resident's wheelchair unable to maneuver around bed preventing access to bathroom; no reasonable accommodation provided.
Resident's Health Care Agent did not receive written notice or explanation for room change.
Facility diverted resident's income to personal needs account without informing court-appointed Legal Guardian.
Facility's surety bond was less than the total amount of resident personal needs accounts managed by the facility.
Facility did not post survey results in a place readily accessible to residents and families.
Resident receiving continuous oxygen therapy without a documented respiratory/oxygen care plan.
Resident's insulin order had a discrepancy and was not followed as written; sliding scale used without additional unit of insulin.
Multiple residents on oxygen observed with oxygen flow rates inconsistent with physician orders; delayed implementation of humidified oxygen as recommended by ENT.
Facility did not provide sufficient nursing staff per facility assessment; residents reported staffing shortages affecting care.
Certified nurse aide performance reviews were incomplete or not conducted annually for several aides.
Expired medical supplies found in medication storage rooms; undated open supplement bottle found on medication cart.
Food items in kitchen and unit pantries were not properly sealed, dated, or stored; expired food was not discarded; food served at inappropriate temperatures.
Trash compactor had food spilling out and recycled boxes were littered around dumpster area.
Staff failed to maintain infection prevention and control practices including improper use of personal protective equipment for residents on enhanced barrier precautions and failure of some staff to receive influenza vaccination or wear masks.
Report Facts
Residents reviewed for dignity while dining: 35
Residents reviewed for resident rights: 2
Residents reviewed for environment: 7
Residents reviewed for choices: 7
Residents reviewed for personal funds: 3
Resident personal needs accounts: 106
Sum total of resident personal needs accounts: 278452.49
Certified Nurse Aides reviewed for performance: 5
Residents reviewed for respiratory care: 3
Residents reviewed for insulin treatment: 4
Residents reviewed for infection control: 3
Staff reviewed for influenza vaccination: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Aide #21 | Certified Nurse Aide | Observed standing while feeding Resident #168 and interviewed about feeding practice |
| Registered Nurse #27 | Registered Nurse | Observed standing while feeding Resident #14 and interviewed about feeding protocol |
| Director of Nursing | Director of Nursing | Interviewed regarding medication administration and facility protocols |
| Nurse Practitioner | Nurse Practitioner | Interviewed regarding medication discontinuation for Resident #233 |
| Administrator | Administrator | Interviewed regarding resident room access issues and survey posting |
| Fiscal Manager | Fiscal Manager | Interviewed regarding resident funds management and representative payee status |
| Staffing Educator | Staffing Educator | Interviewed regarding nurse aide performance reviews and training |
| Certified Nurse Aide #36 | Certified Nurse Aide | Observed providing care without proper PPE for resident on enhanced barrier precautions |
| Licensed Practical Nurse #17 | Licensed Practical Nurse | Observed not wearing mask and not vaccinated for influenza |
| Certified Nurse Aide #15 | Certified Nurse Aide | Observed not wearing mask and not vaccinated for influenza |
| Registered Nurse Unit Manager #5 | Registered Nurse Unit Manager | Interviewed regarding oxygen care plan and insulin order discrepancy |
| Licensed Practical Nurse Unit Manager #3 | Licensed Practical Nurse Unit Manager | Interviewed regarding oxygen administration and flow rate |
| Registered Nurse #2 | Registered Nurse | Interviewed regarding oxygen administration and tubing connection |
| Medical Doctor #1 | Medical Doctor | Interviewed regarding delayed notification of ENT recommendations |
| Nurse Educator | Nurse Educator | Interviewed regarding staff immunization records |
| Staffing Coordinator | Staffing Coordinator | Interviewed regarding staffing levels and facility assessment |
| Certified Nurse Aide #1 | Certified Nurse Aide | Interviewed regarding staffing shortages |
| Human Resource Director | Human Resource Director | Interviewed regarding performance review documentation and influenza vaccination policy |
Inspection Report — Jan 21, 2025
Abbreviated Survey
Citations: 2
Date: Jan 21, 2025
Visit Reason
The abbreviated survey was conducted to assess the facility's compliance with regulations regarding resident safety and supervision, specifically focusing on accident prevention and monitoring of residents at risk for harm.
Findings
The facility failed to provide adequate supervision and monitoring to prevent accidents for two residents, including lack of documented 1:1 monitoring for a resident with suicidal behavior and insufficient care plan interventions and therapy evaluations for a resident with multiple falls and severe cognitive impairment.
Citations (2)
Failure to provide documented 1:1 monitoring for Resident #3 with suicidal history after a self-inflicted wrist laceration.
Lack of appropriate care plan interventions and therapy evaluations following multiple falls for Resident #10 with severe cognitive impairment.
Report Facts
Falls without injury: 6
Falls with injury: 1
Brief Interview for Mental Status (BIMS) score: 15
Brief Interview for Mental Status (BIMS) score: 4
Barthel Index Score: 24
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Aide #1 | Interviewed regarding lack of knowledge of monitoring for Resident #3 | |
| Certified Nurse Aide #2 | Interviewed about incident and monitoring for Resident #3 | |
| Certified Nurse Aide #3 | Reported blood on floor and interaction with Resident #3 | |
| Nursing Supervisor #1 | Nursing Supervisor | Provided information on monitoring and assessment of Resident #3 |
| Director of Nursing | Director of Nursing | Interviewed about monitoring expectations and documentation |
| Administrator | Administrator | Interviewed about expectations for monitoring documentation |
| Director of Social Services | Director of Social Services | Interviewed about room assignment and family interactions for Resident #10 |
| Physical Therapist | Physical Therapist | Interviewed about therapy evaluations for Resident #10 |
Inspection Report — Aug 21, 2024
Abbreviated Survey
Citations: 2
Date: Aug 21, 2024
Visit Reason
The abbreviated survey was conducted from 8/19/24 to 8/20/24 to evaluate compliance with care planning and pain management standards, specifically focusing on Resident #1's care after being placed on Comfort Care.
Findings
The facility failed to ensure Resident #1's preferences and designated representative were included in pain management care planning. Pain management was inadequate, with no documented pain assessments or interventions after the family requested morphine. The primary physician did not order morphine due to medical concerns and did not communicate effectively with the family. The resident was found unresponsive and pronounced dead on 8/10/24.
Citations (2)
Failure to allow resident to participate in the development and implementation of his or her person-centered plan of care, specifically excluding the designated representative in pain management care planning.
Failure to provide safe, appropriate pain management for a resident who requires such services, including lack of documented pain assessments and interventions despite family requests for pain medication.
Report Facts
Residents reviewed for pain management: 3
Residents affected: 1
Physician's Orders date: Aug 1, 2024
Date resident placed on Comfort Care: Aug 9, 2024
Date resident pronounced dead: Aug 10, 2024
Number of facilities physician was on call for: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse Supervisor #1 | Registered Nurse Supervisor | Documented family request for morphine and communicated with primary physician |
| Registered Nurse #2 | Registered Nurse | Provided care to Resident #1 and reported awareness of Comfort Care status |
| Assistant Medical Director | Assistant Medical Director | Informed about Resident #1's condition and ordered to hold medication |
| Primary Physician | Primary Physician | Made decisions regarding pain medication orders and communicated with family and staff |
| Director of Nursing | Director of Nursing | Provided statements regarding Comfort Care policies and communication responsibilities |
| Administrator | Administrator | Stated expectations for pain management for residents on Comfort Care |
Inspection Report — Aug 8, 2024
Abbreviated Survey
Citations: 4
Date: Aug 8, 2024
Visit Reason
The inspection was conducted as an abbreviated survey to investigate allegations of abuse and to assess compliance with care planning and accident prevention regulations.
Complaint Details
The complaint investigation involved allegations that a Certified Nurse Assistant shoved Resident #1 on 2/20/2023 and that Licensed Practical Nurse #2 pinched Resident #4 on 1/25/2024. The facility conducted investigations but did not substantiate the abuse due to lack of evidence, including no video footage. The facility delayed reporting the incidents to the State Department of Health and failed to complete required documentation timely. Resident #1's abuse care plan was not updated to reflect the incident. Licensed Practical Nurse #2 was suspended for not reporting the incident but later returned to work on the same unit.
Findings
The facility failed to ensure residents were free from abuse, did not thoroughly investigate and report abuse allegations timely, failed to update care plans to reflect abuse incidents, and did not provide adequate supervision or safety measures to prevent accidents for at least two residents.
Citations (4)
Failure to protect residents from physical abuse, specifically a Certified Nurse Assistant shoved a resident.
Failure to respond appropriately to alleged violations of abuse, including incomplete investigations and delayed reporting to the State Department of Health.
Failure to develop and revise the comprehensive care plan to reflect an allegation of abuse for a resident.
Failure to ensure adequate supervision and assistive devices to prevent accidents, resulting in a resident fall with injury.
Report Facts
Residents reviewed for abuse: 6
Brief Interview of Mental Status score: 15
Brief Interview for Mental Status score: 12
Fall risk score: 6
Date of fall resulting in injury: Oct 12, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Assistant #1 | Named in physical abuse allegation for shoving Resident #1 and subsequently terminated | |
| Licensed Practical Nurse #2 | Named in allegation of pinching Resident #4 and suspended for not reporting the incident | |
| Staff #2 | Registered Nurse Supervisor | Interviewed regarding abuse allegation investigation and reporting |
| Assistant Director of Nursing | Conducted investigation and interviews related to abuse allegations and care plan updates | |
| Director of Nursing | Provided statements regarding investigation, reporting, and care plan responsibilities |
Inspection Report — Mar 21, 2022
Annual Inspection
Citations: 5
Date: Mar 21, 2022
Visit Reason
The inspection was a recertification and abbreviated survey conducted from 3/14/22 to 3/21/22 to assess compliance with federal regulations for nursing home care.
Findings
The facility was found deficient in multiple areas including failure to ensure resident dignity related to catheter bag privacy, failure to protect residents from abuse resulting in actual harm, failure to develop and implement comprehensive care plans for residents' needs including contractures and respiratory care, failure to provide appropriate care to maintain range of motion, and failure to implement infection prevention and control practices including proper sanitization of nebulizer tubing and glucometer.
Citations (5)
Failure to ensure resident dignity by not covering urine-filled catheter bag visible from hallway for resident #155.
Failure to protect resident #119 from abuse by resident #58 resulting in a wrist fracture.
Failure to develop and implement a comprehensive care plan for resident #82's contractures and for resident #102's nebulizer treatment.
Failure to provide appropriate care to maintain or improve range of motion for resident #82 by not applying ordered splint device.
Failure to implement infection prevention and control program including improper protection and labeling of nebulizer tubing for resident #102 and failure to sanitize glucometer between residents.
Report Facts
Residents reviewed for dignity: 2
Residents reviewed for abuse: 5
Residents reviewed for positioning/mobility: 1
Residents reviewed for respiratory care: 1
Residents reviewed for limited ROM: 2
Residents reviewed for blood glucose check: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #11 | Licensed Practical Nurse | Mentioned in relation to catheter bag privacy and responsibility for CNA oversight |
| RN/Staff Educator | Inservice Coordinator | Provided information on catheter bag privacy practices |
| CNA #5 | Certified Nursing Assistant | Interviewed about catheter bag placement |
| LPN #12 | Licensed Practical Nurse | Documented escalating behaviors of Resident #58 |
| LPN #9 | Licensed Practical Nurse | Documented aggressive behavior and incident with Resident #58 |
| LPN #6 | Licensed Practical Nurse | Documented incidents involving Resident #58 and Resident #119 |
| RN #3 | Registered Nurse | Assessed aggressive behavior of Resident #58 and involved in hospital transfer |
| Administrator #1 | Administrator | Provided statements about Resident #58 placement and behavior management |
| CNA #1 | Certified Nursing Assistant | Interviewed about care and device application for Resident #82 |
| RNUM #3 | Registered Nurse/Unit Manager | Interviewed about care plan and device application for Resident #82 and glucometer sanitization |
| COTA | Certified Occupational Therapy Assistant | Provided information on splint device recommendation and rehab follow-up |
| RS | Rehab Supervisor | Discussed device replacement and nursing notification |
| LPN #7 | Licensed Practical Nurse | Interviewed about nebulizer treatment and tubing protection |
| RNUM #2 | Registered Nurse Unit Manager | Interviewed about Albuterol order and care plan initiation |
| LPN #1 | Licensed Practical Nurse | Observed not sanitizing glucometer between residents |
| DON | Director of Nursing Services | Commented on glucometer sanitization compliance and monitoring |
Inspection Report — Jul 17, 2019
Annual Inspection
Citations: 9
Date: Jul 17, 2019
Visit Reason
The inspection was a recertification survey to assess compliance with federal regulations for nursing homes.
Findings
The facility was found deficient in multiple areas including failure to provide timely written notification to resident representatives upon hospital transfers, incomplete care plans and inadequate implementation of pain management and nutrition interventions, failure to provide appropriate treatment and care according to physician orders, unsafe equipment monitoring, inadequate catheter care, medication availability issues, failure to monitor antipsychotic medication effects, unsecured medications, and improper food storage and sanitation procedures.
Citations (9)
Failure to provide timely written notification to resident representatives upon hospital transfers for 3 residents.
Incomplete care plans and failure to implement pain management and nutrition interventions for 4 residents.
Failure to provide appropriate treatment and care according to physician orders for 3 residents, including delayed treatment after a fall, wound care omissions, and failure to administer critical medication.
Failure to implement effective monitoring procedures to ensure resident assistive equipment (Hoyer lift pads) remain free from repeat accident hazards.
Failure to provide appropriate catheter care and urine output monitoring for a resident with an indwelling catheter.
Medications were not available when needed, resulting in delayed administration of Kayexalate for a resident with elevated potassium levels.
Failure to ensure diagnostic monitoring results (EKGs) for a resident on antipsychotic medication were available and reviewed by the physician, with no evidence of medication discontinuation after abnormal EKG findings.
Medications, including prescription eye drops, were not secured in a locked storage area and were found in a resident's bedside table without physician orders or care plan authorization for self-administration.
Improper food handling and sanitation practices including delayed storage of potentially hazardous food, freezer packed to the door with ice buildup, and dishwasher not sanitizing dishes due to malfunction and inadequate sanitizer concentration.
Report Facts
Residents reviewed for hospitalization: 3
Residents sampled for care plan review: 40
Residents reviewed for pain management: 3
Residents reviewed for skin impairment: 6
Residents reviewed for medication administration: 5
EKG reports uploaded: 8
Freezer temperature: 45
Freezer temperature: -10
Dishwasher final rinse temperature: 160
Dishwasher final rinse temperature: 170
Potassium level: 7.5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #3 | Registered Nurse Manager | Interviewed about written notices to families regarding hospital transfers and catheter care documentation |
| RN #4 | Registered Nurse/Unit Manager | Interviewed about pain monitoring and hospital transfer notifications |
| LPN #2 | Medication Nurse | Interviewed about pain assessment and medication administration |
| LPN #5 | Medication Nurse | Interviewed about nutrition plan implementation |
| RD | Registered Dietitian | Interviewed about nutrition plan implementation |
| RN #1 | Unit Manager | Interviewed about medication availability and medication security |
| LPN #1 | Medication Nurse | Interviewed about medication availability |
| RN #2 | Night Nurse | Interviewed about medication availability |
| RN #5 | Registered Nurse Supervisor | Interviewed about wound care orders |
| LPN #3 | Licensed Practical Nurse | Interviewed about laundry inspection of Hoyer lift pads |
| Physician | Primary Care Physician | Interviewed about medication and EKG monitoring for Resident #179 and Resident #66 |
| Food Service Manager | Interviewed about freezer operation and food delivery | |
| Regional Food Service Manager | Interviewed about dishwasher sanitizing process | |
| Technician | Interviewed about dishwasher malfunction and repair | |
| CNA #1 | Certified Nursing Assistant | Interviewed about catheter care for Resident #205 |
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