4 Reports
Inspection Report — Sep 10, 2025
Complaint Investigation State
Date: Sep 10, 2025
Visit Reason
State-compiled facility profile showing 3 inspections from 2023 to 2025 with deficiency history and complaint details.
Complaint Details
The state logged 78 complaints about this facility; 3 led to on-site inspections. No citations resulted from those complaints.
Findings
Across three inspections, inspectors issued a total of 52 citations including 19 standard health and 33 Life Safety Code citations. No formal enforcement actions were recorded, and most citations were corrected by the facility.
Citations (34)
Standard Health Citation — quality of care: Covid-19 Immunization protocols were deficient.
Standard Health Citation — quality of care: Food procurement, storage, preparation, and serving were unsanitary.
Standard Health Citation — quality of care: Failed to increase or prevent decrease in range of motion/mobility.
Standard Health Citation — quality of care: Infection prevention and control measures were inadequate.
Standard Health Citation — quality of care: Personal privacy and confidentiality of records were not maintained.
Standard Health Citation — quality of care: Resident rights were not fully exercised or respected.
Standard Health Citation — quality of care: Environment was not safe, clean, comfortable, or homelike.
Life Safety Code Citation — NFPA requirements: Building construction type and height did not meet code.
Life Safety Code Citation — NFPA requirements: Corridor doors were noncompliant.
Life Safety Code Citation — NFPA requirements: Discharge from exits was inadequate.
Life Safety Code Citation — NFPA requirements: Electrical systems maintenance and testing were deficient.
Life Safety Code Citation — NFPA requirements: EP testing requirements were not met.
Life Safety Code Citation — NFPA requirements: Fire alarm system testing and maintenance were inadequate.
Life Safety Code Citation — NFPA requirements: Hazardous areas were not properly enclosed.
Life Safety Code Citation — NFPA requirements: Maintenance, inspection, and testing of doors were deficient.
Life Safety Code Citation — NFPA requirements: Sprinkler system installation was noncompliant.
Life Safety Code Citation — NFPA requirements: Sprinkler system maintenance and testing were inadequate.
Life Safety Code Citation — NFPA requirements: Subsistence needs for staff and patients were not adequately met.
Standard Health Citation — quality of care: Activities of daily living maintenance abilities were deficient.
Standard Health Citation — quality of care: Food procurement, storage, preparation, and serving were unsanitary.
Standard Health Citation — quality of care: Resident rights were not fully exercised or respected.
Standard Health Citation — quality of care: Environment was not safe, clean, comfortable, or homelike.
Life Safety Code Citation — NFPA requirements: Building construction type and height did not meet code.
Life Safety Code Citation — NFPA requirements: Corridor doors were noncompliant.
Life Safety Code Citation — NFPA requirements: Electrical equipment power cords and extensions were unsafe.
Life Safety Code Citation — NFPA requirements: Exit signage was inadequate.
Life Safety Code Citation — NFPA requirements: HVAC systems were deficient.
Life Safety Code Citation — NFPA requirements: Illumination of means of egress was inadequate.
Life Safety Code Citation — NFPA requirements: Maintenance, inspection, and testing of doors were deficient.
Life Safety Code Citation — NFPA requirements: Physical environment was deficient.
Life Safety Code Citation — NFPA requirements: Sprinkler system installation was noncompliant.
Life Safety Code Citation — NFPA requirements: Sprinkler system maintenance and testing were inadequate.
Life Safety Code Citation — NFPA requirements: Subdivision of building spaces with smoke barriers was deficient.
Standard Health Citation — quality of care: Reporting to National Health Safety Network was deficient.
Report Facts
Inspections on page: 3
Total violations/deficiencies cited: 52
Inspections with violations: 3
Inspections without violations: 0
Total complaints: 78
On-site complaint inspections: 3
Total enforcement actions: 0
Total citations: 52
Inspection Report — Dec 4, 2023
Annual Inspection CMS
Date: Dec 4, 2023
Visit Reason
The inspection was conducted as a recertification survey from 11/28/2023 to 12/4/2023 to assess compliance with regulatory requirements for nursing home care.
Findings
The facility was found deficient in multiple areas including residents' rights to dignified existence, maintenance of a safe and homelike environment, ensuring residents maintain mobility, and food service safety. Deficiencies included unauthorized signage in a resident's room, broken bathroom door not repaired for over a year, failure to assist a resident with mobility as ordered, and multiple food safety violations such as soiled fans, improper food handling, expired and unlabeled food items, lack of thermometers for microwaves, and improper sanitation of food thermometers.
Citations (4)
Unauthorized sign next to Resident #46's bed stating 'walk me every day' violating resident's right to dignified existence.
Accordion style bathroom door in Resident #40's room was broken and falling off the track for at least a year.
Resident #65 was not assisted to get out of bed as ordered, risking loss of mobility.
Food service safety violations including heavily soiled circulation fans in food areas, kitchen staff using bare hands to retrieve foil from food, peeling food cart surfaces, multiple unlabeled and expired food items in nourishment refrigerators, lack of thermometers and procedures for microwaves on resident units, and improper sanitation of food thermometer probes.
Report Facts
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 3
Date survey completed: Dec 4, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Aide #1 | Certified Nurse Aide | Stated signs were to alert staff to walk Resident #46 |
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Stated sign was placed to remind staff to ambulate Resident #46 |
| Rehabilitation Director | Stated signs were placed to remind Resident #46 to walk with staff | |
| Licensed Practical Nurse #2 | Licensed Practical Nurse | Stated they never noticed the broken bathroom door in Resident #40's room |
| Registered Nurse #1 | Registered Nurse | Knew bathroom door was broken and documented it in maintenance logbook |
| Environmental Services Director | Stated they were unsure why bathroom door was not fixed and provided information on fan cleaning logs | |
| Certified Nurse Aide #2 | Certified Nurse Aide | Stated Resident #65 had not been out of bed this week |
| Director of Nursing | Director of Nursing | Stated Resident #65 should be out of bed daily and no formal system was in place to ensure this |
| Dietary Aide #1 | Dietary Aide | Observed working under dusty fan and stated they did not check fan cleanliness |
| Maintenance Worker #1 | Maintenance Worker | Responsible for cleaning fans monthly but fans were heavily soiled |
| Food Service Director | Acknowledged dusty fans, improper food handling, lack of thermometer use, and improper thermometer sanitation | |
| Licensed Practical Nurse #3 | Licensed Practical Nurse | Unaware of ownership of expired food items in nourishment refrigerator |
| Licensed Practical Nurse #4 | Licensed Practical Nurse | Stated no thermometer was available for microwaved foods |
Inspection Report — Oct 13, 2020
Annual Inspection CMS
Date: Oct 13, 2020
Visit Reason
The inspection was conducted as a recertification survey to assess compliance with professional standards for food safety in the storage of food brought in by visitors for residents.
Findings
The facility failed to ensure that foods stored in resident refrigerators on the first and second floors were properly labeled with the resident's name and date, and some food items were kept beyond the allowed 72 hours, posing a risk for foodborne illness.
Citations (1)
Foods stored in 2 of 3 unit refrigerators were not labeled with the resident's name or the date the item was brought to the facility.
Report Facts
Days food kept beyond allowed time: 5
Food discard timeframe: 72
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #1 | Observed first-floor refrigerator and stated food must be dated and labeled. | |
| LPN #1 | Unit Manager | Observed second-floor refrigerator and stated nursing is supposed to examine and discard food items after 72 hours. |
| Food Service Director | Interviewed regarding policy for food stored in residents' refrigerators and stated nursing is responsible for labeling and dating foods. |
Inspection Report — Mar 8, 2019
Annual Inspection CMS
Date: Mar 8, 2019
Visit Reason
The inspection was conducted as part of the recertification survey to assess compliance with federal, state, and local regulations and professional standards for nursing home care.
Findings
The facility was found deficient in multiple areas including failure to notify resident representatives and ombudsman in writing of hospital transfers, incomplete care plans addressing pain and depression, failure to include residents in care plan meetings, failure to provide ordered positioning devices, lack of timely optometry services, incomplete nurse staffing postings, administration of unnecessary medications without proper monitoring, storage of expired medications, failure to follow written menus, inadequate food safety and sanitation, lack of carbon monoxide detectors in mechanical rooms, improper infection control practices including hand hygiene, and unsafe mechanical equipment maintenance including roof leaks and inadequate ventilation.
Citations (13)
Failure to provide timely written notification to resident representatives and ombudsman of hospital transfers for 3 residents.
Failure to develop and implement care plans addressing pain and depression for residents.
Failure to include resident in care plan meetings.
Failure to provide ordered positioning splints to resident.
Failure to provide optometry services as ordered.
Failure to post nurse staffing information daily including resident census.
Failure to monitor pain level and effectiveness of pain medication for a resident receiving PRN pain medication.
Storage of expired medications in medication storage room.
Failure to follow written menus and provide adequate fresh fruits as planned.
Failure to ensure refrigerated food safety and maintain food service equipment free of debris.
Failure to install carbon monoxide detectors in mechanical rooms housing fuel-fired equipment.
Failure to maintain infection prevention and control program including hand hygiene and water management plan for Legionella.
Failure to maintain mechanical equipment in safe operating condition including roof leaks and inadequate ventilation in employee dining room.
Report Facts
Medication administration dates: 9
Expired medication dates: 3
Dates of nurse staffing postings: 10
Dates missing nurse staffing postings: 23
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Social Worker | Interviewed regarding lack of written notification to families and ombudsman of hospital transfers | |
| RN #1 | Registered Nurse | Interviewed regarding notification procedures and hand hygiene during meal observation |
| LPN #1 | Licensed Practical Nurse | Interviewed regarding responsibility for applying splints |
| LPN #2 | Licensed Practical Nurse | Interviewed regarding responsibility for applying splints |
| CNA #1 | Certified Nursing Assistant | Interviewed regarding application of splints and hand hygiene during meal observation |
| Nurse Practitioner | Interviewed regarding pain medication order monitoring and resident pain assessment | |
| Director of Nursing (DON) | Interviewed regarding care plan meetings and nurse staffing postings | |
| Food Service Director (FSD) | Interviewed regarding fresh fruit availability and food safety | |
| Director of Environmental Services | Interviewed regarding carbon monoxide detectors, roof leaks, and ventilation issues | |
| Maintenance Department staff member | Interviewed regarding carbon monoxide detectors, roof leaks, ventilation, and fire alarm system |
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