Deficiencies per Year
36
27
18
9
0
Severe
High
Moderate
Low
Unclassified
Inspection Report
Complaint Investigation
Census: 53
Capacity: 59
Deficiencies: 34
Nov 3, 2025
Visit Reason
State-compiled facility profile showing 10 inspections from 2023-2025 with deficiency history and enforcement actions
Findings
Multiple inspections revealed numerous deficiencies including failure to ensure resident safety, abuse and neglect investigations, inadequate staffing, medication errors, infection control lapses, and food safety violations. Several deficiencies were corrected while others remained uncorrected across inspections.
Complaint Details
Multiple complaint investigations documented including abuse allegations involving Staff 3 (RN) forcing care on residents, failure to report and investigate abuse allegations, and failure to protect residents from abuse and neglect.
Deficiencies (34)
| Description | Severity |
|---|---|
| F0000 - INITIAL COMMENTS | — |
| F0554 - Resident Self-Admin Meds-Clinically Approp: Failure to assess residents for safe self-administration of medications, resulting in medications found at bedside without proper assessment | — |
| F0600 - Free from Abuse and Neglect: Failure to ensure residents were free from mental, verbal and physical abuse and intimidation | — |
| F0602 - Free from Misappropriation/Exploitation: Misappropriation of resident's personal property (missing oxycodone card) due to improper narcotic counts | — |
| F0604 - Right to be Free from Physical Restraints: Failure to assess use of seatbelt restraint on resident's motorized wheelchair | — |
| F0605 - Right to be Free from Chemical Restraints: Use of trazodone without appropriate diagnosis, associated with multiple resident falls | — |
| F0656 - Develop/Implement Comprehensive Care Plan: Failure to include monitoring for infection and proper ostomy care in resident's care plan | — |
| F0689 - Free of Accident Hazards/Supervision/Devices: Failure to prevent falls and ensure adequate staffing and supervision | — |
| F0725 - Sufficient Nursing Staff: Inadequate staffing leading to delayed call light response and unmet resident care needs | — |
| F0732 - Posted Nurse Staffing Information: Inaccurate or incomplete nurse staffing postings on multiple days | — |
| F0756 - Drug Regimen Review, Report Irregular, Act On: Failure to document clinical rationale for pharmacy recommendations | — |
| F0759 - Free of Medication Error Rts 5 Prcnt or More: Medication errors including late administration and incorrect dosing | — |
| F0761 - Label/Store Drugs and Biologicals: Medication refrigerator temperature logs incomplete and out of range temperatures noted | — |
| F0812 - Food Procurement,Store/Prepare/Serve-Sanitary: Failure to maintain sanitary food storage, labeling, and kitchen cleanliness | — |
| F0825 - Provide/Obtain Specialized Rehab Services: Missed therapy sessions and lack of documentation for ordered therapy services | — |
| F0880 - Infection Prevention & Control: Failure to follow transmission-based precautions and hand hygiene | — |
| M0183 - Nursing Services: Minimum CNA Staffing: Failure to meet mandatory minimum CNA staffing ratios on multiple dates | — |
| M0481 - Electrical System: Nurse Call System: Nurse call system not audible or visible, inadequate call light monitoring | — |
| F0884 - Reporting - National Health Safety Network: Failure to report complete COVID-19 information to NHSN during required periods | — |
| F0656 - Develop/Implement Comprehensive Care Plan (2024 inspection): Failure to implement care plans for ADLs for sampled residents | — |
| F0677 - ADL Care Provided for Dependent Residents: Failure to provide necessary personal hygiene care | — |
| F0684 - Quality of Care: Failure to monitor skin conditions and bruises | — |
| F0688 - Increase/Prevent Decrease in ROM/Mobility: Failure to prevent loss of range of motion and contractures | SS G |
| F0689 - Free of Accident Hazards/Supervision/Devices (2024 inspection): Failure to implement fall prevention and investigate falls | — |
| F0695 - Respiratory/Tracheostomy Care and Suctioning: Failure to obtain physician orders and maintain respiratory equipment | — |
| F0756 - Drug Regimen Review, Report Irregular, Act On (2024 inspection): Failure to document clinical rationale for pharmacy recommendations | — |
| F0758 - Free from Unnec Psychotropic Meds/PRN Use: Failure to attempt gradual dose reductions for psychotropic medications | — |
| F0759 - Free of Medication Error Rts 5 Prcnt or More (2024 inspection): Medication errors including late administration and incorrect dosing | — |
| F0812 - Food Procurement,Store/Prepare/Serve-Sanitary (2024 inspection): Failure to ensure proper food labeling, storage, and sanitation | — |
| F0600 - Free from Abuse and Neglect (2023 inspection): Failure to ensure residents free from abuse and intimidation, including forced care | — |
| F0609 - Reporting of Alleged Violations: Failure to report allegations of abuse | — |
| F0610 - Investigate/Prevent/Correct Alleged Violation: Failure to thoroughly investigate abuse allegations | — |
| F0658 - Services Provided Meet Professional Standards: Staff forced care on residents against their wishes and were rude | — |
| F0835 - Administration: Administrator failed to implement policies and prevent further abuse incidents | — |
Report Facts
Inspections on page: 10
Total deficiencies: 39
Total surveys: 10
Licensing violations: 20
Abuse violations: 0
Census: 53
Licensed beds: 59
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff 3 | RN | Named in multiple abuse and neglect findings involving forced care and intimidation |
| Staff 1 | Administrator | Named in findings related to failure to investigate and report abuse allegations |
| Staff 2 | DNS | Named in findings related to staffing and infection control |
| Staff 11 | Human Resources/Payroll/Staffing Coordinator | Named in staffing and nurse posting deficiencies |
| Staff 25 | Regional Director of Rehabilitation | Named in therapy service deficiencies |
| Staff 39 | Pharmacist | Named in medication review deficiencies |
| Staff 18 | CNA | Named in medication and care findings |
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