Inspection Report Summary
The most recent inspection on June 17, 2025, found no deficiencies and confirmed the facility was back in compliance as of May 10, 2025. Earlier inspections showed a pattern of deficiencies related primarily to medication administration errors, medication storage issues, neurological assessment documentation, infection control practices, and care plan implementation. Complaint investigations included substantiated findings of medication errors and improper medication storage, as well as failure to conduct neurological assessments after a resident fall. Enforcement actions such as fines or license suspensions were not listed in the available reports. The facility appears to have addressed prior deficiencies with corrective actions and follow-up inspections indicating improvement over time.
Deficiencies (last 8 years)
Deficiencies are regulatory violations found during state inspections.
Deficiencies per year
Census
Based on a June 2025 inspection.
Census over time
| Name | Title | Context |
|---|---|---|
| Andrew Wildman | Administrator | Personnel contacted during inspection |
| Linda M Gagnon | Surveyor | Surveyor conducting the inspection |
| Name | Title | Context |
|---|---|---|
| Lisa Taylor | Personnel contacted during inspection | |
| Emily Quade | Personnel contacted during inspection | |
| Marie Mathieu | Survey Team Leader | Survey team leader and report submitter |
| Norma Schuberth | Supervisor | Survey supervisor |
| Description |
|---|
| Violation #1 |
| Violation #2 |
| Name | Title | Context |
|---|---|---|
| Pedro Roman | DNS | Personnel contacted during inspection |
| Andrew Wildman | Administrator | Personnel contacted during inspection |
| Danielle Castro | NC | Report submitted by |
| Stephanie Schumann | NC | Signature of FLIS Staff |
| Name | Title | Context |
|---|---|---|
| Andrew Wildman | Administrator | Personnel contacted during inspection |
| Pedro Roman | DNS | Personnel contacted during inspection and notified of correction |
| Stephanie Schumann | Report submitted by | |
| Karen Gworek | Supervisor | Survey team supervisor |
| Danielle Castro | FLIS staff signature |
| Description |
|---|
| Violation #1 identified in previous inspection |
| Name | Title | Context |
|---|---|---|
| Pedro Roman | DNS | Notified in person of correction of violations |
| Andrew Wildman | Administrator | Notified in person of correction of violations |
| Name | Title | Context |
|---|---|---|
| Andrew Wildman | Administrator | Contacted during inspection and notified of correction status |
| Danielle Castro | RN, NC | Report submitted by |
| Karen Gworek | Supervisor | Supervisor of the survey team |
| Description | Severity |
|---|---|
| Failed to administer medication per physician's order resulting in a medication error for Resident #1. | F760, SS=D |
| Failed to ensure medications were stored in a clean, sanitary manner and properly labeled. | F761, SS=E |
| Name | Title | Context |
|---|---|---|
| Andrew Wildman | Administrator | Facility administrator contacted during inspection. |
| Pedro Roman | Director of Nursing (DON) | Interviewed regarding medication administration and medication cart cleaning policies. |
| Karen Gworek | Supervising Nurse Consultant | Author of the violation notice letter related to complaint #36746. |
| Licensed Practical Nurse (LPN) #1 | Administered medication in error to Resident #1. | |
| Licensed Practical Nurse (LPN) #5 | Identified loose pills in medication cart on Deerfield 2 unit. | |
| Licensed Practical Nurse (LPN) #4 | Identified loose pills in medication cart on Deerfield 1 unit. | |
| Licensed Practical Nurse (LPN) #6 | Identified loose pills in medication cart on Birchwood 1 unit and discussed cleaning schedules. | |
| Licensed Practical Nurse (LPN) #7 | New employee unaware of medication cart cleaning schedules. | |
| Licensed Practical Nurse (LPN) #8 | Responsible for daily cleaning of medication cart during night shift. |
| Name | Title | Context |
|---|---|---|
| Pedro Roman | RN, DNS | Personnel contacted during the inspection |
| Kibby Phillips | Generalist Surveyor, HPA | Signature of FLIS Staff and report submitter |
| Description | Severity |
|---|---|
| Failure to conduct neurological assessments in accordance with facility policy for a resident who had an unwitnessed fall. | SS=D |
| Name | Title | Context |
|---|---|---|
| RN #1 | 3-11PM Nursing Supervisor | Conducted initial assessment and neurological checks after resident fall. |
| RN #3 | Charge Nurse | Responsible nurse on unit during fall; reported swelling and discoloration of resident's eye. |
| Assistant Director of Nursing | Assistant Director of Nursing (ADON) | Provided interview regarding facility fall and neurological check policies. |
| Description |
|---|
| Failure to conduct neurological assessments in accordance with the facility's policy and procedure for a resident who had an unwitnessed fall. |
| Name | Title | Context |
|---|---|---|
| Ellen Casey | Administrator | Named as personnel contacted and recipient of the important notice. |
| Karen Gworek | Supervising Nurse Consultant | Supervisor and signatory of the inspection report and notice. |
| Kathleen Plaskon | Survey Team Leader | Survey team leader and report submitter. |
| Description | Severity |
|---|---|
| Failure to perform a comprehensive risk assessment for new/readmissions and appropriately cohort residents based on that risk assessment. | SS=E |
| Failure to ensure signage was visible on the door of residents' rooms who were on transmission-based precautions. | SS=E |
| Description |
|---|
| Failure to perform a comprehensive risk assessment for new/readmissions and appropriately cohort residents based on transmission-based precautions. |
| Failure to ensure signage was visible on doors of residents' rooms on transmission-based precautions. |
| Failure to ensure PPE was available outside the doors of residents on droplet precautions. |
| Name | Title | Context |
|---|---|---|
| Ellen Casey | Administrator | Interviewed on 9/24/20 regarding hospital relationship and Covid-19 case transparency |
| Norma Schuberth | Supervising Nurse Consultant | Author of the report and contact for questions regarding violations |
| Director of Nursing Services | Interviewed on 9/24/20; ultimately responsible for compliance with plan of correction |
| Description |
|---|
| Violations 1a, 1b, 2a, 2b, 2c, 2d, 2e, and 3a were corrected. |
| Name | Title | Context |
|---|---|---|
| Holly Dwyer | Director of Nursing Services (DNS) | Personnel contacted during inspection |
| Ronald Arnone | RN | Report submitted by |
| Description |
|---|
| Failure to ensure the resident's urinary catheter bag was covered to promote dignity. |
| Medications and biologicals were not expired and/or labeled properly, including expired insulin and undated tuberculin solution. |
| Failure to maintain the catheter according to professional standards for infection control. |
| Failure to report alleged abuse immediately and failure to ensure staff reported abuse per policy. |
| Failure to ensure timely assessment and treatment of residents' wounds and pressure ulcers. |
| Failure to ensure fall care plans were implemented and residents were supervised as directed. |
| Failure to ensure medications that expired were removed and destroyed per facility policy. |
| Name | Title | Context |
|---|---|---|
| Ellen Casey | Administrator | Named in relation to findings and plan of correction |
| Holly Dwyer | RN DNS | Named in relation to inspection and findings |
| Norma Schuberth | Supervising Nurse Consultant | Signed enforcement and violation letters |
| Cheryl Davis | Supervising Nurse Consultant | Signed complaint investigation correspondence |
| Margaret Hager | Reported submitted inspection reports | |
| Melissa Dziob | Supervisor | Signed final compliance letter |
| Description | Severity |
|---|---|
| Failure to ensure staff reported an allegation of abuse immediately in accordance with facility policy for Resident #1. | SS=D |
| Failure to implement care plan interventions for Resident #2 related to fall prevention, including 1:1 supervision and use of non-skid footwear. | SS=D |
| Failure to promptly notify the ordering physician of abnormal X-ray results for Resident #3. | SS=D |
| Name | Title | Context |
|---|---|---|
| Nurse #1 | Licensed Practical Nurse | Named in abuse allegation involving Resident #1 |
| CNA #1 | Nurse Aide | Reported alleged abuse of Resident #1 |
| Assistant Director of Nursing | Reported abuse allegation to DON and participated in investigation | |
| Director of Nurses | Reviewed abuse investigation and care plan deficiencies | |
| APRN #1 | Advanced Practice Registered Nurse | Ordered X-ray and involved in diagnostic result notification for Resident #3 |
| Description |
|---|
| Failure to report abnormal x-ray results promptly to the physician. |
| Failure to properly report and address an alleged abuse incident involving a nurse and a resident. |
| Failure to revise and implement fall care plans for residents who experienced falls. |
| Name | Title | Context |
|---|---|---|
| Ellen Casey | Administrator | Signed the Plan of Correction letter. |
| Description |
|---|
| Failure to ensure a homelike environment due to foam tubing held with masking tape on a resident's padded side rail. |
| Failure to ensure a hazard-free environment resulting in a resident falling from a wheelchair due to dislodged backrest pins. |
| Failure to monitor and track residents on active isolation precautions and ineffective housekeeping practices for residents on isolation. |
| Failure to ensure dietary staff followed accepted infection control practices while handling clean dishes and washing hands. |
| Failure to maintain a three-day emergency food supply with missing items such as pudding, wax beans, peas, and baked beans. |
| Name | Title | Context |
|---|---|---|
| Kim Hriceniak | Supervising Nurse Consultant | Signed the violation letters and reports. |
| Mary Tobin | Administrator | Named as personnel contacted during the inspection. |
| Director of Nursing Services | Interviewed regarding foam tubing and wheelchair backrest issues. | |
| LPN #1 | Licensed Practical Nurse | Interviewed regarding resident fall from wheelchair. |
| OT #1 | Occupational Therapist | Interviewed regarding wheelchair backrest pins. |
| OT #2 | Occupational Therapist | Evaluated wheelchair after resident fall. |
| Housekeeper #1 | Interviewed about cleaning procedures for rooms with active infections. | |
| Housekeeper #2 | Interviewed about cleaning procedures. | |
| Housekeeper #3 | Interviewed about cleaning procedures. | |
| Housekeeper #4 | Interviewed about cleaning procedures. | |
| Director of Food Services | Interviewed about emergency food supply and dietary staff practices. | |
| Dietary Aide #1 | Observed removing clean dishes improperly and interviewed about handwashing. | |
| Infection Control Nurse/RN #1 | Interviewed about infection control practices. |
| Description |
|---|
| Failure to ensure proper resident assessments and documentation after incidents such as falls and skin tears. |
| Failure to notify the state ombudsman's office concerning residents transferred and admitted to the hospital. |
| Failure to maintain specialty air mattress according to physician orders. |
| Failure to ensure medication was transcribed according to physician orders. |
| Failure to ensure RN assessment after skin tear and proper clinical documentation regarding end of life status and pronouncement of death. |
| Name | Title | Context |
|---|---|---|
| Director of Nurses | Responsible for ensuring compliance and quality assurance monitoring | |
| Administrator | Responsible to ensure compliance with notification to ombudsman's office |
| Name | Title | Context |
|---|---|---|
| LPN #1 | Removed from the building and terminated following the event | |
| DNS | Completed the investigation and education of staff |
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