Inspection Reports
| Number of Complaints The total number of complaints received about the facility during the reporting period. | 10 This Facility 51,680 Statewide |
| Number of Complaints per 100 Occupied Beds This rate demonstrates the number of complaints and incidents received per 100 occupied beds during the reporting period. Occupied beds are approximated by taking the daily occupancy rate data from the most recent year's audited Nursing Home Cost Report. This rate allows the user to compare a specific facility's complaint experience with that of other homes or a statewide average. | 5.9 This Facility 50.0 Statewide |
| Percentage of Complaints Representing Facility-Reported Incidents Facilities are required to report certain kinds of incidents to the Department of Health whenever they occur, and these are included in the complaint count. This measure shows the percentage of complaints that represents such facility-reported incidents. | 41.0% This Facility 54.0% Statewide |
| All Complaint-Related On-Site Inspections The number of complaint-related inspections at the facility completed by the Department of Health during the reporting period. Not all inspections necessarily result in deficiencies being cited. | 14 This Facility 7,360 Statewide |
| Citations The total number of complaints-related citations during the reporting period. | 7 This Facility 4,035 Statewide |
| Citations per 100 Occupied Beds This rate demonstrates the number of citations per 100 occupied beds during the reporting period. Occupied beds are approximated by taking the daily occupancy rate data from the most recent year's audited Nursing Home Cost Report. This rate allows the user to compare a specific facility's complaint experience with that of other homes or a statewide average. | 2.4 This Facility 3.9 Statewide |
| Administration The number of complaint-related deficiencies pertaining to administrative issues. | 1 This Facility |
| Dietary Services The number of complaint-related deficiencies pertaining to dietary services. | 3 This Facility |
| Other Services The number of complaint-related deficiencies pertaining to other issues, i.e., those that cannot be categorized under administration, quality of care, resident rights, diet, or physical environment. | 0 This Facility |
| Physical Environment The number of complaint-related deficiencies pertaining to the physical environment of the facility. | 3 This Facility |
| Quality of Care The number of complaint-related deficiencies pertaining to quality of care. | 12 This Facility |
| Resident Rights The number of complaint-related deficiencies pertaining to resident rights. | 0 This Facility |
| Total Complaints-Related Citations The total number of citations during the reporting period resulting directly from complaints made against the facility. | 19 This Facility |
| Standard Health Citations The number of citations falling into the category of standard health deficiencies, which pertain to quality of care, e.g., resident care, staff/resident interaction, environment, and record-keeping. | 15 This Facility 18 State Average |
| Life Safety Code Citations The number of citations falling into the category of Life Safety Code deficiencies, which pertain to a wide range of requirements established by the National Fire Protection Agency (NFPA), including construction, protection and operational features designed to provide safety from fire, smoke, and panic. | 8 This Facility 11 State Average |
| Total Citations The total number of citations of any kind received by the nursing home during the reporting period | 23 This Facility 29 State Average |
| Citations Related to Actual Harm or Immediate Jeopardy The number of citations involving defiencies in which actual harm to a resident occurred, as opposed to deficiencies that only created the potential to cause such harm. | 1 This Facility 1 State Average |
| Percentage of Citations Related to Actual Harm or Immediate Jeopardy The percentage of citations received for deficiencies resulting in actual resident harm, as opposed to those that only created the potential for harm. | 4.3% This Facility 2.0% State Average |
The citations above resulted from a total of 7 inspections. There were also 7 inspections resulting in no citations.
| Deficiency | Severity | Scope | SQC | Corrected |
|---|---|---|---|---|
| Activities daily living (adls)/mntn abilities Standard Health Inspection Citation: pertains to quality of care, e.g., resident care, staff/resident interaction, environment, and record-keeping. | Level 2 No actual harm or immediate jeopardy, but has caused minor discomfort and has the potential to cause more than minimal harm. | Isolated Isolated | Deficiency does not indicate severe, systemic problems in quality of care. | Corrected as of November 11, 2024 |
| ADL care provided for dependent residents Standard Health Inspection Citation: pertains to quality of care, e.g., resident care, staff/resident interaction, environment, and record-keeping. | Level 2 No actual harm or immediate jeopardy, but has caused minor discomfort and has the potential to cause more than minimal harm. | Isolated Isolated | Deficiency does not indicate severe, systemic problems in quality of care. | Corrected as of November 18, 2024 |
| 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 No actual harm or immediate jeopardy, but has caused minor discomfort and has the potential to cause more than minimal harm. | Isolated Isolated | Deficiency does not indicate severe, systemic problems in quality of care. | Corrected as of November 14, 2024 |
| Comprehensive assessment after signifcant chg Standard Health Inspection Citation: pertains to quality of care, e.g., resident care, staff/resident interaction, environment, and record-keeping. | Level 2 No actual harm or immediate jeopardy, but has caused minor discomfort and has the potential to cause more than minimal harm. | Isolated Isolated | Deficiency does not indicate severe, systemic problems in quality of care. | Corrected as of December 12, 2024 |
| 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 No actual harm or immediate jeopardy, but has caused minor discomfort and has the potential to cause more than minimal harm. | Isolated Isolated | Deficiency does not indicate severe, systemic problems in quality of care. | Corrected as of November 20, 2024 |
| Free of medication error rts 5 prcnt or more Standard Health Inspection Citation: pertains to quality of care, e.g., resident care, staff/resident interaction, environment, and record-keeping. | Level 2 No actual harm or immediate jeopardy, but has caused minor discomfort and has the potential to cause more than minimal harm. | Pattern Pattern | Deficiency does not indicate severe, systemic problems in quality of care. | Corrected as of November 8, 2024 |
| Reporting of alleged violations Standard Health Inspection Citation: pertains to quality of care, e.g., resident care, staff/resident interaction, environment, and record-keeping. | Level 2 No actual harm or immediate jeopardy, but has caused minor discomfort and has the potential to cause more than minimal harm. | Isolated Isolated | Deficiency does not indicate severe, systemic problems in quality of care. | Corrected as of November 8, 2024 |
| 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 No actual harm or immediate jeopardy, but has caused minor discomfort and has the potential to cause more than minimal harm. | Pattern Pattern | Deficiency does not indicate severe, systemic problems in quality of care. | Corrected as of December 9, 2024 |
| 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 No actual harm or immediate jeopardy, but has caused minor discomfort and has the potential to cause more than minimal harm. | Isolated Isolated | Deficiency does not indicate severe, systemic problems in quality of care. | Corrected as of November 8, 2024 |
| Deficiency | Severity | Scope | SQC | Corrected |
|---|---|---|---|---|
| Ep program patient population 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 No actual harm or immediate jeopardy, but has caused minor discomfort and has the potential to cause more than minimal harm. | Widespread Widespread | Deficiency does not indicate severe, systemic problems in quality of care. | Corrected as of November 22, 2024 |
| Protection - other 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 No actual harm or immediate jeopardy, but has caused minor discomfort and has the potential to cause more than minimal harm. | Widespread Widespread | Deficiency does not indicate severe, systemic problems in quality of care. | Corrected as of November 25, 2024 |
| Deficiency | Severity | Scope | SQC | Corrected |
|---|---|---|---|---|
| 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 No actual harm or immediate jeopardy, but has caused minor discomfort and has the potential to cause more than minimal harm. | Isolated Isolated | Deficiency does not indicate severe, systemic problems in quality of care. | Corrected as of July 20, 2021 |
| Deficiency | Severity | Scope | SQC | Corrected |
|---|---|---|---|---|
| Electrical equipment - testing and maintenanc 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 No actual harm or immediate jeopardy, but has caused minor discomfort and has the potential to cause more than minimal harm. | Pattern Pattern | Deficiency does not indicate severe, systemic problems in quality of care. | Corrected as of December 31, 2023 |
| Subdivision of building spaces - smoke barrie 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 No actual harm or immediate jeopardy, but has caused minor discomfort and has the potential to cause more than minimal harm. | Pattern Pattern | Deficiency does not indicate severe, systemic problems in quality of care. | Corrected as of December 31, 2023 |
| Vertical openings - 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 No actual harm or immediate jeopardy, but has caused minor discomfort and has the potential to cause more than minimal harm. | Pattern Pattern | Deficiency does not indicate severe, systemic problems in quality of care. | Corrected as of December 31, 2023 |
| Deficiency | Severity | Scope | SQC | Corrected |
|---|---|---|---|---|
| Reporting of alleged violations Standard Health Inspection Citation: pertains to quality of care, e.g., resident care, staff/resident interaction, environment, and record-keeping. | Level 2 No actual harm or immediate jeopardy, but has caused minor discomfort and has the potential to cause more than minimal harm. | Isolated Isolated | Deficiency does not indicate severe, systemic problems in quality of care. | Corrected as of May 19, 2023 |
| Deficiency | Severity | Scope | SQC | Corrected |
|---|---|---|---|---|
| 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 No actual harm or immediate jeopardy, but has caused minor discomfort and has the potential to cause more than minimal harm. | Pattern Pattern | Deficiency does not indicate severe, systemic problems in quality of care. | Corrected as of January 23, 2022 |
| Deficiency | Severity | Scope | SQC | Corrected |
|---|---|---|---|---|
| ADL care provided for dependent residents Standard Health Inspection Citation: pertains to quality of care, e.g., resident care, staff/resident interaction, environment, and record-keeping. | Level 2 No actual harm or immediate jeopardy, but has caused minor discomfort and has the potential to cause more than minimal harm. | Isolated Isolated | Deficiency does not indicate severe, systemic problems in quality of care. | Corrected as of January 30, 2022 |
| 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 No actual harm or immediate jeopardy, but has caused minor discomfort and has the potential to cause more than minimal harm. | Pattern Pattern | Deficiency does not indicate severe, systemic problems in quality of care. | Corrected as of January 23, 2022 |
| Free from unnec psychotropic meds/prn use Standard Health Inspection Citation: pertains to quality of care, e.g., resident care, staff/resident interaction, environment, and record-keeping. | Level 2 No actual harm or immediate jeopardy, but has caused minor discomfort and has the potential to cause more than minimal harm. | Isolated Isolated | Deficiency does not indicate severe, systemic problems in quality of care. | Corrected as of January 23, 2022 |
| 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 4 Immediate jeopardy to resident health or safety requiring immediate action. An event has caused or is likely to cause serious injury, harm, impairment, or death. | Isolated Isolated | Substandard quality of care: a severe, systemic deficiency. | Corrected as of December 15, 2021 |
| Personal privacy/confidentiality of records Standard Health Inspection Citation: pertains to quality of care, e.g., resident care, staff/resident interaction, environment, and record-keeping. | Level 2 No actual harm or immediate jeopardy, but has caused minor discomfort and has the potential to cause more than minimal harm. | Isolated Isolated | Deficiency does not indicate severe, systemic problems in quality of care. | Corrected as of January 30, 2022 |
| Reporting of alleged violations Standard Health Inspection Citation: pertains to quality of care, e.g., resident care, staff/resident interaction, environment, and record-keeping. | Level 2 No actual harm or immediate jeopardy, but has caused minor discomfort and has the potential to cause more than minimal harm. | Isolated Isolated | Deficiency does not indicate severe, systemic problems in quality of care. | Corrected as of January 30, 2022 |
| Deficiency | Severity | Scope | SQC | Corrected |
|---|---|---|---|---|
| Egress 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 No actual harm or immediate jeopardy, but has caused minor discomfort and has the potential to cause more than minimal harm. | Isolated Isolated | Deficiency does not indicate severe, systemic problems in quality of care. | Corrected as of January 23, 2022 |
| Ramps and other exits 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 No actual harm or immediate jeopardy, but has caused minor discomfort and has the potential to cause more than minimal harm. | Pattern Pattern | Deficiency does not indicate severe, systemic problems in quality of care. | Corrected as of January 23, 2022 |
| Deficiency | Severity | Scope | SQC | Corrected |
|---|---|---|---|---|
| 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 No actual harm or immediate jeopardy, but has caused minor discomfort and has the potential to cause more than minimal harm. | Widespread Widespread | Deficiency does not indicate severe, systemic problems in quality of care. |
| Survey Date | Details |
|---|---|
| February 29, 2016 |
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| August 13, 2015 |
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| November 25, 2013 |
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