Delaware Oaks Center for Rehabilitation and Nursing

Inspection Reports

Complaints

Nursing Home Complaints, November 1, 2021 to October 31, 2025

Number of Complaints
The total number of complaints received about the facility during the reporting period.
19 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.
40.4 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.
50.0% 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.
16 This Facility
7,360 Statewide
Citations
The total number of complaints-related citations during the reporting period.
9 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.
9.6 This Facility
3.9 Statewide

Complaints-Related Citations by Category, November 1, 2021 to October 31, 2025

Administration
The number of complaint-related deficiencies pertaining to administrative issues.
0 This Facility
Dietary Services
The number of complaint-related deficiencies pertaining to dietary services.
2 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.
8 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.
1 This Facility
Total Complaints-Related Citations
The total number of citations during the reporting period resulting directly from complaints made against the facility.
23 This Facility

Citations

Citations from October 1, 2021 through September 30, 2025

Citations Summary

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.
23 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.
7 This Facility
11 State Average
Total Citations
The total number of citations of any kind received by the nursing home during the reporting period
30 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.
3.3% This Facility
2.0% State Average

The citations above resulted from a total of 7 inspections. There were also 6 inspections resulting in no citations.

Inspections (with citations)
7
Inspections (no citations)
6
Total citations
30

Citation Details

March 26, 2025 — Complaint Survey — Health: 1 — LSC: 0

March 26, 2025 Complaint Survey

Standard Health Citations 

Deficiency Severity Scope SQC Corrected
Infection prevention & control
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 15, 2025
August 9, 2024 — Complaint Survey — Health: 9 — LSC: 12

August 9, 2024 Complaint Survey

Standard Health Citations 

Deficiency Severity Scope SQC Corrected
Develop/implement comprehensive care plan
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 October 7, 2024
Free from abuse and neglect
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 October 7, 2024
Increase/prevent decrease in rom/mobility
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 October 7, 2024
Maintains effective pest control program
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. Corrected as of October 7, 2024
Physical environment
Standard Health Inspection Citation: pertains to quality of care, e.g., resident care, staff/resident interaction, environment, and record-keeping.
Level 0
👤Scope
Deficiency does not indicate severe, systemic problems in quality of care. Corrected as of October 7, 2024
Resident allergies, preferences, substitutes
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 October 7, 2024
Right to be free from physical restraints
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 October 7, 2024
Safe/clean/comfortable/homelike environment
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 October 7, 2024
Treatment/svcs to prevent/heal pressure ulcer
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 October 7, 2024

Standard Life Safety Code Citations 

Deficiency Severity Scope SQC Corrected
Building construction type and height
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 September 26, 2024
Corridor - 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.
👤👤👤Pattern
Pattern
Deficiency does not indicate severe, systemic problems in quality of care. Corrected as of October 7, 2024
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 October 7, 2024
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 1
No actual harm done, but potential to cause minimal harm with minor negative impacts on residents.
👤👤👤👤👤Widespread
Widespread
Deficiency does not indicate severe, systemic problems in quality of care. Corrected as of October 7, 2024
Ep testing requirements
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 1
No actual harm done, but potential to cause minimal harm with minor negative impacts on residents.
👤👤👤👤👤Widespread
Widespread
Deficiency does not indicate severe, systemic problems in quality of care. Corrected as of October 7, 2024
Fire alarm system - testing and maintenance
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 October 7, 2024
Gas equipment - cylinder and container storag
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 October 7, 2024
Hazardous areas - 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 October 7, 2024
Illumination of means of egress
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 October 7, 2024
Maintenance, inspection & testing - 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.
👤👤👤Pattern
Pattern
Deficiency does not indicate severe, systemic problems in quality of care. Corrected as of October 7, 2024
Sprinkler system - maintenance and testing
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 October 7, 2024
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.
👤Isolated
Isolated
Deficiency does not indicate severe, systemic problems in quality of care. Corrected as of October 7, 2024
March 24, 2023 — Complaint Survey — Health: 7 — LSC: 15

March 24, 2023 Complaint Survey

Standard Health Citations 

Deficiency Severity Scope SQC Corrected
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.
👤👤👤👤👤Widespread
Widespread
Deficiency does not indicate severe, systemic problems in quality of care. Corrected as of May 12, 2023
Free from abuse and neglect
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 12, 2023
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 May 12, 2023
Physical environment
Standard Health Inspection Citation: pertains to quality of care, e.g., resident care, staff/resident interaction, environment, and record-keeping.
Level 0
👤Scope
Deficiency does not indicate severe, systemic problems in quality of care. Corrected as of June 14, 2023
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 12, 2023
Resident call system
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 May 12, 2023
Standards of construction for new nh
Standard Health Inspection Citation: pertains to quality of care, e.g., resident care, staff/resident interaction, environment, and record-keeping.
Level 0
👤Scope
Deficiency does not indicate severe, systemic problems in quality of care. Corrected as of May 29, 2023

Standard Life Safety Code Citations 

Deficiency Severity Scope SQC Corrected
Alcohol based hand rub dispenser (abhr)
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 May 12, 2023
Building construction type and height
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 May 12, 2023
Corridor - 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.
👤👤👤Pattern
Pattern
Deficiency does not indicate severe, systemic problems in quality of care. Corrected as of May 12, 2023
Doors with self-closing devices
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 May 12, 2023
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 May 12, 2023
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 May 12, 2023
Elevators
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 May 12, 2023
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 1
No actual harm done, but potential to cause minimal harm with minor negative impacts on residents.
👤👤👤👤👤Widespread
Widespread
Deficiency does not indicate severe, systemic problems in quality of care. Corrected as of May 12, 2023
Fire alarm system - testing and maintenance
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 May 12, 2023
Gas equipment - cylinder and container storag
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 May 12, 2023
Hazardous areas - 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 May 12, 2023
Means of egress - general
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 May 12, 2023
Portable space heaters
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 May 12, 2023
Roles under a waiver declared by secretary
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 1
No actual harm done, but potential to cause minimal harm with minor negative impacts on residents.
👤👤👤👤👤Widespread
Widespread
Deficiency does not indicate severe, systemic problems in quality of care. Corrected as of May 12, 2023
Sprinkler system - maintenance and testing
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 May 12, 2023
January 3, 2023 — Complaint Survey — Health: 1 — LSC: 3

January 3, 2023 Complaint Survey

Standard Health Citations 

Deficiency Severity Scope SQC Corrected
Essential equipment, safe operating condition
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 February 17, 2023

Standard Life Safety Code Citations 

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 February 17, 2023
Fire alarm system - out of service
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 February 17, 2023
Sprinkler system - out of service
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 February 17, 2023
May 11, 2022 — Complaint Survey — Health: 1 — LSC: 0

May 11, 2022 Complaint Survey

Standard Health Citations 

Deficiency Severity Scope SQC Corrected
Quality of care
Standard Health Inspection Citation: pertains to quality of care, e.g., resident care, staff/resident interaction, environment, and record-keeping.
Level 3
Actual harm has occurred, resulting in a negative outcome compromising the resident's ability to reach the highest practicable level of functioning.
👤Isolated
Isolated
Deficiency does not indicate severe, systemic problems in quality of care. Corrected as of July 8, 2022
April 12, 2022 — Complaint Survey — Health: 1 — LSC: 0

April 12, 2022 Complaint Survey

Standard Health Citations 

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 1, 2022
November 5, 2021 — Covid-19 Survey — Health: 1 — LSC: 0

November 5, 2021 Covid-19 Survey

Standard Health Citations 

Deficiency Severity Scope SQC Corrected
Infection prevention & control
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 17, 2021

Enforcement

November 1, 2015 through October 31, 2025

Survey DateDetails
May 11, 2022
  • Stipulation & Order #: NH-22-122
  • Stipulation and Order date: August 9, 2022
  • Fine: $12,000
  • Description: Multiple Deficiencies
November 5, 2021
  • Stipulation & Order #: NH-22-085
  • Stipulation and Order date: May 25, 2022
  • Fine: $2,000
  • Description: Quality of Care
December 23, 2020
  • Stipulation & Order #: NH-21-047
  • Stipulation and Order date: March 13, 2021
  • Fine: $8,000
  • Description: Quality of Care
Date not yet available
  • Stipulation & Order #: NH-18-042
  • Stipulation and Order date: September 24, 2018
  • Fine: $2,000
  • Description: Multiple Deficiencies
June 17, 2013
  • Stipulation & Order #: NH-16-187
  • Stipulation and Order date: August 9, 2017
  • Fine: $10,000
  • Description: Quality of Care
January 24, 2017
  • Stipulation & Order #: NH-17-038
  • Stipulation and Order date: June 19, 2017
  • Fine: $6,000
  • Description: Multiple Deficiencies