Van Duyn 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.
81 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.
18.4 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.
10.0% 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.
38 This Facility
7,360 Statewide
Citations
The total number of complaints-related citations during the reporting period.
24 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.
4.9 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.
1 This Facility
Dietary Services
The number of complaint-related deficiencies pertaining to dietary services.
11 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.
18 This Facility
Quality of Care
The number of complaint-related deficiencies pertaining to quality of care.
66 This Facility
Resident Rights
The number of complaint-related deficiencies pertaining to resident rights.
23 This Facility
Total Complaints-Related Citations
The total number of citations during the reporting period resulting directly from complaints made against the facility.
119 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.
43 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.
4 This Facility
11 State Average
Total Citations
The total number of citations of any kind received by the nursing home during the reporting period
47 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.
4 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.
8.5% This Facility
2.0% State Average

The citations above resulted from a total of 13 inspections. There were also 2 inspections resulting in no citations.

Inspections (with citations)
13
Inspections (no citations)
2
Total citations
47

Citation Details

July 14, 2025 — Complaint Survey — Health: 1 — LSC: 0

July 14, 2025 Complaint Survey

Standard Health Citations 

Deficiency Severity Scope SQC Corrected
Pharmacy srvcs/procedures/pharmacist/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 August 19, 2025
April 18, 2025 — Complaint Survey — Health: 29 — LSC: 9

April 18, 2025 Complaint Survey

Standard Health Citations 

Deficiency Severity Scope SQC Corrected
Accuracy of assessments
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 June 3, 2025
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 June 3, 2025
Bedrails
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 June 3, 2025
Department criminal history review
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 3, 2025
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 June 3, 2025
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 June 3, 2025
Free from misappropriation/exploitation
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 June 3, 2025
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 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 June 3, 2025
Frequency of meals/snacks at bedtime
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.
Infection prevention & control
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.
👤👤👤Pattern
Pattern
Deficiency does not indicate severe, systemic problems in quality of care. Corrected as of June 3, 2025
Investigate/prevent/correct alleged violation
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 June 3, 2025
Label/store drugs and biologicals
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 June 3, 2025
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.
👤👤👤Pattern
Pattern
Deficiency does not indicate severe, systemic problems in quality of care. Corrected as of June 3, 2025
Nutrition/hydration status maintenance
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 June 3, 2025
Nutritive value/appear, palatable/prefer temp
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 June 3, 2025
Pain management
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 June 3, 2025
Physician visits - review care/notes/order
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 June 3, 2025
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 June 3, 2025
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.
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.
👤👤👤Pattern
Pattern
Deficiency does not indicate severe, systemic problems in quality of care. Corrected as of June 3, 2025
Resident rights/exercise of rights
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.
👤👤👤Pattern
Pattern

Substandard quality of care: a severe, systemic deficiency.
Corrected as of June 3, 2025
Resident self-admin meds-clinically approp
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 June 3, 2025
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 June 3, 2025
Responsibilities of providers; required notif
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 3, 2025
Routine/emergency dental srvcs in nfs
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 June 3, 2025
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 June 3, 2025
Self-determination
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.
👤👤👤Pattern
Pattern

Substandard quality of care: a severe, systemic deficiency.
Corrected as of June 3, 2025
Services provided meet professional standards
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 June 3, 2025
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 June 3, 2025

Standard Life Safety Code Citations 

Deficiency Severity Scope SQC Corrected
Electrical equipment - power cords and extens
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 28, 2025
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.
👤Isolated
Isolated
Deficiency does not indicate severe, systemic problems in quality of care. Corrected as of May 28, 2025
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.
👤Isolated
Isolated
Deficiency does not indicate severe, systemic problems in quality of care. Corrected as of May 28, 2025
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.
👤Isolated
Isolated
Deficiency does not indicate severe, systemic problems in quality of care. Corrected as of May 28, 2025
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.
👤Isolated
Isolated
Deficiency does not indicate severe, systemic problems in quality of care. Corrected as of May 28, 2025
Sprinkler system - installation
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 28, 2025
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.
👤Isolated
Isolated
Deficiency does not indicate severe, systemic problems in quality of care. Corrected as of May 28, 2025
Stairways and smokeproof enclosures
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 May 28, 2025
Utilities - gas and electric
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 28, 2025
January 23, 2025 — Complaint Survey — Health: 1 — LSC: 0

January 23, 2025 Complaint Survey

Standard Health Citations 

Deficiency Severity Scope SQC Corrected
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 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.
September 11, 2024 — Complaint Survey — Health: 1 — LSC: 0

September 11, 2024 Complaint Survey

Standard Health Citations 

Deficiency Severity Scope SQC Corrected
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.
November 20, 2023 — Covid-19 Survey — Health: 1 — LSC: 0

November 20, 2023 Covid-19 Survey

Standard Health Citations 

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.
October 26, 2023 — Complaint Survey — Health: 1 — LSC: 0

October 26, 2023 Complaint Survey

Standard Health Citations 

Deficiency Severity Scope SQC Corrected
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.
👤Isolated
Isolated
Deficiency does not indicate severe, systemic problems in quality of care. Corrected as of November 29, 2023
September 13, 2023 — Complaint Survey — Health: 2 — LSC: 0

September 13, 2023 Complaint Survey

Standard Health Citations 

Deficiency Severity Scope SQC Corrected
Notice requirements before transfer/discharge
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 September 14, 2023
Preparation for safe/orderly transfer/dschrg
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
Deficiency does not indicate severe, systemic problems in quality of care. Corrected as of September 14, 2023
July 28, 2023 — Complaint Survey — Health: 17 — LSC: 5

July 28, 2023 Complaint Survey

Standard Health Citations 

Deficiency Severity Scope SQC Corrected
Activities meet interest/needs each resident
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 August 30, 2023
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 August 30, 2023
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 August 30, 2023
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.
👤Isolated
Isolated
Deficiency does not indicate severe, systemic problems in quality of care. Corrected as of August 30, 2023
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 August 30, 2023
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.
👤👤👤Pattern
Pattern

Substandard quality of care: a severe, systemic deficiency.
Corrected as of August 30, 2023
Grievances
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 August 30, 2023
Investigate/prevent/correct alleged violation
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.
Label/store drugs and biologicals
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 August 30, 2023
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.
👤Isolated
Isolated
Deficiency does not indicate severe, systemic problems in quality of care. Corrected as of August 30, 2023
Nurse aide registry verification, retraining
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 August 30, 2023
Provided diet meets needs of each resident
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 August 30, 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 August 30, 2023
Resident rights/exercise of rights
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 August 30, 2023
Responsibilities of providers; required notif
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 August 30, 2023
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 August 30, 2023
Tube feeding mgmt/restore eating skills
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 August 30, 2023

Standard Life Safety Code Citations 

Deficiency Severity Scope SQC Corrected
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 August 30, 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.
👤Isolated
Isolated
Deficiency does not indicate severe, systemic problems in quality of care. Corrected as of August 30, 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.
👤👤👤👤👤Widespread
Widespread
Deficiency does not indicate severe, systemic problems in quality of care. Corrected as of August 30, 2023
Rubbish chutes, incinerators, and laundry chu
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 August 30, 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.
👤Isolated
Isolated
Deficiency does not indicate severe, systemic problems in quality of care. Corrected as of August 30, 2023
January 25, 2023 — Complaint Survey — Health: 1 — LSC: 0

January 25, 2023 Complaint Survey

Standard Health Citations 

Deficiency Severity Scope SQC Corrected
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 February 28, 2023
November 3, 2022 — Complaint Survey — Health: 1 — LSC: 0

November 3, 2022 Complaint Survey

Standard Health Citations 

Deficiency Severity Scope SQC Corrected
Request/refuse/dscntnue trmnt;formlte adv dir
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 14, 2022
October 17, 2022 — Covid-19 Survey — Health: 1 — LSC: 0

October 17, 2022 Covid-19 Survey

Standard Health Citations 

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.
July 22, 2022 — Complaint Survey — Health: 2 — LSC: 0

July 22, 2022 Complaint Survey

Standard Health Citations 

Deficiency Severity Scope SQC Corrected
Nutritive value/appear, palatable/prefer temp
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 September 14, 2022
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 September 14, 2022
October 19, 2021 — Complaint Survey — Health: 2 — LSC: 0

October 19, 2021 Complaint Survey

Standard Health Citations 

Deficiency Severity Scope SQC Corrected
Nutrition/hydration status maintenance
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 30, 2021
Pain management
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 30, 2021

Enforcement

November 1, 2015 through October 31, 2025

Survey DateDetails
January 23, 2025
  • Stipulation & Order #: NH-25-078
  • Stipulation and Order date: November 6, 2025
  • Fine: $10,000
  • Description: Resident Rights
April 18, 2025
  • Stipulation & Order #: NH-25-079
  • Stipulation and Order date: November 6, 2025
  • Fine: $34,000
  • Description: Multiple Deficiencies
September 13, 2023
  • Stipulation & Order #: NH-24-030
  • Stipulation and Order date: May 24, 2024
  • Fine: $4,000
  • Description: Other Services
July 28, 2023
  • Stipulation & Order #: NH-24-013
  • Stipulation and Order date: January 17, 2024
  • Fine: $2,000
  • Description: Quality of Care
June 21, 2021
  • Stipulation & Order #: NH-22-042
  • Stipulation and Order date: February 22, 2022
  • Fine: $30,000
  • Description: Quality of Care
October 5, 2018
  • Stipulation & Order #: NH-19-009
  • Stipulation and Order date: January 9, 2019
  • Fine: $2,000
  • Description: Multiple Deficiencies
December 19, 2017
  • Stipulation & Order #: NH-18-033
  • Stipulation and Order date: August 8, 2018
  • Fine: $10,000
  • Description: Multiple Deficiencies
December 5, 2012
  • Stipulation & Order #: NH-17-010
  • Stipulation and Order date: January 11, 2017
  • Fine: $10,000
  • Description: Quality of Care
October 14, 2015
  • Stipulation & Order #: NH-16-172
  • Stipulation and Order date: June 6, 2016
  • Fine: $14,000
  • Description: Multiple Deficiencies
Date not yet available
  • Stipulation & Order #: NH-16-136
  • Stipulation and Order date: March 14, 2016
  • Fine: $40,000
  • Description: Multiple Deficiencies