Inspection Reports
| 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. | 19.9 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. | 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. | 17 This Facility 7,360 Statewide |
| Citations The total number of complaints-related citations during the reporting period. | 5 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. | 2.6 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. | 1 This Facility |
| Quality of Care The number of complaint-related deficiencies pertaining to quality of care. | 13 This Facility |
| Resident Rights The number of complaint-related deficiencies pertaining to resident rights. | 4 This Facility |
| Total Complaints-Related Citations The total number of citations during the reporting period resulting directly from complaints made against the facility. | 22 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. | 20 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. | 2 This Facility 11 State Average |
| Total Citations The total number of citations of any kind received by the nursing home during the reporting period | 22 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. | 0 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. | 0.0% This Facility 2.0% State Average |
The citations above resulted from a total of 4 inspections. There were also 3 inspections resulting in no citations.
| Deficiency | Severity | Scope | SQC | Corrected |
|---|---|---|---|---|
| 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 April 8, 2025 |
| 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 December 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 December 30, 2023 |
| 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 December 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. | Isolated Isolated | Deficiency does not indicate severe, systemic problems in quality of care. | Corrected as of December 30, 2023 |
| Quality of care 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 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 December 30, 2023 |
| 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 December 30, 2023 |
| Deficiency | Severity | Scope | SQC | Corrected |
|---|---|---|---|---|
| Cooking facilities 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 December 28, 2023 |
| Discharge from 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. | Isolated Isolated | Deficiency does not indicate severe, systemic problems in quality of care. | Corrected as of December 28, 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 December 28, 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 December 28, 2023 |
| Exit signage 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 28, 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. | Isolated Isolated | Deficiency does not indicate severe, systemic problems in quality of care. | Corrected as of December 28, 2023 |
| 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 December 28, 2023 |
| 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 December 28, 2023 |
| Portable fire extinguishers 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 December 28, 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. | Isolated Isolated | Deficiency does not indicate severe, systemic problems in quality of care. | Corrected as of December 28, 2023 |
| 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 February 28, 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 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 |
| Deficiency | Severity | Scope | SQC | Corrected |
|---|---|---|---|---|
| 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 February 16, 2023 |
There have been no enforcement actions against the Operator of this facility during this reporting period.