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. | 26.3 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. | 33.0% 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. | 13 This Facility 7,360 Statewide |
| Citations The total number of complaints-related citations during the reporting period. | 8 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. | 14.0 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. | 8 This Facility |
| Resident Rights The number of complaint-related deficiencies pertaining to resident rights. | 3 This Facility |
| Total Complaints-Related Citations The total number of citations during the reporting period resulting directly from complaints made against the facility. | 16 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. | 18 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 | 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 8 inspections.
| Deficiency | Severity | Scope | SQC | Corrected |
|---|---|---|---|---|
| Dispose garbage and refuse properly 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 18, 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 May 18, 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. | Isolated Isolated | Deficiency does not indicate severe, systemic problems in quality of care. | Corrected as of May 18, 2025 |
| 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. | Widespread Widespread | Deficiency does not indicate severe, systemic problems in quality of care. | Corrected as of May 18, 2025 |
| Other laws, codes, rules and regulations. 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 18, 2025 |
| 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. | Pattern Pattern | Deficiency does not indicate severe, systemic problems in quality of care. | Corrected as of May 18, 2025 |
| Deficiency | Severity | Scope | SQC | Corrected |
|---|---|---|---|---|
| Building rehabilitation 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 18, 2025 |
| 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. | Widespread Widespread | Deficiency does not indicate severe, systemic problems in quality of care. | Corrected as of May 18, 2025 |
| 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 18, 2025 |
| 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 18, 2025 |
| 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 18, 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. | Pattern Pattern | Deficiency does not indicate severe, systemic problems in quality of care. | Corrected as of May 18, 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. | Pattern Pattern | Deficiency does not indicate severe, systemic problems in quality of care. | Corrected as of May 18, 2025 |
| 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. | Widespread Widespread | Deficiency does not indicate severe, systemic problems in quality of care. | Corrected as of May 18, 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 18, 2025 |
| 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. | Pattern Pattern | Deficiency does not indicate severe, systemic problems in quality of care. | Corrected as of May 18, 2025 |
| Smoking regulations 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 18, 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. | Widespread Widespread | Deficiency does not indicate severe, systemic problems in quality of care. | Corrected as of May 18, 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. | Isolated Isolated | Deficiency does not indicate severe, systemic problems in quality of care. | Corrected as of May 18, 2025 |
| 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 May 18, 2025 |
| Subsistence needs for staff and patients 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 18, 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. | Pattern Pattern | Deficiency does not indicate severe, systemic problems in quality of care. | Corrected as of May 18, 2025 |
| 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 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 16, 2024 |
| 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. | Pattern Pattern | Deficiency does not indicate severe, systemic problems in quality of care. | Corrected as of December 16, 2024 |
| 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 15, 2024 |
| 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 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 29, 2024 |
| Deficiency | Severity | Scope | SQC | Corrected |
|---|---|---|---|---|
| Encoding/transmitting resident 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 November 27, 2023 |
| 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 November 27, 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. | Isolated Isolated | Deficiency does not indicate severe, systemic problems in quality of care. | Corrected as of November 27, 2023 |
| Deficiency | Severity | Scope | SQC | Corrected |
|---|---|---|---|---|
| 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 October 18, 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. | Isolated Isolated | Deficiency does not indicate severe, systemic problems in quality of care. | Corrected as of October 18, 2023 |
| 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. |
| 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. |
| 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 December 31, 2021 |
| Comprehensive assessments & timing 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 31, 2021 |
| 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. | Pattern Pattern | Deficiency does not indicate severe, systemic problems in quality of care. | Corrected as of December 31, 2021 |
| Survey Date | Details |
|---|---|
| May 10, 2021 |
|