Deficiencies per Year
8
6
4
2
0
Severe
High
Moderate
Low
Unclassified
Census Over Time
Inspection Report
Complaint Investigation
Deficiencies: 0
Oct 16, 2025
Visit Reason
Investigation of facility reported incident #2632953-M conducted on October 15-16, 2025.
Findings
The investigation resulted in no deficiencies. Findings for the incident will be sent to the facility at a later date under separate cover.
Complaint Details
Investigation of facility reported incident #2632953-M; no deficiencies found.
Inspection Report
Plan of Correction
Deficiencies: 0
Sep 23, 2025
Visit Reason
A facility investigation for a reported incident #2588909-I was conducted on September 23, 2025.
Findings
The facility was found to be in substantial compliance with no deficiencies cited.
Report Facts
Incident number: 2588909
Inspection Report
Plan of Correction
Deficiencies: 0
Jun 25, 2025
Visit Reason
The document serves as a Plan of Correction following a prior inspection, indicating acceptance of the facility's credible allegation of substantial compliance.
Findings
The facility was found to be in substantial compliance based on the accepted Plan of Correction, and will be certified in compliance effective June 25, 2025.
Inspection Report
Annual Inspection
Census: 53
Deficiencies: 6
May 29, 2025
Visit Reason
The inspection was conducted as part of the facility's annual recertification survey and an investigation of complaint #128028-C from May 27 to May 29, 2025.
Findings
The facility was found deficient in multiple areas including failure to ensure dependent adult abuse training for staff, inadequate documentation and assessment of skin conditions for residents, failure to protect residents from accidents related to wheelchair use, medication errors exceeding the allowed rate, failure to provide prescribed therapeutic diets, and insufficient infection prevention and control practices.
Complaint Details
Complaint #128028-C was investigated during the survey and resulted in a deficiency related to dependent adult abuse training.
Severity Breakdown
Level D: 6
Deficiencies (6)
| Description | Severity |
|---|---|
| Failure to ensure completion of dependent adult abuse training within six months of hire for staff. | Level D |
| Failure to document follow-up skin assessments and skin concerns for residents with wounds or bruises. | Level D |
| Failure to protect residents from potential accidents and hazards related to wheelchair use. | Level D |
| Medication error rate exceeded 5%, with 2 errors out of 30 opportunities (6.67%). | Level D |
| Failure to provide residents with prescribed therapeutic diets and proper food textures. | Level D |
| Failure to establish and maintain an effective infection prevention and control program. | Level D |
Report Facts
Census: 53
Medication error rate: 6.67
Medication error opportunities: 30
Medication errors: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff P | Certified Medication Aide | Named in deficiency for lack of dependent adult abuse training. |
| Director of Nursing | Confirmed lack of dependent adult abuse training documentation for Staff P and involved in skin assessment interviews. | |
| Staff F | Certified Nurse Aide (CNA) | Observed improperly pushing Resident #46 in wheelchair. |
| Staff K | Licensed Practical Nurse (LPN) | Reported resident condition changes and incomplete skin assessments. |
| Staff M | Licensed Practical Nurse (LPN) | Reported skin assessments and monitoring of Resident #2. |
| Staff N | Certified Nursing Assistant (CNA) | Reported on bruises and care of Resident #2. |
| Staff H | Certified Medication Aide (CMA) | Reported on wheelchair safety and medication administration. |
| Staff J | Registered Nurse (RN) | Reported wound care assessments and use of Enhanced Barrier Precautions. |
| Staff O | Certified Medication Aide (CMA) | Observed medication preparation and administration errors. |
| Staff A | Licensed Practical Nurse (LPN) | Reported on alternate medication forms and wound care. |
Inspection Report
Re-Inspection
Deficiencies: 0
Apr 10, 2025
Visit Reason
A revisit of the survey ending March 12, 2025 was conducted on April 9, 2025 to April 10, 2025 to verify correction of previous deficiencies.
Findings
All deficiencies were corrected and the facility is in substantial compliance effective March 25, 2025.
Inspection Report
Complaint Investigation
Census: 53
Deficiencies: 1
Mar 12, 2025
Visit Reason
The inspection was conducted as a complaint investigation related to Complaint #126928-C, which was substantiated. The investigation focused on quality of care concerns for Resident #1, including failure to provide timely assessment and pain management after a fall and injury.
Findings
The facility failed to provide a thorough assessment and timely intervention for Resident #1 after she was found on the floor and in pain on 2/23/25. Pain medications were ordered but not administered as prescribed, and an x-ray revealing a hip fracture was delayed until 2/25/25. The resident was transferred for surgery but later died on 3/11/25. Multiple staff interviews revealed communication failures and inadequate response to the resident's pain and fall.
Complaint Details
Complaint #126928-C was substantiated. The complaint involved failure to assess and treat pain and injuries after Resident #1 was found on the floor on 2/23/25, resulting in a delayed diagnosis of a hip fracture and inadequate pain management.
Severity Breakdown
G: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to provide a thorough assessment and timely intervention for Resident #1 after being found on the floor and in pain. | G |
Report Facts
Census: 53
Dates of complaint investigation: Complaint investigation completed on 3/10/25 to 3/12/25
Pain medication administration times: Acetaminophen administered on 2/23/25, 2/24/25, 2/25/25 at 8AM, 2PM, 10PM; PRN meds given early morning 2/25/25
Date of fracture x-ray: X-ray revealing hip fracture performed on 2/25/25
Date of resident death: Resident died on 3/11/25 at 10:10 AM
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Licensed Practical Nurse (LPN) | Named in failure to assess and administer pain medication after resident was found on floor |
| Staff B | Medical Doctor | Ordered pain medication and evaluated resident; stated expectation that Oxycodone be administered |
| Staff C | Registered Nurse (RN) | Documented skilled assessment on 2/23/25 |
| Staff D | Licensed Practical Nurse (LPN) | Notified physician and obtained order for x-ray on 2/25/25 |
| Staff F | Certified Nurse Assistant (CNA) | Reported resident on floor and pain complaints; notified nurse who failed to assess |
| Staff G | Certified Nurse Assistant (CNA) | Assisted resident off floor and reported pain complaints |
| Staff H | Physical Therapy Assistant (PTA) | Provided therapy and described resident's condition on 2/21/25 |
| Staff I | Director of Rehabilitation | Observed resident's condition and notified ADON of pain and distress |
| Staff J | Speech Therapist (ST) | Assisted resident and reported pain and distress on 2/24/25 |
| Staff K | Licensed Practical Nurse (LPN) | Night shift nurse not informed of resident on floor or pain |
| ADON | Assistant Director of Nursing | Conducted assessments, notified physician, and managed care after resident found on floor |
Inspection Report
Plan of Correction
Deficiencies: 0
Dec 23, 2024
Visit Reason
The document serves as a Plan of Correction following acceptance of the facility's credible allegation of substantial compliance.
Findings
The facility was found to be in substantial compliance and will be certified effective December 3, 2024, based on the Plan of Correction submitted.
Report Facts
Certification effective date: Facility certification effective December 3, 2024
Inspection Report
Complaint Investigation
Census: 55
Deficiencies: 1
Nov 26, 2024
Visit Reason
The inspection was conducted as an investigation of complaint #123823-C regarding failure to provide post-fall assessments and interventions.
Findings
The facility failed to provide required post-fall assessments and neurological follow-up for three residents who had unwitnessed falls. The complaint was substantiated based on record reviews, staff interviews, and policy review.
Complaint Details
Complaint #123823-C was substantiated based on investigation findings.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to provide post-fall assessments and interventions for residents with unwitnessed falls. | SS=D |
Report Facts
Residents reviewed for post-fall assessments: 3
Census: 55
Required follow-up neurological assessments: 14
Completed neurological assessments: 12
Completed neurological assessments: 3
Completed neurological assessments: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Licensed Practical Nurse (LPN) | Verified the residents' falls and neurological assessment documentation. |
| Director of Nursing | Director of Nursing (DON) | Provided statements regarding fall assessment protocols and documentation practices. |
Inspection Report
Plan of Correction
Deficiencies: 0
Jun 29, 2024
Visit Reason
The document serves as a statement of deficiencies and plan of correction following a facility inspection, confirming certification in compliance based on acceptance of a credible allegation of substantial compliance and plan of correction.
Findings
The facility was found to be in substantial compliance, and the plan of correction was accepted, resulting in certification effective June 29, 2024.
Inspection Report
Annual Inspection
Census: 51
Deficiencies: 4
Jun 3, 2024
Visit Reason
The inspection was conducted as the facility's Annual Recertification survey from June 3, 2024 to June 6, 2024.
Findings
The facility was found deficient in multiple areas including failure to notify the long-term care ombudsman of resident transfers, incomplete documentation of skin assessments for residents with wounds, improper pericare practices, and failure to maintain required RN staffing levels for at least 8 consecutive hours a day, 7 days a week.
Severity Breakdown
SS=D: 3
SS=F: 1
Deficiencies (4)
| Description | Severity |
|---|---|
| Failed to notify the long term care ombudsman for a resident transfer to an acute care hospital. | SS=D |
| Failed to document skin assessments for one of two residents reviewed for skin conditions. | SS=D |
| Failed to provide incontinent care minimizing risk of cross-contamination and urinary tract infections for one of four residents observed. | SS=D |
| Failed to maintain RN coverage for at least 8 consecutive hours a day, 7 days a week. | SS=F |
Report Facts
Census: 51
Deficiencies cited: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff E | Certified Medication Aide (CMA) | Reported nurse completed residents' skin assessments. |
| Staff F | Registered Nurse (RN) | Reported nurse completed residents' skin assessments at least weekly. |
| Staff G | Registered Nurse (RN) | Reported skin assessments documented weekly and marked on MAR. |
| Director of Nursing | Director of Nursing (DON) | Reported nurses completed skin assessments and documented in EHR; confirmed deficiencies and corrective actions. |
| Staff A | Certified Nursing Assistant (CNA) | Observed providing incontinent care during inspection. |
| Staff B | Certified Nursing Assistant (CNA) | Observed providing incontinent care during inspection. |
| Administrator | Provided information on IT report issues and facility policies. |
Inspection Report
Complaint Investigation
Deficiencies: 0
May 23, 2024
Visit Reason
A complaint investigation was conducted for Complaints #116320-C and #118106-C from May 20, 2024 to May 23, 2024.
Findings
The facility was found to be in substantial compliance.
Complaint Details
Investigation of Complaints #116320-C and #118106-C; facility found in substantial compliance.
Inspection Report
Complaint Investigation
Deficiencies: 0
Oct 17, 2023
Visit Reason
The inspection was conducted as a complaint survey regarding an investigation of complaint #116201-C.
Findings
The facility was found to be in substantial compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities, and the complaint #116201-C was not substantiated.
Complaint Details
Complaint #116201-C was investigated and found not substantiated.
Inspection Report
Annual Inspection
Deficiencies: 0
May 4, 2023
Visit Reason
An onsite revisit regarding the facility's annual recertification survey was conducted on May 2-4, 2023.
Findings
The facility was found in substantial compliance effective March 31, 2023.
Inspection Report
Annual Inspection
Census: 53
Deficiencies: 4
Mar 6, 2023
Visit Reason
The inspection was the facility's annual recertification survey conducted from March 6, 2023 to March 9, 2023 to assess compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities.
Findings
The facility was found not in compliance with several requirements including timely issuance of Medicare Non-Coverage Notices, prevention and treatment of pressure ulcers, and maintenance of nutritional status for residents. Deficiencies were identified related to notification processes, skin integrity, and nutrition/hydration status.
Severity Breakdown
Level 2: 3
Level 3: 1
Deficiencies (4)
| Description | Severity |
|---|---|
| Failure to provide required Medicare Liability Notices and Beneficiary Appeals within 48 hours for skilled services ending for residents #17 and #100. | Level 2 |
| Failure to implement interventions to prevent development of pressure ulcers for resident #6. | Level 3 |
| Failure to maintain acceptable nutritional status parameters for residents #26 and #37, resulting in significant weight loss. | Level 2 |
| Failure to complete a significant change assessment within 14 days for resident #3. | Level 2 |
Report Facts
Census: 53
Residents reviewed for Medicare Non-Coverage Notices: 3
Residents reviewed for pressure ulcer deficiency: 1
Residents reviewed for nutrition deficiency: 2
Residents reviewed for significant change assessment deficiency: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Licensed Practical Nurse (LPN) | Documented stage four pressure area and wound care for Resident #6 |
| Staff C | Registered Nurse (RN) | Documented pressure wound and notified physician for Resident #6 |
| Staff D | Licensed Practical Nurse (LPN) | Documented wound care and observations for Resident #6 |
| Staff F | Nurse | Provided wound care and repositioning for Resident #6 |
| Director of Nursing | Director of Nursing (DON) | Reported wound care and weight loss issues for Resident #6 and Resident #26 |
| Registered Dietitian | Registered Dietitian (RD) | Authored dietary notes and weight change documentation for Residents #26 and #37 |
| Social Worker | Social Worker (SW) | Reported notification processes for skilled services ending |
| Administrator | Administrator | Provided information on facility policies and education regarding ABN and MDS processes |
Inspection Report
Plan of Correction
Deficiencies: 0
Oct 31, 2022
Visit Reason
The document is a plan of correction submitted following a prior inspection, indicating the facility's acceptance of compliance and certification effective September 13, 2022.
Findings
The facility was found to be in compliance based on acceptance of a credible allegation of compliance and plan of correction as per 42 CFR Part 483, Subpart B-C.
Inspection Report
Complaint Investigation
Census: 55
Deficiencies: 3
Aug 18, 2022
Visit Reason
The inspection visit was conducted as an investigation of complaints #103578-C, #105093-C, and #106985-C from August 18 to August 25, 2022. Complaints #103578-C and #106985-C were substantiated.
Findings
The facility failed to update a Care Plan for a resident at risk for elopement and failed to notify appropriate staff members after the resident eloped. The resident was found outside unattended, and staff did not properly supervise or report the incident. The facility lacked documentation related to the resident's risk of elopement and failed to ensure proper supervision to prevent residents from going outside unattended.
Complaint Details
Complaints #103578-C and #106985-C were substantiated based on observations, clinical record reviews, staff interviews, and facility policy review. The investigation found failures related to care planning, supervision, and notification after a resident eloped.
Severity Breakdown
SS=D: 2
SS-D: 1
Deficiencies (3)
| Description | Severity |
|---|---|
| Failed to update a Care Plan for a resident at risk for elopement. | SS=D |
| Failed to notify appropriate staff members after resident eloped so an assessment could be completed. | SS=D |
| Residents did not have appropriate supervision to prevent them from going outside unattended. | SS-D |
Report Facts
Complaint investigation dates: August 18, 2022 to August 25, 2022
Census: 55
Resident wandering days: 4
Alarm response time: 23
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff C | Dietary Aide | Noticed Resident #1 outside and alerted Staff B |
| Staff B | Certified Nursing Assistant (CNA) | Responded to Resident #1 outside and brought him back inside |
| Staff A | Licensed Practical Nurse (LPN) | Reported not being informed about Resident #1 leaving the building |
| Staff D | Certified Medication Aide (CMA) | Administered medications and did not report Resident #1 leaving the building |
| Director of Nursing | DON | Responded to questions about elopement assessments and policies |
| Education Director | Provided investigation summary and education on emergency door alarms | |
| MDS Coordinator | Coordinated investigation and communication regarding Resident #1 elopement |
Inspection Report
Complaint Investigation
Census: 55
Deficiencies: 2
Sep 9, 2021
Visit Reason
A recertification health survey and investigation of Complaint #96746-C and Facility Reported Incidents #97076-I and #98544-I was completed from 8/31/21 to 9/9/21.
Findings
The facility failed to follow physician orders for one resident regarding ACE wraps and failed to provide rationale for continuing psychotropic medications for two residents as recommended by the pharmacist.
Complaint Details
Complaint #96746-C was not substantiated. Facility Reported Incident #97076-I was not substantiated. Facility Reported Incident #98544-I was not substantiated.
Deficiencies (2)
| Description |
|---|
| Facility failed to follow physician orders for ACE wraps for Resident #29. |
| Facility failed to provide rationale for continuing psychotropic medications for two residents (#48 and #51) as recommended by the pharmacist for a Gradual Dose Reduction (GDR). |
Report Facts
Census: 55
Residents reviewed for GDR: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Confirmed resident did not wear ACE wraps and acknowledged physician orders; reported plans to follow up with staff |
Inspection Report
Complaint Investigation
Census: 42
Deficiencies: 2
Jul 23, 2020
Visit Reason
The inspection was a COVID-19 Focused Infection Control Survey and investigation of Facility Reported Incident #91444-I and Complaint #91893-C, conducted due to a complaint and reported incident involving resident care and abuse allegations.
Findings
The facility failed to report an incident of neglect and immediately segregate the alleged perpetrator after Resident #2 fell due to improper ambulation assistance by Staff A. The resident suffered injuries including bruises and an open wound on the left knee. Staff did not follow care plans requiring use of a gait belt and wheelchair follow during ambulation. The facility also failed to ensure adequate supervision and assistance devices to prevent accidents.
Complaint Details
Complaint #91893-A was substantiated. Facility Reported Incident #91444-I was not substantiated.
Severity Breakdown
SS=D: 1
SS=G: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to report an incident of neglect and immediately segregate the alleged perpetrator as required by Abuse Prevention policy. | SS=D |
| Failure to ensure resident received transfer assistance as directed by care plan, resulting in a fall and injuries. | SS=G |
Report Facts
Resident census: 42
Date of fall incident: Jun 16, 2020
Date survey completed: Jul 23, 2020
Number of bruises documented: 4
Size of largest bruise: 6
Number of eschar/dry scab open areas: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | CNA/CMA | Named in findings for improper ambulation and failure to follow care plan resulting in resident fall |
| Staff C | CNA | Witnessed fall and improper ambulation by Staff A |
| Staff D | CNA | Witnessed fall and improper ambulation by Staff A |
| Staff E | LPN | Provided education to Staff A on following care plan after fall |
| Staff F | Occupational Therapist | Observed resident ambulation with gait belt and walker |
| Assistant Director of Nursing | ADON | Conducted fall investigation and obtained witness statements |
Inspection Report
Routine
Census: 41
Deficiencies: 0
Jun 10, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the Department of Inspections and Appeals to assess compliance with CMS and CDC recommended practices for COVID-19 preparation.
Findings
The facility was found to be in compliance with CMS and CDC recommended practices to prepare for COVID-19.
Report Facts
Total census: 41
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