Inspection Report
Annual Inspection
Deficiencies: 0
Dec 3, 2025
Visit Reason
An annual recertification survey was conducted from December 1, 2025 through December 3, 2025.
Findings
The facility was found to be in substantial compliance.
Inspection Report
Complaint Investigation
Deficiencies: 0
Jun 10, 2025
Visit Reason
A complaint investigation for complaint #128654-C was conducted on June 10, 2025.
Findings
The facility was found to be in substantial compliance.
Complaint Details
Complaint #128654-C was investigated and the facility was found to be in substantial compliance.
Inspection Report
Plan of Correction
Deficiencies: 0
Nov 13, 2024
Visit Reason
The document serves as a Plan of Correction following a Recertification Survey and Complaint Survey ending on 2024-10-10 to address deficiencies and certify the facility in compliance.
Findings
The facility was found to be in substantial compliance based on the credible allegation and Plan of Correction submitted, leading to certification effective 2024-10-23.
Complaint Details
The Plan of Correction relates to a Complaint Survey ending on 2024-10-10; the facility's substantial compliance was accepted.
Report Facts
Survey end date: Oct 10, 2024
Certification effective date: Oct 23, 2024
Inspection Report
Annual Inspection
Census: 50
Deficiencies: 3
Oct 10, 2024
Visit Reason
The inspection was conducted as part of the facility's annual recertification survey and investigation of a reported incident.
Findings
The facility was found deficient in accuracy of assessments for residents and medication administration errors. Additionally, the facility failed to ensure residents were up to date with influenza and pneumococcal immunizations.
Severity Breakdown
Level D: 2
Level E: 1
Deficiencies (3)
| Description | Severity |
|---|---|
| Accuracy of Assessments: The facility failed to update the comprehensive assessment to ensure accuracy for 1 of 5 residents reviewed (Resident #16). | Level D |
| Residents are Free of Significant Med Errors: The facility failed to prepare a medication as directed for 1 of 1 residents reviewed (Resident #31). | Level D |
| Influenza and Pneumococcal Immunizations: The facility failed to screen for pneumococcal vaccines, educate residents or responsible parties, or offer pneumococcal vaccines for 4 of 5 residents reviewed. | Level E |
Report Facts
Resident census: 50
Residents reviewed for assessment accuracy: 5
Residents reviewed for medication errors: 1
Residents reviewed for immunizations: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Certified Nursing Assistant (CNA) | Explained alarm placement on Resident #16's chair |
| Staff D | Certified Nursing Assistant (CNA) | Explained alarms started after Resident #16's falls |
| Staff E | Licensed Practical Nurse (LPN) | Observed crushing of medications for Resident #31 |
| Director of Nursing | DON | Explained prior fall interventions and medication policies |
| Assistant Director of Nursing | ADON | Informed about immunization registry checks |
Inspection Report
Complaint Investigation
Deficiencies: 0
Sep 13, 2024
Visit Reason
A complaint investigation was conducted for a facility reported incident #123402-I on September 13, 2024.
Findings
The facility was found to be in substantial compliance with no deficiencies noted.
Complaint Details
Complaint investigation related to incident #123402-I; facility found in substantial compliance.
Inspection Report
Complaint Investigation
Deficiencies: 0
May 21, 2024
Visit Reason
A complaint investigation for complaint #120949-C and facility reported incident #120955-I was conducted on May 21, 2024.
Findings
The facility was found to be in substantial compliance.
Complaint Details
Complaint #120949-C and facility reported incident #120955-I were investigated; the facility was found to be in substantial compliance.
Inspection Report
Plan of Correction
Deficiencies: 0
Aug 14, 2023
Visit Reason
The document serves as a Plan of Correction following a survey, indicating acceptance of the facility's credible allegation of substantial compliance.
Findings
The facility was certified in compliance effective August 14, 2023, based on acceptance of the Plan of Correction and credible allegation of substantial compliance.
Inspection Report
Annual Inspection
Census: 52
Deficiencies: 5
Aug 10, 2023
Visit Reason
The inspection was conducted as part of the facility's annual recertification survey from August 7, 2023 to August 10, 2023 to assess compliance with federal regulations for long term care facilities.
Findings
The facility was found not in compliance with several requirements including resident rights related to dignity and catheter care, advance directives documentation, medication administration standards, bowel/bladder incontinence management, and food safety practices. Immediate corrective actions and systematic changes were implemented to address these deficiencies.
Deficiencies (5)
| Description |
|---|
| Failure to provide dignity covers for urinary catheters and hanging catheter bags for wheelchairs for residents #4 and #46. |
| Failure to maintain accurate advance directive records based on resident preference for 1 of 24 residents reviewed (#12). |
| Failure to administer levothyroxine medication as ordered for resident #302, including late administration and lack of physician notification. |
| Failure to ensure residents with urinary catheters have catheter bags and tubing kept off the floor for residents #4, #46, and #203. |
| Failure to follow food safety requirements, including failure to cover food and drinks during meal tray distribution for six out of six observed trays. |
Report Facts
Facility Census: 52
Residents reviewed for advance directives: 24
Residents with dignity cover deficiency: 2
Residents with catheter bag floor contact: 3
Meal trays observed uncovered: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff E | Certified Nurse Aide (CNA) | Revealed catheter drainage bag came with dignity cover attached and explained cover use. |
| Staff B | Licensed Practical Nurse (LPN) | Reported catheter drainage bags are changed weekly and dignity covers are attached but sometimes not replaced. |
| Staff F | Licensed Practical Nurse (LPN) | Explained administration of levothyroxine medication and timing expectations. |
| Staff A | Certified Medication Aide (CMA) | Reported not giving Resident #302 her medications yet and completed passing medications after 10 AM. |
| Staff D | Certified Nurse Aide (CNA) | Reported keeping Resident #46's catheter drainage bag in wire basket to keep off floor. |
| Staff C | Cook | Observed dropping menu tickets on floor and failure to complete hand hygiene. |
| Dietary Supervisor | Prepared room trays without covering drinks and side dishes; confirmed expectation for covering food and drinks during room tray delivery. | |
| Director of Nursing | Director of Nursing (DON) | Reported expectations for catheter bag coverage and medication administration timing; verified inaccuracies in code status documentation. |
Inspection Report
Complaint Investigation
Census: 51
Deficiencies: 0
Apr 27, 2023
Visit Reason
A COVID-19 Focused Infection Control Survey and a Complaint investigation for Complaints #106622-C, #109907-C, #110345-C, and #111484-C was conducted by the Department of Inspection and Appeals.
Findings
The facility was found to be in compliance with CMS and CDC recommended practices to prepare for COVID-19 and was found to be in substantial compliance.
Complaint Details
Investigation involved multiple complaints (#106622-C, #109907-C, #110345-C, and #111484-C) and resulted in a finding of substantial compliance.
Report Facts
Total Residents: 51
Inspection Report
Plan of Correction
Deficiencies: 0
Jun 23, 2022
Visit Reason
The document is a plan of correction submitted following a survey to address deficiencies and ensure compliance.
Findings
The facility was certified in compliance based on acceptance of the credible allegation of compliance and plan of correction effective June 23, 2022.
Inspection Report
Annual Inspection
Census: 44
Deficiencies: 1
Jun 16, 2022
Visit Reason
The inspection visit was conducted as part of the facility's Annual Recertification Survey and an investigation of Complaint #101856-C.
Findings
The facility failed to develop and implement comprehensive care plans addressing insulin and anti-depressant medications for 3 of 5 residents reviewed. The complaint was not substantiated. Immediate corrective actions and systemic changes were implemented to ensure compliance.
Complaint Details
Complaint #101856-C was investigated and found to be not substantiated.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to develop and implement comprehensive care plans addressing insulin and anti-depressant medications for residents. | SS=D |
Report Facts
Resident census: 44
Residents reviewed for unnecessary medications: 5
Residents with medication issues: 3
Resident #8 MDS score: 9
Resident #11 MDS score: 9
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Interviewed on 6/16/22 regarding care plan expectations and medication administration |
Inspection Report
Complaint Investigation
Census: 40
Deficiencies: 0
Oct 4, 2021
Visit Reason
The inspection was conducted as a complaint investigation for Complaint #98628-C and an investigation of a facility-reported incident #99319-I, along with a focused COVID-19 infection survey.
Findings
The complaint was not substantiated, and the facility-reported incident did not result in any deficiency. The facility was found to be in compliance with CMS and CDC recommended practices for COVID-19 preparation.
Complaint Details
Complaint #98628-C was not substantiated.
Report Facts
Total residents: 40
Inspection Report
Complaint Investigation
Census: 36
Deficiencies: 2
Apr 29, 2021
Visit Reason
The inspection was conducted as a Recertification Survey and investigation of Complaint #96547 from 4/26 to 4/29/2021. The complaint was not substantiated.
Findings
The facility was found deficient in ensuring residents were free of accident hazards and in providing adequate supervision and assistance during transfers, as well as in catheter care and hygiene practices for a resident with a Foley catheter.
Complaint Details
Complaint #96547 was investigated from 4/26 to 4/29/2021 and was not substantiated.
Deficiencies (2)
| Description |
|---|
| Facility failed to transfer 1 out of 2 residents needing assistance according to the Care Plan during 2 out of 3 transfers observed. |
| Facility failed to provide complete catheter care, keep the catheter bag off the floor, and complete hand hygiene after cares for 1 out of 1 residents reviewed with a Foley catheter. |
Report Facts
Residents needing assistance: 2
Transfers observed: 3
Residents reviewed with Foley catheter: 1
Census: 36
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Reported expectations for nursing staff to use gait belts and catheter care procedures |
| Staff A | Certified Nurses Aid (CNA) | Observed assisting Resident #30 during transfers |
| Staff B | Certified Nurses Aid (CNA) | Observed assisting Resident #30 and performing catheter care |
| Staff C | Certified Nurses Aid (CNA) | Reported catheter care procedures and hand hygiene practices |
Inspection Report
Abbreviated Survey
Census: 42
Deficiencies: 0
Jan 7, 2021
Visit Reason
A Focused COVID-19 Infection Control Survey was conducted by the Department of Inspections and Appeals on 01/6-7/21 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 residents: 42
Inspection Report
Abbreviated Survey
Census: 41
Deficiencies: 0
Jun 17, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the Department of Inspections and Appeals on 6/17/20 to assess the facility's 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 Residents: 41
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