Inspection Reports for Centerville Specialty Care

This document is a statement of deficiencies and plan of corrections following an inspection, indicating acceptance of credible allegation of substantial compliance and plan of correction.

The facility will be certified in compliance effective December 19, 2025, based on acceptance of the credible allegation of substantial compliance and plan of correction.

The inspection was conducted as an annual recertification survey of Centerville Specialty Care from December 2 to December 4, 2025.

The facility was found to have multiple deficiencies related to residents' rights to be informed and make treatment decisions, quality of care including blood sugar management, free of accident hazards, menu adequacy, and infection prevention and control. Corrective actions and education plans were outlined for nursing and dietary staff to address these issues.

The investigation was conducted in response to complaint #2582139-C from October 13, 2025 to October 15, 2025.

The facility was found to be in substantial compliance with no deficiencies noted.

Investigation of complaint #2582139-C; facility found in substantial compliance.

A complaint investigation was conducted for Complaint #129325-C and facility reported incidents #129184-I and #129323-I from June 17, 2025 to June 25, 2025.

The facility was found to be in substantial compliance with no deficiencies cited.

Complaint #129325-C and facility reported incidents #129184-I and #129323-I were investigated and found to be in substantial compliance.

A complaint investigation was conducted for facility reported incident #124765-I from January 6, 2025 to January 7, 2025.

The facility was found to be in compliance and the incident #124765-I was not substantiated.

Incident #124765-I was not substantiated.

The document serves as a Plan of Correction following a prior inspection, indicating acceptance of credible allegation of substantial compliance and certification of the facility.

The facility was found to be in substantial compliance based on the credible allegation and Plan of Correction, resulting in certification effective October 31, 2024.

The inspection was conducted as part of the facility's annual recertification survey completed from 10/14/24 to 10/17/24.

The facility was found deficient in meeting nutritional needs of residents on pureed diets and in food procurement, kitchen sanitation, and food handling practices. Specific issues included incorrect portion sizes and textures served, inadequate kitchen sanitation, and food safety violations.

The inspection was conducted as an investigation of complaints #122478-C, #122486-C and a facility self-report #122524-I from August 21 to August 22, 2024.

The facility was found to have failed to ensure that one resident (Resident #1) was treated with respect and dignity during interactions, as evidenced by staff behavior that escalated to physical contact. The complaints and self-report were substantiated, and the facility had corrected the deficiency from a prior non-compliance dated August 2, 2024.

The investigation was based on complaints #122478-C, #122486-C and facility self-report #122524-I. The complaints and self-report were substantiated. The deficiency involved staff escalating interactions with Resident #1, including physical contact and pushing, which was not in line with facility policies on abuse prevention.

The document serves as a statement of deficiencies and plan of correction related to the facility's certification compliance.

The facility was certified in compliance effective August 2, 2024, based on acceptance of a credible allegation of compliance and plan of correction.

The inspection was conducted as a result of complaints #120070-C, #120181-C, #121268-C, and #121820-C from July 25, 2024 to August 1, 2024. Complaint #120070-C was substantiated.

The facility failed to ensure residents were appropriately assessed and provided interventions to maintain optimal health and well-being for 2 of 4 residents reviewed. Specific issues included improper catheter management and failure to monitor neurological assessments as required.

Complaint #120070-C was substantiated based on clinical record review and staff interviews indicating failure to properly manage catheter removal and voiding for Resident #5, and failure to conduct required neurological assessments for Resident #6.

A complaint investigation for Complaint #116406-C was conducted from March 26, 2024 to March 28, 2024.

The facility was found to be in substantial compliance.

Complaint #116406-C was investigated and the facility was found to be in substantial compliance.

The document serves as a Plan of Correction following a survey, indicating acceptance of a credible allegation of substantial compliance and certification of the facility.

The facility was found to be in substantial compliance based on the credible allegation and Plan of Correction, resulting in certification effective October 9, 2023.

The inspection was conducted as part of the facility's Annual Recertification Survey and investigation of a Facility Reported Incident #115431-I.

The facility was found to have multiple deficiencies including failure to maintain a safe, clean, comfortable, and homelike environment; inadequate housekeeping and maintenance; failure to meet professional standards of medication administration; failure to provide adequate bathing care; failure to ensure safe administration of medications; failure to provide adequate supervision and assistance devices to prevent accidents; and failure to ensure call lights were accessible to residents.

Facility reported incident #115431-I was unsubstantiated.

A complaint investigation for complaints #112121-C and #112328-C was conducted from May 4, 2023 to May 12, 2023.

The facility was found to be in substantial compliance.

Complaint investigation for complaints #112121-C and #112328-C; facility found in substantial compliance.

A revisit of the survey ending February 16, 2023 was conducted from May 4, 2023 through May 12, 2023 to verify correction of previous deficiencies.

All deficiencies were corrected and the facility is in substantial compliance effective March 17, 2023.

The inspection was conducted as a result of investigation of multiple complaints and facility-reported incidents concerning resident care and safety at Centerville Specialty Care.

The facility was found to have deficiencies related to resident participation in care planning, notification of changes in condition, prevention and treatment of pressure ulcers, accident hazards and supervision, and other care and safety issues. Several residents were identified as being affected by these deficiencies, including Resident #1, #4, and #9. The facility failed to meet regulatory requirements in multiple areas, including communication with residents and families, care planning, and environmental safety.

Complaints #108491-C, #109045-C, #109588-C, #109770-C, #109816-C, #110729-C, #110800-C and facility reported incidents #100898-I and #110836-I were investigated. Complaints #108491-C, #109816-C, #110729-C and #110800-C were substantiated. Facility reported incidents #100898-I and #110836-I were substantiated.

An onsite revisit survey was conducted with an investigation of complaints 105381-C and 106778-C from 8/15/22 to 8/24/22, for the recertification survey and investigation of multiple intakes conducted on 7/5/22 - 7/9/22.

All deficiencies identified in the prior investigations have been corrected and the facility is in compliance with all regulations surveyed effective 8/3/22. A discretionary denial of payment for new admissions was effectuated from 8/9/22 to 8/15/22.

The visit included investigation of complaints 105381-C and 106778-C and multiple intakes (#101173-C, #103171-C, #103248-C, #105298-C, and #105395-I).

The inspection was conducted as part of the facility's annual recertification survey and investigation of complaints and facility-reported incidents.

The report details multiple deficiencies related to medication administration, resident rights, food service, infection control, call light response, and quality of care. Corrective actions and plans of correction were provided for each deficiency.

A Focused Infection Control Survey and Complaint #94395 were conducted by the Department of Inspection and Appeals on November 16 - 18, 2020.

The facility was found to be in compliance with CMS and CDC recommended practices for COVID-19. Complaint #94395-C was not substantiated.

Complaint #94395-C was not substantiated.

A Focused Infection Control Survey and Facility Reported Incident #90800 were conducted by the Department of Inspection and Appeals on September 21 - 24, 2020.

The facility was found to be in compliance with CMS and Centers for Disease Control and Prevention (CDC) recommended practices. Facility Reported Incident #90800-I was not substantiated.

The inspection was a COVID-19 Focused Infection Control Survey and complaint investigation (#91253) conducted by the Department of Inspection and Appeals from June 15 to 17, 2020, to assess compliance with CMS and CDC recommended infection control practices.

The facility was found not in substantial compliance with CMS and CDC recommended COVID-19 infection control practices, including failure to implement effective screening, proper hand hygiene, and appropriate use of personal protective equipment (PPE) by staff. The complaint was substantiated.

Complaint #91253-C was substantiated.

The inspection was conducted as an annual health survey to assess compliance with federal regulations and evaluate the facility's care and infection control practices.

The facility was found deficient in several areas including accuracy of resident assessments, development and implementation of comprehensive care plans, and infection prevention and control practices. Specific issues included inaccurate MDS assessments, incomplete care plans for residents, and failure to follow infection control protocols.

The inspection was conducted due to reported incidents involving falls and safety concerns for residents at Centerville Specialty Care.

The facility failed to provide adequate supervision and use of safety devices to prevent falls for two residents, resulting in serious injuries including a femur fracture and a cervical fracture. Staff failed to secure a safety strap on a shower chair and did not use a footboard on a wheelchair as required by care plans.

The investigation was triggered by complaints related to falls and inadequate use of safety devices for Residents #1 and #2. Resident #1 fell from a shower chair without the safety belt secured, and Resident #2 tipped her wheelchair due to lack of a footboard, sustaining serious injuries.