The most recent inspection on October 7, 2025, found the facility in substantial compliance with no deficiencies cited. Earlier inspections showed a pattern of some deficiencies related mainly to resident care, including issues with supervision during transfers, use of gait belts, and incontinence care. Several complaint investigations were substantiated, such as failures to prevent accidents and provide adequate assistance, but no fines, immediate jeopardy findings, or license actions were listed in the available reports. Most complaints were substantiated when deficiencies were found, while some investigations were unsubstantiated. The facility’s record shows improvement over time, with the last two inspections in 2025 free of deficiencies after addressing prior concerns.
Deficiencies (last 6 years)
Deficiencies (over 6 years)1.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
An Annual Recertification survey was conducted from August 5, 2024 to August 8, 2024.
Findings
The facility was found to be in substantial compliance.
Inspection Report Plan of CorrectionDeficiencies: 0May 1, 2024
Visit Reason
The document serves as a Plan of Correction following a survey to address deficiencies and certify the facility's compliance.
Findings
The facility was found to be in substantial compliance based on the credible allegation and Plan of Correction, resulting in certification effective May 1, 2024.
The inspection was conducted as an investigation of Complaint #116386-C and Facility Reported Incident #120021-1 from April 16 to April 18, 2024.
Findings
The facility was found to have deficiencies in quality of care and free of accident hazards/supervision/devices. The facility failed to assess and intervene after a resident's mental status change and failed to ensure proper use of gait belts during resident transfers. Both complaints were substantiated.
Complaint Details
Complaint #116386-C was substantiated. Facility Reported Incident #120021-1 was substantiated.
Severity Breakdown
Level D: 2
Deficiencies (2)
Description
Severity
Facility failed to further assess and intervene after a change in mental status for 1 of 4 residents reviewed.
Level D
Facility failed to ensure staff utilized a gait belt in accordance with the care plan for 1 of 3 residents reviewed for transfers.
Level D
Report Facts
Resident census: 42Residents reviewed for mental status assessment: 4Residents reviewed for transfers: 3
Employees Mentioned
Name
Title
Context
Tanya Powell
Administrator
Signed the plan of correction
Staff A
Certified Nursing Assistant (CNA)
Provided information regarding Resident #1's transfer assistance needs
Staff B
Registered Nurse (RN)
Reported on Resident #1's fall and gait belt usage
Staff C
Doctor of Medicine (MD)
Stated expectations for notification of resident mental status changes
Inspection Report Plan of CorrectionDeficiencies: 0Oct 17, 2023
Visit Reason
The document serves as a plan of correction following a survey, indicating acceptance of credible allegation of substantial compliance and certification of the facility.
Findings
The facility was found to be in substantial compliance based on the credible allegation and plan of correction, resulting in certification effective October 17, 2023.
The inspection was conducted as part of the facility's Annual Recertification Survey and investigation of multiple complaints (#111646-C, #115105-C, #115424-C, and #115799-C) from October 2 to October 5, 2023.
Findings
The facility was found deficient in providing adequate ADL care for dependent residents, specifically failing to provide complete perineal care to prevent contamination following an incontinent episode for one resident. The complaint #115105-C was substantiated with detailed observations of improper incontinence care practices by staff.
Complaint Details
Complaint #115105-C was substantiated based on clinical record review, observations, staff interviews, and policy review indicating inadequate incontinence care.
Severity Breakdown
SS=D: 1
Deficiencies (1)
Description
Severity
Failure to provide complete perineal care to prevent contamination following an incontinent episode for Resident #12.
The inspection was conducted as an annual certification survey to determine compliance with regulatory requirements.
Findings
Based on the onsite visit completed September 26-27, 2022, the facility was certified in compliance effective August 20, 2022. No deficiencies or plans of correction were effectuated.
The inspection was conducted as a result of investigations into Complaints #105489-C, #105492-C, and a Facility Self-Reported Incident #105502-I from August 12 to August 19, 2022.
Findings
The facility failed to safely transfer one resident, resulting in injury including facial bone fractures and other injuries. The investigation substantiated the complaints and self-reported incident, revealing inadequate supervision and assistance during transfers.
Complaint Details
Complaints #105489-C and #105492-C were substantiated. Facility Self-Reported Incident #105502-I was substantiated.
Severity Breakdown
SS=G: 1
Deficiencies (1)
Description
Severity
Failure to ensure the resident environment remains free of accident hazards and to provide adequate supervision and assistance devices to prevent accidents, resulting in injury to Resident #1 during transfer.
SS=G
Report Facts
Resident census: 36Dates of complaint investigation: August 12, 2022 to August 19, 2022MDS Assessment date: 5/26/22Care Plan date: 6/9/22, 7/13/22, 8/1/22Incident Report date: 7/11/22Hospital admission days: 3
Employees Mentioned
Name
Title
Context
Tanya Powell
Administrator
Signed plan of correction and provided statements regarding corrective actions
Staff C
Licensed Practical Nurse (LPN)
Interviewed regarding incident and transfer safety
Staff A
Certified Nursing Assistant (CNA)
Interviewed regarding care and transfer of Resident #1
Staff B
Certified Nursing Assistant (CNA)
Interviewed regarding assistance with transfer and incident
Staff D
Certified Nursing Assistant (CNA)
Interviewed regarding training and transfer procedures
Staff E
Certified Nursing Assistant (CNA), Restorative Director
Interviewed regarding training and documentation
Director of Nursing
Director of Nursing (DON)
Interviewed regarding incident and corrective actions
Inspection Report Plan of CorrectionDeficiencies: 0Jun 17, 2022
Visit Reason
The document is a plan of correction submitted following a deficiency statement, indicating the facility's acceptance of compliance and corrective actions.
Findings
The facility was certified in compliance based on acceptance of a credible allegation of compliance and plan of correction effective June 17, 2022.
The inspection was conducted as part of the facility's Recertification Survey and investigation of Complaint #096135-C, which was unsubstantiated.
Findings
The facility failed to properly assess residents for risk of entrapment from bed rails prior to installation and did not use appropriate alternatives to bed rails for three of 31 residents reviewed. The facility also failed to ensure safety and proper use of side rails for residents.
Complaint Details
Complaint #096135-C was investigated and found to be unsubstantiated.
Severity Breakdown
SS=D: 1
Deficiencies (1)
Description
Severity
Failure to assess residents for risk of entrapment from bed rails prior to installation and failure to use alternatives to bed rails for three residents.
SS=D
Report Facts
Residents reviewed for bed rails: 31Census: 38
Employees Mentioned
Name
Title
Context
Tanya Powell
Administrator
Named in plan of correction as responsible for implementing side rail assessment process
The inspection was conducted as a recertification survey from January 11 to January 14, 2021, to assess compliance with federal regulations for the facility.
Findings
The facility failed to maintain cleanliness in the kitchen, with observations of cobwebs, dead insects, and black fuzz on vents and ceiling tiles. The cleaning schedule lacked direction for cleaning these areas, and staff interviews revealed inconsistent cleaning practices.
Severity Breakdown
SS=E: 4
Deficiencies (4)
Description
Severity
Cobweb on the underside of the right front hood over the stove.
SS=E
Top of stove hood covered with fuzz and residue, including cobwebs and a dead fly.
SS=E
Dead moth hung from the gas line pipe where it met the ceiling tile.
SS=E
Heating/cooling vents and ceiling tiles contained 15-50% black fuzz.
A COVID-19 Focused Infection Control Survey was conducted by the Department of Inspections and Appeals on 8/12-13/20 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.
A COVID-19 Focused Infection Control Survey was conducted by the Department of Inspection and Appeals on 6/25/20 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: 45
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