Deficiencies per Year
8
6
4
2
0
Severe
High
Moderate
Low
Unclassified
Census Over Time
Inspection Report
Complaint Investigation
Deficiencies: 0
Oct 9, 2025
Visit Reason
A complaint investigation was conducted for complaints #2568829-C and #1675308-C on October 9, 2025.
Findings
The facility was found to be in substantial compliance with no deficiencies cited.
Complaint Details
Complaint investigation for complaints #2568829-C and #1675308-C; facility found to be in substantial compliance.
Inspection Report
Plan of Correction
Deficiencies: 0
Jul 7, 2025
Visit Reason
The document is a Plan of Correction submitted following a prior inspection, indicating acceptance of a credible allegation of substantial compliance and certification of the facility effective June 27, 2025.
Findings
The facility was found to be in substantial compliance based on the accepted Plan of Correction, with no specific deficiencies detailed in this document.
Inspection Report
Complaint Investigation
Census: 52
Deficiencies: 1
Jun 24, 2025
Visit Reason
The inspection was conducted as a result of complaint #127271-C and facility self-report #127248-I, focusing on allegations related to respect, dignity, and the right to have personal property.
Findings
The facility failed to provide a private pay resident being discharged to another facility with her unused medications and controlled medications, violating the resident's right to retain personal property. The resident was left without pain medications for over 10 hours after discharge.
Complaint Details
Investigation of complaint #127271-C found the facility did not meet the requirement to respect the resident's right to retain personal property, including medications, during discharge. The complaint was substantiated based on clinical record review, staff interviews, and pharmacy communication.
Severity Breakdown
D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to provide a private pay resident with her unused medications and controlled medications upon discharge, violating respect and dignity requirements. | D |
Report Facts
Resident census: 52
BIMS score: 13
Medication doses: 2
Correction date: Jun 27, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing (DON) | Provided interview regarding discharge medication process and facility policy |
| Administrator | Facility Administrator | Provided interview about Resident #2's discharge and medication issues |
Inspection Report
Re-Inspection
Deficiencies: 0
Jan 29, 2025
Visit Reason
A revisit of the survey ending December 30, 2024 was conducted on January 29, 2025 to verify correction of previous deficiencies.
Findings
All deficiencies were corrected and the facility is in substantial compliance. DPNA was not effectuated.
Inspection Report
Annual Inspection
Census: 51
Deficiencies: 3
Dec 12, 2024
Visit Reason
The inspection was conducted as part of the facility's annual recertification survey and investigation of complaint #123071-C from December 9, 2024 to December 12, 2024.
Findings
The facility was found to have deficiencies in meeting professional standards for comprehensive care plans, free of accident hazards, and food procurement, storage, preparation, and sanitation. The complaint was not substantiated. The facility failed to consistently complete physician's orders for weekly weights, protect residents from falls, and ensure proper food handling and hygiene during meal service.
Complaint Details
Complaint #123071-C was investigated during the survey and was not substantiated.
Deficiencies (3)
| Description |
|---|
| Failure to meet professional standards of quality in comprehensive care plans, including inconsistent completion of physician's orders for weekly weights for Resident #13. |
| Failure to ensure resident environment remains free of accident hazards and provide adequate supervision and assistance devices to prevent accidents, specifically for Resident #15 with frequent falls. |
| Failure to ensure proper food handling and hand hygiene practices during meal service, including staff handling food with bare hands without proper hygiene. |
Report Facts
Resident census: 51
Inspection dates: 4
Weights recorded: 9
Falls reviewed: 1
Meal service audits: 4
Fall interventions audit: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| L N H A | Administrator | Signed the plan of correction on 12/31/2024. |
| Director of Nursing | Interviewed regarding oversight of weight monitoring and fall interventions. | |
| Staff D | Certified Medication Aide (CMA) | Interviewed regarding Resident #15's falls and wheelchair use. |
| Staff B | Van Driver and Certified Nursing Assistant | Observed during meal service handling food with bare hands. |
| Staff A | Certified Nursing Assistant | Observed during meal service handling food with bare hands. |
| Staff C | Cook | Observed during meal service handling food with bare hands. |
| Certified Dietary Manager | Interviewed regarding food handling practices. |
Inspection Report
Complaint Investigation
Deficiencies: 0
Jul 30, 2024
Visit Reason
A complaint investigation for complaint #122290-C was conducted on July 29, 2024 to July 30, 2024.
Findings
The facility was found to be in substantial compliance.
Complaint Details
Complaint #122290-C was investigated and the facility was found to be in substantial compliance.
Inspection Report
Plan of Correction
Deficiencies: 0
Feb 7, 2024
Visit Reason
The document reflects acceptance of a credible allegation of substantial compliance and the facility's Plan of Correction, resulting in certification of 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 February 7, 2024.
Inspection Report
Complaint Investigation
Census: 52
Deficiencies: 6
Jan 19, 2024
Visit Reason
The inspection was conducted as a result of investigations of multiple substantiated complaints (#117753-C, #118156-C, #118157-C, and #118184-C) from January 16 to January 19, 2024.
Findings
The facility was found to have multiple deficiencies including failure to treat residents with dignity and respect, inadequate assistance with activities of daily living, failure to provide restorative exercises, insufficient nursing staff leading to delayed call light responses, unsafe and unsanitary environment with foul odors and jagged heating unit edges, and ineffective pest control with evidence of mouse droppings and sightings.
Complaint Details
The visit was complaint-related based on substantiated complaints #117753-C, #118156-C, #118157-C, and #118184-C.
Severity Breakdown
SS=D: 2
SS=E: 4
Deficiencies (6)
| Description | Severity |
|---|---|
| Facility staff failed to treat 1 of 4 residents with dignity and respect while providing resident cares, including entering rooms without knocking or invitation. | SS=D |
| Failed to properly provide perineal cares for 2 of 3 residents and failed to reposition residents according to their individual needs. | SS=E |
| Failed to provide restorative exercises according to the resident's individual plan of care for 1 of 3 residents reviewed. | SS=D |
| Failed to have sufficient nursing staff to provide nursing care and failed to answer resident call lights within 15 minutes for 2 of 4 residents reviewed. | SS=E |
| Failed to maintain a safe, sanitary, odor free and homelike environment; foul, long lasting urine odor throughout the facility; rough and jagged edges along baseboard heating units in rooms 6 and 7. | SS=E |
| Failed to maintain an effective pest control program; mouse droppings found in multiple resident rooms and mice sightings reported by residents and staff. | SS=E |
Report Facts
Resident census: 52
Call light response time: 15
Restorative exercise frequency: 3
Restorative exercise frequency: 6
Resident BIMS score: 15
Number of residents requiring 2 staff assistance: 9
Inspection Report
Plan of Correction
Deficiencies: 0
Jan 16, 2024
Visit Reason
The document serves as a statement of deficiencies and plan of correction related to the facility's certification compliance.
Findings
The facility was found to be in substantial compliance based on the acceptance of a credible allegation and plan of correction, resulting in certification effective December 22, 2023.
Inspection Report
Annual Inspection
Census: 51
Deficiencies: 3
Dec 21, 2023
Visit Reason
The inspection was conducted as part of the facility's annual recertification survey and included investigation of multiple complaints and a reported incident.
Findings
The facility was found deficient in completing comprehensive assessments after significant changes, accuracy of assessments, and providing/restorative nursing services. Specific residents' records showed failures in timely updates, coding accuracy, and restorative care provision.
Complaint Details
The survey included investigation of complaints #114568-C, #111008-C, #112659-C, and a facility-reported incident #113418-I.
Severity Breakdown
Level 3: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Failure to complete the Minimum Data Set (MDS) within 14 days after a significant change in a resident's condition. | Level 3 |
| Failure to accurately code and complete assessments, including Preadmission Screening and Resident Review (PASRR). | Level 3 |
| Failure to provide individualized restorative nursing services as per care plans for residents with limited range of motion and mobility needs. | Level 3 |
Report Facts
Census: 51
Deficiencies cited: 3
Audits: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing (DON) | Stated the MDS Coordinator is the restorative nurse and described restorative nursing expectations |
| MDS Coordinator | MDS Coordinator | Interviewed regarding assessment completion timelines, restorative aide documentation, and audit responsibilities |
Inspection Report
Plan of Correction
Deficiencies: 0
Feb 22, 2023
Visit Reason
The document serves as a statement of deficiencies and plan of correction following a survey completed on February 22, 2023.
Findings
The facility submitted a credible allegation of compliance and plan of correction, resulting in certification of compliance effective February 22, 2023. No specific deficiencies or severity levels are detailed in the report.
Inspection Report
Complaint Investigation
Census: 67
Deficiencies: 2
Feb 9, 2023
Visit Reason
The inspection was conducted as a result of investigations into multiple complaints and a facility self-reported incident between February 6, 2023 and February 9, 2023.
Findings
The facility was found to have substantiated deficiencies related to failure to follow physician's orders for pain management in a hospice resident and failure to ensure accurate transcription of advanced directives for a resident who experienced cardiac arrest. The facility was compliant with COVID-19 infection control practices.
Complaint Details
The investigation involved Complaints #107433-C, #107765-C, #107799-C, #107827-C, #109258-C, #109623-C, #109772-C, #110527-C, #110745-C, #110813-C and Facility Self-Reported Incident #109643-I. Complaints #107433-C, #109623-C, #110527-C, #110745-C, and #110813-C were substantiated. Facility Self-Reported Incident #109643-I was substantiated.
Severity Breakdown
SS=D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to provide services that met professional standards by not following physician's orders for morphine administration for a hospice resident. | SS=D |
| Failure to ensure accurate transcription of Advanced Directives for a resident who experienced cardiac arrest, resulting in CPR being initiated despite a DNR order. | SS=D |
Report Facts
Total Residents: 67
Complaints investigated: 10
Facility Self-Reported Incidents: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Licensed Practical Nurse (LPN) | Named in the finding related to inaccurate transcription of Advanced Directives and CPR initiation |
| Staff B | Registered Nurse | Named in the finding related to failure to follow morphine orders |
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding morphine order and advanced directive transcription issues |
Inspection Report
Plan of Correction
Deficiencies: 0
Oct 14, 2022
Visit Reason
The document is a plan of correction following a survey ending August 25, 2022, submitted to certify the facility in compliance.
Findings
The facility was found to be in compliance based on acceptance of the credible allegation of compliance and plan of correction following the survey.
Inspection Report
Annual Inspection
Census: 64
Deficiencies: 1
Aug 25, 2022
Visit Reason
The inspection was conducted as part of the facility's annual recertification survey and included an investigation of complaint #105828-C, which was found to be unsubstantiated.
Findings
The facility failed to ensure the accuracy of the pre-admission screening and resident review (PASRR) upon admission for one resident (Resident #45), as the PASRR did not reflect the resident's mental health diagnoses of anxiety disorder and major depressive disorder.
Complaint Details
Complaint #105828-C was investigated during the survey and was unsubstantiated.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure the pre-admission screening and resident review (PASRR) was accurate upon admission for Resident #45. | SS=D |
Report Facts
Census: 64
Sampled residents for PASRR review: 3
Resident #45 admission date: Apr 18, 2022
Admission MDS assessment date: Apr 22, 2022
Quarterly MDS assessment date: Jul 21, 2022
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Social Services/Admission employee | Responsible for reviewing resident PASARR upon admission and ensuring accuracy; confirmed PASARR was missing mental health diagnoses for Resident #45. |
| Director of Nursing | Confirmed Admissions (Staff A) received and reviewed resident PASARRs for accuracy. | |
| Administrator | Stated Admissions (Staff A) was responsible for ensuring PASARRs were completed and accurate. |
Inspection Report
Re-Inspection
Deficiencies: 0
Jul 12, 2022
Visit Reason
A revisit was conducted from July 7 to July 12, 2022, to investigate multiple facility-reported incidents, mandatory reports, and complaints, including complaint #105201-C.
Findings
Complaint #105201-C was not substantiated. All deficiencies identified in prior reports have been corrected, and the facility is in compliance with all surveyed regulations.
Complaint Details
Complaint #105201-C was investigated and found not substantiated.
Report Facts
Incident and complaint identifiers: 12
Inspection Report
Complaint Investigation
Census: 59
Deficiencies: 8
Jun 16, 2022
Visit Reason
The inspection was conducted in response to multiple complaints and facility-reported incidents alleging abuse and improper use of physical restraints involving Resident #1, investigated between May 23 and June 16, 2022.
Findings
The facility was found to have restrained Resident #1 with a bed sheet tied to the wheelchair arms, constituting abuse. The investigation identified two nurses as alleged perpetrators, resulting in suspensions and termination. The facility failed to ensure residents were free from physical restraints for convenience and failed to maintain adequate supervision to prevent abuse. Additional deficiencies were found related to dependent residents' care, quality of care, free of accident hazards, and sufficient nursing staff.
Complaint Details
Complaints #101254-A, #101321-A, #101453-C, #101894-C, #102010-C, #102882-C, #104485-C, and #104818-C were substantiated. Facility-reported incidents #100108-I and #102202-I were substantiated. Facility-reported incident #100422-I was not substantiated. Investigation of #101847-M resulted in deficiency.
Severity Breakdown
Immediate Jeopardy: 2
Severity D: 1
Deficiencies (8)
| Description | Severity |
|---|---|
| Failure to ensure Resident #1 was free from physical restraints imposed for convenience, resulting in abuse by tying a bed sheet to wheelchair arms. | Immediate Jeopardy |
| Failure to investigate and prevent abuse, neglect, exploitation, or mistreatment thoroughly and timely. | Immediate Jeopardy |
| Failure to provide grooming needs including oral hygiene, nail care, and incontinence care for dependent residents. | Severity D |
| Failure to provide treatment and care in accordance with professional standards for skin care and wound management. | — |
| Failure to maintain an environment free of accident hazards and provide adequate supervision to prevent accidents. | — |
| Failure to provide sufficient nursing staff with appropriate competencies and skills to assure resident safety and care. | — |
| Failure to provide prompt response to nurse call system for Resident #11. | — |
| Failure to complete required nurse aide in-service education annually. | — |
Report Facts
Census: 59
Falls: 17
Nurse Aide Training Records: 3
Residents Reviewed for Grooming Needs: 3
Residents Reviewed for Skin Care: 4
Residents Reviewed for Accident Hazards: 4
Residents Reviewed for Call Light Response: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Licensed Practical Nurse (LPN) | Identified as alleged perpetrator in abuse involving Resident #1 |
| Staff B | Nurse | Identified as alleged perpetrator in abuse involving Resident #1 |
| Director of Nursing | Director of Nursing (DON) | Conducted investigation and concluded abuse of Resident #1; involved in staff suspensions and facility corrective actions |
| Administrator | Administrator | Informed of abuse allegations and investigation outcomes; involved in corrective action plans |
| Staff C | Certified Nursing Assistant (CNA) | Witnessed abuse and reported incident involving Resident #1 |
| Charge Nurse 2 | Charge Nurse | Suspended and terminated following abuse investigation |
| Staff D | Certified Nursing Assistant | Reviewed nurse aide training records |
| Staff M | Certified Nursing Assistant | Reviewed nurse aide training records |
| Staff O | Certified Nursing Assistant | Reviewed nurse aide training records |
Inspection Report
Complaint Investigation
Census: 61
Deficiencies: 1
Aug 5, 2021
Visit Reason
The inspection was conducted as a result of an investigation of facility self-reported incidents #98548, #98549, and #98809 related to a resident wandering outside the facility without supervision.
Findings
The facility failed to provide adequate nursing supervision to prevent hazards for one resident who exited the facility unsupervised. The resident was found outside the building without injuries, and corrective actions including installation of door alarms and wander guard bracelets were implemented.
Complaint Details
Investigation of self-reported incidents #98548 and #98549 was not substantiated; incident #98809 was substantiated with a deficiency related to inadequate supervision leading to a resident exiting the facility unsupervised.
Deficiencies (1)
| Description |
|---|
| Facility failed to provide adequate nursing supervision to prevent hazards for one resident who exited the facility unsupervised. |
Report Facts
Total Residents: 61
MDS Assessment Score: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Maggie McClain | Administrator | Signed the Statement of Deficiencies and Plan of Correction |
Inspection Report
Complaint Investigation
Census: 58
Deficiencies: 1
Mar 30, 2021
Visit Reason
A Focused Infection Control Survey was conducted to investigate Facility Reported Incident #93178 and Complaint #96424 between March 22-30, 2021.
Findings
The facility failed to immediately isolate residents who developed respiratory illness and/or signs and symptoms of COVID-19 for 3 of 5 sampled residents. The complaint was substantiated while the facility reported incident was not substantiated.
Complaint Details
Complaint #96424-C was substantiated. Facility Reported Incident #93178-I was not substantiated.
Deficiencies (1)
| Description |
|---|
| The facility failed to immediately isolate residents who developed respiratory illness and/or other signs and symptoms of COVID-19 for 3 of 5 sampled residents. |
Report Facts
Resident census: 58
Sampled residents: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding Resident #3 and Resident #4 respiratory symptoms and isolation procedures |
| Infection Preventionist | Infection Preventionist (IP) | Interviewed regarding resident assessments and infection control procedures |
Inspection Report
Abbreviated Survey
Deficiencies: 0
Nov 5, 2020
Visit Reason
A Focused Infection Control Survey was conducted from November 3 to 5, 2020 to assess compliance with CMS and CDC recommended practices for COVID-19.
Findings
The facility was found to be in compliance with CMS and CDC recommended practices for COVID-19 during the focused infection control survey.
Inspection Report
Abbreviated Survey
Census: 61
Deficiencies: 0
Jun 22, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the Department of Inspection and Appeals 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.
Inspection Report
Complaint Investigation
Census: 66
Deficiencies: 2
Feb 27, 2020
Visit Reason
The inspection was conducted as an investigation of mandatory complaint #87644 related to allegations of abuse and neglect at Corydon Specialty Care.
Findings
The facility failed to ensure residents remained free from abuse, neglect, and verbal mistreatment as evidenced by staff comments and actions toward Residents #1 and #2. The facility also failed to report allegations of abuse in a timely manner and did not ensure staff completed mandatory abuse reporting training prior to the incidents.
Complaint Details
The complaint investigation was substantiated based on staff interviews and record review. Staff A and Staff B failed to report incidents of verbal abuse immediately. The facility self-reported alleged abuse incidents involving Residents #1 and #2 occurring on 11/27/19 and 12/16/19. Staff disciplinary actions and resignations followed the investigation.
Severity Breakdown
SS=G: 1
SS=F: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Facility failed to ensure residents remained free from abuse, neglect, and exploitation, including verbal abuse and inappropriate staff comments. | SS=G |
| Facility failed to report allegations of abuse to the department in a timely manner and failed to take appropriate corrective action. | SS=F |
Report Facts
Census: 66
Mandatory reporter training completion deadline: Dec 31, 2019
Date of compliance: Mar 11, 2020
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Nurse Aide Trainee | Named in findings related to verbal abuse incidents and failure to report abuse |
| Staff B | Nurse Aide | Named in findings related to verbal abuse incidents and failure to report abuse |
| Staff C | Involved in verbal abuse incidents witnessed by Staff A and Staff B | |
| Markie Madmain | Administrator | Signed the report and provided information on staff training and disciplinary actions |
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