Inspection Report
Complaint Investigation
Deficiencies: 0
Oct 7, 2025
Visit Reason
A complaint investigation for facility reported incident #2563367-I was conducted from October 06, 2025 to October 07, 2025.
Findings
The facility was found to be in substantial compliance.
Complaint Details
Complaint investigation related to incident #2563367-I; facility found in substantial compliance.
Inspection Report
Complaint Investigation
Deficiencies: 0
Jun 25, 2025
Visit Reason
An investigation of mandatory report #128853-M was conducted from June 23, 2025 to June 25, 2025.
Findings
The facility was found in substantial compliance. The results of report #128853-M will be sent to the facility under a different cover.
Complaint Details
Investigation of mandatory report #128853-M from June 23 to June 25, 2025; facility found in substantial compliance.
Inspection Report
Plan of Correction
Deficiencies: 0
Jun 3, 2025
Visit Reason
The document is a Plan of Correction submitted following a prior inspection, 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, leading to certification effective May 30, 2025.
Inspection Report
Annual Inspection
Census: 59
Deficiencies: 3
Apr 28, 2025
Visit Reason
The inspection was conducted as the facility's annual recertification survey from April 28, 2025 to May 1, 2025.
Findings
The facility was found deficient in making reasonable accommodations for resident needs, specifically for a resident unable to reach clothing hung in a closet. Additionally, deficiencies were found in dietary support personnel training and food safety practices, including puree food preparation and food temperature monitoring.
Deficiencies (3)
| Description |
|---|
| Facility failed to make reasonable accommodations for a resident to reach her clothes hanging in the closet. |
| Facility failed to provide sufficient dietary staff with appropriate skills and training for food service, including puree food preparation. |
| Facility failed to ensure food safety by not properly monitoring and documenting internal food temperatures. |
Report Facts
Census: 59
Deficiencies cited: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Certified Nursing Assistant (CNA) | Acknowledged resident's inability to reach clothing in closet. |
| Staff C | Laundry Staff | Recalled resident's concerns about reaching clothing. |
| Staff D | Assistant Director of Nursing (ADON)/RN | Acknowledged resident's requests and staff communication failures. |
| Director of Nursing (DON) | Acknowledged unawareness of resident's concern and staff reporting failures. | |
| Staff A | Cook | Observed lacking training in puree food preparation and food temperature logging. |
| Registered Dietician (RD) | Advised on puree food preparation and food temperature monitoring deficiencies. | |
| Kitchen Supervisor | Acknowledged need for additional dietary staff training and monitoring failures. |
Inspection Report
Plan of Correction
Deficiencies: 0
Nov 5, 2024
Visit Reason
The document is a Plan of Correction submitted 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 30, 2024. No specific deficiencies or severity levels are detailed in the report.
Inspection Report
Complaint Investigation
Census: 58
Deficiencies: 2
Sep 30, 2024
Visit Reason
The inspection was conducted as an investigation of facility reported incidents #122906-I, #123719-I, and #123720-I from 9/27/24 to 9/30/24 to determine substantiation of complaints.
Findings
The facility was found to have insufficient nursing staff to respond to door alarms promptly, with multiple alarms sounding without staff response. Additionally, the facility failed to ensure proper use and documentation of psychotropic medications for residents, including lack of diagnoses for depression and anxiety in medication records.
Complaint Details
Facility reported incidents #122906-I and #123720-I were substantiated; incident #123719-I was unsubstantiated.
Severity Breakdown
Level D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Insufficient nursing staff to respond to door alarms and ensure resident safety. | Level D |
| Failure to ensure psychotropic medications were administered only when clinically indicated and properly documented. | Level D |
Report Facts
Residents present: 58
Residents scoring 12 or lower on BIMS: 34
Residents using wander guards: 5
Door alarms sounded without staff response: 4
Residents reviewed for psychotropic medication issues: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Certified Nurses Aide (CNA) | Stated inability to hear door alarms and expectations for checking grounds |
| Staff A | Licensed Practical Nurse (LPN) | Reported inability to hear door alarms and described search procedures |
| Director of Nursing | Confirmed alarm codes and monitoring procedures; acknowledged diagnosis record issues | |
| Administrator | Confirmed alarm codes and monitoring procedures; involved in corrective actions |
Inspection Report
Plan of Correction
Deficiencies: 0
Sep 3, 2024
Visit Reason
The document serves as a statement of deficiencies and plan of correction, indicating acceptance of a credible allegation of compliance and plan of correction for certification.
Findings
The facility will be certified in compliance effective September 2, 2024, based on acceptance of the credible allegation of compliance and plan of correction.
Inspection Report
Plan of Correction
Deficiencies: 0
Aug 14, 2024
Visit Reason
The document is a statement of deficiencies and plan of correction related to the facility's certification compliance.
Findings
The facility was certified in compliance based on acceptance of a credible allegation of compliance and plan of correction effective August 9, 2024.
Inspection Report
Complaint Investigation
Census: 50
Deficiencies: 1
Aug 1, 2024
Visit Reason
The inspection was conducted as an investigation of complaints #122188-C and #122284-C from July 25, 2024 to August 1, 2024, focusing on nutritional and hydration status maintenance.
Findings
The facility failed to implement interventions to prevent weight loss for one resident, with documented refusals of nutritional supplements and lack of a weight loss policy. The complaint #122188-C was substantiated, while #122284-C was not substantiated.
Complaint Details
Complaint #122188-C was substantiated. Complaint #122284-C was not substantiated.
Severity Breakdown
S=S: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility failed to implement interventions to prevent weight loss for one resident, including lack of weight loss policy and failure to provide appropriate diet and hydration. | S=S |
Report Facts
Resident census: 50
Number of refusals of nutritional supplement: 33
Weight measurements: 146.4
Weight measurements: 139.6
Weight measurements: 140.2
Weight measurements: 130.6
Weight measurements: 129.6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jennifer Brooks | Administrator | Signed the statement of deficiencies and plan of correction |
Inspection Report
Annual Inspection
Census: 53
Deficiencies: 9
Jul 9, 2024
Visit Reason
The inspection was conducted as the facility's annual recertification survey combined with an investigation of multiple complaints (#121269-C, #120669-C, #120636-C, #120363-C, & #119711-C) from June 30, 2024 to July 9, 2024.
Findings
The facility was found deficient in multiple areas including failure to notify family of falls, medication refusals, and significant weight loss; failure to administer medications according to professional standards; inadequate care for dependent residents including toileting and hygiene; failure to provide adequate skin care and wound treatment; insufficient supervision leading to accidents and wandering; improper tube feeding management; insufficient nursing staff response to call lights; and failure to provide specialized rehabilitative services. The facility reported a census of 53 residents during the survey.
Complaint Details
Complaints #121269-C, #120669-C, #120363-C, and #119711-C were substantiated. Complaint #120636-C was not substantiated.
Severity Breakdown
SS=D: 8
SS=E: 1
Deficiencies (9)
| Description | Severity |
|---|---|
| Failed to notify resident's representative of a fall, medication refusals, and significant weight loss for Resident #48. | SS=D |
| Failed to administer medications in accordance with professional standards for 3 residents. | SS=D |
| Failed to provide adequate care for dependent residents including timely toileting, proper hygiene, and prevention of voiding in inappropriate locations. | SS=E |
| Failed to provide adequate quality of care including timely treatment orders and skin care for residents with pressure ulcers and wounds. | SS=D |
| Failed to ensure free of accident hazards and adequate supervision for residents known to wander. | SS=D |
| Failed to properly manage tube feeding including elevation of head of bed and priming of tubing. | SS=D |
| Failed to provide sufficient nursing staff to respond timely to call lights for 5 of 5 residents reviewed. | SS=D |
| Failed to provide pharmacy services including routine and emergency drugs and consultation. | SS=D |
| Failed to provide specialized rehabilitative services including speech therapy as ordered. | SS=D |
Report Facts
Census: 53
Residents reviewed for medication administration: 6
Residents reviewed for sufficient nursing staff response: 5
Residents reviewed for toileting and hygiene: 3
Residents reviewed for wandering supervision: 2
Residents reviewed for skin/wound care: 6
Residents reviewed for tube feeding management: 1
Residents reviewed for speech therapy services: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Named in relation to findings on notification of falls, medication refusals, weight loss, wound care, supervision, and education of staff. |
| Staff F | Advanced Registered Nurse Practitioner (ARNP) | Interviewed regarding medication administration practices. |
| Staff A | Licensed Practical Nurse (LPN) | Interviewed regarding insulin administration. |
| Staff B | Certified Nursing Assistant (CNA) | Observed providing incontinence care. |
| Staff C | Certified Nursing Assistant (CNA) | Observed providing incontinence care. |
| Staff D | Certified Nursing Assistant (CNA) | Observed providing incontinence care and toileting assistance. |
| Staff E | Certified Nursing Assistant (CNA) | Observed providing incontinence care. |
| Staff G | Licensed Practical Nurse (LPN) | Observed providing tube feeding and wound care. |
| Staff L | Registered Nurse (RN) | Reported wound infection signs and need for notification. |
| Staff J | Medication Aide | Reported insufficient supervision on lower level. |
| Staff K | Certified Nursing Assistant (CNA) | Reported assisting wandering resident to restroom. |
| Staff F | Licensed Practical Nurse (LPN) | Prepared feeding tube and observed procedure. |
Inspection Report
Plan of Correction
Deficiencies: 0
Mar 5, 2024
Visit Reason
The document is a Plan of Correction following a prior inspection, 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 March 5, 2024.
Inspection Report
Complaint Investigation
Census: 48
Deficiencies: 2
Feb 5, 2024
Visit Reason
The inspection was conducted as a result of complaints #113396-C, #115642-C, and #117286-C, as well as facility self-reported incidents #116036-I and #116850-I, to investigate substantiated complaints regarding pressure ulcer care and medication administration errors.
Findings
The facility failed to appropriately assess and document skin alterations for residents with pressure ulcers and failed to ensure residents were free from significant medication errors. Deficiencies were found related to inadequate skin assessments, failure to notify family of wound severity, and medication administration errors including a wrong dose of ABH cream.
Complaint Details
Complaints #115642-C and #117286-C were substantiated.
Deficiencies (2)
| Description |
|---|
| Failure to appropriately assess and document skin alterations for residents with pressure ulcers. |
| Failure to ensure residents are free from significant medication errors, including administration of wrong dose of medication. |
Report Facts
Resident census: 48
Medication administration error dose: 1
Medication administration error date: 11
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Certified Medication Aide (CMA) | Named in medication error finding for administering wrong dose of ABH cream |
| Staff B | Advanced Registered Nurse Practitioner (ARNP) | Questioned facility policy regarding medication administration after error |
| Staff C | Licensed Practical Nurse (LPN) | Provided skin treatments and reported wound condition |
| Staff D | Director of Nursing (DON) | Reported lack of awareness of resident wound condition upon admission |
| Staff E | Registered Nurse (RN) | Completed transfer form and informed about resident treatments |
Inspection Report
Plan of Correction
Deficiencies: 0
Jun 1, 2023
Visit Reason
The document is a plan of correction submitted following a survey to address deficiencies and certify compliance.
Findings
The facility was found to be in compliance based on acceptance of the credible allegation of compliance and plan of correction effective June 1, 2023.
Inspection Report
Re-Inspection
Census: 45
Deficiencies: 3
May 4, 2023
Visit Reason
The inspection was conducted as a Recertification Survey and investigation of a Facility Self-Reported Incident #108254-1, carried out from May 1, 2023 to May 4, 2023.
Findings
The facility was found deficient in developing and implementing comprehensive care plans for residents, including failure to address medical diagnoses and provide consistent care conferences. Additionally, the facility failed to ensure adequate fall interventions and supervision for residents at high risk of falling.
Severity Breakdown
SS=D: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Failure to develop and implement a comprehensive person-centered care plan for each resident, including measurable objectives and timeframes. | SS=D |
| Failure to provide consistent care conferences on a quarterly basis for residents reviewed. | SS=D |
| Failure to ensure the resident environment remains free of accident hazards and to provide adequate supervision and assistance devices to prevent accidents. | SS=D |
Report Facts
Census: 45
Residents reviewed for care plans: 12
Residents reviewed for care conferences: 3
Resident #18 BIMS score: 15
Resident #10 BIMS score: 13
Resident #40 BIMS score: 9
Resident #40 Fall Risk Assessment score: 75
Inspection Report
Annual Inspection
Census: 41
Deficiencies: 2
Oct 7, 2021
Visit Reason
The inspection was conducted as part of the facility's annual health survey and complaint investigation related to complaints #95109-C, #95205-C, #96454-C, #96474-C, and #96661-C.
Findings
The facility was found deficient in providing complete incontinence care and infection prevention and control practices, including hand hygiene and catheter care. Some complaints were substantiated, and others were not. The facility failed to ensure proper hand hygiene and wound care procedures among staff.
Complaint Details
Complaints #95109-C, #95205-C, and #96454-C were not substantiated. Complaints #96474-C and #96661-C were substantiated. Facility-reported incidents #94902-I and #95217-I did not result in deficiency.
Deficiencies (2)
| Description |
|---|
| Failure to provide complete incontinence care for residents requiring assistance with pericare. |
| Failure to establish and maintain an infection prevention and control program including proper hand hygiene and wound care. |
Report Facts
Census: 41
Residents reviewed for incontinence care: 6
Residents reviewed for infection control: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Certified Medication Aide (CMA) | Involved in pericare procedure observation and education |
| Staff B | Certified Nurse Aide (CNA) | Assisted with pericare and observed for hand hygiene |
| Staff C | Nurse | Educated on hand hygiene and peri-care practices |
| Staff D | Registered Nurse (RN) | Observed performing wound treatment and hand hygiene |
| Staff E | Certified Nurse Aide (CNA) | Observed transferring resident and hand hygiene |
| Staff F | Certified Nurse Aide (CNA) | Observed performing catheter care and hand hygiene |
| Director of Nursing | Provided education and stated expectations for staff hygiene and care procedures | |
| MDS Coordinator | Educated staff on peri-care procedures | |
| Assistant Director of Nurses | Educated staff on hand hygiene and catheter care |
Inspection Report
Complaint Investigation
Census: 41
Deficiencies: 2
Oct 5, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey and an investigation of a Facility Self-Reported Incident #93405 and Complaint #93583 was conducted by the Department of Inspections and Appeals on 9/28-10/5/20. The complaint #93583 was substantiated with deficiencies.
Findings
The facility was found not in compliance with CMS and CDC recommended practices to prepare for COVID-19. Deficiencies included failure to provide adequate bathing assistance to dependent residents and failure to establish and maintain an infection prevention and control program, including proper screening of staff and visitors for COVID-19 symptoms and exposure.
Complaint Details
Complaint #93583 was substantiated with deficiencies related to bathing assistance and infection prevention and control.
Deficiencies (2)
| Description |
|---|
| A resident unable to carry out activities of daily living did not receive the necessary bathing assistance twice a week as required; staff failed to document baths properly. |
| The facility failed to consistently screen staff, visitors, and Hospice Staff entering and leaving the facility as protocol for the COVID-19 pandemic. |
Report Facts
Total residents: 41
Resident bathing frequency: 2
Dates of bathing documented: 3
Dates of bathing documented: 2
Dates of bathing documented: 3
Dates of bathing documented: 3
Screening compliance monitoring period: 6
Inspection Report
Routine
Census: 40
Deficiencies: 0
Aug 19, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the Department of Inspections 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
Routine
Census: 50
Deficiencies: 0
Jun 15, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the Department of Inspection 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 residents: 50
Inspection Report
Renewal
Census: 47
Deficiencies: 2
Feb 27, 2020
Visit Reason
The inspection was conducted as a recertification survey and investigation of Complaint #81881 completed from 2/24/20 to 2/27/20. The complaint was not substantiated.
Findings
The facility failed to update comprehensive care plans for two residents and failed to carry out sanitary food handling during three meal service observations. Deficiencies included lack of documentation for high risk medications in care plans and failure of staff to properly restrain hair during food service.
Complaint Details
Complaint #81881 was investigated during the recertification survey and was not substantiated.
Severity Breakdown
D: 1
E: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to update comprehensive care plans for two residents regarding high risk medications including diuretics, anticoagulants, and antipsychotics. | D |
| Failed to carry out sanitary food handling during 3 of 3 meal service observations, including staff not properly restraining hair. | E |
Report Facts
Census: 47
Complaint number: 81881
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Interviewed regarding expectations for including antipsychotic medication in resident care plans |
| Staff D | Oral Medication Technician (OMT) | Interviewed about identification of residents at risk for bleeding or altered fluid status |
| Staff E | Certified Nursing Assistant (CNA) | Interviewed about communication book usage for residents with bleeding risk |
| Staff A | Dietary Aide | Observed during food service not properly restraining hair |
| Staff B | Dietary Aide | Observed during food service not properly restraining hair |
| Staff C | Cook | Observed during food service not properly restraining hair |
| Dietary Manager | Dietary Manager | Interviewed regarding hair restraint policy and monitoring compliance |
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