Deficiencies per Year
8
6
4
2
0
Severe
High
Moderate
Low
Unclassified
Census Over Time
Inspection Report
Plan of Correction
Deficiencies: 0
Jan 6, 2026
Visit Reason
The document serves as a statement of deficiencies and plan of correction following a survey ending on December 11, 2025, with acceptance of a credible allegation of substantial compliance.
Findings
The facility will be certified in compliance effective January 1, 2026, based on acceptance of the credible allegation of substantial compliance and plan of correction. No specific deficiencies are detailed in this document.
Report Facts
Survey completion date: Jan 6, 2026
Plan of Correction effective date: Jan 1, 2026
Inspection Report
Annual Inspection
Census: 66
Deficiencies: 4
Dec 11, 2025
Visit Reason
The inspection was conducted as part of the facility's annual recertification survey and investigation of reported incidents.
Findings
The facility was found deficient in multiple areas including food safety and temperature control, sanitary dining practices, quality assurance and performance improvement (QAPI) program implementation, infection prevention and control, and wound care management. Several corrective actions and updated policies were planned or initiated.
Severity Breakdown
D: 3
F: 1
Deficiencies (4)
| Description | Severity |
|---|---|
| Failure to document food temperatures before and after meals in the memory care unit. | D |
| Failure to ensure sanitary dining experience due to staff not wearing hair restraints properly. | F |
| Failure to develop and maintain an effective, comprehensive, data-driven QAPI program. | D |
| Failure to establish and maintain an infection prevention and control program including proper infection control practices during wound care. | D |
Report Facts
Residents census: 66
Deficiency count: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Licensed Practical Nurse (LPN) | Named in wound care observation and remediation |
| Staff C | Certified Nursing Assistant (CNA) | Named in wound care observation |
| Administrator | Interviewed regarding infection control and staff expectations | |
| Dietary Manager | Interviewed regarding temperature logs and dining service policies | |
| ADON (Assistant Director of Nursing)/Infection Preventionist | Interviewed regarding wound care and infection control practices |
Inspection Report
Complaint Investigation
Deficiencies: 0
Apr 24, 2025
Visit Reason
A complaint investigation for facility reported incident #126888-I was conducted from April 23, 2025 to April 24, 2025.
Findings
The facility was found to be in substantial compliance with no deficiencies cited.
Complaint Details
Complaint investigation related to incident #126888-I; facility found in substantial compliance.
Inspection Report
Plan of Correction
Deficiencies: 0
Dec 10, 2024
Visit Reason
The document is a Plan of Correction related to a prior survey ending on October 31, 2024, indicating acceptance of credible allegation of substantial compliance.
Findings
The facility was found to be in substantial compliance based on the Plan of Correction submitted, with certification effective November 26, 2024. No specific deficiencies or severity levels are detailed in this document.
Report Facts
Survey end date: Oct 31, 2024
Certification effective date: Nov 26, 2024
Inspection Report
Annual Inspection
Census: 71
Deficiencies: 5
Oct 31, 2024
Visit Reason
The inspection was conducted as part of the facility's annual recertification survey and investigation of complaint #123276-C and facility reported incident #123479-I from October 28, 2024 to October 31, 2024.
Findings
The facility was found to have multiple deficiencies including failure to maintain accurate advance directive records, failure to maintain a safe, clean, and homelike environment, failure to report allegations of abuse timely, failure to maintain proper food temperatures, and failure to implement infection prevention and control measures. Several residents' records and observations revealed issues with care and safety.
Complaint Details
The complaint investigation revealed failure to maintain accurate advance directive records and failure to report an allegation of abuse for Resident #75. The abuse involved aggressive care by Staff J and failure to report the incident timely. The facility failed to investigate and report the abuse allegation as required.
Severity Breakdown
Level D: 2
Level E: 3
Deficiencies (5)
| Description | Severity |
|---|---|
| Failed to maintain accurate Advance Directive records based on resident preference for 1 of 18 residents reviewed. | Level D |
| Failed to maintain a safe, clean, comfortable, and homelike environment in the facility dining room during 4 of 4 dining observations. | Level E |
| Failed to report an allegation of abuse to the state agency for 1 out of 1 allegation reviewed. | Level D |
| Failed to maintain proper food temperatures during noon meal service. | Level E |
| Failed to establish and maintain an infection prevention and control program including proper use of enhanced barrier precautions for residents with indwelling medical devices. | Level E |
Report Facts
Resident census: 71
Residents reviewed for advance directive records: 18
Residents reviewed for abuse allegation: 1
Residents reviewed for infection control: 3
Food temperatures recorded: 177
Food temperatures recorded: 200
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff J | Certified Nursing Assistant | Named in abuse allegation involving aggressive care to Resident #75 |
| Staff H | Licensed Practical Nurse | Interviewed regarding discrepancy in Resident #42's code status record |
| Director of Nursing | Directed Staff J to be sent home after abuse incident; involved in abuse reporting and investigation | |
| Assistant Director of Nursing | Involved in abuse incident reporting and investigation | |
| Staff A | Licensed Practical Nurse | Observed not wearing gown during administration of feeding tube formula |
| Staff E | Licensed Practical Nurse | Adjusted dignity cover on Resident #125's catheter bag |
| Staff D | Certified Nursing Assistant | Adjusted clothing protector of Resident #125 at dining table |
Inspection Report
Re-Inspection
Deficiencies: 0
Oct 3, 2024
Visit Reason
A revisit of the survey ending August 30, 2024 was conducted to verify correction of previous deficiencies.
Findings
All deficiencies were corrected and the facility is in substantial compliance effective September 3, 2024.
Inspection Report
Complaint Investigation
Census: 73
Deficiencies: 2
Aug 30, 2024
Visit Reason
The inspection was conducted as an investigation of complaint #123010-C from August 28 to August 30, 2024, to determine compliance with federal regulations related to comprehensive care plans and quality of care.
Findings
The facility was found deficient in developing and implementing comprehensive care plans for residents, specifically related to anticoagulant medication management and monitoring. The complaint was substantiated, and the facility failed to ensure proper monitoring of warfarin use and INR lab testing for residents, leading to serious health risks.
Complaint Details
Complaint #123010-C was substantiated based on findings related to inadequate comprehensive care plans and failure to obtain routine INR lab tests for residents on warfarin.
Severity Breakdown
SS=D: 1
SS=J: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to develop and implement a comprehensive person-centered care plan for residents, including measurable objectives and timely monitoring of anticoagulant medication. | SS=D |
| Failure to obtain routine laboratory orders for INR testing to monitor warfarin use for 2 of 4 residents reviewed. | SS=J |
Report Facts
Census: 73
Residents reviewed: 2
Residents receiving warfarin: 4
Complaint number: 123010
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Julie [Last name not fully visible] | Administrator | Signed the plan of correction document |
| Director of Nursing | Director of Nursing (DON) | Interviewed on 8/30/24 regarding care plans and INR orders |
| Staff A | Registered Nurse (RN) | Interviewed on 8/29/24 regarding hospice admission of Resident #1 |
Inspection Report
Plan of Correction
Deficiencies: 0
Aug 27, 2024
Visit Reason
The document is a statement of deficiencies and plan of correction related to the facility's compliance status, indicating acceptance of a credible allegation of compliance and plan of correction.
Findings
The facility will be certified in compliance effective August 25, 2024, based on acceptance of the credible allegation of compliance and plan of correction. No specific deficiencies are detailed in this document.
Inspection Report
Complaint Investigation
Census: 73
Deficiencies: 1
Jul 11, 2024
Visit Reason
The inspection was conducted as a complaint investigation based on substantiated complaints #118412-C, #119749-C, #120798-C, #121581-C and facility reported incident #118360-I, focusing on bowel/bladder incontinence, catheter, and urinary tract infection issues.
Findings
The investigation found that the facility failed to ensure appropriate assessment and care for residents with urinary catheters, resulting in catheter-related complications and resident discomfort. Deficiencies were noted in catheter care, monitoring, and staff education, leading to a resident being transferred to a hospital due to catheter issues.
Complaint Details
Complaint #119749-C was substantiated. The investigation included clinical record review, staff and resident interviews, and observation. Findings revealed inadequate catheter care and monitoring, leading to resident injury and hospital transfer.
Deficiencies (1)
| Description |
|---|
| Failure to ensure appropriate assessment and services for residents with urinary catheters, resulting in catheter-related complications and discomfort. |
Report Facts
Residents reviewed for urinary catheter: 2
Resident census: 73
Dates of complaint survey: July 7-11, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Registered Nurse (RN) | Named in nursing progress note and interview regarding catheter care and resident condition |
| Staff A | Licensed Practical Nurse (LPN) | Named in nursing progress note and interview regarding catheter care and resident condition |
| Director of Nursing (DON) | Director of Nursing | Provided statements regarding catheter care protocols and expectations |
Inspection Report
Complaint Investigation
Deficiencies: 0
Jan 17, 2024
Visit Reason
A complaint investigation was conducted for Complaint #118104-C from January 16, 2024 to January 17, 2024.
Findings
The facility was found to be in substantial compliance with no deficiencies noted.
Complaint Details
Complaint #118104-C was investigated and the facility was found to be in substantial compliance.
Inspection Report
Complaint Investigation
Deficiencies: 0
Nov 14, 2023
Visit Reason
An investigation of Complaints #116712-C and #116713-C was conducted from November 9, 2023 to November 14, 2023.
Findings
The facility was found to be in substantial compliance.
Complaint Details
Investigation of Complaints #116712-C and #116713-C; facility found in substantial compliance.
Inspection Report
Complaint Investigation
Deficiencies: 0
Oct 18, 2023
Visit Reason
An investigation of complaint #116227-C was conducted from October 16, 2023 to October 18, 2023.
Findings
The facility was found to be in substantial compliance following the complaint investigation.
Complaint Details
Investigation of complaint #116227-C; facility found in substantial compliance.
Inspection Report
Plan of Correction
Deficiencies: 0
Oct 11, 2023
Visit Reason
This document is a plan of correction related to deficiencies identified during a prior survey, as indicated by the reference to event ID #KYNT11 for survey results.
Findings
No specific deficiencies or findings are detailed in this document; it primarily references another event ID for the survey results.
Inspection Report
Re-Inspection
Deficiencies: 0
Oct 11, 2023
Visit Reason
An on-site revisit of the recertification survey ending July 27, 2023, and investigation of Complaints #115391-C and #115752-C was conducted from October 3, 2023 to October 11, 2023.
Findings
All deficiencies were corrected and the facility was found to be in substantial compliance effective August 17, 2023. The Denial of Payment for New Admits (DPNA) was not effectuated.
Complaint Details
Investigation of Complaints #115391-C and #115752-C was conducted; all deficiencies were corrected.
Report Facts
Complaint numbers: 2
Inspection Report
Complaint Investigation
Deficiencies: 0
Oct 18, 2022
Visit Reason
A complaint investigation for Complaint #107601-C was conducted from October 10, 2022 to October 18, 2022.
Findings
The facility was found to be in substantial compliance.
Complaint Details
Complaint #107601-C was investigated and the facility was found to be in substantial compliance.
Report Facts
Complaint number: 107601
Inspection Report
Re-Inspection
Deficiencies: 0
Aug 26, 2022
Visit Reason
An onsite revisit of the survey ending July 26, 2022 and investigation of Complaint #106779 was conducted from August 25 to August 26, 2022.
Findings
All deficiencies were corrected and the facility was found to be in substantial compliance effective August 2, 2022. Complaint #106779 was not substantiated.
Complaint Details
Complaint #106779 was investigated and found not substantiated.
Inspection Report
Annual Inspection
Census: 68
Deficiencies: 6
Jul 26, 2022
Visit Reason
The inspection was conducted as an Annual Recertification Survey and investigation of multiple complaints and a facility self-reported incident between July 18, 2022 and July 26, 2022.
Findings
The facility was found to have multiple deficiencies including failure to report a resident to resident incident of possible abuse, failure to follow physician orders for medication discontinuation, failure to maintain a safe environment to prevent elopement, failure to notify physicians of lab results, and failure to maintain proper food temperatures. Several complaints and the self-reported incident were substantiated.
Complaint Details
Complaints #104793-C, #105409-C, and #105412-C were substantiated. Facility Self-Reported Incident #100117-I was substantiated.
Severity Breakdown
SS=D: 3
SS=J: 1
SS=E: 2
Deficiencies (6)
| Description | Severity |
|---|---|
| Failure to report a resident to resident incident of possible abuse to the State Agency within required timeframes. | SS=D |
| Failure to follow physician orders for discontinued medication for one resident. | SS=D |
| Failure to provide adequate supervision and alarm system to prevent elopement for one resident. | SS=J |
| Failure to notify physician of lab results and follow up for one resident receiving dialysis. | SS=D |
| Failure to maintain hot food temperatures at safe levels during meal service. | SS=E |
| Failure to properly label and store food items with expiration dates and remove expired items. | SS=E |
Report Facts
Resident census: 68
Resident census: 24
Temperature: 171
Temperature: 175
Temperature: 130
Temperature: 127
Temperature: 87
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Diane Cloude | Administrator | Signed the report on pages 2 and 3. |
| Staff D | Licensed Practical Nurse (LPN) | Interviewed regarding resident incident and elopement. |
| Staff J | Licensed Practical Nurse (LPN) | Observed during video surveillance of elopement incident. |
| Staff G | Certified Nursing Assistant (CNA) | Interviewed regarding resident elopement and observations. |
| Staff E | Certified Nursing Assistant (CNA) | Interviewed regarding resident elopement and observations. |
| Staff I | Licensed Practical Nurse (LPN) and MCU Unit Manager | Interviewed regarding elopement risk and staffing. |
| Staff F | Certified Nursing Assistant (CNA) | Interviewed regarding resident elopement and observations. |
| Staff K | Registered Nurse (RN) | Interviewed regarding dialysis assessments. |
| Director of Nursing (DON) | Interviewed multiple times regarding incident reporting, medication orders, lab results, and quality assurance monitoring. | |
| Dietary Director | Interviewed regarding food temperatures, food storage, and labeling. |
Inspection Report
Complaint Investigation
Census: 66
Deficiencies: 4
Mar 25, 2021
Visit Reason
The inspection was conducted as a Recertification Survey and investigation of Complaint #90384 and a Facility Self-Reported Incident #95996 completed 3/22-25/2020. Both complaint intakes were unsubstantiated.
Findings
The facility failed to provide required Medicaid State plan notices, failed to provide required Notice before Transfer/Discharge documentation and notifications to the Ombudsman for resident discharges, failed to complete Pre-Admission Screening and Resident Review (PASARR) for one resident, and failed to follow infection control practices including PPE use and isolation procedures. Random QA monitors and staff education were planned to ensure compliance.
Complaint Details
Complaint #90384 and Facility Self-Reported Incident #95996 were investigated and found unsubstantiated.
Severity Breakdown
SS=B: 2
SS=D: 2
Deficiencies (4)
| Description | Severity |
|---|---|
| Failure to provide required Medicaid State plan notices to residents and documentation for Advanced Beneficiary Notice (ABN). | SS=B |
| Failure to provide required Notice before Transfer/Discharge and timely notification to Ombudsman for resident discharges. | SS=B |
| Failure to complete Pre-Admission Screening and Resident Review (PASARR) for one resident with mental disorder and intellectual disability. | SS=D |
| Failure to establish and maintain an infection prevention and control program including proper PPE use, isolation procedures, and staff education. | SS=D |
Report Facts
Census: 66
Residents reviewed for Medicaid State plan notices: 2
Residents reviewed for Ombudsman notification: 4
Residents reviewed for PASARR: 1
Residents reviewed for infection control observations: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing (DON) | Reported expected notification to Ombudsman and inability to locate PASARR for Resident #55. |
| Housekeeping Supervisor | Housekeeping Supervisor | Reviewed fact sheets for Clostridium Difficile and administered quizzes; provided PPE training. |
| Administrator | Administrator | Acknowledged failure to provide CMS form 10055; completed root cause analysis; notified Ombudsman of discharges. |
| Staff B | Unit Manager | Confirmed unable to locate admission PASARR for Resident #55. |
| Staff A | Staff | Observed cleaning and PPE use during infection control observations. |
| Staff C | Nursing Staff | Reported Resident #14 isolation status. |
| Infection Preventionist | Infection Preventionist (IP) | Reported quarantine needs and PPE procedures. |
Inspection Report
Complaint Investigation
Census: 70
Deficiencies: 1
Nov 5, 2020
Visit Reason
A COVID-19 focused infection control survey and an investigation of Complaints #90570, #94076, and #94319 were conducted by the Department of Inspection and Appeals from 10/26/20 through 11/5/20.
Findings
The facility was found to be in compliance with CDC recommended practices for COVID-19. Complaint #94076 was substantiated due to failure to provide proper incontinence care to one of six residents observed, including improper peri-care technique.
Complaint Details
Complaint #94076 was substantiated with the deficiency related to improper incontinence care. The investigation included observations, record reviews, staff and family interviews, and review of urine culture reports. Staff interviews revealed inconsistent peri-care practices contrary to facility policy.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to provide proper incontinence care for a resident, including improper peri-care technique and failure to wash from front to back as required by facility policy. | SS=D |
Report Facts
Total residents: 70
Complaints investigated: 3
BIMS score: 8
Urine culture CFU: 100000
Inspection Report
Complaint Investigation
Census: 77
Deficiencies: 0
Jun 11, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey and an investigation of Complaint #90484 were conducted by the Department of Inspections and Appeals on 6/10/20 - 6/11/20.
Findings
The facility was found to be in compliance with CMS and CDC recommended practices to prepare for COVID-19. The complaint was not substantiated.
Complaint Details
Complaint #90484 was investigated and found not substantiated.
Report Facts
Total residents: 77
Report
File
ScannedReport_1071_2023-09-19_022605.pdf
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