Deficiencies per Year
12
9
6
3
0
Severe
High
Moderate
Low
Unclassified
Census Over Time
Inspection Report
Annual Inspection
Census: 41
Deficiencies: 5
Mar 21, 2025
Visit Reason
The Centers for Medicare and Medicaid Services conducted a comparative Federal Monitoring Survey from 3/17/25 through 3/21/25, including investigation of 1 Facility Reported Incident and 1 complaint.
Findings
Deficiencies were cited related to failure to meet professional standards of care for 1 of 5 residents, inadequate supervision to prevent falls for 1 of 3 residents, improper storage of respiratory supplies for 2 residents, and failure to ensure proper medication storage and administration including insulin pen handling. The facility also failed to maintain an effective water management plan for Legionella risks.
Complaint Details
One complaint was investigated as part of the survey. The complaint involved issues with blood sugar monitoring and physician notification for a resident. The complaint was substantiated as evidenced by cited deficiencies.
Severity Breakdown
Level D: 3
Level E: 1
Level F: 1
Deficiencies (5)
| Description | Severity |
|---|---|
| Facility failed to provide services meeting professional standards of quality of care for 1 of 5 residents related to blood sugar monitoring and physician notification. | Level D |
| Facility failed to adequately supervise residents to prevent falls for 1 of 3 residents, including failure to investigate falls and ensure safe environment. | Level E |
| Respiratory supplies for 2 residents were not properly stored, risking infection. | Level D |
| Facility failed to ensure medications were stored and administered according to accepted professional principles, including improper handling of an insulin pen. | Level D |
| Facility failed to have an effective water management plan to address Legionella risks, potentially affecting all residents. | Level F |
Report Facts
Census: 41
Deficiencies cited: 5
Blood sugar readings: 450
Blood sugar readings: 423
Blood sugar readings: 417
Fall risk score: 10
BIMS score: 6
BIMS score: 5
BIMS score: 15
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Faith Epperson | Director of Nursing | Named in plan of correction and interviews related to blood sugar monitoring and fall prevention |
| Registered Nurse 1 | Observed blood sugar check and insulin administration for resident R21 | |
| License Practical Nurse 1 | Checked blood sugar and administered insulin for resident R21 | |
| Advanced Registered Nurse Practitioner | Interviewed regarding physician notifications and resident care | |
| Certified Medication Aide 1 | Observed administering medications to residents R12 and R10 | |
| Administrator | Conducted audits and education related to care plans, medication administration, and infection control | |
| Vice President | Corporate Compliance | Interviewed regarding medication self-administration assessments |
Inspection Report
Annual Inspection
Deficiencies: 0
Feb 27, 2025
Visit Reason
An annual recertification survey and investigation of complaint #122797-C, and facility reported incident #124901-I, were conducted from February 24, 2025 to February 27, 2025.
Findings
The facility was found to be in substantial compliance.
Complaint Details
Investigation of complaint #122797-C was conducted during the visit.
Inspection Report
Recertification
Deficiencies: 0
Feb 24, 2025
Visit Reason
A recertification survey and investigation of complaint #122797-C and incident #124901-I was conducted from February 24, 2025 to February 27, 2025, followed by a Federal Monitoring Survey from March 17 to March 21, 2025.
Findings
Based on acceptance of the credible allegation of substantial compliance and the Plan of Correction, the facility was certified in compliance with health requirements effective April 24, 2025.
Complaint Details
Investigation of complaint #122797-C and incident #124901-I was completed during the survey period.
Inspection Report
Complaint Investigation
Deficiencies: 0
Jul 18, 2024
Visit Reason
A complaint investigation for complaint #120790-C was conducted from July 16, 2024 to July 18, 2024.
Findings
The facility was found to be in substantial compliance.
Complaint Details
Complaint #120790-C was investigated and the facility was found to be in substantial compliance.
Inspection Report
Plan of Correction
Deficiencies: 0
May 8, 2024
Visit Reason
The document serves as a Plan of Correction following a prior inspection, indicating acceptance of the facility's credible allegation of substantial compliance.
Findings
The facility was found to be in substantial compliance based on the accepted Plan of Correction, and certification in compliance is effective May 7, 2024.
Inspection Report
Complaint Investigation
Census: 42
Deficiencies: 2
Apr 18, 2024
Visit Reason
The inspection was conducted as an investigation of complaints #118015-C and #119293-C, and a self-report #119878-I, related to medication administration and pharmaceutical services at the facility.
Findings
The facility failed to ensure residents received medications per physician orders, specifically for Resident #1, resulting in medication administration errors and delays in pharmacy ordering and receiving medications. The complaint #118015-C was substantiated, while complaint #119293-C and self-report #119878-I were not substantiated.
Complaint Details
Complaint #118015-C was substantiated. Complaint #119293-C was not substantiated. Self-report #119878-I was not substantiated.
Deficiencies (2)
| Description |
|---|
| Facility failed to ensure residents received medications per physician orders, including incomplete administration of Tamiflu and Albuterol nebulizer treatments for Resident #1. |
| Facility failed to provide pharmaceutical services to meet the needs of Resident #1, including delays and errors in ordering and receiving medications. |
Report Facts
Resident census: 42
Medication doses ordered vs received: 15
Medication doses administered: 9
Medication doses missed: 8
Correction date: May 7, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing (DON) | Stated on 4/17/24 that she would look into medication availability issues and confirmed medication ordering procedures |
Inspection Report
Plan of Correction
Deficiencies: 0
Jan 4, 2024
Visit Reason
The document reflects acceptance of the facility's credible allegation of substantial compliance and Plan of Correction for surveys ending November 20, 2023 and December 21, 2024, leading to certification of compliance effective January 4, 2024.
Findings
The facility was found to be in substantial compliance based on the Plan of Correction submitted for prior surveys, resulting in certification of compliance.
Report Facts
Survey end dates: Surveys ending November 20, 2023 and December 21, 2024 referenced in Plan of Correction
Inspection Report
Plan of Correction
Deficiencies: 0
Jan 4, 2024
Visit Reason
The document certifies the facility in compliance based on acceptance of a credible allegation of substantial compliance and Plan of Correction for surveys ending November 20, 2023 and December 21, 2024.
Findings
The facility was found to be in substantial compliance and will be certified effective January 4, 2024, based on the Plan of Correction submitted.
Inspection Report
Complaint Investigation
Census: 43
Deficiencies: 2
Dec 21, 2023
Visit Reason
The inspection was conducted following an investigation of a facility-reported incident #117429-I from December 12 to December 21, 2023, to determine if the complaint was substantiated regarding failure to notify physician and family of a resident's change in condition.
Findings
The facility was found to have failed to notify the physician and family of a significant change in condition for one resident, including increased pain and a sternal wound. The resident experienced inadequate pain management and lack of timely assessment and intervention, resulting in a substantiated deficiency related to quality of care and notification of changes.
Complaint Details
Complaint #117429-I was substantiated. The facility failed to notify the physician and family of a resident's significant change in condition and failed to provide adequate pain management and assessment.
Deficiencies (2)
| Description |
|---|
| Failure to notify physician and family of a resident's significant change in condition including increased pain and sternal wound. |
| Failure to provide adequate assessment and timely intervention for pain management for one resident. |
Report Facts
Resident census: 43
Pain levels recorded: 7
Sternal wound measurement: 9
Sternal wound measurement: 1
Pain scale score: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff G | Registered Nurse (RN) | Stated resident was very tired but alert and able to answer questions |
| Staff F | Certified Nursing Assistant (CNA) | Reported resident was cognitive and could answer questions |
| Staff E | Certified Nursing Assistant/Certified Medication Aide (CNA/CMA) | Documented administering medication and resident's responses |
| Staff H | Certified Nursing Assistant (CNA) | Worked overnight shifts and reported resident complaints and care |
| Staff D | Certified Nursing Assistant (CNA) | Worked specific days and reported resident behavior and care |
| Staff C | Registered Nurse (RN) | Interviewed CNA and reported on resident's condition and care |
| Staff B | Registered Nurse (RN) | Reported on resident's pain and medication administration issues |
Inspection Report
Annual Inspection
Census: 43
Deficiencies: 9
Nov 20, 2023
Visit Reason
The inspection was conducted as part of the facility's annual recertification survey and investigation of complaints #115149-C and #116718-C, with complaint #116718-C substantiated.
Findings
The facility failed to maintain a home-like environment due to a strong offensive urine odor throughout the facility, failed to communicate necessary information during an emergency hospital transfer, failed to accurately complete assessments, failed to develop and update baseline and comprehensive care plans appropriately, failed to meet professional standards for catheter orders, failed to provide appropriate incontinence care, and failed to maintain proper infection prevention and control practices including hand hygiene.
Complaint Details
Complaint #116718-C was substantiated.
Severity Breakdown
SS=E: 1
SS=D: 8
Deficiencies (9)
| Description | Severity |
|---|---|
| Facility repeatedly had a strong offensive urine odor throughout the facility. | SS=E |
| Failed to communicate necessary information to receiving facility during emergency transfer of Resident #44. | SS=D |
| Failed to accurately complete MDS assessments reflective of resident status for Residents #12 and #23. | SS=D |
| Failed to complete a baseline care plan including catheter care for Resident #45. | SS=D |
| Failed to develop a comprehensive care plan addressing risk factors and interventions for skin impairment and pressure ulcers for Resident #12. | SS=D |
| Failed to update care plan after Resident #22 attempted to leave the facility. | SS=D |
| Failed to have a physician's order for a resident admitted with a foley catheter (Resident #45). | SS=D |
| Failed to provide appropriate incontinence care for Resident #27, including incomplete cleansing and improper glove and hand hygiene use. | SS=D |
| Failed to maintain proper hand hygiene and standard precautions during care of Residents #27 and #34. | SS=D |
Report Facts
Deficiency count: 9
Resident census: 43
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | MDS Coordinator | Acknowledged and verified MDS assessment inaccuracies and care plan deficiencies |
| Director of Nursing | Director of Nursing | Acknowledged missing transfer documentation, care plan expectations, and hand hygiene standards |
| Staff B | Certified Nurse Aide | Observed failing to perform proper hand hygiene and infection control during resident care |
| Staff C | Non-Certified Aide | Observed failing to perform proper hand hygiene and infection control during resident care |
| Staff D | Certified Nurse Aide | Observed failing to perform proper hand hygiene and infection control during resident care |
Inspection Report
Plan of Correction
Deficiencies: 0
Aug 9, 2023
Visit Reason
The document serves as a Plan of Correction following acceptance of a credible allegation of substantial compliance by the facility.
Findings
The facility was found to be in substantial compliance based on the accepted Plan of Correction and will be certified in compliance effective August 9, 2023.
Inspection Report
Complaint Investigation
Census: 41
Deficiencies: 1
Aug 8, 2023
Visit Reason
The inspection was conducted as a result of investigations into complaints #113175-C, #112685-C, and #112616-C from August 1 to August 8, 2023. The complaints were substantiated and related to controlled substance record-keeping and medication administration.
Findings
The facility failed to maintain accurate and complete records of controlled substances, including lack of staff signatures on narcotic counts and inconsistent reconciliation of medications. Multiple discrepancies were found in narcotic counts for medication carts and individual residents, indicating poor compliance with pharmacy service procedures.
Complaint Details
Complaints #113175, #112685, #112628, and #112616 were substantiated following investigation from August 1 to August 8, 2023.
Deficiencies (1)
| Description |
|---|
| Failure to ensure drug records are in order and accurate, including lack of staff signatures on controlled substance counts and failure to reconcile medications consistently. |
Report Facts
Census: 41
Complaints investigated: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing (DON) | Reported completion of facility investigations and narcotic count discrepancies. |
| Staff A | Registered Nurse (RN) | Documented medication administration and provided a typed recount statement regarding narcotic counts. |
| Staff B | Certified Medication Aide (CMA) | Administered tramadol and involved in medication discrepancy. |
| Staff C | Certified Medication Aide (CMA) | Reported on narcotic count practices and shift procedures. |
| Staff D | Licensed Practical Nurse (LPN) | Reported narcotic count concerns and interactions with DON. |
| Staff E | Licensed Practical Nurse (LPN) | Reported narcotic count practices and verification issues. |
| Assistant Director of Nursing | Assistant Director of Nursing (ADON) | Reported on narcotic count completion and observations. |
Inspection Report
Re-Inspection
Deficiencies: 0
Apr 5, 2023
Visit Reason
The visit was an on-site revisit conducted to verify compliance following a previous inspection.
Findings
Based on the on-site revisit completed on 2023-04-05, the facility was certified in compliance effective 2023-03-21.
Inspection Report
Complaint Investigation
Census: 43
Deficiencies: 1
Mar 8, 2023
Visit Reason
The inspection was conducted as a result of an investigation of multiple complaints and facility-reported incidents related to respiratory and tracheostomy care and suctioning at Fonda Specialty Care.
Findings
The facility failed to ensure that a resident requiring respiratory care, including tracheostomy suctioning, received care consistent with professional standards. Specifically, the facility did not provide required suctioning for Resident #2, leading to respiratory distress and ultimately the resident's death. Staff interviews confirmed the resident's need for suctioning and availability of suction equipment, but suctioning was not performed timely.
Complaint Details
The complaint #111171-C was substantiated. The investigation included review of multiple complaints (#108529-C, #108838-C, #108860-C, #109201-C, #109263-C, #110210-C, #110798-C, #111030-C, #111171-C, #111173-C) and facility-reported incidents (#108385-I and #111450-I) conducted from February 23, 2023 to March 8, 2023.
Deficiencies (1)
| Description |
|---|
| The facility failed to provide required suctioning for a resident needing respiratory care including tracheostomy suctioning, resulting in inadequate care. |
Report Facts
Facility census: 43
Date of survey completion: Mar 8, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jennifer Blair | Administrator | Signed the Plan of Correction on 03/22/2023 |
| Staff A | LPN (licensed practical nurse) | Interviewed and confirmed Resident #2's communication and suctioning needs |
| Staff B | CMA/CNA (certified medication aide/certified nursing assistant) | Interviewed and confirmed Resident #2's suctioning needs |
| Staff C | RN (registered nurse) | Interviewed and confirmed Resident #2's suctioning needs and procedure |
| Staff D | CNA | Interviewed and described Resident #2's condition and suctioning needs |
| Staff E | CNA | Interviewed and confirmed Resident #2's communication about suctioning needs |
| Staff F | CNA | Interviewed and described Resident #2's condition and suctioning needs |
| Staff G | LPN | Interviewed and described events around Resident #2's decline and suctioning |
| Staff H | CMA/CNA | Interviewed and confirmed Resident #2's communication about suctioning needs |
| Staff I | ADON (assistant director of nursing) | Interviewed and confirmed nursing expectations for suctioning Resident #2 |
| Staff J | RN | Interviewed and confirmed Resident #2's suctioning needs and availability of suction machine |
Inspection Report
Plan of Correction
Deficiencies: 0
Nov 17, 2022
Visit Reason
The document is a plan of correction submitted following a survey to address deficiencies and certify compliance.
Findings
The facility was certified in compliance based on acceptance of a credible allegation of compliance and the submitted plan of correction effective November 17, 2022.
Inspection Report
Annual Inspection
Census: 43
Deficiencies: 11
Oct 24, 2022
Visit Reason
The inspection was conducted as part of the facility's annual recertification survey and investigation of complaints #107528-C, #107895-C, and #108394-C from October 17, 2022 to October 24, 2022.
Findings
The facility failed to complete a comprehensive admission assessment within 14 days for one resident, failed to develop a complete baseline care plan for a new admission, failed to provide adequate bathing assistance for dependent residents, failed to provide treatments and care as ordered by physicians, failed to ensure proper food temperatures and food safety, failed to maintain infection prevention and control practices, and failed to ensure proper documentation and administration of psychotropic medications. The facility also had deficiencies related to resident transfer supervision and COVID-19 infection control.
Complaint Details
Complaints #107528-C and #108394-C were substantiated. Complaint #107895-C was not substantiated.
Deficiencies (11)
| Description |
|---|
| Failed to complete admission Minimum Data Set (MDS) assessment within 14 days for Resident #145. |
| Failed to develop and implement a complete baseline care plan for Resident #145. |
| Failed to provide bathing assistance per resident preference for Residents #9, #39, and #3. |
| Failed to provide treatments and interventions as ordered by physicians for Residents #33 and #21. |
| Failed to ensure food was served at proper temperatures and maintain food safety standards. |
| Failed to establish and maintain an infection prevention and control program, including proper use of PPE and hand hygiene. |
| Failed to ensure psychotropic medications were limited to 14 days unless properly documented and renewed. |
| Failed to ensure adequate RN coverage for required hours and days. |
| Failed to ensure proper supervision and assistance during resident transfers, resulting in falls and injuries. |
| Failed to properly document and administer influenza and pneumococcal vaccinations for residents. |
| Failed to ensure COVID-19 infection control measures, including signage and PPE use, were properly implemented. |
Report Facts
Resident census: 43
BIMS score: 15
BIMS score: 15
BIMS score: 7
BIMS score: 6
BIMS score: 12
BIMS score: 3
BIMS score: 13
BIMS score: 14
BIMS score: 99
Medication doses: 1
Temperature: 123
Temperature: 122
Temperature: 118
RN coverage hours: 8
PRN order duration: 14
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff K | Registered Nurse (RN) | Administered medications and tube feeding to Resident #145 and provided statements regarding tracheostomy care. |
| Staff I | Licensed Practical Nurse (LPN) | Confirmed admission MDS for Resident #145 had not been completed. |
| Staff C | Certified Nursing Assistant (CNA) | Observed transferring Resident #39 using Sit-To-Stand lift and assisted with resident care. |
| Staff J | Registered Nurse (RN) | Removed old dressing and applied new dressing for Resident #6 and #11. |
| Staff A | Activities Director | Observed not wearing gloves and failing to use sanitizer during COVID-19 outbreak. |
| Staff B | Certified Medication Aide (CMA) | Failed to perform hand hygiene during medication administration. |
| Staff D | Housekeeping Staff | Not wearing gown or gloves while cleaning resident rooms. |
| Staff E | Registered Nurse (RN) | Handled oxygen tubing for Resident #17 without gloves or gown. |
| Staff F | Certified Nursing Assistant (CNA) | Assisted Resident #19 who tested positive for COVID-19. |
| Staff G | Certified Nursing Assistant (CNA) | Assisted Resident #19 who tested positive for COVID-19. |
| Director of Nursing | Director of Nursing | Commented on improper positioning of resident during Sit-To-Stand transfer. |
| Administrator | Administrator | Provided statements regarding MDS completion, care plans, vaccination refusals, and COVID-19 infection control. |
| Regional Nurse Consultant | Regional Nurse Consultant | Confirmed lack of RN coverage and vaccination status for residents. |
| Dietary Manager | Dietary Manager | Provided statements regarding food temperatures, sanitation, and meal service. |
| Staff J | Registered Nurse (RN) | Removed old dressing and applied new dressing for Resident #6 and #11. |
Inspection Report
Plan of Correction
Deficiencies: 0
Sep 24, 2022
Visit Reason
The document reflects acceptance of a credible allegation of compliance and plan of correction for the facility.
Findings
The facility will be certified in compliance effective September 24, 2022, based on acceptance of the credible allegation of compliance and plan of correction.
Inspection Report
Complaint Investigation
Census: 44
Deficiencies: 7
Aug 16, 2022
Visit Reason
The inspection was conducted as a result of investigations into multiple complaints and facility reported incidents between August 16 and August 24, 2022.
Findings
The facility was found to have deficiencies related to reasonable accommodations, safe and clean environment, professional standards, ADL care, increase/prevent decrease in range of motion, medication errors, and infection prevention and control. Several residents were affected, and staff were re-educated on various protocols.
Complaint Details
The inspection resulted from investigation of complaints #100324-C (unsubstantiated), #102967-C (substantiated), #102969-C (unsubstantiated), #103169-C (unsubstantiated), #104416-C (unsubstantiated), #104741-C (unsubstantiated), #104455-C (substantiated), #104709-C (substantiated), #105398-C (substantiated), and facility reported incidents #100951-I (unsubstantiated), #103320-I (unsubstantiated).
Deficiencies (7)
| Description |
|---|
| Reasonable Accommodations Needs/Preferences not met for Resident #12 regarding call light accessibility. |
| Safe/Clean/Comfortable/Homelike Environment not maintained; Resident #1's trash can was full and wheelchair had food/debris. |
| Services Provided did not meet Professional Standards; Resident #1 lacked a physician's order for oxygen use. |
| ADL Care Provided for Dependent Residents was inadequate; bathing assistance not consistently provided for Residents #2 and #4. |
| Increase/Prevent Decrease in Range of Motion not met; restorative nursing care not fully provided for Residents #1 and #2. |
| Residents were not free of significant medication errors; Resident #1 had medication ordering and administration errors. |
| Infection Prevention and Control program deficiencies; failure to prevent infection for Resident #1 with oxygen and Residents #2 and #11 with incontinence care. |
Report Facts
Census: 44
Complaints investigated: 9
Facility reported incidents investigated: 2
Residents reviewed for bathing assistance: 4
Residents audited for call light use: 3
Residents audited for oxygen order compliance: 3
Residents audited for bathing completion: 3
Residents audited for ADL care: 3
Residents reviewed for medication errors: 3
Residents assessed for infection control: 3
Inspection Report
Complaint Investigation
Census: 39
Deficiencies: 1
Oct 4, 2021
Visit Reason
The inspection was conducted as a complaint investigation related to an elopement incident involving Resident #1, as identified during investigations of Self-Report #91418-I and Complaint #91458-C.
Findings
The facility failed to adequately supervise residents at risk for elopement, specifically Resident #1 who eloped from the building on 6/13/21. The care plan did not identify or have sufficient interventions to prevent elopement. The resident was found outside the facility after removing an air conditioner from a window and leaving the building. The facility implemented corrective actions including securing windows and door alarms.
Complaint Details
The complaint investigation was related to an elopement incident involving Resident #1. The self-report #97594-I was substantiated, while complaint #98828-C was not substantiated.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility failed to adequately supervise residents at risk for elopement, resulting in Resident #1 eloping from the building. | SS=D |
Report Facts
Census: 39
Deficiency severity: 1
Inspection Report
Annual Inspection
Census: 38
Deficiencies: 1
Jan 28, 2021
Visit Reason
The inspection was conducted as the facility's annual survey from January 25, 2021 to January 28, 2021 to assess compliance with federal regulations.
Findings
The facility was found deficient in ensuring residents' rights to dignity and respect, specifically related to staff speaking Spanish while providing care, which made some residents uncomfortable. The facility planned corrective actions including staff education and monitoring.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to provide care with dignity and respect as evidenced by staff speaking Spanish to residents during care, causing discomfort to residents. | SS=D |
Report Facts
Census: 38
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Interviewed on January 28, 2021 regarding staff communication with residents |
Inspection Report
Complaint Investigation
Census: 39
Deficiencies: 0
Nov 9, 2020
Visit Reason
Investigation of Complaint #84882-C and #83540-C, and a COVID-19 Focused Infection Control Survey conducted from 11/4 to 11/9/2020.
Findings
No deficiencies were found during the complaint investigations or the COVID-19 Focused Infection Control Survey. Both complaints were not substantiated, and the facility was found to be in compliance with CMS and CDC recommended practices for COVID-19 preparation.
Complaint Details
Complaint #84882-C was not substantiated. Complaint #83540-C was not substantiated.
Report Facts
Total residents: 39
Inspection Report
Routine
Census: 36
Deficiencies: 0
Jun 9, 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.
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