Deficiencies per Year
8
6
4
2
0
Severe
High
Moderate
Low
Unclassified
Census Over Time
Inspection Report
Plan of Correction
Deficiencies: 0
Nov 29, 2025
Visit Reason
The document is a statement of deficiencies and plan of correction related to the facility's compliance certification.
Findings
Based on acceptance of the facility's credible allegation of compliance and plan of correction, the facility will be certified in compliance effective November 25, 2025. No specific deficiencies are detailed in this document.
Inspection Report
Complaint Investigation
Census: 29
Deficiencies: 1
Sep 25, 2025
Visit Reason
The inspection was conducted as a result of complaints #1801716-C and #1801706-C between September 23, 2025 and September 25, 2025 to investigate alleged deficiencies related to respiratory/tracheostomy care and suctioning.
Findings
The facility failed to provide adequate respiratory care for one of three residents reviewed, specifically Resident #3, who required supplemental oxygen. The staff failed to increase monitoring and consult with the resident and family before changing oxygen orders, resulting in low oxygen saturations, increased lethargy, and hospitalization. Documentation and communication regarding oxygen orders and monitoring were inconsistent and incomplete.
Complaint Details
The investigation was triggered by complaints #1801716-C and #1801706-C, which resulted in a deficiency related to respiratory care for Resident #3. The complaints were substantiated as evidenced by the findings.
Severity Breakdown
Level D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility failed to provide adequate respiratory care for Resident #3, including failure to increase monitoring and consult with resident and family before changing oxygen orders, resulting in low oxygen saturations and hospitalization. | Level D |
Report Facts
Census: 29
Complaint numbers: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff C | Registered Nurse | Completed communication to physician to change oxygen order for Resident #3 |
| Staff F | Registered Nurse | Reported Resident #3 was non-compliant with oxygen and continued to check oxygen frequently |
| Staff B | Registered Nurse | Reported Resident #3 was struggling to eat and had blue lips |
| Staff E | Licensed Practical Nurse | Reported difficulty keeping Resident #3's oxygen on and uncertainty about order change |
| Staff D | Registered Nurse | Changed oxygen order from PRN back to continuous |
| Physician #1 | Approved oxygen order changes verbally and stated unfamiliarity with Resident #3 | |
| Director of Nursing | DON | Acknowledged decreased documentation of oxygen monitoring after order change |
Inspection Report
Plan of Correction
Deficiencies: 0
Apr 28, 2025
Visit Reason
The document is a Plan of Correction submitted following a prior inspection, indicating acceptance of the facility's credible allegation of substantial compliance.
Findings
The facility was certified in compliance with health requirements effective April 25, 2025, based on acceptance of the Plan of Correction and credible allegation of substantial compliance.
Inspection Report
Plan of Correction
Deficiencies: 0
Apr 17, 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 accepted Plan of Correction, leading to certification effective April 17, 2024.
Inspection Report
Annual Inspection
Census: 29
Deficiencies: 7
Apr 4, 2024
Visit Reason
The inspection was the facility's annual recertification survey conducted from April 1, 2024 to April 4, 2024.
Findings
The facility was found deficient in several areas including discharge summaries, restorative programs, urinary catheter care, menu and nutritional adequacy, food safety, immunizations including influenza, pneumococcal, and COVID-19 vaccinations. Deficiencies were based on record reviews, staff interviews, observations, and policy reviews.
Severity Breakdown
SS=D: 5
SS=E: 2
Deficiencies (7)
| Description | Severity |
|---|---|
| Facility failed to assure a discharged resident had a discharge summary including a recapitulation of the resident's stay. | SS=D |
| Facility failed to assure restorative program was completed as planned for a resident with limited mobility. | SS=D |
| Facility failed to provide a resident with a urinary catheter care and services to prevent infection. | SS=D |
| Facility failed to follow the menu as written and assure menus were reviewed and approved by a dietician. | SS=E |
| Facility failed to store, prepare, and serve food in accordance with professional food service safety standards. | SS=E |
| Facility failed to assure residents and/or their representatives were educated on influenza and pneumococcal immunizations and documentation was lacking. | SS=D |
| Facility failed to assure residents had access to the most recent COVID-19 vaccine and education regarding COVID-19 vaccination was incomplete. | SS=D |
Report Facts
Census: 29
Residents reviewed: 5
Deficiencies cited: 7
Inspection Report
Plan of Correction
Deficiencies: 0
Jan 13, 2023
Visit Reason
The document is a plan of correction submitted following a survey to address deficiencies and demonstrate compliance.
Findings
The facility was certified in compliance based on acceptance of a credible allegation of compliance and the submitted plan of correction effective January 13, 2023.
Inspection Report
Annual Inspection
Census: 26
Deficiencies: 2
Jan 12, 2023
Visit Reason
The inspection was conducted as the facility's annual recertification survey from January 9, 2023 to January 12, 2023.
Findings
The facility failed to document an accurate code status for one resident and did not ensure food safety requirements were met, including labeling and dating of stored food items. Several expired or unlabeled food items were found in the kitchen and storage areas.
Deficiencies (2)
| Description |
|---|
| Failure to document an accurate code status for 1 of 16 residents reviewed for advanced directives. |
| Failure to ensure food was labeled with dates after opening, labeled with product after removing from original package, and discarded after product expiration date. |
Report Facts
Residents reviewed for advanced directives: 16
Resident census: 26
Date of inspection: Jan 9, 2023
Date of inspection: Jan 12, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Met with MDS Liasson and conducted audit of resident charts related to advanced directives |
| Staff A | Licensed Practical Nurse | Reported on 1/10/23 regarding resident code status documentation |
| Dietary Manager | Dietary Manager | Inspected refrigerators, freezers, and pantry; educated staff on labeling; conducted weekly audits of stored food items |
| Administrator | Administrator | Interviewed regarding food labeling and expiration practices |
Inspection Report
Annual Inspection
Census: 33
Deficiencies: 7
Jun 10, 2021
Visit Reason
The inspection was conducted as part of the facility's annual survey and investigation of complaint #92698-C conducted on June 7-10, 2021.
Findings
The complaint #92698-C was substantiated. The facility was found deficient in notifying the Power of Attorney (POA) of significant weight loss for residents, maintaining resident personal property inventories, establishing and following grievance procedures, and developing comprehensive care plans. The facility failed to provide reasonable care for protection of resident property and failed to hold care plan meetings including residents or their representatives.
Complaint Details
Complaint #92698-C was substantiated following the investigation conducted June 7-10, 2021.
Deficiencies (7)
| Description |
|---|
| Failed to notify the Power of Attorney (POA) of significant weight loss for residents. |
| Failed to maintain personal inventory lists for residents' property, resulting in missing items. |
| Failed to establish and follow a grievance procedure ensuring residents were informed and grievances were properly documented and resolved. |
| Failed to provide a safe, clean, comfortable, and homelike environment, including protection of resident property from loss or theft. |
| Failed to develop and implement comprehensive, person-centered care plans with measurable objectives and timeframes, and failed to hold care plan meetings with residents or their representatives. |
| Failed to ensure restorative treatment programs were completed timely and care plans were reviewed quarterly. |
| Failed to ensure residents received services to maintain highest level of functioning related to mobility and range of motion. |
Report Facts
Resident census: 33
Residents reviewed: 12
Residents with grievances reviewed: 6
Residents with care plans reviewed: 12
Residents with restorative program reviewed: 12
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff C | Registered Nurse (RN) | Interviewed regarding notification of POA of significant weight loss and care plan deficiencies. |
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding expectations for staff notification of POA, grievance procedures, care plan meetings, and restorative treatment programs. |
| Administrator | Administrator | Met with Director of Nursing and other staff to implement corrective actions and discussed grievance policies and care plan improvements. |
| Staff A | Certified Nursing Assistant (CNA) | Mentioned as hired to do restorative program and follow through with exercises. |
Inspection Report
Routine
Census: 28
Deficiencies: 0
Dec 31, 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.
Inspection Report
Routine
Census: 30
Deficiencies: 0
Dec 3, 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.
Inspection Report
Abbreviated Survey
Census: 24
Deficiencies: 0
Jun 17, 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.
Report Facts
Total residents: 24
Report
Apr 28, 2025
File
ScannedReport_789_2025-04-28_123402.pdf
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