Inspection Report Summary
Most inspections found multiple deficiencies across areas such as resident rights, safe environment, emergency preparedness, medication management, and staff training. Several complaint investigations substantiated abuse and neglect issues, including failure to assist residents properly and physical abuse by staff. The most recent report from March 26, 2025, continued to identify deficiencies but did not list any fines or enforcement actions. Many issues involved environmental safety hazards, emergency power failures, and incomplete staff training, while medication errors and care plan shortcomings were also noted. There is no clear pattern of improvement or decline, as serious concerns have persisted throughout the inspection period.
Deficiencies per Year
80
60
40
20
0
Severe
High
Moderate
Low
Unclassified
Inspection Report
Complaint Investigation
Census: 58
Capacity: 162
Deficiencies: 65
Mar 26, 2025
Visit Reason
State-compiled facility profile showing 19 inspections from 2023-2025 with deficiency history including complaint and annual compliance surveys.
Findings
The inspections revealed multiple deficiencies across various areas including resident rights, safe environment, emergency preparedness, medication management, and staff training. Several complaint investigations found substantiated abuse and neglect issues, while annual and other surveys identified environmental, safety, and procedural deficiencies.
Complaint Details
Multiple complaint investigations were conducted between 2023 and 2025, with some substantiated findings of abuse, neglect, and failure to provide adequate care and services to residents, including failure to report injuries and failure to ensure resident rights.
Deficiencies (65)
| Description |
|---|
| §483.10(g)(17) and §483.10(g)(18) Advanced Beneficiary Notice: Failed to ensure residents and/or representatives received accurate and complete ABN forms when Medicare services terminated. |
| §483.10(i) Safe Environment: Failed to ensure adequate and comfortable temperature levels for residents, resulting in uncomfortably warm rooms for multiple residents. |
| R9-10-406.B.1.b.ii Annual Staff Training: Failed to implement and maintain effective annual training programs for abuse, resident rights, infection control, dementia, and emergency preparedness for multiple staff. |
| R9-10-406.F.3.c Fingerprint Clearance Cards: Failed to ensure two staff had required fingerprint clearance cards. |
| R9-10-406.F.3.i Tuberculosis Testing: Failed to ensure one staff was free of tuberculosis prior to working in the facility. |
| §483.21(b)(3) Comprehensive Care Plans: Failed to ensure initial and ongoing weights were conducted for one resident. |
| §483.24(a)(2) ADL Assistance: Failed to ensure one resident received assistance with bathing as scheduled. |
| R9-10-407.5.a Advanced Beneficiary Notice: Failed to ensure two residents and/or representatives received accurate and complete ABN forms when Medicare services terminated. |
| §483.35(g) Nurse Staffing Information: Failed to ensure daily staff posting included correct information, specifically actual hours worked. |
| §483.60(i) Food Safety: Failed to ensure multiple food items were stored at safe temperatures in the walk-in refrigerator. |
| §483.80 Infection Control: Failed to ensure one staff was free of tuberculosis prior to working in the facility. |
| §483.90(c) Emergency Power: Failed to ensure emergency and standby power systems functioned properly during power outage; generator failed to start automatically. |
| §483.90(i) Other Environmental Conditions: Failed to maintain safe and comfortable environment; multiple areas with peeling paint, gouges, protruding nails, and metal braces posing injury risks. |
| §483.95 Training Requirements: Failed to maintain effective annual training program for multiple staff on abuse, resident rights, infection control, dementia, and emergency preparedness. |
| R9-10-412.B.4.d Daily Staff Posting: Failed to include actual number of hours worked by nursing personnel on daily staff posting. |
| R9-10-414.B.3.b Care Plan: Failed to ensure resident was weighed initially and monthly to monitor weight changes. |
| R9-10-423.A.3.b Food Storage: Failed to store, refrigerate, and reheat food to meet dietary needs; walk-in refrigerator temperatures exceeded safe limits. |
| R9-10-425.A.1.b Physical Plant Safety: Failed to maintain safe environment free from physical injury risks due to damaged door frames, handrails, and protruding nails. |
| R9-10-425.A.6 Heating and Cooling: Failed to maintain facility temperature between 70°F and 84°F for residents' comfort. |
| R9-10-426 Physical Plant Standards: Failed to ensure emergency and standby power systems functioned properly during power outage; generator failed to start automatically. |
| [(a) Emergency Plan] Failed to develop and maintain a community-based risk assessment for emergency preparedness plan. |
| [(a) Emergency Plan] Failed to include patient population needs and delegation of authority in emergency preparedness plan. |
| (b) Policies and Procedures: Failed to develop emergency preparedness policies based on current risk assessments. |
| [(b) Policies and Procedures] Failed to maintain policies ensuring refrigerated foods stored at or below 41°F. |
| [(b) Policies and Procedures] Failed to have comprehensive safe evacuation policies and procedures. |
| (d) Training and Testing: Failed to develop and maintain emergency preparedness training and testing program for staff. |
| (e) Emergency and Standby Power Systems: Failed to ensure emergency generator functioned properly during power outage; generator failed to start automatically. |
| Means of Egress - General: Failed to provide safe means of egress; soiled laundry room exit blocked by laundry cart and medication cart blocking fire doors. |
| Hazardous Areas - Enclosure: Failed to maintain proper rated fire doors and self-closing hardware on hazardous area doors. |
| Cooking Facilities: Failed to protect cooking equipment per NFPA 96; no approved hood system in therapy room. |
| Sprinkler System - Maintenance and Testing: Failed to ensure sprinkler coverage in storage areas; hydraulic design plate missing. |
| Utilities - Gas and Electric: Failed to provide protective guards on light bulbs in multiple locations. |
| Fire Drills: Failed to provide all required fire drills per NFPA 101; missing drills for 2024 first and second quarters. |
| Electrical Systems - Essential Electric System Categories: Failed to have emergency generator permanently mounted. |
| Electrical Systems - Essential Electric System Maintenance and Testing: Failed to ensure emergency generator transferred to emergency power within 10 seconds during power outage. |
| Electrical Equipment - Power Cords and Extension Cords: Failed to ensure appliances plugged directly into wall outlets; power strips used improperly. |
| §483.12 Freedom from Abuse, Neglect, and Exploitation: Failed to prevent neglect of resident #48; staff refused to assist with brief change and acted abusively. |
| R9-10-410.B.3.b Neglect: Failed to prevent neglect of resident #48; staff refused to assist with brief change and acted abusively. |
| §483.10(b)(3) Resident Rights: Failed to ensure resident representative could exercise rights regarding care decisions for resident #4. |
| §483.12 Freedom from Abuse, Neglect, and Exploitation: Failed to prevent neglect of resident #4; no neurological assessment after injury. |
| §483.12(c) Reporting Abuse and Neglect: Failed to report injury of unknown origin to administrator and state agency within 24 hours for resident #4. |
| §483.21(b)(3) Comprehensive Care Plans: Failed to assess resident #4 according to professional standards; no neurological assessment after injury. |
| R9-10-410.B.3.b Neglect: Failed to prevent neglect of resident #4; no neurological assessment after injury. |
| R9-10-410.C.8 Resident Rights: Failed to ensure resident representative could participate in care decisions for resident #4. |
| R9-10-414.B.3.b Care Plan: Failed to assess resident #4 according to professional standards; no neurological assessment after injury. |
| §483.12 Freedom from Abuse, Neglect, and Exploitation: Failed to prevent physical abuse of resident #10 by staff. |
| R9-10-410.B.3.a Abuse: Failed to prevent physical abuse of resident #10 by staff. |
| R9-10-403.C.2.d Medication Management: Failed to ensure medication was obtained and available to meet needs of resident #43. |
| §483.10(g)(17) and §483.10(g)(18) Advanced Beneficiary Notice: Failed to ensure three residents and/or representatives received SNFABN when Medicare services terminated. |
| §483.10(i) Safe Environment: Failed to maintain environment free of pervasive urine odors near resident #38's room. |
| §483.24(a)(2) ADL Assistance: Failed to provide nail care for resident #18. |
| §483.25 Quality of Care: Failed to provide care and services in accordance with physician orders and care plan for resident #60. |
| §483.25(e) Incontinence Care: Failed to provide appropriate catheter care for resident #4, increasing risk of infection. |
| §483.45 Pharmacy Services: Failed to ensure medication was obtained and available to meet needs of resident #43. |
| §483.45(f) Medication Errors: Medication error rate exceeded 5% due to incorrect administration for residents #26 and #48. |
| §483.45(g) and (h) Drug Labeling and Storage: Failed to ensure medications were stored safely and secured in medication cart. |
| [The facility] Emergency Preparedness: Failed to maintain, review, and update emergency preparedness plan annually. |
| Means of Egress Requirements: Failed to provide proper signage for special locking exit door. |
| Portable Fire Extinguishers: Failed to conduct and document monthly visual inspections of fire extinguishers. |
| Corridor Doors: Failed to maintain doors to ensure proper latching and smoke resistance. |
| Fire Drills: Failed to provide documentation for required fire drills in 2022. |
| Electrical Systems Maintenance: Failed to conduct and document annual electrical receptacle testing in patient care areas. |
| Electrical Systems Essential Electric System Categories: Failed to have emergency generator permanently mounted. |
| Electrical Systems Essential Electric System Maintenance and Testing: Failed to provide documentation for annual load bank test of emergency generator. |
| Electrical Equipment Power Cords and Extension Cords: Failed to prevent use of daisy chained power strips and improper power strip use. |
Report Facts
Inspections on page: 19
Total deficiencies: 74
Complaint inspections: 16
Facility capacity: 162
Facility census: 58
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| CAYLOR COX | Administrator | Named in relation to expectations and findings in multiple deficiencies |
| Staff #110 | Administrator / Executive Director | Named in multiple findings related to training, tuberculosis testing, fingerprint clearance, ABN completion, emergency preparedness, and environmental issues |
| Staff #59 | Director of Nursing | Named in multiple interviews and findings related to training, neglect investigations, emergency preparedness, and care plan compliance |
| Staff #32 | Maintenance Director | Named in multiple findings related to environmental conditions, emergency power, and facility maintenance |
| Staff #50 | Registered Nurse / Certified Nursing Assistant | Named in abuse and medication error findings |
| Staff #33 | Assistant Maintenance Technician | Named in emergency power and temperature control findings |
| Staff #66 | Registered Dietician / Kitchen Manager | Named in food safety and nutritional assessment findings |
| Staff #73 | Human Resources Accounting Clerk | Named in training and fingerprint clearance findings |
| Staff #16 | Director of Nursing | Named in abuse investigation findings |
| Staff #91 | Licensed Practical Nurse | Named in abuse and neglect investigation findings |
| Staff #45 | Licensed Practical Nurse | Named in medication management findings |
| Staff #41 | Licensed Practical Nurse | Named in medication error findings |
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