Deficiencies per Year
4
3
2
1
0
Severe
High
Moderate
Low
Unclassified
Census Over Time
Inspection Report
Complaint Investigation
Deficiencies: 0
Nov 17, 2025
Visit Reason
A complaint investigation for complaint #2636013-C was conducted from November 13, 2025 to November 17, 2025.
Findings
The facility was found to be in substantial compliance with no deficiencies cited.
Complaint Details
Complaint #2636013-C was investigated and the facility was found to be in substantial compliance.
Inspection Report
Complaint Investigation
Deficiencies: 0
Oct 14, 2025
Visit Reason
A complaint investigation for complaint #2583300-C was conducted from October 9, 2025 to October 14, 2025.
Findings
The facility was found to be in substantial compliance with no deficiencies cited.
Complaint Details
Complaint #2583300-C was investigated and the facility was found to be in substantial compliance.
Inspection Report
Plan of Correction
Deficiencies: 0
Jun 16, 2025
Visit Reason
The document serves as a Plan of Correction following a survey ending May 29, 2025, addressing the facility's compliance status.
Findings
The facility was found to be in substantial compliance based on the credible allegation and Plan of Correction, resulting in certification effective June 16, 2025.
Inspection Report
Annual Inspection
Census: 31
Deficiencies: 2
May 29, 2025
Visit Reason
The inspection was conducted as the facility's annual recertification survey from May 27, 2025 to May 29, 2025.
Findings
The facility failed to meet professional standards of quality related to following physician's orders for pressure ulcers and bowel movement documentation for multiple residents. Deficiencies included lack of proper documentation, failure to notify physicians timely, and inconsistent medication administration and bowel management.
Deficiencies (2)
| Description |
|---|
| Failure to follow physician's orders for 1 of 3 residents reviewed for pressure ulcers. |
| Failure to ensure bowel regularity and proper documentation for 3 of 4 residents reviewed. |
Report Facts
Residents reviewed for pressure ulcers: 3
Residents reviewed for bowel regularity: 4
Facility census: 31
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kellie McClure | CEO, NHA | Signed the inspection report |
| Staff A | Registered Nurse (RN) | Applied betadine to resident's heel and interviewed regarding treatment orders |
| Director of Nursing | Stated nurses should look at orders prior to treatment and described routine orders for bowel management | |
| Staff D | Registered Nurse (RN) | Interviewed about bowel movement documentation and lists |
| Staff C | Certified Nursing Assistant (CNA) | Interviewed about bowel movement list and resident status |
| Staff E | Assistant Director of Nursing (ADON) | Interviewed about bowel movement list discrepancies |
| Staff B | Registered Nurse (RN) | Interviewed about bowel movement refusals and nursing staff practices |
Inspection Report
Annual Inspection
Census: 27
Deficiencies: 3
Jul 11, 2024
Visit Reason
The inspection was conducted as the facility's annual recertification survey from July 8, 2024 to July 11, 2024 to assess compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities.
Findings
The facility was found not in compliance with resident rights and professional standards, including failure to recognize and respect psychosocial feedback from residents regarding alarms and failure to follow manufacturer recommendations for insulin administration. Deficiencies were identified related to resident rights and medication administration.
Severity Breakdown
Level D: 2
Level E: 1
Deficiencies (3)
| Description | Severity |
|---|---|
| Failure to recognize and respect psychosocial feedback and responses for 2 of 3 residents reviewed regarding alarms that sounded when standing, causing anxiety and fear. | Level D |
| Failure to follow manufacturer recommendations while administering insulin using an insulin pen for 1 of 1 resident reviewed. | Level D |
| Failure to ensure a registered nurse worked at least 8 consecutive hours a day, 7 days a week as required. | Level E |
Report Facts
Total Census: 27
Resident Census: 28
Resident Census: 28
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kellie McDuff | CEO, LNHA | Signed the statement of deficiencies and plan of correction |
| Staff A | Licensed Practical Nurse (LPN) | Administered insulin using insulin pen and acknowledged manufacturer recommendations |
| Staff B | Registered Nurse (RN) | Worked night shift on 6/16/24; involved in staffing deficiency |
| Staff C | Registered Nurse (RN) | Responded to Resident #4 alarm mat incident |
| Staff D | Registered Nurse (RN) | Involved in Resident #4 alarm and restorative program |
| Staff E | Certified Nurse Aide (CNA) | Reported on Resident #4 alarm use and observations |
| Director of Nursing (DON) | Acknowledged alarm concerns and staffing issues | |
| Executive Director | Acknowledged concerns with alarms and call light company | |
| Physical Therapist | Provided input on Resident #4 alarm use and therapy | |
| Physical Therapy Aide (PTA) | Reported on Resident #10 floor alarm discussion |
Inspection Report
Renewal
Deficiencies: 0
May 11, 2023
Visit Reason
A Recertification Survey was conducted from May 08, 2023 to May 22, 2023 to assess the facility's compliance for renewal purposes.
Findings
The facility was found to be in substantial compliance during the recertification survey.
Inspection Report
Annual Inspection
Census: 34
Deficiencies: 1
Dec 22, 2021
Visit Reason
The inspection visit was conducted as the facility's annual health survey to assess compliance with federal regulations related to respiratory care and tracheostomy suctioning.
Findings
The facility failed to ensure proper weekly changing and documentation of oxygen tubing for residents requiring oxygen therapy, with observations showing tubing without dates and inconsistent documentation. The facility's oxygen concentrator policy was reviewed and staff interviews revealed gaps in knowledge and documentation practices.
Deficiencies (1)
| Description |
|---|
| Failure to ensure residents requiring respiratory care, including tracheostomy suctioning, received care consistent with professional standards, specifically related to weekly changing and documentation of oxygen tubing. |
Report Facts
Resident census: 34
Correction date: Dec 27, 2021
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kellie McLaughlin | BSN, NHA | Signed the statement of deficiencies and plan of correction |
Inspection Report
Abbreviated Survey
Census: 34
Deficiencies: 0
Dec 23, 2020
Visit Reason
A COVID 19 Focused Infection Control Survey was conducted by the Department of Inspections and Appeals from 12/21/2020 through 12/23/2020.
Findings
The facility was found in compliance with CMS and Centers for Disease Control and Prevention (CDC) recommended practices to prepare for COVID 19.
Inspection Report
Renewal
Census: 35
Deficiencies: 0
Sep 10, 2020
Visit Reason
The inspection was conducted as a recertification survey and COVID-19 Focused Infection Control Survey from September 8 to 10, 2020.
Findings
The facility was found to be in substantial compliance at the time of the recertification survey and COVID-19 Focused Infection Control Survey.
Inspection Report
Abbreviated Survey
Census: 33
Deficiencies: 0
Jun 16, 2020
Visit Reason
A COVID 19 Focused Infection Control Survey was conducted by the Department of Inspections and Appeals on 6/16/2020.
Findings
The facility was found to be in compliance with CMS and Centers for Disease Control and Prevention (CDC) recommended practices to prepare for COVID 19.
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