Deficiencies per Year
20
15
10
5
0
High
Moderate
Unclassified
Census Over Time
Inspection Report
Plan of Correction
Deficiencies: 0
Dec 10, 2025
Visit Reason
The document is a statement of deficiencies and plan of correction related to the facility's compliance status, based on acceptance of a credible allegation of substantial compliance and a Plan of Correction dated October 9, 2025.
Findings
The facility was found to be in substantial compliance and will be certified in compliance effective November 21, 2025. No specific deficiencies or severity levels are detailed in this document.
Inspection Report
Complaint Investigation
Census: 48
Deficiencies: 1
Oct 9, 2025
Visit Reason
The inspection was conducted as a result of complaints #2574734-C and #2571772-C regarding pest control issues at the facility.
Findings
The facility failed to maintain an effective pest control program, evidenced by the presence of flies in resident rooms and dining areas, and inadequate maintenance of fluorescent light bug traps. Observations and interviews confirmed ongoing pest issues despite monthly pest control visits.
Complaint Details
Complaint #2571772-C resulted in a deficiency related to pest control issues.
Severity Breakdown
E: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failed to maintain an effective pest control program to keep the facility free of pests and rodents. | E |
Report Facts
Resident census: 48
BIMS score: 13
BIMS score: 15
Number of fluorescent light bug traps: 3
Dates of insecticide spray and rodenticide bait use: July 16, 2025; August 13, 2025; September 17, 2025
Date of survey completion: October 9, 2025
Correction date: November 21, 2025
Inspection Report
Plan of Correction
Deficiencies: 0
Jul 29, 2025
Visit Reason
The document is a statement of deficiencies and plan of correction related to a survey ending July 3, 2025, indicating acceptance of a credible allegation of substantial compliance and plan of correction.
Findings
The facility was found to be in substantial compliance based on the accepted plan of correction for the survey ending July 3, 2025, and will be certified in compliance effective July 25, 2025. No specific deficiencies are detailed in this document.
Report Facts
Survey end date: Jul 3, 2025
Certification effective date: Jul 25, 2025
Inspection Report
Renewal
Census: 49
Deficiencies: 8
Jul 3, 2025
Visit Reason
The inspection was an annual recertification survey conducted from June 30, 2025 to July 3, 2025, to assess compliance with federal regulations and facility licensing requirements.
Findings
The facility was found to have multiple deficiencies including failure to properly document advance directives, notify physicians of significant resident changes, provide ongoing activity programs, maintain a safe environment free of accident hazards, adhere to dietary and food safety requirements, and ensure influenza and pneumococcal immunizations for residents. The facility submitted a plan of correction with specific actions and timelines.
Severity Breakdown
Level D: 6
Level E: 2
Deficiencies (8)
| Description | Severity |
|---|---|
| Failure to ensure resident advance directives were properly documented and communicated. | Level D |
| Failure to notify physician of significant changes such as weight gain. | Level D |
| Failure to provide ongoing activity programs meeting resident interests and needs. | Level D |
| Failure to maintain a safe environment free of accident hazards and ensure adequate supervision. | Level D |
| Failure to secure medications and chemicals from cognitively impaired residents. | Level D |
| Failure to meet nutritional needs including menu adherence, food preparation, and food safety. | Level E |
| Failure to maintain sanitary kitchen conditions and proper refrigerator/freezer temperatures. | Level E |
| Failure to provide influenza and pneumococcal immunizations to all eligible residents. | Level D |
Report Facts
Census: 49
Weight gain: 22
Temperature: 48
Temperature: 45
Temperature: 52
Temperature: 55
Sanitizer level: 50
Sanitizer level: 25
Weight: 158
Weight: 180
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Named in relation to remedying resident code status and notification deficiencies |
| Staff C Licensed Practical Nurse | Licensed Practical Nurse | Mentioned in relation to determining resident code status |
| Staff D Registered Nurse | Registered Nurse | Mentioned in relation to weight gain monitoring |
| Life Enrichment Coordinator | Life Enrichment Coordinator | Interviewed regarding resident activities |
| Director of Activities | Director of Activities | Interviewed regarding resident activities |
| Staff B Certified Nursing Assistant | Certified Nursing Assistant | Mentioned in relation to unsecured medication found |
| Director of Nursing (DON) | Director of Nursing | Interviewed regarding medication and chemical safety, immunization policies |
| Staff E Dietary Cook/Aide | Dietary Cook/Aide | Mentioned in relation to food preparation and sanitation |
| Dietary Manager | Dietary Manager | Interviewed regarding food safety, dishwasher sanitation, refrigerator temperatures |
| Staff F Dietary Cook | Dietary Cook | Mentioned in relation to food preparation and dishwasher sanitation |
| Staff G Dietary Aide | Dietary Aide | Mentioned in relation to dishwasher sanitation and temperature monitoring |
| Administrator | Administrator | Interviewed regarding dishwasher sanitation and corrective actions |
Inspection Report
Plan of Correction
Deficiencies: 0
Oct 1, 2024
Visit Reason
The document is a Plan of Correction related to a prior survey ending on August 15, 2024, indicating acceptance of credible allegation of substantial compliance and certification of the facility effective September 13, 2024.
Findings
The facility was found to be in substantial compliance based on the prior survey and plan of correction, leading to certification in compliance.
Report Facts
Survey end date: Aug 15, 2024
Certification effective date: Sep 13, 2024
Inspection Report
Annual Inspection
Census: 47
Deficiencies: 2
Aug 12, 2024
Visit Reason
The inspection was conducted as the facility's annual recertification survey from August 12, 2024 to August 15, 2024.
Findings
The facility was found deficient in ensuring residents' rights related to dignity and proper clothing, as Resident #6 was observed with torn clothing and inadequate personal attire. Additionally, the facility failed to employ a Certified Dietary Manager to oversee food and nutrition services.
Severity Breakdown
SS=D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to ensure a resident's clothing fit properly and was in good repair, compromising personal privacy. | SS=D |
| Failure to employ a Certified Dietary Manager to carry out food and nutrition service functions. | SS=D |
Report Facts
Resident census: 47
Brief Interview for Mental Status (BIMS) score: 5
Dates of Dietary Supervisor schedule: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff F | Certified Medication Aide (CMS) | Interviewed regarding clothing assistance and reporting procedures |
| Staff G | Certified Nursing Assistant (CNA) | Interviewed regarding resident clothing needs and assistance |
| Staff E | Social Services | Acknowledged resident's need for new clothing and donations list |
| Administrator | Provided expectations for staff regarding resident clothing and confirmed dietary manager status | |
| Dietary Supervisor | Interviewed about education and training for Certified Dietary Manager |
Inspection Report
Re-Inspection
Deficiencies: 0
May 8, 2024
Visit Reason
A revisit of the survey ending April 22, 2024 was conducted on May 8, 2024 to verify correction of previous deficiencies.
Findings
All deficiencies were corrected and the facility is in substantial compliance effective May 2, 2024.
Inspection Report
Complaint Investigation
Census: 44
Deficiencies: 2
Apr 22, 2024
Visit Reason
The inspection resulted from investigation of complaints #120002-C and #120037-C, as well as facility self-reports #120049-I and #120094-I, conducted from April 15, 2023 to April 22, 2024. Complaints #120002-C and #120037-C were substantiated.
Findings
The facility failed to ensure residents were appropriately assessed and provided interventions to maintain their optimal health and well-being, specifically for one resident who had bowel issues and complications following a fall and fracture. Additionally, the facility failed to maintain an effective pest control program, with multiple reports and observations of mice infestation.
Complaint Details
Complaints #120002-C and #120037-C were substantiated based on investigation findings.
Severity Breakdown
Level G: 1
Level F: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Quality of care deficiency related to failure to appropriately assess and intervene for residents' health needs, specifically Resident #1's bowel issues and condition. | Level G |
| Failure to maintain an effective pest control program, resulting in ongoing mouse infestation in resident rooms and facility areas. | Level F |
Report Facts
Resident census: 44
Brief Interview for Mental Status (BIMS) score: 14
Brief Interview for Mental Status (BIMS) score: 15
Brief Interview for Mental Status (BIMS) score: 13
Oxygen saturation: 67
Oxygen flow rate: 10
Blood pressure: 80
Blood pressure: 111
Blood pressure: 28
Pulse: 44
Respirations: 26
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Registered Nurse | Wrote progress notes, updated physician, and involved in Resident #1's care and hospital transfer |
| Staff B | Registered Nurse | Interviewed regarding Resident #1's complaints and care; involved in medication and suppository administration |
| Staff C | Licensed Practical Nurse | Administered suppository, removed impaction, and provided care to Resident #1 |
| Staff D | Licensed Practical Nurse | Administered suppository and documented Resident #1's condition |
| Staff E | Certified Nurse Aide | Interviewed about Resident #1's bowel discomfort and care |
| Staff F | Certified Medication Aide | Interviewed about Resident #1's condition and medication administration |
| Staff G | Certified Nurse Aide | Provided care and observations for Resident #1 |
| Staff H | Licensed Practical Nurse | Administered enemas and provided care to Resident #1 |
| Staff I | Registered Nurse | Checked Resident #1's vital signs and administered oxygen |
| Staff J | Certified Nurse Aide | Interviewed about Resident #1's condition and bowel movements |
| Staff K | Certified Medication Aide | Interviewed about medication administration to Resident #1 |
| Staff N | Housekeeper | Reported mouse sightings and pest control issues |
| Staff M | Certified Nurse Aide | Witnessed mouse on resident's lap and reported pest issues |
| Staff O | Housekeeping Supervisor | Reported pest control history and mouse sightings |
Inspection Report
Plan of Correction
Deficiencies: 0
Mar 15, 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 and will be certified in compliance effective March 15, 2024.
Inspection Report
Complaint Investigation
Census: 47
Deficiencies: 19
Feb 19, 2024
Visit Reason
Investigation of complaints #115256-C, #117565-C, 118455-C, facility reported incident #115878-I and mandatory #118383-M conducted from February 12, 2024 to February 19, 2024.
Findings
The facility had multiple deficiencies including failure to honor resident food preferences, failure to notify responsible parties of injuries timely, failure to prevent physical abuse, failure to complete and transmit MDS assessments timely and accurately, failure to revise care plans timely, failure to administer medications properly, failure to provide adequate ADL care, failure to assess wounds and notify providers timely, failure to supervise residents to prevent falls, failure to address significant weight loss, failure to ensure timely physician visits, failure to prevent medication errors, failure to secure medication storage, failure to maintain sanitary food preparation, failure to implement a Legion Water Management Program, and failure to offer required immunizations.
Complaint Details
Complaints #115256-C, #117565-C, and 118455-C were substantiated. Facility reported incident #115878-I was substantiated.
Severity Breakdown
SS=D: 13
SS=E: 3
SS=F: 1
Deficiencies (19)
| Description | Severity |
|---|---|
| Failed to honor a resident's food and beverage preferences during dining services. | — |
| Failed to notify a resident's responsible party and hospice provider in a timely manner when an injury occurred. | SS=D |
| Failed to ensure a resident was free from physical abuse. | SS=D |
| Failed to complete Minimum Data Set (MDS) assessments on time for 3 residents. | SS=D |
| Failed to accurately code the Minimum Data Set (MDS) Assessment for a resident's Level II PASRR. | SS=D |
| Failed to submit a Preadmission Screening and Resident Review (PASRR) related to a new diagnosis for a resident. | SS=D |
| Failed to revise the care plan for residents with significant weight loss and new diagnoses. | SS=D |
| Failed to use professional standards by not cleaning the rubber seal of an insulin pen with an alcohol pad or priming the insulin pen prior to administration. | — |
| Failed to provide incontinence care and nail care for residents as needed. | SS=D |
| Failed to regularly assess a wound and notify the provider of changes, and failed to intervene timely after a critical lab result. | SS=D |
| Failed to ensure resident environment free of accident hazards and failed to supervise a resident in a shower chair resulting in a fall. | SS=D |
| Failed to maintain acceptable nutritional status and offer different food options to encourage adequate nourishment for a resident with significant weight loss. | SS=D |
| Failed to ensure a resident was seen by a physician every 60 days. | SS=D |
| Failed to administer a Risperidone injection when ordered, resulting in behavioral changes. | SS=D |
| Failed to keep medication carts locked when not in use and failed to keep medication storage room keys secured. | SS=D |
| Failed to prepare foods under sanitary conditions including improper glove use and inadequate hand hygiene. | SS=E |
| Failed to implement a Legion Water Management Program including lack of water system mapping, temperature monitoring, and control measures. | SS=F |
| Failed to offer influenza vaccine annually and pneumococcal vaccine at recommended times to residents. | SS=E |
| Failed to offer COVID-19 booster vaccination to residents. | SS=D |
Report Facts
Deficiencies cited: 17
Resident census: 47
Weight loss percentage: 11.58
Risperdal Consta dose: 50
Risperdal Consta injection frequency: 14
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff E | Certified Nursing Assistant | Named in food preference deficiency and ADL care deficiency |
| Staff J | Certified Nursing Assistant | Named in food preference deficiency and ADL care deficiency |
| Director of Nursing | Director of Nursing | Named in multiple findings including notification of changes, abuse prevention, MDS completion, care plan revision, physician visits, medication administration, medication storage, infection control, and immunizations |
| Staff N | Certified Nursing Assistant | Named in abuse deficiency and terminated |
| Staff M | Certified Nursing Assistant | Named in abuse deficiency |
| Staff I | Registered Nurse | Named in notification of changes and ADL care deficiency |
| Staff A | Licensed Practical Nurse | Named in medication administration deficiency |
| Staff P | Registered Nurse | Named in medication administration deficiency |
| Staff B | Registered Nurse | Named in medication storage deficiency |
| Staff F | Dietary Staff | Named in food preparation deficiency |
| Staff G | Dietary Staff | Named in food preparation deficiency |
| Staff H | Dietary Staff | Named in food preparation deficiency |
| Staff Q | Maintenance Staff | Named in infection control deficiency |
| Staff L | Advanced Registered Nurse Practitioner | Named in wound care deficiency |
Inspection Report
Complaint Investigation
Census: 44
Deficiencies: 0
Apr 19, 2023
Visit Reason
A COVID-19 Focused Infection Control Survey and investigation of complaints #110905-C, #110240-C, and #103029-C was conducted by the Department of Inspection and Appeals from April 17, 2023 to April 19, 2023.
Findings
The facility was found to be in compliance with CMS and CDC recommended practices to prepare for COVID-19 and was found to be in substantial compliance.
Complaint Details
Investigation involved complaints #110905-C, #110240-C, and #103029-C; facility found in substantial compliance.
Report Facts
Total Residents: 44
Inspection Report
Plan of Correction
Deficiencies: 0
Oct 14, 2022
Visit Reason
The document reports on the acceptance of the facility's credible allegation of compliance and plan of correction following a survey and investigation ending August 11, 2022.
Findings
The facility was certified in compliance effective October 14, 2022, based on acceptance of the plan of correction and credible allegation of compliance.
Inspection Report
Annual Inspection
Census: 42
Deficiencies: 7
Aug 11, 2022
Visit Reason
The inspection was conducted as part of the facility's annual recertification and investigation of multiple complaints (#97763-C, #97864-C, #102024-C, #102277-C, #102278-C, and #103628).
Findings
The facility was found to have deficiencies related to notification of changes, freedom from abuse, neglect and exploitation, investigation of abuse, labeling and storage of drugs and biologicals, quality assessment and assurance, infection prevention and control, and safe/functional/sanitary environment. One complaint (#102024-C) was substantiated. The facility failed to ensure proper notification to resident representatives, failed to prevent resident-to-resident abuse, failed to properly label and store medications, and failed to maintain a safe environment including issues with the emergency exit door.
Complaint Details
Complaint #102024-C was substantiated. Complaints #97763-C, #97864-C, #102277-C, #102278-C, and #103628-C were not substantiated.
Deficiencies (7)
| Description |
|---|
| Failure to notify resident representative of change in condition. |
| Failure to ensure resident freedom from abuse, neglect, and exploitation. |
| Failure to investigate and report allegations of abuse thoroughly. |
| Failure to properly label and store drugs and biologicals, including expired medication vials. |
| Failure of Quality Assessment and Assurance committee to meet and maintain required membership. |
| Failure to maintain an effective infection prevention and control program, including improper medication administration hygiene. |
| Failure to maintain a safe, functional, sanitary, and comfortable environment; emergency exit door was bent and panic bar did not latch properly. |
Report Facts
Facility census: 42
Medication administration observation: 5
Date of survey completion: Aug 11, 2022
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Sarah Flattery | Administrator | Signed the Plan of Correction. |
Inspection Report
Abbreviated Survey
Census: 42
Deficiencies: 0
Dec 23, 2020
Visit Reason
A Focused Infection Control Survey was conducted by the Department of Inspection and Appeals on December 22 - 23, 2020 to assess compliance with CMS and CDC recommended practices for COVID-19.
Findings
The facility was found to be in compliance with CMS and CDC recommended practices for COVID-19 during the focused infection control survey.
Inspection Report
Abbreviated Survey
Census: 46
Deficiencies: 1
Nov 23, 2020
Visit Reason
The inspection was a Focused Infection Control Survey conducted by the Department of Inspection and Appeals on November 22-23, 2020, to evaluate the facility's infection prevention and control protocols related to COVID-19.
Findings
The facility failed to develop and implement effective infection prevention and control protocols, including an effective screening process to mitigate COVID-19 risk. Observations, record reviews, and staff interviews revealed multiple staff members tested positive for COVID-19 and inadequate screening procedures were in place.
Deficiencies (1)
| Description |
|---|
| Failure to develop and implement infection prevention and control protocols including effective screening to mitigate COVID-19 risk. |
Report Facts
Census: 46
Staff Screening Entries: 73
Staff Positive COVID Tests: 9
Screening Entries with 1 Symptom: 1
Screening Entries with 2 Symptoms: 90
Screening Entries with 3 or More Symptoms: 24
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Sarah Flattery | Administrator | Signed the Plan of Correction and mentioned as Administrator in corrective actions |
| Staff B | Licensed Practical Nurse | Interviewed regarding staff screening and temperature checks |
| Staff C | Nurse Aide | Interviewed regarding staff screening and temperature checks |
| Staff D | Nurse Aide | Interviewed regarding staff screening and temperature checks |
| Staff E | Nurse Aide | Interviewed regarding staff screening and temperature checks; tested positive for COVID-19 |
| Director of Nursing | Director of Nursing | Interviewed about staff screening responsibilities and expectations |
Inspection Report
Complaint Investigation
Census: 53
Deficiencies: 2
Jul 2, 2020
Visit Reason
The inspection was conducted to investigate complaints #90388 and #91735 regarding the facility's compliance with resident hydration and food safety requirements.
Findings
The facility was found to have failed to ensure residents had adequate access to fresh ice water and failed to serve drinks according to professional food safety standards during certain times. Complaint #90388 was substantiated, while complaint #91735 was not substantiated.
Complaint Details
Complaint #90388-C was substantiated. Complaint #91735-C was not substantiated.
Severity Breakdown
SS=E: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Facility failed to ensure residents were provided access to fresh ice water to meet their needs and preferences. | SS=E |
| Facility failed to serve drinks in accordance with professional standards for food service safety during evening snack and drink pass. | SS=E |
Report Facts
Resident census: 53
Pitchers on cart: 26
Deficiencies cited: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Sarah Flattery | Administrator | Signed the report and plan of correction |
Inspection Report
Routine
Census: 54
Deficiencies: 0
Jun 23, 2020
Visit Reason
A COVID-19 Focused Infection Control survey was conducted to assess the facility's compliance with CMS and CDC recommended practices for COVID-19 preparation.
Findings
The facility was found to be in substantial compliance with 42 CFR 483 subpart B and CDC recommended practices to prepare for COVID-19.
Report Facts
Sample Size: 5
Inspection Report
Annual Inspection
Census: 56
Deficiencies: 12
Jan 23, 2020
Visit Reason
The inspection was conducted as part of the annual survey and investigation of complaints #87084-C, #87542-C, #88187-C, and #88357.
Findings
The facility was found to have multiple deficiencies related to personal privacy/confidentiality of records, transfer and discharge requirements, accuracy of assessments, development and implementation of comprehensive care plans, services meeting professional standards, infection prevention and control, smoking policies, and medication management. Several residents' care plans and documentation were incomplete or inaccurate, and the facility failed to ensure privacy and proper handling of residents' medical information.
Complaint Details
Complaint #86382 was not substantiated. The inspection also investigated complaints #87084-C, #87542-C, #88187-C, and #88357.
Deficiencies (12)
| Description |
|---|
| Failed to provide privacy for 1 of 5 sampled residents during care areas. |
| Failed to complete appropriate documentation on discharge for 1 of 2 sampled residents. |
| Assessment failed to accurately reflect resident status for 1 of 1 sampled resident. |
| Failed to develop and implement comprehensive person-centered care plans for 4 of 19 sampled residents. |
| Failed to revise care plans to reflect current needs for 2 of 19 sampled residents. |
| Failed to meet professional standards for services provided including medication management and nursing care. |
| Failed to provide adequate infection prevention and control program. |
| Failed to obtain nurse aide registry verification prior to employment for 2 of 4 files reviewed. |
| Failed to maintain accurate pharmacy records and medication storage. |
| Failed to provide frequency of meals/snacks at bedtime for 1 of 19 sampled residents. |
| Failed to maintain smoking policies and assessments for 1 of 3 sampled residents. |
| Failed to prevent pressure ulcers and provide adequate wound care for multiple residents. |
Report Facts
Census: 56
Number of sampled residents for privacy deficiency: 1
Number of sampled residents for discharge documentation deficiency: 1
Number of sampled residents for care plan deficiencies: 4
Number of sampled residents for care plan revision deficiency: 2
Number of sampled residents for nurse aide registry verification deficiency: 2
Number of sampled residents for medication storage deficiency: 7
Number of sampled residents for smoking policy deficiency: 1
Number of sampled residents for meal/snack frequency deficiency: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Sarah Flattery | Administrator | Signed the report and mentioned in plan of correction. |
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