Deficiencies per Year
16
12
8
4
0
Severe
High
Moderate
Low
Unclassified
Census Over Time
Census
Capacity
Inspection Report
Plan of Correction
Deficiencies: 1
Oct 30, 2025
Visit Reason
A revisit of the survey ending October 2, 2025 was conducted on October 30, 2025 to verify correction of previous deficiencies.
Findings
All deficiencies were corrected and the facility is in substantial compliance effective October 27, 2025.
Deficiencies (1)
| Description |
|---|
| Initial comments regarding correction of deficiencies from prior survey |
Report Facts
Survey completion date: Oct 30, 2025
Inspection Report
Annual Inspection
Census: 55
Deficiencies: 5
Oct 2, 2025
Visit Reason
The inspection was conducted as part of the facility's annual recertification survey and investigation of multiple complaints and facility reported incidents from September 29, 2025 to October 2, 2025.
Findings
The survey identified deficiencies related to abuse prevention, dialysis care, food safety, quality assurance and performance improvement (QAPI), infection prevention and control, and enhanced barrier precautions. Specific incidents included physical abuse resulting in fractures to a resident, failure to properly assess and monitor dialysis sites, food safety violations, and lapses in infection control practices.
Complaint Details
The visit included investigation of complaints #2611087-C, #2620974-C, #2620897-A, and facility reported incidents #2626150-I, #2620953-M. Complaint #262087-A and incident #262093-M resulted in deficiencies.
Severity Breakdown
G: 1
F: 3
D: 2
Deficiencies (5)
| Description | Severity |
|---|---|
| Failure to provide a safe environment free from abuse and neglect resulting in physical harm to a resident. | G |
| Failure to complete dialysis site assessments and monitor for bleeding or bruising for a resident receiving dialysis. | D |
| Failure to store food properly and maintain sanitary food service practices. | F |
| Failure to maintain an effective Quality Assurance and Performance Improvement (QAPI) program. | F |
| Failure to establish and maintain an infection prevention and control program including proper use of enhanced barrier precautions. | D |
Report Facts
Census: 55
Resident number: 64
Resident number: 11
Resident number: 2
Dates: 09/29/2025 to 10/02/2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff Q | Certified Nursing Assistant (CNA) | Named in abuse and neglect deficiency related to resident #64. |
| Staff L | Certified Nurse Aide (CNA) | Interviewed regarding abuse incident involving resident #64. |
| Staff P | Licensed Practical Nurse (LPN) | Reported on abuse incident involving resident #64. |
| Staff N | Registered Nurse (RN) | Involved in abuse incident investigation and dialysis care deficiency. |
| Director of Nursing | Provided statements regarding abuse incident and dialysis care. | |
| Staff K | Registered Nurse (RN) | Observed performing tube feeding and infection control deficiency. |
| Staff F | Executive Chef | Named in food safety deficiency. |
| Staff H | Dietary Aide | Named in food safety deficiency. |
Inspection Report
Plan of Correction
Deficiencies: 0
Apr 21, 2025
Visit Reason
The document serves as a Plan of Correction following a survey ending on March 19, 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, leading to certification effective April 18, 2025.
Inspection Report
Complaint Investigation
Census: 61
Deficiencies: 1
Mar 19, 2025
Visit Reason
The inspection was conducted as an investigation of complaints #125842-C, #125907-C, #126150-C and facility reported incidents #126270-I and #126834-M from March 10, 2025 to March 19, 2025.
Findings
The facility was found to have failed to ensure staff assisted 3 of 6 residents to eat in a dignified manner during meal service, violating resident rights to dignity and respect. Specific observations showed staff standing over residents while feeding and residents left unattended during meals. Resident #8, a long-term hospice resident, expired on 4/3/25.
Complaint Details
Complaint #125907-C was substantiated. Findings for facility reported incident #126834-M will be sent under separate cover.
Deficiencies (1)
| Description |
|---|
| Failure to ensure staff assisted residents to eat in a dignified manner, including standing over residents and leaving them unattended during meals. |
Report Facts
Resident census: 61
Residents assisted improperly: 3
Audit frequency: 5
Audit frequency: 3
Audit frequency: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Certified Nursing Assistant (CNA) | Observed feeding Resident #5 and then walking away |
| Staff D | Certified Nursing Assistant (CNA) | Observed feeding Resident #5 and then walking away |
| Staff C | Certified Nursing Assistant (CNA) | Observed feeding Resident #5 with a spoon and repositioning Resident #6 |
| Director of Nursing | Interviewed and stated expectations for staff interaction during meals |
Inspection Report
Re-Inspection
Deficiencies: 0
Oct 30, 2024
Visit Reason
A revisit of the survey ending September 26, 2024 was conducted on October 30, 2024 to verify correction of previous deficiencies.
Findings
All deficiencies were corrected and the facility is in substantial compliance effective October 24, 2024.
Inspection Report
Annual Inspection
Census: 51
Deficiencies: 13
Sep 26, 2024
Visit Reason
The inspection was an annual recertification survey conducted from September 23, 2024 to September 26, 2024 to assess compliance with federal regulations for nursing facilities.
Findings
The facility was found to have multiple deficiencies related to resident rights, comprehensive assessments, care planning, drug regimen, quality of care, infection control, and quality assurance. Several residents' care plans and assessments were incomplete or not timely, and there were issues with medication administration and infection prevention practices.
Severity Breakdown
J: 13
Deficiencies (13)
| Description | Severity |
|---|---|
| Resident #5 was not treated with dignity and respect during care and transport. | J |
| Failure to ensure timely completion of comprehensive resident assessments. | J |
| Failure to ensure timely completion of quarterly Minimum Data Set (MDS) assessments. | J |
| Failure to ensure timely submission and accuracy of resident assessments. | J |
| Failure to complete baseline care plans within 48 hours of admission for residents. | J |
| Failure to revise care plans timely following changes in resident condition. | J |
| Failure to maintain drug regimen free from unnecessary drugs; specifically warfarin administration errors leading to immediate jeopardy. | J |
| Failure to serve food at safe and appetizing temperatures. | J |
| Failure to maintain an effective Quality Assurance Performance Improvement (QAPI) program. | J |
| Failure to maintain an effective Quality Assessment and Assurance (QAA) committee. | J |
| Failure to establish and maintain an infection prevention and control program. | J |
| Failure to follow isolation precautions and use appropriate personal protective equipment (PPE) for residents with COVID-19. | J |
| Failure to provide proper wound care and change gloves appropriately during dressing changes. | J |
Report Facts
Census: 51
Deficiencies cited: 13
INR values: 9.3
INR values: 7.8
Food temperature: 148.4
Food temperature: 153.6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Brent R. Fullmore | Administrator | Signed the initial comments and plan of correction on 10/24/24. |
| Staff A | Certified Nursing Assistant (CNA) | Involved in assisting Resident #5 in a Broda chair during observation. |
| Staff O | Certified Nursing Assistant (CNA) | Interviewed regarding proper use of Broda chair and resident transport. |
| Assistant Director of Nursing (ADON) | Interviewed about resident transport and care plan revisions. | |
| Staff J | Registered Nurse (RN) | Interviewed about care planning and baseline care plan completion. |
| Director of Nursing (DON) | Interviewed about care plan revisions, hospice notifications, and medication administration. | |
| Staff F | Registered Nurse (RN) | Interviewed about resident care, tracheostomy care, and medication administration. |
| Staff B | Cook | Interviewed about food temperature and food handling practices. |
| Staff C | Licensed Practical Nurse (LPN) | Observed wearing PPE and interviewed about infection control practices. |
| Staff D | Certified Nursing Aide (CNA) | Observed wearing PPE and interviewed about infection control practices. |
| Staff H | Physical Therapist Assistant | Observed entering resident room without goggles. |
| Staff K | Medical Assistant | Interviewed about anticoagulation clinic and medication administration. |
| Staff L | Former Director of Nursing (DON) | Interviewed about computer access and medication order entry. |
| Staff M | Licensed Practical Nurse (LPN) | Interviewed about medication order entry and clinic procedures. |
| Staff N | Hospice Case Manager | Interviewed about hospice notifications and resident hospitalizations. |
| Staff G | Licensed Practical Nurse (LPN) | Interviewed about wound care and isolation gown use. |
Inspection Report
Re-Inspection
Deficiencies: 0
Sep 4, 2024
Visit Reason
A revisit of the survey ending August 8, 2024 was conducted to verify correction of previous deficiencies.
Findings
All deficiencies were corrected and the facility is in substantial compliance effective September 1, 2024.
Inspection Report
Complaint Investigation
Census: 51
Deficiencies: 3
Aug 8, 2024
Visit Reason
The inspection was conducted as a result of investigation of complaint #120656-C and facility reported incidents #120284-I and #122242-I from July 31, 2024 to August 8, 2024.
Findings
The facility failed to identify and respond timely to an elopement incident involving a resident, resulting in injury. Deficiencies were found related to supervision, accident hazards, and catheter care, including failure to provide appropriate urinary catheter care and medication administration errors.
Complaint Details
Complaint #120656-C and Facility reported incident #122242-I were substantiated; Facility reported incident #120284 was not substantiated.
Deficiencies (3)
| Description |
|---|
| Facility failed to identify and respond to an elopement in a timely manner, resulting in resident injury. |
| Facility failed to provide appropriate urinary catheter care and follow infection control practices for residents with catheters. |
| Facility failed to ensure residents received medications as ordered, resulting in a resident transfer to hospital. |
Report Facts
Census: 51
Dates of complaint investigation: Investigation conducted from July 31, 2024 to August 8, 2024
Correction dates: Correction dates noted for deficiencies: 8/20/2024 for F689, 9/1/2024 for F690 and F755
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Brent R. Fillmore | Administrator | Signed the report and plan of correction |
| Staff C | Registered Nurse (RN) | Involved in resident search and assessment during elopement incident |
| Staff D | Certified Nursing Assistant (CNA) | Reported observations during night shift and resident search |
| Staff E | Licensed Practical Nurse (LPN) | Reported observations during night shift and resident search |
| Staff G | Licensed Practical Nurse (LPN) | Reported observations during night shift and resident search |
| Staff H | Support Services Coordinator | Checked door alarms and reported issues |
| Director of Nursing (DON) | Provided statements regarding staff education and incident response |
Inspection Report
Plan of Correction
Deficiencies: 0
Feb 3, 2024
Visit Reason
The document certifies the facility in compliance based on acceptance of a credible allegation of substantial compliance and Plan of Correction.
Findings
The facility was found to be in substantial compliance, leading to certification effective February 3, 2024. No specific deficiencies are detailed in this report.
Inspection Report
Annual Inspection
Census: 50
Deficiencies: 15
Jan 3, 2024
Visit Reason
The inspection was conducted as part of the facility's Annual Recertification Survey and investigation of multiple complaints.
Findings
The facility was found deficient in multiple areas including resident rights, abuse/neglect policies, accuracy of assessments, PASRR coordination, care plan timing and revision, professional standards of services provided, ADL care, accident and incident management, catheter care, bed rails, nursing staff competency, psychotropic medication use, dental services, food procurement and sanitary practices, and infection control.
Complaint Details
Complaints #112797-C, #115036-C, #116986-C, #117394-C, #117420-C and #117651-C were substantiated.
Deficiencies (15)
| Description |
|---|
| Resident Rights/Exercise of Rights - Facility failed to treat residents with dignity and respect, including referring to residents as 'feeders'. |
| Develop/Implement Abuse/Neglect Policies - Facility failed to ensure all newly hired nurses completed mandatory reporter abuse training within required timeframe. |
| Accuracy of Assessments - Facility failed to ensure accurate coding on Minimum Data Set (MDS) assessments for residents. |
| Coordination of PASRR and Assessments - Facility failed to properly identify and update care plans for residents requiring PASRR Level II assessments. |
| Care Plan Timing and Revision - Facility failed to update care plans timely to reflect residents' current needs. |
| Services Provided Meet Professional Standards - Facility failed to administer insulin and medications according to physician orders and manufacturer guidelines. |
| ADL Care Provided for Dependent Residents - Facility failed to consistently assist residents with activities of daily living including dining and perineal care. |
| Accidents and Incidents - Facility failed to implement appropriate fall interventions and staff failed to follow safe transfer practices. |
| Bowel/Bladder Incontinence, Catheter, UTI - Facility failed to ensure proper placement of urinary catheter tubing and bags. |
| Bed Rails - Facility failed to properly assess, obtain consents, and document physician orders for bed rails. |
| Competent Nursing Staff - Facility failed to ensure all nursing staff had current licensure prior to employment. |
| Free from Unnecessary Psychotropic Meds/PRN Use - Facility failed to properly review and document gradual dose reductions for psychotropic medications. |
| Dental Services - Facility failed to assist residents in obtaining routine and emergency dental care. |
| Food Procurement, Store/Prepare/Serve-Sanitary - Facility failed to ensure dietary staff wore hair nets properly and followed hygiene practices. |
| Infection Control/Infection Prevention - Facility failed to implement proper infection control practices including C-diff precautions and legionella testing. |
Report Facts
Census: 50
Deficiencies cited: 15
Dates of complaint investigations: Complaints investigated between December 11, 2023 and January 3, 2024.
Correction Date: Correction date set for February 3, 2024.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff Q | Re-educated about not referring to residents as 'feeders' and dignity policy. | |
| Staff M | Nurse | Failed to complete mandatory reporter abuse training within required timeframe. |
| Staff C | Re-educated on insulin pen administration per manufacturer guidelines. | |
| Staff D | Re-educated on medication crushing and pantoprazole administration. | |
| Staff B | Re-educated regarding ADL performance including perineal care and dining assistance. | |
| Staff P | Re-educated on C-diff precautions and infection control practices. | |
| Staff L | Registered Nurse | Reviewed for current licensure and re-educated on new hire process. |
| Staff F | Educated regarding safe wheelchair pushing and fall prevention. | |
| Staff A | Re-educated regarding hair net use and hygiene practices. | |
| Staff R | Re-educated regarding hair net use and hygiene practices. | |
| Staff O | Re-educated on C-diff precautions and infection control practices. | |
| Staff J | Re-educated on C-diff precautions and infection control practices. |
Inspection Report
Complaint Investigation
Census: 47
Deficiencies: 0
May 4, 2023
Visit Reason
A COVID-19 Focused Infection Control Survey and an investigation of Complaints #107815-C and #109512-C were conducted by the Department of Inspection and Appeals from April 27, 2023 to May 4, 2023.
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 and in overall substantial compliance.
Complaint Details
Investigation of Complaints #107815-C and #109512-C was conducted; the facility was found in compliance.
Report Facts
Total Residents: 47
Inspection Report
Complaint Investigation
Census: 41
Capacity: 41
Deficiencies: 9
Oct 11, 2022
Visit Reason
The inspection was conducted as a complaint investigation related to allegations of neglect and abuse, including failure to respond to call lights, inadequate care for residents with cognitive impairments, and failure to notify families of COVID-19 positive cases.
Findings
The facility was found to have multiple deficiencies including failure to provide timely assistance to residents, inadequate supervision and care, failure to notify families of significant changes and COVID-19 positive cases, and insufficient nursing staff to meet residents' needs. Several residents experienced neglect, and the facility failed to follow proper abuse prevention and reporting policies.
Complaint Details
The complaint investigation was substantiated. Allegations included neglect, failure to respond to call lights, failure to notify families of COVID-19 positive residents, and abuse. The facility failed to adequately investigate and prevent abuse and failed to notify appropriate parties. The facility was found to have a census of 41 residents at the time of the investigation.
Deficiencies (9)
| Description |
|---|
| Failure to treat each resident with dignity and respect, including failure to respond promptly to call lights and provide assistance. |
| Failure to notify resident representatives of significant changes and positive COVID-19 test results. |
| Failure to investigate and prevent abuse, including failure to separate alleged abuser and victim and failure to report to appropriate authorities. |
| Failure to provide adequate care and supervision to residents with cognitive impairments, including failure to prevent falls and ensure proper nutrition and hydration. |
| Failure to maintain a safe, clean, and comfortable environment for residents. |
| Failure to provide sufficient nursing staff to meet the needs of residents. |
| Failure to meet professional standards of care, including medication administration and pain management. |
| Failure to provide adequate nutrition and maintain appropriate food temperatures. |
| Failure to conduct COVID-19 testing and notify residents and families in a timely manner. |
Report Facts
Census: 41
Total Capacity: 41
Deficiencies cited: 9
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff S | Certified Nursing Assistant (CNA) | Named in findings related to failure to respond to call lights and resident assistance |
| Staff BB | Licensed Practical Nurse (LPN) | Named in abuse investigation and re-education on abuse policy |
| Staff Z | Licensed Practical Nurse (LPN) | Named in abuse investigation and re-education on abuse policy |
| Director of Nursing (DON) | Director of Nursing | Named in interviews regarding abuse investigation and facility policies |
| Staff F | Certified Nursing Assistant (CNA) | Named in observations and interviews related to resident care and call light response |
| Staff T | Licensed Practical Nurse (LPN) | Named in medication administration and resident care findings |
| Staff Q | Licensed Practical Nurse (LPN) | Named in medication administration and resident care findings |
| Staff AA | Registered Nurse (RN) | Named in staffing and medication administration findings |
| Staff X | Registered Nurse (RN) | Named in medication administration and resident care findings |
Inspection Report
Plan of Correction
Deficiencies: 0
Oct 1, 2022
Visit Reason
The document serves as a plan of correction following a prior inspection, indicating acceptance of the facility's credible allegation of compliance.
Findings
The facility was certified in compliance effective October 1, 2022, based on acceptance of the credible allegation of compliance and plan of correction.
Inspection Report
Plan of Correction
Deficiencies: 0
May 14, 2022
Visit Reason
The document reflects acceptance of a credible allegation of compliance and plan of correction for the facility.
Findings
The facility was certified in compliance effective May 14, 2022, based on acceptance of the plan of correction. No specific deficiencies or severity levels are detailed in the report.
Inspection Report
Annual Inspection
Census: 43
Deficiencies: 7
Apr 11, 2022
Visit Reason
The inspection was conducted as part of the facility's Annual Recertification Survey and an investigation of Complaint #98114-C, along with review of Facility Self-Reported Incidents #100443-I, #101007-I, and #102076-I.
Findings
The facility was found to have multiple deficiencies including failure to treat residents with dignity, failure to provide choice of meal options, failure to provide appropriate notice of bed hold policy, failure to timely encode and transmit resident assessments, failure to develop comprehensive care plans timely, failure to ensure adequate food and hydration services, and failure to maintain food safety and sanitation standards. Some complaints were substantiated and corrective actions were taken.
Complaint Details
Complaint #98114-C was substantiated. Facility Self-Reported Incidents #101007-I and #102076-I were substantiated.
Deficiencies (7)
| Description |
|---|
| Facility failed to treat a resident with dignity by telling her she would be charged $10 each time she used the call light. |
| Facility failed to provide choice of meal options on the Menu Slips for 3 residents reviewed. |
| Facility failed to provide appropriate notice of bed hold policy before transfer for one resident. |
| Facility failed to encode and transmit Minimum Data Set (MDS) Assessments within required timeframes for 5 residents sampled. |
| Facility failed to develop comprehensive care plan within 7 days after assessment for one resident. |
| Facility failed to ensure each resident received adequate drinks including thickened liquids and failed to provide no straw for a resident requiring it. |
| Facility failed to procure, prepare, and store food from approved or satisfactory sources; food safety violations including expired and improperly stored food items. |
Report Facts
Census: 43
Residents reviewed: 14
Residents reviewed: 5
Residents reviewed: 3
Residents reviewed: 1
Residents reviewed: 1
Residents reviewed: 7
Food items: 9
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff L | Certified Nurse Aide (CNA) | Named in dignity violation for charging resident $10 for call light use |
| Staff M | Certified Nurse Aide (CNA) | Reported Staff L's statement about charging resident for call light |
| Administrator | Administrator | Reported Staff L no longer worked at the facility and stated expectation of dignity and respect |
| Mrs. Dash | Dietary staff | Responsible for meal options and resident meal trays |
| Staff D | Dietary Server | Reported issues with meal tickets and food service |
| Staff J | Certified Nurse Assistant (CNA) | Reported issues with menu slips and food service |
| Staff K | Licensed Practical Nurse (LPN) | Reported responsibility for delivering menus to residents |
| DON | Director of Nursing | Re-educated staff on bed hold policy and meal service |
| Staff C | Licensed Practical Nurse/Administration Nurse | Reported inability to find bed hold notice for resident |
| Assistant Director of Nursing (ADON) | Assistant Director of Nursing | Reported on menu slip process and care plan policy |
| Staff A | Registered Nurse (RN) | Observed administering medications and thickened liquids |
| Staff E | Dietary Cook | Failed to properly wash and sanitize food preparation equipment |
| Staff F | Dietary Cook | Failed to properly wash and sanitize food preparation equipment |
| Staff G | Certified Nursing Assistant (CNA) | Returned pudding to kitchen and reported resident could not drink cranberry juice |
| Staff I | Dietary Staff | Re-educated on cleaning dishes and fan removal |
| Staff T | Certified Nursing Assistant (CNA) | Returned pudding to kitchen and reported resident could not drink cranberry juice |
| Culinary Manager | Culinary Manager | Reported training on food temperatures and food safety |
| Registered Dietitian Consultant | Registered Dietitian Consultant | Re-educated on proper storage of thick-it scoop and handling items |
Inspection Report
Complaint Investigation
Deficiencies: 0
Mar 10, 2021
Visit Reason
An investigation of Complaint #89214 and a Mandatory #92394 was conducted from 3/8/21 to 3/10/21.
Findings
The Complaint #89214 was not substantiated according to the Code of Federal Regulations (42CFR) Part 483, Subpart B-C.
Complaint Details
Complaint #89214 was investigated and found not substantiated.
Report Facts
Complaint number: 89214
Mandatory number: 92394
Inspection Report
Abbreviated Survey
Census: 52
Deficiencies: 0
Jan 6, 2021
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the Department of Inspection and Appeals on 1/6/21 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.
Inspection Report
Routine
Census: 61
Deficiencies: 0
Aug 25, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the Department of Inspections and Appeals on 8/24/20 - 8/25/20 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: 65
Deficiencies: 0
May 21, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the Centers for Medicare & Medicaid Services (CMS) to assess compliance with CMS and CDC recommended practices to prepare for COVID-19.
Findings
The facility was found to be in compliance with CMS and CDC recommended practices for COVID-19 infection control.
Inspection Report
Complaint Investigation
Deficiencies: 0
Jan 21, 2020
Visit Reason
The visit was conducted to investigate a self-reported incident #87641 and complaint #87439 during the period 1/15/20 to 1/21/20.
Findings
The investigation found that the self-reported incident and complaint were not substantiated.
Complaint Details
The facility's Self-Reported Incident #87641 and Complaint #87439, investigated 1/15/20-1/21/20, were not substantiated.
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