Deficiencies per Year
8
6
4
2
0
Severe
High
Moderate
Low
Unclassified
Census Over Time
Inspection Report
Complaint Investigation
Deficiencies: 0
Oct 22, 2025
Visit Reason
A complaint investigation was conducted for facility reported incident #2604169-I from October 20, 2025 to October 22, 2025.
Findings
The facility was found to be in substantial compliance with no deficiencies cited.
Complaint Details
Complaint investigation for incident #2604169-I; facility found in substantial compliance.
Inspection Report
Plan of Correction
Deficiencies: 0
Sep 29, 2025
Visit Reason
The document is a plan of correction submitted following a survey ending August 25, 2025, indicating acceptance of credible allegation of substantial compliance.
Findings
The facility was certified in compliance effective September 17, 2025, based on acceptance of the plan of correction and substantial compliance. No specific deficiencies are detailed in this document.
Inspection Report
Annual Inspection
Census: 34
Deficiencies: 3
Aug 25, 2025
Visit Reason
The inspection was conducted as part of the facility's annual recertification survey and investigation of complaints #1802558-A and #1802590-C from August 18 to August 25, 2025.
Findings
The facility was found to have deficiencies related to resident rights and notification of changes, including failure to empty bedside commodes in a dignified manner and failure to notify family members timely about significant changes in residents' conditions. The facility reported a census of 34 residents during the survey.
Complaint Details
Complaint #1802590-C resulted in a deficiency. Complaint #1802558-A findings will be sent separately.
Severity Breakdown
D: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Failure to care for a resident in a dignified manner by not emptying the bedside commode after use. | D |
| Failure to notify family members prior to chest x-ray and after hospitalization for two residents. | D |
| Failure to provide timely notification of resident discharge/readmission status to the Long Term Care Ombudsman for 3 residents. | D |
Report Facts
Census: 34
Deficiencies cited: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Certified Nurse Aide (CNA) | Interviewed regarding bedside commode use and emptying |
| Staff B | Certified Nurse Aide (CNA) | Interviewed regarding bedside commode awareness and emptying |
| Staff C | Certified Nurse Aide (CNA) | Interviewed regarding bedside commode emptying frequency |
| Staff D | Certified Nurse Aide (CNA) | Interviewed regarding bedside commode cleaning and emptying |
| Staff E | Licensed Practical Nurse (LPN) | Interviewed regarding family notifications for Resident #18 |
| Staff F | Licensed Practical Nurse (LPN) | Interviewed regarding family notifications and hospital discharge orders |
| Staff G | Registered Nurse (RN) | Interviewed regarding resident assessments and admissions |
| Director of Nursing | Director of Nursing | Interviewed regarding family notifications and oversight of audits |
| Administrator | Administrator | Interviewed regarding family notifications and oversight of facility policies |
Inspection Report
Complaint Investigation
Deficiencies: 0
Apr 1, 2025
Visit Reason
A complaint investigation for complaint #127412-C and facility reported incident #127251-I was conducted from March 31, 2025 to April 1, 2025.
Findings
The facility was found to be in substantial compliance.
Complaint Details
Investigation was related to complaint #127412-C and facility incident #127251-I; facility found in substantial compliance.
Inspection Report
Plan of Correction
Deficiencies: 0
Sep 30, 2024
Visit Reason
The document is a plan of correction following a survey ending on August 29, 2024, indicating acceptance of credible allegation of substantial compliance.
Findings
The facility was found to be in substantial compliance based on the credible allegation and plan of correction submitted, leading to certification effective September 29, 2024.
Report Facts
Survey end date: Aug 29, 2024
Certification effective date: Sep 29, 2024
Inspection Report
Annual Inspection
Census: 32
Deficiencies: 6
Aug 29, 2024
Visit Reason
The inspection was an annual recertification survey conducted from August 26, 2024 to August 29, 2024, to determine compliance with State licensure and Federal participation requirements for long-term care facilities participating in Medicare and/or Medicaid programs.
Findings
The facility was found deficient in several areas including resident self-administration of medications, care plan timing and revision, sufficient nursing staff response to call lights, use of psychotropic medications, and influenza and pneumococcal immunizations. The facility reported a census of 32 residents and failed to ensure safe medication self-administration, timely care plan updates, prompt call light responses, proper documentation and use of psychotropic drugs, and adequate vaccination policies and procedures.
Severity Breakdown
SS=D: 6
Deficiencies (6)
| Description | Severity |
|---|---|
| Facility failed to ensure only residents able to safely self-administer medications had access to medications for 1 of 5 residents reviewed. | SS=D |
| Facility failed to develop and revise comprehensive care plans within required timeframes and include all resident care needs for 1 of 5 residents reviewed. | SS=D |
| Facility failed to respond to call lights in a timely manner for 1 of 2 residents reviewed. | SS=D |
| Facility failed to document non-pharmacological interventions prior to administration of PRN psychotropic medications for 1 of 1 residents reviewed. | SS=D |
| Facility failed to offer pneumococcal vaccine at recommended times for 2 of 5 residents reviewed. | SS=D |
| Facility failed to ensure influenza immunization education and offer to residents or representatives. | SS=D |
Report Facts
Residents reviewed for medication self-administration: 5
Residents reviewed for care plan timing: 5
Residents reviewed for call light response: 2
Residents reviewed for psychotropic medication documentation: 1
Residents reviewed for pneumococcal vaccination: 5
Facility census: 32
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Alice Byrd | Administrator | Signed the report and involved in statements regarding medication administration and call light policy |
Inspection Report
Plan of Correction
Deficiencies: 0
May 2, 2024
Visit Reason
The document serves as a statement of deficiencies and plan of correction following a survey completed on May 2, 2024.
Findings
The facility was found to be in substantial compliance based on a credible allegation and plan of correction, resulting in certification effective April 19, 2024.
Inspection Report
Complaint Investigation
Census: 30
Deficiencies: 2
Apr 2, 2024
Visit Reason
The inspection was conducted as a result of complaints #119756-C and #119758-C and a facility reported incident #119769-I, with the investigation period from March 28, 2024 to April 2, 2024.
Findings
The facility was found deficient in quality of care and free of accident hazards/supervision. Specifically, the facility failed to complete neuro assessments after an unwitnessed fall of a resident, and failed to ensure adequate supervision resulting in a fall. Complaints and the incident were substantiated.
Complaint Details
Complaints #119756-C and #119758-C were substantiated. Facility reported incident #119769-I was substantiated.
Deficiencies (2)
| Description |
|---|
| Failure to complete neuro assessments after an unwitnessed fall for one resident. |
| Failure to ensure adequate supervision of a resident in a wheelchair, resulting in a fall. |
Report Facts
Census: 30
Dates of investigation: Investigation conducted from 2024-03-28 to 2024-04-02
Inspection Report
Plan of Correction
Deficiencies: 0
Feb 21, 2024
Visit Reason
The document is a Plan of Correction submitted following a survey, indicating acceptance of credible allegation of substantial compliance and certification of the facility.
Findings
The facility was found to be in substantial compliance based on the credible allegation and Plan of Correction, resulting in certification effective February 16, 2024.
Inspection Report
Annual Inspection
Census: 35
Deficiencies: 5
Jan 22, 2024
Visit Reason
The inspection was conducted as the facility's annual recertification survey and investigation of facility-reported incidents #115917-I and #117712-I from January 22, 2024 to January 25, 2024 to determine compliance with State licensure and Federal participation requirements for long-term care facilities.
Findings
The facility was found to have multiple deficiencies including failure to obtain timely physician orders for advance directives, failure to provide correct information to residents being discharged from skilled services, failure to complete background checks for staff, failure to document dialysis assessments, and failure to post nurse staffing information daily. The facility reported a census of 35 residents during the survey.
Deficiencies (5)
| Description |
|---|
| Failure to obtain physician orders to address advance directives in a timely manner for residents newly admitted. |
| Failure to provide correct information to residents being discharged from skilled services regarding discontinuation of therapy and appeal options. |
| Failure to complete background checks for staff including child abuse, criminal history, and other required checks. |
| Failure to document assessments of resident's fistula before and after dialysis. |
| Failure to post daily nurse staffing information as required. |
Report Facts
Census: 35
Dates of survey: January 22, 2024 to January 25, 2024
Number of employee files reviewed: 6
Number of residents reviewed for discharge information: 3
Number of residents reviewed for dialysis documentation: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff C | Certified Nursing Assistant | Named in deficiency for lack of completed background check |
| Director of Nursing | Involved in corrective actions and staffing postings | |
| Business Office Manager | Reported on background check process and corrective actions | |
| Administrator | Reported on corrective actions and facility policies |
Inspection Report
Complaint Investigation
Deficiencies: 0
Sep 6, 2023
Visit Reason
A complaint investigation for complaints #111802-C and #111953-C was conducted from September 5, 2023 to September 6, 2023.
Findings
The facility was found to be in substantial compliance with no deficiencies noted.
Complaint Details
Complaint investigation for complaints #111802-C and #111953-C; facility found in substantial compliance.
Inspection Report
Plan of Correction
Deficiencies: 0
Apr 6, 2023
Visit Reason
The document is a plan of correction submitted following a survey to address deficiencies and certify compliance.
Findings
The facility was found to be in compliance based on acceptance of the credible allegation of compliance and plan of correction effective April 6, 2023.
Inspection Report
Complaint Investigation
Census: 37
Deficiencies: 2
Mar 2, 2023
Visit Reason
The inspection was conducted as a result of Complaint #108780-C, which was substantiated. The complaint involved failure to report an injury of unknown origin and failure to provide adequate supervision during a mechanical lift transfer.
Findings
The facility failed to report an injury of unknown origin within 24 hours to the State Survey Agency and did not provide the results of their investigation within five days. Additionally, the facility failed to provide adequate supervision using a mechanical lift, resulting in a resident being dropped and bruised during transfer.
Complaint Details
Complaint #108780-C was substantiated. The complaint involved failure to report an injury of unknown origin within required timeframes and failure to provide adequate supervision during resident transfer using a mechanical lift.
Severity Breakdown
SS=D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to report an injury of unknown origin within 24 hours and failure to provide investigation results within five days. | SS=D |
| Failure to provide adequate supervision using a mechanical lift to ensure a safe transfer. | SS=D |
Report Facts
Facility census: 37
Complaint number: 108780
Inspection Report
Annual Inspection
Deficiencies: 0
Aug 18, 2022
Visit Reason
A recertification survey and investigation of complaints #97338-C, #101478-C, and #103696-C was conducted from August 15 to August 18, 2022.
Findings
The facility was found in substantial compliance at the time of the survey. Complaints #97338-C, #101478-C, and #103696-C were not substantiated.
Complaint Details
Complaints #97338-C, #101478-C, and #103696-C were investigated and found not substantiated.
Report Facts
Complaint numbers investigated: 3
Inspection Report
Abbreviated Survey
Deficiencies: 0
Jun 22, 2020
Visit Reason
The Department of Inspection and Appeals conducted a COVID-19 Focused Infection Control Survey 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.
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