Deficiencies per Year
8
6
4
2
0
Severe
High
Moderate
Low
Unclassified
Census Over Time
Inspection Report
Plan of Correction
Deficiencies: 0
Dec 26, 2025
Visit Reason
The document is a plan of correction accepted based on a credible allegation of substantial compliance for a survey ending on December 4, 2025, to certify the facility in compliance effective December 17, 2025.
Findings
No specific deficiencies are detailed in this document; it acknowledges acceptance of the plan of correction and substantial compliance for the prior survey.
Report Facts
Survey end date: Dec 4, 2025
Certification effective date: Dec 17, 2025
Inspection Report
Renewal
Census: 32
Deficiencies: 2
Dec 4, 2025
Visit Reason
The inspection was an annual recertification survey conducted from December 1 to December 4, 2025, to assess compliance with federal regulations and facility licensing requirements.
Findings
The survey identified deficiencies related to failure to notify physicians of significant weight loss in residents and inaccuracies in Minimum Data Set (MDS) assessments, including coding errors and failure to document use of wander guard alarms. The facility submitted plans of correction addressing these issues.
Severity Breakdown
Level D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to notify the physician or designee of significant weight loss for Resident #17. | Level D |
| Failure to accurately complete Minimum Data Set (MDS) assessments for Residents #6, #9, and #20, including incorrect coding and documentation. | Level D |
Report Facts
Census: 32
Deficiencies cited: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Notified physician of significant weight loss; acknowledged MDS coding discrepancies | |
| Registered Dietitian | Reviewed resident weights and participated in plan of correction | |
| MDS Coordinator | Corrected MDS assessments and participated in interviews regarding deficiencies | |
| Staff A | Certified Nursing Assistant | Acknowledged use of wander guard alarms |
Inspection Report
Complaint Investigation
Deficiencies: 0
Oct 23, 2025
Visit Reason
An investigation for facility reported incidents #1764716-I and #2644105-I was conducted from October 15, 2025 to October 23, 2025.
Findings
The facility was found to be in substantial compliance.
Complaint Details
Investigation was related to two facility reported incidents. The facility was found to be in substantial compliance.
Inspection Report
Complaint Investigation
Deficiencies: 0
Jun 24, 2025
Visit Reason
A complaint investigation for complaint #125884-C was conducted.
Findings
The facility was found to be in substantial compliance.
Complaint Details
Complaint #125884-C was investigated and the facility was found to be in substantial compliance.
Inspection Report
Renewal
Deficiencies: 0
Nov 13, 2024
Visit Reason
The visit was conducted as a recertification survey to verify substantial compliance and to certify the facility's compliance status.
Findings
The facility was found to be in substantial compliance based on the acceptance of the credible allegation and Plan of Correction for the recertification survey ending on 2024-10-17, resulting in certification effective 2024-11-09.
Report Facts
Recertification survey end date: Oct 17, 2024
Certification effective date: Nov 9, 2024
Inspection Report
Annual Inspection
Census: 32
Deficiencies: 4
Oct 17, 2024
Visit Reason
The inspection was conducted as the facility's annual recertification survey from October 14 to October 17, 2024.
Findings
The facility was found deficient in multiple areas including failure to complete significant change assessments, inaccuracies in Minimum Data Set (MDS) coding, failure to revise care plans timely, and improper food handling practices during meal service.
Severity Breakdown
SS=D: 3
SS=E: 1
Deficiencies (4)
| Description | Severity |
|---|---|
| Failure to complete a significant change assessment after a resident discharged from hospice services. | SS=D |
| Failure to accurately code MDS assessments for residents receiving hospice services and those not taking anticoagulants. | SS=D |
| Failure to revise care plans to include use of warfarin and personalized interventions to prevent falls. | SS=D |
| Failure to ensure proper infection control practices during meal service, including improper glove use by dietary staff. | SS=E |
Report Facts
Deficiencies cited: 4
Resident census: 32
Dates of survey: 2024-10-14 to 2024-10-17
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | MDS Coordinator | Interviewed regarding significant change assessments and MDS coding errors. |
| Director of Nursing | DON | Interviewed regarding care plan revisions and MDS accuracy. |
| Staff B | Cook | Observed during meal service with improper glove use. |
| Dietary Supervisor | Interviewed regarding food service expectations and glove use. |
Inspection Report
Complaint Investigation
Deficiencies: 0
Sep 12, 2024
Visit Reason
A complaint investigation for complaints #118724-C and #120836-C was conducted from September 09, 2024 to September 12, 2024.
Findings
The facility was found to be in substantial compliance following the complaint investigation.
Complaint Details
Complaint investigation for complaints #118724-C and #120836-C; facility found in substantial compliance.
Inspection Report
Plan of Correction
Deficiencies: 0
Sep 19, 2023
Visit Reason
The document serves as a Plan of Correction following a prior inspection, indicating acceptance of a credible allegation of substantial compliance and certification of the facility in compliance effective September 19, 2023.
Findings
The facility was found to be in substantial compliance based on the accepted Plan of Correction, leading to certification of compliance effective September 19, 2023.
Inspection Report
Annual Inspection
Census: 30
Deficiencies: 3
Aug 17, 2023
Visit Reason
The inspection was conducted as the facility's annual recertification survey from August 14 to August 17, 2023.
Findings
The facility was found deficient in meeting professional standards for medication administration related to Digoxin therapy, payroll-based journal submission inaccuracies, and inadequate pneumococcal vaccination documentation for residents. The facility reported a census of 30 residents during the survey.
Severity Breakdown
Level D: 1
Level C: 1
Level E: 1
Deficiencies (3)
| Description | Severity |
|---|---|
| Failure to follow physician's order for pulse monitoring prior to Digoxin administration for one resident. | Level D |
| Failure to submit accurate payroll data for 5 of 90 days during the second quarter of 2023. | Level C |
| Failure to ensure adequate pneumococcal vaccinations were offered or administered to residents, with documentation lacking for four of five residents reviewed. | Level E |
Report Facts
Residents with missing pneumococcal immunizations: 4
Days with inaccurate payroll data: 5
Resident census: 30
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Clifford McEwen | Administrator | Signed the initial comments and plan of correction. |
| Staff A | Licensed Practical Nurse (LPN) | Observed administering Digoxin without pulse check and interviewed about medication administration. |
| Director of Nursing | Director of Nursing (D.O.N.) | Interviewed regarding Digoxin order and medication administration procedures. |
| Business Office Manager | Business Office Manager (BOM) | Interviewed regarding payroll-based journal submissions and data accuracy. |
Inspection Report
Complaint Investigation
Census: 29
Deficiencies: 0
Mar 23, 2023
Visit Reason
A complaint investigation was conducted for complaints #111362-C, #111410-C and facility reported incidents #105885-I and #111370-I from March 7, 2023 to March 23, 2023.
Findings
The facility was found to be in substantial compliance. A COVID-19 Focused Infection Control Survey was also conducted during the same period, and the facility was found to be in compliance with CMS and CDC recommended practices.
Complaint Details
Complaint investigation for complaints #111362-C, #111410-C and facility reported incidents #105885-I and #111370-I was conducted. The facility was found to be in substantial compliance.
Report Facts
Total Residents: 29
Inspection Report
Renewal
Deficiencies: 0
Jun 29, 2022
Visit Reason
An onsite revisit survey was conducted from 6/27/22 to 6/29/22 for the recertification survey and investigation of intake #104538-C and #102005-I, conducted 5/16/22 to 5/20/22.
Findings
All deficiencies identified in the previous investigation have been corrected and the facility is in compliance with all surveyed regulations, effective 6/18/22. No plan of correction was effectuated.
Inspection Report
Annual Inspection
Census: 34
Deficiencies: 6
May 20, 2022
Visit Reason
The inspection was the facility's annual recertification survey combined with investigation of complaints and facility reported incidents conducted from 05/16/2022 to 05/20/2022.
Findings
The facility was found non-compliant with infection control requirements leading to an Immediate Jeopardy (IJ) related to COVID-19 due to a staff member working while symptomatic. Additional deficiencies included failure to maintain resident dignity related to urinary catheter privacy, inadequate fall prevention and investigation, unnecessary psychotropic medication use without proper diagnosis or monitoring, unlocked medication carts, and failure to implement and monitor effective quality assurance and infection control programs.
Complaint Details
Complaint #IA00104538-C was unsubstantiated. Facility reported incident #IA00102005-I was substantiated.
Severity Breakdown
SS=G: 1
SS=D: 2
SS=K: 2
Deficiencies (6)
| Description | Severity |
|---|---|
| Failure to ensure indwelling urinary catheter drainage bags were not visible to maintain resident dignity for Residents #7 and #13. | — |
| Failure to conduct thorough investigations into falls and provide adequate supervision to prevent falls with major injuries for Resident #32. | SS=G |
| Failure to ensure Resident #32's medication regimen was free of unnecessary psychotropic medication without appropriate diagnosis and behavioral monitoring. | SS=D |
| Failure to ensure medication carts were locked when unattended (200 Hall medication cart). | SS=D |
| Failure to develop and implement appropriate plans of action to correct identified quality deficiencies related to infection control and staff screening. | SS=K |
| Failure to establish and maintain an infection prevention and control program to prevent transmission of COVID-19, including ineffective staff screening and lack of respiratory protection program with fit testing for N95 respirators. | SS=K |
Report Facts
Residents tested positive for COVID-19: 10
Staff tested positive for COVID-19: 6
Residents present during inspection: 34
Staff interviews conducted: 17
Staff trained on COVID-19 screening and N95 use: 67
Falls documented for Resident #32: 9
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Registered Nurse | Worked while symptomatic with COVID-19 on 5/11/22, causing outbreak; not fit tested for N95 respirator. |
| Staff J | Certified Nursing Assistant | Did not complete COVID-19 screening form on 5/17/22. |
| Staff K | Certified Nursing Assistant | Did not complete COVID-19 screening form on 5/17/22. |
| Staff C | Infection Preventionist/Registered Nurse | Confirmed lack of respiratory protection program and fit testing for N95 respirators. |
| Staff E | Registered Nurse | Wore surgical mask under N95 incorrectly; tested positive for COVID-19 on 5/15/22. |
| Staff L | Licensed Practical Nurse | Wore surgical mask under N95; not fit tested. |
| Director of Nursing | Director of Nursing | Acknowledged lack of respiratory protection program and fit testing; implemented new screening process after surveyor request. |
| Administrator | Administrator | Notified of Immediate Jeopardy on 5/19/22; implemented Removal Plan and staff training. |
Inspection Report
Routine
Census: 33
Deficiencies: 0
Dec 8, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the Department of Inspections and Appeals 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: 31
Deficiencies: 1
Sep 21, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the Department of Inspection and Appeals to assess compliance with CMS and CDC recommended practices for COVID-19 prevention.
Findings
The facility failed to implement and monitor an effective screening process for staff to prevent a COVID-19 outbreak, resulting in 20 of 31 residents testing positive and one resident passing away. The facility corrected the deficiency by revising screening policies and educating staff.
Severity Breakdown
F: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to implement and monitor an effective screening process for staff to prevent COVID-19 outbreak. | F |
Report Facts
Total residents: 31
Residents tested positive for COVID-19: 20
Staff with symptoms: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Certified Nursing Assistant (CNA) | Named in findings related to COVID-19 symptoms and screening failure |
| Staff B | Registered Nurse (RN) | Involved in screening and counseling related to Staff A |
| Director of Nursing | Administrator | Provided policy and education on staff screening |
Inspection Report
Abbreviated Survey
Census: 41
Deficiencies: 0
Jun 16, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the Department of Inspections and Appeals 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.
Report Facts
Total residents: 41
Inspection Report
Annual Inspection
Census: 45
Deficiencies: 5
Jan 9, 2020
Visit Reason
The inspection was conducted as a licensure and recertification survey to assess compliance with federal regulations including resident rights, Medicaid/Medicare coverage, accuracy of assessments, care plan timing and revision, and psychotropic medication use.
Findings
The facility was found deficient in multiple areas including failure to ensure advance directive status was properly documented in the Electronic Health Record, failure to provide required Medicare Liability Notices, inaccurate Minimum Data Set assessments, failure to update care plans timely, and inadequate documentation of diagnoses related to psychotropic medication use.
Deficiencies (5)
| Description |
|---|
| Failure to ensure code status (advance directive) was identified in the Electronic Health Record for Resident #23. |
| Failure to provide required Medicare Liability Notices and Beneficiary Appeals forms for Resident #18 when skilled services were exhausted. |
| Failure to accurately complete Minimum Data Set for Resident #31, specifically regarding anticoagulant medication use. |
| Failure to update care plans timely for Residents #29 and #31, including indwelling catheter and anticoagulant medication. |
| Failure to provide adequate diagnosis related to psychotropic medication use for Residents #31 and #44. |
Report Facts
Deficiencies cited: 5
Resident census: 45
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Interviewed multiple times regarding advance directives, Medicare notices, care plans, and medication documentation. |
| A Nurse | Nurse | Provided information about use of Electronic Health Record as identifier for advance directive status. |
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