Deficiencies per Year
12
9
6
3
0
Severe
High
Moderate
Low
Unclassified
Census Over Time
Census
Capacity
Inspection Report
Annual Inspection
Deficiencies: 0
Jul 24, 2025
Visit Reason
The State Agency conducted an annual recertification survey at the facility from 7/21/25 to 7/24/25 to assess compliance with Minimum Standards for Institutions for the Aged or Infirm and state licensure requirements.
Findings
The facility was found to be in compliance with all applicable standards and licensure requirements, with no deficiencies cited during the survey.
Inspection Report
Annual Inspection
Census: 55
Capacity: 60
Deficiencies: 3
Jul 24, 2025
Visit Reason
The State Agency conducted an annual recertification survey at the facility from July 21 through July 24, 2025, to determine compliance with Medicare and Medicaid participation requirements.
Findings
The facility was found not in compliance with requirements related to quality of care, behavioral health services, and drug labeling and storage. Deficiencies included failure to administer respiratory medications as ordered, inadequate behavioral health support for a grieving resident, and unsecured medications accessible to residents.
Severity Breakdown
SS = D: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Failure to administer Albuterol Sulfate HFA inhalation aerosol as ordered for shortness of breath and wheezing for Resident #11. | SS = D |
| Failure to provide necessary behavioral health care and services to assist Resident #9 with depression and anxiety related to bereavement. | SS = D |
| Failure to ensure medications were securely stored and not accessible to Resident #16, including presence of TUMS and cough drops in resident's room. | SS = D |
Report Facts
Census: 55
Total Capacity: 60
Deficiencies cited: 3
BIMS score: 15
BIMS score: 8
BIMS score: 15
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Named in medication administration deficiency for Resident #11 |
| Licensed Practical Nurse #2 | Licensed Practical Nurse and Medical Records Director | Involved in medication administration and behavioral health deficiencies |
| Director of Nursing | Director of Nursing | Involved in oversight and interviews related to medication administration, behavioral health, and medication storage deficiencies |
| Psychiatric Nurse Practitioner | Psychiatric Nurse Practitioner | Assessed Resident #9 for psychosocial wellbeing and behavioral health deficiency |
Inspection Report
Annual Inspection
Deficiencies: 0
Jul 24, 2025
Visit Reason
The visit was related to the annual survey completed on 07/24/25 to assess compliance with Medicare and Medicaid participation requirements.
Findings
The facility provided information confirming corrective measures were implemented to address prior deficiencies, and the State Agency recommended the facility be placed back in compliance effective 08/13/25.
Report Facts
Survey completion date: Aug 18, 2025
Inspection Report
Annual Inspection
Deficiencies: 0
Jul 24, 2025
Visit Reason
The visit was a desk review conducted on 08/18/2025 of information related to the annual survey completed on 07/24/2025 to confirm compliance with Minimum Standards of Operation for Institutions for the Aged or Infirm.
Findings
The information provided by the facility confirmed compliance with the Minimum Standards of Operation for Institutions for the Aged or Infirm; no deficiencies were noted in the report.
Inspection Report
Life Safety
Deficiencies: 0
Jul 22, 2025
Visit Reason
The survey was conducted to assess the facility's compliance with emergency preparedness requirements and the Life Safety Code (LSC) provisions.
Findings
The facility met all applicable Federal, State, and local emergency preparedness requirements with no deficiencies cited. Additionally, there were no Life Safety Code deficiencies identified during the survey.
Inspection Report
Plan of Correction
Deficiencies: 0
May 13, 2024
Visit Reason
The State Agency conducted a desk review of information related to the annual survey completed on 2024-04-11 to verify corrective measures taken by the facility.
Findings
The facility provided information confirming corrective actions were implemented to address deficient practices and sustain compliance with Medicare and Medicaid requirements. The State Agency recommended the facility be placed back in compliance effective 2024-05-07.
Inspection Report
Plan of Correction
Deficiencies: 0
May 13, 2024
Visit Reason
The State Agency conducted a desk review of information related to the annual survey completed on 2024-04-11 to verify corrective measures taken by the facility.
Findings
The facility provided information confirming that corrective actions were implemented to address deficient practices and sustain compliance with Medicare and Medicaid participation requirements. The State Agency recommended the facility be placed back in compliance effective 2024-05-07.
Report Facts
Annual survey date: Apr 11, 2024
Desk review date: May 13, 2024
Inspection Report
Annual Inspection
Deficiencies: 1
Apr 11, 2024
Visit Reason
The State Agency conducted an annual recertification survey along with complaint investigations at the facility from April 9, 2024 through April 11, 2024.
Findings
The facility was found not in compliance with infection control standards, specifically failing to prevent the spread of infection due to lack of barrier use during eye drop administration and improper cleaning of a glucometer between residents. Noncompliance related to abuse was also cited in one complaint investigation, while another complaint investigation found no deficiencies.
Complaint Details
Complaint Investigations MS #24746 and MS #24754 were conducted. Noncompliance related to abuse was cited for MS #24754, and no deficiencies were cited for MS #24746 related to allegations of abuse.
Severity Breakdown
Level II: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to prevent the spread of infection as evidenced by no barrier used during eye drops and not properly cleaning a glucometer between residents. | Level II |
Report Facts
Direct care observations with deficiencies: 3
In-service training frequency: 3
Monitoring frequency: 3
Monitoring start date: Apr 12, 2024
Survey period: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Named in infection control deficiency for improper eye drop administration and glucometer cleaning. |
| Director of Nursing | Director of Nursing | Assessed residents for infection signs, confirmed deficiencies, and provided in-service training. |
| Infection Preventionist | Infection Preventionist | Conducted in-service training and monitoring of nursing staff on infection prevention and medication administration procedures. |
Inspection Report
Annual Inspection
Census: 57
Capacity: 58
Deficiencies: 3
Apr 11, 2024
Visit Reason
The State Agency conducted an annual recertification survey along with complaint investigations at the facility from April 9, 2024 through April 11, 2024 to assess compliance with Medicare and Medicaid requirements.
Findings
The facility was found noncompliant with infection prevention and control requirements (F880), failure to prevent abuse (F600), and failure of staff to report abuse (F609) related to one complaint investigation. No deficiencies were cited for the other complaint investigation. The infection control deficiency involved failure to use barriers during eye drop administration and improper cleaning of glucometers, risking infection spread.
Complaint Details
Complaint investigations MS #24746 and MS #24754 were conducted. Noncompliance was identified related to MS #24754 for failure to prevent and report abuse. No deficiencies were cited for MS #24746 related to an allegation of abuse.
Severity Breakdown
SS=D: 1
Deficiencies (3)
| Description | Severity |
|---|---|
| Failure to prevent the possibility of the spread of infection as evidenced by no barrier used during eye drops and not properly cleaning a glucometer between residents. | SS=D |
| Failure to prevent abuse (F600) related to complaint investigation MS #24754. | — |
| Failure of staff to report abuse (F609) related to complaint investigation MS #24754. | — |
Report Facts
Census: 57
Total Capacity: 58
Direct Care Observations: 9
Deficient Observations: 3
In-service Training Duration: 3
Monitoring Frequency: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Named in infection control deficiencies for not using barrier during eye drop administration and improper glucometer cleaning |
| Director of Nursing | Director of Nursing (DON) | Assessed residents for infection signs, confirmed deficiencies, and provided in-service training |
| Infection Preventionist | Infection Preventionist | Conducted in-service training and monitoring of infection control practices |
Inspection Report
Complaint Investigation
Deficiencies: 1
Apr 11, 2024
Visit Reason
The inspection was conducted based on a complaint alleging abuse of a resident during transfer by a Certified Nurse Aide (CNA).
Findings
The facility failed to prevent abuse of one resident (#25) during transfer by a CNA who handled the resident roughly, causing distress. The facility conducted interviews, assessments, and in-service training for staff on abuse prevention and reporting. Both CNAs involved were suspended pending investigation.
Complaint Details
The complaint involved alleged rough handling and abuse of Resident #25 by CNA #1 during transfer on 04/09/24. Resident #25 reported pain and rough treatment. CNA #2 confirmed witnessing rough handling but did not report it. The Administrator confirmed the allegation was reported to the State Agency and both CNAs were suspended pending investigation.
Severity Breakdown
Level II: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to prevent abuse of a resident during transfer by a CNA who handled the resident roughly. | Level II |
Report Facts
Residents reviewed for abuse: 4
Residents interviewed for abuse: 7
BIMS score: 15
Admission date: Jan 5, 2022
In-service training date: Apr 9, 2024
Monitoring start date: Apr 12, 2024
Monitoring frequency: 3
Quality Assurance meetings: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| CNA #1 | Certified Nurse Aide | Named in abuse allegation for rough handling of Resident #25 during transfer |
| CNA #2 | Certified Nurse Aide | Witnessed rough handling by CNA #1 but did not report it; involved in transfer of Resident #25 |
| Administrator | Conducted assessments, interviews, reported allegation to State Agency, and suspended CNAs pending investigation | |
| Social Worker | Participated in assessment and interviews related to abuse allegation | |
| Registered Nurse #1 | Registered Nurse | Participated in assessment of Resident #25 for bruising, skin tears, and distress |
Inspection Report
Complaint Investigation
Deficiencies: 2
Apr 11, 2024
Visit Reason
The inspection was conducted due to a complaint alleging abuse of Resident #25 by a Certified Nurse Aide during a transfer on 04/09/2024.
Findings
The facility failed to prevent abuse of Resident #25 as evidenced by rough handling during transfer by CNA #1. Additionally, the facility failed to report the abuse allegation in a timely manner. Both CNAs involved were suspended pending investigation, and in-service training was conducted for all staff on abuse prevention and reporting.
Complaint Details
The complaint involved allegations that CNA #1 was rough with Resident #25 during a transfer on 04/09/2024. Resident #25 reported pain caused by CNA #1's handling. CNA #2 witnessed the event but did not report it as Resident #25 asked her not to. The Administrator confirmed the abuse report and suspended both CNAs pending investigation.
Severity Breakdown
SS=D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to prevent abuse of a resident during transfer by CNA #1. | SS=D |
| Failure to report abuse allegations in a timely manner. | SS=D |
Report Facts
Deficiencies cited: 2
BIMS score: 15
Admission date: Jan 5, 2022
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| CNA #1 | Certified Nurse Aide | Named in abuse allegation for rough handling during transfer |
| CNA #2 | Certified Nurse Aide | Witnessed abuse but failed to report it timely |
| Administrator | Interviewed staff and resident, reported abuse to State Agency, suspended CNAs | |
| Social Worker | Interviewed Resident #25 regarding abuse concern | |
| Registered Nurse #1 | Registered Nurse | Assessed Resident #25 for bruising, skin tears, and distress |
Inspection Report
Annual Inspection
Deficiencies: 0
Apr 11, 2024
Visit Reason
The State Agency conducted a desk review of information related to the annual survey completed on 04/11/24 to assess compliance with Minimum Standards of Operation for Institutions for the Aged or Infirm.
Findings
The facility was found to be in compliance with the Minimum Standards of Operation, and the State Agency recommended the facility be placed back in compliance effective 05/07/24.
Inspection Report
Annual Inspection
Deficiencies: 0
Apr 11, 2024
Visit Reason
The State Agency conducted a desk review of information related to the annual survey completed on 04/11/24 to assess compliance with Minimum Standards of Operation for Institutions for the Aged or Infirm.
Findings
The facility was found to be in compliance with the Minimum Standards of Operation, and the State Agency recommended the facility be placed back in compliance effective 05/07/24.
Inspection Report
Life Safety
Deficiencies: 0
Apr 9, 2024
Visit Reason
The survey was conducted to assess compliance with the 2012 Edition of the Life Safety Code (LSC) of the National Fire Protection Association (NFPA).
Findings
The facility met the applicable provisions of the 2012 Edition of the Life Safety Code, and no LSC deficiencies were cited during this survey.
Inspection Report
Deficiencies: 0
Apr 9, 2024
Visit Reason
The survey was conducted to assess the facility's compliance with Federal, State, and local emergency preparedness requirements.
Findings
The facility met all applicable Federal, State, and local emergency preparedness requirements with no deficiencies cited.
Inspection Report
Plan of Correction
Deficiencies: 1
Feb 20, 2024
Visit Reason
The inspection was conducted to assess the facility's compliance with COVID-19 reporting requirements to the Centers for Disease Control and Prevention's National Healthcare Safety Network (NHSN).
Findings
The facility failed to report complete COVID-19 information to the NHSN during a seven-day period from 02/12/2024 to 02/18/2024 as required by regulation, which has the potential to cause more than minimal harm to residents.
Severity Breakdown
SS=F: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to report complete information about COVID-19 to the CDC's NHSN during a required seven-day period. | SS=F |
Report Facts
Reporting period: 7
Inspection Report
Plan of Correction
Deficiencies: 1
Feb 12, 2024
Visit Reason
The inspection was conducted to assess the facility's compliance with COVID-19 reporting requirements to the Centers for Disease Control and Prevention's National Healthcare Safety Network (NHSN).
Findings
The facility failed to report complete information about COVID-19 to the NHSN during a required seven-day reporting period between 02/05/2024 and 02/11/2024, which has the potential to cause more than minimal harm to all residents.
Severity Breakdown
SS=F: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to report complete COVID-19 information to the CDC's National Healthcare Safety Network during a seven-day period as required by regulation. | SS=F |
Report Facts
Reporting period: 7
Inspection Report
Plan of Correction
Deficiencies: 1
Feb 6, 2024
Visit Reason
The facility was surveyed due to failure to report complete COVID-19 information to the CDC's National Healthcare Safety Network as required by regulation.
Findings
The facility failed to report complete COVID-19 data to the CDC's NHSN during the seven-day period from 01/29/2024 to 02/04/2024, which has the potential to cause more than minimal harm to all residents.
Severity Breakdown
SS=F: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to report complete information about COVID-19 to the CDC's National Healthcare Safety Network during a required seven-day period. | SS=F |
Report Facts
Reporting period: 7
Inspection Report
Plan of Correction
Deficiencies: 1
Oct 10, 2023
Visit Reason
The inspection was conducted to assess the facility's compliance with COVID-19 reporting requirements to the Centers for Disease Control and Prevention's National Healthcare Safety Network (NHSN).
Findings
The facility failed to report complete information about COVID-19 to the NHSN during a seven-day period from 10/02/2023 to 10/08/2023 as required by regulation, which has the potential to cause more than minimal harm to all residents.
Severity Breakdown
F 884: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to report complete information about COVID-19 to the CDC's National Healthcare Safety Network during a required seven-day period. | F 884 |
Report Facts
Reporting period: 7
Inspection Report
Complaint Investigation
Deficiencies: 1
Aug 14, 2023
Visit Reason
The State Agency conducted a Complaint Investigation at the facility on 2023-08-14 related to staff to resident abuse/exploitation.
Findings
The facility failed to protect a resident from misappropriation of property by a Certified Nurse Aide (CNA) who accepted money and sent an explicit video to the resident. The facility investigated, provided in-services on abuse and the Vulnerable Adult Act, terminated the employee, and had the resident assessed by psychiatric services. The deficiency was determined to be Past Non-Compliance and corrected prior to the survey date.
Complaint Details
The complaint investigation was triggered by a Facility Reported Incident related to staff to resident abuse/exploitation. The CNA admitted to receiving cash from the resident and sending an explicit video. The resident denied giving money. The Attorney General's Office investigated and the facility took corrective actions including staff in-services, employee termination, and psychiatric assessment of the resident.
Severity Breakdown
Level II Past Non-Compliance: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failed to protect a resident from misappropriation of property by a CNA who accepted money and sent an explicit video to the resident. | Level II Past Non-Compliance |
Report Facts
Amount of money given to CNA: 481
Date of resident admission: Jan 17, 2023
BIMS score: 15
Date of facility corrective action: Jul 28, 2023
Date deficiency corrected: Jul 29, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| CNA #1 | Certified Nurse Aide | Involved in misappropriation of resident property and sending explicit video |
| Administrator in Training | Interviewed regarding the incident and facility response | |
| Administrator | Conducted one-on-one in-services with staff on abuse policy and vulnerable adult act | |
| CNA #2 | Certified Nurse Aide | Reported CNA #1's receipt of money from resident |
Inspection Report
Complaint Investigation
Census: 53
Capacity: 58
Deficiencies: 1
Aug 14, 2023
Visit Reason
The State Agency conducted a complaint investigation related to an employee to resident abuse/exploitation incident reported by the facility.
Findings
The facility failed to protect a resident from misappropriation of property by a Certified Nurse Aide (CNA) who accepted money and sent an explicit video to the resident. The deficiency was determined to be past non-compliance and was corrected prior to the survey date with corrective actions including staff in-services, termination of the employee, and psychiatric assessment of the resident.
Complaint Details
The complaint investigation was triggered by a Facility Reported Incident involving a CNA who accepted money from a resident and sent an explicit video to him. The Attorney General's Office investigated, and the facility took corrective actions including in-services and termination of the CNA.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failed to protect a resident from misappropriation of property by an employee. | SS=D |
Report Facts
Licensed beds: 58
Resident census: 53
Amount of money alleged given to CNA: 481
Date of facility corrective action: Jul 28, 2023
Date deficiency corrected: Jul 29, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Administrator in Training | Administrator in Training (AIT) | Interviewed regarding the incident and facility corrective actions. |
| CNA #1 | Certified Nurse Aide | Employee who accepted money and sent explicit video to resident. |
| CNA #2 | Certified Nurse Aide | Reported information about CNA #1 accepting money from resident. |
| Administrator | Administrator | Conducted one-on-one in-services with staff regarding abuse policies. |
Inspection Report
Complaint Investigation
Deficiencies: 0
Jun 27, 2023
Visit Reason
The State Agency conducted a complaint investigation at the facility from 6/26/2023 through 6/27/2023 related to misappropriation of property.
Findings
The facility was found to be in compliance with the Minimum Standards for Institutions for the Aged or Infirm and state licensure requirements. No deficiencies were cited.
Complaint Details
Complaint investigation MS #21212 related to misappropriation of property; no deficiencies cited.
Inspection Report
Complaint Investigation
Census: 54
Capacity: 58
Deficiencies: 0
Jun 27, 2023
Visit Reason
The State Agency conducted a complaint investigation at the facility from 6/26/23 to 6/27/23 regarding misappropriation of property.
Findings
The facility was found to be in compliance with Medicare and Medicaid participation requirements, and no deficiencies were cited.
Complaint Details
Investigation of complaint MS #21212 for misappropriation of property resulted in no deficiencies and compliance with requirements.
Report Facts
Census: 54
Total licensed capacity: 58
Inspection Report
Plan of Correction
Deficiencies: 1
Apr 17, 2023
Visit Reason
The facility was inspected due to failure to report complete COVID-19 information to the CDC's National Healthcare Safety Network as required by regulation.
Findings
The facility failed to report complete COVID-19 data to the NHSN during the seven-day period from 04/10/2023 to 04/16/2023, which could potentially cause more than minimal harm to all residents.
Severity Breakdown
SS=F: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to report complete information about COVID-19 to the CDC's National Healthcare Safety Network during a required seven-day period. | SS=F |
Report Facts
Reporting period: 7
Inspection Report
Plan of Correction
Deficiencies: 0
Feb 9, 2023
Visit Reason
The State Agency conducted a desk review of information related to the annual survey completed on 2023-01-05 to confirm compliance with Minimum Standards of Operation for Institutions for the Aged or Infirm.
Findings
The facility was found to be in compliance with the Minimum Standards of Operation, and the State Agency recommended the facility be placed back in compliance effective 2023-02-01.
Inspection Report
Plan of Correction
Deficiencies: 0
Feb 9, 2023
Visit Reason
The State Agency conducted a desk review of information related to the annual survey completed on 2023-01-05 to verify corrective measures taken by the facility.
Findings
The facility provided information confirming that measures were put in place to correct deficient practices and sustain compliance with Medicare and Medicaid requirements. The State Agency recommended the facility be placed back in compliance effective 2023-02-01.
Inspection Report
Annual Inspection
Deficiencies: 1
Jan 5, 2023
Visit Reason
The State Survey Agency conducted an annual survey at the facility from January 3, 2023 through January 5, 2023 to assess compliance with the Minimum Standards for Institutions for the Aged or Infirm and state licensure requirements.
Findings
The facility was found not in compliance with residents' rights policies, specifically failing to provide mail delivery on Saturdays to residents, affecting all 49 residents. The facility acknowledged inconsistent weekend mail delivery due to staff turnover and lack of a consistent charge nurse.
Severity Breakdown
Level I: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failed to provide mail delivery on Saturday to residents, affecting 6 residents in the resident council meeting and potentially all 49 residents. | Level I |
Report Facts
Residents affected: 49
Residents in resident council meeting: 6
Inspection Report
Annual Inspection
Census: 49
Capacity: 58
Deficiencies: 5
Jan 5, 2023
Visit Reason
The State Survey Agency conducted an annual re-certification survey at the facility from 01/03/2023 to 01/05/2023 to determine compliance with Medicare and Medicaid participation requirements.
Findings
The facility was found not in compliance with multiple requirements including management of personal funds, resident communication rights, activities programming, incontinent care, and infection prevention and control. Deficiencies were cited in areas such as resident access to funds on weekends, mail delivery, weekend activities, proper incontinent care, and infection control practices.
Severity Breakdown
SS=C: 2
SS=D: 3
Deficiencies (5)
| Description | Severity |
|---|---|
| Failed to ensure residents had reasonable and ready access to their personal funds on weekends. | SS=C |
| Failed to provide mail delivery on Saturdays to residents. | SS=C |
| Failed to provide an activities program on weekends for residents. | SS=D |
| Failed to provide incontinent care to prevent urinary tract infections for a resident by not cleaning the front perineal area. | SS=D |
| Failed to prevent possible spread of infection by placing dirty linen on the floor and not washing or sanitizing hands after contact with body fluids during incontinent care. | SS=D |
Report Facts
Census: 49
Total Capacity: 58
Residents with Trust Fund Accounts: 38
Residents interviewed regarding funds and mail delivery: 6
Residents affected by lack of weekend activities: 3
BIMS scores: 15
BIMS score: 12
BIMS score: 9
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| CNA #1 | Certified Nurse Aide | Failed to clean front perineal area during incontinent care and did not change gloves or wash hands before repositioning resident and placing clean linen. |
| Director of Nursing | Director of Nursing | Confirmed deficiencies in incontinent care and infection control practices. |
| Administrator | Facility Administrator | Interviewed regarding mail delivery and resident funds access issues; responsible for corrective actions and monitoring. |
| Activities Director | Activity Director | Confirmed lack of weekend activities and staffing limitations. |
Inspection Report
Life Safety
Deficiencies: 0
Jan 5, 2023
Visit Reason
The inspection was conducted to assess compliance with the 2012 Edition of the Life Safety Code (LSC) of the National Fire Protection Association (NFPA).
Findings
The facility met the applicable provisions of the 2012 Edition of the Life Safety Code, and no LSC deficiencies were cited during this survey.
Inspection Report
Deficiencies: 0
Jan 5, 2023
Visit Reason
The survey was conducted to assess the facility's compliance with Federal, State, and local emergency preparedness requirements.
Findings
The facility met all applicable Federal, State, and local emergency preparedness requirements with no deficiencies cited.
Inspection Report
Routine
Census: 57
Capacity: 58
Deficiencies: 0
May 18, 2022
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the State Agency on 5/18/22 to assess compliance with infection control regulations and implementation of CMS and CDC recommended practices.
Findings
The facility was found to be in compliance with infection control regulations and no deficiencies were cited during the survey.
Inspection Report
Routine
Census: 57
Capacity: 58
Deficiencies: 0
May 18, 2022
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the State Agency to assess compliance with infection control regulations and implementation of CMS and CDC recommended practices for COVID-19 preparation.
Findings
The facility was found to be in compliance with infection control regulations and no deficiencies were cited during the survey.
Inspection Report
Routine
Deficiencies: 0
May 18, 2022
Visit Reason
A COVID-19 Focused Emergency Preparedness Survey was conducted by the Centers for Medicare & Medicaid Services (CMS) on 5/18/22.
Findings
The facility was found to be in compliance with 42 CFR §483.73 related to E-0024 (b)(6).
Inspection Report
Complaint Investigation
Deficiencies: 0
Apr 7, 2022
Visit Reason
The State Agency conducted a Complaint Investigation (CI) MS #18289 from 4/6/22 through 4/7/22.
Findings
The State Agency determined the facility was in compliance with the Minimum Standards of Operation for Institutions for the Aged or Infirm, state licensure requirements and there were no deficiencies cited.
Complaint Details
Complaint Investigation MS #18289 was conducted and found no deficiencies; the facility was in compliance.
Inspection Report
Complaint Investigation
Census: 54
Capacity: 58
Deficiencies: 0
Apr 7, 2022
Visit Reason
The State Agency conducted a Complaint Investigation (CI) MS #18289 at the facility from 4/6/22 through 4/7/22 to determine compliance with Medicare and Medicaid participation requirements.
Findings
The investigation found the facility in compliance with Medicare and Medicaid requirements, with no deficiencies cited and the complaint not substantiated due to lack of evidence of poor quality of care.
Complaint Details
Complaint Investigation MS #18289 was not substantiated due to lack of evidence of poor quality of care and no deficiencies were cited.
Inspection Report
Plan of Correction
Deficiencies: 1
Dec 13, 2021
Visit Reason
The inspection was conducted to review the facility's compliance with COVID-19 reporting requirements to the Centers for Disease Control and Prevention's National Healthcare Safety Network (NHSN).
Findings
The facility failed to report complete information about COVID-19 to the NHSN during a seven-day period from 12/06/2021 to 12/12/2021 as required by regulation, which has the potential to cause more than minimal harm to residents.
Severity Breakdown
SS=F: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to report complete COVID-19 information to the CDC's NHSN during a required seven-day period. | SS=F |
Report Facts
Reporting period: 7
Inspection Report
Plan of Correction
Deficiencies: 1
Dec 13, 2021
Visit Reason
The facility was surveyed for compliance with COVID-19 reporting requirements to the Centers for Disease Control and Prevention's National Healthcare Safety Network (NHSN).
Findings
The facility failed to report complete COVID-19 information to the NHSN during a required seven-day period between 12/06/2021 and 12/12/2021, as determined by CMS based on CDC data. This failure has the potential to cause more than minimal harm to all residents.
Severity Breakdown
SS=F: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to report complete COVID-19 information to the CDC's National Healthcare Safety Network during a required seven-day period. | SS=F |
Report Facts
Reporting period: 7
Inspection Report
Complaint Investigation
Census: 44
Capacity: 58
Deficiencies: 0
Oct 14, 2020
Visit Reason
The State Agency conducted a COVID-19 Focused Infection Control Survey and Complaint Investigations #16912 and #17119 from 10/13/20 to 10/14/20 to assess compliance with infection control regulations and investigate complaints related to quality of care, staffing, neglect, environmental concerns, staff screening for COVID-19, and physical abuse.
Findings
The facility was found in compliance with infection control regulations and implemented recommended practices by CMS and CDC. Both complaint investigations were not substantiated, and no deficiencies were cited.
Complaint Details
Complaint Investigation #16912 was not substantiated for concerns related to Quality of Care, Staffing, Neglect, Environmental concerns, and staff screening for COVID-19. Complaint Investigation #17119 was not substantiated for Physical Abuse.
Report Facts
Complaint Investigations: 2
Beds licensed: 58
Census: 44
Inspection Report
Complaint Investigation
Census: 44
Capacity: 58
Deficiencies: 0
Oct 14, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey and Complaint Investigation (#16912 and #17119) were conducted to assess compliance with infection control regulations and investigate complaints related to quality of care, staffing, neglect, environmental concerns, staff screening for COVID-19, and physical abuse.
Findings
The facility was found to be in compliance with infection control regulations and CMS/CDC recommended practices. Both complaints were not substantiated, and no deficiencies were cited during the survey.
Complaint Details
Complaint Investigation #16912 was not substantiated for concerns related to Quality of Care, Staffing, Neglect, Environmental concerns, and staff screening for COVID-19. Complaint Investigation #17119 was not substantiated for Physical Abuse.
Report Facts
Census: 44
Total licensed capacity: 58
Inspection Report
Complaint Investigation
Census: 44
Capacity: 58
Deficiencies: 0
Oct 14, 2020
Visit Reason
The State Agency conducted a COVID-19 Focused Infection Control Survey and Complaint Investigations #16912 and #17119 from 10/13/20 to 10/14/20 to assess compliance with infection control regulations and investigate complaints related to quality of care, staffing, neglect, environmental concerns, staff screening for COVID-19, and physical abuse.
Findings
The facility was found in compliance with infection control regulations and implemented recommended practices by CMS and CDC. Both complaint investigations were not substantiated, and no deficiencies were cited. No concerns were noted during the review of infection prevention policies, PPE availability, staffing, visitor restrictions, COVID-19 cases, hospital transfers, or reporting.
Complaint Details
Complaint Investigation #16912 was not substantiated for concerns related to Quality of Care, Staffing, Neglect, Environmental concerns, and staff screening for COVID-19. Complaint Investigation #17119 was not substantiated for Physical Abuse.
Report Facts
Census: 44
Total licensed capacity: 58
Inspection Report
Complaint Investigation
Census: 44
Capacity: 58
Deficiencies: 0
Oct 14, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness Survey and Complaint Investigation were conducted due to concerns related to Quality of Care, Staffing, Neglect, Environmental concerns, staff screening for COVID-19, and Physical Abuse.
Findings
The facility was found to be in compliance with infection control regulations and CMS/CDC recommended practices. Both complaint investigations were not substantiated and no deficiencies were cited.
Complaint Details
Complaint Investigation #16912 was not substantiated for concerns related to Quality of Care, Staffing, Neglect, Environmental concerns, and staff screening for COVID-19. Complaint Investigation #17119 was not substantiated for Physical Abuse.
Report Facts
Census: 44
Total licensed capacity: 58
Inspection Report
Abbreviated Survey
Census: 37
Deficiencies: 0
Sep 11, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the Centers for Medicare & Medicaid Services (CMS) to assess the facility's compliance with infection control regulations related to COVID-19.
Findings
The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and had implemented CMS and CDC recommended practices to prepare for COVID-19.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Sep 11, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness Survey was conducted by the Centers for Medicare & Medicaid Services (CMS) on September 11, 2020.
Findings
The facility was found to be in compliance with 42 CFR §483.73 related to E-0024 (b)(6).
Inspection Report
Routine
Census: 37
Capacity: 58
Deficiencies: 0
May 26, 2020
Visit Reason
A Covid-19 Focused Infection Control Survey was conducted by the State Agency to assess compliance with infection control regulations and preparedness for COVID-19.
Findings
The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and had implemented CMS and CDC recommended practices to prepare for COVID-19.
Report Facts
Census: 37
Total licensed capacity: 58
Inspection Report
Abbreviated Survey
Census: 37
Capacity: 58
Deficiencies: 0
May 26, 2020
Visit Reason
A Covid-19 Focused Infection Control Survey was conducted by the State Agency on 5/26/2020 to assess compliance with infection control regulations and preparedness for COVID-19.
Findings
The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and had implemented CMS and CDC recommended practices to prepare for COVID-19.
Inspection Report
Original Licensing
Census: 39
Capacity: 58
Deficiencies: 0
Nov 27, 2019
Visit Reason
The State Agency conducted an initial certification survey and complaint investigation related to medications availability, which was unsubstantiated.
Findings
The facility was found to be in compliance with Medicaid and Medicare requirements with no deficiencies cited related to medication availability.
Complaint Details
Complaint Investigation MS #16428 was unsubstantiated for medications not being available.
Report Facts
Census at entrance: 39
Total capacity: 58
Inspection Report
Original Licensing
Census: 39
Capacity: 58
Deficiencies: 0
Nov 27, 2019
Visit Reason
The State Agency conducted an initial certification survey and complaint investigation related to medication availability.
Findings
The complaint investigation was unsubstantiated with no deficiencies cited. The facility was determined to be in compliance with Medicaid and Medicare requirements.
Complaint Details
Complaint Investigation MS #16428 was unsubstantiated for medications not being available.
Inspection Report
Annual Inspection
Census: 34
Capacity: 60
Deficiencies: 6
Jun 13, 2019
Visit Reason
The State Agency conducted an annual recertification survey from 6/11/2019 to 6/13/2019 to determine compliance with Minimum Standards of Operation for Institutions for the Aged or Infirm and state licensure requirements. Complaint surveys were also conducted during the recertification survey but were not substantiated.
Findings
The facility was found not in compliance with several standards including residents' rights, activities of daily living, accident prevention, medical records management, activity programming, and safe food handling procedures. Deficiencies included failure to provide privacy during toileting, inadequate oral care, failure to provide smoking aprons for safety, inaccurate medical record documentation, insufficient resident activities, and improper calibration of food thermometers leading to unsafe food temperatures.
Complaint Details
Complaint surveys MS #15927 and MS #15977 were conducted during the recertification survey but were not substantiated. No deficiencies were cited related to the complaints of Quality of Care/Treatment-Resident Safety/Falls or misappropriation of Property/misuse of residents personal property.
Severity Breakdown
Level II: 6
Deficiencies (6)
| Description | Severity |
|---|---|
| Failure to provide privacy during toileting for Resident #3. | Level II |
| Failure to provide adequate oral care to Resident #9. | Level II |
| Failure to provide smoking apron to Resident #3 assessed for smoking risks. | Level II |
| Failure to accurately document appropriate related diagnosis for use of Dilantin medication for Resident #17. | Level II |
| Failure to provide activities meeting residents' interests and needs, resulting in lack of group activities and resident dissatisfaction. | Level II |
| Failure to properly calibrate food thermometers, resulting in inaccurate food temperature readings and potential food safety risk. | Level II |
Report Facts
Census: 34
Total Capacity: 60
Deficiency count: 6
Residents affected: 32
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #4 | Licensed Practical Nurse | Named in privacy during toileting deficiency for Resident #3 |
| Director of Nursing | Director of Nursing | Involved in multiple deficiencies including privacy, oral care, smoking apron, and activity program |
| Regional Nurse Consultant | Regional Nurse Consultant | Conducted interview and in-service related to privacy deficiency |
| Corporate Regional Registered Nurse | Corporate Regional Registered Nurse | Conducted audit related to oral care deficiency |
| Licensed Practical Nurse #3 | Medical Records Nurse | Identified inaccurate diagnosis documentation for Resident #17 |
| Registered Pharmacist Consultant | Registered Pharmacist Consultant | Reviewed medication and diagnosis for Resident #17 |
| Medical Doctor | Medical Doctor | Confirmed inaccurate diagnosis for Resident #17 |
| Activity Director | Activity Director | Involved in activity program deficiency |
| Social Worker | Social Worker | Promoted from activities, involved in activity program deficiency |
| Dietary Manager #1 | Dietary Manager | Involved in food thermometer calibration deficiency |
| Dietary Staff #2 | Dietary Staff | Involved in food thermometer calibration deficiency |
| Dietary Staff #1 | Dietary Staff | Involved in food thermometer calibration deficiency |
Inspection Report
Annual Inspection
Census: 34
Capacity: 60
Deficiencies: 10
Jun 13, 2019
Visit Reason
The State Agency conducted an annual recertification survey along with complaint investigations from 6/11/19 to 6/13/19 to determine compliance with Medicare and Medicaid participation requirements.
Findings
The facility was found not in compliance with multiple regulatory requirements including resident rights, accuracy of assessments, comprehensive care plans, activities, food safety, and sanitary environment. Complaints were not substantiated. Deficiencies were cited in areas such as privacy during toileting, inaccurate MDS coding, failure to follow care plans, inadequate activities, improper thermometer calibration, and strong urine odor in a resident's room.
Complaint Details
Complaints MS #15927 for Quality of care/treatment and resident safety Falls and MS #15977 for Misappropriation of Funds were investigated and not substantiated; no citations related to the complaints.
Severity Breakdown
SS=D: 8
SS=E: 2
Deficiencies (10)
| Description | Severity |
|---|---|
| Failed to provide privacy during toileting for Resident #3. | SS=D |
| Failed to accurately code the Minimum Data Set (MDS) assessment for Resident #9. | SS=D |
| Failed to follow the comprehensive care plan for personal hygiene for Resident #9. | SS=D |
| Failed to update the comprehensive care plan to include the use of a smoking apron for Resident #3. | SS=D |
| Failed to provide oral care to Resident #9. | SS=D |
| Failed to provide activities to meet the interests and physical, mental, and psychosocial well-being of residents. | SS=E |
| Failed to provide a smoking apron to Resident #3 to prevent smoking accidents. | SS=D |
| Failed to accurately calibrate the food thermometer, risking unsafe food temperatures. | SS=E |
| Failed to accurately document an appropriate related diagnosis for the use of medication Dilantin for Resident #17. | SS=D |
| Failed to provide a sanitary room environment free of strong urine odor for Resident #29. | SS=D |
Report Facts
Deficiencies cited: 10
Census: 34
Total licensed capacity: 60
Brief Interview for Mental Status (BIMS) score: 10
Brief Interview for Mental Status (BIMS) score: 12
Brief Interview for Mental Status (BIMS) score: 15
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #4 | Licensed Practical Nurse | Named in privacy during toileting deficiency for Resident #3. |
| Licensed Practical Nurse #2 | Minimum Data Set Coordinator | Named in MDS coding and care plan deficiencies. |
| Director of Nursing | Director of Nursing | Involved in multiple findings including privacy, care plans, oral care, and smoking apron issues. |
| Regional Nurse Consultant | Regional Nurse Consultant | Conducted in-services and audits related to privacy and care plans. |
| Corporate Regional Director of Operations | Corporate Regional Director of Operations | Interviewed regarding activities and odor issues. |
| Dietary Manager #1 | Dietary Manager | Involved in food thermometer calibration deficiency. |
| Dietary Staff #2 | Dietary Staff | Observed improperly calibrating food thermometers. |
| Licensed Practical Nurse #3 | Medical Records Director | Named in medication diagnosis documentation deficiency. |
| Registered Pharmacist Consultant | Pharmacist | Interviewed regarding medication diagnosis review. |
| Registered Nurse #1 | Corporate Registered Nurse | Interviewed regarding medication diagnosis and odor issues. |
| Activity Director | Activity Director | Interviewed regarding lack of activities and resident complaints. |
| Social Worker | Social Worker | Interviewed regarding activities program. |
Inspection Report
Annual Inspection
Census: 34
Capacity: 60
Deficiencies: 10
Jun 13, 2019
Visit Reason
The State Agency conducted an annual recertification survey along with complaint investigations MS #15927 and MS #15977 from 6/11/19 to 6/13/19.
Findings
The facility was found not in compliance with Medicare and Medicaid participation requirements and cited multiple deficiencies. The complaints were not substantiated and no citations were related to them.
Complaint Details
Complaints MS #15927 for Quality of care/treatment and resident safety Falls, and MS #15977 for Misappropriation of Funds were investigated but not substantiated; no citations related to the complaints.
Deficiencies (10)
| Description |
|---|
| Deficiency F550 cited |
| Deficiency F641 cited |
| Deficiency F656 cited |
| Deficiency F657 cited |
| Deficiency F677 cited |
| Deficiency F679 cited |
| Deficiency F689 cited |
| Deficiency F812 cited |
| Deficiency F842 cited |
| Deficiency F921 cited |
Report Facts
Census: 34
Total licensed capacity: 60
Inspection Report
Annual Inspection
Census: 30
Capacity: 58
Deficiencies: 0
Dec 28, 2018
Visit Reason
The State Survey Agency conducted an annual recertification survey at the facility from 12/26/18 to 12/28/18 to determine compliance with Medicare and Medicaid requirements.
Findings
The facility was found to be in compliance with Medicare and Medicaid requirements for participation with no deficiencies cited during the survey.
Report Facts
Census: 30
Total Capacity: 58
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