Inspection Report
Plan of Correction
Deficiencies: 1
Jun 27, 2025
Visit Reason
The visit was conducted based on acceptance of a credible allegation of substantial compliance and Plan of Correction to certify the facility in compliance with health requirements effective June 27, 2025.
Findings
The facility was found to be in compliance with health requirements following the acceptance of the Plan of Correction. No new deficiencies were cited in this report.
Deficiencies (1)
| Description |
|---|
| Initial comments indicating acceptance of credible allegation of substantial compliance and Plan of Correction. |
Inspection Report
Annual Inspection
Census: 73
Deficiencies: 1
Jun 12, 2025
Visit Reason
The inspection was conducted as part of the facility's Annual Recertification Survey from June 9, 2025 to June 12, 2025.
Findings
The facility failed to meet food safety requirements related to procurement, storage, preparation, and serving of food, with observations of improper handling practices by staff during meal service that could lead to foodborne illness.
Severity Breakdown
SS=E: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Food safety requirements not met due to improper food handling and sanitation practices observed during meal service. | SS=E |
Report Facts
Census: 73
Inspection Report
Complaint Investigation
Deficiencies: 0
Mar 17, 2025
Visit Reason
A complaint investigation for Facility Reported Incident #127203-I was conducted from March 13, 2025 to March 17, 2025.
Findings
The facility was found to be in substantial compliance.
Complaint Details
Complaint investigation related to Facility Reported Incident #127203-I; facility found in substantial compliance.
Inspection Report
Complaint Investigation
Deficiencies: 0
Jan 22, 2025
Visit Reason
A complaint investigation for Complaints #124086-C and #125418-C was conducted from January 21, 2025 to January 22, 2025.
Findings
The facility was found to be in substantial compliance following the complaint investigation.
Complaint Details
Investigation was conducted for Complaints #124086-C and #125418-C; the facility was found to be in substantial compliance.
Inspection Report
Complaint Investigation
Deficiencies: 0
Sep 13, 2024
Visit Reason
A complaint investigation for Complaints #122008-C and #122730-C was conducted on September 13, 2024.
Findings
The facility was found to be in substantial compliance.
Complaint Details
Complaint investigation for Complaints #122008-C and #122730-C; facility found to be in substantial compliance.
Inspection Report
Annual Inspection
Deficiencies: 0
Jul 11, 2024
Visit Reason
An annual recertification survey and investigation of complaint #121533-C were conducted from July 8th, 2024 to July 11th, 2024.
Findings
The facility was found to be in substantial compliance.
Complaint Details
Investigation of complaint #121533-C was conducted during the survey.
Inspection Report
Complaint Investigation
Deficiencies: 0
May 17, 2024
Visit Reason
A complaint investigation for Complaints #120768-C and Facility Reported Incidents #118671-I was conducted from May 10, 2024 to May 17, 2024.
Findings
The facility was found to be in substantial compliance.
Complaint Details
Investigation was related to Complaints #120768-C and Facility Reported Incidents #118671-I; the facility was found to be in substantial compliance.
Inspection Report
Complaint Investigation
Census: 70
Deficiencies: 0
Sep 21, 2023
Visit Reason
A complaint investigation for complaint #112725-C was conducted from September 19, 2023 to September 21, 2023. Additionally, a COVID-19 Focused Infection Control Survey was conducted during the same period.
Findings
The facility was found to be in substantial compliance with no deficiencies noted. The COVID-19 survey found the facility in compliance with CMS and CDC recommended practices.
Complaint Details
Complaint #112725-C was investigated and the facility was found to be in substantial compliance.
Report Facts
Total Residents: 70
Inspection Report
Plan of Correction
Deficiencies: 0
May 23, 2023
Visit Reason
The document is a plan of correction submitted following a deficiency statement, indicating the facility's acceptance of compliance and corrective actions.
Findings
The facility was found to be in compliance based on acceptance of the credible allegation of compliance and plan of correction, effective May 19, 2023.
Inspection Report
Annual Inspection
Census: 75
Capacity: 75
Deficiencies: 3
Apr 17, 2023
Visit Reason
The inspection was conducted as the facility's annual recertification survey from April 17, 2023 to April 20, 2023.
Findings
The facility was found deficient in meeting professional standards of care related to comprehensive care plans, hydration and nutrition, infection prevention and control, and proper use of personal protective equipment. Specific issues included failure to follow physician orders for a gastrostomy tube flush, inadequate hydration provision, and lapses in infection control practices.
Deficiencies (3)
| Description |
|---|
| Failure to follow physician orders for gastrostomy tube flush for Resident #71. |
| Failure to provide fresh water to meet resident needs and preferences for Resident #19. |
| Failure to properly implement infection prevention and control program including hand hygiene, PPE use, and sanitization of equipment. |
Report Facts
Resident census: 75
Total licensed capacity: 75
Brief Interview for Mental Status (BIMS) score: 9
Brief Interview for Mental Status (BIMS) score: 13
Fluid volume prescribed: 2200
Fluid flush volume: 180
Fluid flush volume: 30
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Registered Nurse (RN) | Reported planned gastrostomy tube flush and performed blood sugar checks |
| Staff B | Assistant Director of Nursing (ADON) | Reported on water flush procedures and PPE supply |
| Staff C | Certified Nurse Assistant (CNA) | Reported water pass for shift |
| Staff D | Housekeeping | Observed wearing same gloves while collecting dirty laundry |
| Staff E | Certified Nurse Assistant (CNA) | Delivered meal to COVID isolation room and failed to don proper PPE |
| Staff F | Certified Nurse Assistant (CNA) | Reported PPE training and compliance |
| Staff G | Licensed Practical Nurse (LPN) | Reported staff training and audits on PPE |
| Staff J | Food and Beverage Assistant | Observed wearing cloth mask improperly |
| Staff K | Food and Beverage Assistant | Observed wearing cloth mask improperly |
| Director of Nursing (DON) | Director of Nursing | Reported expectations for following physician orders and infection control policies |
| Corporate Clinical Quality Specialist | Reported on EMAR system errors and infection control findings |
Inspection Report
Plan of Correction
Deficiencies: 0
Feb 20, 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 a credible allegation of compliance and plan of correction, effective February 6, 2023.
Inspection Report
Complaint Investigation
Census: 73
Deficiencies: 1
Jan 9, 2023
Visit Reason
Investigation of complaints #104409-C, #106618-C, #106619-C, #108072-C, and #108217-C was conducted from December 28, 2022 to January 9, 2023.
Findings
The facility failed to provide sufficient nursing supervision to prevent a resident from falling out of bed during incontinence care. Complaints #104409-C and #106619-C were substantiated, while #106618-C, #108072-C, and #108217-C were not substantiated.
Complaint Details
Complaints #104409-C and #106619-C were substantiated. Complaints #106618-C, #108072-C, and #108217-C were not substantiated.
Deficiencies (1)
| Description |
|---|
| Facility failed to provide sufficient nursing supervision to prevent a resident from falling out of bed during incontinence care. |
Report Facts
Census: 73
Complaints investigated: 5
Inspection Report
Plan of Correction
Deficiencies: 0
May 7, 2022
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 May 7, 2022.
Inspection Report
Complaint Investigation
Census: 67
Deficiencies: 1
Apr 7, 2022
Visit Reason
The inspection was conducted as a result of a complaint investigation (#103510-C) and a facility self-reported incident (#103614-I) concerning an injury to Resident #3 during transfer with a Hoyer lift.
Findings
The facility failed to immediately report a resident incident that resulted in injury, specifically a facial bruise sustained by Resident #3 during transfer with a Hoyer lift. Staff did not report the incident to nursing or the Director of Nursing as required by facility policy, though the incident was substantiated. The facility took corrective actions including education and audits.
Complaint Details
Complaint #103510-C and Facility Self-Reported Incident #103614-I were substantiated. The investigation revealed failure to report an injury incident involving Resident #3 during transfer with a Hoyer lift.
Deficiencies (1)
| Description |
|---|
| Facility staff failed to immediately report a resident incident that resulted in injury to Resident #3 during transfer with a Hoyer lift. |
Report Facts
Census: 67
Incident dates: 3
Bruise size: 2.9
Bruise size: 3.4
Bruise size: 3
Bruise size: 1.8
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Certified Nursing Assistant | Interviewed regarding the incident with Resident #3 and reported the incident to the nurse on duty. |
| Staff B | Certified Nursing Assistant | Worked with Resident #3 during the incident, did not report the injury to nurse or DON. |
| Staff C | Certified Nursing Assistant | Worked with Staff B during the incident, did not report the injury to nurse or DON. |
| Director of Nursing | Director of Nursing | Provided education on accident/incident reporting and initiated corrective actions. |
Inspection Report
Annual Inspection
Census: 65
Deficiencies: 12
Dec 13, 2021
Visit Reason
The inspection was the facility's annual health survey conducted from 11/29/21 to 12/13/21 to assess compliance with federal regulations.
Findings
The survey identified multiple deficiencies including failure to treat residents with dignity, failure to report reasonable suspicion of a crime, failure to involve residents in care planning, inadequate pain management, failure to provide pre and post dialysis assessments, insufficient nursing staff leading to delayed call light responses, failure to document narcotic counts, improper drug storage, failure to serve appropriate food textures, improper food handling and hand hygiene, and failure to follow infection control procedures during catheter care.
Severity Breakdown
SS=D: 4
SS=G: 1
SS=E: 7
Deficiencies (12)
| Description | Severity |
|---|---|
| Failure to ensure staff treated residents with respect and dignity while providing care for 1 of 24 residents reviewed (Resident #29). | SS=D |
| Failure to notify proper officials of reasonable suspicion of a crime and unexplained loss of money for 1 of 1 resident reviewed (Resident #23). | SS=D |
| Failure to prevent further financial exploitation from occurring while the facility had reasonable suspicion for 1 of 1 resident reviewed (Resident #23). | SS=D |
| Failure to involve the resident and/or resident's representative in the interdisciplinary team care planning process for 3 of 17 sampled residents (Residents #23, #26, #28). | SS=D |
| Failure to ensure staff provided pain management consistent with professional standards for 1 of 2 residents reviewed (Resident #23). | SS=G |
| Failure to consistently provide pre and post dialysis assessments for 1 of 1 resident reviewed (Resident #63). | SS=D |
| Failure to respond to residents' call lights in a timely manner (within 15 minutes) for 8 of 17 residents reviewed (Residents #12, #26, #28, #29, #36, #49, #53, #57). | SS=E |
| Failure to document narcotic counts to ensure accurate reconciliation accounting for all controlled narcotic medications for 2 of 2 medication carts reviewed. | SS=E |
| Failure to ensure staff stored drugs in accordance with professional principles and narcotic keys were only accessible to authorized personnel. | SS=E |
| Failure to ensure staff served appropriate food textures for 6 of 6 residents requiring mechanical soft diets (Residents #12, #14, #19, #36, #41, #42). | SS=E |
| Failure to serve food in accordance with professional standards for food service safety and failure to practice proper hand hygiene during lunch meal service. | SS=E |
| Failure to ensure staff followed accepted infection control techniques while providing catheter care for 3 of 5 residents reviewed (Residents #36, #53, #113). | SS=E |
Report Facts
Residents with delayed call light response: 8
Narcotic sign-out sheet missing nurse initials: 25
Expired medications found: 7
Residents reviewed for mechanical soft diet: 6
Residents reviewed for catheter care: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff Q | Agency Certified Nursing Assistant | Reported witnessing another agency CNA strike Resident #29's foot |
| Staff P | Agency Certified Nursing Assistant | Alleged to have struck Resident #29's foot and forcibly pushed resident's legs down |
| Staff N | Social Worker | Handled financial exploitation case of Resident #23, failed to report to authorities |
| Staff J | Licensed Practical Nurse | Administered pain medication to Resident #23 but did not reassess pain |
| Staff F | Dining Staff | Served inappropriate food textures and failed hand hygiene during meal service |
| Staff K | Certified Nursing Assistant | Failed to follow infection control during catheter care for Resident #53 |
| Staff M | Certified Nursing Assistant | Assisted Resident #36 with catheter care but left catheter bag on floor |
| Staff D | Certified Medication Aide | Assisted Resident #36 with catheter care and left catheter bag on floor |
| Staff C | Licensed Practical Nurse | Counted narcotics but did not always sign narcotic log |
| Staff B | Licensed Practical Nurse | Counted narcotics but noted previous shift nurse did not sign narcotic log |
| Staff S | Certified Nursing Assistant | Reported staffing adequate 9/10 times but asked nurses for help when needed |
| Staff T | Registered Nurse | Acknowledged call light delays and phone system issues |
| Staff U | Certified Medical Assistant | Reported call light delays and phone system issues |
| Director of Nursing | Director of Nursing | Provided education on call light response, narcotic counts, medication storage, pain management, catheter care, and medication audits |
| Administrator | Administrator | Reported call light system issues and staff education |
| Dining Director | Dining Director | Provided education on food textures and hand hygiene |
| Dietician | Dietician | Provided education on food textures and hand hygiene |
| Physician | Primary Physician | Expected pain management and timely notification |
Inspection Report
Complaint Investigation
Census: 66
Deficiencies: 2
Sep 8, 2021
Visit Reason
The inspection was conducted due to investigation of facility reported incidents 97449-I and 99401-I, and complaints 97423-C and 99271-C. The facility reported incidents and complaints were substantiated.
Findings
The facility failed to ensure residents received treatment and care in accordance with professional standards, including failure to thoroughly assess and intervene after a fall, and failure to prevent and assess pressure ulcers. Specific deficiencies were found related to quality of care and skin integrity for residents reviewed.
Complaint Details
The investigation related to complaints 97423-C and 99271-C was substantiated. Facility reported incidents 97449-I and 99401-I were also substantiated.
Deficiencies (2)
| Description |
|---|
| Facility failed to assure staff complete thorough assessment and intervention at the time of a fall for 1 of 3 residents reviewed. |
| Facility failed to prevent and thoroughly assess a pressure ulcer for 1 of 3 residents reviewed. |
Report Facts
Residents reviewed: 3
Census: 66
Inspection Report
Abbreviated Survey
Census: 60
Deficiencies: 0
Nov 3, 2020
Visit Reason
A focused COVID-19 infection survey was conducted to assess the facility's compliance with CMS and CDC recommended practices for COVID-19 preparation.
Findings
The facility was found to be in compliance with CMS and CDC recommended practices to prepare for COVID-19.
Inspection Report
Complaint Investigation
Census: 69
Deficiencies: 0
Sep 24, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey and investigation of Complaint #93209-C was conducted by the Department of Inspection and Appeals.
Findings
The facility was found to be in compliance with CMS and CDC recommended practices to prepare for COVID-19. Complaint #93209-C was not substantiated.
Complaint Details
Complaint #93209-C was investigated and found not substantiated.
Report Facts
Total census: 69
Inspection Report
Abbreviated Survey
Census: 58
Deficiencies: 0
Jun 10, 2020
Visit Reason
A COVID 19 Focused Infection Control Survey was conducted by the Department of Inspections and Appeals on 6/10/2020 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.
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