Deficiencies per Year
12
9
6
3
0
Severe
High
Moderate
Low
Unclassified
Census Over Time
Inspection Report
Plan of Correction
Deficiencies: 0
Jun 12, 2025
Visit Reason
The document is a Plan of Correction related to a survey ending on May 29, 2025, addressing the facility's compliance status.
Findings
The facility was found to be in substantial compliance based on the credible allegation and Plan of Correction, resulting in certification effective June 11, 2025.
Inspection Report
Annual Inspection
Census: 27
Deficiencies: 3
May 29, 2025
Visit Reason
The inspection was conducted as part of the facility's annual recertification survey and investigation of complaint #128279-C, conducted from May 27, 2025 to May 29, 2025.
Findings
The facility was found deficient in updating comprehensive care plans for residents at risk of elopement and antibiotic use, failure to meet professional standards in medication administration, and failure to ensure accident hazards were minimized. Specific deficiencies included incomplete care plans for residents #18 and #26, improper inhaler administration for resident #16, and inconsistent implementation of fall prevention interventions for resident #18.
Complaint Details
The visit included investigation of complaint #128279-C.
Severity Breakdown
SS=D: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Failure to update Care Plan for 2 of 12 residents for risk of elopement and use of an antibiotic. | SS=D |
| Failure to instruct a resident to swish and spit after inhalation medication administration. | SS=D |
| Failure to ensure fall interventions were consistently implemented for 1 of 3 residents reviewed for accidents. | SS=D |
Report Facts
Census: 27
Residents reviewed for care plan deficiency: 12
Residents reviewed for accident interventions: 3
Brief Interview for Mental Status (BIMS) score: 7
Brief Interview for Mental Status (BIMS) score: 15
Brief Interview for Mental Status (BIMS) score: 14
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff D | Certified Medication Aide (CMA) | Named in medication administration deficiency for improper inhaler use. |
| Staff C | Certified Nursing Assistant (CNA) | Interviewed regarding resident #18's wandering behavior. |
| Staff F | Certified Nursing Assistant (CNA) | Interviewed regarding resident #18's wandering behavior. |
| Assistant Director of Nursing | Assistant Director of Nursing (ADON) | Provided information about resident #18's confusion and care plan. |
| Staff A | Licensed Practical Nurse (LPN) | Queried about alarms for resident #18. |
| Staff B | Certified Nursing Assistant (CNA) | Observed and managed alarms for resident #18. |
Inspection Report
Complaint Investigation
Deficiencies: 0
Mar 10, 2025
Visit Reason
A complaint investigation for complaint #124601-C was conducted on March 10, 2025.
Findings
The facility was found to be in substantial compliance.
Complaint Details
Complaint #124601-C was investigated and the facility was found to be in substantial compliance.
Inspection Report
Annual Inspection
Deficiencies: 0
Aug 8, 2024
Visit Reason
An annual recertification survey and investigation of complaint #122601-C was conducted from August 5, 2024 to August 8, 2024.
Findings
The facility was found to be in substantial compliance with no deficiencies cited.
Complaint Details
Investigation of complaint #122601-C was conducted during the survey.
Inspection Report
Plan of Correction
Deficiencies: 0
Mar 17, 2024
Visit Reason
The document serves as a Plan of Correction following a survey to address deficiencies and certify the facility in compliance.
Findings
The facility was found to be in substantial compliance based on the credible allegation and Plan of Correction accepted, resulting in certification effective March 17, 2024.
Inspection Report
Complaint Investigation
Census: 29
Deficiencies: 1
Mar 13, 2024
Visit Reason
The inspection was conducted as a revisit of the survey ending January 22, 2024, and investigation of Complaints #118918-C and #119081-C from March 11 to March 13, 2024.
Findings
The facility failed to provide daily showers per physician orders for 3 of 3 residents reviewed, including Resident #5, who refused some showers. The facility lacked documentation of nurse notification of refusals. Complaint #118918-C was substantiated.
Complaint Details
Complaint #118918-C was substantiated based on findings related to inadequate ADL care and shower provision.
Deficiencies (1)
| Description |
|---|
| Failure to provide showers daily per physician orders for dependent residents and lack of documentation of nurse notification of refusals. |
Report Facts
Resident census: 29
Correction date: Mar 17, 2024
Number of residents reviewed for showers: 3
Bathing audit period: 14
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Employee B | Certified Nurse Aide (CNA) | Received corrective action and was removed from Shower Aide position for not reporting resident refusals |
| Assistant Director of Nursing | Assistant Director of Nursing (ADON) | Interviewed regarding shower schedules and refusals |
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding shower frequency and refusals |
Inspection Report
Annual Inspection
Census: 30
Deficiencies: 7
Jan 22, 2024
Visit Reason
The inspection was conducted as part of the facility's Annual Recertification Survey and investigation of Complaint #114806-C and Facility Self-Reported Incident #116131-I from January 8, 2024 to January 22, 2024.
Findings
The facility was found to have deficiencies related to failure to notify the physician of significant resident changes, failure to protect residents from verbal abuse and neglect by staff, failure to report alleged violations timely, failure to update care plans, failure to ensure medication cart security, and failure to provide adequate staff training and supervision. The complaint and self-reported incidents were substantiated.
Complaint Details
Complaint #114806-C was substantiated. Facility Self-Reported Incident #116131-I was substantiated.
Deficiencies (7)
| Description |
|---|
| Failure to notify the physician after resident expressed thoughts of self-harm and significant change in condition. |
| Failure to protect residents from verbal abuse and neglect by a staff member. |
| Failure to report allegations of abuse and verbal abuse from a staff member to the State Agency within required timeframes. |
| Failure to update care plans timely, including for residents on diuretics and high-risk medications. |
| Failure to ensure medication cart was locked and secure when unattended. |
| Failure to provide adequate ongoing Quality Assurance and Performance Improvement (QAPI) training and education to staff. |
| Failure to ensure residents were free from accident hazards, including burns from hot liquids. |
Report Facts
Census: 30
Dates of Survey: January 8, 2024 through January 22, 2024
Number of residents reviewed for abuse: 6
Number of residents with verbal abuse by staff: 3
Number of residents with severely impaired cognition: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Certified Nursing Assistant (CNA) | Named in verbal abuse and neglect findings; suspended pending investigation. |
| Staff F | Registered Nurse (RN) | Interviewed regarding notification of physician and resident self-harm. |
| Staff D | Certified Nursing Assistant (CNA) | Witnessed verbal abuse by Staff B and provided statements. |
| Staff E | Registered Nurse (RN) | Reported negative sarcastic comments by Staff B to residents. |
| Staff J | Certified Nursing Assistant (CNA) | Provided statements about Staff B's behavior and staffing issues. |
| Staff Q | Certified Nursing Assistant (CNA) | Interviewed about staff treatment concerns and Staff B's behavior. |
| Staff R | Certified Nursing Assistant (CNA) | Explained incidents involving Staff B and resident agitation. |
| Staff M | Licensed Practical Nurse (LPN) | Denied hearing anything concerning about camera device in resident room. |
| Staff O | Certified Nursing Assistant (CNA) | Explained knowledge of staffing CNA passing trays and resident care. |
| Staff A | Licensed Practical Nurse (LPN) | Confirmed medication cart lock status during observation. |
| V. Irvin | RN MHA COO Capstone Management | Met with IDT and staff to re-educate regarding QAPI policy and procedures. |
Inspection Report
Plan of Correction
Deficiencies: 0
May 25, 2023
Visit Reason
The document reflects acceptance of a credible allegation of compliance and plan of correction for the facility.
Findings
The facility was certified in compliance effective May 25, 2023, based on acceptance of the credible allegation of compliance and plan of correction.
Inspection Report
Complaint Investigation
Census: 34
Deficiencies: 1
May 8, 2023
Visit Reason
The inspection was conducted as a result of investigations into Complaints #107104-C, #108352-C and Facility Reported Incidents #107940-I and #111320-I from May 1, 2023 to May 8, 2023. Complaint #108352-C was substantiated.
Findings
The facility failed to ensure that Resident #5's medical needs were met according to professional standards of care, specifically regarding coordination and follow-up of urology appointments and transportation, which contributed to the resident's decline and hospitalization for sepsis.
Complaint Details
The visit was complaint-related, investigating Complaints #107104-C, #108352-C and Facility Reported Incidents #107940-I and #111320-I. Complaint #108352-C was substantiated.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure Resident #5's medical needs were met in accordance with professional standards of care, including inadequate follow-up on urology appointments and transportation arrangements. | SS=D |
Report Facts
Facility reported census: 34
Complaints investigated: 2
Facility Reported Incidents investigated: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff E | MDS coordinator | Interviewed regarding transportation arrangements and follow-up on Resident #5's urology appointments |
| Staff H | Registered Nurse | Interviewed about education provided to Resident #5's spouse and observations related to hematuria and resident's condition |
| Assistant Director of Nursing | Assistant Director of Nursing (ADON) | Interviewed regarding coordination of transportation and physician notification about Resident #5's decline |
Inspection Report
Annual Inspection
Deficiencies: 0
Aug 31, 2022
Visit Reason
The inspection was conducted as an annual health survey and investigation to assess compliance with regulatory requirements.
Findings
Based on acceptance of the credible allegation of compliance and plan of correction following the annual health survey and investigation ending August 12, 2022, the facility was certified in compliance effective August 31, 2022.
Inspection Report
Annual Inspection
Census: 31
Deficiencies: 10
Aug 12, 2022
Visit Reason
The inspection was conducted as part of the facility's annual recertification survey and investigation of complaint #104069-C and facility-reported incidents #98965-I and #106858-I.
Findings
The facility was found deficient in multiple areas including failure to ensure advance directives were properly completed and signed, failure to prevent staff-to-resident abuse, failure to develop and implement abuse prevention policies and training, failure to report abuse allegations timely, failure to thoroughly investigate abuse allegations, failure to develop a comprehensive care plan for respiratory therapy, failure to provide proper respiratory care including CPAP equipment cleaning, failure to properly label and store medications, failure to update the facility-wide assessment annually, and failure to ensure all staff received abuse prevention training.
Complaint Details
Complaint #104069-C was not substantiated. Facility-reported incidents #98965-I and #106858-I were substantiated.
Severity Breakdown
SS=E: 6
SS=D: 2
SS=F: 1
Deficiencies (10)
| Description | Severity |
|---|---|
| Failed to ensure advance directives were completed and signed by appropriate persons for five residents. | SS=E |
| Failed to ensure 6 residents were free from staff-to-resident abuse. | SS=E |
| Failed to ensure written abuse prohibition policies and procedures were developed and consistently implemented. | SS=E |
| Failed to ensure allegations of abuse were reported immediately to the facility Administrator and other officials. | SS=E |
| Failed to ensure thorough investigations were completed related to allegations of staff-to-resident abuse. | SS=E |
| Failed to develop a care plan for a resident's sleep apnea and CPAP therapy. | SS=D |
| Failed to provide respiratory services in accordance with standards of practice for a resident using CPAP therapy, including proper cleaning and storage of equipment. | SS=D |
| Failed to ensure all medications and biologicals were stored and labeled properly, including undated opened medications and improper storage of topical and oral medications. | SS=E |
| Failed to update the facility-wide assessment annually to determine resources necessary to competently care for residents. | SS=F |
| Failed to ensure all staff received planned abuse prevention training. | SS=D |
Report Facts
Residents reviewed for advance directives: 17
Current residents census: 31
Residents reviewed for abuse: 7
BIMS score: 15
BIMS score: 11
BIMS score: 6
BIMS score: 14
BIMS score: 15
CPAP order date: 2022
Tubersol Tuberculin stability: 30
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff Q | Certified Nursing Assistant | Named in multiple abuse allegations involving several residents. |
| Staff O | Certified Nursing Assistant | Named in abuse allegations and removed from facility. |
| Staff P | Certified Nursing Assistant | Named in abuse allegations and removed from facility. |
| Staff G | Certified Medication Aide | Failed to receive required abuse prevention training and administered unlabeled medication. |
| Staff L | Registered Nurse | Named in verbal abuse allegation by Resident #13. |
| Staff R | Registered Nurse | Reported abuse allegations but delayed reporting to Administrator. |
| Staff Y | Certified Nursing Assistant | Heard abuse complaints but did not report timely. |
| Staff AA | Licensed Practical Nurse | Heard abuse complaints but did not report timely. |
| Staff Z | Certified Nursing Assistant | Heard abuse complaints but did not report timely. |
| Staff T | Licensed Practical Nurse | Heard abuse complaints but did not report timely. |
| Staff U | Certified Nursing Assistant | Heard abuse complaints but did not report timely. |
| Staff V | Certified Nursing Assistant | Heard abuse complaints but did not report timely. |
| Staff W | Certified Nursing Assistant | Heard abuse complaints but did not report timely. |
| Staff K | Certified Nursing Assistant | Heard abuse complaints but did not report timely. |
| Staff J | Certified Nursing Assistant | Reported agency staff abuse and cursing. |
| Staff F | Registered Nurse | Responsible for CPAP care and medication cart observations. |
| Staff D | Infection Control Preventionist / MDS Nurse | Responsible for care plans and infection control. |
| Administrator | Facility Administrator | Responsible for abuse investigations and reporting. |
| ADON | Assistant Director of Nursing | Responsible for care plans and staff education. |
Inspection Report
Renewal
Deficiencies: 0
Mar 25, 2021
Visit Reason
A Recertification Survey and Facility Reported Incident #96394-I were conducted March 22 - 25, 2021.
Findings
The facility was found in substantial compliance. Facility Reported Incident #96394-I was not substantiated.
Inspection Report
Routine
Census: 25
Deficiencies: 1
Dec 8, 2020
Visit Reason
A COVID-19 focused infection control survey was conducted by the Centers for Medicare & Medicaid Services (CMS) to assess compliance with CDC recommended practices for COVID-19 preparation and infection prevention.
Findings
The facility failed to implement an ongoing system of surveillance to identify possible trends of communicable diseases, specifically lacking timely infection tracking and trending for November 2020. This deficiency had the potential to affect all 25 residents. The facility was found not in compliance with infection prevention and control requirements.
Deficiencies (1)
| Description |
|---|
| Failure to implement an ongoing system of surveillance designed to identify possible trends of communicable diseases, including timely infection tracking and trending. |
Report Facts
Total residents: 25
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Mavis Johnson | Administrator | Signed the statement of deficiencies |
| Director of Nursing | Interviewed regarding infection control and resident COVID-19 positive case | |
| Infection Prevention Nurse | Interviewed regarding infection control tracking and trending |
Inspection Report
Abbreviated Survey
Census: 29
Deficiencies: 0
Oct 12, 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
Complaint Investigation
Census: 29
Deficiencies: 2
Aug 17, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey and facility reported incident #92672 were conducted from August 10-17, 2020. The visit was complaint-related and focused on investigating the substantiated incident involving inadequate supervision of a cognitively impaired resident who eloped from the facility.
Findings
The facility failed to adequately supervise a cognitively impaired resident who eloped from the facility without staff knowledge. The resident was found approximately 10 miles away at her home. The facility identified 4 residents as independently mobile and cognitively impaired. Additionally, the facility failed to complete annual performance reviews for nurse aides as required.
Complaint Details
Facility reported incident #92672 was substantiated involving inadequate supervision leading to elopement of Resident #1.
Deficiencies (2)
| Description |
|---|
| Facility failed to adequately supervise a cognitively impaired resident who eloped from the facility. |
| Facility failed to complete annual performance reviews for 3 of 3 nurse aides sampled. |
Report Facts
Census: 29
Residents identified as independently mobile and cognitively impaired: 4
Nurse Aides sampled for performance review: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Housekeeper | Interviewed regarding elopement incident and front door alarm |
| Staff C | Nurse Aide | Interviewed and noted as one of the nurse aides missing annual performance review |
| Staff D | Nurse Aide | Interviewed and noted as one of the nurse aides missing annual performance review |
| Staff E | Nurse Aide | Interviewed and noted as one of the nurse aides missing annual performance review |
| Staff B | Registered Nurse | Interviewed regarding elopement incident and resident whereabouts |
| Director of Nurses | Director of Nursing | Interviewed regarding elopement incident and facility safety concerns |
| Administrator | Administrator | Interviewed regarding elopement drills and staff procedures |
| Business Office Manager | Business Office Manager | Interviewed regarding delays in completion of performance reviews |
Inspection Report
Routine
Deficiencies: 0
Jun 3, 2020
Visit Reason
A COVID-19 survey was conducted on June 3, 2020 to assess compliance with relevant regulations.
Findings
No deficiencies were identified during the COVID-19 survey conducted on June 3, 2020.
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