Deficiencies per Year
4
3
2
1
0
Severe
High
Moderate
Low
Unclassified
Census Over Time
Inspection Report
Complaint Investigation
Deficiencies: 0
Jun 3, 2025
Visit Reason
A complaint investigation for complaint #128986-C was conducted from May 30, 2025 to June 3, 2025.
Findings
No deficiency was cited related to the investigation of complaint #128986-C.
Complaint Details
Complaint #128986-C was investigated and found to have no deficiencies.
Inspection Report
Annual Inspection
Deficiencies: 0
Dec 12, 2024
Visit Reason
An annual recertification survey was conducted from December 9, 2024 through December 12, 2024.
Findings
The facility was found to be in substantial compliance.
Inspection Report
Complaint Investigation
Census: 45
Deficiencies: 0
Aug 8, 2024
Visit Reason
Investigation of a facility self-reported incident #122161-I and complaint #122055-C conducted from August 7, 2024 through August 8, 2024.
Findings
No deficiencies resulted from the investigation of the self-reported incident and complaint.
Complaint Details
Investigation of complaint #122055-C and incident #122161-I found no deficiencies.
Inspection Report
Complaint Investigation
Deficiencies: 0
Apr 30, 2024
Visit Reason
A complaint investigation for complaint #115348-C was conducted from April 29, 2024 to April 30, 2024.
Findings
The facility was found to be in substantial compliance.
Complaint Details
Complaint #115348-C was investigated and the facility was found to be in substantial compliance.
Inspection Report
Plan of Correction
Deficiencies: 0
Nov 28, 2023
Visit Reason
The document serves as a Plan of Correction following a survey to address deficiencies and certify the facility's compliance.
Findings
The facility was found to be in substantial compliance based on the credible allegation and Plan of Correction, resulting in certification effective November 28, 2023.
Inspection Report
Annual Inspection
Census: 50
Deficiencies: 1
Nov 16, 2023
Visit Reason
The inspection visit was conducted as part of the facility's Annual Recertification Survey and an investigation of Complaint #114091-C and Facility Self-Reported Incident #116828-I from November 13, 2023 to November 16, 2023.
Findings
The facility failed to ensure comprehensive care plans were reviewed and revised for residents as required, including hearing aid placement, pain management, and medication monitoring. Deficiencies were noted in care plan timing, revision, and documentation for multiple residents.
Complaint Details
The visit included an investigation of Complaint #114091-C and Facility Self-Reported Incident #116828-I.
Deficiencies (1)
| Description |
|---|
| Care plans were not developed within 7 days after completion of the comprehensive assessment and were not reviewed and revised by the interdisciplinary team after each assessment. |
Report Facts
Resident census: 50
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Richard Curley | Administrator | Signed the initial comments on the statement of deficiencies |
| Director of Nursing (DON) | Stated plans for resident hearing aids and care plan expectations | |
| RAI Coordinator | Confirmed hearing aid placement and care plan documentation issues |
Inspection Report
Plan of Correction
Deficiencies: 0
Dec 14, 2022
Visit Reason
The document is a plan of correction submitted following a survey to address deficiencies and certify compliance of the facility.
Findings
The facility was found to be in compliance based on acceptance of the credible allegation of compliance and plan of correction effective December 14, 2022.
Inspection Report
Annual Inspection
Census: 45
Deficiencies: 4
Nov 17, 2022
Visit Reason
The inspection was conducted as the facility's Annual Recertification Survey from November 14, 2022 to November 17, 2022.
Findings
The facility was found deficient in multiple areas including accuracy of resident assessments, care plan timing and revision, professional standards of services provided, and infection prevention and control. Specific issues included inaccurate pain medication coding, failure to follow care plans for residents, inadequate infection control practices, and failure to document incidents properly.
Severity Breakdown
SS=D: 4
Deficiencies (4)
| Description | Severity |
|---|---|
| Accuracy of Assessments - facility failed to accurately code the use of as needed pain medication on the Minimum Data Set (MDS) Assessment for residents. | SS=D |
| Care Plan Timing and Revision - facility failed to follow care plans as written for residents and did not include all required interdisciplinary team members in care plan development. | SS=D |
| Services Provided Meet Professional Standards - facility failed to provide professional standards of quality for medication review and care planning. | SS=D |
| Infection Prevention & Control - facility failed to establish and maintain an infection prevention and control program including proper hand hygiene and blood glucose monitoring procedures. | SS=D |
Report Facts
Census: 45
Deficiencies cited: 4
Pain medication doses: 10
Brief Interview for Mental Status (BIMS) score: 11
Brief Interview for Mental Status (BIMS) score: 3
Brief Interview for Mental Status (BIMS) score: 15
Brief Interview for Mental Status (BIMS) score: 4
Fluid intake: 501
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Registered Nurse (RN) | Observed administering medication and performing hand hygiene incorrectly |
| Staff B | Registered Nurse (RN) | Observed performing blood glucose monitoring with improper glove use |
| Staff C | Registered Nurse (RN) | Reported use of isolation bin and failure to wear gown during PICC line care |
| Staff D | Certified Nurse Aide (CNA) | Interviewed regarding incident recall |
| Staff E | Certified Nurse Aide (CNA) | Interviewed regarding resident pills incident |
| Director of Nursing (DON) | Director of Nursing | Interviewed regarding policies and expectations for MDS accuracy and care plans |
| Staff F | Registered Nurse (RN) | Re-educated on assessment and reporting requirements and provided late medication error report |
| Staff nurse | Requires additional training on glucometer use and hand hygiene/gloving per corrective action plan |
Inspection Report
Re-Inspection
Deficiencies: 0
Oct 26, 2022
Visit Reason
On-site revisit completed October 25-26, 2022 to verify compliance and certification status of the facility.
Findings
The facility was certified in compliance effective October 11, 2022. The plan of correction was not effectuated.
Inspection Report
Complaint Investigation
Census: 50
Deficiencies: 1
Sep 21, 2022
Visit Reason
The inspection was conducted as an investigation of complaints #105176-C, #105230-C, #107464-C, and a facility self-reported incident #105168-M during the period 9/13/22 to 9/21/22.
Findings
The facility failed to assess, document, notify the provider and family, and provide ongoing assessment and treatment for a reported wound on Resident #2, which led to infection, surgery, and the resident's death. Complaints #105176-C and #105230-C were substantiated, while complaint #107464 was not substantiated.
Complaint Details
Complaints #105176-C and #105230-C were substantiated. Complaint #107464 was not substantiated.
Severity Breakdown
SS=G: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to assess, document, notify provider and family, and provide ongoing assessment and treatment for a reported wound on Resident #2. | SS=G |
Report Facts
Complaint numbers: 3
Facility self-reported incident: 1
Census: 50
Dates of incident and survey: Incident dates 9/13/22 to 9/21/22; wound dressing dated 5/31/22; resident passed away 6/27/22
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Registered Nurse (RN) | Named in wound assessment and documentation deficiencies |
| Staff B | Registered Nurse (RN) | Completed Re-Admission Skin Assessment and notified provider and family |
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding wound assessment and documentation |
| Medical Director | Medical Director (MD) | Interviewed regarding wound care expectations and resident condition |
| Physical Therapist | Physical Therapist (PT) | Confirmed open area on resident's left elbow |
| Orthopedic Surgeon | Orthopedic Surgeon | Provided medical opinion on wound and surgery |
| MDS Coordinator | MDS Coordinator | Confirmed wound assessment and documentation deficiencies |
Inspection Report
Renewal
Census: 43
Deficiencies: 2
Jul 29, 2021
Visit Reason
The inspection was conducted as a Recertification Survey and investigation of a Facility Self-Reported Incident #91050 from 7/26/21 to 7/29/21.
Findings
The facility was found to have deficiencies related to enteral nutrition and food safety requirements, including failure to ensure proper checking of gastric tube placement prior to feeding and failure to date opened food items in the refrigerator and properly label and store dried food items.
Deficiencies (2)
| Description |
|---|
| Failure to ensure a resident fed by enteral means receives appropriate treatment and services to prevent complications of enteral feeding. |
| Failure to date opened items when placed in the refrigerator and to properly label and store dried food items. |
Report Facts
Census: 43
Deficiencies cited: 2
Inspection Report
Abbreviated Survey
Census: 39
Deficiencies: 0
Dec 3, 2020
Visit Reason
A Focused COVID-19 Infection Control Survey was conducted from 12/2 - 12/3/2020 by the Department of Inspections and Appeals 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.
Inspection Report
Routine
Census: 33
Deficiencies: 0
Jul 14, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the Department of Inspections and Appeals on 7/13-14/20 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.
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 Inspection 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
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