Inspection Report Summary
The most recent inspection on June 11, 2025, found no deficiencies related to the complaint investigated. Earlier inspections showed a pattern of deficiencies primarily involving medication management, life safety code compliance, and individualized resident care, including failure to follow physician orders and inadequate fire safety maintenance. Complaint investigations generally resulted in no deficiencies, though a few substantiated complaints cited issues such as failure to report abuse timely and inadequate care planning for residents with dementia-related behaviors. Enforcement actions such as fines or license suspensions were not listed in the available reports. The facility’s recent clean inspections suggest some improvement following prior citations, particularly in complaint investigations and medication handling.
Deficiencies (last 3 years)
Deficiencies (over 3 years)
14 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
233% worse than Indiana average
Indiana average: 4.2 deficiencies/yearDeficiencies per year
8
6
4
2
0
Census
Latest occupancy rate
100% occupied
Based on a June 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Census over time
Inspection Report
Complaint Investigation
Census: 27
Capacity: 27
Deficiencies: 0
Date: Jun 11, 2025
Visit Reason
This visit was conducted for the investigation of Complaint IN00459469.
Complaint Details
Complaint IN00459469 was investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to the complaint allegations were cited. The facility was found to be in compliance with applicable regulations.
Report Facts
Census Payor Type - Medicare: 2
Census Payor Type - Medicaid: 20
Census Payor Type - Other: 5
Inspection Report
Complaint Investigation
Census: 28
Capacity: 28
Deficiencies: 0
Date: May 9, 2025
Visit Reason
This visit was conducted for the investigation of Complaint IN00457843.
Complaint Details
Complaint IN00457843 was investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to the complaint allegations were cited. The facility was found to be in compliance with applicable regulations.
Report Facts
Medicare residents: 4
Medicaid residents: 20
Other payor residents: 4
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Apr 11, 2025
Visit Reason
The visit was a paper compliance review related to the Investigation of Complaint IN00453004 completed on March 13, 2025.
Complaint Details
Investigation of Complaint IN00453004 was completed with findings of compliance.
Findings
Envive of Hartford City was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 based on the paper review of the complaint investigation.
Inspection Report
Complaint Investigation
Census: 31
Capacity: 31
Deficiencies: 0
Date: Apr 9, 2025
Visit Reason
This visit was conducted for the investigation of Complaint IN00456841.
Complaint Details
Complaint IN00456841 was investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to the complaint allegations were cited. The facility was found to be in compliance with applicable regulations.
Report Facts
Census: 31
Total Capacity: 31
Medicare Census: 2
Medicaid Census: 21
Other Payor Census: 8
Inspection Report
Complaint Investigation
Census: 29
Capacity: 29
Deficiencies: 1
Date: Mar 13, 2025
Visit Reason
The visit was conducted for the investigation of Complaints IN00453004 and IN00453733. Complaint IN00453004 resulted in federal/state deficiencies cited, while Complaint IN00453733 had no deficiencies related to the allegations.
Complaint Details
Complaint IN00453004 was substantiated with federal/state deficiencies cited at F761. Complaint IN00453733 was not substantiated with no deficiencies cited.
Findings
The facility failed to ensure resident medications were properly labeled and disposed of for 1 of 3 medication carts observed. Specifically, an uncovered paper medication cup with medications was found in the medication cart, indicating failure to destroy refused medications immediately as required by policy.
Deficiencies (1)
Facility failed to ensure resident medications were properly labeled and disposed of for 1 of 3 medication carts observed.
Report Facts
Census: 29
Licensed Capacity: 29
Medicare Residents: 4
Medicaid Residents: 21
Other Payor Residents: 4
Medication Cart Audits Frequency: 5
Medication Cart Audits Frequency: 3
Medication Cart Audits Frequency: 2
Date of Completion: Apr 2, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Sarah Jackman | Laboratory Director or Provider/Supplier Representative | Signed the report |
| Director of Nursing | Interviewed regarding medication disposal procedures | |
| LPN 3 | Licensed Practical Nurse | Interviewed regarding observation of medication cart |
Inspection Report
Complaint Investigation
Census: 30
Capacity: 78
Deficiencies: 0
Date: Feb 26, 2025
Visit Reason
An Emergency Preparedness Survey was conducted including a Complaint Survey for complaint number IN00453892. The complaint investigation was conducted by the Indiana Department of Health in accordance with 42 CFR 483.90(a).
Complaint Details
Complaint Number IN00453892 was unsubstantiated.
Findings
The facility was found in compliance with Emergency Preparedness Requirements and Life Safety Code requirements. The complaint was unsubstantiated. The facility is fully sprinklered with appropriate fire alarm and smoke detection systems.
Report Facts
Facility capacity: 78
Census: 30
Inspection Report
Re-Inspection
Census: 29
Capacity: 78
Deficiencies: 2
Date: Jan 31, 2025
Visit Reason
A Post Survey Revisit (PSR) to the Life Safety Code Recertification and State Licensure Survey conducted on 12/05/24 was performed to verify compliance with fire safety and licensure requirements.
Findings
The facility was found in compliance with Medicare/Medicaid participation requirements, Life Safety from Fire, and the 2012 edition of the NFPA 101 Life Safety Code. Two deficiencies related to ramps and sprinkler system maintenance were noted but temporarily waived.
Deficiencies (2)
Ramps and Other Exits did not meet requirements per NFPA 101 provisions 7.2.5 through 7.2.12 and 18.2.2.6 to 18.2.2.10 or 19.2.2.6 to 19.2.2.10.
Sprinkler System - Maintenance and Testing not in compliance with NFPA 25 standards; records and testing details missing.
Report Facts
Facility capacity: 78
Census: 29
Inspection Report
Complaint Investigation
Census: 26
Capacity: 26
Deficiencies: 0
Date: Jan 14, 2025
Visit Reason
This visit was conducted for the investigation of Complaint IN00450281.
Complaint Details
Complaint IN00450281 was investigated and found to have no deficiencies related to the allegation.
Findings
No deficiencies related to the complaint allegation were cited. The facility was found to be in compliance with applicable regulations.
Report Facts
Census: 26
Total Capacity: 26
Medicare Residents: 1
Medicaid Residents: 19
Other Payor Residents: 6
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Jan 13, 2025
Visit Reason
Paper compliance review for the Annual Recertification and State Licensure survey and the Investigation of Complaint IN00444162 completed on November 8, 2024.
Complaint Details
Investigation of Complaint IN00444162 was completed and found to be in compliance.
Findings
Envive of Hartford City was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 based on the paper review of the Recertification and State Licensure survey and the complaint investigation.
Inspection Report
Complaint Investigation
Census: 24
Capacity: 24
Deficiencies: 0
Date: Dec 19, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00448147.
Complaint Details
Complaint IN00448147 was investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to the complaint allegations were cited. The facility was found to be in compliance with applicable regulations.
Report Facts
Census: 24
Total Capacity: 24
Medicaid Census: 19
Other Payor Census: 5
Inspection Report
Annual Inspection
Census: 29
Capacity: 78
Deficiencies: 7
Date: Dec 5, 2024
Visit Reason
The inspection was conducted as an Annual Survey including Emergency Preparedness, Life Safety Code Recertification, and State Licensure Survey to assess compliance with Medicare and Medicaid participation requirements.
Findings
The facility was found in compliance with Emergency Preparedness requirements but was not in compliance with Life Safety Code requirements. Multiple deficiencies were identified including non-compliant exit ramps, inadequate fire alarm system testing, sprinkler system maintenance issues, smoke barrier penetrations, HVAC fire damper failures, dryer room combustion air intake issues, and malfunctioning electrical system indicator lights.
Deficiencies (7)
Ramps in 2 of 6 exit discharges did not meet Life Safety Code provisions; ramps lacked handrails and had excessive slope.
Fire alarm system initiating devices, specifically heat detectors, were not tested in accordance with NFPA 72 schedules.
Automatic sprinkler systems were not maintained per NFPA 25; several sprinkler heads tested abnormal and replacement documentation was lacking.
One of five smoke barrier walls was not protected to maintain fire resistance rating due to unsealed penetrations above corridor door.
Six of 44 fire dampers failed inspection and repair/replacement documentation was not available.
Dryer room lacked continuous intake combustion air due to disconnected mechanical arm on intake vent.
Automatic transfer switch indicator lights were not illuminated to indicate switch position.
Report Facts
Facility capacity: 78
Census: 29
Deficiencies cited: 7
Ramp measurements: 25.5
Ramp rise: 7
Ramp measurements: 6.6
Ramp rise: 9
Number of heat detectors: 9
Number of fire dampers: 44
Number of failed fire dampers: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Sarah Jackman | HFA | Signed as Laboratory Director or Provider/Supplier Representative |
| Director of Maintenance | Named in multiple findings related to ramp measurements, fire alarm testing, sprinkler system, smoke barrier, fire dampers, HVAC, and electrical system | |
| Field Maintenance Supervisor | Named in multiple findings related to ramp measurements, fire alarm testing, sprinkler system, smoke barrier, fire dampers, HVAC, and electrical system | |
| Administrator | Participated in observations and exit conference | |
| Director of Nursing | Participated in observations and exit conference |
Inspection Report
Annual Inspection
Census: 33
Capacity: 33
Deficiencies: 5
Date: Nov 8, 2024
Visit Reason
This visit was for a Recertification and State Licensure Survey, including the Investigation of Complaint IN00444162.
Complaint Details
Complaint IN00444162 was investigated, with federal/state deficiencies related to the allegations cited at F684.
Findings
The facility was found deficient in following physician orders for resident care, timely addressing pharmacy recommendations, ensuring non-pharmacological interventions prior to PRN psychoactive medication administration, infection prevention during insulin administration, and accurate documentation of mandatory tuberculin skin tests for employees.
Deficiencies (5)
Facility failed to follow physician's orders for 1 of 16 residents reviewed for resident choices.
Facility failed to ensure pharmacy recommendations were reviewed and addressed in a timely manner for 2 of 5 residents reviewed for unnecessary medications.
Facility failed to ensure non-pharmacological interventions were attempted prior to administration of PRN psychoactive medication for 2 of 5 residents reviewed.
Facility failed to utilize infection prevention and control procedures during insulin administration for 2 of 4 residents reviewed for medication administration.
Facility failed to accurately document the administration and results of mandatory tuberculin skin tests performed on 4 of 5 new employee files reviewed.
Report Facts
Residents reviewed for choices: 16
Residents reviewed for unnecessary medications: 5
Residents reviewed for medication administration: 4
New employee files reviewed: 5
Facility census: 33
Facility total capacity: 33
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Sarah Jackman | HFA | Signed the report |
| LPN 7 | Interviewed regarding PRN medication and TB test procedures | |
| RN 8 | Interviewed regarding PRN medication and TB test procedures | |
| DON | Director of Nursing | Interviewed regarding follow-up on physician orders, PRN medication administration, and TB test documentation |
| Vice President of Clinical Services | Interviewed regarding facility policies and physician order follow-up | |
| Vice President of Clinical Operations | Interviewed regarding insulin pen administration | |
| DNS | Director of Nursing Services | Educated on multiple deficiencies and responsible for monitoring compliance |
Inspection Report
Original Licensing
Census: 32
Capacity: 78
Deficiencies: 0
Date: Oct 17, 2024
Visit Reason
A Preoccupancy Survey was conducted for the addition of a locked separation door for a memory care unit including specific rooms, to ensure compliance with regulatory requirements.
Findings
The facility was found in compliance with Medicare/Medicaid participation requirements, Life Safety from Fire, and the 2012 edition of the National Fire Protection Association (NFPA) 101 Life Safety Code. The facility is fully sprinklered with appropriate smoke detection systems.
Inspection Report
Complaint Investigation
Census: 36
Capacity: 36
Deficiencies: 0
Date: Aug 14, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00440908.
Complaint Details
Complaint IN00440908 was investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to the complaint allegations were cited. The facility was found to be in compliance with applicable regulations.
Report Facts
Census Bed Type: 36
Medicare Census: 7
Medicaid Census: 24
Other Payor Census: 5
Inspection Report
Complaint Investigation
Census: 36
Deficiencies: 0
Date: Jul 26, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00438237 at Envive of Hartford City.
Complaint Details
Complaint IN00438237 was investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to the complaint allegations were cited. The facility was found to be in compliance with applicable regulations.
Report Facts
Census: 36
Medicare residents: 4
Medicaid residents: 25
Other payor residents: 7
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jul 22, 2024
Visit Reason
Paper compliance review to the Investigation of Complaint IN00432995 completed on June 17, 2024.
Complaint Details
Investigation of Complaint IN00432995 completed on June 17, 2024; facility found in compliance.
Findings
Envive of Hartford City was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the paper compliance review to the Complaint Investigation.
Inspection Report
Complaint Investigation
Census: 41
Deficiencies: 1
Date: Jun 14, 2024
Visit Reason
This visit was conducted for the investigation of complaints IN00432995 and IN00434633 at Envive of Hartford City.
Complaint Details
Complaint IN00432995 was substantiated with deficiencies related to abuse reporting. Complaint IN00434633 was not substantiated with any deficiencies.
Findings
The facility failed to ensure an abuse allegation was reported to the Indiana Department of Health for 1 of 4 residents reviewed for abuse. Complaint IN00432995 resulted in federal/state deficiencies cited, while Complaint IN00434633 had no deficiencies related to the allegations.
Deficiencies (1)
Failure to report an abuse allegation to the Indiana Department of Health in a timely manner for 1 of 4 residents reviewed for abuse.
Report Facts
Census: 41
Medicare residents: 6
Medicaid residents: 22
Other residents: 13
Inspection Report
Complaint Investigation
Census: 39
Deficiencies: 0
Date: Mar 13, 2024
Visit Reason
This visit was conducted for the investigation of complaints IN00428406 and IN00427956.
Complaint Details
Complaint IN00428406 - No deficiencies related to the allegations are cited. Complaint IN00427956 - No deficiencies related to the allegations are cited.
Findings
No deficiencies related to the allegations in complaints IN00428406 and IN00427956 were cited. The facility was found to be in compliance with relevant regulations.
Report Facts
Census SNF/NF beds: 39
Census total residents: 39
Census Medicare residents: 2
Census Medicaid residents: 22
Census Other payor residents: 15
Inspection Report
Life Safety
Census: 34
Capacity: 78
Deficiencies: 0
Date: Feb 2, 2024
Visit Reason
A Post Survey Revisit (PSR) to the Life Safety Code Recertification and State Licensure Survey conducted on 01/08/24 by the Indiana Department of Health.
Findings
Envive of Hartford City was found in compliance with the Requirements for Medicare and Medicaid Participating Providers and Suppliers, 42 CFR 483.90(a).
Inspection Report
Re-Inspection
Census: 33
Capacity: 33
Deficiencies: 0
Date: Jan 22, 2024
Visit Reason
This visit was a Post Survey Revisit (PSR) to the Recertification and State Licensure Survey completed on December 19, 2023.
Findings
Envive of Hartford City was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 in regard to the PSR to the Recertification and State Licensure Survey.
Report Facts
Census Payor Type - Medicare: 6
Census Payor Type - Medicaid: 24
Census Payor Type - Other: 3
Inspection Report
Life Safety
Census: 30
Capacity: 78
Deficiencies: 7
Date: Jan 8, 2024
Visit Reason
A Life Safety Code Recertification and State Licensure Survey was conducted by the Indiana Department of Health in accordance with 42 CFR 483.90(a) to assess compliance with life safety and fire protection requirements.
Findings
The facility was found not in compliance with several Life Safety Code requirements including maintenance of smoke barrier doors, documentation of smoke alarm maintenance, corridor door latching, fire extinguisher installation, smoke barrier penetrations, and ground fault circuit interrupter (GFCI) protection in wet locations. Immediate interventions were taken and plans of correction were submitted.
Deficiencies (7)
Failed to maintain latching hardware on 1 of 5 smoke barrier doors which did not close and latch properly.
Failed to ensure documentation for preventative maintenance of all battery operated smoke alarms on 100 Hall was complete.
Failed to maintain 1 of 3 corridor doors for cooking facilities to ensure they are protected and not open to the corridor.
Failed to ensure 1 portable fire extinguisher in the maintenance shop was installed and secured per NFPA standards.
Failed to ensure 1 corridor door to janitor closet would close and latch into the frame.
Failed to ensure penetrations caused by wire/conduit through 1 of 5 smoke barrier walls were protected to maintain smoke resistance.
Failed to ensure 3 of over 10 wet locations were provided with functioning ground fault circuit interrupter (GFCI) protection.
Report Facts
Facility capacity: 78
Census: 30
Number of smoke barrier doors inspected: 5
Number of corridor doors for cooking facilities: 3
Number of portable fire extinguishers in maintenance shop: 1
Number of smoke barrier walls with penetrations: 5
Number of wet locations without GFCI protection: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Sarah Jackman | HFA | Signed as Laboratory Director's or Provider/Supplier Representative's Signature |
| Director of Maintenance | Named in multiple findings related to repairs and corrective actions for smoke doors, smoke alarms, fire extinguishers, corridor doors, smoke barrier penetrations, and GFCI replacements | |
| Administrator | Participated in exit conferences and interviews regarding findings | |
| Executive Director | Provided education to Director of Maintenance on corrective actions |
Inspection Report
Annual Inspection
Census: 30
Capacity: 30
Deficiencies: 7
Date: Dec 19, 2023
Visit Reason
This visit was for a Recertification and State Licensure Survey conducted December 13-19, 2023.
Findings
The facility was found deficient in multiple areas including residents' right to receive mail on Saturdays, trauma-informed care for a resident with PTSD, ensuring 8 consecutive hours of RN coverage daily, individualized non-pharmacological interventions for dementia care, proper medication storage and disposal, food storage temperatures, and offering the latest COVID-19 vaccines to residents.
Deficiencies (7)
Facility failed to ensure residents’ right to receive mail on Saturdays was maintained for 9 of 9 residents interviewed during a resident council meeting.
Facility failed to ensure a resident with PTSD received care to mitigate triggers that may cause re-traumatization for 1 of 1 resident reviewed for trauma informed care.
Facility failed to ensure a Registered Nurse (RN) worked 8 consecutive hours in the facility on any given day. This had the potential to affect 30 of 30 residents.
Facility failed to ensure a resident received individualized, non-pharmacological interventions for dementia-type behaviors before increasing psychoactive medications for 2 of 5 residents reviewed for dementia care.
Facility failed to ensure residents’ medications were properly disposed of or sent back to pharmacy for credit for 1 of 1 medication storage rooms observed.
Facility failed to ensure the appropriate storage of refrigerated foods using a refrigerator unable to maintain refrigeration at safe levels. The deficiency had the potential to affect 30 of 30 residents.
Facility failed to ensure residents were offered the latest and recommended COVID-19 vaccine for 4 of 5 residents reviewed for COVID-19 vaccinations.
Report Facts
Census: 30
Total Capacity: 30
Deficiency Count: 7
Refrigerator Temperature: 46
Refrigerator Temperature Range: 41
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Sarah Jackman | HFA | Signed report |
| LPN 7 | Interviewed regarding trauma informed care and resident behaviors | |
| LPN 52 | Interviewed regarding resident behaviors and medication | |
| Administrator | Interviewed regarding mail delivery and refrigerator issues | |
| Social Service Director | Interviewed regarding trauma informed care and behavior monitoring | |
| DON | Director of Nursing | Interviewed regarding RN coverage, trauma informed care, medication storage, and COVID-19 vaccine |
| Business Office Manager | Interviewed regarding RN coverage coding | |
| Dietary Manager | Interviewed regarding refrigerator temperatures and food storage | |
| Maintenance Director | Interviewed regarding refrigerator maintenance |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Dec 7, 2023
Visit Reason
Paper compliance review to the Investigation of Complaint IN00420684 completed November 3, 2023.
Complaint Details
Investigation of Complaint IN00420684 completed November 3, 2023; facility found in compliance.
Findings
Envive of Hartford City was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the paper compliance review to the Complaint Investigation.
Inspection Report
Complaint Investigation
Census: 31
Deficiencies: 1
Date: Nov 3, 2023
Visit Reason
The visit was conducted for the investigation of Complaint IN00420684 regarding allegations related to treatment and service for dementia.
Complaint Details
Complaint IN00420684 was substantiated with federal/state deficiencies cited related to treatment/service for dementia and failure to implement individualized care plans for sexually inappropriate behaviors.
Findings
The facility failed to develop and implement individualized interventions for a cognitively impaired resident (Resident C) who displayed sexually inappropriate behaviors. The investigation included interviews and record reviews documenting multiple incidents of inappropriate sexual behavior and inadequate care planning.
Deficiencies (1)
Failed to develop and implement individualized interventions for a cognitively impaired resident who displayed sexual behaviors.
Report Facts
Census: 31
Medicare residents: 3
Medicaid residents: 22
Other residents: 6
Deficiency completion date: Dec 4, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Sarah Jackman | HFA | Signed the report as Laboratory Director or Provider/Supplier Representative |
Inspection Report
Complaint Investigation
Census: 37
Capacity: 37
Deficiencies: 0
Date: Oct 10, 2023
Visit Reason
This visit was conducted for the investigation of complaints IN00419149 and IN00419153.
Complaint Details
Investigation of Complaints IN00419149 and IN00419153 found no deficiencies related to the allegations.
Findings
No deficiencies related to the allegations in complaints IN00419149 and IN00419153 were cited. The facility was found to be in compliance with relevant regulations.
Report Facts
Census: 37
Total Capacity: 37
Medicare Census: 6
Medicaid Census: 25
Other Payor Census: 6
Inspection Report
Re-Inspection
Census: 31
Capacity: 31
Deficiencies: 0
Date: Mar 31, 2023
Visit Reason
This visit was a Post Survey Revisit (PSR) to the Recertification and State Licensure Survey completed on February 10, 2023.
Findings
Envive of Hartford City was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 in regard to the PSR to the Recertification and State Licensure Survey.
Report Facts
Census Payor Type - Medicare: 5
Census Payor Type - Medicaid: 22
Census Payor Type - Other: 4
Inspection Report
Re-Inspection
Census: 31
Capacity: 78
Deficiencies: 0
Date: Mar 15, 2023
Visit Reason
A Post Survey Revisit (PSR) to the Life Safety Code Recertification and State Licensure Survey conducted on 02/21/23 was performed by the Indiana Department of Health.
Findings
At this Life Safety Code Survey, Envive of Hartford City was found in compliance with the Requirements for Medicare and Medicaid Participating Providers and Suppliers, 42 CFR 483.90(a).
Inspection Report
Life Safety
Census: 33
Capacity: 78
Deficiencies: 8
Date: Feb 21, 2023
Visit Reason
A Life Safety Code Recertification and State Licensure Survey was conducted by the Indiana Department of Health in accordance with 42 CFR 483.90(a) to assess compliance with fire safety and life safety code requirements.
Findings
The facility was found not in compliance with several Life Safety Code requirements including malfunctioning self-closing corridor doors, lack of current inspection certificates for fuel fired water heaters, exposed wiring in the kitchen, missing annual fire door inspections, untested non-hospital grade electrical receptacles in resident rooms, and improper use of extension cords and power strips.
Deficiencies (8)
Corridor door to kitchen dishwashing room self-closing device not functioning properly, door would not latch.
Resident room 201 corridor door would not close due to bed obstruction.
Four fuel fired water heaters lacked current inspection certificates; last certificates expired 03/13/21.
Exposed wiring on refrigerator/freezer plug in kitchen.
Annual inspection and testing of fire door assemblies not completed; last inspection in 2021.
Non-hospital grade electrical receptacles in 39 resident sleeping rooms were not tested annually.
Flexible cords used as substitute for fixed wiring in kitchen; freezer plugged into extension cord.
Power strip in activity room did not meet UL-1363 standards.
Report Facts
Facility capacity: 78
Census: 33
Fuel fired water heaters: 4
Resident sleeping rooms: 39
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Tammy Bledsoe | Executive Director | Named in relation to review of findings during exit conference |
| Maintenance Director | Interviewed and involved in observations related to deficiencies and corrective actions |
Inspection Report
Annual Inspection
Census: 30
Capacity: 30
Deficiencies: 3
Date: Feb 10, 2023
Visit Reason
This visit was for a Recertification and State Licensure Survey conducted from February 6 to 10, 2023.
Findings
The facility was found deficient in following the grievance process for a resident-reported concern regarding edema, failure to prevent and treat pressure ulcers for one resident, and failure to administer ordered medications for one resident. Corrective actions and plans of correction were submitted for these deficiencies.
Deficiencies (3)
Facility failed to follow the grievance process for a resident-reported concern for 1 of 2 residents reviewed for edema (Resident 27).
Facility failed to prevent the development and progression of pressure injuries for 1 of 5 residents reviewed for pressure injuries (Resident 25).
Facility failed to administer ordered medications for 1 of 5 residents reviewed for unnecessary medications (Resident 3).
Report Facts
Census: 30
Total Capacity: 30
Survey Dates: 5
Medication doses unavailable: 18
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Tammy Bledsoe | Executive Director | Signed the report |
| CNA 6 | Reported resident's swelling and discomfort with elevation methods | |
| Maintenance Manager | Discussed recliner availability and resident requests | |
| CNA 7 | Reported resident's frequent requests for recliner or foot elevation | |
| Registered Nurse 9 | Noted resident edema and lack of recliner | |
| ADON | Assistant Director of Nursing | Discussed grievance process and recliner policy |
| DON | Director of Nursing | Discussed grievance process and recliner availability |
| Social Services Director | Explained grievance process and resident recliner requests | |
| LPN 4 | Observed pressure injuries and discussed medication administration | |
| CNA 12 | Encouraged resident to wear heel boots | |
| CNA 6 | Encouraged resident to wear heel boots | |
| LPN 2 | Described medication unavailability and notification process | |
| LPN 3 | Described medication unavailability and notification process |
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Nov 7, 2025
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Sep 26, 2025
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Mar 13, 2025
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Nov 8, 2024
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Jun 17, 2024
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Dec 19, 2023
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Nov 3, 2023
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