Health inspections
Federal rules call for a standard inspection at least every 15 months, plus a visit whenever a complaint is filed. Each mark below is one citation, colored by how serious inspectors rated it. How to read a citation.
Under each citation, the quoted text is the inspector's own summary from the federal statement of deficiencies (CMS form 2567), word for word apart from a privacy scrub; CMS removes residents' and staff names before it publishes the text. The full notes are on Medicare.gov.
Potential for minimal harm Potential for more than minimal harm Actual harm Immediate jeopardy Found on a complaint visit
Where its citations fall on CMS's grid
CMS rates every citation by how much harm it caused (rows) and how many residents it touched (columns). The count in each box is this home's, across all 70 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
3G
0H
0I
Potential for more than minimal harm
54D
7E
1F
Potential for minimal harm
0A
5B
0C
March 31, 2026Complaint inspection · 1 citation
- F
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observations, facility documentation, facility policy and interviews, the facility failed follow the Center for Disease Control (CDC) guidance for scheduled testing of the water, obtain the appropriate amount of water samples to be tested, and replace the sink filters every ninety (90) days according to the manufacturer's guidance after a resident had tested positive for legionella at the hospital.
March 19, 2026Complaint inspection · 5 citations
- G
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Inspectors wroteBased on review of the clinical record, facility documentation/policy, and interviews for two (2) of three (3) residents (Resident #2 and Resident #14) reviewed for neglect, the facility failed to ensure nail care was performed for a dependent resident (Resident #2) with a contracted hand, failed to implement effective interventions when the resident resisted care, and failed to report ongoing care concerns to the provider for further evaluation, resulting in overgrown, unkempt fingernails and a left fourth finger infection requiring surgical intervention (incision and drainage); and failed to ensure bathing care was provided for a cognitively impaired resident (Resident #14) and failed to identify, report, and address ongoing gaps in care delivery, resulting in poor hygiene requiring hand soaks to remove fecal matter from underneath the fingernails.
- E
Provide enough food/fluids to maintain a resident's health.
Inspectors wroteBased on review of the clinical record, facility documentation/policy, and interviews for three (3) of three (3) residents (Residents #2, #14, and #18) reviewed for significant weight loss, the facility failed to ensure adequate nutritional monitoring and intervention to prevent significant weight loss by failing to obtain weights per policy and physician orders, failing to obtain timely re-weights following significant changes, and failing to consistently document and evaluate meal intake to guide care resulting in an inability to identify and respond to nutritional decline and contributed to continued weight loss, and for Resident #14, malnutrition.
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on review of the clinical record, facility documentation/policy, and interviews for two (2) of three (3) residents (Resident #2 and Resident #14) reviewed for activities of daily living, the facility failed to provide necessary assistance with personal hygiene, including hand and nail care for a dependent resident with a contracted hand (Resident #2), and bathing care for a cognitively impaired resident (Resident #14), and failed to implement effective interventions when care was resisted, resulting in poor hygiene, including overgrown, unkempt fingernails with compromised skin integrity and the need for hand soaks to remove fecal matter from underneath the fingernails.
- B
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Inspectors wroteBased on review of clinical records, interviews, and review of facility documentation and policy for seven (7) of nine (9) residents (Resident #1, #3, #4, #7, #8, #9, and #13) reviewed for discharge, the facility failed to provide timely notification to the ombudsman when residents were discharged and/or planned for discharge from the facility.
- B
Ensure each resident receives an accurate assessment.
Inspectors wroteBased on review of the clinical record, facility documentation, facility policy and interviews for one (1) of three (3) sampled residents (Resident #14) reviewed for significant weight loss, the facility failed to ensure the comprehensive assessment accurately reflected the resident's significant weight loss greater than ten (10) percent (%) in the last six (6) months at the time of the assessment.
October 2, 2025Complaint inspection · 8 citations
- G
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Inspectors wroteBased on clinical record reviews, facility policy and interviews for one (1) of three (3) sampled residents (Resident #2) who were reviewed for a change in condition, the facility failed to notify the provider at the time Resident #2 reported shortness of breath until three (3) hours later.
- G
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on review of the clinical record, facility documentation, facility policy and interviews for one (1) of three (3) sampled residents (Resident #2) reviewed for supplemental oxygen, the facility failed to assess the resident and notify the provider when Resident #2 experienced Shortness of Breath (SOB) related to the facility's lack of oxygen concentrators and emergency tank supplies. The facility failed to ensure continuous, functioning supplemental oxygen and failed to provide timely, appropriate intervention for Resident #2's acute respiratory distress, resulting in Resident #2's condition deteriorating to acute respiratory arrest, ultimately leading to death.
- E
Provide and implement an infection prevention and control program.
Inspectors wroteBased on clinical record reviews, observations, facility policies and interviews for three (3) of seven (7) sampled residents (Residents #3, #4 and #5) who required supplemental oxygen use via a concentrator, the facility failed to ensure the oxygen tubing was changed every seven (7) days per facility policy.
- D
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Inspectors wroteBased on clinical record reviews, observations, review of facility policy and interviews for one (1) of three (3) sampled residents (Resident #3) reviewed for supplemental oxygen usage, the facility failed to develop a care plan to address Resident #3's need for oxygen use.
- D
Ensure services provided by the nursing facility meet professional standards of quality.
Inspectors wroteBased on clinical record reviews, facility policy and interviews for one (1) of three (3) sampled residents (Resident #2) reviewed for supplemental oxygen, the facility failed to assess the resident when staff reported Resident #2 was experiencing shortness of breath.
- D
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Inspectors wroteBased on observations, clinical record reviews, facility policy and interviews, the facility failed to ensure a medication cart located in the hallway was locked and medication was secured to prevent unauthorized access.
- D
Provide timely, quality laboratory services/tests to meet the needs of residents.
Inspectors wroteBased on clinical record reviews, facility documentation, facility policy and interviews for two (2) of twenty-one (21) randomly selected residents (Residents #5 and #11), the facility failed to ensure blood work was obtained per the physician's order.
- D
Keep all essential equipment working safely.
Inspectors wroteBased on clinical record reviews, observations, facility documentation, facility policies and interviews for two (2) of seven (7) sampled residents (Residents #6 and #7) who required supplemental oxygen usage via a concentrator, the facility failed to ensure the oxygen concentrators were inspected annually for function and safety.
August 20, 2025Complaint inspection · 4 citations
- D
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Inspectors wroteBased on clinical record review, facility documentation review, facility policy review and interviews for one of three residents (Residents #1) reviewed for medication administration, the facility failed to ensure the physician/APRN was notified timely when medications were not administered in accordance with orders, and for two (2) of three (3) residents (Resident #14 and Resident #16) reviewed for medication administration, the facility failed to notify the physician/APRN timely when medications were not available for administration in accordance with physician orders.
- D
Protect each resident from the wrongful use of the resident's belongings or money.
Inspectors wroteBased on clinical record review, facility documentation review, facility policy review and interviews for three sampled residents (Residents #1, #12, and #13) reviewed for medication administration, the facility failed to ensure the resident was free from misappropriate of resident property.
- D
Ensure services provided by the nursing facility meet professional standards of quality.
Inspectors wroteBased on clinical record review, facility documentation review, facility policy review and interviews for three sampled residents (Residents #1, 12, and 13) reviewed for medication administration, the facility failed to ensure services provided met professional standards to include controls of narcotic medications as per facility policy.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on clinical record review, facility documentation review, facility policy review and interviews for three of six residents (Residents #1, Resident #14 and Resident #16) reviewed for medication administration, the facility failed to ensure medications were available and administered in accordance with physician orders.
June 4, 2025Complaint inspection · 2 citations
- D
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Inspectors wroteBased on observation, clinical record review, facility documentation, facility policy, and interviews for one of three residents (Resident #2) reviewed for abuse or neglect, the facility failed to ensure the resident was free from physical abuse.
- D
Ensure services provided by the nursing facility meet professional standards of quality.
Inspectors wroteBased on clinical record review, facility documentation, facility policy, and interviews for one of three residents (Resident #1), reviewed for abuse or neglect, the facility failed to obtain vital signs according to provider order for a resident who required monitoring after a newly discontinued medication.
April 22, 2025Complaint inspection · 4 citations
- D
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Inspectors wroteBased on clinical record review, facility documentation review, facility policy review, and interviews for one of three residents (Resident #3) reviewed for accidents, the facility failed to ensure that the medical provider was notified timely of a change in condition.
- D
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Inspectors wroteBased on clinical record review, facility documentation review, facility policy review, and interviews for one of three residents (Resident #2), reviewed for accidents, the facility failed to ensure the care plan was revised timely after a fall.
- D
Ensure services provided by the nursing facility meet professional standards of quality.
Inspectors wroteBased on clinical record review, facility documentation review, facility policy review, and interviews for one of three residents (Resident #2), reviewed for accidents, the facility failed to ensure neurological assessments were completed timely after an unwitnessed fall in accordance with facility Monitoring guidelines.
- D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on a review of clinical records, facility documentation, facility policies, and interviews with one of three residents (Resident #3) reviewed for accidents, the facility failed to ensure the medical record was complete and accurate to include timely documentation of a medical evaluation.
March 24, 2025Complaint inspection · 2 citations
- D
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Inspectors wroteBased on clinical record review, facility documentation review, facility policy review, and interviews for one of three residents (Resident #2) reviewed for medication administration, the facility failed to notify the physician regarding the resident not receiving his/her medication for two (2) days.
- D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Inspectors wroteBased on clinical record review, facility documentation review, facility policy review, and interviews for one of three residents (Resident #2) reviewed for medication administration, the facility failed to ensure a medication provided by the family for facility staff to administer was verified/confirmed to be the drug ordered by the physician and failed to ensure the contents of each container have been verified by a licensed pharmacist in accordance with facility policy.
March 17, 2025Complaint inspection · 1 citation
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on clinical record reviews, facility documentation, facility policy, and interviews for one (1) of three (3) sampled residents (Resident #1) reviewed for pressure ulcers, the facility failed to ensure the treatment plans recommended by the wound care physician were entered into the clinical record and implemented.
February 13, 2025Complaint inspection · 1 citation
- D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteBased on clinical record reviews, facility documentation, facility policy and interviews for one (1) of three (3) sampled residents (Resident #1) who were reviewed for resident rights, the facility failed to ensure Resident #1 was treated with dignity and respect.
January 29, 2025Standard inspection, Complaint inspection · 18 citations
- E
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on clinical reviews, observations, review of policy and interviews for 1 of 4 residents reviewed for smoking (Resident #21), the facility failed to provide a safe smoking environment and for 1 of 4 residents (Resident #187) reviewed for accidents, the facility failed to ensure staff reported resident behavior that presented as a fire hazard.
- E
Ensure that the resident and his/her doctor meet face-to-face at all required visits.
Inspectors wroteBased on clinical record reviews, reviews of facility policy and staff interviews for 1 of 1 resident (Resident #166), reviewed for physician visits, the facility failed to ensure that physician visits were completed timely.
- E
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Inspectors wroteBased on clinical record reviews, observations, facility documentation, facility policy and interviews for 28 of 28 sampled residents (Resident #105, #89, #151, #183, #19, #474, #113, #475, #190,# 476, #96, #163, #148, #133, #21, #100,# 200, #199, #177, #479, #185, #182, #188, #143, #198, #147, #193,# 211) reviewed for medication storage, the facility failed to develop and implement policies for the recordkeeping of individual use and chain of custody controlled substances, failed to maintain an unbroken chain of custody for controlled medications once received and distributed to nursing unit(s) and failed to document inventory across shifts and failed to maintain an accurate disposition log for the destruction and return of unused controlled medication.
- E
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Inspectors wroteBased on tour of the dietary department and staff interview, the facility failed to ensure food was served at an appropriate temperature to maintain palpable taste.
- E
Implement a program that monitors antibiotic use.
Inspectors wroteBased on review of facility Infection Control Program, facility documentation and interviews, the facility failed to ensure staff conducted and maintained documentation of yearly ongoing review of antibiotic use within the facility based on Antibiotic stewardship guidelines.
- D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteBased on clinical record review, facility documentation, and staff interviews for 1 of 5 for (Resident # 70), reviewed for dignity, the facility failed to ensure staff interacted with the resident respectfully.
- D
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Inspectors wroteBased on clinical record reviews, observations, facility documentation, facility policy and interviews for 1of 3 residents (Resident # 173) reviewed for personal property, the facility failed to ensure the resident's personal medication was not missing and for 2 of 2 residents ( Residents # 164 and # 181) reviewed for environment, the facility failed to ensure a shared room had a functioning bathroom sink and for 1 of 2 residents (Resident #118) reviewed for environment, the facility failed to ensure resident furniture was maintained and in proper working order.
- D
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Inspectors wroteBased on clinical record reviews, facility documentation, facility policy and interviews for 2 of 5 sampled residents (Resident #144) reviewed for abuse, the facility failed implement policies to ensure the protection residents following an allegation of abuse and for (Resident # 214), the facility failed to timely followed up on Resident # 214 concerns regarding Resident # 1's physical and verbal abuse toward staff to rule out Resident # 1 was not a danger to self and others.
- D
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Inspectors wroteBased on clinical record reviews, observations, facility policy and interviews for 1 of 6 residents (Resident #111) reviewed for specialized treatment, the facility failed to ensure staff developed a care plan reflecting the needs of a resident receiving dialysis care and for1 of 2 residents (Resident # 109), reviewed for communication- Sensory, the facility failed to ensure that the care plan reflected the residents' sensory needs.
- D
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Inspectors wroteBased on clinical record reviews, policy the facility and interviews for 2 of 4 residents ( Resident # 104) reviewed for urinary retention, the facility failed to revised the care plan after the resident returned from an inpatient stay and for 1 of 1 resident ( Resident # 207)reviewed for care planning, the facility failed to ensure staff revised the residents a resident's care plan to reflect resident's choice regarding bathroom preferences .
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on clinical review, facility documentation, facility policy and interviews for of 1 of 5 sampled residents (Resident #144) reviewed for abuse, the facility failed to offer Activities of Daily Living (ADL) care to a resident who required toileting assist.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on clinical record reviews, review of facility documents, policy review and interviews for 1 of 2 residents ( Resident # 144) reviewed for pain, the facility failed to ensure a a resident with reports of increasing pain was reported/assessed by an Registered Nurse and for 1 of 5 residents (Resident #324), reviewed for dignity, the facility failed to ensure a follow-up appointment with a specialist provider was provided as scheduled .
- D
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Inspectors wroteBased on clinical record reviews, facility policy and documentation for 1 of 1 resident (Resident # 104) reviewed for urinary retention, the facility failed to follow the resident's discharge summary physician's order for urinary retention and for 1 of 1 resident reviewed for Bowel and Bladder Incontinence (Resident #207), the facility failed to assess a resident with frequent incontinence for participation in a bowel and bladder re-training program.
- D
Provide enough food/fluids to maintain a resident's health.
Inspectors wroteBased on review of the clinical record, facility policy review and interviews for 1 of 5 residents (Resident #105) reviewed for nutrition, the facility failed to ensure staff obtained a readmission weight timely and obtained re-weights for a resident at nutritional risk.
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on clinical record review, observation, facility documentation, facility policy and interviews for 1 or 2 residents (Resident #78) reviewed for specialized treatment, the facility failed to ensure respiratory equipment was in working condition.
- D
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Inspectors wroteBased on clinical record reviews, review of facility policy and interviews for 5 of 6 residents ( Residents #14, #39, #84, #111 and #424) reviewed for dialysis, the facility failed to ensure staff consistently monitored vital signs, the resident's hemodialysis access sites and follow facility policy.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, facility policy review and staff interviews, the facility failed to ensure staff followed correct infection control practices for a resident ( Resident #86) requiring droplet and contact precautions and failed to ensure staff followed appropriate infection control practices when a resident bathroom sink ( Resident #164 and #181) was out of service.
- B
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Inspectors wroteBased on review of Resident Assessment during survey, review of facility documentation and interviews for 17 of 17 residents (Residents 84,90,195,197,11,40,62,173,79,24,68,100,120,192,80,194,64), the facility failed to ensure the residents Minimum Data Set (MDS) assessment were transmitted timely to the state agency.
September 26, 2024Complaint inspection · 2 citations
- D
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Inspectors wroteBased on review of the clinical record, facility documentation, facility policy and interviews for one (1) of three (3) residents (Resident #1) reviewed for medication administration, the facility failed to notify the Advanced Practice Registered Nurse (APRN) timely of missed anti-seizure medication.
- D
Ensure that residents are free from significant medication errors.
Inspectors wroteBased on review of the clinical record, facility documentation, facility policy and interviews for one (1) of three (3) residents (Resident #1) reviewed for medication errors the facility failed to ensure that a resident received an anti-seizure medication as ordered by the physician.
July 30, 2024Complaint inspection · 1 citation
- D
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Inspectors wrote(1) of three (3) sampled residents (Resident #2) who were reviewed for comprehensive care planning, the facility failed to develop a comprehensive person-centered care plan to address the resident's wound that was present on admission.
October 2, 2023Complaint inspection · 1 citation
- D
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Inspectors wroteBased on observations, clinical record review, facility documentation review, facility policy review and interviews for environmental review, the facility failed to ensure a sanitary and comfortable environment for residents, staff and the public and failed to ensure five of eleven resident's (Resident #1, #2, #3, #4, and #5) rooms were free of bugs/roaches.
September 7, 2023Complaint inspection · 3 citations
- D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteBased on clinical record review, facility documentation review, facility policy review, and interviews for one of three residents (Resident #2) reviewed for abuse, the facility failed to honor the resident's right by not providing assistance when requested.
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on clinical record review, facility documentation review, facility policy review, and interviews for one (1) of three (3) residents, (Resident #2), reviewed for abuse, the facility failed ensure the State Agency was notified of an allegation of abuse in a timely manner.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on review of the clinical record, facility documentation, facility policy, and interviews for 1 resident (Resident #1) reviewed for quality of care, the facility failed to ensure medications were administered in accordance with physician orders.
April 4, 2022Standard inspection · 9 citations
- D
Reasonably accommodate the needs and preferences of each resident.
Inspectors wroteBased on observations, clinical record review and interviews for one observed resident (Resident #618), the facility failed to ensure the call bell was within reach.
- D
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Inspectors wroteBased on review of the clinical record, facility policy review and interviews for one of three residents (Resident #119) reviewed for a pressure ulcer (R#119), the facility failed to ensure the responsible party notified timely when a wound was identified.
- D
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Inspectors wroteBased on observations, review of facility policy, facility documentation review, and interviews for on one of seven nursing unit shower rooms (S-3 Unit), reviewed for environment, the facility failed to ensure that the shower room was maintained in a clean, comfortable home-like manner and/or free from disrepair.
- D
Ensure services provided by the nursing facility meet professional standards of quality.
Inspectors wroteBased on clinical record review and staff interviews for one of four residents reviewed for nutrition (Resident #119) and for one of two residents reviewed for indwelling catheters (Resident #119), the facility failed to ensure intake and output were monitored for a resident with a feeding tube and a Foley catheter.
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on observations, clinical record review, facility policy review and interviews for one of three residents reviewed for a pressure ulcer (Resident #119), the facility failed to ensure a wound treatment was provided in a clean manner with supplies placed on a clean surface.
- D
Provide enough food/fluids to maintain a resident's health.
Inspectors wroteBased on clinical record review, facility policy review and interviews for two of four residents (Resident #23 and #119), the facility failed to ensure a significant weight loss was addressed timely and the facility failed to ensure a reweight was obtained timely for a resident identified with a weight loss.
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observation, clinical record review, policy review, and interviews for one of two residents (Resident #616) reviewed for respiratory care, the facility failed to ensure oxygen tubing was changed timely.
- D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on observations, review of the clinical record, facility policy and procedures and interviews for one of three residents reviewed for a pressure ulcer (R#119), the facility failed to ensure the clinical record was maintained in a complete and accurate manner to include accurate dates weekly skin checks were completed.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observations, clinical record review, facility policy review and interviews for one of two residents (Resident #188) reviewed for tracheostomy care, the facility failed to ensure supplies were stored appropriately and not stored on the floor, and for facility Infection Control Review, the facility failed to ensure facility infections were tracked and expired IV supplies were removed from staff access timely.
September 26, 2019Standard inspection · 8 citations
- D
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Inspectors wroteBased on resident interview, clinical record review, and staff interview, for one of two residents in the survey sample reviewed for abuse (Resident #19), the facility failed to ensure a staff member reported an allegation of mistreatment in a timely manner.
- D
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Inspectors wroteBased on clinical record review, review of facility documentation, review of facility policy, and interviews for one sampled resident (Resident #330) reviewed for anticoagulant medication, the facility failed to implement a care plan to reflect the use of an anticoagulant medication.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on clinical record review, review of facility documentation, review of facility policy, and interviews, for 1 of 5 residents, (Resident #126) reviewed for unnecessary medications, the facility failed to follow physician's order for orthostatic blood pressure monitoring and/or for one sampled resident (Resident #330) reviewed for anticoagulant medication, the facility failed to implement a care plan to reflect the use of an anticoagulant medication.
- D
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Inspectors wroteBased on observations, clinical record review, review of facility documentation, review of facility policy, and interviews, for one sampled resident (Resident #202) reviewed for enteral feeding, the facility failed to remove a gastrostomy tube (GT) feeding set up after 24 hours of use and/or failed to maintain complete daily intake measurements.
- D
Provide timely, quality laboratory services/tests to meet the needs of residents.
Inspectors wroteBased on clinical record review and staff interview, for one resident in the survey sample reviewed for laboratory services (Resident #97), the facility failed to ensure a laboratory test was completed to monitor a medication per physician's orders.
- D
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on observation, review of facility policy, and interviews, the facility failed to ensure that a beard guard was utilized during food handling and/or failed to properly maintain temperatures in nourishment refrigerator.
- B
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Inspectors wroteBased on clinical record reviews, review of facility documentation, review of facility policy, and interviews, for 9 of 9 sampled residents (Residents #14, #20, #25, #28, #29, #32, #39, #42, and #46) reviewed for resident assessment, the facility failed to transmit the resident's quarterly and/or annual Minimum Data Set (MDS) assessments to the state agency in a timely manner.
- B
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on clinical record review, review of facility documentation, and interview, for 1 of five residents reviewed for unnecessary medications (Resident #198), the facility failed to ensure the clinical record was complete.
Fire safety inspections
18 fire safety citations on file: 10 on January 29, 2025, 4 on April 4, 2022, 4 on September 26, 2019.
Every fire safety citation18 citations
- E
Keep aisles, corridors, and exits free of obstruction in case of emergency.
K 211 · January 29, 2025 · Corrected (the home has a date of correction)
- E
Install corridor and hallway doors that block smoke.
K 363 · January 29, 2025 · Corrected (the home has a date of correction)
- E
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · January 29, 2025 · Corrected (the home has a date of correction)
- E
Meet requirements for the installation and maintenance of electrical systems.
K 911 · January 29, 2025 · Corrected (the home has a date of correction)
- D
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
K 225 · January 29, 2025 · Corrected (the home has a date of correction)
- D
Install emergency lighting that can last at least 1 1/2 hours.
K 291 · January 29, 2025 · Corrected (the home has a date of correction)
- D
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · January 29, 2025 · Corrected (the home has a date of correction)
- D
Install an approved automatic sprinkler system.
K 351 · January 29, 2025 · Corrected (the home has a date of correction)
- D
Inspect, test, and maintain automatic sprinkler systems.
K 353 · January 29, 2025 · Corrected (the home has a date of correction)
- D
Properly select, install, inspect, or maintain portable fire extinguishes.
K 355 · January 29, 2025 · Corrected (the home has a date of correction)
- D
Properly provide smoke detection systems in areas open to corridors.
K 347 · April 4, 2022 · Corrected (the home has a date of correction)
- D
Inspect, test, and maintain automatic sprinkler systems.
K 353 · April 4, 2022 · Corrected (the home has a date of correction)
- D
Meet requirements for operating features, such as evacuation plans, fire drills, smoking regulations, draperies, decorations and the inspection, testing and maintenance of fire doors.
K 700 · April 4, 2022 · Corrected (the home has a date of correction)
- D
Have simulated fire drills held at unexpected times.
K 712 · April 4, 2022 · Corrected (the home has a date of correction)
- D
Keep aisles, corridors, and exits free of obstruction in case of emergency.
K 211 · September 26, 2019 · Corrected (the home has a date of correction)
- D
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
K 321 · September 26, 2019 · Corrected (the home has a date of correction)
- D
Install smoke barrier doors that can resist smoke for at least 20 minutes.
K 374 · September 26, 2019 · Corrected (the home has a date of correction)
- D
Have restrictions on the use of highly flammable decorations.
K 753 · September 26, 2019 · Corrected (the home has a date of correction)