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 65 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
48D
10E
4F
Potential for minimal harm
0A
0B
3C
June 16, 2026Complaint inspection · 2 citations
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on medical record review, staff interview, and review of facility policy, the facility failed to timely assess a resident's wounds. This affected one (#95) of three residents reviewed for wounds. The census was 98.684Findings include: Review of Resident #95's medical record revealed an admission date of 04/26/23. Diagnoses listed included hypertension, chronic obstructive pulmonary disease, osteomyelitis, end stage renal disease, dependence on renal dialysis, morbid obesity, and diabetic neuropathy. Review of a quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #95 had moderately impaired cognition and had no venous or arterial ulcers. Review of the physician orders for Resident #95 revealed an order dated 04/27/26 for calcium alginate (absorbent wound dressing) and duoderm (bordered foam dressing) to the bottom of right foot. [...]
- 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 medical record review, observation, resident interview, staff interview, and review of facility policy, the facility to ensure resident medications were not left at bedside during administration. This affected one (#88) of three reviewed for medications. The census was 98. Review of Resident #88's medical record revealed an admission date of 01/28/19. Diagnoses listed included obstructive sleep apnea, osteoarthritis, arthritis, and obesity. Review of a quarterly Minimum Data Set (MDS) revealed Resident #88 had moderately impaired cognition. Observation during an interview with Resident #88 on 06/15/26 at 10:58 A.M. revealed a medication cup containing various pills and tablets on the bedside table. Resident #88 stated his nurse had left them there for him to take. Interview and observation with the Director of Nursing (DON) on 06/15/26 at 11:01 A.M. [...]
March 19, 2026Complaint inspection · 3 citations
- 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 medical record review, observation and staff interview, the facility failed to ensure residents were receiving the correct urinary catheter size in accordance with the resident's physician order and care plan. This affected one (#93) of three residents reviewed for urinary catheter placement. The facility census was 102.
- D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Inspectors wroteBased on medical record review, staff and pharmacist interviews and policy review, the facility failed to ensure medications were administered as physician ordered. This affected one (#104) of three residents reviewed for medication administration. The facility censes was 102.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on medical record review, observations and staff interviews, the facility failed to ensure staff appropriately changed contaminated gloves during incontinent care. This affected one (#95) of three residents reviewed for incontinent care. The facility census was 102.
April 21, 2025Standard inspection, Complaint inspection · 18 citations
- F
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, medical record review, water management plan review, water management plan log review, staff interviews, and policy reviews, the facility failed to update their Legionella water management plan and complete the routine monitoring of the Legionella water management plan. This affected 110 out of 110 residents that resided at the facility. The facility failed to follow enhanced barrier precautions and contact precautions. This affected three (#10, #63 and #82) of three residents reviewed for infection control precautions. The facility census was 110.
- E
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on observation, resident, family and staff interview, review of facility policy, and record review, the facility failed to ensure residents who required assistance with activities of daily living (ADL) were provided regular assistance with showers and grooming. This affected four (#4, #63, #67, and #263) of four residents reviewed for ADLs. The facility census was 110.
- E
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 and staff interviews, the facility failed to maintain resident rooms in a clean and homelike manner. This affected 14 residents (#4, #5, #6, #11, #15, #32, #34, #37, #47, #51, #80, #85, #94, and #101) of 15 residents reviewed for environment. The facility census was 110.
- D
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Inspectors wroteBased on record review, review of facility policy, and staff interviews, the facility failed to ensure the resident's advance directives were clearly maintained and documented in the resident's medical record. This affected two (Residents #11 and #47) of two residents reviewed for advanced directives. The facility census was 110.
- D
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Inspectors wroteBased on medical record review, review of facility's self-reported incident (SRI) and investigation, resident and staff interview, review of police report, personnel file, and e-mails, and policy review, the facility failed to ensure a resident was free from verbal abuse by an employee and staff witnessing the abuse did not intervene. This affected one (Resident #90) of three residents reviewed for abuse. The facility census was 110.
- D
Ensure each resident receives an accurate assessment.
Inspectors wroteBased on staff interview and record review, the facility failed to ensure the resident's Minimum Data Set (MDS) assessments were accurately coded for falls and discharge location. This affected two (#90 and #109) of 23 residents reviewed for MDS accuracy. The facility census was 110.
- D
Notify the appropriate authorities when residents with MD or ID services has a significant change in condition.
Inspectors wroteBased on record review and staff interview, the facility failed to notify the state mental health authority with a significant change Preadmission Screening and Resident Review (PASARR) for a resident that had a change in their mental health condition. This affected one (#90) of two residents reviewed for significant change PASARR. The facility census was 110.
- 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 review of facility policy, staff interview, and record review, the facility failed to develop care plans to address a resident's use of an anticoagulant and a resident's vision needs. This affected two (#67 and #90) of 23 residents reviewed for care planning. The facility census was 110.
- 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 observation, interview and record review, the facility failed to ensure residents were given the opportunity to participate in the development of their care plans and the care plan meetings had a interdisciplinary team present. This affected three (#16, #63, and #90) of six residents reviewed for resident participation in care planning. The facility census was 110.
- D
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Inspectors wroteBased on observation, resident and staff interview, and record review, the facility failed to ensure staff communicated with residents in a language or manner they could understand. This affected one (Resident #94) of one resident reviewed for communication and language. The facility census was 110.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on observations, medical record review, staff interview, resident interview and policy review, the facility failed to ensure skin checks were completed weekly as care planned, wound treatments were completed as order and physician orders were clarified for skin impairment treatments. This affected one (#18) of three reviewed for non-pressure skin impairments. The facility census was 110.
- D
Assist a resident in gaining access to vision and hearing services.
Inspectors wroteBased on medical record review, family interview, staff interview and policy review, the facility failed to ensure vision services were provided as recommended by vision specialist. This affected one (#67) of one resident reviewed for vision services. The facility census was 110.
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on record reviews, staff interviews and policy review, the facility failed to ensure falls were thoroughly investigated to determine potential cause of the falls to prevent future falls. This affected one (#67) of three residents reviewed for falls. The facility census was 110.
- 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 medical record review, observation, staff interview, and review of facility policy, the facility failed to ensure a resident's urinary catheter collection bag was properly maintained to prevent potential infections. This affected one (#211) of two residents reviewed for urinary catheters. The census was 110.
- D
Provide or obtain dental services for each resident.
Inspectors wroteBased on record review, resident interview, staff interview and policy review, the facility failed to ensure a resident received routine dental care. This affected one (#63) of two residents reviewed for dental care. The facility census was 110.
- D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on medical record review, policy reviews and staff interviews, the facility failed to ensure the accuracy and thoroughness of the documentation in the resident medical record. This affected two (#18 and #107) of 23 sampled resident records reviewed. Facility census was 110.
- D
Provide a neutral and fair arbitration process and agree to arbitrator and venue.
Inspectors wroteBased on record review and staff interview, the facility failed to ensure arbitration agreements provided for the selection of a venue that was convenient to both parties. This affected three (#90, #98 and #99) of three residents reviewed for arbitration agreements. The facility census was 110.
- D
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Inspectors wroteBased on observation, medical record review, policy review, pest control invoice review and staff interviews, the facility failed to ensure a pest free environment. This affected two (#5 and #94) of two residents reviewed for pest control. Facility census was 110.
February 4, 2025Complaint inspection · 3 citations
- E
Reasonably accommodate the needs and preferences of each resident.
Inspectors wroteBased on observation, and resident and staff interviews, the facility failed to accommodate resident preferences to create a home-like environment when the common dining room was closed without resident notice. This affected 10 (#6, #25, #32, #36, #38, #41, #71, #79, #92, and #110) of 114 residents who frequently dine in the common dining room. The facility identified two (#33 and #53) residents who receive no food by mouth. The census was 116.
- E
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Inspectors wroteBased on observation, resident and staff interviews, and policy review, the facility failed to ensure there was sufficient staffing levels to accommodate for the common dining room to remain open for resident use. This affected 10 (#6, #25, #32, #36, #38, #41, #71, #79, #92, and #110) of 114 residents who frequently dine in the common dining room. The facility identified two (#33 and #53) residents who receive no food by mouth. The census was 116.
- C
Post nurse staffing information every day.
Inspectors wroteBased on observation, staff interview, and policy review, the facility failed to ensure nurse staffing information was updated and posted daily as required. This affected all 116 residents who resided in the facility. The census was 116.
December 30, 2024Complaint inspection · 9 citations
- F
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Inspectors wroteBased on observation, resident interview, family interview, staff interview, record review, review of the staffing tool, review of staff schedules, and review of facility policy, the facility failed to ensure the facility had adequate staffing to meet the resident's needs. This affected one (Resident #104) of three residents reviewed for staffing and had potential to affect all facility residents. The facility census was 113.
- E
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on observations, staff interview, and review of facility policy, the facility failed to ensure resident meals were prepared, distributed, and served in a clean and sanitary manner to prevent contamination. This had the potential to affect all facility residents, except two (#74 and #87) that were identified with orders for no oral intake (NPO). The census was 113.
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on resident interviews, family interviews, staff interviews, record review, review of the State agency online reporting portal, and review of facility policy, the facility failed to ensure allegations of abuse were reported to the State agency within the required timeframes. This affected one (Resident #100) of five residents reviewed for abuse.
- D
Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy.
Inspectors wroteBased on record review, staff interview, review of hospital records, and review of facility policy, the facility failed to ensure Resident #115 was able to return to the facility following a hospital stay. This affected one (Resident #115) out of three residents reviewed for discharges.
- D
Plan the resident's discharge to meet the resident's goals and needs.
Inspectors wroteBased on record review, resident interview, staff interview, and facility policy and procedure, the facility failed to ensure Resident #100 received the home health company of choice upon discharge. This affected one (Resident #100) out of three residents reviewed for discharges.
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on observations, residents and staff interviews, record reviews, and review of facility policy and procedure, the facility failed to ensure dependent residents received assistance with activities of daily living (ADL). This affected one (Resident #104) of three residents reviewed for activities of daily living.
- D
Ensure that the facility has sufficient staff members who possess the competencies and skills to meet the behavioral health needs of residents.
Inspectors wroteBased on record review, staff interview, and review of facility policy, the facility failed to ensure appropriate nursing services to assure residents could attain and/or maintain the highest practicable physical, mental, and psychosocial well-being while ensuring Resident #115's mobility was not restricted. This affected one (Resident #115) out of three residents reviewed for discharges.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, staff interview, and policy review, the facility failed to ensure medications were administered in a clean and sanitary manner. This affected three residents (#97, #100, and #104) out of five residents reviewed for medication administration.
- 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, resident and staff interviews, record review, and facility policy, the facility failed to ensure equipment was maintained and in working order. This affected two residents (#99 and #100) of three reviewed for environment.
September 24, 2024Complaint inspection · 1 citation
- D
Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
Inspectors wroteBased on closed record review and interview, the facility failed to provide residents with discharge summaries. This affected three (#110, #111, and #112) out of three residents reviewed for discharge. The facility census was 100.
January 10, 2024Complaint inspection · 1 citation
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on record review, observation, staff interview and policy review, the facility failed to initiate treatment on a pressure ulcer present upon a resident readmission. This affected one (#77) out of three residents reviewed for wound care. The facility census was 102.
March 30, 2023Standard inspection · 16 citations
- F
Provide activities to meet all resident's needs.
Inspectors wroteBased on observations, resident and staff interviews, activity calendar review and policy review, the facility failed to ensure a variety of activities were offered to meet residents' needs and interests. This affected two (#41 and #48) of two residents reviewed for activities and had potential to affect all facility residents. The facility census was 100.
- F
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on observations, staff interview, and policy review, the facility failed to safely store food in the walk in freezer and dry storage areas of the kitchen. This affected all residents except Resident #16 and #76 who do not eat food from the kitchen. The facility census was 100.
- E
Honor the resident's right to organize and participate in resident/family groups in the facility.
Inspectors wroteBased on review of resident council minutes, staff and resident interviews and policy review, the facility failed to ensure resident council concerns were addressed in a timely manner. The facility also failed to ensure residents were knowledgeable on how to file a complaint with the state or contact the Ombudsman. This affected three (#31, #36, #20) of 10 residents that regularly attend the resident council, with the potential to affect the 10 residents. The facility census was 100.
- E
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wrote2. Interview on 03/28/23 at 9:10 A.M., with Resident #31 revealed at times the bathroom sink water was too hot. Observation on 03/28/23 from 9:29 A.M. to 9:42 A.M., revealed Resident #31's bathroom sink had a temperature of 139 degrees Fahrenheit (F) and Resident #41's bathroom sink had a temperature of 138 degrees F. Interview on 03/28/23 at 9:42 A.M., with Resident #41 revealed the bathroom sink water temperature was hot to touch. Observation on 03/28/23 from 9:50 A.M. to 10:10 A.M., with Administrator revealed water temperature as follows: Resident #31's room water temperature was 137.8 degrees F; Resident #28 and #87's room water temperature was 135.3 degrees F; Resident #23 and #41's room water temperature was 137.8 degrees F; Resident #53 and #58's room water temperature was 132.9 degrees F; Resident #2 and #10's room water temperature was 138.6 degrees F; [...]
- E
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 observation, review of policy, and staff interviews, the facility failed to ensure medications were stored with open dates and not kept past expiration dates. This affected 13 (#10, #15, #21, #87, #54, #86, #89, #96, #19, #95, #37, #64, and #27) of 13 residents' insulins observed in medication storage. The facility identified 23 Residents who currently receive insulin. The facility census was 100.
- D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteBased on observation, medical record review, staff and resident interviews and policy review, the facility failed to ensure a resident was treated with respect and dignity during resident care. This affected one (#48) of three residents reviewed for dignity and respect. The facility census was 100.
- D
Allow resident to participate in the development and implementation of his or her person-centered plan of care.
Inspectors wroteBased on medical record review, resident and staff interview and policy review, the facility failed to ensure residents and resident representatives were offered the opportunity to participate in care planning. This affected two (#31 and #60) of two residents reviewed for care conferences. Facility census was 100.
- D
Allow residents to self-administer drugs if determined clinically appropriate.
Inspectors wroteBased on observation, staff and resident interviews and medical record review, the facility failed to ensure a resident was assessed for self-administration of medication. This affected one (#41) of 26 residents observed in the sample. The facility census was 100.
- D
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Inspectors wroteBased on record review and staff interview, the facility failed to issue the CMS -20052 form to indicate skilled coverage was ending. This affected two (#35 and #26) of three residents who exhausted their Medicare Part A Skilled Services. The facility census was 100.
- 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, resident and staff interviews, the facility failed to ensure a resident's room was provided a room in a home like environment by not utilizing the resident's room for facility storage. The affected one (#18) of six residents reviewed for environment. The facility census was 100.
- D
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Inspectors wroteBased on medical record review, review of policy, and staff interview, the facility failed to notify residents or resident representatives of facility policy for bed holds, to include amount of bed hold days used and left and potential cost liability. This affected two (#54 and #86) of three residents reviewed for hospitalization. The census was 100.
- 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 record review, resident and staff interview and policy review, facility failed to ensure members of the interdisciplinary team (IDT) with the resident and/or resident representative reviewed and revised care plans at least quarterly. This affected two (#31 and #60) of two residents reviewed for care conferences. The facility census was 100.
- D
Plan the resident's discharge to meet the resident's goals and needs.
Inspectors wroteBased on record review, resident and staff interviews and policy reviews, the facility failed to provide timely assistance with discharge planning for a resident requesting to discharge from the facility. This affected one (#48) of one resident reviewed for discharge planning. The facility census was 100.
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on medical record review, staff and resident interview and policy review, the facility failed to ensure bathing was provided for dependent residents. This affected three (#64, #27, #48) of three residents reviewed for bathing. The census was 100.
- 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 observation, medical record review, staff and resident interview, the facility failed to ensure a resident was provided with incontinence supplies to prevent the potential for infections and skin impairments. This affected one (#48) of two residents reviewed for bowel and bladder incontinence during the annual survey. The census was 100.
- 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, resident and staff interviews and policy review, the facility failed to ensure a complete an accurate medical record was maintained for a resident. This affected one (#48) of 33 total resident records reviewed. The facility census was 100.
January 30, 2020Standard inspection · 12 citations
- E
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 medical record review, interview and review of facility policy,the facility failed to update the care plan when a resident's fluid restriction was discontinued. This affected one (Resident #94) of one resident reviewed for hydration. The facility also failed to conduct quarterly care conferences for three Residents (#22, #72, and #109) of five residents reviewed for participation in care planning. The census was 121.
- E
Provide and implement an infection prevention and control program.
Inspectors wroteBased on medical record review, observation, staff interview, and review of directions for sani cloth bleach germicidal disposable wipes the facility failed to follow appropriate infection control procedures for the cleaning of the blood glucose monitoring machine after each use to prevent the spread of infections. This affected one (Resident #102) of two residents reviewed for blood glucose monitoring. The facility identified 10 Residents (#9, #16, #36, #37, #48, #49, #53, #54, #56, and #96) who received blood glucose monitoring on the 200 hallway. The facility census was 121.
- D
PASARR screening for Mental disorders or Intellectual Disabilities
Inspectors wroteBased on medical record review, staff nterview, and review of facility guidelines the facility failed to accurately assess residents in the Pre-admission Screening/Resident Review (PASRR) process. This affected two Resident's (#66 and #109) of four residents reviewed for PASRR's. The census was 121.
- D
Notify the appropriate authorities when residents with MD or ID services has a significant change in condition.
Inspectors wroteBased on medical record review, staff interview and review of facility guidelines, the facility failed to notify the state mental health authority and state intellectual disability (ID) authority after a significant change. This affected one (Resident #109) of four residents screened for Pre-admission Screens/Resident Reviews (PASRR). The census was 121.
- 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 medical record review, interview, and review of facility policy the facility failed to address frequent urinary tract infections (UTIs) on the comprehensive care plan. This affected one (Resident #10) of 22 residents reviewed for comprehensive care plans. The census was 121.
- D
Plan the resident's discharge to meet the resident's goals and needs.
Inspectors wroteBased on review of closed medical record, interview with facility staff, and review of facility policy, the facility failed to develop a post-discharge plan of care that addressed discharge needs, goals, treatment preferences, caregiver support as well as referrals made to address post-discharge needs. This affected one (Resident #119) of one resident reviewed for appropriate discharge planning. The census was 121.
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on medical record review, observation, and interview with facility staff, the facility failed to provide set-up assistance with eating. This affected one (Resident #109) of three residents reviewed for activities of daily living (ADLs). The facility identified 100 residents who required at minimum set-up assistance with eating. The census was 121.
- D
Provide enough food/fluids to maintain a resident's health.
Inspectors wroteBased on medical record review, observation, resident and staff interviews, and review of the facility's policy the facility failed to provide fluids when a fluid restriction was discontinued. This affected one (Resident #94) of one resident reviewed for hydration. Facility census was 121.
- D
Ensure that residents are free from significant medication errors.
Inspectors wroteBased on medical record review, observation, staff interview, and manufacturers recommendations review the facility failed to ensure residents were free from significant medication errors. Staff failed to ensure insulin lispro Humalog Kwikpen was primed prior to use according to manufacturer's recommendations. This may cause the resident to get too much or too little insulin. This affected one (Resident #49) of two residents observed for insulin administration. The facility census was 121.
- 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 review of medical record, observation, resident and staff interview, and review of facility policy the facility failed to ensure medications were not left at a residents bedside. This affected one (Resident #95) of five residents observed for medication administration. Facility census was 121.
- C
Honor the resident's right to organize and participate in resident/family groups in the facility.
Inspectors wroteBased on review of resident council meetings, staff and resident interview, review of facility policy and Resident [NAME] of Rights, the facility failed to act promptly upon grievances of Resident Council nor demonstrate their response and rationale. This had the potential to affect all 121 residents.
- C
The resident has the right to receive notices in a format and a language he or she understands.
Inspectors wroteBased on observation, interview with facility staff and residents, observations, and review of Resident [NAME] of Rights the facility failed to ensure a list of names, addresses, and telephone numbers for pertinent State regulatory and informational advocates were posted. This had the potential to affect all the residents. The census was 121.
Fire safety inspections
31 fire safety citations on file: 14 on April 21, 2025, 15 on March 30, 2023, 2 on January 30, 2020.
Every fire safety citation31 citations
- F
Install emergency lighting that can last at least 1 1/2 hours.
K 291 · April 21, 2025 · Corrected (the home has a date of correction)
- F
Provide properly protected cooking facilities.
K 324 · April 21, 2025 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · April 21, 2025 · Corrected (the home has a date of correction)
- F
Properly select, install, inspect, or maintain portable fire extinguishes.
K 355 · April 21, 2025 · Corrected (the home has a date of correction)
- F
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
K 521 · April 21, 2025 · Corrected (the home has a date of correction)
- F
Have simulated fire drills held at unexpected times.
K 712 · April 21, 2025 · Corrected (the home has a date of correction)
- F
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
K 914 · April 21, 2025 · Corrected (the home has a date of correction)
- F
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · April 21, 2025 · Corrected (the home has a date of correction)
- E
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
K 222 · April 21, 2025 · Corrected (the home has a date of correction)
- E
Install corridor and hallway doors that block smoke.
K 363 · April 21, 2025 · Corrected (the home has a date of correction)
- E
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · April 21, 2025 · Corrected (the home has a date of correction)
- E
Have properly installed electrical wiring and gas equipment.
K 511 · April 21, 2025 · Corrected (the home has a date of correction)
- E
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
K 741 · April 21, 2025 · Corrected (the home has a date of correction)
- E
Have restrictions on the use of portable space heaters.
K 781 · April 21, 2025 · Corrected (the home has a date of correction)
- F
Conduct testing and exercise requirements.
E 39 · March 30, 2023 · Corrected (the home has a date of correction)
- F
Provide properly protected cooking facilities.
K 324 · March 30, 2023 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · March 30, 2023 · Corrected (the home has a date of correction)
- F
Provide a written emergency evacuation plan.
K 711 · March 30, 2023 · Corrected (the home has a date of correction)
- F
Have simulated fire drills held at unexpected times.
K 712 · March 30, 2023 · Corrected (the home has a date of correction)
- F
Have restrictions on the use of portable space heaters.
K 781 · March 30, 2023 · Corrected (the home has a date of correction)
- F
Have a battery powered remote alarm panel in a location accessible by operating personnel.
K 916 · March 30, 2023 · Corrected (the home has a date of correction)
- E
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
K 223 · March 30, 2023 · Corrected (the home has a date of correction)
- E
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
K 321 · March 30, 2023 · Corrected (the home has a date of correction)
- E
Install an approved automatic sprinkler system.
K 351 · March 30, 2023 · Corrected (the home has a date of correction)
- E
Install corridor and hallway doors that block smoke.
K 363 · March 30, 2023 · Corrected (the home has a date of correction)
- E
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · March 30, 2023 · Corrected (the home has a date of correction)
- E
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
K 741 · March 30, 2023 · Corrected (the home has a date of correction)
- E
Ensure proper usage of power strips and extension cords.
K 920 · March 30, 2023 · Corrected (the home has a date of correction)
- E
Have proper medical gas storage and administration areas.
K 923 · March 30, 2023 · Corrected (the home has a date of correction)
- F
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
K 741 · January 30, 2020 · Corrected (the home has a date of correction)
- C
Provide primary/alternate means for communication.
E 32 · January 30, 2020 · deficient, provider has