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 67 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
1J
0K
0L
Actual harm
1G
0H
0I
Potential for more than minimal harm
50D
15E
0F
Potential for minimal harm
0A
0B
0C
July 15, 2026Complaint inspection · 2 citations
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure residents received the necessary care and treatment related to oxygen not administered as ordered for 1 of 3 residents reviewed for respiratory care. (Resident C)
- D
Provide safe, appropriate pain management for a resident who requires such services.
Inspectors wroteBased on record review and interview, the facility failed to ensure pain medications were available and administered as ordered when residents complained of pain for 2 of 3 residents reviewed for pain. (Residents B and D)
May 13, 2026Complaint inspection · 1 citation
- 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 observation and interview, the facility failed to maintain comfortable and home like environment for 1 of 3 residents reviewed for environment. (Resident B)
April 1, 2026Complaint inspection · 1 citation
- J
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on record review and interview, the facility failed to initiate effective resident-specific interventions and provide adequate supervision to prevent the elopement from the facility of a resident with a diagnosis of dementia, a history of exit-seeking behaviors and a wanderguard (door alarm bracelet) in place for 1 of 3 residents reviewed for elopement risk. The resident exited the building without the knowledge of the staff working in the facility and was found the next day by the local police department and was taken to the hospital Emergency Room. (Resident B)The Immediate Jeopardy began on [DATE], when the facility was unaware that the resident had exited the facility without supervision. The resident walked independently and was found over 24 hours later by local police, and Emergency Services transported the resident to the hospital. [...]
February 10, 2026Complaint inspection · 1 citation
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on record review and interview, the facility failed to provide treatments as ordered and did not complete a skin assessment upon readmission for 1 of 3 residents reviewed for pressure ulcers. (Resident B)
December 9, 2025Standard inspection · 12 citations
- E
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure activities of daily living (ADLs) were completed for dependent residents related to the removal of facial hair, dirty fingernails, and hair care for 3 of 7 residents reviewed for ADLs. The facility also failed to ensure a dependent resident received a sack lunch to take with him to dialysis for 1 of 1 resident reviewed for dialysis. (Residents 5, 11, 6 and 7)
- E
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure follow up documentation after a fall was completed for 1 of 4 residents reviewed for accidents. The facility also failed to ensure a treatment to a skin tear was completed as ordered, areas of bruising and skin lesions were assessed and monitored, and geri-sleeves and/or long sleeves were in use for 5 of 6 residents reviewed for skin conditions non-pressure related. The facility also failed to monitor and assess edema for 2 of 2 residents reviewed for edema. (Residents 6, 9, 70, 14, and 28)
- E
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on observation, record review, and interview, the facility failed to maintain clinical records that were complete and accurately documented related to documentation of food consumption for 2 of 2 residents reviewed for nutrition. The facility also failed to ensure documentation was completed on the medication and treatment records as well as in the nursing progress notes related to medication administration and oxygen use for 1 of 5 residents reviewed for unnecessary medications and 1 of 3 residents reviewed for oxygen. There was also no discharge note completed for a resident who left the facility against medical advice (AMA) for 1 of 3 closed records reviewed. (Residents 59, 8, 74, 11, 12, and 123)
- E
Provide and implement an infection prevention and control program.
Inspectors wroteBased on random observations, record review and interview, the facility failed to ensure infection control practices were in place and implemented related to the storage of urinals and wash basins for 3 of 4 units throughout the facility. The facility also failed to ensure the glucometer was disinfected correctly for 1 of 1 glucometer observed as well as nursing staff dispensing pills into their bare hand for 1 of 11 residents observed during medication administration. (Residents 59, 88, and 10, the 100, 200, and 300 units)
- 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 observation and interview, the facility failed to keep the resident's environment clean and in good repair related to marred walls and door frames, dirty ceiling vents, walls, windows, and closet shelves, warped floor tile, missing paper towel covers, rusted toilet bolts and missing covers, stained toilets, and broken medication drawers on the medication carts for 3 of 4 units. (Units 100, 200, and 300)
- D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure each resident's dignity was maintained related to not offering a resident a snack while others were eating around him and a resident's abdomen being exposed during an activity for 2 of 5 residents reviewed for dignity. (Residents 8 and 93)
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on record review and interview, the facility failed to report allegations of resident-to-resident abuse to the State Agency for 1 of 1 resident reviewed for abuse. (Resident 117)
- D
Assist a resident in gaining access to vision and hearing services.
Inspectors wroteBased on record review and interview, the facility failed to ensure a resident with hearing loss, was seen by an Audiologist for 1 of 1 resident reviewed for vision and hearing. (Resident 9)
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure fall precautions were in place for a resident with a history of falls for 1 of 4 residents reviewed for accidents. (Resident 9)
- 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 record review and interview, the facility failed to ensure signs and symptoms of a urinary tract infection (UTI) were treated in a timely manner for 1 of 1 resident reviewed for urinary tract infections. (Resident 8)
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure residents received proper treatment and care related to following physician's orders for oxygen administration, and the lack of pre and post nebulizer assessments for 2 of 3 residents reviewed for respiratory care. (Residents 127 and 14)
- D
Provide or obtain dental services for each resident.
Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure a resident received routine dental services and a denture follow up appointment had been completed for 2 of 2 residents reviewed for dental services. (Residents 5 and 9)
October 8, 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 record review and interview, the facility failed to ensure a dependent resident's family or representative was notified of changes related to a dislodged gastrostomy tube (g-tube; a tube inserted through the skin into the stomach to provide nutrition and mediations) and antibiotic orders for 1 of 3 residents reviewed for g-tubes. (Resident C)
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on record review and interview, the facility failed to ensure residents received the necessary care and treatment related to antibiotics not given as ordered, wound treatments not provided as ordered and incomplete wound assessments for 3 of 3 residents reviewed for infections. (Residents C, B and D)
July 30, 2025Complaint inspection · 2 citations
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on record review and interview, the facility failed to ensure activities of daily living (ADLs) were completed for a dependent resident related to lack of showers provided twice a week for 1 of 3 residents reviewed for ADLs. (Resident B)
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure a treatment was completed as ordered for 1 of 3 residents reviewed for non-pressure related skin conditions. (Resident D)
June 3, 2025Standard inspection, Complaint inspection · 12 citations
- E
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 observation and interview, the facility failed to maintain comfortable and safe temperature levels for 27 of 27 residents who resided on the memory care unit.
- E
Provide care by qualified persons according to each resident's written plan of care.
Inspectors wroteBased on record review and interview, the facility failed ensure only licensed qualified persons poured, prepared, and passed medications for 5 memory care residents on the midnight shift. (Residents 14, 60, 86, 87, and 90)
- E
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on observation, record review, and interview, the facility failed to serve food under sanitary conditions related to touching toast with bare hands and transporting uncovered food down the hallway for 1 of 4 units. (The Memory Care Unit). This had the potential to affect 27 of 27 residents residing on the unit.
- D
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
Inspectors wroteBased on record review and interview, the facility failed to ensure non-pharmacological interventions were documented and attempted prior to administering a PRN (as needed) anti-anxiety medication for 2 of 5 residents reviewed for unnecessary medications. (Residents 89 and 91)
- D
Provide activities to meet all resident's needs.
Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure an ongoing activity program was implemented for cognitively impaired and dependent residents for 1 of 1 resident reviewed for activities. (Resident 44)
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure a treatment was completed as ordered for 1 of 2 residents reviewed for non-pressure related skin conditions. (Resident 48)
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure the appropriate treatment was completed for a resident with an existing pressure ulcer for 1 of 6 residents reviewed for pressure ulcers. (Resident 91)
- D
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure a resident with a limited range of motion had a physician-ordered splint in place for 2 of 2 residents reviewed for range of motion. (Residents 21 and 5)
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on observation and interview, the facility failed to ensure residents in the memory care unit were supervised during meals for 1 of 1 resident reviewed for supervision. (Resident B)
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure oxygen and flow rate was documented per titration and oxygen was on at the correct flow rate for 2 of 2 residents reviewed for oxygen. (Residents 23 and 322)
- 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 observation and interview, the facility failed to ensure medications were stored properly and not expired for 2 of 5 medication carts observed. (100 Unit Cart 1 and 400 Unit Odd Cart)
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure infection control practices were in place and implemented related to the disposal of used lancets into the garbage can for 1 of 1 glucometer (machine used to test blood sugar levels) testing observed and the placement of clean treatment materials on dirty tables for 2 of 5 treatments observed. (Residents 18, 48 and 317)
December 13, 2024Standard inspection, Complaint inspection · 16 citations
- G
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wrote3. The record for Resident T was reviewed on [DATE] at 2:11 p.m. Diagnoses included, but were not limited to, dementia without behavioral disturbance, Alzheimer's disease, major depressive disorder, and stress incontinence. The Quarterly Minimum Data Set (MDS) assessment, dated [DATE], indicated the resident was cognitively impaired for daily decision making. She required partial to moderate assistance with rolling left and right in bed and had one Stage 2 (a partial thickness loss of skin) pressure ulcer, one Stage 4 (damage through all layers of the skin) pressure area, and one Unstageable (full thickness tissue loss that is covered by necrotic tissue) pressure ulcer. A Care Plan, dated [DATE], indicated the resident had a pressure ulcer to her right and left hip and right knee related to history of ulcers, immobility, and progression of disease process. [...]
- E
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure activities of daily living (ADLs) were completed for dependent residents related to greasy hair, incontinence care, providing assistance in getting out of bed, facial hair, dirty fingernails, assistance with turning and repositioning, and assistance with dressing for 7 of 9 residents reviewed for ADLs. (Residents Q, P, G, C, F, H, and R)
- E
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure treatments were completed as ordered and bruises were assessed and monitored for 4 of 4 residents reviewed for non-pressure related skin conditions, medications were signed out as ordered for 2 of 5 residents reviewed for unnecessary medications, signs and symptoms of constipation were addressed for 2 of 2 residents reviewed for constipation, and assessments were documented prior to being discharged to the hospital for 1 of 1 resident reviewed for hospitalization. (Residents Q, G, F, D, B, M, N, and R)
- 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 and interview, the facility failed to ensure medications were properly stored in clean, sanitary conditions for 4 of 4 medication carts observed (Even Cart for 400 hall, Cart 1 for 200 hall, Odd Cart for 400 hall, and Cart 1 for 300 hall) and 1 of 2 medication storage rooms observed (200 hall).
- E
Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.
Inspectors wroteBased on observation, record review and interview, the facility failed to ensure residents had snacks available for 8 of 8 residents who attended the Resident Council meeting. (Residents 8, 13, 29, 39, 52, 63, 109 and 110) This had the potential to affect all residents who were able to request and receive oral snacks.
- E
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, record review and interview, the facility failed to ensure infection control practices were in place and implemented related to having no personal protective equipment (PPE) in enhanced barrier precaution rooms, staff failing to perform hand hygiene after glove removal, using gloved hands to apply ointment for 1 of 10 pressure ulcer treatments observed, not cleaning multi-use equipment, soiled washcloth used during bathing to clean urinary catheter tubing and a gastrostomy tube site, and staff failing to remove soiled PPE during a treatment during random infection control observations. (Residents K, C, H, and U)
- D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure each resident's dignity was maintained related to wearing a hospital gown while in bed during the day and a personal care sign posted above the bed for 2 of 4 residents reviewed for dignity. (Residents P and F)
- D
Ensure that residents are fully informed and understand their health status, care and treatments.
Inspectors wroteBased on observation, record review and interview, the facility failed to ensure a resident's right to participate in his care related to not being able to receive medications during their scheduled time window for 1 of 8 residents observed for medication administration. (Resident L)
- D
Allow residents to self-administer drugs if determined clinically appropriate.
Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure a resident was assessed to self-administer medications and had Physician's Orders for the medications for 1 of 1 resident reviewed for self-administration of medication. (Resident 60)
- D
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Inspectors wroteBased on record review and interview, the facility failed to file a grievance form, thoroughly investigate, and resolve grievances for missing personal items that were reported to staff for 1 of 1 resident reviewed for grievances. (Resident S)
- 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 and interview, the facility failed to ensure a resident was invited to attend and participate in care planning conferences for 1 of 4 residents reviewed for participation in care planning. (Resident U)
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure fall precautions were in place to prevent injury from a fall for 1 of 2 residents reviewed for accidents. (Resident J)
- D
Provide enough food/fluids to maintain a resident's health.
Inspectors wroteBased on record review and interview, the facility failed to ensure food consumption logs were completed for a resident with a history of weight loss for 1 of 1 residents reviewed for nutrition. (Resident 3)
- 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 observation, record review, and interview, the facility failed to ensure a resident's peg tube (a tube inserted directly into the stomach for nutrition) was monitored, assessed and being cleaned as ordered for 2 of 4 residents reviewed for tube feeding. (Residents C and H)
- D
Provide safe, appropriate pain management for a resident who requires such services.
Inspectors wroteBased on record review and interview, the facility failed to ensure residents' pain medications were available for administration for 2 of 3 residents reviewed for pain. (Residents K and 101)
- D
Ensure that residents are free from significant medication errors.
Inspectors wroteBased on observation, record review and interview, the facility failed to ensure medications were given as ordered to prevent significant medication errors for 1 of 8 residents observed for medication administration. (Resident L)
June 28, 2024Complaint inspection · 1 citation
- E
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on observation, record review, and interview, the facility failed to provide ADL (activities of daily living) assistance to dependant residents related to bathing, incontinence care, nail care, oral care, and dressing for 5 of 7 residents reviewed for ADL care. (Residents B, E, C, D, and F)
March 26, 2024Complaint inspection · 3 citations
- D
Provide safe, appropriate pain management for a resident who requires such services.
Inspectors wroteBased on record review and interview, the facility failed to ensure pain medication was administered as ordered by the Physician, for 2 of 3 residents reviewed for hospice. (Residents D and E)
- D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Inspectors wroteBased on record review and interview, the facility failed to establish and/or maintain a system that accounted for, periodically reconciled, and ensured the disposition of all controlled drugs, related to incomplete and inaccurate documentation of narcotic medications, for 1 of 3 residents reviewed for hospice. (Resident E)
- D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on record review and interview, the facility failed to ensure a medical record was complete and accurately documented, related to a resident death, for 1 of 3 residents reviewed for hospice. (Resident E)
January 24, 2024Complaint inspection · 3 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, record review, and interview, the facility failed to ensure residents were free from physical abuse, related to a physical altercation by a resident with a history of aggression towards others, which resulted in physical contact with two residents, and was witnessed by another resident. (Residents D, E, and S)
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on record review and interview, the facility failed to ensure adequate supervision was provided to residents in the designated smoking area, which resulted in resident to resident physical altercations involving 3 residents. (Residents C, D, and E)
- 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 observation, record review, and interview, the facility failed to ensure gastrostomy tubes (g-tubes/ feeding tubes) were cleaned at the insertion site as ordered by the Physician, for 2 of 3 residents reviewed for g-tubes. (Residents B and M)
November 3, 2023Complaint inspection · 11 citations
- 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 observation and interview, the facility failed to ensure the residents' environment was sanitary and comfortable, related to dirty bathrooms, broken and chipped toilets, dirty walls, debris on the floor, unsanitary storing of personal use items, holes in the walls, unmade beds, a dirty fan, over the bed table veneer loose and coming off, flooring coming up in the bathroom, and tears on the wheelchair arms for 11 of 24 rooms observed on 4 of 4 units (100, 200, 300, and 400)
- D
Allow residents to self-administer drugs if determined clinically appropriate.
Inspectors wroteBased on record review and interview, the facility failed to ensure a resident was thoroughly assessed for self-administration of insulin and received a Physician's Order that the resident was appropriate for self-administration for 1 of 1 resident reviewed for self-administration of medications. (Resident S)
- 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 record review and interview, the facility failed to notify a Physician for a follow up consult/appointment as ordered and failed to notify a resident's responsible party in a timely manner about skin tear injuries for 2 of 13 residents reviewed for Physician notification. (Residents B and M)
- D
Respond appropriately to all alleged violations.
Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure injuries to residents were thoroughly investigated for the cause of the injury to rule out potential abuse for 2 of 4 residents reviewed for injuries and abuse. (Residents M and L)
- 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 observation, record review, and interview, the facility failed to ensure individualized Care Plans were developed and implemented related to behaviors and self-administration of medications, for 3 of 13 residents reviewed for care plan development and implementation. (Residents M, Q, and S)
- D
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure a resident who required set up assistance with eating was assisted with his supper meal for 1 of 6 residents reviewed for meal assistance. (Resident Q)
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure a resident who was dependent for dietary and fluid intake was assisted with the evening meal and was fed slowly and in an enjoyable manner, for 1 of 2 dependent residents observed during meal times. (Resident H)
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure adequate supervision was provided to a resident during a transfer related to a mechanical lift transfer (Resident H). The facility also failed to ensure a Care Planned intervention was in place to prevent injury to the skin related to geri-sleeves (skin protector) for 2 of 4 residents reviewed for injuries and assistive devices. (Resident L)
- D
Provide enough food/fluids to maintain a resident's health.
Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure a resident who had a Physician's Order for a dietary supplement to assist with caloric and protein needs, received the supplement as ordered for 1 of 4 residents reviewed for nutritional status. (Resident Q)
- D
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Inspectors wroteBased on record review and interview, the facility failed to manage medications appropriately, related to missing medication doses, not administering or ensuring insulin was administered, and blood sugar monitoring not completed as ordered for 1 of 4 residents reviewed for unnecessary medications. (Resident S)
- D
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Inspectors wroteBased on record review and interview, the facility failed to ensure residents were free from unnecessary psychotropic medications related to a lack of a GDR (Gradual Dose Reduction) for anti-anxiety and antidepressant medications completed for 2 of 4 residents reviewed for unnecessary medications. (Residents B and H)
Fire safety inspections
12 fire safety citations on file: 6 on December 9, 2025, 3 on June 3, 2025, 2 on December 13, 2024, 1 on January 24, 2024.
Every fire safety citation12 citations
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · December 9, 2025 · Corrected (the home has a date of correction)
- F
Have properly installed electrical wiring and gas equipment.
K 511 · December 9, 2025 · Corrected (the home has a date of correction)
- E
Install an approved automatic sprinkler system.
K 351 · December 9, 2025 · Corrected (the home has a date of correction)
- E
Install corridor and hallway doors that block smoke.
K 363 · December 9, 2025 · Corrected (the home has a date of correction)
- E
Install smoke barrier doors that can resist smoke for at least 20 minutes.
K 374 · December 9, 2025 · Corrected (the home has a date of correction)
- E
Ensure proper usage of power strips and extension cords.
K 920 · December 9, 2025 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · June 3, 2025 · Corrected (the home has a date of correction)
- F
Ensure proper usage of power strips and extension cords.
K 920 · June 3, 2025 · Corrected (the home has a date of correction)
- E
Have properly installed electrical wiring and gas equipment.
K 511 · June 3, 2025 · Corrected (the home has a date of correction)
- F
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
K 354 · December 13, 2024 · Corrected (the home has a date of correction)
- E
Have exits that are accessible at all times.
K 271 · December 13, 2024 · Corrected (the home has a date of correction)
- E
Have proper fire barriers, ventilation and signs for the transfilling of oxygen.
K 927 · January 24, 2024 · Corrected (the home has a date of correction)