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
0G
0H
0I
Potential for more than minimal harm
48D
20E
1F
Potential for minimal harm
0A
0B
1C
May 11, 2026Complaint inspection · 4 citations
- E
Dispose of garbage and refuse properly.
Inspectors wroteBased on observations and interviews it was determined that the facility staff failed to dispose of furniture and refuse in a sealed container. This was evident in 1 of 1 refuse disposal areas observed during the complaint survey.
- E
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observations and interviews it was determined that the facility staff failed to ensure the clean linen was in a clean area without dust. This was evident in 1 of 1 laundry areas observed during the complaint survey.
- D
Respond appropriately to all alleged violations.
Inspectors wroteBased on review of an investigation and interview it was determined that the facility staff failed to complete a through investigation of an allegation of abuse. This deficient practice was evidenced in 1 (#1) of 1 resident allegation investigation reviewed during the complaint survey.
- 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 and interviews it was determined that the facility staff failed to ensure the laundry area maintenance was completed, this was evident in 1 of 1 laundry areas observed during the complaint survey.
February 25, 2026Standard inspection, Complaint inspection · 23 citations
- E
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Inspectors wroteBased on observation and interview it was determined the facility failed to ensure food maintained appropriate temperature in accordance with professional standards for food service safety. This was evident during the surveyor's review of the kitchen task during the facility's recertification survey.
- 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 and interview it was determined the facility failed to: 1) Ensure professional standards for food service safety were followed. 2) Maintain a sanitary kitchen environment: Ensure thorough cleaning of kitchen, equipment, and areas where food is served and stored. Ensure surfaces used for food preparation, storage and serving were clean and in good repair. 3) Ensure the kitchen environment was pest free. 4) Ensure furniture for dining was clean and in good repair. This was evident during the surveyor's kitchen and dining tour during the facility's recertification survey.
- E
Dispose of garbage and refuse properly.
Inspectors wroteBased on observation and interview it was determined the facility failed to ensure the garbage area was maintained in sanitary condition. This was evident during the surveyor's initial tour of the facility for 1 out of 1 trash area observed during the facility's recertification survey.
- E
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation and interview it was determined the facility failed to adhere to infection control practices and guidelines. This was found to be evident during observations made throughout the facility's annual Medicare/Medicaid survey.
- E
Keep all essential equipment working safely.
Inspectors wroteBased on observation and interview it was determined the facility failed to ensure essential kitchen equipment needed to manage functions of food service was maintained in safe operating condition. This was evident for: 1 out of 2 steamer compartments, 1 out of 1 single door reach in refrigerator, 1 out of 2 convection oven compartments, and 1 out of 6 steam table wells observed during the facility's recertification survey.
- E
Have enough backup water supply for essential areas of the nursing home.
Inspectors wroteBased on observation, interview and record review it was determined the facility failed to ensure onsite emergency water supply. This was evident during the surveyor's tour of the emergency water storage area during the facility's recertification survey.
- E
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Inspectors wroteBased on observation, interview and record review it was determined the facility failed to ensure effective management of pest control. This was evident for all floors of the facility during surveyor review of environment during the facility's recertification survey.
- D
Allow residents to self-administer drugs if determined clinically appropriate.
Inspectors wroteBased on observation, interview and record review it was determined the facility failed to ensure a Resident (#97) had the capability of safe self administration of a medication and failed to ensure the interdisciplinary team was aware of the Resident's self administration of the medication. This was evident for 1 (#97) out of 2 Residents reviewed for quality of care during the facility's recertification survey.
- D
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Inspectors wroteBased on resident interview, staff interview, and clinical record review it was determined that the facility staff failed to ensure a resident received showers according to personal preference. This was evident for 1 (Resident #104) out of 1 resident reviewed for preference in shower schedule.
- D
Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home.
Inspectors wroteBased on resident interview and staff interview, it was determined that the facility staff failed to provide a resident with a quarterly statement for a personal funds account. This was evident for 1 (#104) out of 2 residents reviewed for a personal funds account.
- 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 and interviews with resident's and facility staff, it was determined the facility failed to ensure Resident's room furniture and the resident's environment was clean and well maintained for residents residing in the facility . This was evident during the surveyor's initial tour of the facility for two Resident rooms (#208, and #210) located on the second floor, observations of Resident # 19 Room and for Room # 309 during the facility's recertification survey.
- 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 interviews with staff and a resident representative, it was determined that the facility failed to follow the grievance process for a resident and resident representative. This was evident for 1 (Resident #180) of 2 residents reviewed for grievances during the annual recertification and complaint survey.
- D
Protect each resident from the wrongful use of the resident's belongings or money.
Inspectors wroteBased on interview and record review it was determined the facility failed to ensure Resident #4's personal funds was appropriately managed. This was evident for 1 out of 2 Residents reviewed for personal funds during the facility's recertification survey.
- D
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Inspectors wroteBased on record reviews and interviews, the facility failed to provide written information regarding transfers to the hospital and discharge to; the resident and/or the resident's responsible party (RP), and the local Ombudsman. This was evident for 6 (# 94, # 181, # 179, # 12, #140, # 7) of 6 residents reviewed for transfer / discharge.
- D
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Inspectors wroteBased on record review and interview it was determined the facility failed to ensure resident minimum data set assessments were completed timely. This was evident for 2 out of 2 Residents (#34 and #17) reviewed for the Resident Assessment task during the facility's recertification survey.
- D
Ensure services provided by the nursing facility meet professional standards of quality.
Inspectors wroteBased on observation and interviews with staff, it was determined that the facility failed to administer medication according to professional standards of practice. This was evident for 1 (Resident #126) out of 7 residents observed for medication administration during the annual recertification survey.
- 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 a resident had their wound dressing changed according to physician's order for 1 (#104) of 1 resident wound dressing observation, and to ensure medications were administered as ordered by the physician for 1 (#140) of 1 resident reviewed for medication administration.
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on medical record review and interviews with facility staff it was determined the facility failed to ensure that a resident was kept safe and free from accidents after observing the resident to be in distress. This was found to be evident for 1 (Resident #2) of 5 residents reviewed for accidents and observations made during the facility's annual Medicare/Medicaid survey.
- D
Provide safe, appropriate pain management for a resident who requires such services.
Inspectors wroteBased on resident interview, staff interview, observation, and clinical record review it was determined that the facility failed to ensure a resident's pain management was adequately addressed. This was evident for 1 (#104) out of 1 resident being reviewed for wound care.
- D
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Inspectors wroteBased on clinical record review and staff interview, it was determined that the facility staff failed to ensure a pain medication was administered according to the physician's order. This was evident for 1 (#104) out 1 resident reviewed for pain medication.
- D
Provide or obtain dental services for each resident.
Inspectors wroteBased on clinical record review, observation, and staff interview, it was determined that the facility staff failed to ensure a resident received routine and follow-up dental care. This was evident for 2 residents (#9 and # 180) out of 2 residents reviewed for dental care during the facility's annual Medicare/Medicaid survey.
- D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on interviews and record reviews the facility failed to maintain medical records in accordance with the accepted professional standards and practices for complete and accurate records. This was evident in 3 (#94, #97, #165) of the 51 residents' records reviewed.
- 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 observation and interview, the facility failed to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable environment for residents on 2 of 2 units observed (Somerset and Arcadia Memory Care). This had the potential to affect all residents residing on these units.
October 7, 2025Complaint inspection · 1 citation
- D
Ensure services provided by the nursing facility meet professional standards of quality.
Inspectors wroteBased on resident interviews, record reviews and staff interviews, it was determined that the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice. This was evident for 1 resident (Resident #1) receiving medications late.
February 14, 2025Complaint inspection · 1 citation
- E
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Inspectors wroteBased on observations, interviews, and record review, the facility failed to maintain an effective pest control program, failed to seal gaps in the walls, and prevent rodents from entering residents rooms for six residents (R20, R18, R6, R15, R16, and R14) residing on the third floor. The facility census was 164.
October 24, 2024Standard inspection, Complaint inspection · 6 citations
- E
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to provide respiratory care in accordance with professional standards for four of four residents (Residents (R) 18, R22, R120 and R357) reviewed for respiratory care out of 32 sampled residents. This failure had the potential for the residents to be subjected to contaminated respiratory equipment and to not receive proper airflow.
- E
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, interview, and facility policy review, the facility failed to ensure residents received appropriate supervision during medication administration for three of 161 residents (Resident (R) 122, 97, and 103) reviewed during initial tour. This failure could result in unwarranted medication side effects and mismanaged medical conditions.
- 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 interview, record review, and policy review, the facility failed to ensure a grievance was adequately documented and investigated to ensure satisfactory resolution for one of 32 sampled residents (Resident (R) 97). This failure had the potential to cause dissatisfaction with care, feelings of helplessness, and fear for R97.
- D
Provide activities to meet all resident's needs.
Inspectors wroteBased on observations, interviews, record review, and policy review, the facility failed to ensure an ongoing program of meaningful activities was designed for one of one resident (Resident (R) 113) reviewed for activities out 32 sampled residents. This failure had the potential to contribute to feelings of boredom, depression, loneliness, or helplessness for R113.
- 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 observations, interviews, record review, and policy review, the facility failed to ensure a splint was applied to address a hand contracture for one of five residents (Resident (R) 71) reviewed for limited range of motion out of 32 sampled residents. This failure had the potential to lead to increased contracture, pain, or skin breakdown for the resident.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observations, record review, interviews, and policy review, the facility failed to ensure appropriate personal protective equipment (PPE) was worn for two of four sample residents (Resident (R) 107 and R205) reviewed for transmission-based or enhanced barrier precautions out of 32 sampled residents. These failures have the potential to contribute to spread of infection among staff and residents.
September 26, 2024Complaint inspection · 2 citations
- 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 interview and staff interviews, it was determined that the facility failed to ensure interventions for a care plan focus were revised with interventions to address residents' medication refusals. This was evident for 1 (#MD00209998) of 1 complaint reviewed. A care plan is a guide that addresses the unique needs of each resident. It is used to plan, assess and evaluate the effectiveness of the resident's care. It should be revised to reflect the resident's plan of care.
- 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 it was determined that facility staff failed to ensure the safety of a Resident by not providing adequate supervision as evidenced by the fact that the Resident fell and was found on the floor 5 times in a 4-month period and making rounds. This was evident for 1 (# MD00210090) of 1 complaint reviewed. Care plan - is a guide that addresses the unique needs of each resident. It is used to plan, assess, and evaluate the effectiveness of the resident ' s care.
September 18, 2024Complaint inspection · 7 citations
- F
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Inspectors wroteBased on review of a complaint, interviews, and documentation review, it was determined the facility failed to have an effective pest control program as evidenced by numerous reports and observation of mice throughout the facility. This had the potential to affect all residents in the facility.
- E
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on record review and interview it was determined the facility failed to report allegations of abuse within 2 hours of the allegation and an injury of unknown origin within 24 hours to the regulatory agency, the Office of Health Care Quality (OHCQ). This was evident for 3(#10, #8, #2) residents involved in 14 facility reported incidents reviewed during a complaint survey.
- E
Respond appropriately to all alleged violations.
Inspectors wroteBased on review of facility administrative records, facility investigations, and staff interview, it was determined the facility failed to thoroughly investigate incidents of alleged abuse, neglect, and misappropriation of property. This was evident for 4 (#10, #8, #2, #30) residents involved in 14 facility reported incidents reviewed during a complaint survey.
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on the review of a complaint, medical record review and interview with staff, it was determined that the facility failed to timely implement wound care orders for a resident with a scrotal ulcer. This was evident for 1 (Resident #35) of 28 complaints reviewed during a complaint survey.
- D
Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit.
Inspectors wroteBased on medical record review, policy review, and interview, it was determined the facility staff failed to ensure the physician wrote, dated, and signed progress notes at each resident's visit. This was evident for 1 (Resident #24) of 28 complaints reviewed during a complaint survey.
- D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Inspectors wroteBased on review of complaint MD00977840, interviews, and medical record review, it was determined the facility failed to ensure that pain and anxiety medications were available to a resident. This was evident for 1 (#18) of 28 complaints reviewed during a complaint survey.
- 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 and interview with family and facility staff, it was determined that the facility failed to ensure medical records were complete, accurate and up to date related to residents' status in the facility. This was evident during the review of 2 of 38 (#22 and #24) residents reviewed during a complaint survey.
July 18, 2019Standard inspection · 26 citations
- E
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Inspectors wroteBased on medical record review and interview, the facility staff failed to honor a resident's choices (Resident #157) ,the facility staff failed to provide showers to Resident (#24), the facility nursing staff failed to 1. know what days of the week a resident was to receive a shower and 2. follow a resident's choice to receive a shower as indicated in the medical record for Resident (#101). This was evident for 3 of 9 residents reviewed for choices during this survey.
- 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 staff interview it was determined that the facility staff failed to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior. This was evident for 14 resident rooms and 1 shower room and 1 resident lounge.
- E
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on medical record review, observation and interview, it was determined the facility failed to maintain the environment for Residents (#16 and #67) free from potential accidents. This was evident for 2 of 2 resident selected for review of accidents and 2 of 67 residents selected for review during the annual survey process.
- E
Provide enough food/fluids to maintain a resident's health.
Inspectors wroteBased on record review, observation and interview, it was determined the facility staff failed to administer dietary supplements to Residents (#115, #16, #136, #105, #148, #17, #147 and #117) and failed to obtain weekly weights on (Resident #148) as ordered. This was evident for 8 out of 14 residents selected for review of nutrition and 8 out of 67 residents selected for review during the annual survey.
- E
Ensure medication error rates are not 5 percent or greater.
Inspectors wroteBased on observation of medication pass and interview, it was determined the facility staff failed to obtain a medication error rate less than 5% (Residents #77, and #368). This includes 2 out of 4 residents observed for medication pass, 5 errors out of 27 opportunities with a medication error rate of 18.52%.
- 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, it was determined the facility staff failed to ensure that medications were properly secured, thoroughly labeled with residents' name, and dated when the medication was open. This was evident for 2 of 6 medication carts observed during the annual survey process.
- D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteBased on observation and interview, it was determined the facility staff failed to provide Residents (#23 and #148) with the most dignified existence. This was evident for 2 of 8 residents reviewed for dignity during the survey process and 2 of 67 residents selected for review.
- D
Reasonably accommodate the needs and preferences of each resident.
Inspectors wroteBased on resident complaint and observation, it was determined that the facility failed to have the facility complaint/compliment forms readily available to wheelchair dependent Resident (#18) and the facility failed to ensure that Residents (#9 and #145) had access to their nurse call button. This was evident for 3 of 3 resident's reviewed for accommodation of needs during this survey.
- D
Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home.
Inspectors wroteBased on resident complaint, reviews of administrative records including a resident's personal funds records, individual resident account statements, transaction reports, transaction receipts, and staff interview, it was determined the facility staff failed to maintain a system that ensures a full and complete accounting of a resident's personal monies entrusted to this facility. This was evident for 1 (Resident #18) of 2 residents reviewed for personal property during an annual recertification survey.
- 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 resident complaint, review of a medical record review and staff interview, it was determined the facility staff failed to immediately notify a resident's physician regarding the resident's refusal of taking his/her anti-seizure medications. This was evident for 1 (Resident #117) of 2 residents reviewed for notification during an annual recertification survey.
- D
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Inspectors wroteBased on medical record review and staff interview, it was determined the facility failed to provide the resident and their representative with a summary of the baseline care plan within 48 hours of admission to the facility. This was evident for 1 (Resident #366) of 4 resident reviewed for care plan participation and 1 of 67 residents reviewed during an annual recertification survey.
- 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 the medical record and interviews with staff, it was determined that the facility staff failed to develop a comprehensive activities care plan for residents (#316, #20). The facility failed to follow the care plan to provide eating assistance for a resident (#157). This was evident for 3 of 67 residents reviewed during the annual survey.
- 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 medical record review, it was determined the facility failed to implement a comprehensive care plan for the use of an anticoagulant medication for a resident (#117) and the facility staff failed to implement interventions for Resident (#16) as noted on a care plan. This was evident for 2 of 5 residents reviewed for care planning during an annual recertification survey.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on medical record review and interview, it was determined the facility staff failed to obtain a podiatry consultation as ordered for Resident (#24), the facility staff failed to initiate a medication and a Iodosorb dressing in a timley manner for Resident (#135) and the facility staff failed to administer medications in a timely manner per physician's orders for Resident (#91). This was evident for 3 of 67 residents reviewed during the annual survey process.
- D
Assist a resident in gaining access to vision and hearing services.
Inspectors wroteBased on resident complaint, reviews of a medical record, and staff interview, it was determined that the facility staff failed to follow up with an audiologist office since March 2019 to obtain a resident's hearing aids for Resident (#39) and failed to obtain an ophthalmology consultation as ordered by the physician for Resident (#148). This was evident for 2 of 8 residents reviewed for vision/hearing during an annual recertification survey.
- 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 medical record review and interview it was determined the facility staff failed to provide ambulatory services to Resident (#23) to maintain mobility. This was evident for 1 of 2 residents selected for range of motion during the survey process and 1 of 67 residents selected for review during the annual survey process.
- D
Provide safe, appropriate pain management for a resident who requires such services.
Inspectors wroteBased on a review of the clinical records and staff interview it was determined that the facility staff failed to document the administered of pain medication and failed to assess the need for pain medication and thoroughly monitor the effectiveness. This was true for Resident (#135), 1 out of the 7 residents reviewed for pain management during an annual recertification survey.
- D
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Inspectors wroteBased on staff interview and documentation review it was determined that facility staff failed to provide evidence that the facility's Geriatric Nursing Assistant (GNA), have been deemed competent to provide resident care independently. This is true for 1 GNA (Staff #22) employed by this facility.
- D
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Inspectors wroteBased on medical record review and interview, it was determined the consultant pharmacist failed to conduct a thorough medical record review to identify and bring to the facility staff's attention Resident (#100) receiving Nystatin cream for 2 months and the facility failed to conduct thorough medication regimen reviews and identify that Resident (#72) was receiving an antipsychotic. This was evident for 2 of 6 residents selected for review of un-necessary medications and 2 of 67 residents selected for review during the annual survey.
- D
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Inspectors wroteBased on medical record review and interview, it was determined the facility staff failed to ensure Resident (#100) was free from an un-necessary medication. This was evident for 1 of 6 residents reviewed for un-necessary medication and 1 of 67 residents reviewed during the annual survey process.
- D
Provide or obtain dental services for each resident.
Inspectors wroteBased upon staff interview and medical record review it was determined the facility staff failed to obtain a dental consultation as ordered for Resident (#5). This was evident for 1 of 4 residents selected for review of dental services and 1 of 67 resident selected for review during the annual survey.
- 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 and interviews of facility staff, it was determined that food service employees failed to ensure that sanitary practices were followed, equipment was maintained and safe food handling practices were followed to reduce the risk of foodborne illness. This deficient practice has the potential to affect all residents.
- 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 and interview, it was determined the facility staff failed to maintain medical records in the most accurate form for Residents(#157, #158 ). This was evident for 2 of 67 residents reviewed in the annual survey.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation and interview it was determined that the facility staff failed to provide a safe, sanitary environment to prevent the development and transmission of disease and infection by failing to post an isolation sign on Resident's (#135 and #367) door and to have the necessary equipment to alert visitors, residents, and staff to see the nurse before entering the room. This was true for 2 out of 3 residents selected for review during the annual survey process.
- D
Keep all essential equipment working safely.
Inspectors wroteBased on observation, staff interview and record review it was determined that the facility failed to maintain kitchen equipment in safe operating condition. This deficient practice has the potential to affect all residents.
- C
Post nurse staffing information every day.
Inspectors wroteBased on observation it was determined the facility failed to post the required nursing staffing data on the Daily Staffing Schedule. The facility also failed to post the Daily Staffing Schedule in a prominent place and readily accessible to visitors and residents. This was evident on 1 out of 4 nursing units.
Fire safety inspections
42 fire safety citations on file: 2 on April 24, 2026, 13 on February 25, 2026, 24 on October 24, 2024, 3 on July 18, 2019.
Every fire safety citation42 citations
- E
Have properly installed electrical wiring and gas equipment.
K 511 · April 24, 2026 · Corrected (the home has a date of correction)
- D
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
K 521 · April 24, 2026 · Corrected (the home has a date of correction)
- F
Install a fire alarm system that can be heard throughout the facility.
K 341 · February 25, 2026 · Corrected (the home has a date of correction)
- F
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
K 761 · February 25, 2026 · 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 · February 25, 2026 · Corrected (the home has a date of correction)
- E
Provide properly protected cooking facilities.
K 324 · February 25, 2026 · Corrected (the home has a date of correction)
- E
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · February 25, 2026 · Corrected (the home has a date of correction)
- E
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
K 362 · February 25, 2026 · Corrected (the home has a date of correction)
- E
Install properly constructed and protected linen or trash chutes.
K 541 · February 25, 2026 · Corrected (the home has a date of correction)
- E
Have restrictions on the use of portable space heaters.
K 781 · February 25, 2026 · Corrected (the home has a date of correction)
- D
Meet other general requirements.
K 100 · February 25, 2026 · Corrected (the home has a date of correction)
- D
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 · February 25, 2026 · Corrected (the home has a date of correction)
- D
Have properly located and lighted "Exit" signs.
K 293 · February 25, 2026 · Corrected (the home has a date of correction)
- D
Have properly installed electrical wiring and gas equipment.
K 511 · February 25, 2026 · Corrected (the home has a date of correction)
- D
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
K 741 · February 25, 2026 · Corrected (the home has a date of correction)
- F
Include a process for Emergency Preparedness collaboration.
E 9 · October 24, 2024 · Corrected (the home has a date of correction)
- F
Address subsistence needs for staff and patients.
E 15 · October 24, 2024 · Corrected (the home has a date of correction)
- F
Provide properly protected cooking facilities.
K 324 · October 24, 2024 · Corrected (the home has a date of correction)
- F
Install a fire alarm system that can be heard throughout the facility.
K 341 · October 24, 2024 · Corrected (the home has a date of correction)
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · October 24, 2024 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · October 24, 2024 · Corrected (the home has a date of correction)
- F
Install properly constructed and protected linen or trash chutes.
K 541 · October 24, 2024 · Corrected (the home has a date of correction)
- F
Have simulated fire drills held at unexpected times.
K 712 · October 24, 2024 · 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 · October 24, 2024 · Corrected (the home has a date of correction)
- F
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
K 761 · October 24, 2024 · 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 · October 24, 2024 · Corrected (the home has a date of correction)
- F
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · October 24, 2024 · Corrected (the home has a date of correction)
- E
Keep aisles, corridors, and exits free of obstruction in case of emergency.
K 211 · October 24, 2024 · 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 · October 24, 2024 · Corrected (the home has a date of correction)
- E
Have properly located and lighted "Exit" signs.
K 293 · October 24, 2024 · Corrected (the home has a date of correction)
- E
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
K 362 · October 24, 2024 · Corrected (the home has a date of correction)
- E
Install corridor and hallway doors that block smoke.
K 363 · October 24, 2024 · Corrected (the home has a date of correction)
- E
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
K 521 · October 24, 2024 · Corrected (the home has a date of correction)
- E
Have proper medical gas storage and administration areas.
K 923 · October 24, 2024 · Corrected (the home has a date of correction)
- D
Have exits that are accessible at all times.
K 271 · October 24, 2024 · Corrected (the home has a date of correction)
- D
Install emergency lighting that can last at least 1 1/2 hours.
K 291 · October 24, 2024 · Corrected (the home has a date of correction)
- D
Properly select, install, inspect, or maintain portable fire extinguishes.
K 355 · October 24, 2024 · Corrected (the home has a date of correction)
- D
Install smoke barrier doors that can resist smoke for at least 20 minutes.
K 374 · October 24, 2024 · Corrected (the home has a date of correction)
- D
Have restrictions on the use of portable space heaters.
K 781 · October 24, 2024 · 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 · July 18, 2019 · Corrected (the home has a date of correction)
- E
Have proper medical gas storage and administration areas.
K 923 · July 18, 2019 · Corrected (the home has a date of correction)
- D
Meet other general requirements.
K 100 · July 18, 2019 · Corrected (the home has a date of correction)