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 63 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
2J
0K
0L
Actual harm
1G
0H
0I
Potential for more than minimal harm
40D
17E
2F
Potential for minimal harm
0A
1B
0C
March 19, 2026Standard inspection, Complaint inspection · 14 citations
- E
The resident has the right to receive notices in a format and a language he or she understands.
Inspectors wroteBased on observations, resident interviews, and staff interviews, it was determined that the facility failed to post the State Survey Agency phone number and contact information readily accessible on the two of two nursing floors. (1st Floor, and 2nd Nursing Units) Findings Include: Review of the facility policy titled, Resident's Right to Freedom from Abuse, Neglect, Misappropriation of Resident Property and Exploitation dated November 25, 2024 states, Policy- It is the policy of the facility to ensure that all residents rights are upheld and that residents are free from abuse, neglect, misappropriation of their property, and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, and any physical or chemical restraint not required to treat the resident's medical symptoms. [...]
- E
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Inspectors wroteBased on review of facility documentation, observations, and staff and resident interviews it was determined that the facility failed to ensure that food was served in accordance with the planned menus for one of four days observed (lunch meal 3/18/2026). Findings Include: Review of the facility menu revealed the lunch meal offered on March 18, 2026, was listed as tomato soup, grilled American cheese sandwich, mixed vegetables, crackers, chilled peaches, and a beverage. There was no alternate lunch item listed on the main menu; however, the facility had an always available menu with daily food items available at lunch and dinner. The undated always available food menu consisted of cottage cheese, fresh fruit, chicken salad sandwich, grilled cheese sandwich, hot dog, turkey hoagie, and cheeseburger. [...]
- E
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Inspectors wroteBased on review of facility documentation, observations, and interviews with staff and residents it was determined that the facility failed to ensure food was served for palatable taste and temperature. Findings Include: Review of the facility's undated Test Tray Evaluation form revealed the acceptable delivery temperature of the starch and vegetable should be 135-165 degrees Fahrenheit. A test tray was conducted during the lunch time meal service on March 18, 2026, at 12:25 p.m. with the Food Service, Employee E18, and the Nursing Home Administrator, Employee E1. The test tray consisted of three pureed food items that was supposed to be pureed mac and cheese, mashed potato, and mixed vegetables. Temperatures and tastings revealed the food temperature resulted below standards at 110 degrees Fahrenheit and had a bland, unfamiliar taste. The pureed vegetables tasted more like pureed meat. [...]
- E
Provide and implement an infection prevention and control program.
Inspectors wroteBased on review of facility's policy, interview with staff, and review of facility provided documentation, it was determined that facility did not ensure to maintain an effective antibiotic stewardship program that includes ongoing tracking, analysis, and reporting of antibiotic use for 11 of 11 months reviewed (May 2025 through March 2026)
- E
Implement a program that monitors antibiotic use.
Inspectors wroteBased on review of facility policy and facility provided documentation, and staff interview, it was determined that the facility did not ensure to maintain an effective antibiotic stewardship program that includes a system to effectively monitor antibiotic usage for 11 of 11 months of antibiotic stewardship program data reviewed (May 2026 through March 2026)
- E
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Inspectors wroteBased on observations, review of facility policy, interviews with residents, and facility record review it was determined that the facility did not ensure an effective pest control program was maintained so that the facility is free of pests and rodents for two of two nursing floors reviewed. (First floor and Second floor) Findings Include: Review of pest control policy titled, Pest Control dated April 1, 2022 states, Policy Statement-The facility shall maintain an effective pest control program. Further review of the policy revealed, Policy Interpretation and Implementation 1. The facility maintains an on-going pest control program to ensure that the building is kept free of insects and rodents Interview held with six awake, alert, and oriented resident on March 18, 2026 at 1:30 p.m. During resident council four of the residents reported having mice and roaches in their room at times. [...]
- D
Respond appropriately to all alleged violations.
Inspectors wroteBased on review of facility policy, review of facility documentation, review of clinical records, and interviews with staff and residents it was determined that the facility failed to conduct a complete and thorough investigation to rule out neglect for one of 31 residents reviewed (Resident R24). Findings Include: Review of facility policy Residents Right to Freedom from Abuse, Neglect, Misappropriation of Resident Property and Exploitation effective/revised 2025 revealed it is the policy of the facility to ensure that all resident's rights are upheld and that residents are free from abuse, neglect, misappropriate of their property, and exploitation. [...]
- 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 policies, clinical record reviews and interviews with staff, it was determined that the facility failed to develop a person-centered comprehensive care plan related to restraints and restorative nursing program for two of 30 residents reviewed (Resident R1 and R13).
- D
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Inspectors wroteBased on observations, interview with resident and staff, and review of policy and clinical record, it was determined that facility did not ensure that resident received necessary assistance with activities of daily living, related to bathing, grooming and personal hygiene for one of 31 residents reviewed (Resident R86)
- 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 upon observation, interviews with resident and staff, and review of clinical records and facility policy it was determined the facility failed to ensure rehabilitative nursing care was provided to two of 31 resident records reviewed (Resident R1 and Resident R7).
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on review of facility policy, review of facility documentation, review of clinical records, and interviews with staff and residents it was determined that the facility failed to provide assistance devices necessary to prevent an avoidable accident for one of 31 residents reviewed (Resident R24). Findings Include: Review of Resident R24's quarterly Minimum Data Set (MDS - federally mandated resident assessment and care screening) dated December 9, 2025, revealed the resident was admitted to the facility on [DATE], and had diagnoses of malnutrition (imbalance in a person's energy/nutrient intake), hemiplegia (paralysis that affects one side of the body) affecting left-side, contracture of right hand, and homonymous bilateral field defects (visual impairments affecting the same side of the visual field in both eyes). [...]
- D
Provide enough food/fluids to maintain a resident's health.
Inspectors wroteBased on review of facility policy, review of facility documentation, review of clinical records, and interviews with staff and residents it was determined that the facility failed to ensure adequate monitoring and timely reassessment to maintain acceptable parameters of nutrition status for 3 of 9 residents reviewed for nutrition (Resident R1, R87, and R11). Findings Include: Review of facility policy titled, Weight Policy with a revision date on July 2025 states, Policy- It is the policy of this facility to weigh each resident on admission, weekly for four weeks, then monthly thereafter, unless otherwise ordered by the physician/interdisciplinary team. The facility will utilize consistent procedures for monitoring weights to prevent unnecessary weight loss/gain in our residents. [...]
- D
Ensure medication error rates are not 5 percent or greater.
Inspectors wroteBased on observations, review of clinical record and review of policy, as well as interview with staff, it was determined that facility did not ensure the accurate administration of psychotropic medication by administering a medication at a dose different from that prescribed for one of three residents observed (Resident R50)
- B
Let each resident or the resident's legal representative access or purchase copies of all the resident's records.
Inspectors wroteBased on review of facility documentation, clinical record review, and interviews with staff, it was determined that the facility failed to provide copies of medical records as requested in a timely manner and reasonable cost for one of one resident reviewed for medical record request (Resident R162).
December 11, 2025Complaint inspection · 2 citations
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on clinical record review, staff interview and review of facility provided documentation, and review of clinical records, it was determined that facility failed to timely monitor and assess a resident's medical condition for one of eight residents reviewed. (Resident R1)
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteReview of Resident R2 ' s quarterly Minimum Data Set (MDS - federally mandated resident assessment and care screening) dated August 5, 2025, revealed the resident was rarely/never understood and had diagnoses of hemiplegia or hemiparesis, and functional quadriplegia. Continued review of Resident R2's quarterly MDS dated [DATE], revealed the resident had functional limitation in range of motion impairments on both sides of upper extremity. Review of Section GG0170. Mobility of Resident R2's quarterly MDS dated [DATE], revealed the resident was dependent (helper does ALL of the effort. Resident does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the resident to complete the activity) on staff to roll left and right (the ability to roll from lying on back to left and right side, and return to lying on back on the bed). [...]
May 8, 2025Standard inspection, Complaint inspection · 23 citations
- G
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on observations, review of facility documentation and clinical records, and staff and resident interviews, it was determined the facility failed to ensure that one of four residents reviewed (Resident R51) was adequately secured during transportation in the facility's van. This failure resulted in actual harm to Resident R51 who sustained a fracture of the right knee after sliding out of the wheelchair on the way to an appointment. (Resident R51) Findings Include: Review of Resident R51's quarterly Minimum Data Set (MDS - federally mandated resident assessment and care screening) dated February 5, 2025, revealed the resident had diagnoses of muscle weakness, lack of coordination, Aphasia (communication disorder), Cerebrovascular Accident (CVA - stoke; [...]
- F
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on review of facility policy, observations, and interviews with staff and residents, it was determined that the facility did not ensure that food was stored, prepared, and served in accordance with professional standards for food service safety. Findings Include: Review of facility policy Dishwashing Machine Use revised March 2010 revealed dishwashing machine chemical sanitizer for use of chlorine solution, the minimum concentration should be 50-100 ppm (parts-per-million) for a contact time of 10 seconds. A tour of the main kitchen conducted on May 5, 2025, 9:30 a.m. with Food Service Director, Employee E29, revealed the following: Observations of the walk-in refrigerator revealed an open large sleeve of ground beef, poorly resealed, and not labeled with received or open date. [...]
- E
Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home.
Inspectors wroteBased on review of facility documentation, interview with staff and residents, it was determined that the facility failed to make financial record available to the resident through quarterly statements and upon request for one out one resident reviewed. (Resident R63).
- E
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 clinical record reviews, review of facility policies and documentation and interviews with staff, it was determined that the facility failed to ensure that pharmacist recommendations were reviewed by the physician in a timely manner for four of five residents reviewed related to medication regime reviews (Residents R48, R86, R85 and R125).
- E
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Inspectors wroteBased on review of facility policy, observations, and staff and resident interviews, it was determined that the facility failed to maintain an effective pest control program for two of three nursing units and the main kitchen (2nd floor South nursing unit, 1-North Nursing Unit, and main kitchen ).
- D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteBased on observations, facility policy and interviews with resident and staff, it was determined that the facility failed to protect personal property of Resident's (R68) by removing items from her/his room without prior notice. This failure resulted in the facility not providing an environment that maintains and enhances the dignity of one of 30 residents reviewed. (Resident R68)
- D
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Inspectors wroteBased on observations, review of facility policies, and interviews with residents and staff, it was determined that the facility failed to provide a safe, clean, comfortable and homelike environment for three of three nursing units observed (2 South Nursing Unit, 2 North Nursing Unit and 1 North Nursing Unit).
- 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 interviews with residents and staff, review grievance, and review of facility policy, it was determined that the facility did not ensure prompt efforts were made to resolve residents' grievances and/or concerns for 7 of 7 residents interviewed (Residents R79, R52, R63, R61, R46, R68, R98) and related to missing items for one of 30 resident records reviewed (Resident R54).
- D
Respond appropriately to all alleged violations.
Inspectors wroteBased on review of facility policy, review of facility documentation, review of clinical records, and staff interviews, it was determined that the facility failed to complete a thorough investigation and maintain documentation that an allegation of neglect was thoroughly investigated for one of two residents reviewed (Resident R51). Findings Include: Review of undated facility policy Residents Right to Freedom from Abuse, Neglect, and Exploitation Policy and Procedure revealed in response to allegations of abuse, neglect, or mistreatment the facility should have evidence that alleged violations are thoroughly investigated and prevent further abuse, neglect, or mistreatment while the investigation is in progress. [...]
- D
PASARR screening for Mental disorders or Intellectual Disabilities
Inspectors wroteBased on clinical record reviews, review of facility policies and staff interviews, it was determined that the PASRR (Preadmission Screening and Resident Review) was not appropriately completed according to the resident assessment for three of three residents reviewed related to PASRR assessments (Residents R24, R63 and R125).
- D
Notify the appropriate authorities when residents with MD or ID services has a significant change in condition.
Inspectors wroteBased on review of facility policy, review of clinical record, and staff interviews, it was determined that the facility failed to notify the state mental health authority of a significant change in a mental health condition for one of three residents reviewed for Preadmission Screening and Resident Review (PASARR) screening (Resident R24). Findings Include: The PASRR (Preadmission Screening Resident Review) was created in 1987 through language in the Omnibus Budget Reconciliation Act (OBRA) and it has three goals: to identify individuals with mental illness and/or intellectual disability, to ensure they are placed appropriately, whether in the community or in a nursing facility, and to ensure they receive the services they require for their mental illness or intellectual disability. [...]
- 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 review of facility policy and review of clinical records, it was determined that the facility failed to develop and implement a baseline careplan for one of two new admissions reviewed (Resident R449). Findings Include: Review of facility policy, Comprehensive Person-Centered Care Planning Policy and Procedure dated 2025, revealed, the facility will develop and implement a baseline care plan, within 48 hours of a resident's admission, that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care. Review of Resident 449's clinical record revealed the resident was admitted to the facility on [DATE], and had a diagnosis of opioid dependence with other opioid-induced disorder, and cannabis abuse with other cannabis-induced disorder. [...]
- 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 policies, clinical record reviews and interviews with staff, it was determined that the facility failed to develop comprehensive person-centered care plans related to behavioral health needs for one of 34 residents reviewed (Resident R85).
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on review of facility documentation, review of clinical records, and staff interview, it was determined that the facility failed to promptly assess a resident status post a fall for one of two residents reviewed for falls (Resident R51). Findings Include: Review of Resident R51's quarterly Minimum Data Set (MDS - federally mandated resident assessment and care screening) dated February 5, 2025, revealed the resident had diagnoses of muscle weakness, lack of coordination, Aphasia (communication disorder), Cerebrovascular Accident (CVA - stoke; loss of blood flow to part of the brain), Hemiplegia (paralysis on one side of the body) and Hemiparesis (weakness on one side of the body). Continued review of Resident R51's MDS assessment revealed the resident's BIMS (Brief Interview of Mental status) score of 14, which indicated that the resident was cognitively intact. [...]
- 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, review of facility policy, review of clinical records, and staff interviews, it was determined that the facility failed to ensure that residents with limited range of motion received treatment and services to maintain or improve range of motion/mobility for two of 34 residents reviewed for limited range of motion (Resident R1 and Resident R36).
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on a review of clinical records and facility policies and procedures, observations of care and services, and interviews with staff, it was determined that the facility failed to consistently provide respiratory care and supplemental oxygen as ordered by the physician for one of 30 residents reviewed. (Resident R95).
- 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 observations, review of facility documentation, review of personnel files and interviews with staff, it was determined that the facility failed to ensure that agency nursing staff demonstrated competencies and skill sets necessary to care for residents' needs for three of three agency personnel files reviewed (Employees E3, E15 and E16).
- D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Inspectors wroteBased on observations, review of facility policies and interviews with staff, it was determined that the facility failed to ensure that drug records were in order and that an account of all controlled drugs was maintained and periodically reconciled for four of four medication carts reviewed (2 North upper medication, 2 North low medication cart, 2 South back medication cart ) and maintain a system that allows for timely identification of narcotic diversion.
- D
Ensure medication error rates are not 5 percent or greater.
Inspectors wroteBased on observations, review of facility policies, clinical record review and interviews with staff, it was determined that the facility failed to ensure that the medication error rate was less than five percent for two of four residents observed during medication administration (Residents R83 and R88).
- D
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Inspectors wroteBased on observations, review of facility policies and interviews with staff, it was determined that the facility failed to ensure that medications were stored and labeled in accordance with professional practice standards and failed to ensure that compartments for storage of controlled medications were permanently affixed within storage areas, for thee of five medication storage areas reviewed (2 North upper medication, 2 North low medication cart, 1 North low medication cart, first floor medication room.).
- D
Have a policy regarding use and storage of foods brought to residents by family and other visitors.
Inspectors wroteBased on observations, review of facility policies and interviews with staff, it was determined that the facility failed to ensure that personal foods were stored and labeled in accordance with food safety standards for one of two nursing units reviewed (2 North medication room).
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observations, review of facility policies, clinical record reviews and interviews with staff, it was determined that the facility failed to maintain an effective infection control program related to insulin administration and hand hygiene during medication administration for two of three licensed nurses observed (Employee E3 and E20).
- D
Keep all essential equipment working safely.
Inspectors wroteBased on observations and staff interviews, it was determined that the facility failed to ensure equipment was maintained in safe and operating conditions related to the main kitchen and fire doors. Findings Include: An initial tour of the main kitchen was conducted on May 5, 2025, at 9:30 a.m. with Food Service Director, Employee E29. Observations and interview with Food Service Director, Employee E29, revealed the main kitchen is equipped with two steamers, four ovens, and one tilt skillet. Further interview and observation revealed one steamer, three ovens, and the tilt skillet are broken. Further observations during the initial tour of the main kitchen on May 5, 2025, at 9:30 a.m. revealed the stainless steel, industiral preparation table was noted to be on a slant. [...]
July 29, 2024Standard inspection, Complaint inspection · 12 citations
- F
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Inspectors wroteBased on observations of the physical environment of the dietary department, reviews of the pest control operators reports and interviews with residents and staff, it was determined that the facility failed to ensure an effective pest control program so that the facility was pest free.
- E
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on observations, review of clinical records, review of facility policy and interview with staff, it was determined that the facility did not ensure residents receive adequate supervision to prevent accidents for three of 29 residents reviewed (Residents R51, R126, R446). Facility did not ensure to provide environment free of potential hazards related to unlocked housekeeping storage rooms on two units. (Unit One North and Two North )
- E
Provide enough food/fluids to maintain a resident's health.
Inspectors wroteBased on observations of care and services, clinical record review, interviews with residents and staff and reviews of policies and procedures, it was determined that the facility failed to ensure that two of 29 residents reviewed maintained acceptable parameters of nutritional status for usual body weight, desirable body weight and electrolyte values. (Residents R113, R118)
- E
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Inspectors wroteBased on clinical record reviews, interviews with staff and reviews of policies and procedures, it was determined that the facility failed to ensure that one of 29 residents received medications consistent with professional standards of practice through an on going communication and collaboration of care with the dialysis care center. (Resident R113)
- E
Ensure medication error rates are not 5 percent or greater.
Inspectors wroteBased on observations, review of clinical records, and interviews with facility staff, it was determined that the facility failed to ensure that it was free of medication error rate of five percent or greater, for 11 out of 31 medications reviewed.
- E
Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs.
Inspectors wroteBased on reviews of policies and procedures, interviews with staff, observations of the meals served throughout the facility, interviews with residents, reviews of resident council meeting minutes and planned menus, it was determined that the facility failed to take in consideration food preferences of seven of seven resident reviewed. (Residents R113, R54, R106, R132, R110, R77 and R11)
- E
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on review of policies and procedures, observations of the operations within the food and nutrition department and interviews with staff, it was determined that the facility failed to ensure that food was stored, prepared, distributed and served in accordance with professional stadards for food service safety.
- E
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observations, review of facility policy as well as review of facility provided documentation, interview with staff, it was determined that facility did not maintain and implement a comprehensive program to monitor and prevent infections in the facility.
- E
Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
Inspectors wroteBased on review of facility provided documentation, review of policy, and interview of staff, it was determined facility did not ensure to designate one or more individual as the infection preventionist and therefore did not meet the requirement for professional and specialized training.
- D
Protect each resident from the wrongful use of the resident's belongings or money.
Inspectors wroteBased on review of facility policy, clinical record review, and interviews with staff, it was determined that the facility failed to ensure a resident was free from misappropriation of personal property for one of three residents reviewed. (Resident R143). Findings Include: Review of facility policy titled, Personal Property with a revision date on August 2022 states, Resident are permitted to retain and use personal possessions, including furniture and clothing, as space permits, unless doing so would infringe on the rights or health and safety of other residents. 2. Resident belongings are treated with respect by facility staff, regardless of perceived value. 6. The resident's personal belongings and clothing are inventoried and documented upon admission and updated as necessary. [...]
- D
Respond appropriately to all alleged violations.
Inspectors wroteBased on review of facility documentation, facility policy, clinical records, and interview with staff and residents, it was determined that the facility failed to conduct a thorough investigation related to misappropriation of resident property and did not have evidence that all alleged violations were thoroughly investigated for one of 29 residents reviewed. (Resident R70)
- D
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
Inspectors wroteBased on review of facility documents of Quality Assurance meeting attendance and staff interviews, it was determined that the facility failed to ensure that the Infection Preventionist and Medical Director or their designee attended a quarterly Quality Assurance Process Improvement (QAPI) committee meetings for one of four quarters (February 2024 through June 2024). Findings Include: A review of QAPI committee meeting sign in-sheets revealed no sign in sheets for the month of February 2024, March 2024, April 2024, or June 2024. Further review of the QAPI binder revealed a sign in sheet for month of May 2024 that lacked an Infection Preventionist and Medical Director. Interview with the Director of Nursing, Employee E1 and the interim Nursing Home, Administrator Employee E2 on July 29, 2024 at 12:20 p.m. [...]
June 6, 2024Complaint inspection · 1 citation
- 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 interviews with facility staff and review of facility documentation, it was determined that the facility did not initiate the grievance process for one of three residents reviewed (Resident R2).
April 2, 2024Complaint inspection · 3 citations
- J
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on review of clinical records, interview with resident and staff, and review of facility policies, it was determined that the facility failed to adequately supervise one of six residents reviewed (Resident R2), who was able to board a bus and train and elope from the facility. This failure placed Resident R2 at high risk for injury and resulted in an Immediate Jeopardy situation. (Resident R2)
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on review of facility policies, review of facility documentation, clinical record review and interviews with residents and staff, it was determined that the facility failed to ensure that an elopement incident and a transfer to the hospital as a result of a possible drug overdose were reported the the State Survey Agency for two of six residents reviewed (Resident R1 and Resident R2).
- D
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Inspectors wroteBased on observations, staff interviews, and a review of facility documentation, it was determined that the facility was not maintaining an effective pest control program.
March 9, 2024Complaint inspection · 3 citations
- J
Plan the resident's discharge to meet the resident's goals and needs.
Inspectors wroteBased on clinical record reviews, interviews with staff, review of hospital records and review of policy and procedure, it was determined that the facility failed to properly discharge Resident Cl1 who was assessed by the facility as requiring guidance for safety awareness and problems with short term memory for one of three closed records reviewed. (Resident Cl1) This failure resulted in an Immediate Jeopardy situation for Resident Cl1 whose safety device was removed by facility staff allowing the resident to exit the building, discharging the resident against medical advice to an unknown location and without returning resident's identification documents. Further the facility failed to notify the required State authorities and resident's family of the resident's discharge. (Resident Cl1)
- D
Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder.
- D
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Inspectors wroteBased on a review of clinical records, facility documentation and interviews with staff, it was determined that the Nursing Home Administrator and the Director of Nursing failed to effectively manage the facility related to to the proper discharge on one of three residents reviewed (Resident Cl1) and resulted in an Immediate Jeopardy situation.
February 5, 2024Complaint inspection · 1 citation
- 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 facility policy, observation, review of clinical records, interview with staff and residents, it was determined the facility failed to ensure that medications were administered in accordance with professional standards for two of five residents reviewed (Resident R1 and Resident R2).
October 30, 2023Complaint inspection · 1 citation
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on review of facility policy, interview with staff, and review of clinical records, it was determined that the facility failed to maintain proper infection control practices during care for one of two residents reviewed (Resident R1)
October 10, 2023Complaint inspection · 3 citations
- 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 residents and staff, it was determined that the facility failed to maintain a safe and homelike environment on one of three nursing units observed (1 North unit).
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on clinical record reviews and interviews with residents and staff, it was determined that the facility failed to follow physician orders related to blood sugar monitoring for one of six residents reviewed (Resident R1).
- D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on clinical record reviews and interviews with staff, it was determined that the facility failed to ensure complete and accurate documentation of medications and assessments for two of six residents reviewed (Residents R5 and R6).
Fire safety inspections
9 fire safety citations on file: 5 on May 8, 2025, 2 on April 2, 2025, 2 on July 29, 2024.
Every fire safety citation9 citations
- F
Establish emergency prep training and testing.
E 36 · May 8, 2025 · Corrected (the home has a date of correction)
- C
Develop and maintain an Emergency Preparedness Program (EP).
E 4 · May 8, 2025 · Corrected (the home has a date of correction)
- C
Establish policies and procedures for medical documentation.
E 23 · May 8, 2025 · Corrected (the home has a date of correction)
- C
Establish staff and initial training requirements.
E 37 · May 8, 2025 · Corrected (the home has a date of correction)
- C
Conduct testing and exercise requirements.
E 39 · May 8, 2025 · Corrected (the home has a date of correction)
- F
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 2, 2025 · deficient, provider has
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · April 2, 2025 · deficient, provider has
- C
Establish staff and initial training requirements.
E 37 · July 29, 2024 · Corrected (the home has a date of correction)
- C
Conduct testing and exercise requirements.
E 39 · July 29, 2024 · Corrected (the home has a date of correction)