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 58 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
2G
0H
0I
Potential for more than minimal harm
29D
23E
4F
Potential for minimal harm
0A
0B
0C
May 6, 2026Complaint 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 staff interview, clinical record review, and facility document review, the facility staff failed to inform the physician of a change in condition timely for one of nine residents in the survey sample, (Resident #3).
- D
Ensure services provided by the nursing facility meet professional standards of quality.
Inspectors wroteBased on staff interviews, facility document review and clinical record review, the facility staff failed to follow professional standards of quality for one of nine residents in the survey sample (Resident #3).
May 7, 2025Complaint inspection · 1 citation
- 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 staff interview, and clinical record review, the facility staff failed to develop and implement a baseline care plan for one Resident (Resident #4) in a survey sample of 5 residents.
February 19, 2025Complaint inspection · 3 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 staff interviews, clinical record review, and facility documentation review the facility staff failed to provide notification to the family of a change in condition for one resident (Resident #2, R2) out of a survey sample of 11 residents.
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observation, clinical record review, staff interview and facility documentation review the facility staff failed to administer oxygen according to physician orders for two residents (Resident#3, R3 and Resident #4, R4) out of a survey sample of 11 residents.
- D
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Inspectors wroteBased on observation, resident interview, staff interview, clinical record review and facility documentation review, the facility staff failed to honor resident's food preferences for two residents (Resident #5, R5 and Resident #6, R6) out of a survey sample of 11 residents.
August 28, 2024Standard inspection, Complaint inspection · 22 citations
- E
Reasonably accommodate the needs and preferences of each resident.
Inspectors wroteBased on staff interview and clinical record review, the facility failed to ensure preferences were met for showers/bathing for 3 of 31 residents. Resident #'s 71, 57, and 53 did not receive showers on multiple scheduled shower days. The Findings Include: 1. Resident #71 (R71) received one shower between 7/29/24 through 8/27/24. R71's most current MDS (minimum data set) was a quarterly assessment with an ARD (assessment reference date) of 8/5/24 and assessed R71 with a cognitive score of 15 indicating cognitively intact. On an annual MDS dated [DATE] preferences were assessed and indicated that it was very important to choose between tub bath, shower and bed bath. On 8/26/24 at 7:40 PM during an interview with R71, R71 verbalized showers were not being provided twice a week as scheduled and rarely gets a shower anymore and contributed it to staff just not doing their job. [...]
- E
Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made.
Inspectors wroteBased on resident interview, staff interview, facility document review, and clinical record review, the facility staff failed to provide written notice prior to room changes for five of thirty-one residents in the survey sample (Residents #12, #13, #53, #57 and #200).
- E
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Inspectors wroteBased on employee record review, facility document review, and staff interview, the facility staff failed to follow abuse prevention policies regarding pre-employment screening and background checks for 18 of twenty-five records reviewed.
- E
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Inspectors wrote2. For R57, who fell on 8/13/24, the facility staff failed to review and revise the care plan to indicate the fall and if any needed revisions were needed to prevent a future fall. On 8/26/24 at approximately 7:30 p.m., R57 was visited in his room. R57 reported he had recently fallen. When asked what the facility had done following the fall to prevent future falls, the resident said he didn't know. On 8/27/24, a clinical record review was conducted. This review revealed a nursing note entry dated 8/13/24, that read, Resident was informed that he needs to move to room [ROOM NUMBER]. CNA reports resident became anxious and agitated and called his wife. Afterwards this nurse was called to resident's room, resident was observed on the floor on his left hip/buttock. Resident reports pain in left hip but also has chronic pain in left hip. [...]
- E
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on observation, resident and staff interviews, clinical record reviews, and facility documentation reviews, the facility staff failed to provide activities of daily living (ADL) care to residents who required staff's assistance, for five residents (resident #12- R12, resident #22- R22, resident #57-R57, resident #40-R40, and resident #49-R49), in a survey sample of 31 residents.
- E
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on staff interview and clinical record review, the facility staff failed to follow physician orders for three of thirty-one residents in the survey sample (Residents #32, #57 and #77).
- E
Ensure that residents are free from significant medication errors.
Inspectors wroteBased on resident interview, staff interview, clinical record review, and facility documentation review, the facility staff failed to ensure two residents (Resident #32-R32 and Resident #249) were free from significant medication errors/omissions, in a survey sample of 31 residents.
- 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, resident interview, staff interview, clinical record review and facility documentation review, the facility staff failed to maintain a complete and accurate clinical record for four residents (resident #79-R79, resident #57-R57, resident #32-R32 and resident #93-R93), in a survey sample of 31 residents.
- E
Provide and implement an infection prevention and control program.
Inspectors wroteBased on resident interview, staff interviews, clinical record review, and facility documentation review, the facility staff failed to maintain an infection prevention and control program to help prevent the development and transmission of communicable diseases and infections, and failed to respond to a COVID outbreak in accordance with the guidance from the Centers for Disease Prevention and Control (CDC), which involved two residents (Resident #22 and Resident #57) but had the potential to affect numerous residents on 2 of 2 nursing units.
- E
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Inspectors wroteBased on staff interview, clinical record review, and facility documentation review, the facility staff failed to provide education and offer the flu and pneumonia immunizations to 3 of 5 residents (Resident #80 - R80, Resident #42 -R42, and Resident #70 - R70) sampled for immunizations.
- E
Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
Inspectors wroteBased on staff interview, clinical record review, and facility documentation review, the facility staff failed to provide education and offer the COVID-19 immunization to 4 of 5 residents (Resident #80 - R80, Resident #42 - R42, Resident #60 - R60 and Resident #70 - R70). The facility also failed to provide education to the employee regarding the spike vaccine booster for the 2023-2024 season for 1 of 1 staff sampled (Other Employee #8).
- D
Allow residents to self-administer drugs if determined clinically appropriate.
Inspectors wroteBased on observation, resident interview, staff interview, facility documentation review, and clinical record review the facility staff failed to ensure it was determined clinically appropriate to self-administer medications by the interdisciplinary team for one resident (Resident #79- R79) in a survey sample of 31 Residents.
- D
Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
Inspectors wroteBased on resident interview, staff interview, and clinical record review, the facility staff failed to provide dignity when moving personal property for one of thirty-one residents in the survey sample (Resident #200).
- D
Honor the resident's right to manage his or her financial affairs.
Inspectors wroteBased on resident interview, staff interviews, and facility documentation review, the facility staff failed to maintain adequate funds on-site so that two residents (resident #226 - R226 and resident #53 - R53) had access to their personal funds/trust accounts, which had the potential to affect 41 residents with a trust account.
- 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 staff interview and clinical record review, the facility failed to develop a care plan for one of thirty one residents. Resident #60 (R60) did not have a complete care plan developed for dialysis. The Findings Include: Diagnoses for R60 included: End stage renal disease receiving dialysis, congestive heart failure, pulmonary embolism, and hypertension. The most current MDS (minimum data set) was a quarterly assessment with an ARD (assessment reference date) of 6/13/24. R60 was assessed with a cognitive score of 12 indicating cognitively intact. Review of R60's blood pressures (BP) from 7/25/24 through 8/24/24 indicated an average systolic pressure of 140's and diastolic pressure of 70's and also indicated recently (on 8/22/24 and 8/23/24) an increase in BP to 183/83 and 179/83. Review of physicians orders did not indicated blood pressure parameters for dialysis. [...]
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on resident interview, staff interview, clinical record review and facility documentation review, the facility staff failed to implement interventions in response to a resident's fall to prevent future falls and prevent accidents for one resident (resident #57-R57) in a survey sample of 31 residents.
- D
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Inspectors wroteBased on observation, staff interview and clinical record review, the facility failed to ensure a device was implemented for a catheter for one of thirty one residents and failed to ensure a catheter bag was located to prevent infection for one of thirty one residents. 1. Resident 41 (R41) did not have catheter tube anchored to prevent dislodging. 2. Resident 77 (R77) catheter bag was touching the floor and had potential for infection. The Findings Include: 1. Diagnoses for R41 included; Benign prostatic hyperlasia, and obstructive uropathy requiring catheter. The most current MDS (minimum data set) was an annual assessment with an ARD (assessment reference date) of 7/16/24. R41 was assessed with a cognitive score of 15 indicating cognitively intact. Review of R41's physician orders (on 8/27/24) revealed an order to check placement of catheter strap every shift. [...]
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observation, resident interview, staff interview, and clinical record review, the facility failed to provide oxygen therapy consistent with infection control measure and professional standards of practice for one resident (Resident #79- R79) in a survey sample of 31 residents.
- D
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Inspectors wroteBased on observation, interview, record review, and facility menu review, the facility failed to coordinate services and provide meals and/or snacks for one of three sampled residents (Resident #32- R32) reviewed for dialysis and received dialysis treatments at an outside dialysis center.
- 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, staff interview and facility document review, the facility staff failed to label a medication per pharmacy standards on one of two units (B wing).
- D
Provide special eating equipment and utensils for residents who need them and appropriate assistance.
Inspectors wroteBased on observation, resident interview, staff interview and clinical record review, the facility staff failed to provide a handled cup for one of thirty-one residents in the survey sample (Resident #28).
- 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, staff interview, and facility documentation review, the facility staff failed to store, prepare, and serve food accordance with professional standards for food safety in the main kitchen and on one of two units (B Wing).
January 3, 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 observation, resident review, staff interview, facility document review, and clinical record review the facility failed to review and revise the care plan for one of five residents in the survey sample (Resident #3).
- D
Ensure services provided by the nursing facility meet professional standards of quality.
Inspectors wroteBased on staff interview, facility document review, and clinical record review, the facility failed to follow professional standards of care for one of five residents in the survey sample (Resident #4). Facility staff failed to document an assessed skin impairment at Resident #4's pacemaker site and failed to provide ongoing assessment/monitoring of the impairment.
December 9, 2021Standard inspection · 14 citations
- F
Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
Inspectors wroteBased on staff interview and facility document review, the facility staff failed to employee a qualified dietary manager. The facility's dietary manager had no certifications or education in food service management or food safety.
- E
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Inspectors wroteBased on review of facility personnel files, facility policy and procedures, and staff interview, the facility failed to implement the policy and procedure to ensure applicants for employment completed a Sworn Disclosure Statement disclosing .any criminal convictions or pending criminal charges Review of 25 personnel files revealed none of the 25 files reviewed contained a Sworn Disclosure Statement.
- E
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on resident interview, staff interview, clinical record review, and in the course of complaint investigation, the facility failed to ensure baths/showers were being provided as scheduled for three of 20 residents, Resident # 48, 7, and 13. The Findings Include: 1. Resident #48 was admitted to the facility on [DATE] with a readmission on [DATE]. Diagnoses for Resident #48 included: Diabetes, kidney disease, neuropathy, and dysphagia. The most current MDS (minimum data set) was a quarterly assessment with an ARD (assessment reference date) of 11/5/21. Resident #48 was assessed with a cognitive score of 15 indicating cognitively intact. On 12/07/21 at 12:00 PM Resident #48 was interviewed. Resident #48 stated that she liked to take baths but had not been receiving baths as scheduled and had been told there was not enough staff to give baths. [...]
- E
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on resident interview, observation, staff interview and clinical record review, the facility staff failed to follow physician orders for four of 20 residents in the survey sample, Residents # 12, 68, 15, and 46. 1. Resident # 12 was not administered the correct probiotic as ordered by the physician. 2. Resident # 68 did not have weekly weights obtained per physician order. 3. Resident #15 was not administered the medications gabapentin and Eliquis as ordered by the physician. 4. Resident #46 did not have daily weights obtained as ordered by the physician.
- E
Provide safe, appropriate pain management for a resident who requires such services.
Inspectors wroteBased on staff interview and clinical record review, the facility staff failed to assess and attempt non-drug interventions prior to the administration of opioid pain medication for one of 20 residents in the survey sample, Resident #15. Resident #15 was administered twenty-two doses of the pain medication hydromorphone (Dilaudid) without documented pain assessments or prior attempts or offers of non-drug interventions.
- E
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Inspectors wroteBased on resident interview, staff interview, clinical record review, and in the course of complaint investigation, the facility failed to ensure sufficient nursing staff were available to provide nursing care for three of 20 residents, Residents #48, #7, and #13; and failed to promptly respond to call bells for one of 20 residents, Resident #13. The Findings Include: Resident #48 was admitted to the facility on [DATE] with a readmission on [DATE]. Diagnoses for Resident #48 included: Diabetes, kidney disease, neuropathy, and dysphagia. The most current MDS (minimum data set) was a quarterly assessment with an ARD (assessment reference date) of 11/5/21. Resident #48 was assessed with a cognitive score of 15 indicating cognitively intact. On 12/07/21 at 12:00 PM Resident #48 was interviewed. [...]
- E
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 staff interview and clinical record review, the facility staff failed to ensure one of twenty residents was free from unnecessary medications, Resident #15. Resident #15 was administered multiple doses of the anti-anxiety medication lorazepam without a documented assessment of the need for the medication or of any prior attempts or offers of non-drug interventions.
- 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, facility document review and staff interview, the facility staff failed to prepare, store and serve food in a sanitary manner in the main kitchen and on one of two nursing units.
- E
Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
Inspectors wroteBased on staff interview, facility document review and clinical record review, the facility staff failed to coordinate services with a hospice provider for one of twenty residents in the survey sample, Resident #15. Resident #15, on hospice services since her admission on [DATE], had no hospice plan of care and no evidence of services provided for the resident by hospice personnel.
- 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 complaint investigation, clinical record review, resident interview, and review of facility documents, the facility failed to acknowledge the resident's personal choice for bathing, for one of 20 residents in the survey sample Resident # 13. Resident # 13, whose personal preference for bathing was a shower, received two showers between October 2, 2021 and December 1, 2021.
- D
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Inspectors wroteBased on observation, staff interview, clinical record review and facility document review, the facility staff failed to review and revise a comprehensive care plan for 1 of 20 residents in the survey sample, Resident #3. Resident #3's comprehensive care plans were not reviewed and revised for the discontinuation of anticoagulant use.
- D
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Inspectors wroteBased on staff interview and facility document review, the facility staff failed to provide RN (registered nurse) coverage for two of fourteen days reviewed.
- D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Inspectors wroteBased on resident interview, staff interview and clinical record review, the facility staff failed to ensure medications were available for administration for one of twenty residents in the survey sample, Resident #15. Doses of the medications gabapentin and apixaban (Eliquis) for Resident #15 were not provided from the pharmacy in a timely manner.
- 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, staff interview and facility document review, the facility staff failed to ensure Tuberculin PPD (purified protein derivative) solution was dated when opened, in one of two medication rooms. One multi-dose vial of PPD solution was observed opened, not dated and available for administration on the A wing.
March 7, 2019Standard inspection · 14 citations
- G
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on clinical record review, review of hospital documents, review of facility policy and procedure, and staff interview, the facility failed to ensure a resident received treatment and care in accordance with professional standards of practice to maintain the highest level of practicable well being, for one of 24 residents in the survey sample (Resident # 83). Facility staff failed to monitor blood sugars according to facility hypoglycemic protocol, failed to contact the physician according to facility hypoglycemic protocol and physician orders, and failed to seek emergency help in a timely manner. There was a delay of approximately four hours in sending the resident to the hospital for evaluation and treatment after a second hypoglycemic event within 24 hours. This resulted in harm to the resident who was hospitalized .
- G
Provide enough food/fluids to maintain a resident's health.
Inspectors wroteBased on observation, staff interview, family interview and clinical record review, the facility staff failed to ensure one of 24 residents maintained acceptable parameters of nutritional status, Resident #70. Resident #70 had a weight loss of 6.12 % in three months and a significant weight loss of 10.20% in six months. Resident #70 was unable to feed herself, and facility staff did not offer assistance at meal time per Resident #70's care plan. This was identified as harm by the survey team.
- F
Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
Inspectors wroteBased on staff interview and facility document review, the facility staff failed to ensure qualified dietary staff in the main kitchen. The Dietary Manager (DM) failed to provide evidence of certification or a degree from an accredited institute of higher learning to qualify him as the director of food and nutrition services.
- F
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on observation, staff interview and facility document review, the facility staff failed to procure, store, prepare, and serve food in a sanitary manner in the main kitchen. Items in the freezer were observed covered in ice due to a malfunctioning condenser, the freezer door did not seal with resulting ice crystals/frost on the items near the freezer door, scoops were stored with handles touching both the flour and sugar in the storage bins, and the can opener blade was covered with dry food debris.
- F
Keep all essential equipment working safely.
Inspectors wroteBased on observation, staff interview and facility document review, the facility staff failed to ensure the walk-in freezer in the main kitchen was in safe operating condition. The freezer was observed with frozen water on the floor, on food stored under the condenser, and the freezer door did not seal properly.
- 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 observation, resident interview, and staff interview, facility staff failed to ensure one of 24 residents bathing preferences, Resident #20. Facility staff failed to offer Resident #20 a tub/whirlpool bath weekly, stating the tub was broken.
- E
Provide activities to meet all resident's needs.
Inspectors wroteBased on observation, resident interview, staff interview, and clinical record review, facility staff failed to implement an ongoing, individual centered activities program for one of 24 residents in the survey sample, Resident #39.
- 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 observation, resident interview, family interview, clinical record review, and facility document review, the facility staff failed to provide a nourishing, well-balanced diet, that meets nutritional and special dietary needs; and failed to take into consideration dietary preference for two of 24 residents in the survey sample, Residents #55 and #95. 1. The facility staff failed to provide menu items and serving portions per resident choice for Resident # 55. 2. The facility staff failed to honor the dietary needs and preferences of Resident #95. The resident had a diagnoses of colitis and diverticulitis and was served corn and other food items that were communicated by the resident and documented by staff that the resident did not like or want, but the resident continued to receive the food items.
- E
Provide and implement an infection prevention and control program.
Inspectors wrote3. On 03/06/19 at 8:10 AM, the medication pass and pour observation was conducted with LPN (Licensed Practical Nurse) #1. LPN #1 prepared medications for Resident #44. While pulling the medications, the LPN stated that this resident took her medications whole in applesauce and then LPN #1 pulled one single packet of OcuSoft (eye lid scrub cloth) from the box, opened it and proceeded into the resident's room with the medications. LPN #1 attempted to administer the applesauce mixture with medications to the resident several times without success. LPN #1 then applied gloves and took the single OcuSoft cloth and began wiping the resident's eyes, the right eye, then the left and then the right again. LPN #1 then removed her gloves went to the sink and turned on the water. LPN #1 applied soap to her hands and washed her hands for approximately two seconds under the running water. [...]
- D
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Inspectors wroteBased on clinical record review and staff interview, the facility staff failed for one of 24 residents in the survey sample (Resident # 83), to offer a written bed-hold notice. Resident # 83, who was her own Responsible Party, was not offered a written bed-hold notice upon discharge to the hospital.
- 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, resident interview, staff interview, and clinical record review, facility staff failed to develop a comprehensive care plan (CCP) for one of 24 residents in the survey sample, Resident #39. Facility staff failed to develop an activities care plan for Resident #39.
- 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 clinical record review and staff interview, the facility staff failed for two of 24 residents in the survey sample (Residents # 35 and 83) to ensure PRN (as needed) psychotropic medications were not ordered for more than 14 days. 1. Resident # 35 had a PRN order for Lorazepam with out end date. 2. Resident # 85 had two PRN orders for Lorazepam; one for 29 days without a rationale for the extended use, and one with no end date.
- D
Ensure medication error rates are not 5 percent or greater.
Inspectors wroteBased on a medication pass and pour observation, staff interview, and clinical record review, the facility staff failed to ensure a medication error rate of less than 5% (percent). The facility staff had a three medication errors out of 26 opportunities which resulted in a medication error rate of 11.54 percent (%).
- D
Provide or obtain dental services for each resident.
Inspectors wroteBased on resident interview, family interview, clinical record review, and facility document review, the facility staff failed to ensure one of 24 residents was provided routine and/or emergency dental services, Resident #95. Resident #95's lower denture was broken and the facility did not promptly assist the resident with dental services. The facility staff did not document any information regarding the damaged dentures and did not document any information regarding the resident's ability to adequately consume meals during this time.
Fire safety inspections
9 fire safety citations on file: 3 on August 28, 2024, 1 on December 9, 2021, 5 on March 7, 2019.
Every fire safety citation9 citations
- D
Have properly located and lighted "Exit" signs.
K 293 · August 28, 2024 · Corrected (the home has a date of correction)
- D
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
K 761 · August 28, 2024 · Corrected (the home has a date of correction)
- D
Meet requirements for the installation and maintenance of electrical systems.
K 911 · August 28, 2024 · Corrected (the home has a date of correction)
- D
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
K 321 · December 9, 2021 · Corrected (the home has a date of correction)
- D
Have properly installed hallway dispensers for alcohol-based hand rub.
K 325 · March 7, 2019 · Corrected (the home has a date of correction)
- D
Inspect, test, and maintain automatic sprinkler systems.
K 353 · March 7, 2019 · Corrected (the home has a date of correction)
- D
Install corridor and hallway doors that block smoke.
K 363 · March 7, 2019 · 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 · March 7, 2019 · Corrected (the home has a date of correction)
- D
Have proper medical gas storage and administration areas.
K 923 · March 7, 2019 · Corrected (the home has a date of correction)