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 59 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
3J
0K
0L
Actual harm
4G
0H
0I
Potential for more than minimal harm
34D
11E
5F
Potential for minimal harm
0A
2B
0C
July 27, 2026Standard inspection, Complaint inspection · 9 citations
- F
Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.
Inspectors wroteBased on record review, observations, and staff interviews, the facility failed to serve 3 of 4 meals observed (the lunch meal on 7/19/26 and the breakfast and lunch meals on 7/21/26) at scheduled mealtimes. This failure had the potential to affect all residents who received food by mouth on 2 of 2 hallways (Halls 100 and 200). The facility had a census of 115.
- 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 and staff interviews, the facility failed to ensure food was stored, prepared, and maintained in a sanitary manner. The facility failed to label food stored for use and failed to discard expired food in the walk in refrigerator. The facility failed to ensure employees' personal food was not stored in 1 of 1 reach in refrigerator. Staff failed to keep the oven, stove, deep fryer, and ice machine clean and free of burnt food and food stains. In addition, the facility failed to keep trash containers in the kitchen covered, failed to store cleaning equipment away from clean dishes, and failed to discard chipped plates from the tray line. The facility also failed to maintain hot food on the tray line above 135 degrees Fahrenheit (F). These failures had the potential to affect the safety and quality of food served to residents.
- D
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Inspectors wroteBased on record review, observations, resident, and staff interviews, the facility failed to notify the physician of missed medication administration for 1 of 7 residents reviewed for medication administration (Resident #77).
- D
Protect each resident from the wrongful use of the resident's belongings or money.
Inspectors wroteBased on record review, observations, and interviews with resident, pharmacist, physician, Nurse Practitioner, and staff, the facility failed to protect a resident's right to be free from misappropriation of tirzepatide (a medication used for the treatment of elevated blood glucose levels, sleep apnea and weight management) for 1 of 3 residents reviewed for misappropriation of property (Resident #77).
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on record review and interviews with resident and staff, the facility failed to report an allegation of misappropriation of property to the State Agency, Adult Protective Services and law enforcement for suspicion of diversion of a resident's medication for 1 of 3 residents reviewed for misappropriation of property (Resident #77).
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on observation, record review, and interviews with staff, resident, and the resident's Responsible Party, the facility failed to provide incontinence care when needed for 1 of 8 dependent residents reviewed for activities of daily living (ADL) (Resident #23).
- 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, record reviews, and interviews with staff and the Nurse Practitioner, the facility failed to apply a right hand C grip splint (a hand orthosis designed to support the wrist and fingers) as ordered by the physician for 1 of 1 residents (Resident #10) reviewed for contractures and range of motion (ROM).
- D
Ensure that residents are free from significant medication errors.
Inspectors wroteBased on record review, observations, and interviews with resident, pharmacist, physician, Nurse Practitioner, and staff, the facility failed to administer tirzepatide (a medication used for the treatment of elevated blood glucose levels, sleep apnea and weight management) as ordered for 1 of 7 residents reviewed for significant medication errors (Resident #77).
- D
Provide bedrooms that don't allow residents to see each other when privacy is needed.
Inspectors wroteBased on observation, record review, and interviews with staff, the facility failed to ensure that the required privacy curtain was in place and maintained in a shared resident room for 1 of 6 residents reviewed for privacy (Resident #73).
November 18, 2025Complaint inspection · 2 citations
- 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 record review, and staff, Consultant Pharmacist and Medical Director interviews, the Consultant Pharmacist failed to identify and report medication transcription errors for 1 of 3 residents reviewed for medication review (Resident #6).
- D
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Inspectors wroteBased on record review, observation, and staff, Consultant Pharmacist and Medical Director interviews, the facility failed to have effective systems in place for ensuring medication orders for a new admission were transcribed accurately. Resident #6 was prescribed Finasteride (medication for enlarged prostate) 5 milligrams daily and instead was administered the Finasteride twice a day from 10/10/25 through 10/27/25. This occurred for 1 of 3 residents reviewed for unnecessary medications (Resident #6).
August 7, 2025Complaint inspection · 2 citations
- D
Provide appropriate foot care.
Inspectors wroteBased on observation, record review, and staff interviews, the facility failed to provide foot care treatment ordered by the Podiatrist for 1 of 3 residents reviewed for foot care (Resident #1).
- D
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Inspectors wroteBased on observation, record review, staff and physician interviews, the facility failed to enter hospital discharge orders for tube feedings and free water administration for 1 of 3 residents reviewed for tube feedings (Resident #1).
July 18, 2025Complaint inspection · 1 citation
- J
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on record review, observations, and staff, resident representative, and physician interviews, the facility failed to effectively supervise a resident with moderate cognitive impairment, repeated falls, and impulsive behaviors. Around 12:00 PM on 7/13/25 Resident #1 left the facility without staff's knowledge and ambulated approximately 0.6 miles from the facility in 90-degree heat with 60% humidity. Resident #1 was discovered sitting in a ditch on the side of the road approximately 0.6 miles from the facility. Two passersby stopped to help him and called Emergency Medical Services (EMS). In addition, Housekeeper #1 was on her lunch break and in a car when she happened to see him on the ground on the side of the road. Housekeeper #1 stopped to give Resident #1 assistance and stayed with Resident #1 until EMS arrived. [...]
June 27, 2025Standard inspection, Complaint inspection · 16 citations
- G
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on record reviews, and staff, Physician Assistant (PA), and Medical Director interviews, the facility failed to identify a change in medical condition required medical evaluation and treatment. Resident #85 fell and complained of pain to his lower right extremity on 3/17/2025. Resident #85 was assessed by PA #1 on 3/18/25 and an x-ray of the right lower extremity was ordered. The x-ray was completed on 3/19/25 and the results of an intertrochanteric fracture of right femur (type of broken hip that occurs between the bumpy parts at the top of the thigh bone) were reported to the facility on 3/19/25 at 12:13 PM. A medical evaluation and treatment of the fracture was delayed due to the x-ray results not being reviewed by facility staff or communicated to PA #1 until 3/20/25. [...]
- G
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on record review, and resident, staff, and Nurse Practitioner (NP) interviews, the facility failed to provide safe transport for a resident (Resident #421) in a wheelchair when Nurse Aide (NA) #5 transported Resident #421 to the shower room in a wheelchair without footrests. Resident #421's feet got caught underneath the wheelchair and she fell forward out of the wheelchair and onto the floor. Resident #421 sustained an acute comminuted fracture (broken into pieces) of the right distal femur (thigh bone just above the knee) requiring hospitalization and surgery. This deficient practice occurred for 1 of 11 residents reviewed for accidents.
- G
Provide or obtain x-rays/tests when ordered and promptly tell the ordering practitioner of the results.
Inspectors wroteBased on record review and staff, Medical Director, Physician Assistant (PA), and mobile x-ray provider interviews, the facility failed to notify a medical provider when the results of an x-ray revealing an intertrochanteric fracture of the right femur (type of broken hip that occurs between the bumpy parts at the top of the thigh bone) were reported to the facility on 3/19/25. This resulted in the fracture not being reported to PA #1 until 3/20/25 which delayed Resident #85's transfer to the hospital for evaluation and treatment. Resident #85 was sent to the hospital for an evaluation on 3/20/25 and on 3/21/25 Resident #85 received open reduction and internal fixation (a procedure to realign and secure broken bones with metal fasteners) to the right femur. This occurred for 1 of 15 residents (Resident #85) reviewed for accidents.
- F
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on observations, record reviews and staff interview the facility failed to maintain frozen foods at or below 0 degrees Fahrenheit and failed to sanitize a thermometer probe used to test internal temperatures of food. These practices had the potential to affect food served to residents.
- 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 record review, observations, and staff interviews, the facility failed to date and label insulin (Medication Cart #3 and Medication Cart #5) and failed to discard an opened out of date insulin injection pen (Medication Cart #3). The deficient practice were found in 2 of 3 medications carts reviewed for medication storage (Medication Cart #3 and Medication Cart #5).
- E
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Inspectors wroteBased on record review, observations, and staff interviews, the facility failed to maintain effective pest control in 2 of 13 rooms (room [ROOM NUMBER] and room [ROOM NUMBER]) reviewed for environmental concerns. Ants were observed in room [ROOM NUMBER] and room [ROOM NUMBER].
- D
Allow resident to participate in the development and implementation of his or her person-centered plan of care.
Inspectors wroteBased on record review, and resident, responsible party, and staff interviews, the facility failed to afford the resident and/or responsible party the right to participate in the care plan process for 2 of 3 (Resident #28 and Resident #60) reviewed for quarterly care plan reviews.
- 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 staff and Resident Representative (RR) interviews, the facility failed to implement their grievance policy and procedure by failing to promptly address grievances, notify the resident and/or RR of the action that was taken to resolve their concerns or follow up with the Resident Representatives regarding resolution. This deficient practice occurred for 2 of 3 residents (Resident #220 and Resident #518) reviewed for grievances.
- D
Ensure each resident receives an accurate assessment.
Inspectors wroteBased on record review and staff interviews, the facility failed to accurately code the Minimum Data Set (MDS) assessment in the area of dental status for 1 of 34 residents reviewed for accuracy of assessments (Resident #21).
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on observations, record review, and resident representative and staff interviews, the facility failed to provide nail care and shave facial hair for 1 of 11 residents reviewed for activities of daily living (ADL) (Resident #56).
- D
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Inspectors wroteBased on record review, physician, and staff interviews, the facility failed to change a suprapubic catheter per the Urologist's order for 1 of 2 residents reviewed for catheter care (Resident #56).
- D
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Inspectors wroteBased on record review, observations, and staff and Responsible Party interviews the facility failed to store an enteral feeding syringe with the plunger separated from the syringe for 1 of 4 resident (Resident #60) reviewed for enteral feeding management. This deficient practice has the potential for bacterial growth and contamination.
- D
Provide safe, appropriate pain management for a resident who requires such services.
Inspectors wroteBased on observations, record review, and resident, hospice nurse, physician, physician assistant (PA), and staff interviews, the facility failed to effectively manage a hospice resident's pain and administer an ordered scheduled pain medication for 1 of 2 residents reviewed for pain control (Resident #100).
- 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 record review, observation, and resident, Responsible Party, and staff interviews the facility failed to honor a resident's preference for sandwiches for 1 of 9 residents reviewed for nutritional status (Resident #26).
- D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wrote2. A review of Resident #85's physician orders revealed an order on 3/17/25 for acetaminophen 325 milligrams (mg) orally two tablets every 8 hours as need for pain management status post fall for 3 days. A review of the nursing progress note dated 3/18/25 at 6:19 AM and authored by Nurse #8, indicated Resident #85 fell on 3/17/25 at 10:00 PM. The note further indicated Resident #85 had pain in his right leg and received an order for acetaminophen which was already given, (meaning the medication had been administered). A review of the administration progress note dated 3/18/25 at 10:05 PM indicated Nurse #8 administered acetaminophen 325 mg 2 tablets for pain. A review of progress notes dated 3/19/25 revealed a note authored by Nurse #8 that indicated she administered acetaminophen 325 mg 2 tablets for pain management at 7:27 PM and it was effective. [...]
- B
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Inspectors wroteBased on record review and staff interviews, the facility failed to transmit residents' Minimum Data Set assessments within 14 days of completing assessments for 4 of 5 residents reviewed for transmission of resident assessments (Resident #14, Resident #60, Resident #90, and Resident #61).
April 11, 2025Complaint inspection · 2 citations
- D
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Inspectors wroteBased on record review and staff, Nurse Practitioner, Medical Director, and Responsible Party interviews, the facility failed to notify the Physician and the Responsible Party immediately of Resident #1's change in condition after an unwitnessed fall for 1 of 3 residents reviewed for accidents (Resident #1).
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on record review, and staff, Responsible Party, and Nurse Practitioner interviews, the facility failed to provide complete, thorough and ongoing assessments after a fall which caused a delay in receiving treatment for 1 of 3 sampled residents reviewed for accidents (Resident #1).
January 9, 2025Complaint inspection · 2 citations
- J
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Inspectors wroteBased on record review, and staff and physician interviews, the facility failed to protect Resident # 2's right to be free from resident-to-resident abuse for 1 of 6 residents reviewed for abuse. On 12/7/2024, Resident #1 who had a history of aggression and anger outbursts; and received as needed antipsychotic medications, required a net bed (bed with mesh tent over hospital bed to prevent a person from getting out of bed) and a sitter while hospitalized , wandered into Resident #2's room and pulled Resident #2 from his bed while Resident #2 was asleep. Resident #1 struck Resident #2 in the throat and upper body with his foot and his fist. Both Resident #1 and Resident #2 were sent to the hospital for further evaluation on 12/7/2024. The resident-to-resident abuse had a high likelihood of resulting in serious physical and psychosocial harm. [...]
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on record review and staff interview facility failed to submit a 5-day investigative report to the State Agency within the required time frame for 1 of 4 allegations of abuse (Resident #1 and Resident#2) reviewed for resident to resident abuse.
October 2, 2024Complaint inspection · 1 citation
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on record review, observations, resident, physician, and staff interviews, the facility failed to provide care in a safe manner when a resident fell out of bed during incontinence care for 1 of 3 residents reviewed for accidents (Resident #7). Nursing assistant (NA) #1 rolled Resident #7 away from her during incontinence care, and Resident #7 fell out of bed sustaining bruising to his face and skin tears to his arms. Resident #7 was prescribed an antiplatelet medication, which thins the blood.
August 29, 2024Complaint inspection · 5 citations
- G
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on record review, observations, and Nurse Practitioner and staff interviews, the facility failed to provide care in a safe manner when a resident fell out of bed during incontinence care for 1 of 3 residents reviewed for accidents (Resident #9). Nursing Assistant (NA) #2 rolled Resident #9 away from her during incontinence care, and Resident #9 fell out of bed. Resident #9 sustained a fractured left femur (long bone of the upper leg) and required surgical repair on 8/28/24.
- D
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Inspectors wroteBased on record reviews, staff and resident interviews and observations, the facility failed to protect 1 of 4 residents (Resident #8) the right to be free of physical abuse when Resident #7 struck Resident #8 on the left hand with a metal bar that resulted in redness, swelling and a skin tear to Resident #8's left hand and wrist.
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on staff interviews and record review, the facility failed to submit an initial report within 2 hours to the state regulatory agency for an allegation of resident- to- resident abuse for 1 of 4 residents reviewed for abuse (Resident #8).
- D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Inspectors wroteBased on record review, observations, and Pharmacist, Nurse Practitioner, and staff interviews, the facility failed to provide routine medications ordered by the physician for 1 of 3 residents reviewed for medication pharmaceutical services (Resident #3).
- D
Ensure that residents are free from significant medication errors.
Inspectors wroteBased on record review, observations, and Nurse Pracitioner and staff interviews, the facility failed to administer 3 of 4 doses over 2 days of quetiapine fumarate (an antipsychotic medication) as ordered by the physician for 1 of 3 residents reviewed for pharmaceutical services (Resident #3).
July 16, 2024Complaint inspection · 1 citation
- E
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteBased on record review, observations and interviews with staff and resident the facility failed to provide a fork during a lunch meal for 4 of 6 residents (Resident #3, Resident #9, Resident #10, and Resident #11) who ate independently. Resident #3, Resident #9, Resident #10, and Resident #11 were given a spoon on their lunch meal tray and indicated they would prefer a fork to eat their meal of breaded chicken covered with barbeque sauce, cabbage, dressing, and a piece of cake.
April 18, 2024Standard inspection, Complaint inspection · 15 citations
- F
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on observations and staff interviews the facility failed to ensure milk and thickened juice for the lunch meal observation was within safe temperature range of 41 degrees Fahrenheit (F) or below and failed to maintain the wash temperature of the high temperature dishwasher according to manufacturer's recommendations for sanitation of dishware. The facility also failed to ensure soiled cups did not come in contact with the clean ice scoop used to refill residents' water cups. The practices had the potential to affect food served to residents.
- F
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Inspectors wroteBased on observations, record review, resident, and staff interviews, the facility's Quality Assurance and Performance Improvement committee (QAPI) failed to maintain implemented procedures and monitor the interventions that the committee put into place in following the recertification survey of recertification surveys of 7/15/2021 and 12/8/2022, and complaint investigation survey of 10/17/2023. This was for 2 deficiencies in the areas of F584 Safe/Clean/Comfortable/Homelike Environment and F812 Food Procurement, Store/Prepare/Serve Sanitary. These deficiencies were recited on the current recertification and complaint investigation survey of 4/18/2024. The continued failure of the facility during two or more federal surveys of record shows a pattern of the facility's inability to sustain an effective QAPI program.
- E
Protect each resident from the wrongful use of the resident's belongings or money.
Inspectors wroteBased on record review, resident and staff interviews, the facility failed to protect the resident's right to be free from misappropriation of resident property. This deficient practice was for 6 of 7 residents reviewed for misappropriation of resident property (Resident #3, Resident #63, Resident #86, Resident #89, Resident #4 and Resident #41).
- E
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on record review, observations, and staff and responsible party interviews the facility failed to ensure a resident's hair was not greasy for 1 of 4 residents (Resident #44) who were dependent on staff for personal hygiene.
- E
Observe each nurse aide's job performance and give regular training.
Inspectors wroteBased on record reviews and staff interviews, the facility failed to complete a performance review every 12 months for 4 of 5 nursing assistants (NAs) reviewed to ensure in-service education was designed to address the outcome of the performance reviews (NA #4, NA #5, NA #6, and NA #7).
- 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 record review, staff, Pharmacist and Medical Director interviews, the facility failed to act upon a pharmacy recommendation by failing to change the dose of atorvastatin (medication to decrease unhealthy fat in the body) from 40 milligram (mg) to 20 mg as ordered by the physician for 1 of 1 resident reviewed for drug regimen (Resident #88).
- E
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Inspectors wroteBased on record review, staff, Pharmacist and Medical Director interviews, the facility failed to change the dose of atorvastatin (medication to decrease unhealthy fat in the body) from 40 milligram (mg) to 20 mg as ordered by the physician for 1 of 6 residents reviewed for unnecessary medications (Resident #88).
- 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 observations and staff interviews the facility failed to date five medications that had been opened and stored in 2 of 2 medication carts (2-hall cart and 3-hall cart) observed for medication storage.
- D
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Inspectors wroteBased on staff interviews and record reviews the facility failed to maintain accurate advance directive information (code status) throughout both the electronic medical record and paper medical record for 1 of 6 residents reviewed for advance directives (Resident #37).
- 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, observation, resident, and staff interviews the facility failed to resolve a grievance for 1 of 1 resident reviewed for grievances (Resident #63).
- D
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Inspectors wroteBased on record review and staff interviews, the facility failed to implement their abuse policy in the area of reporting for an allegation of misappropriation of property for 2 of 7 residents reviewed for misappropriation of resident property (Resident #4 and Resident #86).
- D
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Inspectors wroteBased on record review and staff interviews, the facility failed to refer a resident with a new mental health diagnosis for a Level II Preadmission Screening and Resident Review (PASRR) for 1 of 3 residents reviewed for PASRR (Resident #52).
- D
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Inspectors wroteBased on record review, observation, and staff interviews the facility failed to provide 1 of 1 resident (Resident #63) a meal for a resident who had dialysis. Resident #63 traveled to a dialysis center three days a week, leaving before breakfast was served and returning to the facility after breakfast was served.
- 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 observations, record reviews, resident, and staff interviews, the facility failed to honor a resident's preference for meals when they served him a double portion of peas when he had requested not to be served peas (Resident #69). This was for 1 of 2 residents reviewed for choices.
- B
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Inspectors wroteBased on record reviews and staff interviews, the facility failed to provide written notification for the ombudsman for residents who were transferred to the hospital for 2 of 3 residents reviewed for hospitalization (Resident #29 and Resident #145).
October 17, 2023Complaint inspection · 3 citations
- J
Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
Inspectors wroteBased on record review, family, staff, Medical Director, and Pharmacist interviews, the facility failed to ensure a safe and orderly discharge for 1 of 1 sampled resident when Resident #3 was discharged to the community with medications prescribed for another resident (Resident #8) instead of his own medication on 4/9/23. On 4/18/23 Resident #3's Primary Care Physician (PCP) discovered that Resident #3 had been taking multiple medications he was not prescribed and had not taken his own prescribed medications since his discharge from the facility on 4/9/23. Discharging a resident with medications not prescribed for him and without his own prescribed medications had a high likelihood of resulting in serious harm. In addition, the facility failed to have the discharge summary signed by the resident and/or responsible party. [...]
- E
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on observations and staff interviews the facility failed to remove expired food from 1 of 1 dry storage room and failed to date and label opened food in 1 of 1 walk in cooler.
- E
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Inspectors wroteBased on record review and staff interviews and observations, the facility's Quality Assurance and Performance committee (QAPI) failed to maintain implemented procedures and monitor the interventions the committee put into place for 1 re-cited deficiency F812. F812 was originally cited during the recertification and complaint investigation survey dated 07/15/21, F812 was re-cited during a revisit and complaint investigation dated 09/20/21, F812 was re-cited during a recertification and complaint investigation dated 12/08/22, and F812 was re-cited during a complaint investigation dated 10/17/23. The continued failure of the facility during four federal surveys of record showed a pattern of the facility's inability to sustain an effective Quality Assurance and Performance Improvement Program.
Fire safety inspections
9 fire safety citations on file: 1 on June 27, 2025, 4 on April 18, 2024, 4 on December 8, 2022.
Every fire safety citation9 citations
- F
Conduct testing and exercise requirements.
E 39 · June 27, 2025 · Corrected (the home has a date of correction)
- F
Develop and maintain an Emergency Preparedness Program (EP).
E 4 · April 18, 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 · April 18, 2024 · 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 · April 18, 2024 · Corrected (the home has a date of correction)
- D
Have proper medical gas storage and administration areas.
K 923 · April 18, 2024 · Corrected (the home has a date of correction)
- E
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · December 8, 2022 · 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 8, 2022 · Corrected (the home has a date of correction)
- C
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
K 741 · December 8, 2022 · Corrected (the home has a date of correction)
- C
Have proper medical gas storage and administration areas.
K 923 · December 8, 2022 · Corrected (the home has a date of correction)