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 92 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
1J
0K
1L
Actual harm
1G
0H
0I
Potential for more than minimal harm
34D
47E
7F
Potential for minimal harm
0A
0B
1C
May 11, 2026Complaint inspection · 1 citation
- E
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Inspectors wroteBased on observation and interview, the facility failed to secure medications in a medication cart for 58 residents on the 600 Unit (residents were identified by the census list provided by the Director of Nursing (DON) on 05/07/26). This deficient practice could likely result in residents obtaining medication not prescribed to them resulting in adverse side effects.
March 13, 2026Complaint inspection · 4 citations
- E
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on record review and interview, the facility failed to ensure medical records were complete and accurate for 1 (R #18) of 3 (R #17, R #18, and R #27) residents reviewed accuracy of documentation when staff failed to: 1. Document R #18's enteral feedings (tube feeding, delivers liquid nutrition directly into the stomach or small intestine via a tube for individuals unable to meet nutritional needs orally, despite having a functional gastrointestinal tract.) 2. Document R #18's residual volume (the amount of formula and gastric juice remaining in the stomach, often checked to assess tube feeding tolerance).3. Document R #18's enteral flushes (water administered through enteral tube). These deficient practices have the potential to negatively impact the care staff provide to meet residents' needs due to inaccurate records.
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on record review and interview, the facility failed to report allegations of misappropriation of resident property (the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's belongings or money without the resident's consent) to the State Agency within 24 hours of an allegation for 1 (R #17) of 4 (R #16, R #17, R #27, and R #29) residents reviewed for misappropriation of property, when staff failed to report allegations of missing money for R #17. If the facility fails to report allegations of misappropriation of resident property to the state agency within 24 hours of the allegation, then corrective action may not be taken, and residents may suffer increased anxiety and fear that their belongings are not being protected.
- D
Respond appropriately to all alleged violations.
Inspectors wroteBased on record review and interview, the facility failed to thoroughly investigate an allegation of misappropriation of property (the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's belongings or money without the resident's consent) for 1 (R #17) of 4 (R #16, R #17, R #27, and R #29) residents reviewed for misappropriation of property. If the facility does not adequately investigate allegations of misappropriation of resident property, then corrective action may not be implemented to protect other residents which could cause residents to suffer increased anxiety and fear that their belongings are not being protected.
- D
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Inspectors wroteBased on record review and interview, the facility failed to ensure care plans were revised for 1 (R #24) of 5 (R #24, R #25, R #26, R #27 and R #28) residents when staff failed to revise R #24's care plan with the most current resident information regarding care preferences. This deficient practice could likely result in the care plan not being updated with the most current resident conditions and appropriate interventions, staff being unaware of changes in care provided, and residents not receiving the care related to changes in their health status or healthcare decisions.
December 23, 2025Complaint inspection · 1 citation
- D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on record review, and interview, the facility failed to ensure medical records were complete and accurate for 1 (R #9) of 4 (R #8, R #9, R #10, and R #11) residents reviewed for documentation accuracy when staff failed to document R #9's skin impairment (the skin's normal structure and function are compromised). This deficient practice has the potential to negatively impact the care staff provide to meet residents' needs due to missing or inaccurate records and resident information.
July 14, 2025Complaint inspection · 4 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 observation and interview, the facility failed to provide a comfortable and homelike environment for 1(R #8) of 1 (R #8) resident when staff failed to keep R #8's bathroom clean of urine around the toilet. This deficient practice could likely cause the residents to feel like they are not living in a comfortable home-like environment and like they are not valued.
- D
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Inspectors wroteBased on record review and interview, the facility failed to ensure a comprehensive MDS assessment was completed within 14 calendar days after admission for 1 (R #1) of 9 (R #1, R #3, R #4, R #5, R #8, R #9, R #10, R #25, and R #26) residents reviewed for MDS assessment timing. This deficient practice could likely result in residents' care not being met.
- D
Assess the resident when there is a significant change in condition
Inspectors wroteBased on record review and interview, the facility failed to complete and transmit (electronically sending encoded information) a Significant Change in Condition (SCIC; major decline or improvement in the patient's health status) MDS assessment within 14 days after the facility determined a significant change in the resident's physical or mental condition for 1 (R #2) of 3 (R #1, R #2 and R #3) residents reviewed for SCIC MDS assessment timing. This deficient practice could likely result in the residents not receiving the appropriate care and services they need related to changes in their condition.
- C
Post nurse staffing information every day.
Inspectors wroteBased on observation and interview, the facility failed to post nurse staffing data on a daily basis for access by the public and all 102 residents (residents were identified by the census list provided by the Administrator on 07/10/25) included the following:1. The total number and the actual hours worked by the following categories of licensed and unlicensed nursing staff directly responsible for resident care per shift to include: a. Registered Nurses. b. Licensed Practical Nurses. c. Certified Nurse Aides. This deficient practice could likely result in residents not knowing which staff is working.
June 5, 2025Standard inspection · 19 citations
- F
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 observation, record review, and interview, the facility failed to maintain appropriate staffing levels to meet the needs of the residents. This failure has the potential to affect all 98 residents (residents were identified by the resident census list provided by the Administrator on 06/01/25). This deficient practice could likely result in residents not receiving the care and service needed while in the facility.
- F
Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
Inspectors wroteBased on record review and interview, the facility failed to submit direct care staffing information to the federal agency overseeing certification for long term care facilities for July 2024 through December 2024. This has the potential to affect all 98 residents in the facility, (residents were identified by the Resident Matrix provided by the Administrator on 06/01/25). This deficient practice could likely result in inaccurate direct care staffing information for residents/facility.
- E
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Inspectors wroteRecite from [DATE] Based on observation and interview, the facility failed to provide a comfortable and homelike environment for all 69 residents who do not reside in the secure unit (residents were identified by the census provided by the Administrator on [DATE]) when staff failed to: 1. Store a deceased resident's belongings out of common areas share by residents. 2. Repair the floor in front of R #31's restroom, and replace ceiling covers above R #31's bed. These deficient practices could likely cause residents to feel like they are not living in a comfortable home like environment and like they are not valued.
- E
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
Inspectors wroteBased on record review and interview, the facility failed to ensure residents did not receive psychotropic medications (group of drugs that affect behavior, mood, thoughts, or perception) unless the medication was medically necessary for 4 (R #14, R #15, R #33 and R #63) of 7 (R #14, R #15, R #18, R #28, R #33, R #35 and R #63) residents reviewed for unnecessary medications, when staff failed to ensure: 1. A gradual dose reduction (GDR; stepwise tapering of a dose to determine if symptoms, conditions, or risks can be managed by a lower dose or if the dose or medication can be discontinued) was carried out for R #14 and R #63. 2. [...]
- 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 wroteRecite from 08/21/24 Based on record review and interview, the facility failed to ensure care plan revisions occurred for 2 (R #68 and R #86) of 6 (R #21, R #28, R #33, R #35, R #68, and R #86) residents when the staff failed to revise the care plan with the most current resident information. This deficient practice could likely result in the care plan not being updated with the most current resident conditions and appropriate interventions, staff being unaware of changes in care provided, and residents not receiving the care related to changes in their health status or healthcare decisions.
- E
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
Inspectors wroteBased on record review, and interview, the facility failed to ensure residents received necessary behavioral health care to meet their needs for 1 (R #63) of 2 (R #14 and R #63) residents reviewed for behavioral health concerns when staff failed to ensure consistent psychiatric services. This deficient practice could likely result in residents not receiving the behavioral or mental health care and assistance needed to attain or maintain the highest practicable physical, mental, and psychosocial well-being.
- E
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Inspectors wroteBased on record review and interview the facility failed to ensure a resident diagnosed with dementia (group of symptoms related to loss of memory, judgment, language, complex motor skills, and other intellectual function, caused by the permanent damage or death of the brain's nerve cells) received appropriate treatment and services to attain his highest mental and psychosocial well-being for 1 (R #33) of 1 (R #33) resident reviewed for dementia treatment and services when the facility failed to: 1. Ensure R #33's care and services are person centered and help maximize his dignity and autonomy. 2. Utilize individualized, non-pharmalogical (treatments or interventions that do not involve the use of medications or drugs) approaches to his care. [...]
- 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 and interview, the facility failed to ensure the consultant pharmacist's recommendations were reviewed and implemented by the physician and/or the physician provided documentation of a rationale (set of reasons or a logical basis for a course of action) for not following the consultant pharmacist's recommendation for 3 (R #14, R #33 and R #63) of 7 (R #14, R #15, R #18, R #28, R #33, R #35, and R #63) residents reviewed for unnecessary medications. This deficient practice could likely result in residents receiving medications that are no longer necessary and may cause unnecessary drug interactions (changes to medication action caused by being combined with other foods, beverages, or drugs) or adverse side effects (unwanted, undesirable effects from medication).
- E
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteRecite from 04/24/24 Based on observation and interview, the facility failed to store food under sanitary conditions for all 94 residents who eat food from the kitchen (residents were identified by the resident matrix provided by the administrator on (06/01/25) when staff failed label and date all items in the kitchen refrigerator. Failure to store food under safe and sanitary conditions could likely lead to foodborne illnesses in residents.
- D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteBased on observation and interview, the facility failed to ensure residents were treated with respect and dignity for 2 (R #86 and R #253) of 3 (R #33, R #86 and R #253) residents when the facility failed to do the following: 1. Use a privacy bag for R #86's foley catheter bag (a urine drainage bag that collects urine from the bladder). 2. Treat R #253 with dignity when serving him lunch.
- D
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Inspectors wroteRecite from 04/24/24 Based on observation, record review, and interview, the facility failed to notify the provider of missed medication doses and treatment for 2 (R #46 and R #86) of 2 (R #46 and R #86) residents reviewed for medication administration and edema, (swelling caused by an accumulation of fluid in the body's tissues, often in the feet, ankles, and legs). when staff failed to: 1. Notify the provider that R #46 refused her lactulose (medication used to treat constipation. It can also treat liver disease) on 06/04/25. 2. Notify the provider that R #46 received a partial (incomplete) dose of Albuterol (medication that is inhaled to treat or prevent spasms of the respiratory tract) on 06/04/25. 3. [...]
- D
Ensure each resident receives an accurate assessment.
Inspectors wroteRecite from 04/24/24 Based on interview and record review, the facility failed to ensure the Minimum Data Set Assessment (MDS; federally mandated assessment instrument completed by facility staff) were accurate for 2 (R #35 and R #66) of 9 (R #14, R #21, R #28, R #35, R #46, R #60, R #63, R #66 and R #77) residents reviewed for accurate MDS assessments. This deficient practice could likely result in the facility not having an accurate assessment of the residents' needs.
- D
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Inspectors wroteRecite from 10/18/24 Based on record review and interview, the facility failed to create an accurate baseline care plan (minimum healthcare information necessary to properly care for a resident immediately upon their admission to the facility) within 48 hours of admission for 1 (R #254) of 3 (R #33, R #72 and R#254) residents reviewed for baseline care plans. This deficient practice could likely result in residents not receiving the appropriate care and may place residents at risk of an adverse event (undesirable experience, preventable or non-preventable, that caused harm to a resident because of medical care or lack of medical care) or worsening of current condition after admission.
- D
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Inspectors wroteRecite from 08/21/24 Based on observation, record review, and interview, the facility failed to develop and implement accurate, person-centered comprehensive care plan for 2 (R #21 and R #33) of 4 (R #21, R #28, R #33, and R #35) residents reviewed for care plans when staff failed to: 1. Ensure R #21 had a fall mat in place next to her bed as indicated in her care plan. 2. Include R #33's diagnosis of dementia and interventions in place to treat R #33's dementia. These deficient practices could likely result in resident injury and staff being unaware of the current and actual needs of the residents.
- D
Ensure services provided by the nursing facility meet professional standards of quality.
Inspectors wroteRecite from 10/18/24 Based on observation, interview, and record review, the facility failed to ensure residents received care that meets professional standards for 1 (R #86) of 1 (R #86) resident sampled for limited range of motion, when staff failed to follow the order for compression stockings (specially designed hosiery that provide controlled compression to the legs, promoting blood flow and reducing swelling). This deficient practice could likely result in worsening of resident's edema (excess of watery fluid collecting in the cavities or tissues of the body) or unnecessary pain and discomfort.
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on record review, observation, and interview, the facility failed to provide activities of daily living (ADL) assistance for 2 (R #2 and R #33) of 2 (R #2 and R #23) residents reviewed for ADL care when staff failed to do the following: 1. Assist R #2 with toenail care. 2. Assist R #33 with nail care. This deficient practice is likely to affect the dignity and health of the residents.
- D
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Inspectors wroteBased on observation and interview, the facility failed to secure a treatment cart for all 69 residents who do not reside in the secure unit (residents were identified by the census list provided by the Administrator on 06/01/25). This deficient practice could result in residents obtaining medication not prescribed to them resulting in adverse side effects.
- D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteRecite from 04/24/24 Based on record review, observation, and interview, the facility failed to ensure medical records were complete and accurate for 2 (R #14 and R #35) of 4 (R #14, R #21, R #28, and R #35) residents reviewed for documentation accuracy. This deficient practice has the potential to negatively impact on the care staff provided to meet residents' needs due to missing or inaccurate records and resident information.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteRecite from 04/24/24 Based on observation, record review, and interview, the facility failed to maintain an infection prevention and control program designed to provide a safe and sanitary environment to prevent the development and transmission of communicable diseases and infections when staff failed to implement and follow enhanced barrier precautions (EBP, an infection control intervention) for 2 (R #15 and R #21) of 2 (R #15 and R #21) residents reviewed for infection prevention. If the facility fails to maintain an effective infection control program, then infections could spread to residents throughout the facility, resulting in illness.
October 18, 2024Complaint inspection · 4 citations
- E
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on record review and interview, the facility failed to report allegations of abuse within two hours to the State Agency (SA) for 5 (R #1, R #2, R #16, R #17, and R #18) of 5 (R #1, R #2, R #16, R #17, and R #18) residents sampled for abuse. If the facility fails to report allegations of abuse to the SA within two hours, then residents could likely continue to be abused, suffer serious bodily injury, and/or experience psychosocial distress (unpleasant emotions associated with a highly stressful situation) or worsening of current mental health conditions.
- E
Ensure services provided by the nursing facility meet professional standards of quality.
Inspectors wroteBased on record review and interview, the facility failed to provide services that meet professional standards of practice for 2 (R #1 and R #19) of 3 (R #1, R #3, and R #19) residents reviewed for medication orders when staff failed to: 1. Obtain orders for R #1 when the resident returned from the emergency room. 2. Enter medication orders for R #19 upon admission. This deficient practice could likely result in worsening of medical conditions.
- 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 record review and interview, the facility failed to create an accurate baseline care plan (minimum healthcare information necessary to properly care for a resident immediately upon their admission to the facility) within 48 hours of admission for 1 (R #3) of 2 (R #3 and #R #19) residents reviewed for baseline care plans. This deficient practice could likely result in residents not receiving the appropriate care and may place residents at risk of an adverse event (undesirable experience, preventable or non-preventable, that caused harm to a resident because of medical care or lack of medical care) or worsening of current condition after admission.
- D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Inspectors wroteBased on record review and interview, the facility failed to ensure pharmaceutical services (the direct, responsible provision of medication-related care) were met for 1 (R #3) of 4 (R #1, R #3, R #19, and R #20) residents reviewed for medications when they failed to provide routine medication for a resident. This deficient practice could likely lead to unnecessary pain for the resident.
August 21, 2024Complaint inspection · 2 citations
- 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 record review and interview, the facility failed to develop an accurate, person-centered comprehensive care plan for 2 (R #2 and R #21) of 5 (R #1, R #2, R #3, R #21, and R #22) residents reviewed for care plans. This deficient practice could likely result in staff being unaware of the current and actual needs of the residents.
- D
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Inspectors wroteBased on record review and interview, the facility failed to ensure care plan revision occurred for 1 (R #21) of 3 (R #1, R #21, and R #22) residents reviewed for care plans, when they failed to update R #21's care plan after he fell. This deficient practice could likely result in the care plan not being updated with the most current resident conditions and appropriate interventions, staff being unaware of changes in care provided, and residents not receiving the care related to changes in their health status or healthcare decisions.
April 24, 2024Standard inspection, Complaint inspection · 27 citations
- J
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for 1 (R #108) of 2 (R #78 and R #108) residents when they failed to: 1. Notify the provider about R #108's abnormal lab values (high potassium). 2. Notify the provider about potential drug-to-drug interactions for R #108. 3. Monitor potassium levels for R #108 who had elevated potassium blood levels, chronic kidney disease (a condition in which the kidneys are damaged and cannot filter blood as well as they should), and an order for medications that can cause hyperkalemia (elevated potassium blood levels). 4. Notify the provider about R #108 experiencing nausea and vomiting. These deficient practices likely lead to R #108's death.
- F
Keep residents' personal and medical records private and confidential.
Inspectors wroteBased on observation and interview, the facility failed to safeguard resident medical record information for all 101 residents (residents were identified by the census provided by the Administrator on 04/15/24). This deficient practice could likely result in the residents' information being viewed by unauthorized residents, visitors, and staff.
- F
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Inspectors wroteBased on record review and interview the facility failed to maintain a grievance policy that maintained records of grievances results for up to three years. This has the potential to affect all 101 residents in the facility (residents were identified by the resident matrix provided by the Administrator on 04/15/24). If the facility does not maintain a grievance policy, then resident concerns could go without resolution leaving residents depressed and anxious.
- 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 interview, the facility failed to provide a clean, sanitary area for food storage and preparation of food and a holding temperature for puree cold foods at 41 degrees Fahrenheit or lower. This deficient practice is likely to affect all 100 residents (residents were identified by the census provided by the Administrator on 04/15/24) could likely lead to foodborne illnesses (illness caused by food contaminated with bacteria, viruses, parasites, or toxins) if: food is stored or prepared in unsanitary conditions and is not held at a temperature outside the danger zone (the temperature range where bacteria grow at a rapid rate, between 41 degrees (°) Fahrenheit (F) and 140° F).
- F
Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.
Inspectors wroteBased on record review and interview, the facility failed to ensure that nursing staff have completed the mandatory QAPI (Quality Assurance/Performance Improvement) training for 5 (ADON #1, ADON #2, CNA #21, LPN #24, and CNA #31) of 5 (ADON #1, ADON #2, CNA #21, LPN #24, and CNA #31) staff randomly sampled for staffing. This deficient practice could likely result in staff being unable to identify opportunities for improvement, address gaps in systems or processes, develop and implement an improvement or corrective plan, and continuously monitor the effectiveness of interventions.
- E
Reasonably accommodate the needs and preferences of each resident.
Inspectors wroteBased on observation and interview, the facility failed to provide reasonable accommodations of resident needs for 2 (R #102 and R #359) of 2 (R #102 and R #359) residents reviewed for care when the facility failed to ensure that resident's bedside table with frequently used items and call light were within the resident's reach. This deficient practice could result in the residents' needs not being met, leaving them at risk for accidents and falls.
- E
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Inspectors wroteBased on record review and interview, the facility failed to notify the provider of a change in condition for 1 (R #108) of 1 (R #108) residents reviewed for change of condition, when they failed to notify the facility provider about R #108's nausea. This deficient practice could likely result in residents not receiving necessary care or a delay in treatment.
- E
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Inspectors wroteBased on observation and interview the facility failed to provide a home-like environment for all 16 residents in the secure unit (residents were identified by the resident Matrix provided by the Administrator on 04/15/24) when they left resident meals and drinks on the serving trays during the lunch meal for all 16 residents. This deficient practice could likely cause residents to feel depressed and anxious that they are not living in a comfortable home-like environment.
- E
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on record review and interview the facility failed to report an allegations of abuse or neglect within two hours to the State Agency (SA) for 1 (R #66) of 1 (R #66) residents sampled for abuse and accidents. If the facility fails to report allegations of abuse or neglect to the SA within two hours, then residents could likely continue to be abused or suffer serious bodily injury.
- E
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 review and interview the facility failed to ensure that residents and their representatives received a written notice of transfer as soon as practicable for 1 ( R #89) of 3 (R #82, R #86, and R #89) residents reviewed for hospitalization. This deficient practice could likely result in the resident and/or their representative not knowing the reason or location the resident was discharged .
- E
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 record review and interview, the facility failed to ensure that residents and their representatives received a written notice of the bed hold policy which indicated the duration the bed would be held for 3 (R #82, R #86, and R #89) of 3 (R #82, R #86, and R #89) residents reviewed for hospitalization. This deficient practice could likely result in the resident and/or their representative being unaware of the bed hold policy upon return from the hospital.
- E
Assess the resident when there is a significant change in condition
Inspectors wroteBased on record review and interview, the facility failed to complete and transmit (electronically sending encoded information) a Significant Change (major decline or improvement in the patient's health status) Minimum Data Set assessment within 14 days after the facility determined a significant change in the resident's physical or mental condition for 1 (R #30) of 2 (R #30 and R #31) residents reviewed for MDS assessment timing. This deficient practice could likely result in the resident not receiving the appropriate care and services they need.
- E
Assure that each resident’s assessment is updated at least once every 3 months.
Inspectors wroteBased on record review and interview, the facility failed to ensure that an Minimum Data Set (MDS) was completed every three months for 3 (R #13, R #68, and R #73) of 5 (R #13, R #29, R #58, R #68, and R #73) resident reviewed for MDS assessments, when they failed to complete quarterly MDS assessments timely (completed 14 days after the assessment reference date (ARD)). This failed practice could result in residents assessments being outdated and residents not receiving care and treatment that meets their current needs.
- E
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Inspectors wroteBased on record review and interview, the facility failed to develop a baseline care plan within 48 hours, that accurately reflected the resident's current condition for 2 (R #100 and R #359) of 3 (R #100, R #359 and R #310) residents sampled for baseline care plans. This deficient practice could likely result in residents not receiving the appropriate care and services and may place residents at risk of an adverse event (an event, preventable or nonpreventable, that caused harm to a patient as a result of medical care or lack of medical care) or worsening of current condition after admission.
- E
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 record review and interview, the facility failed to develop a comprehensive care plan for 2 (R #9, and R #108) of 2 (R #9, and R #108) residents sampled for care plans. This deficient practice could likely result in staff being unaware of the needs of residents.
- 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 wroteBased on record review, observation, and interview, the facility failed to ensure that the care plan had been revised for 4 (R #66, R #86, R #88, and R #108) of 5 (R #62, R #66, R #86, R #88, and R #108) residents reviewed by: 1. Not revising R #66's care plan to reflect that she was not in the secured unit. 2. Not revising R #86's care plan to include his diagnosis of seizures. 3. Not revising R #88's care plan to include medications and orders for wounds. 4. Not revising R #108's care plan to include her diagnosis of urinary tract infection (UTI, an infection in any part of the urinary system). This deficient practice could likely result in staff being unaware of changes in care provided, and residents not receiving the care related to changes in their health status or healthcare decisions.
- E
Provide enough food/fluids to maintain a resident's health.
Inspectors wroteBased on interview and record review, the facility failed to maintain acceptable parameters of nutritional status, such as usual body weight for 1 (R #62) of 2 (R #25 and R #62) residents sampled for nutrition, when they failed to follow dietitian's order. This deficient practice could likely result in residents losing weight without the facility being aware causing physical and mental health issues.
- E
Provide safe, appropriate pain management for a resident who requires such services.
Inspectors wroteBased on record review and interview, the facility failed to effectively (use of different techniques and medication to reduce and control the amount of pain a person experiences) manage pain for 1 (R #22) of 1 (R #22) residents reviewed for pain when staff did not assess for pain and provide pain treatment. This deficient practice could likely result in residents experiencing unnecessary pain.
- E
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Inspectors wroteBased on record review and interview, the facility failed to ensure staff adequately monitored medications for 1 (R #86) of 5 (R #1, R #86, R #88, R #89, and R #359) residents reviewed for unnecessary medications, when they failed to monitor R #86's antiseizure medication levels as ordered by the physician. If the facility is not adequately monitoring medication levels in the blood, then residents are likely to be at risk of agitation, drowsiness, difficulty breathing, and/or behavior changes.
- 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 record review and interview, the facility failed to ensure residents did not receive unnecessary psychotropic medications (any drug that affects brain activities associated with mental processes and behavior) for 3 (R #86, R #89 and R #359) of 5 (R #1, R #86, R #88, R #89, and R #359) residents reviewed for unnecessary medications when they failed to document appropriate diagnosis in the resident medical record for psychotropic medications. This deficient practice is likely to result in residents being administered medications they do not need and could likely suffer from adverse side effects (unwanted, harmful, or abnormal result).
- E
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on record review and interview, the facility failed to ensure medical records were complete and accurate for 2 (R #1 and R #108) of 2 (R #1 and R #108) residents reviewed for documentation accuracy. This deficient practice has the potential to negatively impact the care staff provide to meet residents' needs due to missing or inaccurate records.
- E
Provide and implement an infection prevention and control program.
Inspectors wroteBased on record review, observation and interview, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 6 (R #25, R #30, R #82, R #94, R #109, and R #359) of 6 (R #25, R #30, R #82, R #94, R #109, and R #359) when they failed to have: 1) PPE (personal protective equipment equipment designed to protect from infection) was available for R #25, R #30, R #82, R #94, and R #109, who were on enhanced barrier precautions (refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms (bacteria that are resistant to three or more classes of antimicrobial drugs) that require gown and glove use during high contact resident care activities). [...]
- 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 record review and interview, the facility failed to offer Covid-19 (is an infectious disease caused by the SARS-CoV-2 virus) vaccinations to 1 (R #1) of 5 (R #1, R #60, R #71, R #82, and R #88) residents sampled for Covid-19 vaccination. This deficient practice could result in residents getting Covid-19 resulting in other illnesses or death.
- D
Ensure each resident receives an accurate assessment.
Inspectors wroteBased on record review and interview, the facility failed to ensure the Minimum Data Set Assessment was accurate for 1 (R #31) of 5 (R #2, R #6, R #22, R #31, and R #32) residents review for MDS assessment accuracy. This deficient practice could likely result in the facility not having an accurate assessment of the residents' needs.
- D
Assist a resident in gaining access to vision and hearing services.
Inspectors wroteBased on interview and record review, the facility failed to ensure residents received proper treatment to maintain vision for 1 (R #9) of 2 (R #9 and R #30) residents reviewed for vision and hearing. This deficient practice could likely result in residents losing some independence if they cannot see, compromising their quality of life.
- D
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 record review, observation and interview, the facility failed to ensure the nutritional needs and preferences were met for 1 (R #66) of 4 (R #25, R #62, R #66 and R #87) residents by not following the menu. This deficient practice is likely to result in resident weight loss and frustration.
- E
Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
Inspectors wroteBased on record review and interview, the facility failed to ensure could provide cardiopulmonary resuscitation (CPR) (can help save a life during cardiac arrest, when the heart stops beating or beats too ineffectively to circulate blood to the brain and other vital organs) during an emergency for 3 (R #100, R #108, and R #309) of 3 (R #100, R #108, and R #309) residents reviewed for advanced directives, when they failed to ensure staff: 1) Knew and followed facility protocols for determining residents code status [the residents choice as to whether or not they would like to be provided CPR in the event that they stopped breathing and/or their heart stopped]. 2) Had resident code status available for staff use during an emergency. [...]
October 24, 2023Complaint inspection · 4 citations
- L
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 record review and interview, the facility failed to ensure that nursing staff demonstrated competency in skills and techniques necessary to safely administer medications to residents for 4 (RN #1, RN #33, LPN #31, and LPN #32) of 6 (RN #1, RN #31, RN #33, LPN #31, LPN #32, and CMA #31) employees sampled for training. This deficient practice likely resulted in R #1 receiving another residents medication, resulting in R #1 being admitted to the hospital on [DATE] for accidental overdose and hypotension (low blood pressure).
- G
Ensure that residents are free from significant medication errors.
Inspectors wroteBased on record review and interview, the facility failed to ensure residents are free of any significant medication errors for 1 (R #1) of 6 (R #1, R #2, R #3, R #4, R #5, and R #6) residents reviewed for neglect, when they failed to administer medication to the correct resident. This deficient practice likely resulted in R #1 experiencing adverse (unwanted, harmful, or abnormal result) side effects and admission to the hospital.
- E
Make sure that a working call system is available in each resident's bathroom and bathing area.
Inspectors wroteBased on observation and interview, the facility failed to ensure call lights in the residents' bathrooms were adequately equipped to allow residents to call for help using the call light system, for 17 (R #7, R #8, R #9, R #10, R #11, R #12, R #13, R #14, R #15, R #16, R #17, R #18, R #19, R #20, R #21, R #22, R #23) of 17 (R #7, R #8, R #9, R #10, R #11, R #12, R #13, R #14, R #15, R #16, R #17, R #18, R #19, R #20, R #21, R #22, R #23) residents randomly sampled for call light function, when the facility failed to have proper length pull cords for the call light system in the resident's bathrooms. This deficient practice could likely result in residents being unable to call for assistance in the bathrooms in the event of a fall to the floor.
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on interview and record review, the facility failed to send the initial report of an allegation of neglect to the State Agency in the proper timeframes for 1 (R #1) of 6 (R #1, R #2, R #3, R #4, R #5, & R #6) residents sampled for neglect. This deficient practice could likely result in residents suffering physically from receiving inappropriate care.
April 6, 2023Standard inspection · 26 citations
- F
Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.
Inspectors wroteBased on interview and observation, the facility failed to ensure residents knew where the most recent survey was located. This could affect the 72 residents (identified by the facility census provided by the Administrator on 04/27/23). If residents are unable to locate the latest survey conducted by State Surveyors, then residents, representatives, and visitors are unable to know how the facility is doing and make decisions accordingly.
- E
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure residents were treated with respect and dignity for 3 (R #34, R #40, and R #220) of 7 (R #01, R #34, R #40, R #42, R #64, R #44, and R #220) residents randomly sampled, when the facility failed to: 1. Ensure Staff are speaking in a language that R #34 understands while receiving patient care, 2. Ensure R #40 has sheets on his bed, 3. Ensure R #220's room is free of odor, These deficient practices are likely to result in residents feeling embarrassed, ashamed, and that their feelings and preferences are unimportant to the facility staff.
- E
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Inspectors wroteBased on interview and record review the facility failed to protect residents against the loss of resident's personal property for 3 (R #16, R #41 and R #64) of 3 (R #16, R #41 and R #64) residents reviewed for loss of personal property. This deficient practice could likely cause the resident and/or the resident's family frustration with loss of personal belongings and a financial burden of having to purchase those items again.
- E
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Inspectors wroteBased on interviews the facility failed to keep residents free from abuse for 4 (R #16 and R #21, R #64 and R #220) of 4 (R #16 and R #21, R #64 and R #220) residents reviewed for abuse and neglect, when the facility failed to protect: 1. R #16 from mental anguish (mental suffering which includes fright, feelings of distress, anxiety, depression, grief and/or psychosomatic physical symptoms) from PTA #11 (Physical Therapist Assistant) after she became angry that R #16 did not want to do therapy. 2. R #21 from physical abuse when PTA #11 physically attempted to force R #21 into the therapy room. 3. R #64 from physical abuse when PTA #11 pounded on R #64's contracted hand (condition that causes one or more fingers to bend toward the palm of the hand) to flatten it. 4. [...]
- E
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 review and interview, the facility failed to notify the resident/resident's representative(s) of the transfer and the reasons for the move in writing for 3 (R #10, R #17, and R #47) of 3 (R #10, R #17, and R #47) residents sampled for hospitalizations. This deficient practice could likely result in the resident and/or their representative not knowing the reason for the transfer and their rights to advocate and make informed decision regarding their healthcare.
- E
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 record review and interview, the facility failed to provide written information to the resident or resident representative that specifies the bed hold policy at the time of the transfer for 3 (R #10, R #17, and R #47) of 3 (R #10, R #17, and R #47) residents sampled for hospitalizations. This deficient practice could likely result in the resident and/or their representative being unaware of the resident being able to return to their previous room or the next available room upon return from the hospital.
- E
Assess the resident when there is a significant change in condition
Inspectors wroteBased on record review and interview, the facility failed to complete a significant change (major decline or improvement in the patient's health status) MDS (Minimum Data Set; assessment) in a timely manner (within 14 days after the facility determines, or should have determined, that there has been a significant change in the resident's physical or mental condition) for 2 (R #31 and R #42) of 2 (R #31 and R #42) residents sampled for Hospice (care that focuses on alleviating symptoms of the terminally ill). This deficient practice could likely result in the resident not receiving the appropriate care and services they need.
- E
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Inspectors wroteBased on record review and interview, the facility failed to have MDS documents completed, submitted, and finalized in a timely manner (within 14 days of completion) for 2 (R #64 and R #219) of 2 (R #64 and R #219) residents randomly reviewed for Minimum Data Set (MDS; tool for implementing standardized assessment and for facilitating care management in nursing homes) assessments. If MDS assessments are not completed, submitted, and finalized in a timely manner, it is likely that residents will receive less than optimal care:
- E
Ensure each resident receives an accurate assessment.
Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that the Minimum Data Set (MDS) Assessments were accurate for 2 (R #47 and R #58) of 2 (R #47 and R #58) residents sampled for MDS accuracy 1. When Post Traumatic Stress Disorder (PTSD) was included as an active diagnosis for R #47 2. When they failed to capture the severity of R #58's vision problems. These deficient practices could likely result in residents not receiving the care and treatment they need.
- E
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 record review, observation, and interview, the facility failed to develop a comprehensive person-centered care plan for 1 ( R #44) of 5 (R #9, R #17, R #40, R #44, and R #169) residents reviewed for Comprehensive Care Plans. Failure to develop a person-centered care plan is likely to result in staff's failure to understand the needs and treatments for residents to achieve their highest level of well-being.
- E
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 and interview, the facility failed to ensure appropriate treatment and services for Foley Catheter tubing/Collecting bag (soft plastic or rubber tube that is inserted to the bladder to drain the urine and is connected to a collecting bag) care for 1 (R #221) of 1 (R #221) residents randomly observed when they failed to keep R #221's Foley catheter collecting bag and tubing off the floor. This deficient practice could likely result in residents getting infections.
- E
Observe each nurse aide's job performance and give regular training.
Inspectors wroteBased on record review and interview, the facility failed to conduct Nurse Aide performance review at least every 12 months and failed to provide evidence of CNA's completion of the required 12 hours per year In-Services for 3 (CNA #11, CNA #12, and CNA #13) of 3 (CNA #11, CNA #12, and CNA #13). This failed practice could lead to residents not receiving the appropriate care to meet their individual needs.
- 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 and interview, the facility failed to ensure that consultant pharmacists recommendations were reviewed and implemented by the physician or ensure that the physician provides rationale for not following the recommendation for 2 (R #9 and R #42) ) of 5 (R #9, R #30, R #41, R #42, and R #64) residents reviewed for unnecessary medications. This deficient practice could likely result in residents receiving medications that are no longer necessary and may cause unnecessary drug interactions or adverse side effects.
- E
Ensure medication error rates are not 5 percent or greater.
Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure that the medication error rate was 5% or less when medications were not given and the wrong medication was given for 4 (R #7, R #41, R #49, and R #56) of 10 (R #2, R #7, R #10, R #13, R #25, R #38, R #41, R #49, R #53, and R #56) residents observed during medication pass. This deficient practice could likely result in residents not receiving the desired therapeutic effect and exposing residents to a higher risk of adverse side effects (unwanted, harmful, or abnormal result).
- 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 wroteRecite from a complaint survey dated 03/31/23 Based on observation and interview the facility failed to properly store medications in the medication carts for all 72 residents (residents were identified by the resident matrix provided by the Administrator on 03/27/23) that were randomly sampled, when they failed to: 1. Secure the medication carts on the 500 unit. 2. Ensure medications were not expired (expired medications can be less effective or risky due to a decrease in strength) Memory Care Unit Medication Cart. These deficient practices could result in residents obtaining medication not prescribed to them and residents having adverse side effects.
- E
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, and interview, the facility failed to practice proper infection control practices, when they failed to perform proper hand hygiene in the dining room while assisting 2 (R #19 and R #28) of 2 (R #19 and R #28) residents randomly observed during dining. This deficient practice is likely to result in the spread of infections and illness.
- E
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
Inspectors wroteBased on record review and interview the facility failed to have required in-service training for nurse aides for 3 (CNA #11, CNA #12, and CNA #13) of 3 (CNA #11, CNA #12, and CNA #13) CNA's sampled for training when they failed to ensure: 1. Dementia management training and resident abuse prevention training were conducted, 2. Annual trainings are based, in part on facility assessment and performance evaluations. These deficient practices could likely lead to the CNA's not receiving the continuing education needed to provide competent care to the residents.
- D
Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home.
Inspectors wroteBased on interview and record review the facility failed to provide quarterly statements for resident's personal funds for 1 (R #19) of 2 (R #19 and R #64) resident reviewed personal funds entrusted to the facility on the resident's behalf. This deficient practice is likely to cause a resident to be unaware of their personal funds balances.
- 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 record review and interview, the facility failed to ensure that Advance Directives (legal document that specifies what actions should be taken for their health if they are no longer able to make decisions for themselves because of illness or incapacity) form was completed for 1 (R #169) of 7 (R #3, R #9, R #44, R #46, R #47, R #58, and R #169) residents reviewed for Advance Directives. This deficient practice could likely result in staff being unaware of the medical intervention wishes of residents during an emergency.
- D
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Inspectors wroteBased on record review and interview, the facility failed to notify the resident's representative of an incident for 1 (R #21) of 4 (R #16, R #21, R #64, and R #220) residents reviewed for abuse. This deficient practice could likely result in resident's family members not being able to make decisions related to treatment and/or advocate for the resident's care.
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on record review and interview the facility failed to report to the State Survey Agency an allegation of abuse for one 1 (R #21) of 4 (R #16, R #21, R #64, and R#220) residents sampled for abuse, when they failed to report the allegation of R #21's abuse within two hours to the State Agency. If the facility fails to report allegations of abuse to the State Agency within two (2) hours, then residents could likely continue to be abused.
- D
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Inspectors wroteBased on record review and interview, the facility failed to ensure a comprehensive assessment was completed within 14 calendar days after admission for 1 (R #169) of 1 (R #169) residents randomly sampled for completion of a comprehensive MDS (Minimum Data Set) assessment. This deficient practice could likely lead to the residents' preferences and needs not being met.
- 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 observation, record review and interview, the facility failed to create a Baseline Care Plan (Plan that includes the instructions needed to provide effective and person-centered care upon admission) with interventions (actions required by staff to assist resident) within 48 hours of admission for 1 (R #169) of 2 (R #169 and R #217) residents sampled for Baseline Care Plans. This deficient practice could likely result in the resident not receiving the appropriate care and services and may place the resident at risk of an adverse event (An event, preventable or nonpreventable, that caused harm to a patient as a result of medical care or lack of medical care) that could occur after admission.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on observation, and interview, the facility failed to ensure residents receive treatment and care in accordance with professional standards of practice for 1 (R #44) of 1 (R #44) resident reviewed for insulin (hormone which regulates the amount of glucose in the blood used to treat diabetes) administration. This deficient practice could likely result in residents not receiving the appropriate care for current diagnosis, correct medication and exposes residents to a higher risk of adverse side effects (unwanted, harmful, or abnormal result).
- D
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Inspectors wroteBased on record review and interview the facility failed to ensure that psychotropic medications (any medication capable of affecting the mind, emotions, and behavior) were not given as PRN (as needed) for more than 14 days for 1 (R #42) of 5 (R #9, R #30, R #41, R #42, and R #64) residents sampled for unnecessary medications, when they failed to discontinue or reevaluate the need for continued use of psychotropic medication. This deficient practice could likely result in residents receiving medications for longer than needed.
- D
Provide or get specialized rehabilitative services as required for a resident.
Inspectors wroteBased on interview and record review, the facility failed to ensure resident was receiving restorative rehabilitation (focuses on maximizing an optimal level of functioning, enabling clients to regain/retain their independence following the debilitating effects of illness or injury.) services as ordered by the physician for 1 (R #40) of 1 (R #40) resident reviewed for rehab services. This deficient practice is likely to result in a decrease in residents functional mobility.
Fire safety inspections
23 fire safety citations on file: 4 on June 5, 2025, 3 on April 24, 2024, 16 on April 6, 2023.
Every fire safety citation23 citations
- F
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · June 5, 2025 · Corrected (the home has a date of correction)
- F
Meet requirements for the installation and maintenance of electrical systems.
K 911 · June 5, 2025 · Corrected (the home has a date of correction)
- E
Inspect, test, and maintain automatic sprinkler systems.
K 353 · June 5, 2025 · Corrected (the home has a date of correction)
- E
Have power receptacles that are properly grounded.
K 912 · June 5, 2025 · Corrected (the home has a date of correction)
- F
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
K 761 · April 24, 2024 · Corrected (the home has a date of correction)
- E
Properly select, install, inspect, or maintain portable fire extinguishes.
K 355 · April 24, 2024 · Corrected (the home has a date of correction)
- E
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
K 741 · April 24, 2024 · Corrected (the home has a date of correction)
- F
Address patient/client population and determine types of services needed.
E 7 · April 6, 2023 · Corrected (the home has a date of correction)
- F
Address subsistence needs for staff and patients.
E 15 · April 6, 2023 · Corrected (the home has a date of correction)
- F
Install emergency lighting that can last at least 1 1/2 hours.
K 291 · April 6, 2023 · Corrected (the home has a date of correction)
- F
Have properly located and lighted "Exit" signs.
K 293 · April 6, 2023 · Corrected (the home has a date of correction)
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · April 6, 2023 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · April 6, 2023 · Corrected (the home has a date of correction)
- F
Have simulated fire drills held at unexpected times.
K 712 · April 6, 2023 · Corrected (the home has a date of correction)
- F
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
K 761 · April 6, 2023 · Corrected (the home has a date of correction)
- F
Ensure that testing and maintenance of electrical equipment is performed.
K 921 · April 6, 2023 · Corrected (the home has a date of correction)
- F
Have proper fire barriers, ventilation and signs for the transfilling of oxygen.
K 927 · April 6, 2023 · Corrected (the home has a date of correction)
- E
Keep aisles, corridors, and exits free of obstruction in case of emergency.
K 211 · April 6, 2023 · Corrected (the home has a date of correction)
- E
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
K 321 · April 6, 2023 · Corrected (the home has a date of correction)
- E
Provide properly protected cooking facilities.
K 324 · April 6, 2023 · Corrected (the home has a date of correction)
- E
Have properly installed hallway dispensers for alcohol-based hand rub.
K 325 · April 6, 2023 · Corrected (the home has a date of correction)
- E
Have properly installed electrical wiring and gas equipment.
K 511 · April 6, 2023 · Corrected (the home has a date of correction)
- E
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
K 521 · April 6, 2023 · Corrected (the home has a date of correction)