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 54 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
3J
1K
0L
Actual harm
0G
1H
0I
Potential for more than minimal harm
12D
22E
15F
Potential for minimal harm
0A
0B
0C
June 25, 2026Complaint inspection · 1 citation
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on observation, record review, and interviews, the facility failed to complete a physician ordered referral to an orthopedic specialist for post fall follow up care for 1 (R #1) of 3 (R #1, R #2, and R #3) residents reviewed. This deficient practice could result in a delay in evaluation and treatment for possible injuries.
February 5, 2026Complaint inspection · 1 citation
- D
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Inspectors wroteBased on interview and record review, the facility failed to prevent misappropriation of resident money when a payment app account was used by a staff member for 1 (R #1) of 4 (R #1, R #2, R #3 and R #4) residents reviewed for exploitation (the fact of making use of a situation to gain unfair advantage for oneself). This deficient practice is likely to cause residents to feel unsafe, and experience anger and frustration.
December 18, 2025Standard inspection · 15 citations
- F
Post nurse staffing information every day.
Inspectors wroteBased on observation and interview, the facility failed to post nurse staffing data daily at the beginning of the shift that included the following: 1. Facility name. 2. The current date. 3. 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: -Registered nurses. -Licensed practical nurses. -Certified nurse aides. -Resident census. This deficient practice has the potential to affect all 96 residents as identified by the census provided by the Admissions Coordinator (Admit) on 12/14/25 and could likely result in residents and visitors not having the staffing information readily available.
- F
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 ensure safe medication storage practices by not ensuring the medical supply storage rooms were kept free of expired medications. This deficient practice has the potential to affect all 96 residents as identified by the census provided by the Administrator on 12/14/25. If the facility does not ensure safe storage practices, then residents are at risk for adverse effects due to improper storage.
- F
Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame.
Inspectors wroteBased on observation, record review, and interview, the facility failed to conduct regular inspections of all bed frames, mattresses, and bed rails as part of a regular maintenance program to identify areas of possible entrapment 13 (R #2, R #4, R #5, R #6, R #10, R #12, R #13, R #19, R #54, R #55, R #63, R #84, and R #88) of 13 (R #2, R #4, R #5, R #6, R #10, R #12, R #13, R #19, R #54, R #55, R #63, R #84, and R #88). This deficient practice could likely result in serious injury or death if residents become trapped between the mattress, side rail, footboard and headboard.
- 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 2 (R #2 and R #4) of 3 (R #2, R #4 and R #54) residents reviewed for unnecessary medications, when staff failed to: 1. Ensure psychotropic medications were necessary to treat a specific condition as diagnosed and documented in the clinical record for R #2 and R #4, 2. Ensure as needed psychotropic medications are limited to only 14 days or indicate the duration of the as needed (PRN) order for R #2. These deficient practices could likely lead to adverse drug effects and poor patient outcomes.
- 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 observation, record review, and interview, the facility failed to create an accurate and complete 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 4 (R #7, R #15, R #79, R #106) of 6 (R #7, R #8, R #15, R #35, R #79, and R #106) residents reviewed for 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.
- 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 observation, record review, and interview, the facility failed to ensure staff revised the care plan for 4 (R #2, R #5, R #54, and R #55) of 4 (R #2, R #5, R #54, and R #55) residents reviewed when staff failed to:Revise care plans for R #2 and R #55 for the use of bed rails,Revise care plan for R #5's dependence on staff for bed mobility,Revise care plan to include interventions for bed rail usage for R #54. These deficient practices are likely to result in residents' care and needs not being addressed if care plans are not updated.
- E
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure residents were assessed for risk of entrapment (state of being stuck or caught on bed rail) in bed rails for 13 (R #2, R #4, R #5, R #6, R #10, R #12, R #13, R #19, R #54, R #55, R #63, R #84, and R #88) of 13 (R #2, R #4, R #5, R #6, R #10, R #12, R #13, R #19, R #54, R #55, R #63, R #84, and R #88) residents reviewed for accidents. This deficient practice has the potential to cause serious injury by becoming trapped between the mattress and bed rail.
- 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 each resident's drug regimen (plan to manage a person's medication) was free from unnecessary drugs by ensuring indication of use is based on the residents' current diagnosis for 3 (R #2, R #4, and R #54) of 3(R #2, R #4, and R #54) residents reviewed for unnecessary medications. This deficient practice could likely lead to adverse drug effects and poor patient outcomes.
- E
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on observation and interview, the facility failed to complete the following:1. Maintain the ice and water machine in a manner to prevent contamination and foodborne pathogens (a bacterium, virus, or other microorganism that can cause disease), 2. Properly store food items by tracking when to discard, labeling and covering perishable foods, and dating all foods stored in refrigerator, freezer, or pantry.3. Maintain the kitchen environment in a clean and sanitary manner. 4. Temperature tracking sheet on the outside of the refrigerator was dated November 2025. 5. Ensuring food served to residents was sanitary. These failures have the potential to result in cross contamination, the growth of foodborne pathogens, and foodborne illnesses.
- E
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, record review, and interview, the facility failed to maintain proper infection prevention measures for 3(R #6, R #54, and R #98) of 3(R #6, R #54, and R #98) residents reviewed by not: Ensuring Enhanced Barrier Protection (EBP) signage is visibly posted outside resident's room when precautions are in place. Ensuring Personal Protective Equipment is available (PPE) is available,Ensuring EBP signage was posted properly. Infection Control Signs and PPER #6C. Record review of R #6's admission record revealed R #6 was admitted into the facility on [DATE]. D. [...]
- D
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Inspectors wroteBased on record review and interview, the facility failed to ensure residents were provided activities according to their preference for 1 (R #4) of 1 (R #4) resident reviewed for activities of daily living. This deficient practice is likely to result in the residents' personal choices not being honored and loss of dignity.
- 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 the resident's current advance directive (a document which provides an individual's wishes for emergency and lifesaving care) and the resident's Electronic Health Record (EHR) revealed the same resident wishes for 3 (R #9, R #79, and R #84) of 6 (R #9, R #10, R #63, R #67, R #79, and R #84) residents reviewed for advance directives. This deficient practice is likely to cause confusion and delay potentially lifesaving procedures.
- D
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Inspectors wroteBased on observation, 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 4 (R #7, R #15, R #79, R #106) of 6 (R #7, R #8, R #15, R #35, R #79, and R #106) residents reviewed for 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
Ensure medication error rates are not 5 percent or greater.
Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the medication error rate did not exceed 5 percent (%) when staff performed four medication errors out of 32 opportunities for 1 (R #106) of 6 (R #15, R #35, R #41, R #79, R #101, and R #106) residents reviewed during medication administration. This resulted in a medication error rate of 12.5%. This deficient practice could likely result in the residents receiving incorrect medication, not receiving the desired therapeutic effect, and exposing the residents to a higher risk of side effects.
- D
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' rooms were within reach of the residents while in the room for 1 (R #5) of 5 (R #2, R #5, R #54, R #88 and R #98) residents reviewed for call lights. This deficient practice could likely result in residents being unable to notify staff when they need assistance.
September 11, 2025Complaint inspection · 2 citations
- E
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on record review and interview, the facility failed to provide activities of daily living (ADL; activities related to personal care such as bathing, showering, dressing, walking, toileting, and eating) assistance for baths or showers for 3 (R #1, R #2, and R #3) of 3 (R #1, R #2, and R #3) residents reviewed for ADL care. This deficient practice is likely to affect the dignity and health of the residents.
- 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 a suicide attempt where a potential for serious bodily injury can occur within 24 hours to the State Agency (SA) for 1 (R #2) of 1 (R #2) resident reviewed for abuse. If the facility fails to report these incidents to the State Agency, then the State Agency cannot ensure the residents' safety is protected.
September 20, 2024Standard inspection · 19 citations
- F
Honor the resident's right to manage his or her financial affairs.
Inspectors wroteBased on interviews the facility failed to ensure residents have ready and reasonable access to their money. This deficient practice could likely affect all 95 residents who reside at the facility. If the facility is not ensuring residents have access to their money, then residents are likely to feel undignified and unworthy.
- F
Ensure residents have reasonable access to and privacy in their use of communication methods.
Inspectors wroteBased on interviews, the facility failed to ensure that residents are able to receive mail on Saturdays for all 95 residents residing at the facility. This deficient practice is likely to result in residents not receiving timely communication which could result in feelings of isolation.
- F
Ensure that nurse aides who have worked more than 4 months, are trained and competent; and nurse aides who have worked less than 4 months are enrolled in appropriate training.
Inspectors wroteBased on record review and interview, the facility failed to provide documentation confirming on Nurse Aide (NA) #1, employed by the facility, had completed a Nurse Aide Training and Competency Evaluation Program (NATCEP) or a Competency Evaluation Program (CEP) within four months of being employed at the facility. This deficient practice is likely to affect all 95 residents residing in the facility. Residents are likely to experience substandard care because of the use of untrained or unqualified aides providing direct care to residents.
- F
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Inspectors wroteBased on interview and observation, the facility failed: 1. Ensure meals were attractive when served to residents. 2. Ensure foods were palatable (pleasant to taste) and to the resident's satisfaction. 3. Ensure cold and hot foods were served at the appropriate temperatures to prevent scalding and burning. 4. Ensure foods were served timely to each resident and those sharing tables. These deficient practices have the potential to affect all 95 residents' ability to eat and enjoy meals, may decrease their quality of life, and could likely lose weight.
- 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 and interview, the facility failed to ensure the nutritional needs and preferences were met for all 95 residents listed on the facility census provided by the Administrator on 09/16/24 by not having an alternative meal available for residents. If the facility is not providing an alternative meal or offering an alternate meal menu to residents, then residents are likely to experience weight loss, frustration, and depression.
- F
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on record review, observation and interview, the facility failed to store and serve food under sanitary conditions by not ensuring: 1. Kitchen was clean and sanitary. 2. Food items labeled and dated 3. Refrigeration unit was clean. 5. Food storage and handling. 6. Maintenance of kitchen equipment and plumbing These deficient practices are likely to affect all 95 residents listed on the resident census list provided by the Administrator on 09/16/24 and could likely lead to foodborne illnesses in residents if food is not being stored properly, safe food handling practices are not adhered to and sanitation of equipment preparation areas are not cleaned appropriately.
- E
Allow resident to participate in the development and implementation of his or her person-centered plan of care.
Inspectors wroteBased on record reviews and interviews, the facility failed to ensure the resident's right to participate in the care planning process for 3 (R #24, R #30, and R #96) of 5 (R #24, R #30, R #90, R #96, and R #294) residents reviewed for care plans. If the facility fails to ensure resident's participation in the care planning process, then residents are likely to feel unimportant and uninformed.
- E
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Inspectors wroteBased on record review, observations, and interviews, the facility failed to promote residents' choices for 2 (R #28 and R#96) of 2 (R #28 and #96) residents reviewed for choices when staff failed to: 1. Announce themselves prior to entering R #28's room. 2. Accommodate R #96's choice to have her oxygen tube attached to the rail of her bed. These deficient practices are likely to result in the resident's needs, choices and preferences not being honored.
- E
Honor the resident's right to organize and participate in resident/family groups in the facility.
Inspectors wroteBased on interviews, the facility failed to ensure the grievances identified by the Resident Council (RC) were resolved and the resolutions communicated back to the RC committee. This deficient practice could likely affect all 95 residents who reside at the facility. If the staff is not ensuring RC grievances are responded to and resolutions are communicated back to the RC group, then residents are likely to feel that their concerns do not matter, and do not have any influence over changing issues identified by residents.
- E
Ensure each resident receives an accurate assessment.
Inspectors wroteBased on observation, interview and record review, the facility failed to complete an accurate comprehensive assessment for 2 (R #22 and R #75) of 2 (R #22 and R #75) residents reviewed for assessments. This deficient practice is likely to result in residents not receiving an accurate assessment which could result in the residents receiving less than optimal care and treatment.
- E
Provide activities to meet all resident's needs.
Inspectors wroteBased on record review and interview, the facility failed to provide an ongoing program of activities designed to meet the interests for 4 (R #22, R #24, R #30, and R #90) of 6 (R #22, R #24, R #30, R #90, R #242, and R #294) residents reviewed for activities by not providing meaningful individualized activities based upon residents' interests. If residents are not provided or encouraged to attend/participate in activities that meets their interests, then they are likely to experience an increase in boredom, isolation, and depression.
- E
Assist a resident in gaining access to vision and hearing services.
Inspectors wroteBased on record review and interview, the facility failed to ensure residents received proper treatment to maintain vision for 1 (R #24) of 2 (R #24 and R #106) residnets reviewed for vision. This deficient practice could likely result in residents losing some independence if they cannot see, and compromising their quality of life.
- E
Ensure medication error rates are not 5 percent or greater.
Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure the medication error rate was 5% or less when six medication errors occurred out of 43 opportunities, which resulted in an error rate of 13.95% for 4 (R #19, R #24, R #55, and R #76) of 7 (R #19, R #24, R #38, R #41, R #55, R #62, and R #76) residents observed during medication administration. This deficient practice could likely result in the residents receiving the incorrect medication, not receiving the desired therapeutic effect, and exposing the resident to a higher risk of side effects.
- E
Ensure that residents are free from significant medication errors.
Inspectors wroteBased on record review, observation and interview, the facility failed to ensure a resident was free of a significant medication error by not administering medications as ordered for 1 (R #55) of 1 (R #55) resident reviewed for administration of insulin (hormone produced in the pancreas which regulates the amount of glucose in the blood). This deficient practice could likely have severe negative effects on the resident, such as hypoglycemia (too little sugar in the blood) and lead to symptoms of trouble talking, confusion, loss of consciousness, seizures, or death.
- E
Provide or obtain dental services for each resident.
Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure residents obtained routine dental care for 3 (R #22, R #24 and R #75) of 3 (R #22, R #24 and R #75) residents reviewed for dental services. This failure is likely to result in the resident experiencing pain, embarrassment over condition of teeth, and potential weight loss.
- E
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview, record review, the facility failed to administer medications in a manner to prevent cross contamination for 3 (R #19, R #24, and R #76) of 7 (R #19, R #24, R #38, R #41, R # 55, R #62, and R #76) residents. The failure has the potential to cause residents to be exposed to pathogens (organisms that can cause disease) and increased risk of infection.
- E
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Inspectors wroteBased on record review the facility failed to ensure the medical records contained documentation that each resident received, or staff offered the pneumococcal (a bacteria that can cause pneumonia infection of the respiratory tract) or influenza (flu) vaccines for 1 (R #74) of 6 (R #2, R #17, R #22, R #39, R #74, and R #75) residents reviewed for immunizations. If residents are not vaccinated as appropriate against pneumonia and influenza, they have a higher likelihood of contracting that illness and spreading it to other 95 residents on the census list provided by Administrator (ADM) on 09/16/24 and staff in the facility.
- 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 ensure Certified Nurse Aides (CNAs) received the required in-service training of 12 hours per year for 1 (CNA #1) of 2 (CNA #1 and CNA #2) CNAs reviewed for required in-service training. This deficient practice is likely to result in the CNAs not receiving the necessary training to meet the care needs of the 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 promote care with dignity and respect for 4 (R #3, R #44, R #56, and R #70) of 6 (R #3, R #12, R #44, R #56, R #64, and R #70) residents reviewed during a random dining observation when the facility failed to serve lunch at the same time to all the residents who sat at the same dining table. This deficient practice could likely result in residents feeling frustrated and disappointed.
September 10, 2024Complaint inspection · 2 citations
- J
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on record review and interviews, the facility failed to prevent an accident for 1 (R #1) of 3 (R #1, R #2, and R #3) residents reviewed for falls when: 1. R #1 sustained (14) falls in a 6.5 month period. 2. The facility did not implement adequate interventions to prevent falls 3. Neurochecks for unwitnessed falls and falls in which the resident hit her head were incomplete per policy. 4. One- to-one staffing was assigned to R #1, however staff were assigned other duties and R #1 had 3 falls during the time she was ordered to have one-to-one staffing in which she sustained injury to her head. These deficient practices likely resulted in R #1 sustaining multiple acute subarachnoid hemorrhage (bleeding between the space between the brain and tissue covering the brain) and passing away (6) days after her last fall at the facility.
- F
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 interviews, the facility failed to ensure all treatment carts were locked while unattended. This deficient practice had the potential to affect all 94 people residing in the facility by allowing unauthorized persons access to their medical supplies and personal health information.
April 25, 2024Complaint inspection · 2 citations
- 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 interview and record review, the facility failed to ensure grievances (complaints over something believed to be wrong or unfair) were acted upon for 3 (R #3, R #6, and R #12) of 3 (R #3, R #6, and R #12) residents reviewed for grievances. This deficient practice could likely result in residents feeling unimportant and unsatisfied with the results of the grievance process.
- E
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Inspectors wroteBased on record review, and interview, the facility failed to ensure the residents' ability to perform activities of daily living (ADLs) was maintained for 2 (R #10 and R #11) of 4 (R #1, R #4, R #10 and R #11) residents reviewed for restorative therapy (Restorative services refers to nursing interventions that promote the resident ' s ability to adapt and adjust to living as independently and safely as possible). If the facility does not ensure that residents receive restorative services, then the residents are likely to experience a decrease in their ability to walk, transfer, and do other activities of daily living.
March 13, 2024Complaint inspection · 3 citations
- J
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 staff failed to report incidents of alleged abuse for 2 (R #1 and R #2) of 2 (R #1 and R #2) residents sampled. If the staff failed to report allegations of abuse to the facility administration then corrective measures may not be acted on, and the facility would be unable to assure residents are free from abuse and neglect.
- J
Respond appropriately to all alleged violations.
Inspectors wroteBased on record review and interview, the facility failed to complete a thorough investigation regarding allegations of sexual abuse for 1 (R #1) of 1 (R #1) residents that CNA #1 worked with. This failure could likely lead to other residents' being sexully abused.
- H
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 interviews, the facility failed to prevent staff to resident sexual abuse and to protect other residents from ongoing sexual behaviors for 2 (R #1 & R #2) of 2 (R #1 and R #2) residents reviewed for abuse. This deficient practice likely resulted in psychosocial distress (unpleasant emotions associated with a highly stressful situation) for the residents who were subject to this behavior.
December 22, 2023Complaint inspection · 2 citations
- K
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on record review and interview, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice when staff did not routinely check the blood sugar levels of residents with diabetes for 4 (R #'s 1, 2, 3, and 4) of 4 (R #'s 1, 2, 3, and 4) residents reviewed for diabetes mellitus [DM; [...]
- 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 staff revised and updated the care plan for 1 (R #5) of 1 (R #5) residents reviewed for care plans when staff failed to add R #5's behavior to refuse diabetic management practices (insulin and blood sugar level checks). This deficient practice is likely to result in residents' care and needs not being addressed if care plans are not updated.
July 7, 2023Standard inspection · 7 citations
- F
Post nurse staffing information every day.
Inspectors wroteBased on observation, record review, and interview, the facility failed to post Nurse Staffing Information in an accurate manner and at the beginning of each shift, This deficient practice could likely prevent the 71 residents on the facility census list provided by the Administrator on 06/25/23, and any visitors to have access to accurate daily staffing information.
- F
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Inspectors wroteBased on observation, record review, and interview, the facility failed to provide an alternate meal menu for residents that preferred not to eat the meal served on the menu. By failing to post an alternate meal, all 71 residents listed on the census provided by the Administrator, may not be aware that they have choices. This deficient practice could lead to residents having less than optimal nutritional health outcomes, and suffer unwanted weight loss.
- 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 ensure food was labeled and dated in the refrigerators and dry storage areas. This deficient practice could affect the 71 residents, as listed on the facility census provided by the Administrator on 06/25/23, that receive food or meals from the kitchen. If the facility does not ensure food storage is conducted using proper procedures, residents have the potential to receive food that is expired, or potentially exposed to food contamination resulting in foodborne illness.
- F
Dispose of garbage and refuse properly.
Inspectors wroteBased on observation and interview, the facility failed to ensure trash/garbage cans were closed and in good repair. This deficient practice has the potential to affect all 71 residents, as listed on the facility census provided by the Administrator on 06/25/23, by attracting insects, rodents and animals to the facility.
- 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 the consultant pharmacist reviewed each resident's drug regimen for irregularities on a monthly basis for 5 (R #15, 34, 44, 48 and 172) of 5 (R #15, 34, 44, 48 and 172) residents reviewed for unnecessary medications. If the facility fails to conduct monthly reviews, there is potential for residents to experience unnecessary drug interactions and potentially adverse side effects.
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure that 1 (R #18) of 1 (R #18) resident reviewed for falls was free from accidents and hazards by not providing the necessary equipment. This deficient practice could likely result in injuries and/or hospitalizations.
- D
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Inspectors wroteBased on record review and interview, the facility failed to provide services of a Registered Nurse (RN) for at least 8 consecutive hours a day, 7 days a week. This deficient practice could affect all 71 residents, as identified on the facility census list provided by the Administrator on 06/25/23, if the residents cannot maintain their highest achievable status of health, mobility, and mental functioning.
Fire safety inspections
17 fire safety citations on file: 5 on September 20, 2024, 2 on July 7, 2023, 10 on August 10, 2022.
Every fire safety citation17 citations
- F
Address patient/client population and determine types of services needed.
E 7 · September 20, 2024 · Corrected (the home has a date of correction)
- F
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
K 222 · September 20, 2024 · Corrected (the home has a date of correction)
- F
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · September 20, 2024 · Corrected (the home has a date of correction)
- E
Provide properly protected cooking facilities.
K 324 · September 20, 2024 · Corrected (the home has a date of correction)
- E
Inspect, test, and maintain automatic sprinkler systems.
K 353 · September 20, 2024 · Corrected (the home has a date of correction)
- F
Provide properly protected cooking facilities.
K 324 · July 7, 2023 · Corrected (the home has a date of correction)
- F
Meet other general requirements that are deficient.
K 500 · July 7, 2023 · Corrected (the home has a date of correction)
- F
Establish procedures for tracking staff and patients during an emergency.
E 18 · August 10, 2022 · Corrected (the home has a date of correction)
- F
Establish policies and procedures for sheltering.
E 22 · August 10, 2022 · Corrected (the home has a date of correction)
- F
Establish policies and procedures for medical documentation.
E 23 · August 10, 2022 · Corrected (the home has a date of correction)
- F
Provide family notifications of emergency plan.
E 35 · August 10, 2022 · Corrected (the home has a date of correction)
- F
Establish emergency prep training and testing.
E 36 · August 10, 2022 · Corrected (the home has a date of correction)
- F
Establish staff and initial training requirements.
E 37 · August 10, 2022 · Corrected (the home has a date of correction)
- F
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
K 222 · August 10, 2022 · Corrected (the home has a date of correction)
- F
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · August 10, 2022 · Corrected (the home has a date of correction)
- E
Properly select, install, inspect, or maintain portable fire extinguishes.
K 355 · August 10, 2022 · Corrected (the home has a date of correction)
- E
Install corridor and hallway doors that block smoke.
K 363 · August 10, 2022 · Corrected (the home has a date of correction)