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 77 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
1J
0K
0L
Actual harm
2G
0H
0I
Potential for more than minimal harm
44D
28E
2F
Potential for minimal harm
0A
0B
0C
November 13, 2025Complaint inspection · 7 citations
- E
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, staff interview, clinical record review, and facility documentation review, the facility staff failed to implement transmission-based precautions to prevent the spread of infections on two of four nursing units, fourth and fifth floors.
- D
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Inspectors wroteBased on resident interview, staff interview, clinical record review and facility documentation review, the facility staff failed to protect the resident's right to be free from neglect for one resident (Resident #4- R4), in a survey sample of eight residents.
- D
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Inspectors wroteBased on resident interview, staff interview, clinical record review, and facility documentation review, the facility staff failed to implement their abuse policy for one staff member, which affected one resident (Resident #4-R4) in a survey sample of eight residents.
- D
Respond appropriately to all alleged violations.
Inspectors wroteBased on resident interview, staff interview, clinical record review and facility documentation review, the facility staff failed to take measures to prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation was conducted for two residents (Resident #4- R4 and Resident #2-R2), in a survey sample of eight residents.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on observation, staff interview, clinical record review, and facility documentation review, the facility staff failed to follow physician orders for three residents (Resident #1- R1, Resident #5-R5, and Resident #6-R6), in a survey sample of eight residents.
- D
Ensure that residents are free from significant medication errors.
Inspectors wroteBased on staff interview, clinical record review, and facility documentation review, the facility staff failed to ensure a resident was free from significant medication errors affecting one resident (Resident #1- R1) in a survey sample of eight residents.
- D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on observation, staff interview, clinical record review, and facility documentation review, the facility staff failed to maintain a complete and accurate clinical record for three residents (Resident #5- R5, Resident #6-R6, and Resident #8-R8) in a survey sample of eight residents.
June 26, 2025Complaint inspection · 12 citations
- E
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Inspectors wroteBased on observation, staff interview and facility documentation review, the facility staff failed to prepare and serve meals in accordance with the menu, affecting residents on four of four units.
- E
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Inspectors wroteBased on observation, staff interview and facility documentation review, the facility staff failed to prepare and serve food at an appetizing/palatable temperature on one of four units.
- E
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Inspectors wrote3. Resident #103's lunch was supposed to be grilled chicken salad and milk for his beverage and was not served according to his preferences on his meal ticket. On 6/24/25 at 12:45 p.m., an observation was conducted with residents' meal trays in the resident's room. Resident #103 was being served lunch in his room and had requested a grilled chicken salad for lunch. His meal ticket had grilled chicken salad, crackers, apple crisp, tea and milk, and there was no apple crisp, grilled chicken or milk on his lunch tray. On 6/24/25 at 1:00 p.m., an interview was conducted with Resident #103. He stated that it was many times that he did not receive what was on his meal tickets. Resident #103 said, When I request the salads most of the time the meat that is supposed to be on the salad isn't there, sometimes they bring it and sometimes not. [...]
- E
Ensure each resident receives and the facility provides drinks consistent with resident needs and preferences and sufficient to maintain resident hydration.
Inspectors wroteBased on observations, resident interview, staff interview, clinical record review and facility documentation review the facility staff failed to provide beverages to include, but not limited to milk, in accordance with meal tickets to maintain resident hydration for multiple residents on two units out of four units (Unit 4 and Unit 5).
- 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, staff interview, and facility documentation review, the facility staff failed to store, prepare and distribute food in a sanitary manner in accordance with food service safety standards in the main kitchen.
- E
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observations, staff interview, resident interview, clinical record review and facility document review the facility staff failed to ensure staff followed proper infection control practices to include hand hygiene and handling of table linens to prevent contamination during meal service on two of four units ( Unit 4 and Unit 5) and failed to wear the proper personal protective equipment (PPE) for enhanced barrier precautions for Resident #108.
- E
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Inspectors wroteBased on observation, resident interview, staff interview, and facility documentation review, the facility failed to maintain an effective pest control program affecting four of four resident units.
- D
Allow resident to participate in the development and implementation of his or her person-centered plan of care.
Inspectors wroteBased on staff interview, clinical record review, and facility documentation review, the facility failed to notify the resident and the resident's legal representative of a medication change for one of twenty residents (Resident #112- R112).
- D
Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made.
Inspectors wroteBased on staff interview, clinical record review and facility documentation review, the facility staff failed to provide a resident with written notice and reason for a room change for one of twenty residents (Resident #112- R112).
- 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 observation, resident interview, staff interview, clinical record review and facility documentation the facility staff failed to ensure that one resident (Resident #102) out of a survey sample of 20 residents, was treated with respect and dignity by performing personal grooming without the resident's consent.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on resident interviews, staff interview, clinical record review, and facility documentation review, the facility staff failed to administer medications to one of twenty residents (Resident #111- R111).
- D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Inspectors wroteBased on resident interviews, staff interviews, clinical record review, and facility documentation review, the facility staff failed to ensure medications were available for administration to one of twenty residents (Resident #111- R111).
April 24, 2025Standard inspection, Complaint inspection · 26 citations
- J
Provide and implement an infection prevention and control program.
Inspectors wrote4. For Resident #56, staff failed to follow infection control practices for proper positioning of a urinary catheter bag. R56's clinical record documented that Resident #56 (R56) was admitted to the facility with diagnoses that included cerebral infarction with hemiplegia, diabetes, hypertension, anemia, obstructive uropathy, and cognitive communication deficit. The minimum data set (MDS) dated [DATE] assessed R56 with moderately impaired cognitive skills. The record also included a physician's order dated 9/17/24 for a Foley urinary catheter for management of urinary retention due to obstructive uropathy. On 4/21/25 at 2:53 p.m., R56 was observed in bed. The urine collection bag for R56's catheter was positioned with the bottom part of the bag resting on the floor. The bag was strapped to the bed frame but was not positioned or strapped to ensure the bag was off the floor. [...]
- F
Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
Inspectors wroteBased on observation, interviews, and policy review, the facility failed to provide a qualified dietitian or other clinically qualified nutrition professional either full-time, part-time, or on a consultant basis. A qualified dietitian or other clinically qualified nutrition professional with appropriate competencies and skills ensures palatable, therapeutic meals are provided to meet the residents' needs and preferences and carries out the functions of the food and nutrition service for all residents at the facility.
- 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, interview, and facility policy review, the facility failed to date, label, and/or store food products safely to decrease the risk of food borne illness, potentially affecting 185 of 189 residents who consume food prepared from the facility's kitchen.
- E
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteBased on observation, interview, and policy review, the facility failed to ensure a resident's rights (R90) were honored during dining and that staff provided a homelike dining experience during meals affecting many residents on 1 of 4 units.
- E
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Inspectors wroteBased on observation, staff interview and facility documentation review, the facility staff failed to prepare and serve meals in accordance with the menu, affecting residents on four of four units.
- E
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Inspectors wroteBased on observation and interview, the facility failed to ensure food was served at proper and appetizing temperatures for seven (Resident (R) 32, R35, R49, R66, R86, R89 and R154) out of 46 sampled residents, increasing the risk for altered nutritional status.
- E
Ensure each resident receives and the facility provides drinks consistent with resident needs and preferences and sufficient to maintain resident hydration.
Inspectors wroteBased on observations, interviews, and facility documentation, the facility failed to provide drinks at meals that were consistent with the residents' preferences and meal slips for 12 of 46 residents.
- E
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Inspectors wroteBased on facility policy review, record review, and interviews, the facility failed to provide the required documentation and/or refusals related to administration of vaccinations for influenza, pneumococcal, and COVID-19 for four of five Residents (R)(13, 57, 56, 157) which increased the risk of acquiring, transmitting, and/or experiencing complications of respiratory infections.
- E
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Inspectors wroteBased on observation, resident interview, staff interview, and facility documentation review, the facility failed to maintain an effective pest control program affecting four of four resident units.
- D
Ensure that residents are fully informed and understand their health status, care and treatments.
Inspectors wroteBased on record review and staff interview, the facility staff failed to ensure the resident was afforded the right to participate in the treatment plan for one of 46 residents. Resident #27 was not afforded the opportunity to participate in care planning and treatment.
- D
Allow resident to participate in the development and implementation of his or her person-centered plan of care.
Inspectors wroteBased on staff interview, clinical record review, and facility documentation review, the facility failed to notify the resident and the resident's legal representative of a medication change for one of twenty residents (Resident #112- R112).
- D
Reasonably accommodate the needs and preferences of each resident.
Inspectors wroteBased on resident interview, staff interview, and clinical record review, the facility staff failed to honor a preference for twice weekly showers for one of thirty-nine residents in the survey sample (Resident #187).
- D
Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made.
Inspectors wroteBased on staff interview, clinical record review and facility documentation review, the facility staff failed to provide a resident with written notice and reason for a room change for one of twenty residents (Resident #112- R112).
- 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 facility policy review, record review, and interview, the facility failed to obtain food preferences upon admission for one of one residents (R175) in the sample of 46 residents, causing R175 not to have his preferences provided and honored. Failure to provide resident's food preference has the potential to result in weight loss.
- 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 resident interview, staff interview, clinical record review, and facility document review, the facility failed to ensure reasonable care for the protection of personal property for one of forty-six residents, Resident #137 (R137). R137 did not have a personal property invoice completed upon admission. The Findings Include: Clinical record review revealed that diagnoses for R137 included acute respiratory failure, diabetes, urine retention, chronic pain, and obstructive uropathy. The most current MDS (minimum data set) was a quarterly assessment with an ARD (assessment reference date) of 04/2/2025, which assessed R137 with a cognitive score of 12 out of 15, indicating cognitively intact. On 4/21/25 at 4:39 PM, an interview with R137 was conducted. R137 verbalized that he had been missing a pair of ear pods and felt that they had been taken by staff about 6 months prior. [...]
- D
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Inspectors wroteBased on interview, document review and review of facility policy, the facility failed to implement their abuse policy in notifying the Department of Health Professions (DHP) after receiving an allegation of sexual abuse against Registered Nurse (RN) 2, involving one resident (Resident (R)50) reviewed for abuse, out of a sample of 46 residents.
- D
Respond appropriately to all alleged violations.
Inspectors wroteBased on record review, interviews, and facility policy review, the facility failed to provide evidence that actual and potential allegations of abuse/neglect were thoroughly investigated for two residents (Resident 50, Resident 128), of 46 sampled residents.
- D
Ensure each resident receives an accurate assessment.
Inspectors wroteBased on record review, interview and review of the Resident Assessment Instrument (RAI), the facility failed to ensure that a comprehensive MDS assessment was completed accurately for one resident (R41) in the sample of 46 residents.
- D
PASARR screening for Mental disorders or Intellectual Disabilities
Inspectors wroteBased on record review and staff interview, the facility failed to ensure that an accurate Preadmission Screening and Resident Review (PASARR) Level I assessment was completed after admission for one (Resident (R)40) out of 46 sampled residents.
- 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 interviews, the facility failed to develop and implement a care plan for two of two residents (Resident (R) 128 and R175), in the sample of 46 residents.
- D
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 facility policy review, record review, and interview, the facility failed to completely fill out a Durable Do Not Resuscitate form for one of one resident (R)185) in the sample of 46 residents which could cause the R185 to receive unnecessary treatment.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on observation, staff interview and clinical record review, the facility staff failed to follow physician orders for one of thirty-nine residents in the survey sample (Resident #103).
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on observations, interview, record review, and facility documentation, the facility failed to ensure the environment was free of accident hazards, failed to implement fall intervention as care planned, and failed to conduct thorough investigation to identify post-fall causal factors for one resident (Resident 128 -R128) in the sample of 46 residents.
- D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Inspectors wroteBased on resident interviews, staff interviews, clinical record review, and facility documentation review, the facility staff failed to ensure medications were available for administration to one of twenty residents (Resident #111- R111).
- D
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Inspectors wroteBased on observation, resident interview, and staff interview, the facility staff failed to maintain safe and functioning equipment. Resident #80's (R80) hand assist bar in the bathroom was not securely anchored to the wall.
- E
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Inspectors wroteBased on facility policy review, record review, and interview, the facility failed to obtain food preferences upon admission for one of one residents (R175) in the sample of 46 residents, increasing the risk for weight loss, malnutrition, and dehydration.
February 27, 2024Complaint inspection · 3 citations
- E
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on staff interview, facility document review, and clinical record review, the facility staff failed to assess and implement interventions for care/treatment of pressure ulcers for two of six residents in the survey sample (Residents #1 and #5).
- D
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Inspectors wroteBased on staff interview, facility document review, and clinical record review, the facility staff failed to notify the physician of a change in condition requiring treatment for one of six residents in the survey sample (Resident #5)
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on observation, resident interview, staff interview, and clinical record review, the facility staff failed to provide ADL (activities of daily living) care for one of seven residents in the survey sample.
August 18, 2022Standard inspection · 18 citations
- G
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on observation, resident interview, staff interview and clinical record review, the facility staff failed to obtain and/or follow physician orders for five of thirty-seven residents in the survey sample. 1. Resident #78 was not administered the medication epoetin alfa-epbx (Epogen) as ordered by the physician for treatment of anemia. After missing eight consecutive doses of the medication over a period of eight weeks, Resident #78 experienced critically low hemoglobin levels of 6.8 g/dL (grams per deciliter) and 6.7 g/dL and required treatment with a blood transfusion. 2. Resident #46 did not have a dressing applied to a forehead lesion as prescribed by the physician. 3. The facility failed to obtain a physician's order for the care and treatment of a midline (intravenous) catheter for Resident #136. 4. [...]
- 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 staff interview and clinical record review, the facility staff failed to notify the physician of unavailable medications for one of thirty-seven residents in the survey sample. Resident #78's physician was not notified that the resident missed multiple doses of the medication epoetin alfa-epbx (Epogen) for treatment of anemia. After missing eight consecutive doses of the medication over a period of eight weeks, Resident #78 experienced critically low hemoglobin levels of 6.8 and 6.7 g/dL (grams per deciliter) requiring treatment with a blood transfusion.
- 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 observation, resident interview, staff interview, medical record review, and in the coarse of a complaint investigation the facility failed to develop a care plan for three of 37 resident's, and failed to meet with the resident and family regarding care plan goals for one of 37 resident's. A care plan was not developed for the care and monitoring of a Midline (A Intravenous line inserted into the upper arm, usually used for the treatment of antibiotics) for Resident #20. Resident #93 did not have a care plan for dialysis or shunt for dialysis. Resident #46 did not have a care plan for the care and monitoring of a forehead lesion/growth. Care plan goals were not discussed with Resident #166 or the family. This was a complaint deficiency. The Findings Include: 1. Diagnoses for Resident #20 included: Sepsis, stenosis of left carotid artery, depression, and urinary tract infection. [...]
- 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 staff interview, clinical record review, and facility document review, the facility staff failed to review and revise a comprehensive care plan (CCP) for 3 of 37 residents in the survey sample, Resident #135, Resident #42, and Resident #95. Resident #135's CCP was not reviewed and revised for the discontinuation and care of a PICC/Midline and for the change in discharge plans. Resident #42's CCP was not reviewed and revised for the discontinuation of anti-coagulant medication. Resident #95's CCP was not reviewed and revised for the discontinuation of tube-feeding and care of a gastrostomy tube.
- E
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Inspectors wroteBased on resident interview, facility document review and staff interview, the facility staff failed to respond to call bells in a timely manner. Facility staff failed to answer call bells in a timely manner as evidenced by resident interviews and as documented in the resident council meeting minutes.
- E
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Inspectors wroteBased on staff interview and clinical record review, the facility staff failed to ensure medications were available for administration for one of thirty-seven residents in the survey sample. Resident #78 missed twelve doses of the medication epoetin alfa-epbx (Epogen) for treatment of anemia. Following the eight consecutive weeks of the unavailable medication, the resident experienced critically low hemoglobin levels that required treatment with a blood transfusion.
- E
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Inspectors wroteBased on staff interview and clinical record review, the facility staff failed to ensure one of 37 residents (Resident #316) was free of unnecessary medications. Resident #316 had a physician's order to stop Lovenox injections when the resident's INR (international normalization rate) (measures the time for the blood to clot) reached above 2.0, the medication was not stopped at that time.
- E
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Inspectors wroteBased on staff interview and clinical record review, the facility staff failed to implement a gradual dose reduction for one of thirty-seven residents in the survey sample. Resident #159 continued to receive a 75 mg (milligram) dose of the antipsychotic medication Seroquel for 15 weeks after the physician ordered for a dose reduction to 50 mg per day.
- E
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Inspectors wroteBased on observation, resident interview, group interview, staff interview and facility document review, the facility staff failed to ensure food was served at safe temperatures and meals were palatable and appetizing on one of four units. Fourth floor residents were served food items below safe holding temperatures from the steam table. Residents stated food was not hot or appetizing.
- 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, staff interview and facility document review, the facility staff failed to store, prepare and serve food in a sanitary manner. Dietary staff entered the kitchen without washing hands. Refrigerated foods were stored beyond use by dates and/or without labels indicating dates opened. Food temperatures were not checked on the steam tables prior to plating food. Hot foods were stored and served from the unit steam tables below the safe/recommended holding temperature of 135 degrees (F).
- D
Allow residents to self-administer drugs if determined clinically appropriate.
Inspectors wroteBased on observation, staff interview, clinical record review, and facility document review, the facility staff failed to ensure two of 37 residents were assessed for self administration of medications (Resident #99 and Resident #127). 1. Resident # 99 was not assessed to self administer eye drops. A bottle of eye drops were observed at the resident's bedside. 2. Resident #127 was not assessed to self administer eye drops (a bottle of betadine eye drops and a bottle of artificial tears were found at the resident's bedside).
- 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 resident interview, staff interview, clinical record review, and facility document review, the facility staff failed to allow two of 37 residents to have private time together. Resident #103 and Resident #105, both cognitively intact, and consenting, were not allowed by the facility staff to spend time together alone.
- D
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Inspectors wroteBased on review of employee files, staff interview, and review of facility policy and procedure, the facility failed to fully implement their policy for the screening of new employees. The facility filed to conduct a Criminal Background check for one of 24 employee files reviewed, and failed to ensure the Sworn Statement form was completed for two of 24 employee files reviewed.
- D
Ensure each resident receives an accurate assessment.
Inspectors wroteBased on staff interview and clinical record review, the facility failed to ensure an accurate MDS (minimum data set) assessment for two of 37 resident's in the survey sample. Resident #167's discharge MDS assessment was coded as being discharged to the hospital instead of home. Resident #136 was not properly coded for infection in the foot. The Findings Include: 1. Diagnoses for Resident #167 included: Right femur fracture, right hip replacement, and anxiety. The most current MDS (minimum data set) was a 5 day assessment with an ARD (assessment reference date) of 4/25/22. Resident #167's cognitive score was a 15 indicating cognitively intact. During a closed record review, Resident #167 was added to the sample as a hospital discharge review. On 8/17/22 Resident #167's clinical record was reviewed. [...]
- D
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Inspectors wroteBased on staff interview, clinical record review, facility document review, and in the course of a complaint investigation, the facility staff failed to develop and provide a summary of a baseline care plan to one of 37 residents, Resident #166.
- D
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Inspectors wroteBased on staff interview, facility document review and clinical record review, the facility staff failed recognize and report irregularities in the medication regimen review for one of thirty-seven residents in the survey sample. Two monthly pharmacist reviews failed to recognize and report that Resident #78 was not administered weekly injections of epoetin alfa-epbx (Epogen) as ordered by the physician for treatment of anemia.
- D
Ensure medication error rates are not 5 percent or greater.
Inspectors wroteBased on medication pass and pour observation, staff interview, clinical record review, and facility document review the facility staff failed to ensure a medication error rate less than 5 percent. There were two errors out of 27 opportunities resulting in a medication error rate of 7.41 percent. Resident #101's Olanzapine 10 milligrams (mg) ordered for Schizophrenia and Folic Acid 1 mg ordered for anemia was unavailable for administration. The Findings Include: On 09/27/22 at 9:00 am a medication pass and pour observation was conducted. Resident #101's Olanzapine 10 mg and Folic Acid 1 mg was ordered to be given at 9:00 AM. License practical nurse (LPN #1) could not find either of the medications in the medication cart. [...]
- D
Keep all essential equipment working safely.
Inspectors wroteBased on observation and staff interview, the facility staff failed to ensure proper functioning of the dishwasher and a functioning paper towel dispenser in the kitchen. The dishwasher was operated with water leaking from under the center stainless steel panel into the floor. A paper towel dispenser at the handwashing sink near the kitchen entrance was not functional.
January 30, 2020Standard inspection · 11 citations
- G
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on staff interview, facility document review and clinical record review, the facility staff failed to provide a safe transfer for one of 36 residents in the survey sample. Resident #90 was transferred to bed with the assistance of one person when her plan of care required two-person assistance for safe transfers, resulting in a fracture of the left femur.
- E
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Inspectors wroteBased observation, staff interview and clinical record review, the facility staff failed to ensure one of 36 residents, Resident #49, was free from unnecessary medications. Resident #49 was prescribed Depakote without adequate monitoring. The resident had not had a Depakote level drawn in over 14 months.
- 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, staff interview and facility document review, the facility staff failed to ensure drugs and biologicals were labeled and stored in a safe manner. The facility failed to ensure narcotics were stored in a separately locked, permanently affixed compartment on 2 of 2 floors (3rd and 4th floors) and failed to ensure one of five medication carts had an insulin pen properly labeled (medication cart 'U' side on 4th floor).
- 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, staff interview, and facility document review, the facility failed to ensure proper holding temperatures on the steam table for one of 4 floors. The 4th floor steam table had foods at holding temperatures below 135 degrees. The findings Include: On 01/28/20 at 12:20 PM, the food serving line was observed on 4th floor. Dietary aide (other staff, OS #5) was serving from the steam table and was asked to obtain food temperatures from the steam table. The following temperatures were observed: eggplant parmesan 120 degrees, chicken cordon bleu 118 degrees, and broccoli 120 degrees. When asked what food holding temperatures should be, OS #5 stated 135, 145, 150 degrees. On 01/29/20 at 5:19 PM, the above information was presented to the director of nursing and administrator during a staff meeting. A policy concerning holding food temperatures was requested. [...]
- 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 observation, staff interview and clinical record review, the facility staff failed to ensure prevlon boots were maintained in sanitary condition and in good repair for one of 36 residents, Resident #42.
- D
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Inspectors wroteBased on observation, clinical record review and staff interview the facility staff failed to review and revise comprehensive care plans for two of 26 residents. Resident #118's care plan was not revised to include hospice services, and Resident #49's care plan was not revised to include wheelchair positioning.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on medication pass and pour observation, staff interview, facility document review, and clinical record review, facility staff failed to administer Janumet (a diabetic medication) within the specified timeframe for one of 36 residents in the survey sample, Resident #117.
- D
Assist a resident in gaining access to vision and hearing services.
Inspectors wroteBased on resident interview, staff interview, and clinical record review, the facility failed to provide glasses for one of 36 Residents, Resident #122. The findings Include: Resident #122 was admitted to the facility on [DATE]. Diagnoses for Resident #122 included; Osteoarthritis, bipolar disorder, chronic respiratory failure, and joint pain. The most current MDS (minimum data set) was a quarterly assessment with an ARD (assessment reference date) of 1/7/20. Resident #122 was assessed with a cognitive score of 15 indicating cognitively intact. On 01/28/20 at 10:29 AM, an interview was conducted with Resident #122. During the interview Resident #122 stated that that it was hard to see to read and that an optometrist had came to the facility and did an examination and prescribed glasses but had never received the glasses. [...]
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on observation, staff interview, clinical record review, and facility document review, the facility staff failed to provide proper care and treatment for pressure ulcers for two of 36 in the survey sample, Resident #80 and Resident #355. Staff failed perform hand hygiene after glove changes during a pressure ulcer dressing change for Resident #80, and failed to follow physician orders for a dressing change for Resident #335.
- D
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Inspectors wroteBased on observation, staff interview and clinical record review, the facility staff failed to ensure appropriate services, equipment, and assistance to maintain or improve mobility and positioning for one of 36 residents in the survey sample, Resident #49. Resident #49's wheelchair was not equipped with bilateral leg rests, and the resident's legs did not touch the floor, and were hanging approximately one foot off the ground.
- D
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, staff interview and clinical record review, the facility staff failed to attempt alternatives, identify risks/benefits and obtain informed consent prior to the use of bed rails for one of 36 residents in the survey sample (Resident #90).
Fire safety inspections
12 fire safety citations on file: 4 on April 24, 2025, 4 on August 18, 2022, 4 on January 30, 2020.
Every fire safety citation12 citations
- D
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
K 321 · April 24, 2025 · Corrected (the home has a date of correction)
- D
Install corridor and hallway doors that block smoke.
K 363 · April 24, 2025 · Corrected (the home has a date of correction)
- D
Install properly constructed and protected linen or trash chutes.
K 541 · April 24, 2025 · Corrected (the home has a date of correction)
- D
Have a battery powered remote alarm panel in a location accessible by operating personnel.
K 916 · April 24, 2025 · Corrected (the home has a date of correction)
- D
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
K 225 · August 18, 2022 · Corrected (the home has a date of correction)
- D
Provide properly protected cooking facilities.
K 324 · August 18, 2022 · Corrected (the home has a date of correction)
- D
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
K 362 · August 18, 2022 · Corrected (the home has a date of correction)
- D
Install corridor and hallway doors that block smoke.
K 363 · August 18, 2022 · Corrected (the home has a date of correction)
- D
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
K 223 · January 30, 2020 · Corrected (the home has a date of correction)
- D
Have an enclosure around a vertical opening shaft.
K 311 · January 30, 2020 · Corrected (the home has a date of correction)
- D
Inspect, test, and maintain automatic sprinkler systems.
K 353 · January 30, 2020 · Corrected (the home has a date of correction)
- D
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
K 362 · January 30, 2020 · Corrected (the home has a date of correction)