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 53 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
1J
0K
0L
Actual harm
4G
0H
0I
Potential for more than minimal harm
26D
22E
0F
Potential for minimal harm
0A
0B
0C
May 21, 2026Complaint inspection · 3 citations
- E
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on observations, resident/staff and RP (responsible party) interview, facility document review and clinical record review, it was determined that the facility staff failed to provide ADL (activities of daily living) care for dependent residents for seven of 70 residents, Residents #17, #195, #66, #145, #190, #88 and #134.
- D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteBased on staff interview and clinical record review, the facility staff failed to maintain dignity by not providing appropriate grooming or clothing before a scheduled outside appointment for 1 of 70 residents (Resident #88), in the survey sample.
- D
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Inspectors wroteBased on observation, staff interview, clinical record review, and facility document review, it was determined that facility staff failed to provide care and services for an indwelling catheter for one of 70 residents in the survey sample, Residents #136.
January 4, 2024Complaint inspection · 2 citations
- G
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on family interviews, staff interviews, and a clinical record review, the facility staff failed to ensure residents received two person assistance during care and bed mobility per care plan and the bed mobility assessment binder to prevent accidents for one (1) of six (6) residents in the survey sample, Resident #1 which resulted in a fall with major injuries.
- 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 a family interview, staff interviews, a clinical record review, and review of facility documents, the facility staff failed to ensure the Power-of-attorney (POA) and/or a designated representative was notified of the identification of a sacral pressure ulcer on [DATE] and of the deterioration of the same sacral pressure on [DATE] for 1 of 15 residents (Resident #1), in the survey sample.
October 30, 2023Complaint inspection · 1 citation
- J
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on a family interview, staff interviews, clinical record review, and review of documents provided by the family, the facility's staff failed to ensure Resident #2 received total assistance of two or more people during care/bed mobility and the needed assistive device (a 47-inch wide bariatric bed) was in use to prevent a fall on [DATE] which resulted in multiple blunt force injuries which contributed to the resident's death resulting in immediate jeopardy.
December 14, 2021Standard inspection · 17 citations
- G
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wrote3. The facility staff failed to ensure the necessary treatment, care and services were provided to prevent development of a pressure ulcer that was initially identified at an advanced stage, resulting in harm. Resident #90 was originally admitted to the facility on [DATE] and readmitted on [DATE] after an acute care hospital stay. The resident has been discharged multiple times from the facility to the community. The admission, Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 11/04/2021 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 15 out of a possible 15. This indicated Resident #90 cognitive abilities for daily decision making were intact. [...]
- G
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 staff interviews, clinical record review and facility's documentation, the facility staff failed to provide the necessary care and services to 1 of 58 residents (Resident #170) for the prevention and complication of a Urinary Tract Infection (UTI) and sepsis. The facility staff failed to notify the physician or Physician Assistant (PA) when orders were given for a UA with C&S, and that they were never obtained, over five days. The resident became unresponsive, with oxygen saturation levels of 83% (normal=95-100%), and was transferred via 911 (emergent) to the local hospital and admitted on [DATE] with a diagnosis of severe sepsis, hypothermia at 88 degrees, complicated UTI and Acute Kidney Injury (AKI); which constitutes harm.
- 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 staff interview, the facility staff failed to provide care and services to one resident (Resident #28) during wound care treatment to promote dignity and respect and failed to remind and assist 3 Residents (#146, #132 and #103) to vote in the November 2021 general election in the survey sample of 58 residents.
- E
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 clinical record reviews, staff interviews and facility documentation review, the facility staff failed to ensure residents were afforded the opportunity to formulate advance directives, and the advance directive was maintained in the clinical record, readily accessible to the direct care staff to convey upon transfer to the emergency medical personnel and/or the hospital for 5 of 58 residents (123, 55, 77, 146 and 170), in the survey sample
- 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 complaint investigation, staff interviews, facility document review, and clinical record review, the facility staff failed to notify the physician and resident's representative of missed laboratory services for 3 residents (Resident #13, Resident #17 and Resident #170), and they failed to notify one representative of a change in condition for one resident (Resident #167), a closed record resident in the survey sample of 58 residents.
- 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, resident interview and staff interviews the facility staff failed to provide reasonable care for the protection of residents' property from loss and to return laundry in a timely manner for 3 of 58 residents (Resident #50, Resident #90 and Resident #138) in the survey sample.
- E
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on clinical record review, staff interviews and facility record review, the facility staff failed to recognize, assess and intervene (to follow physician orders for obtaining daily weights and act upon the spouse's concerns regarding edema to the resident's legs) on behalf of a resident presenting with an acute change in condition for 1 of 58 residents in the survey sample (Resident #123).
- E
Provide safe, appropriate pain management for a resident who requires such services.
Inspectors wroteBased on observation, resident interview, staff interview, clinical record review, and review of facility documents, the facility's staff failed to treat, monitor and manage pain for 1 of 58 residents (Resident #138), in the survey sample.
- E
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, resident interview and staff interviews, the facility staff failed to procure narcotics timely for one resident (Resident #138) in a survey sample of 58 residents.
- E
Ensure that residents are free from significant medication errors.
Inspectors wroteBased on resident interview, clinical record review, and staff interviews, the facility staff failed to ensure the resident was free from significant medication error (the staff failed to administer the intravenous (IV) antibiotic (Cefazolin 2 grams IV every 8 hours) as ordered from 11/16/21 through 12/2/21 for 1 of 58 residents (#55), in the survey sample
- E
Provide timely, quality laboratory services/tests to meet the needs of residents.
Inspectors wroteBased on staff interviews, clinical record review and the facility's policy, the facility staff failed to follow physician orders for laboratory services for 3 out of 58 residents (Resident #13, Resident #17 and Resident #170) in the survey sample.
- 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 resident interview, family interview, staff interview, and clinical record review, the facility staff failed to accommodate the resident's foods preferences to meet nutritional needs for 1 of 58 residents (Resident #123), in the survey sample.
- E
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Inspectors wroteBased on resident interview, staff interview, and clinical record review, the facility staff failed to provide documentation in the resident's clinical record of the influenza vaccine administration or the refusal of or medical contraindications to vaccines for 2 of 58 residents (Resident #129 and 112), in the survey sample.
- E
Perform COVID19 testing on residents and staff.
Inspectors wroteBased on staff interviews and facility documentation, the facility staff failed to provide evidence of the facility's COVID-19 recommended frequency of twice a week staff testing to include agency employees based on the level of community transmission.
- D
Provide or obtain dental services for each resident.
Inspectors wroteBased on resident interview, staff interviews and clinical record review, the facility staff failed to promptly provide 1 out of 58 resident's (Resident #27) the services needed to meet their dental needs after knowing about broken dentures.
- D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on staff interview, clinical record review, review of facility documents and during the course of a complaint investigation, the facility's staff failed to accurately document in one residents medical record for 1 of 58 residents (Resident #167), a closed record, in the survey sample.
- D
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 resident interview, staff interview, and clinical record review, the facility staff failed to provide documentation in the resident's clinical record of the COVID-19 vaccine administration or the refusal of or medical contraindications to vaccines for 1 of 58 residents (Resident #129), in the survey sample.
June 10, 2019Standard inspection · 22 citations
- G
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on staff interviews, clinical record review and facility documentation review the facility staff failed to ensure 2 residents (Residents #99 & Resident #122) of 63 residents in the survey sample received care, consistent with professional standards of practice, to identify a pressure ulcer prior to an advanced stage constituting harm for Resident #99; and inaccurately assessed and documented a pressure ulcer to the shin for Resident #122. 1. The facility staff failed to identify Resident #99's left heel pressure ulcer prior to it being found at an advanced stage resulting in harm. The pressure ulcer was first identified found as an unstageable with 100% eschar (hard black dead tissue). 2. For Resident #122, the facility staff failed to accurately assess and document an area of cellulitis at a surgical incision wound on the right shin. [...]
- E
Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.
Inspectors wrote4. Resident #139 was a [AGE] year old admitted originally to the facility on 4/30/19 and readmitted on [DATE]. resident #139's diagnoses included but were not limited to, Congestive Heart Failure and Chronic Kidney Disease. The most recent comprehensive Minimum Data Set (MDS) assessment was a admission 5 Day with an Assessment Reference date (ARD) of 5/27/19. The Brief Interview for Mental Status (BIMS) was an 11 out of a possible 15 indicating Resident #139 was cognitively intact and capable of daily decision making. Resident #139's MDS transmit history was reviewed and is documented as follows: 5/9/2019 Discharge Assessment-Return Anticipated, Unplanned. 5/20/19 Re-Entry from Acute Hospital. Resident #139's Progress Notes were reviewed and are documented in part, as follows: 5/9/2019 at 12:43 P.M.: Change of Condition: [...]
- 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 wrote5. Resident #139 was a [AGE] year old admitted originally to the facility on 4/30/19 and readmitted on [DATE]. Resident #139's diagnoses included but were not limited to, Congestive Heart Failure and Chronic Kidney Disease. The most recent comprehensive Minimum Data Set (MDS) assessment was a admission 5 Day with an Assessment Reference date (ARD) of 5/27/19. The Brief Interview for Mental Status (BIMS) was an 11 out of a possible 15 indicating Resident #139 was cognitively intact and capable of daily decision making. Resident #139's MDS transmit history was reviewed and is documented as follows: 5/9/2019 Discharge Assessment-Return Anticipated, Unplanned. 5/20/19 Re-Entry from Acute Hospital. Resident #139's Progress Notes were reviewed and are documented in part, as follows: 5/9/2019 at 12:43 P.M.: Change of Condition: [...]
- E
Ensure services provided by the nursing facility meet professional standards of quality.
Inspectors wroteBased on observation, Resident interview, staff interviews, facility document review, and clinical record review, the facility staff failed to follow professional standards of nursing practices for 3 out of 63 residents (Residents #99, 421 and 47). 1. The facility staff failed to follow the physician orders for the administration of [NAME] hose for Resident #99. 2. The facility staff failed to obtain daily weights per physician orders starting on 06/06/19 for Resident #421. 3a. For Resident #47, facility staff failed to notify the physician for weight gain greater than 2 pounds on 5/29/19 per physician's order. 3b. For Resident #47, facility staff failed to accurately assess blisters to her right foot and implement a physician ordered treatment.
- 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 information during a complaint investigation, clinical record review, staff interviews the facility staff failed to ensure 1 of 63 residents (Resident #174) in the survey sample maintained a normal bowel elimination pattern. The facility staff failed to ensure Resident #174 maintained a normal bowel elimination at least every 3 days. Resident #174 went 6 days without having a bowel movement.
- E
Provide safe, appropriate pain management for a resident who requires such services.
Inspectors wroteBased on resident interview, staff interview, facility document review and clinical record review, it was determined that facility staff failed to ensure pain management was provided to 2 of 63 residents in the survey sample (Residents #30 and #47) consistent with professional standards of practice, and the comprehensive person-centered care plan. 1a. For Resident #30, facility staff failed to document the location of pain; and attempt non-pharmacological pain interventions prior to the administration of PRN (as needed) pain medication on several occasions in May and June 2019. 1b. For Resident #30, facility staff failed to clarify two different orders for as needed (PRN) pain medications. 2. For Resident #47, facility staff failed to document the location of pain; [...]
- E
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Inspectors wroteBased on resident interview, staff interview, and facility document review, it was determined that facility staff failed to ensure residents were free from unnecessary pain medications for two of 63 residents in the survey sample, Resident #30 and #47. 1. For Resident #30, facility staff failed to attempt and/or offer non-pharmacological interventions prior to the administration of pain medication on several occasions in May and June of 2019. 2. For Resident #47, facility staff failed to attempt and/or offer non-pharmacological interventions prior to the administration of pain medication on several occasions in May of 2019.
- E
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteThe facility staff failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety. The facility staff failed to store and label food in a safe, sanitary manner.
- D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteBased on observation, resident interview, staff interview, facility documentation review, clinical record review, and in the course of a complaint investigation, the facility staff failed to enhance and promote dignity for 7 residents during the dining experience in the Day Room on Unit 2 in the following ways: 1. Meals were served in an institutional manner to Residents on trays. 2. Certified Nursing Assistant #2 (CNA) was standing with her hands on her hips while feeding a resident. 3. CNA #1, CNA #2, CNA #3 stood while feeding Residents. 4. CNAs placed clothing protectors on Residents without asking their permission. 5. CNA #2 turned off the TV because she felt a resident wasn't eating due to the TV being on. 6. CNA #2 was putting too much food on a spoon to feed a resident and not waiting for the resident to chew and swallow her food before giving her something to drink or eat.
- 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 staff interview, the facility staff failed to provide a homelike environment during the dining observation on 06/07/19 in the Day room on unit two. Facility staff served resident meals on trays during the dining observation in the Day Room on unit one for lunch.
- D
PASARR screening for Mental disorders or Intellectual Disabilities
Inspectors wroteBased on staff interview and clinical record review, the facility staff failed to ensure that 1 resident (Resident #148) of 63 residents in the survey sample, had a Preadmission Screening and Resident Review (PASRR).
- D
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Inspectors wroteBased on staff interview and clinical record review the facility staff failed to develop a comprehensive person-centered care plan for 1 resident (Resident #148) of 63 residents in the survey sample. The facility staff failed to develop a comprehensive person-centered care plan to include Diabetes Mellitus for Resident #148.
- D
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Inspectors wroteBased on observation, staff interview, facility document review and clinical record review, it was determined that facility staff failed to review and revise the care plan for three of 63 residents in the survey sample, Residents #47, 35 and 78. 1. For Resident #47, facility staff failed to review and revise the care plan when she acquired two blisters to her right medial and dorsum foot on 5/17/19, when the blisters had opened with a new treatment order, and when the blisters had resolved. 2. For Resident #35, facility staff failed to revise his care plan with a new diagnosis of COPD (chronic obstructive pulmonary disease) and his new order for oxygen. 3. The facility staff failed to revise the comprehensive care plan to to include how often to release a wheel chair seat belt used for Resident #78.
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on observations, resident interview, staff interviews, medical record review, and facility documentation review the facility staff failed to ensure that activities of daily living necessary to maintain personal grooming was provided for 1 of 63 residents in the survey sample, Resident #48. The facility staff failed to ensure that fingernail and facial hair care was provided to Resident #48 who was unable to carry out these activity of daily grooming tasks independently.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on staff interviews and clinical record review the facility staff failed to ensure 1 resident (Resident #122) of 63 residents in the survey sample received care in accordance with professional standards of practice. The facility staff failed to obtain an order for a stabilization/fracture boot which resulted in cellulitis to a surgical incision wound; and the facility staff inaccurately assessed and documented the cellulitis as a Stage 3 pressure ulcer.
- D
Provide appropriate foot care.
Inspectors wroteBased on observation, staff interviews and clinical record review the facility staff failed to ensure 1 of 63 residents (Resident #164) in the survey sample who was unable to carry out activities of daily living, received the necessary services to maintain toenail care. The facility staff failed to ensure that podiatry services/nail care was provided to Resident #164.
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on observations, staff interviews, and clinical record review, the facility staff failed to ensure 1 of 63 residents in the survey sample, (Resident #78) was transferred according to the comprehensive care plan to prevent potential accidents. The facility staff failed to transfer Resident #78 with a mechanical lift per the resident's plan of care.
- D
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Inspectors wroteBased on observation, staff interview, and clinical record review the facility staff failed to ensure one Resident (Resident #78) of 63 resident's in the survey sample, received appropriate treatment to prevent complications from enteral feeding. The facility staff failed to ensure safety precautions were followed to prevent potential complications from enteral feeding for Resident #78 during ADL (Activities of Daily Living) care.
- D
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Inspectors wroteBased on resident interview, staff interviews, clinical record review and facility documentation review the facility staff failed to communicate an ongoing assessment for one (Resident #421) of 63 residents in the survey sample, for monitoring of complications before after dialysis treatment. The facility staff failed to communicate an ongoing assessment with the dialysis center where Resident #421 attended outpatient dialysis three days per week every Monday, Wednesday and Friday.
- D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Inspectors wroteBased on the facility's medication storage review/inspection of 4 medication carts and 2 medication rooms, the facility staff failed to dispose of Resident #471's medications after the resident was discharged , and failed to ensure accountability for controlled medications awaiting final disposition.
- 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 document review, it was determined that facility staff failed to maintain a complete and accurate clinical record for two of 17 residents in the survey sample, Residents #102 and #107.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observations and staff interviews the facility staff failed to follow infection control practices therefore, increasing the chance of spreading infections, illnesses and diseases for 3 of 63 residents in the survey sample (Residents #39, 113, &104) and 7 dining room residents. 1. The Facility staff failed to perform hand hygiene before assisting 7 Residents during mealtime. 2. The facility staff failed to ensure Resident #39's indwelling catheter was managed in a manner to minimize the risk of cross-contamination and infections. 3. For Resident #113, facility staff failed to maintain his Foley catheter in a sanitary manner. 4. For Resident #104, facility staff failed to maintain respiratory equipment in a sanitary manner. The Findings Included; 1. [...]
September 8, 2017Standard inspection · 8 citations
- E
Store, cook, and serve food in a safe and clean way.
Inspectors wroteBased on observations, facility document review and staff interviews the facility staff failed to prepare, store, distribute and serve food in a safe, sanitary manner. The facility staff failed to ensure that the kitchen was free from pests to include roaches and drain flies, maintain a clean stove and oven that were free from copious amounts of grease and burnt debris, and ensure that an air gap was in place from the two food steamer units drain pipe to the floor drain.
- E
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Inspectors wroteBased on observations, facility document review and staff interviews the facility staff failed to maintain an effective pest control program to ensure the facility is free of pests. 1. The facility staff failed to ensure that the kitchen was free from pests to include roaches and drain flies. 2. The facility staff failed to ensure the facility was free from ants.
- D
Allow residents to self-administer drugs if determined safe.
Inspectors wroteBased on observation, resident interview, staff interview, facility documentation review, clinical record review, and the facility staff failed to assess one of 26 Residents in the survey sample (Resident #15) ability to self administer Voltaren Gel.
- D
Ensure each resident receives an accurate assessment by a qualified health professional.
Inspectors wroteBased on observation, staff interviews, clinical record review, and review of the facility's policy the facility staff failed to accurately code the Minimum Data Set (MDS) assessment for one of 26 residents (Resident #17), in the survey sample. The facility staff failed to code Resident #17's MDS assessment correctly at section A1500 through A1550.
- D
Allow residents the right to participate in the planning or revision of care and treatment.
Inspectors wroteBased on staff interviews, facility documentation review and clinical record review the facility staff failed to update a comprehensive person centered care plan after a fall for one of 26 residents (Resident #10) in the survey sample. The facility staff failed to revise Resident #10's comprehensive care plan to include a fall on 02/12/17.
- D
Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards.
Inspectors wroteBased on observation, staff interviews and facility documentation review the facility staff failed to date two open multidose vials of insulin for 2 out of 26 residents (Resident #19 and Resident #20) in the survey sample. 1. The facility staff failed to date an opened multidose vial of Novolog (1) insulin (Resident #19). 2. The facility staff failed to date an opened multidose vial of Humalog (2) insulin (Resident #20).
- D
Provide or obtain laboratory services only when ordered by the attending physician.
Inspectors wroteBased on clinical record review, staff interviews and facility documentation the facility staff failed to ensure labs were obtained as ordered for one out of 26 residents (Resident #1) in the survey sample. The facility staff failed to ensure labs were obtained as ordered for the following: Basic Metabolic Panel (BMP) (1) and Hemoglobin A1C (2) for the month of August 2017.
- D
Keep accurate, complete and organized clinical records on each resident that meet professional standards.
Inspectors wroteBased on staff interview and clinical record review the facility staff failed to accurately document medical record information for one of 26 residents (Resident #17), in the survey sample. The facility staff failed to accurately document information on Resident #17's Screening for Mental Illness, Mental Retardation/Intellectual Disability, or Related Conditions assessments.
Fire safety inspections
27 fire safety citations on file: 12 on December 14, 2021, 4 on June 10, 2019, 11 on September 8, 2017.
Every fire safety citation27 citations
- E
Have an alternate power supply for its alarm system.
K 344 · December 14, 2021 · Corrected (the home has a date of correction)
- D
Inspect, test, and maintain automatic sprinkler systems.
K 353 · December 14, 2021 · Corrected (the home has a date of correction)
- D
Have proper power supply for life support equipment.
K 915 · December 14, 2021 · Waiver
- C
Conduct risk assessment and an All-Hazards approach.
E 6 · December 14, 2021 · Corrected (the home has a date of correction)
- C
Address patient/client population and determine types of services needed.
E 7 · December 14, 2021 · Corrected (the home has a date of correction)
- C
Develop Emergency Preparedness policies and procedures.
E 13 · December 14, 2021 · Corrected (the home has a date of correction)
- C
Address subsistence needs for staff and patients.
E 15 · December 14, 2021 · Corrected (the home has a date of correction)
- C
Create arrangements with other facilities to receive patients.
E 25 · December 14, 2021 · Corrected (the home has a date of correction)
- C
Develop a communication plan.
E 29 · December 14, 2021 · Corrected (the home has a date of correction)
- C
List the names and contact information of those in the facility.
E 30 · December 14, 2021 · Corrected (the home has a date of correction)
- C
Establish emergency prep training and testing.
E 36 · December 14, 2021 · Corrected (the home has a date of correction)
- C
Conduct testing and exercise requirements.
E 39 · December 14, 2021 · Corrected (the home has a date of correction)
- D
Meet other general requirements.
K 100 · June 10, 2019 · Corrected (the home has a date of correction)
- D
Properly select, install, inspect, or maintain portable fire extinguishes.
K 355 · June 10, 2019 · Corrected (the home has a date of correction)
- D
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
K 741 · June 10, 2019 · Corrected (the home has a date of correction)
- D
Have proper medical gas storage and administration areas.
K 923 · June 10, 2019 · Corrected (the home has a date of correction)
- F
Install smoke barrier doors that can resist smoke for at least 20 minutes.
K 374 · September 8, 2017 · Corrected (the home has a date of correction)
- F
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
K 521 · September 8, 2017 · Corrected (the home has a date of correction)
- D
Keep aisles, corridors, and exits free of obstruction in case of emergency.
K 211 · September 8, 2017 · Corrected (the home has a date of correction)
- D
Provide rooms that can be unlocked from inside without a key.
K 221 · September 8, 2017 · Corrected (the home has a date of correction)
- D
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 8, 2017 · Corrected (the home has a date of correction)
- D
Properly provide smoke detection systems in areas open to corridors.
K 347 · September 8, 2017 · Corrected (the home has a date of correction)
- D
Inspect, test, and maintain automatic sprinkler systems.
K 353 · September 8, 2017 · Corrected (the home has a date of correction)
- D
Properly select, install, inspect, or maintain portable fire extinguishes.
K 355 · September 8, 2017 · Corrected (the home has a date of correction)
- D
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
K 741 · September 8, 2017 · Corrected (the home has a date of correction)
- D
Meet requirements for the use of electrical equipment.
K 919 · September 8, 2017 · Corrected (the home has a date of correction)
- D
Have proper medical gas storage and administration areas.
K 923 · September 8, 2017 · Corrected (the home has a date of correction)