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 81 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
1J
0K
0L
Actual harm
1G
0H
0I
Potential for more than minimal harm
63D
10E
2F
Potential for minimal harm
0A
3B
1C
May 28, 2026Complaint inspection · 1 citation
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on clinical record review, facility documentation, facility policies, and interviews, for one (1) of three (3) sampled residents (Resident #1) reviewed for pressure ulcers, the facility failed to ensure appropriate assessment, monitoring, and treatment of existing pressure ulcers. This included failure to complete Braden Scale for Predicting Pressure Sore Risk assessments in accordance with facility policy; failure to complete weekly skin assessments using the Skin Observation Tool; failure to obtain and document weekly pressure ulcer measurements and wound assessments; and failure to ensure an as needed dressing change order was in place to address dressing dislodgement or soiling.
November 26, 2025Complaint inspection · 3 citations
- F
Keep all essential equipment working safely.
Inspectors wroteBased on facility documentation review and interviews, the facility failed to provide sufficient laundry services to ensure resident laundry was completed timely due to broken washing machines.
- D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteBased on review of clinical records, interview, and review of clinical documentation and policy for one resident (Resident #1) reviewed for resident rights, the facility failed to allow an alert and oriented resident access to an enclosed courtyard.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on review of clinical records, interview, and review of clinical documentation and policy for one resident (Resident #1) reviewed for medication administration, the facility failed to ensure the nurse who prepared a medication was the nurse who administered the medication, in accordance with facility policy.
June 25, 2025Standard inspection, Complaint inspection · 12 citations
- E
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Inspectors wroteBased on observation of the noon meal dining and staff interview, the facility failed to provide a meal that was appealing and palatable to residents.
- D
Not hire anyone with a finding of abuse, neglect, exploitation, or theft.
Inspectors wroteBased on a review of employee files and staff interviews for 1of 2 employees (Rehabilitation Aide # 2), the facility failed to provide evidence that a background check had been conducted for the employee.
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on clinical record review, review of facility documentation, review of policy and staff interviews for 1 of 4 residents reviewed for abuse (Resident #20), the facility failed to ensure a suspected incident of intimidation was reported to the Administrator.
- D
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Inspectors wroteBased on review of the clinical record reviews and staff interviews for 2 of 2 residents reviewed for discharge (Resident #97 and Resident #98), the facility failed to provide evidence of Ombudsman notification for transfers and discharge
- D
PASARR screening for Mental disorders or Intellectual Disabilities
Inspectors wroteBased on clinical record review, facility documentation, facility policy and interview for 1 of 2 residents reviewed for Preadmission Screening and Resident Review (PASARR), the facility failed to refer a resident with known mental health diagnosis to the appropriate state- designated authority for a Level II evaluation and determination.
- 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 review of the clinical record review, facility policy and interviews for 2 of 2 residents reviewed for behaviors (Resident #20 and Resident #89), the facility failed to follow and or develop a resident care plan for addressing the residents' mood and behaviors for the only resident reviewed for Hospice ( Resident #74) the facility failed to ensure a comprehensive care plan was developed for a resident receiving specialized services.
- 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 review of the clinical record, facility policy and staff interview for the only resident reviewed for Dementia Care (Resident #89), the facility failed to revise the resident's comprehensive individualized interdisciplinary dementia care plan timely.
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on clinical record review, review of facility policy and staff interviews only the resident (Resident #65), reviewed for Activities of Daily Living (ADL), the facility failed to ensure ADL care was provided every two hours per facility practice.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on review of the clinical record, facility policy and interview for the only sampled resident (Resident #20) reviewed for Communication/ Sensory, the facility failed to administer eye medications according to physician's orders.
- D
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 clinical record review, review of facility staffing posting, resident interviews, review of the Facility Assessment and staff interviews, the facility failed to provide sufficient staff to care for the needs of a dependent resident (Resident #65) in accordance to facility staffing ratios.
- D
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Inspectors wroteBased on observations, review of facility policy and interviews, the facility failed to ensure staff closed and locked the nursing supervisor's office door with medications stored on counters in unsecured containers and unlocked cabinets when leaving the area. The facility failed to ensure Residents #20, # 21, 38, 71 and #80's eye drops located in one medication cart were dated once opened and failed to remove expired Intravenous Therapy equipment and medication. The facility failed to remove discharge resident medications timely.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observations of glucometer monitoring, review of facility policy and interviews, the facility failed to ensure that used lancets were disposed of in a manner to contain and prevent any potential contamination/spread of bloodborne pathogens.
May 29, 2025Complaint inspection · 5 citations
- F
Keep all essential equipment working safely.
Inspectors wroteBased on observations, facility policy and interviews, the facility failed to ensure that laundry equipment within the facility was maintained timely and in proper working order.
- 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 observations, facility documentation and interviews, the facility failed to ensure that building equipment was maintained to provide a clean, comfortable, home-like environment for the residents.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on review of the clinical record, facility documentation, facility policy and interviews for one (1) of three (3) residents (Resident #1) reviewed for falls, the facility failed to ensure a fall intervention was implemented according to the plan of care and according to physician order, after a resident who was identified as a high fall risk, sustained a fall out of bed.
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on review of the clinical record, facility documentation, facility policy and interviews for one (1) of three (3) residents (Resident #1) reviewed for impaired skin integrity, the facility failed to ensure preventative interventions were initiated and implemented according to facility policy for a resident admitted to the facility with an active pressure injury and after the development of a facility acquired pressure injury.
- D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on review of the clinical record, facility documentation and interviews for one (1) of three (3) residents (Resident #4) reviewed for dependent care, the facility failed to ensure complete and accurate Nurse Aide documentation.
April 23, 2025Complaint inspection · 1 citation
- D
Provide appropriate foot care.
Inspectors wroteBased on clinical record reviews, facility documentation, facility policy, and interviews for one (1) of five (5) sampled residents (Resident #1) who were reviewed for podiatry services, the facility failed to ensure Resident #1 was added to the podiatrist's priority schedule following a diagnosis of an infection of the left great toe.
February 27, 2025Complaint inspection · 7 citations
- J
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on observations, record review, facility documentation, and staff interviews for one of three residents (Resident #1) reviewed for accidents, the facility failed to ensure a resident identified as high risk for wandering received adequate supervision to ensure the resident was not able to leave the facility without staff knowledge, which resulted in the facility unable to locate the resident for 4 hours and 40 minutes. The failures resulted in a finding of Immediate Jeopardy.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on record review, facility documentation, and staff interviews for one of three (Resident #1 and Resident #2) reviewed for accidents, the facility failed to ensure wander guard bracelet physician orders were obtained timely for residents identified as high wander risk and failed to ensure physician orders directed wander guard bracelet daily function checks.
- D
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Inspectors wroteBased on observations, staff interviews, and review of facility policy, regarding medication administration, the facility failed to ensure the failed to ensure only authorized personnel had access to the keys, including keys to the medication rooms and medications, and failed to ensure separately locked, permanently affixed compartments for the storage of controlled drugs was maintained.
- D
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Inspectors wroteBased on clinical record review, facility documentation review, facility policy review, and interviews for facility Administration review, the facility failed to ensure the facility administered its resources effectively and to ensure effective administrative oversight of staff and resident care timely to maintain the highest practicable physical, mental and psychosocial well-being of residents.
- D
Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility.
Inspectors wroteBased on facility documentation, facility record review, and interviews for governing body review, the facility failed to ensure that they had a governing body, or designated persons functioning as a governing body that is legally responsible for establishing and implementing policies regarding the management and operation of the facility, and failed to ensure the Administrator was appointed by a governing body.
- D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on record review, facility documentation, and staff interviews for one of three residents (Resident #1) reviewed for quality of care, the facility failed to ensure the record was complete and accurate to include an RN assessment following an elopement.
- D
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 facility documentation review and interviews for two of five employee files (NA #2 and NA #3) reviewed for in-service training, the facility failed to ensure the Nurse Aides had 12 hours of annual training.
February 4, 2025Complaint inspection · 4 citations
- D
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Inspectors wroteBased on clinical record reviews, facility documentation, facility policy and interviews for one (1) of three (3) sampled residents (Resident #7) who were reviewed for an allegation of abuse, the facility failed to ensure a staff member did not video tape the resident and post the video on social [NAME].
- D
Respond appropriately to all alleged violations.
Inspectors wroteBased on record review, facility documentation and staff interviews for 1 of 3 sampled residents reviewed for accidents (Resident #2), the facility failed to conduct a thorough investigation for an injury of unknown origin.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on record review, facility documentation, and staff interviews for 2 of 3 residents (Resident #1 and Resident #3) reviewed for accidents, the facility failed to complete neurological assessments following an unwitnessed fall, and for 1 of 3 residents reviewed for accidents (Resident #2), the facility failed to provide documentation of wrist stabilization per APRN recommendations following a fracture.
- B
Observe each nurse aide's job performance and give regular training.
Inspectors wroteBased on review of personnel files and interviews for two (2) of four (4) personnel (Nurse Aide #2 and Nurse Aide #3) the facility failed to conduct annual performance evaluations.
September 5, 2024Complaint inspection · 3 citations
- D
Respond appropriately to all alleged violations.
Inspectors wroteBased on review of the clinical record, facility documentation, facility policy, and interviews for one (1) of three (3) residents (Resident #1) reviewed for allegation of neglect, the facility failed to conduct a thorough investigation for a resident with an allegation of neglect.
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on review of the clinical record, facility documentation, facility policy, and interviews for one (1) of three (3) residents, (Resident #1), reviewed for activities of daily living, the facility failed to ensure a resident who required extensive assistance with activities of daily living was provided incontinent care and turning and repositioning in accordance with the plan of care and physician orders.
- D
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 review of the clinical record, facility documentation, facility policy, and interviews for one (1) of three (3) residents (Resident #1) reviewed for neglect, the facility failed to ensure appropriate staffing to meet the needs of the resident.
March 15, 2024Complaint inspection · 1 citation
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on clinical record review, facility documentation review, facility policy review, and interviews for one of three residents (Resident #1) reviewed for a change in condition, the facility failed to ensure hospital discharge orders were acted on timely.
November 7, 2023Complaint inspection · 1 citation
- G
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on clinical record review, facility documentation review, facility policy review and interviews for one of three residents (Resident #1) reviewed for accidents, the facility failed to ensure the resident was transferred in accordance with physician orders and the plan of care to prevent an injury.
June 8, 2023Standard inspection · 38 citations
- 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 observations of the environment, review of facility documentation and staff interview, the facility failed to ensure that resident areas , dinning room and equipment were maintained in a clean and comfortable homelike manner.
- E
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Inspectors wroteBased on a review of the facility admission/ transfer discharge and staff interview, the facility failed to provided evidence of monthly notification to the state Regional Ombudsman Office of residents' transfers and discharge status in the facility.
- E
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Inspectors wroteBased on clinical record reviews, review of facility documentation and interviews for 1 of 2 sampled residents (Resident #11) reviewed for Pre-admission Screening and Resident Review (PASSR), the facility failed to submit a PASSR level of care when a change in the resident's mental status
- E
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on clinical record review, facility policy and interviews for 1 resident (Resident # 28) reviewed for Position, Mobility, the facility failed to ensure the physician's orders were followed for a resting hand splint and for 1 of 5 residents observed dining ( Resident # 24), the facility failed to follow facility practice for staff supervision during meal time to meet profession practice.
- E
Provide medically-related social services to help each resident achieve the highest possible quality of life.
Inspectors wroteBased on clinical record review, facility documentation review, facility policy review, and interviews for 1 sampled resident (Resident #7) reviewed for discharge, the facility failed to timely assist the resident with request to transfer to another facility and for 1 of 2 sampled residents (Resident #51 and Resident # 369) reviewed for Hospice and /or death, the facility failed to ensure medically-related social services were provided.
- 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 review of the clinical records and interviews, for 2 of 5 sampled residents (Resident # 11), the facility failed to ensure pharmacy recommendations that were approved by the physician were implemented and for Resident # 64, the pharmacy failed to notify the physician the resident's laboratory work was not completed .
- E
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Inspectors wroteBased on observations of the noon tray line, review of facility documentation and staff interview, the facility failed to provide food at an appetizing temperature .
- E
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on observations of kitchen, facility documentation, and interviews, the facility failed to properly label foods, discard expired food, maintain, and rotate emergency food supply stock, and serve food at professional standards.
- D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteBased on observations, clinical record reviews and staff interviews for 3 of 4 sampled residents (Resident #29, Resident #32, Resident #77, and Resident #86) reviewed for dining, the facility failed to provide a dignified dining experience by ensuring all residents were served at the same time.
- D
Allow resident to participate in the development and implementation of his or her person-centered plan of care.
Inspectors wroteBased on clinical record review, facility documentation review, facility policy review, and interviews for 1 sampled resident (Resident #7) reviewed for person-centered care planning, the facility failed to ensure interdisciplinary care plan meetings were held with the resident and/or Conservator of Person (COP) to ensure participation in the plan of care .
- D
Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home.
Inspectors wroteBased on a review of Resident Personal Funds Account statements and staff interviews for 2 sampled residents (Resident # 28 and Resident # 37), the facility failed to ensure the resident and /or responsible party received quarterly Personal Fund Account summaries.
- 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 clinical record reviews, facility documentation review, facility policy review, and interviews for 3 of 5 sampled resident (Residents #1, #7 and # 61) reviewed for advance directives, the facility failed to review the resident's advanced directives to reflect the code status wishes of the resident and/or responsible party/conservator of person (COP) following admission and re-admission from the hospital.
- D
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Inspectors wroteBased on clinical record reviews, observations, facility documentation, facility policy and interviews for 2 of 6 sampled residents (Resident # 222) reviewed for abuse the facility failed to ensure the residents was free from verbal abuse and for ( Resident # 70), the facility failed to ensure the resident was free from physical abuse.
- D
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Inspectors wroteBased on review of clinical records, facility documentation, facility policy and interviews for 1 of 6 residents reviewed for abuse (Resident # 57), the facility failed to implement facility policy for investigating an allegation of physical abuse within 5 working days.
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on review of clinical records, facility documentation, facility policy and interviews for 2 of 6 residents reviewed for abuse (Resident #6 and # 57), the facility failed to implement facility policy for investigating and reporting an allegation of abuse to the state agency within 2 hours.
- D
Respond appropriately to all alleged violations.
Inspectors wroteBased on review of clinical records, facility documentation, facility policy and interviews for 2 of 6 residents reviewed for abuse (Resident #6 # and # 99), the facility failed to implement facility policy for protecting the resident during an investigation of allegation of abuse.
- 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 clinical record review and interview for 1 of 3 sampled residents for (Resident # 118) reviewed for discharge, the facility failed to ensure the resident had a discharge care plan at the time of admission.
- 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 clinical record review, observations, facility policy and interviews for 1 of 1 sampled resident (Resident# 59) reviewed for specialized treatment, the facility failed to ensure the resident's care plan was revised to include a port in the right chest.
- D
Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
Inspectors wroteBased on clinical record review and staff interview for 1 of 3 residents (Resident # 118) reviewed for discharge, the facility failed to ensure the resident received a discharge summary prior to the resident's wishes to be discharge Against Medical Advice.
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on clinical record review, observations, and interviews for 1 of 1 sampled resident, (Resident #64) reviewed for ADLs (Activities of Daily Living), the facility failed to assist the resident with applying footwear.
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on clinical record reviews, observations, review of facility and staff interview for 1 of 3 residents at risk for pressure ulcer development for( Resident # 89), the facility failed to ensure that the resident's air mattress was set according to the plan of care and for 1 of 3 residents at risk for skin break down (Resident # 356), the facility failed to provide evidence that staff consistently turn and repositioned and off loaded the residents heel to prevent further skin breakdown.
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on clinical record review and staff interviews for 1 sampled residents, (Resident #64), reviewed for accident, the facility failed to the resident received the necessary supervision to prevent an accident and for for 1 of 3 residents (Resident # 77) who require assistance with mechanical lift for transfers, the facility failed to ensure the resident's skin was safe during a transfer to prevent an injury.
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on clinical record review, observation, facility policy and interviews for 1 resident (Resident # 6) reviewed for Respiratory Care, the facility failed to ensure the physician's orders were followed regarding oxygen therapy.
- D
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Inspectors wroteBased on clinical record review, observations, facility policy and interviews for 1 of 1 sampled resident (Resident# 59) reviewed for specialized treatment, the facility failed to ensure the resident's plan of care included emergency measures.
- D
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 review of facility documentation, and interviews, the facility failed to ensure sufficient direct care staffing in accordance with quarterly Payroll Based Journal (PBJ) staffing data report.
- D
Post nurse staffing information every day.
Inspectors wroteBased on review of facility documentation, review of facility policy and staff interviews, the facility failed to ensure nurse staffing information was available and was reflective of actual staff worked.
- D
Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder.
Inspectors wroteBased on clinical record review and staff interviews for 1 resident (Resident # 98) reviewed for abuse, the facility failed to address the resident's Post Traumatic Stress Disorder (PTSD) regarding fear of residents entering the room.
- D
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
Inspectors wroteBased on clinical record reviews, observations, and staff interview for 1 of 18 residents observed during dining, the facility failed to ensure the residents diet consistency was followed according to the plan of care.
- D
Hire a qualified full-time social worker in a facility with more than 120 beds.
Inspectors wroteBased on clinical record reviews and staff interviews for 1 of 3 residents for (Resident # 118) reviewed for discharge, the facility failed to ensure the social worker document a note regarding the resident's discharge status and failed to ensure the facility employed a social worker to assist with resident with resident psychosocial needs.
- D
Have a plan that describes the process for conducting QAPI and QAA activities.
Inspectors wroteBased on a review of the facilityQuality Assurance and Performance Improvement (QAPI) program, review of facility documentation, review of policy and interviews, the facility failed to implement and maintain effective comprehensive, data driven QAPI program .
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, review of the facility infection control program,, facility policy and interviews, the facility failed to maintain measures to prevent growth of Legionella and other opportunistic waterborne pathogens in building systems according to facility practice and failed to perform hand hygiene after picking up a glove from the floor after disinfecting a glucometer.
- D
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Inspectors wroteBased on clinical record reviews, facility policy and interviews for 2 of 2 sampled residents (Resident #108 and Resident #43) reviewed for Infection Control, the facility failed to offer flu and pneumococcal vaccinations.
- D
Report COVID19 data to residents and families.
Inspectors wroteBased on clinical record review, facility documentation review, interview for 1 sampled resident (Resident #320) reviewed for COVID-19 infection, the facility failed to timely inform the resident, and family representative by 5:00 PM the next calendar day following the occurrence of five confirmed COVID-19 infections.
- 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 clinical record reviews, facility policy and interviews for 1 sampled resident (Resident #108) reviewed for Infection Control, the facility failed to offer the Covid-19 vaccine to the resident.
- D
Keep all essential equipment working safely.
Inspectors wroteBased on clinical record reviews, observation and staff interview for 1 of 3 residents at risk for pressure ulcer development for( Resident # 68), the facility failed to ensure that the resident's air mattress was check to ensure adequate and proper functioning of the mattress .
- C
Assure the security of all personal funds of residents deposited with the facility.
Inspectors wroteBased on review of facility's Resident Personal Fund Account and interview, the facility failed to ensure that a security bond was obtained in an amount substantial enough to cover the total amount of the Resident Personal Fund Account in the event of financial loss.
- B
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Inspectors wroteBased on clinical record review, review of facility MDS submission report and staff interviews for 5 out 9 Resident Assessment for (Residents # 32, # 53, # 61, # 64 and # 111), the facility failed to ensure the residents assessments were submitted to the state agency within 14 days.
- B
Dispose of garbage and refuse properly.
Inspectors wroteBased on observations and interviews, the facility failed to properly dispose of garbage and refuse properly.
March 10, 2021Standard inspection · 5 citations
- D
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Inspectors wroteBased on clinical record review, facility policy review and interviews for one of two residents (Resident #89) reviewed for pressure ulcers, the facility failed to ensure the resident's representative was notified timely when a new pressure ulcer was identified.
- D
Respond appropriately to all alleged violations.
Inspectors wroteBased on clinical record review, facility documentation review, facility policy review, and interviews for one of three residents reviewed for abuse (Resident #92), the facility failed to complete a thorough investigation for a resident injury of unknown origin.
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on clinical record review, facility policy review and interviews for one of two residents (Resident #89) reviewed for pressure ulcers, the facility failed to ensure weekly skin audits were completed in accordance with physician's orders, and the facility failed to ensure a thorough nursing assessment was completed when a new pressure ulcer was identified.
- D
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Inspectors wroteBased on clinical record review, facility documentation review, facility policy review and interviews for two of five residents reviewed for Unnecessary Medications, (Resident #76 and Resident #95), the facility failed to ensure consistent target behavior monitoring for a resident with dementia who received antipsychotic medication, and the facility failed to ensure monitor targeted behaviors in accordance with physician's orders for a resident on an antipsychotic medication.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observations, clinical record review, and facility policy and procedures review for one sampled resident (Resident #68), the facility failed to place a resident with an active drug-resistant infection on appropriate isolation precautions.
Fire safety inspections
24 fire safety citations on file: 5 on June 25, 2025, 14 on June 8, 2023, 5 on March 10, 2021.
Every fire safety citation24 citations
- E
Keep aisles, corridors, and exits free of obstruction in case of emergency.
K 211 · June 25, 2025 · deficient, provider has
- D
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · June 25, 2025 · deficient, provider has
- D
Inspect, test, and maintain automatic sprinkler systems.
K 353 · June 25, 2025 · deficient, provider has
- D
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
K 741 · June 25, 2025 · deficient, provider has
- D
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · June 25, 2025 · Corrected (the home has a date of correction)
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · June 8, 2023 · Corrected (the home has a date of correction)
- F
Provide a written emergency evacuation plan.
K 711 · June 8, 2023 · Corrected (the home has a date of correction)
- F
Ensure proper usage of power strips and extension cords.
K 920 · June 8, 2023 · Corrected (the home has a date of correction)
- F
Ensure that testing and maintenance of electrical equipment is performed.
K 921 · June 8, 2023 · Corrected (the home has a date of correction)
- E
Install an approved automatic sprinkler system.
K 351 · June 8, 2023 · Corrected (the home has a date of correction)
- E
Meet other general requirements that are deficient.
K 500 · June 8, 2023 · Corrected (the home has a date of correction)
- E
Have simulated fire drills held at unexpected times.
K 712 · June 8, 2023 · Corrected (the home has a date of correction)
- D
Keep aisles, corridors, and exits free of obstruction in case of emergency.
K 211 · June 8, 2023 · Corrected (the home has a date of correction)
- D
Install emergency lighting that can last at least 1 1/2 hours.
K 291 · June 8, 2023 · Corrected (the home has a date of correction)
- D
Provide properly protected cooking facilities.
K 324 · June 8, 2023 · Corrected (the home has a date of correction)
- D
Inspect, test, and maintain automatic sprinkler systems.
K 353 · June 8, 2023 · Corrected (the home has a date of correction)
- D
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
K 761 · June 8, 2023 · Corrected (the home has a date of correction)
- D
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · June 8, 2023 · Corrected (the home has a date of correction)
- D
Meet requirements for the use of electrical equipment.
K 919 · June 8, 2023 · Corrected (the home has a date of correction)
- F
Install emergency lighting that can last at least 1 1/2 hours.
K 291 · March 10, 2021 · Corrected (the home has a date of correction)
- F
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
K 741 · March 10, 2021 · Corrected (the home has a date of correction)
- E
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · March 10, 2021 · Corrected (the home has a date of correction)
- D
Install an approved automatic sprinkler system.
K 351 · March 10, 2021 · Corrected (the home has a date of correction)
- D
Inspect, test, and maintain automatic sprinkler systems.
K 353 · March 10, 2021 · Corrected (the home has a date of correction)