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 58 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
1J
0K
0L
Actual harm
2G
0H
0I
Potential for more than minimal harm
39D
7E
7F
Potential for minimal harm
0A
0B
2C
July 28, 2026Complaint inspection · 4 citations
- J
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Inspectors wroteBased on interview and record review, the facility failed to implement and follow their Abuse Prevention Policy and Procedures by failing to protect a resident (R1) from physical and verbal abuse, failed to immediately report allegations of abuse to the state agency, failed to initiate a timely investigation, and failed to take immediate actions to ensure resident safety. These failures resulted in psychosocial harm of R1 who is fearful and scared of another altercation with V5 and fearful he will be abused again. Failure of the facility not following their abuse policy puts all 147 residents at risk of being abused. The Immediate Jeopardy began on 07/05/2026 when R1 and V5 were involved in a physical altercation in the facility. V1 (Administrator) was notified on 07/20/2026 at 3:00 PM of the Immediate Jeopardy. [...]
- 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 interviews and record reviews, the facility failed to follow their abuse and care plan (comprehensive) policy by failing to develop an individualized plan of care with measurable interventions to address a resident's episode of aggression and failed to implement the care plan interventions for aggression resulting in a physical altercation between V5 C.N.A (Certified Nurse Assistant) and R1. This failure affects one (R1) resident of four reviewed for care plan implementation.
- 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 interviews and record reviews, the facility failed to follow their abuse and care plan (comprehensive) policy by failing to revise the care plan approach (interventions) after a physical altercation between R1 and V5 C.N.A (Certified Nurse Assistant) occurred. This failure affects one (R1) resident of four reviewed for care plan revision.
- D
Ensure services provided by the nursing facility meet professional standards of quality.
Inspectors wroteBased on interview and record review the facility failed to provide care and services according to accepted standards of practice by not following their charting and documentation policy and the Licensed Practical Nurse Job Description. The facility failed to document an altercation between R1 and V5 C.N.A (Certified Nurse Assistant) in R1's medical record and complete an incident report per the facility policy. This failure to document the staff and resident altercation caused a lack of investigation into the incident and report of suspected abuse to the state surveying agency by administration. This failure affects one (R1) resident of four reviewed for charting and documentation of incidents.
June 17, 2026Complaint inspection · 2 citations
- F
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Inspectors wroteBased on interview and record review the facility failed to follow policy procedures, failed to ensure that staff are aware of minimum staffing requirements, failed to follow staffing requirements, failed to schedule adequate Nursing staff, failed to replace scheduled staff when call off/NCNS (No Call No Show) occurs, failed to monitor shower/skin sheets to ensure that required care/skin assessments were provided, failed to document/provide required showers/skin assessments, and failed to ensure that adequate staff were available to meet the needs of three of three dependent residents (R1, R2, R3) reviewed for ADL (Activities of Daily Living) care. These failures have the potential to affect 146 residents residing in the facility.
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on interviews and record review the facility failed to follow policy procedures, failed to ensure that (R2's) skin assessments were endorsed by a Nurse, and failed to document and/or provide required showers/skin assessments for three of three dependent residents (R1, R2, R3) reviewed for ADL (Activities of Daily Living) care.
May 1, 2026Complaint inspection · 1 citation
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to follow its enhanced barrier precautions policy and don appropriate PPE (personal protective equipment) prior to entering resident rooms with enhanced barrier precautions and providing wound care treatments. This failure affected three residents (R4, R5, and R6) out of three reviewed for infection control in a sample of 6.
October 1, 2025Complaint inspection · 1 citation
- 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 interview and record review, the facility failed to follow their policy in notifying resident representative of a cognitively impaired resident of changing the resident's room for one (R4) of three residents reviewed for resident rights in a sample of five.
July 31, 2025Standard inspection, Complaint inspection · 22 citations
- F
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Inspectors wroteBased upon observation, interview, and record review the facility failed to follow policy procedures and failed to ensure that 2 of 5 medication carts were locked while unattended while being reviewed for medication storage per policy and procedure.
- 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, interview and record review, the facility failed to ensure that dietary staff are properly certified for food handling. This failure has the potential to affect all 153 residents who receive food by mouth from the kitchen.
- 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 record review, the facility failed to prepare and handle food in a manner that prevents food borne illness by failing to ensure that garbage is properly disposed, failed to date opened cooking seasonings, failed to remove a scoop from a flour bin, failed to allow cooking equipment air dry before use, failed to ensure that the ice machine was kept clean and failed follow proper hand hygiene protocol during food preparation. These failures have the potential to cause food borne illness to 153 residents at the facility that receives oral diet from the kitchenFacilityFindings include:On 7/28/2025 at 9:35AM, during an initial tour of the kitchen, there were two staff members, V18 (Cook) and V17 (Cook/Dietary aide). Surveyor noted three bags of garbage that are full and in the middle of the floor close to where the V17 (Cook) was preparing some food. [...]
- F
Provide and implement an infection prevention and control program.
Inspectors wroteBased on interview and record review, the facility failed to follow their water management policy by 1. Failed to implement the facility's water management program by failing to educate team members on the principles of an effective water management program, 2. failed to maintain documentation that describes the facility's water system, 3. failed to annually conduct a risk assessment and identify control points to identify where Legionella and other opportunistic waterborne pathogens could grow and spread in the water system, 4. failed to ensure control measures were applied to address potential hazards at each control point, 5. failed to evaluate the effectiveness of the water management program annually using infection control surveillance data, water quality data, and rounding data, 6. [...]
- 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 interview and record review, the facility failed to ensure that advance directives were accurately completed and consistently maintained for 5 residents (R17, R55, R69, R92, and R145) reviewed for Advance Directives in a sample of 68 residents, resulting in discrepancies between documented wishes and care provided. R17 is [AGE] years old and have resided at the facility since [DATE], past medical history includes, but not limited to type 2 diabetes, hyperlipidemia, unspecified bipolar disorder, essential primary hypertension, iron deficiency anemia, etc. [DATE] 11:42 AM, per record review, R17 had an advance directive in the system that was signed [DATE], but there was no selection for the type of treatment indicated in the form. [...]
- E
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Inspectors wroteBased on interview and record review, the facility failed to implement its policies and procedures related to the Identified Offenders Program (IOP) for 10 out of 10 residents (R37, R43, R90, R162, R163, R164, R165, R166, R167 and R168), failed to perform criminal background checks for new residents within 24 hours of admission for 4 residents (R37, R164, R166, and R168), and failed to obtain fingerprint orders within 72 hours of a hit on the preliminary criminal history for 10 out of 10 residents (R37, R43, R90, R162, R163, R164, R165, R166, R167 and R168). These failures affected 10 residents (R37, R43, R90, R162, R163, R164, R165, R166, R167 and R168) in the sample of 68 residents reviewed for abuse policies and procedures.
- E
Ensure services provided by the nursing facility meet professional standards of quality.
Inspectors wroteBased upon observation, interview, and record review the facility failed to follow policy procedures, failed to ensure that that prescribed medications were administered within regulatory requirements and failed to document medication administration timely for 14 of 68 residents (R3, R5, R7, R14, R23, R46, R51, R66, R76, R109, R114, R127, R140, R150) in the sample.
- E
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased upon observation, interview, and record review the facility failed to provide supervision, failed to implement fall prevention interventions, and/or failed to address safety hazards for five of 68 residents (R2, R139, R141, R144, R161) in the sample.
- 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 upon observation, interview, and record review the facility failed to ensure that sufficient nursing staff were available to meet the needs for 20 of 68 dependent residents (R2, R3, R5, R7, R8, R14, R23, R36, R46, R51, R66, R76, R109, R114, R127, R139, R140, R141, R150, R161) in the sample and failed to ensure a licensed nurse had the required training/coursework to manage the facility restorative program. These failures have the potential to affect 158 residents.
- E
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Inspectors wroteBased upon observation, interview, and record review the facility failed to maintain an effective pest control program and failed to ensure the facility remained free from flying insects. This affected two residents (R127, R139). These failures have the potential to affect 158 residents.
- D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteBased on observation interview and record review, the facility failed to ensure a resident's urinary drainage bag was covered in a manner that promotes dignity. This failure affects 1 resident (R150) in a sample of 68.
- D
Keep residents' personal and medical records private and confidential.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure 1 resident's (R92) personal and medical information was kept confidential. This failure affects 1 resident (R92) out of a sample of 68 residents reviewed for personal privacy and confidentiality of records.
- 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 upon observation, interview, and record review the facility failed to follow policy procedures and failed to provide a clean, homelike, odor free, and functional environment for three of 68 residents (R127, R129, R140) in the sample and failed to maintain sanitary conditions in the community bathrooms, hallways, and other common areas.
- D
PASARR screening for Mental disorders or Intellectual Disabilities
Inspectors wroteBased on interview and record review, the facility failed to refer 1 resident (R9) with a possible serious mental disorder for Screening and Resident Review to the appropriate state-designated authority for further assessment as required. This failure affects 1 resident (R9) reviewed for pre-admission screening in the sample list of 68 residents.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on observation, interview and record review, the facility failed to assess, document, and treat 2 wounds on 1 resident reviewed for skin conditions. These failures have the potential to affect 1 resident (R106) out of a sample of 68 residents.
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on observation, interview and record review, the facility failed to have the low air loss mattress (LAL) at the correct weight settings for one resident (R13) with a chronic wound, who is also at high for developing pressure ulcers. This failure has the potential to affect 1 resident (R13), reviewed for pressure ulcer prevention interventions, in a total sample of 68 residents.
- 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, interview, and record review, the facility failed to follow policy and procedure and ensure the tube feeding syringe was changed daily on 1 resident (R13) and failed to label 1 resident's (R13) tube feeding syringe with the resident's name. These failures have the potential to affect 1 resident (R1) reviewed for tube feeding management in the total sample of 68 residents.
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased upon observation, interview, and record review the facility failed to ensure that respiratory equipment was labeled with a name/date and failed to contain it in a plastic bag for two of 68 residents (R127, R161) in the sample.
- 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 upon interview and record review the facility failed to follow policy procedures, failed to ensure that pharmacist recommendations for medication gradual dose reduction and/or discontinuation were received, and failed to ensure that pharmacy recommendations were implemented for one of five residents (R8) reviewed for unnecessary medications, chemical restraints/psychotropic medications, and medication regimen review.
- D
Ensure that residents are free from significant medication errors.
Inspectors wroteBased upon observation, interview, and record review the facility failed to follow policy procedures, failed to follow physician orders, and failed to ensure that 2 of 68 residents (R34, R161) in the sample remained free from significant medication errors.
- C
Post nurse staffing information every day.
Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the nursing staffing information contained the required information. This failure has the potential to affect all 153 residents that reside within the facility. Facility census documents the current census is 158 residents. On 7/28/2025 at 10:25 AM, observed a staffing schedule posted in the hallway near the entrance to the lobby. The staffing schedule does not include the facility name, census, or total number/the actual hours worked by of licensed and unlicensed nursing staff directly responsible for resident care per shift. V28 (Assistant Director of Nursing) affirmed that the document is what the facility posts for the required nursing staffing posting. V28 affirmed that the document did not contain the facility name, census or any value of numbers to indicate hours worked by direct care staff. [...]
- C
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
Inspectors wroteBased on interview and record review, the facility failed to ensure that the medical director participated in the facility's QAA/QAPI programming. This failure has the potential to affect all 158 residents that reside within the facility. Facility census documents an active census of 158 residents. Facility QAA committee meeting sign-in sheets (4/30/2025, 7/17/2025) do not document any signature from the facility's medical director affirming the medical director's attendance. On 7/30/2025 at 10:04 AM, QAA meeting minutes were reviewed with V1 (Administrator) and V1 affirmed that the facility's medical director was not at the QAA meetings. V1 affirmed that the medical director is required to be at the QAA meetings. On 7/30/2025 at 11:55 AM, V38 (Nurse Consultant) affirmed that V38 is a member of the governing body of the facility and sometimes attends QAA meetings. [...]
June 20, 2025Complaint inspection · 1 citation
- D
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Inspectors wroteBased on interview and record review the facility failed to follow their abuse policy by failing to keep a resident (R2) free from being hit with a tool by another resident, failing to keep a resident (R5) free from being hit in the face, and a resident (R6) from being pushed by another resident, for three residents out of seven reviewed for abuse in a total sample of seven. Findings Include: A. R1 is a [AGE] year-old male admitted on [DATE] with diagnosis not limited to bipolar disorder, hemiplegia affecting the left side, and dementia. R2 is a [AGE] year-old male admitted on [DATE] with diagnosis of but not limited to dementia, heart failure, and Parkinson's disease. On 6/17/25 at 11:49AM, R1 was sitting in a separate dining room from R2 waiting for the lunch meal. When first asked, R1 denied having any physical altercations but then remembered once the surveyor gave R1 more details. [...]
May 13, 2025Complaint inspection · 3 citations
- G
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on interviews and record reviews the facility failed to follow their policy and procedures for behavior and substance abuse management by not adequately monitoring and communicating suspected or observed substance use in the facility; not conducting room searches per the facility's protocol of reported suspicion of substance abuse; not referring suspected substance abuse to law enforcement; and not identifying or implementing personalized care plan interventions for prevention of suicidal/self-harming behavior and substance use. This failure applied to two of two (R1, R4) residents reviewed for supervision and resulted in R1 and R4 testing positive for drug use while in the facility and R1 engaging in self-harming behavior.
- D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteBased on interviews and record reviews the facility failed to follow their behavior management policy and procedures for ensuring a resident's safety by attempting to physically restrain an alert and oriented resident who refused to return to the facility after eloping. This failure applies to one of one resident (R1) reviewed for resident rights.
- D
Provide medically-related social services to help each resident achieve the highest possible quality of life.
Inspectors wroteBased on interviews and record reviews the facility failed to follow their policy and procedures for behavior and substance use management by not ensuring residents with a significant history of self-harm, suicidal behavior, and substance use received therapeutic mental health or substance abuse counseling or services; not establishing personalized care planned interventions for these behaviors based on identified causes of behaviors, preferences and individual interests; and not performing timely assessment of substance abuse history to apply knowledge and understanding of past and development of person-centered treatment interventions. This failure applies to two of two residents (R1 and R4) reviewed for behavioral health services.
February 13, 2025Complaint inspection · 1 citation
- F
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Inspectors wroteBased on interview and record review, the facility failed to follow the facility policy on conducting background and fingerprint checks for four employees (V11, V12, V13, V14) at time of hire. This failure has the potential to affect 144 residents currently residing in the facility.
January 21, 2025Complaint inspection · 2 citations
- F
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Inspectors wroteBased on interviews and record reviews, the facility failed to follow its staffing policy by not having four nurses working on the overnight shift on 12/31/24. There was no nurse present in this facility from 2:00AM until 6:04AM on 1/1/25. This failure resulted in 4 residents (R8, R9, R10, and R16) not receiving 6:00AM scheduled medications until more than one hour later or not at all; 5 diabetic residents (R7, R11, R13, R14, and R15) not having 6:00AM blood sugar level checked, and insulin administered; none of the residents received scheduled assessments and/or vital sign monitoring on the night shift. This failure has the potential to affect all 155 residents residing in this facility.
- E
Ensure that residents are free from significant medication errors.
Inspectors wroteBased on interviews and record reviews, the facility failed to follow its medication administration policy and consistently monitor the effectiveness of pain medication and accurately document the administration of controlled substances for four of residents (R3, R17, R18, and R19) out of four reviewed for receiving high alert medications in a sample of 19.
October 10, 2024Complaint inspection · 2 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 interview and record review, the facility failed to notify resident's representative of a change in condition. This failure applied to one (R1) of five residents reviewed for change in condition.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on interview and record review, the facility failed to ensure that a follow-up appointment was scheduled with specialists physician for a resident as ordered; they failed to administer prescribed medications and monitor and document resident's respiratory and oxygen status per physician orders and plan of care; and failed to ensure that staff accurately assess and document emergency response for a resident. This failure applied to one (R1) of one resident reviewed for nursing care.
September 13, 2024Standard inspection · 7 citations
- D
Ensure services provided by the nursing facility meet professional standards of quality.
Inspectors wroteBased on observation, interview and record review, the facility failed to follow a professional standard during G-Tube medication administration for one (R27) of one resident observed for G-Tube medication administration in a sample of 29 residents. Findings Include: On 9/11/2024 at 01:15 PM - Observed V16 (LPN) administer medication to R27 via G-Tube. V27 did not check the G-Tube placement before administering the medication. On 9/11/2024 at 1:21 PM, V16 said that she checks the placement by observing and palpating G-Tube placement site. On 9/11/2024 01:38 PM, V2 (Director of Nursing/DON) said that she expects the staff to check G-Tube placement either by auscultation or residual before administering medication. [...]
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on observation, interview, and record review the facility failed to provide feeding assistance, nail care and foot care for resident who need assistance with Activity of Daily Living (ADL). This deficiency affects one (R91) of three residents in the sample of 29 reviewed for ADL care.
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on observation, interview, and record review the facility failed to implement fall preventive measures to resident who is at high risk for falls. This deficiency affects two (R91 and R141) of three residents in the sample of 29 reviewed for Fall Prevention Program.
- 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, interview, and record review the facility failed to follow physician order in administration of enteral feeding. This deficiency affects one (R108) of three residents in the sample of 29 reviewed for Enteral feeding management.
- D
Provide safe, appropriate pain management for a resident who requires such services.
Inspectors wroteBased on observation, interview and record review the facility failed to follow its pain management policy and reassess for pain for 1 of 3 resident's (R141) reviewed for pain management in a sample of 29. Findings Include: On 9/11/2024 at 1:30pm R141 said that his left knee is very painful from a fall in the hallway and the nurses will only give him acetaminophen. On 9/11/2024 at 1:40pm V6 (Licensed Practical Nurse-LPN) said that R141 does not ask for pain medication and the only thing he has ordered is acetaminophen, I'll call the physician for a stronger pain medication. On 9/11/2024 at 2:10pm V2 (Director of Nursing-DON) said I expect the nurses to assess for pain every shift and as needed, and if a resident complains of pain, I expect for the nurses to follow up with the physician. [...]
- D
Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
Inspectors wroteBased on observation, interview, and record review the facility failed to collaborate coordinated care by failure to ensure that resident's updated hospice medical records are available and accessible to all interdisciplinary team (IDT) in the facility. This deficiency affects one (R91) of three residents in the sample of 29 reviewed for Hospice care services.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview, and record review the facility failed to implement infection control policy for resident who is on Enhanced Barrier Precaution (EBP). This deficiency affects one (R108) of three residents in the sample of 29 reviewed for infection control.
August 20, 2024Complaint inspection · 1 citation
- D
Let each resident or the resident's legal representative access or purchase copies of all the resident's records.
Inspectors wroteBased on interview and record review, the facility failed to follow their policy and ensure that medical records were released in a timely manner when requested by legal representative for one (R4) resident. This failure affected one resident (R4) in a sample of 5 residents reviewed for policy and procedures.
August 15, 2024Complaint inspection · 1 citation
- D
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to prevent an incident of resident to resident abuse. This affected two of three residents (R1, R2) reviewed for abuse. This failure resulted in R1, with a history of aggressive behavior, exhibiting verbal aggression towards R2 which escalated to physical aggression with R1 swinging his arms at R2 and pushing R2 onto the floor.
August 8, 2024Complaint inspection · 2 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 observation, interview, and record review, the facility failed to keep a resident (R3) free from abuse by another resident (R5) and failed to keep a resident (R5) free from verbal abuse by staff. These failures applied to two (R3, R5) of five residents reviewed for abuse.
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on interview and record review, the facility failed to follow their policy and procedures for identifying and reporting an injury of unknown origin to the State agency. This failure applied to one (R3) of five residents reviewed for resident injuries.
May 7, 2024Complaint 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 observation, interview, and record review, the facility failed to monitor a high fall risk resident (R2) while in bed, failed to put in additional interventions to address R2's behavior of moving/wiggling around the bed, and failed to keep the call light within reach. This affected one of three residents (R2) reviewed for fall prevetion interventions. This failure resulted in R2 suffering a brain bleed in two areas of the brain after the fall. Findings Include: R2 is a [AGE] year old with the following diagnoses: chronic obstructive pulmonary disease, and nontraumatic intracranial hemorrhage. The admission Hospital Records, dated 2/17/24, documents R2 was sent to the hospital for altered mental status. R2 was noted with elevated blood pressure, has poor attention, span, and has severe encephalopathy. [...]
March 20, 2024Complaint 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 observation, interview, and record review, the facility failed to ensure a resident was not physically abused by another resident for 1 of 5 residents (R10) reviewed for abuse in the sample of 11.
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure an allegation of staff to resident physical abuse was reported immediately to the Administrator for 1 of 5 residents (R1) reviewed for abuse in the sample of 11.
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the safety of a resident by transferring him with a mechanical lift for 1 of 5 residents (R2) reviewed for injuries of unknown origin the sample of 11.
- D
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure appropriate interventions were implemented for a resident experiencing a behavior, and failed to identify a trigger for a resident's behaivor for 1 resident (R1) reviewed for behaviors in the sample of 11.
January 18, 2024Complaint inspection · 1 citation
- D
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Inspectors wroteBased on interview and record review, the facility failed to prevent physical resident to resident abuse for 2 of 3 residents (R1 and R11) reviewed for abuse in the sample of 13.
October 6, 2023Standard inspection · 2 citations
- D
PASARR screening for Mental disorders or Intellectual Disabilities
Inspectors wroteBased on interview and record review, the facility failed to initiate a new Level I screen for a resident who stayed longer than the approved stay, for one of two residents (R133) reviewed for Pre-admission Screening and Record Review (PASARR) in a sample of 29.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview, and record review, the facility failed to sanitize equipment before obtaining blood pressure for two residents (R79 and R119), and failed to perform hand hygiene before obtaining a blood glucose measurement for one resident (R98), of eight residents reviewed for infection control in the sample of 29.
Fire safety inspections
39 fire safety citations on file: 12 on September 13, 2024, 10 on October 6, 2023, 17 on October 7, 2022.
Every fire safety citation39 citations
- F
Implement emergency and standby power systems.
E 41 · September 13, 2024 · Corrected (the home has a date of correction)
- F
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
K 222 · September 13, 2024 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · September 13, 2024 · Corrected (the home has a date of correction)
- F
Have simulated fire drills held at unexpected times.
K 712 · September 13, 2024 · Corrected (the home has a date of correction)
- F
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · September 13, 2024 · Corrected (the home has a date of correction)
- E
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 · September 13, 2024 · Corrected (the home has a date of correction)
- E
Provide properly protected cooking facilities.
K 324 · September 13, 2024 · Corrected (the home has a date of correction)
- E
Properly select, install, inspect, or maintain portable fire extinguishes.
K 355 · September 13, 2024 · Corrected (the home has a date of correction)
- E
Install corridor and hallway doors that block smoke.
K 363 · September 13, 2024 · Corrected (the home has a date of correction)
- E
Install smoke barrier doors that can resist smoke for at least 20 minutes.
K 374 · September 13, 2024 · Corrected (the home has a date of correction)
- E
Ensure proper usage of power strips and extension cords.
K 920 · September 13, 2024 · Corrected (the home has a date of correction)
- E
Have proper medical gas storage and administration areas.
K 923 · September 13, 2024 · Corrected (the home has a date of correction)
- F
Create arrangements with other facilities to receive patients.
E 25 · October 6, 2023 · Corrected (the home has a date of correction)
- F
Establish staff and initial training requirements.
E 37 · October 6, 2023 · Corrected (the home has a date of correction)
- F
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
K 321 · October 6, 2023 · Corrected (the home has a date of correction)
- F
Provide properly protected cooking facilities.
K 324 · October 6, 2023 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · October 6, 2023 · Waiver
- F
Install corridor and hallway doors that block smoke.
K 363 · October 6, 2023 · Corrected (the home has a date of correction)
- F
Install smoke barrier doors that can resist smoke for at least 20 minutes.
K 374 · October 6, 2023 · Corrected (the home has a date of correction)
- E
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 · October 6, 2023 · Corrected (the home has a date of correction)
- E
Provide properly sized and located linen or trash receptacles.
K 754 · October 6, 2023 · Corrected (the home has a date of correction)
- F
Address subsistence needs for staff and patients.
E 15 · October 6, 2023 · Corrected (the home has a date of correction)
- F
Have properly located and lighted "Exit" signs.
K 293 · October 7, 2022 · Corrected (the home has a date of correction)
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · October 7, 2022 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · October 7, 2022 · Corrected (the home has a date of correction)
- F
Properly select, install, inspect, or maintain portable fire extinguishes.
K 355 · October 7, 2022 · Corrected (the home has a date of correction)
- F
Have simulated fire drills held at unexpected times.
K 712 · October 7, 2022 · Corrected (the home has a date of correction)
- F
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · October 7, 2022 · Corrected (the home has a date of correction)
- F
Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk.
K 926 · October 7, 2022 · Corrected (the home has a date of correction)
- E
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 · October 7, 2022 · Corrected (the home has a date of correction)
- E
Provide properly protected cooking facilities.
K 324 · October 7, 2022 · Corrected (the home has a date of correction)
- E
Install corridor and hallway doors that block smoke.
K 363 · October 7, 2022 · Corrected (the home has a date of correction)
- E
Install smoke barrier doors that can resist smoke for at least 20 minutes.
K 374 · October 7, 2022 · Corrected (the home has a date of correction)
- E
Have properly installed electrical wiring and gas equipment.
K 511 · October 7, 2022 · Corrected (the home has a date of correction)
- E
Provide properly sized and located linen or trash receptacles.
K 754 · October 7, 2022 · Corrected (the home has a date of correction)
- E
Have proper medical gas storage and administration areas.
K 923 · October 7, 2022 · Corrected (the home has a date of correction)
- E
Ensure proper storage of liquid oxygen.
K 930 · October 7, 2022 · 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 · October 7, 2022 · Corrected (the home has a date of correction)
- D
Ensure proper usage of power strips and extension cords.
K 920 · October 7, 2022 · Corrected (the home has a date of correction)