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 45 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
1G
0H
0I
Potential for more than minimal harm
30D
11E
3F
Potential for minimal harm
0A
0B
0C
January 23, 2026Standard inspection · 7 citations
- E
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medical records for three of five sampled residents (Residents 1, 5, and 7) were accurate, complete and readily accessible by failing to: 1. Document Resident 1 received Restorative Nursing Aide program (RNA, nursing aide program that help residents to maintain their function and joint mobility) treatment on 12/19/2025, 12/26/2025, 1/13/2026, and 1/19/2026. 2. Document Resident 5 received RNA treatment on 12/26/2025, 12/31/2025, and 1/19/2026. 3. Document Resident 7 received RNA treatment on 12/26/2025, 12/31/2025, and 1/19/2026. 4. Clarify daily dose of Risperdal ([Generic name - Risperidone] a medication used to treat bipolar disorder [sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs]) for Resident 1. [...]
- E
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Inspectors wroteBased on observation, interview, and record review the facility failed to maintain an effective pest control program to prevent the infestation of gnats (fruit flies: flying, winged insects) by not ensuring a sanitary environment for three of five residents (Residents 6, 22, and 69). This deficient practice had the potential to cause an increased risk of pest infestation, which could compromise infection control measures and negatively impact the health, safety, and well-being of 73 residents that reside in the facility.
- 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 interview and record review, the facility failed to develop an individualized care plan with measurable objectives, timeframes, and interventions to meet the resident's needs for one of three sampled residents (Resident 34). The facility failed to include goals and interventions related to Resident 34's antibiotic therapy (medication prescribed to treat infection). This deficient practice had the potential to negatively impact on the delivery of necessary care and services to Resident 34.
- D
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of five sampled residents (Residents 22) received appropriate services to prevent a decline in range of motion (ROM, full movement potential of a joint) and mobility by failing to provide Resident 22 Restorative Nursing Aide (RNA, nursing aide program that help residents to maintain their function and joint mobility) treatment for ambulation (walking) on 1/19/2026. This deficient practice had the potential for Resident 22 to decline in ambulation and overall physical functioning.
- 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 observation, interviews, and record review, the facility failed to ensure that six discontinued medication orders, contained in seven medication bubble packs for Resident 92 who was discharged from the facility more than two years ago were removed from medication storage and properly disposed of in accordance with the facility's policy and procedure titled Medication Destruction (revision date: 01/2025). This deficiency affected one of five sampled medication storage locations (Director of Nursing [DON] office). This deficient practice of failing to ensure removal of discontinued medications that could be expired, ineffective or toxic increased the risk for misuse and drug diversion of Resident 92's medications.
- D
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 maintain the ice machine and scoop bucket under sanitary conditions. The facility failed to:1. Ensure the ice machine does not contain black dust-like substances during inspection.2. Ensure the scoop bucket was clean and sanitary, which had multiple stains in black, brown, and pink colors. This deficient practice had the potential to cause food-borne illnesses (illness caused by food contaminated with bacteria, viruses, parasites, or toxins ).
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview, and record review the facility failed to ensure:Certified Nursing Assistant (CNA) 1 was wearing gloves when handling soiled linen. Clean linen carts were accessed only by facility staff. Staff performed hand hygiene after touching the trash can lid to open the trash receptacle. This failure had the potential to increase the risk of infection and cross-contamination (the transfer of bacteria, viruses, microorganisms, or other harmful substances from one surface to another through improper or unsanitary equipment, procedures, or products) among residents.
July 23, 2025Complaint inspection · 1 citation
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on interview, and record review, the facility failed to ensure one of three sampled residents (Resident 1), who was assessed at risk for falls, and who had Care Plan interventions indicating Resident 1's bed to be in a low position, did not fall. This failure resulted in Resident 1 having an unwitnessed fall from her bed on 7/13/2025 and because of the fall, Resident 1 sustained an abrasion (wound caused by rubbing or scraping the skin against a rough surface) and redness to her forehead, and bilateral knee. Resident 1's bed was found at medium height level (approximately three feet from the floor) per the facility's Post Fall Evaluation dated 7/13/2025, upon her fall. Resident 1 was subsequently transferred to a General Acute Hospital (GACH) for evaluation of her injuries on 7/13/2025 via 911 (emergency transportation). [...]
November 23, 2024Standard inspection · 18 citations
- F
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Inspectors wroteBased on interview and record review the facility's Quality Assessment and Assurance (QAA committees established for the purpose of improving the safety and quality of health services) and Quality Assurance Performance Improvement (QAPI- approach to maintain and improve safety and quality in nursing homes) committee failed to implement corrective action to the potential systemic problems identified: 1. Maintain a system to monitor weight loss. 2. Maintain a system to ensure the reporting of falls with major injury. 3. Maintain a system to ensure pressure injury (localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence) preventive measures were implemented.
- E
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure: a. Ensure Restorative Nursing Aides (RNA- trained nursing staff who help residents gain an improved quality of life by increasing their level of strength and mobility) 1 was competent to perform passive range of motion (PROM, movement at a given joint with full assistance from another person) exercises to Resident 2's both arms. b. Ensure RNA 1 was competent to perform PROM exercises to Resident 18's right arm. These failures had the potential to cause resident pain, harm, injury, and inefficient delivery of ROM exercises resulting in decreased the range of motion and function for residents receiving RNA services. c. Performance Evaluation was completed on Registered Nurse (RN)4 and Licensed Vocational Nurse according to facility's policy and procedure. [...]
- E
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Inspectors wroteBased on interview and record review the facility failed to accurately account for the use of controlled substances (medications with a high potential for abuse) for three out of four sampled residents (Resident 31, Resident 46, and Resident 12) reviewed. 1. Resident 31, the facility failed to accurately account for the administration of a lorazepam 0.5 milligrams ([mg-unit of measurement] a controlled substances used to relieve anxiety, a mental disorder characterized by persistent feelings of worry, nervousness, or unease strong enough to interfere with daily activities) on 10/5/2024 and 10/6/2024. 2. Resident 46, the facility failed to accurately account for the administration of tramadol (a controlled substances used to treat moderate to severe pain) 50 mg on 10/5/2024. 3. Resident 12, the facility failed to accurately account for the administration of tramadol 50 mg on 10/2/2024. [...]
- E
Ensure medication error rates are not 5 percent or greater.
- E
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the standardized recipes for lunch menu was followed on 11/19/202024 when: 1. Facility failed to ensure five residents on mechanical soft chopped diet (for residents who have limited chewing ability and intact swallowing ability) received Chicken alfredo texture in the form that meet their needs when the broccoli was not chopped and there were large pieces of chicken and pasta in the Chicken alfredo. (chicken measured at 1.5 inches using a ruler). 17 residents who were on mechanical soft ground diet received chopped chicken alfredo instead of the ground chicken alfredo per the food production guides (food portion and serving guide). [...]
- E
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on observation, interview and record review, the facility failed to ensure safe and sanitary food storage and food preparation practices in the kitchen when: 1. Nutritional supplement labeled store frozen with manufactures instruction to use within 14 days of thawing, were not monitored for the date they were thawed to ensure expired shakes were discarded after this time frame. One box 30 single serve cartons of vanilla flavored high protein nutrition supplement and another box with 30 single serve cartons of sugar free chocolate high calorie nutrition supplements were stored in the walk-in refrigerator with no thaw date. This failure had the potential to result in food borne illnesses (any illness resulting from eating contaminated/spoiled foods) in 16 residents who were receiving nutrition supplements at the facility. 2. [...]
- D
Keep residents' personal and medical records private and confidential.
Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain right to privacy for one of six sampled residents (Resident 25) by failing to ensure privacy curtains was long enough to cover the resident's room during wound care dressing change. This failure violated Resident 25's right to privacy and had the potential for Resident 25 feeling of embarrassment.
- 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, interview, and record review the facility failed to ensure two of 27 sampled residents (Resident 1 and Resident 49), was provided a safe, clean and homelike environment by failing to provide a room that did not have peeling paint and exposed wall on the bedroom walls. This deficient practice had the potential for Resident 1 and Resident 49 to affect the residents' dignity, mood, and violation of residents' rights to have a homelike environment.
- 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 ensure one of 18 sampled residents (Resident 39) unwitnessed fall that caused a right hip fracture (a break or crack in a bone), required surgical repair and hospitalization at a General Acute Care Hospital (GACH) for four days (9/10/2024 to 9/14/2024) was reported to the state agency (California Department of Public Health [CDPH]). This failure resulted in a delay of an onsite investigation by CDPH to ensure Resident 39's fall was investigated and prevent further falls.
- D
Assess the resident when there is a significant change in condition
Inspectors wroteBased on interview and record review the facility failed to ensure Minimum Data Set Coordinator (MDSC) completed a significant change in status assessment (SCSA- a comprehensive assessment that must be completed when the Interdisciplinary Team [IDT- team of healthcare professionals who discuss and manage resident's care] has determined that a resident meets the significant change guidelines to either major improvement or decline) to one of six sampled residents (Resident 25). This failure had the potential for not providing appropriate care and services to Resident 25.
- D
Ensure each resident receives an accurate assessment.
Inspectors wroteBased on interview and record review the facility failed to ensure two of 18 sampled Residents (Resident 39 and 68 ) entry on the Minimum Data Set (MDS -resident assessment tool) assessment entries were accurate. The facility failed to: a. Ensure Section M in the MDS titled Skin Conditions was accurately documented to reflect Resident 39's current skin condition. b. Ensure Resident 68 discharge status was accurately documented to reflect Resident 68 was discharged home. This failure had the potential to result in a negative effect of Resident 39 and 68's plan of care and delivery of necessary care and 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 wroteb. During a review of Resident 46's admission record, the admission Record indicated Resident 46 was initially admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses including Diabetes Mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing) and osteomyelitis (inflammation of bone, usually due to infection). During a review of Resident 46's History and Physical (H&P), dated 9/13/2024, the H&P indicated Resident 46 had the capacity to understand and make decisions. During a review of Resident 46's Minimum Data Set (MDS - a resident assessment tool), dated 9/19/2024, the MDS indicated Resident 46 was able to understand and be understood by others. [...]
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on interview and record review, one of one sampled resident (Resident 46) received treatment and care when Resident 46 experienced two hypoglycemic (low blood sugar) events (7/18/2024 and 8/18/2024). The facility failed to: a. Conduct and Interdisciplinary Team (IDT- team of health care professionals that work together toward and prioritize the resident's needs) meeting after Resident 46 experienced two hypoglycemic (low blood sugar) events (7/18/2024 and 8/18/2024). b. Activate the emergency response system on 8/18/2024 when Resident 46's continues to be unresponsive after interventions. This failure had the potential to result in Resident 46 experiencing repeated hypoglycemic events, diabetic coma (a life-threatening condition that occurs when someone with diabetes [ DM a disorder characterized by difficulty in blood sugar control and poor wound healing]), including death.
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a resident, who was assessed at a moderate risk (a scoring tool used to predict residents' risk of developing a pressure injury, total scores range from six to 23. [...]
- D
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of five sampled residents (Resident 2) were provided a resting hand splint (splint [rigid material or apparatus used to support and immobilize a broken bone or impaired joint] secured from the hand to the forearm to position the hand in a functional position) to Resident 2's left arm and a hand roll splint (splint placed in the palm of the hand used to position the hand in a functional position) to Resident 2's right hand in accordance with Occupational Therapy (OT, profession that provides services to increase and/or maintain a person's capability to participate in everyday life activities) recommendations on 6/28/2024. [...]
- D
Provide enough food/fluids to maintain a resident's health.
Inspectors wroteBased on observation, interview and record review, the facility failed to prevent the resident's unplanned weight loss of 9.2 percent (%) in three months and greater than 10 % in six months for one of two sampled residents (Resident 25). The facility failed to: a1 Ensure staff identified Resident 25's decrease oral intake (amount of food and water consumed), reassess, and monitor interventions to prevent a weight loss when Resident 25 had a weight loss of 15 pounds (lbs. unit of weight) from 5/7/2024 to 9/7/2024. 2. Ensure the nursing staff reported a decrease in Resident 25's oral intake to Resident 25's physician (MD1), in accordance with the Care Plan titled, Altered Nutrition/Hydration Status and Unplanned/ Unexpected weight loss of 4.8 percent (%) in one month on 9/7/2024, 9.2 % loss in three months and 10.5 % in six months on 11/11/2024. 3. [...]
- D
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents, who were on pureed (food that had been mashed, ground, crushed until it is smooth and has the consistency of a creamy paste) diet received food consistent with diet order and according to the pureed menu recipe for one of 12 sampled residents (Resident 25. This failure had the potential to put Resident 25 at high risk for aspiration (condition when food, liquid, or other material enters a person's airway [passageway for air] and eventually the lungs), choking (life threatening condition where an object such as food lodges in the throat blocking the flow of air), and possible death.
- 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, interview, and record review, the facility failed to ensure clinical records were accurately documented for one of five samples residents (Resident 2). The facility failed to: a Ensure Resident 2's Occupational Therapy (OT, profession that provides services to increase and/or maintain a person's capability to participate in everyday life activities) discharge recommendations for a resting hand splint (splint [rigid material or apparatus used to support and immobilize a broken bone or impaired joint] secured from the hand to the forearm to position the hand in a functional position) to Resident 2's left arm and a hand roll splint (splint placed in the palm of the hand used to position the hand in a functional position) to Resident 2's right hand to be worn for four (4) hours on and 4 hours off (removed) on 6/28/2024 were accurately documented. b. [...]
May 7, 2024Complaint inspection · 1 citation
- G
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on interview and record review the facility failed to ensure the resident, who was assessed as a high risk for developing a pressure ulcer (prolonged pressure on the skin that results in injury to the skin and underlying tissue, usually occur over bony prominence because of long-term pressure), did not develop a deep tissue injury ([DTI] (purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure) on the right heel for one of three sampled residents (Resident 1). The facility failed to: 1. Ensure Resident 1 was turned and repositioned every two hours and provided with a pressure reducing device in bed. 2. [...]
November 3, 2023Standard inspection · 18 citations
- 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 store food in a sanitary manner to prevent growth of microorganisms (an organism that can be seen only through a microscope) that could cause food borne illness (food poisoning: any illness resulting from the food spoilage of contaminated food, disease causing bacteria, viruses, or parasites that contaminate food, as well as toxins) for 70 out 73 total residents in the facility by not: 1. ensuring Foods were dated, labeled, properly sealed, and discarded before the used by date (expiration dates). 2. monitoring and documenting the temperature for the facility's freezers. 3. maintaining a clean environment around the dumpsters outside. 4. monitoring and documenting sanitization bucket log. 5. [...]
- F
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation,interview, and record review the facility failed to: A. Follow their own policy and procedures (P/Ps) titled, Glove Use - Personal Protective Equipment, and Hand Washing - Hand Hygiene to ensure licensed nurses wash or sanitized their hands after removing gloves and before putting on a new pair of gloves. This deficient practice had the potential to expose one out of four residents (Resident 270) to contaminants and infection. B. Clean two of two cloth gait belts (assistive device used for lifting, transferring, and walking patients who have limited mobility issues) in accordance with the manufacturer's recommendations for sanitizing wipes (pre-moistened towelettes that contain a sanitizing or disinfecting formula that kill or reduce germs on surfaces) in-between residents' use with three of 19 sampled residents (Resident 1, 6, and 7). [...]
- E
Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.
Inspectors wroteBased on observation, interview and record review, the facility failed to ensure: A. Dietary Aid (DA) 1 who worked as a cook to fill in the absences of the morning (AM) shift cook had an appropriate competencies and skills set to carry out the duties of a cook for four out of 70 total sampled residents in the facility by not: 1. providing a fortified (added vitamins and minerals that are not naturally present in those foods) diet for Resident 59. 2. providing mechanical soft diet (a diet that was designed for people who have trouble chewing and swallowing) for Resident 48 and Resident 9. This failure resulted in DA 1 not preparing and serving meals as ordered by the physician, to prevent unintended weight loss and accidents such as chocking and aspiration (when food or liquid enters the person's airway and eventually the lungs causing severe illness).
- E
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Inspectors wroteBased on observation interview and record review the facility failed to ensure the written diet menu instructions were followed for two of 45 sampled residents (Resident 59 and Resident 171) when making soup for Resident 59 and failed to honor Resident 171's food preferences. This failure had the potential to result in weight loss for Resident 59 and Resident 171 by not receiving the nutrition they needed for a therapeutic diet (a diet ordered by a physician or delegated registered or licensed dietician as part of treatment for a disease or clinical condition, or to eliminate or decrease specific nutrients in the diet, (e.g., sodium) or to increase specific nutrients in the diet (e.g., potassium), or to provide food the resident is able to eat (e.g., a mechanically altered diet (a diet in which the texture of a diet is altered). [...]
- E
Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.
Inspectors wroteBased on observation, interview, and record review, the facility failed to provide lunch at the facility's established mealtime on 10/31/2023, which included five of five meal carts leaving the kitchen at least 42 minutes late. This deficient practice caused one of 10 sampled residents (Resident 169) for dining observation to feel hungry.
- E
Put firmly secured handrails on each side of hallways.
Inspectors wroteBased on observation, interview, and record review, the facility failed to secure a handrail to the wall on 11/2/2023 and 11/3/2023. This failure had the potential to cause injury for residents who require the use of the handrail for balance and safety.
- 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 maintain respect and dignity on one of three sampled residents (Resident 9) by standing over the resident while assisting her during a meal. This failure had the potential to result in decreased self-esteem and self-worth on Resident 9.
- D
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Inspectors wroteBased on observation, interview, and record review, the facility failed to identify, appropriately assess, and monitor two of two sampled residents (Resident 18 and Resident 270) during the use of wedges (foam devices used to position residents, that have one thick end and taper to a thin edge) to prevent residents from sliding and falling from the bed. This failure had the potential to result in entrapment (being caught in) and injury.
- D
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Inspectors wroteBased on observation, interview, and record review, the facility failed to develop a comprehensive care plan for one of six sampled residents (Resident 4) with limited range of motion [ROM, full movement potential of a joint (where two bones meet)]. This failure had the potential to prevent Resident 4 from receiving intervention and equipment to prevent a decline in ROM in both arms and both legs.
- 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 meet professional standards of quality of care for one of four residents (Resident 270) by failure to follow the facility's policy and procedures (P&Ps) titled, Feeding Tube - Administration of Medication, and Medication Administered through an Enteral Tube, to ensure medications was administered appropriately and safely to residents receiving medication through a gastrotomy/feeding tube (G-Tube, a tube inserted through the belly that brings nutrition and medication directly to the stomach). This failure had the potential to result in clogging and of medications in the G-tube and increased the risk for medication related complications for Resident 270.
- D
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of six sampled residents (Resident 3) with limited range of motion [ROM, full movement potential of a joint (where two bones meet)] received passive range of motion (PROM, movement of joint through the ROM with no effort from the person) exercises to the right leg from 8/29/2023 to 10/31/2023. This failure had the potential for Resident 3 to experience a decline in ROM and development of contractures (chronic joint stiffness associated with joint deformities and pain).
- D
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Inspectors wroteBased on interview and record review, the facility failed to ensure one of six sampled residents (Resident 174) was free from unnecessary medications by failing to clarify with Resident 174's physician the need of continuance of antibiotic (medication to treat infection) medication after a negative chest x-ray result. This failure had the potential for Resident 174 to develop antibiotic resistance (not effective to treat infection) from unnecessary or inappropriate antibiotic use.
- D
Ensure medication error rates are not 5 percent or greater.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure it was free of medication error rate of five percent or greater as evidence by two out of 32 opportunities for error to yield medication error of 6.25 percent (%) for one out of four residents (Resident 270) observed during medication pass (MedPass). This failure resulted in Licensed Vocational Nurse (LVN 1) administering prescribed eye drops for Resident 270 into the wrong eye creating the potential for the resident's glaucoma (a condition in which the pressure in the eye is too high) to worsen (symptoms include, eye pain and pressure, headaches, and vision loss).
- D
Provide or obtain dental services for each resident.
Inspectors wroteBased on observation, interview and record review, the facility failed to follow up necessary dental service for one of three sampled residents (Resident 7). This failure had resulted in delay of dental services and the potential to cause Resident 7 at risk for difficulty chewing and weight loss.
- D
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
Inspectors wroteBased on observation, interview and record review, the facility failed to: 1. Ensure therapeutic diets of mechanical soft (a diet that was designed for people who have trouble chewing and swallowing, chopped, ground and pureed foods [cooked and blended into a smooth, creamy consistency] as well as foods that break apart without a knife) were served as prescribed by the physician for two of 22 sampled residents (Resident 48 and Resident 9) This failure had the potential for Resident 48 and Resident 9 to choke and aspirate (food, liquid, or other material enters a person's airway and eventually the lungs by accident).
- D
Implement a program that monitors antibiotic use.
Inspectors wroteCross referenced F757 Based on interview and record review, the facility failed to implement their protocol for antibiotic stewardship for one of six sampled residents (Resident 174) by prescribing antibiotic (drug that treats infection) without meeting the criteria (checklist used for Infection surveillance) for respiratory tract infection (infection affecting the lungs) used in the facility. This failure had the potential for Resident 174 to develop antibiotic resistance (not effective to treat infection) from unnecessary or inappropriate antibiotic use.
- D
Keep all essential equipment working safely.
Inspectors wrote1. Ensure one of three sampled residents (Resident 37) wheelchair's brakes was in operating condition. This failure had the potential to cause injury and fall to Resident 37 who used the wheelchair for mobility. 2. Ensure therapy equipment in the rehabilitation room were properly functioning, including one of one mechanical treatment mat (cushioned mat used in therapy that allows the therapist to customize the surface to different heights), one of one combination ultrasound (use of sound waves to penetrate soft tissues which increases blood flow) and electrical stimulation (use of mild electrical pulses through the skin to help stimulate injured muscles or manipulate nerves to reduce pain) combination machine. These failures had the potential to place residents receiving therapy services from safe and optimal use of the therapy equipment.
- D
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Inspectors wroteBased on observation interview and record review the facility failed to ensure one of 19 sampled residents (Resident 6) was provided a safe environment by not repairing the transition strip (strips that cover the gap between two different floor types) on Resident 6's bedroom floor. This failure had the potential to result in serious injury related to slips, trips and falls for Resident 6, staff, and visitors.
Fire safety inspections
11 fire safety citations on file: 7 on January 23, 2026, 3 on November 23, 2024, 1 on November 3, 2023.
Every fire safety citation11 citations
- E
Inspect, test, and maintain automatic sprinkler systems.
K 353 · January 23, 2026 · Corrected (the home has a date of correction)
- E
Have properly installed electrical wiring and gas equipment.
K 511 · January 23, 2026 · Corrected (the home has a date of correction)
- E
Ensure proper usage of power strips and extension cords.
K 920 · January 23, 2026 · Corrected (the home has a date of correction)
- D
Keep aisles, corridors, and exits free of obstruction in case of emergency.
K 211 · January 23, 2026 · Corrected (the home has a date of correction)
- D
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
K 321 · January 23, 2026 · Corrected (the home has a date of correction)
- D
Install corridor and hallway doors that block smoke.
K 363 · January 23, 2026 · Corrected (the home has a date of correction)
- D
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
K 761 · January 23, 2026 · Corrected (the home has a date of correction)
- D
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
K 321 · November 23, 2024 · Corrected (the home has a date of correction)
- D
Have a complete alarm system manually initiated and initiated by fire sprinkler system connection.
K 342 · November 23, 2024 · 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 · November 23, 2024 · Corrected (the home has a date of correction)
- E
Have a fire alarm with audible and visual signals that transmits the alarm automatically to notify emergency forces in event of fire.
K 343 · November 3, 2023 · Corrected (the home has a date of correction)