Health inspections
Federal rules call for a standard inspection at least every 15 months, plus a visit whenever a complaint is filed. Each mark below is one citation, colored by how serious inspectors rated it. How to read a citation.
Under each citation, the quoted text is the inspector's own summary from the federal statement of deficiencies (CMS form 2567), word for word apart from a privacy scrub; CMS removes residents' and staff names before it publishes the text. The full notes are on Medicare.gov.
Potential for minimal harm Potential for more than minimal harm Actual harm Immediate jeopardy Found on a complaint visit
Where its citations fall on CMS's grid
CMS rates every citation by how much harm it caused (rows) and how many residents it touched (columns). The count in each box is this home's, across all 53 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
1G
0H
0I
Potential for more than minimal harm
33D
16E
2F
Potential for minimal harm
0A
0B
1C
April 22, 2026Complaint inspection · 4 citations
- D
Allow resident to participate in the development and implementation of his or her person-centered plan of care.
Inspectors wroteBased on interview and record review, the facility failed to incorporate resident's and resident representative's preferences for medical oversight into the plan of care for 1 of 3 residents (Resident 2) reviewed for resident rights. This failure placed residents at risk of suboptimal clinical outcomes, medical complications and frustration.
- 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 provide complete medical records upon request for 2 of 3 residents (Resident 1 and 2) reviewed for medical records. This failure placed residents at risk of lack of knowledge of their medical condition, continuity of care and frustration.
- 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 recognize potential diabetic complications for 1 of 3 residents (Resident 1) and failed to determine and document cause and treatment for a skin tear for 1 of 3 residents (Resident 2) reviewed for quality of care. This failure placed residents at risk of medical complications, infection and a decreased quality of life.
- 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 accurately document the amount of food eaten for 2 of 3 residents (Resident 3 and 4) reviewed for documentation. This failure placed residents at risk for inaccurate medical records, clinical assessments and lack of clinical interventions.
January 28, 2026Complaint inspection · 1 citation
- 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 follow their bowel protocol by not administering necessary bowel medications per policy and provider orders for 1 of 4 residents (Resident 1) reviewed for constipation. This failure placed residents at risk of constipation, rehospitalization, and a diminished quality of life.
June 26, 2025Complaint inspection · 2 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 were complete and accurate for 3 of 3 residents (Resident 1, 2 and 3). This failure placed residents at risk for incomplete and inaccurate medical records and unmet care needs.
- D
Limit the charges against residents' personal funds for items or services for which payment is made under Medicare or Medicaid.
Inspectors wroteBased on interview and record review, the facility failed to notify residents of what the charge would be for services not covered under their Medicare Managed Care and/or private pay agreements for 1 of 1 resident (Resident 3) reviewed for billing practices. This failure put residents at risk of unknown service costs, frustration and lack of services.
May 9, 2025Standard inspection · 15 citations
- E
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and/or implement comprehensive care plans for 5 of 23 sampled residents (Residents 104, 20, 72, 7 and 114) whose care plans were reviewed. Failure to develop/implement a comprehensive care plan related to activities, pain, edema (fluid build-up causing swelling), and personal hygiene placed the resident at risk for unmet needs and a diminished quality of life.
- E
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteResident 7 Resident 7 admitted to the facility on [DATE] with diagnoses that included chronic kidney disease (a long-term disease where the kidneys cannot filter the blood properly), dependence on renal dialysis (a treatment to remove extra fluid from the body), and localized edema (swelling in specific areas in the body). The minimum data set (MDS), an assessment tool, dated 04/21/2025, showed Resident 7 was able to make needs known. Review of provider orders showed Resident 7 had an order to wear compression stockings every day for edema. Review showed compression stockings were ordered to be put on in the morning and removed at bedtime. Observation on 05/05/2025 at 2:15 PM showed Resident 7 with moderate edema to both feet. Resident 7 was sitting up in their wheelchair with feet on the floor. Resident 7 did not have compression socks on. [...]
- E
Provide enough food/fluids to maintain a resident's health.
Inspectors wroteBased on observation, interview, and record review, the facility failed to monitor residents' fluid intake and provide the amount of fluid per provider's orders for 2 of 2 sampled residents (Residents 7 and 381) when reviewed for nutrition/hydration. This failure placed residents at risk of fluid overload, avoidable pain, and a diminished quality of life.
- E
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure oxygen tubing was dated and regularly changed for 3 of 3 sampled residents (Residents 7, 112 and 87) when reviewed for respiratory care. This failure placed residents at risk for unmet care needs, medical complications, and a diminished quality of life.
- 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 provide an opportunity for a resident to see the new location and meet new roommates for 1 of 1 Sample Resident (Resident 31) when reviewed for room changes. This failure placed residents at risk for psychosocial decline and diminished quality of life.
- 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 interview and record review, the facility failed to obtain a court-appointed guardianshipyes (legal process where a court appoints someone to make decisions for a person who is unable to do so for themselves) and/or to obtain and periodically review a resident's advanced directive (AD, a legal document that establishes a medical decisionmaker if you are unable to make decisions for yourself) for 2 of 3 sampled residents (Residents 14 and 99) when reviewed for advanced directive. This failure placed residents at risk of not having an established decisionmaker, lack of ability to direct care, and a diminished quality of life.
- D
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
Inspectors wroteBased on observation, interview, and record review, the facility failed to prevent the use of chemical restraints for 1 of 5 sampled residents (Resident 83) reviewed for unnecessary medications. This failure placed residents at risk of side-effects from the medications, unnecessary chemical restraints, and a diminished quality of life.
- 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 identify and report an allegation of abuse for 1 of 1 sampled resident (Resident 31) when reviewed for abuse. This failure placed residents at risk for unidentified and repeated potential abuse, neglect and a diminished quality of life.
- 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 interview and record review, the facility failed to provide and/or maintain documented care conferences in a timely manner for 2 of 3 sampled residents (Residents 72 and 77) when reviewed for care planning. This failure placed residents at risk for unmet care needs and a diminished quality of life.
- 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 ensure services provided met professional standards of practice by accurately documenting behavior monitoring for 1 of 3 residents (Resident 83) reviewed for dementia care. This failure placed residents/staff at risk of unmet care needs, unnecessary medications, and a diminished quality of life.
- D
Assist a resident in gaining access to vision and hearing services.
Inspectors wroteBased on interview and record review, the facility failed to provide prompt services to maintain vision for 1 of 3 sampled residents (Resident 23) when reviewed for communication/sensory. This failure placed the resident at risk of unmet vision needs, inability to perform activities of daily living, inability to participate in leisure activities and a diminished quality of life.
- 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 residents with limited range of motion received the necessary services to maintain their level of functioning and/or prevent decline for 1 of 3 sampled residents (Resident 31) when reviewed positioning/mobility. This failure placed the residents at risk for decreased range of motion (ROM), increased pain, and diminished quality of life.
- 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 accurately assess and monitor pain for 2 of 4 residents (Residents 20 and 89) when reviewed for pain management. This failure placed the residents at risk for unidentified and unmanaged pain and a decreased quality of life.
- D
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents who experienced dementia-related behaviors received care and services to attain the highest practicable physical, mental, and psychosocial well-being when it did not identify and implement person-centered, individualized interventions for 1 of 3 sampled residents (Resident 83) when reviewed for dementia care. This failure placed residents at risk of unmet care needs, unnecessary medications, and a diminished quality of life.
- C
Post nurse staffing information every day.
Inspectors wroteBased on observation, interview, and record review, the facility failed to post the scheduled and actual hours worked for the nursing staffing hours daily for 4 of 4 observed days during the survey period (05/05/2025-05/08/2025) when reviewed for nurse staff posting. This failure prevented the residents, family members, and visitors from exercising their rights to know the scheduled and actual numbers of available nursing staff in the facility.
March 18, 2025Complaint inspection · 2 citations
- D
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Inspectors wroteBased on interview and record review, the facility failed to promptly resolve grievances for 1 of 5 sample residents (Resident 1) reviewed for grievances and missing property. The failure to thoroughly investigate a grievance and either resolve the resident grievance timely or provide an explanation if the grievance could not be resolved placed residents at risk for frustration and a diminished quality of life.
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on interview, and record review the facility failed to ensure 1 of 3 sample residents (Resident 1) reviewed for Pressure Ulcers (PU - injury to the skin and underlying tissue due to prolonged pressure) received the necessary care and services, consistent with professional standards of practice, to prevent new ulcers from developing, identify and treat PUs. Failure to implement wound prevention, interventions, and to report on worsening conditions, placed residents at risk for deteriorating PU, increased discomfort, and a diminished quality of life.
October 25, 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 evaluate the effectiveness of fall prevention interventions, need for additional action, and/or attempt to mitigate envionmental modifications preferred by the resident that presented a risk to safety for 1 of 3 sampled residents (Resident 1) reviewed for accidents and hazards. Resident 1 experienced harm when they fell out of bed and sustained a neck fracture. This failure placed residents at risk for falls, injury and a diminished quality of life.
September 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 observation, interviews and record review, the facility failed to protect a resident's right to be free from mental and verbal abuse for 1 of 3 sample residents (Resident 2) reviewed for resident to resident altercation. This failure placed residents at risk of verbal and mental abuse, psychosocial harm, and diminished quality of life.
June 5, 2024Standard inspection, Complaint inspection · 15 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 on observation, interview, and record review, the facility failed to ensure proper labeling of insulins in 1 of 4 medication carts (700-hall Medication Cart) reviewed for medication storage. This failure placed residents at risk for receiving expired medications, ineffective medications, and a diminished quality of life.
- 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 and interview, the facility failed to ensure foods were sanitarily stored in the kitchen and 3 of 4 resident refrigerators (Ocean, Mountain, and Narrows Dining) when reviewed for kitchen. These failures placed residents at risk of consuming contaminated foods, avoidable foodborne illness, and a diminished quality of life.
- E
Ensure that residents are fully informed and understand their health status, care and treatments.
Inspectors wroteBased on interview and record review the facility failed to have psychotropic (medications that affect a person's mental state) medication consents signed and in place prior to resident receiving medications for 3 of 5 sampled residents (Residents 40, 78 & 119) reviewed for psychotropic medication use. This failure placed the residents at risk for adverse side effects and diminished quality of life.
- E
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 ensure that residents received treatment and care in accordance with professional standards of practice for 5 of 25 sampled residents (Residents 107, 30, 42, 78, and 2) reviewed for quality of care. Failure to consistently monitor and document edema (swelling caused by too much fluid trapped in the body's tissues) for Resident 107 and 30, provide management of a surgical wound for Resident 42, ensure adequate positioning was provided for Resident 78, and notify the provider of an acute change in respiratory status for Resident 2 placed the residents at risk for worsening conditions, discomfort, and a decreased quality of life.
- E
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 resident environments were free from accident hazards for 3 of 6 sampled residents (Residents 121, 68, and 4) when reviewed for accident hazards. The facility failure to secured medications (Resident 121), investigate falls and implement fall precautions (Resident 68), and ensure bedrails were firmly installed (Resident 4) placed residents at risk of avoidable injury, hospitalization, and a diminished quality of life.
- E
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Inspectors wroteBased on interview and record review, the facility failed to offer, educate, and obtain consent for influenza and/or pneumococcal vaccines for 5 of 5 residents (Residents 74, 90, 102, 108, and 120) when reviewed for influenza and pneumococcal immunizations. These failures denied residents the opportunity to make an informed decision regarding receiving immunizations and/or placed the residents at risk for communicable diseases, complications of other medical conditions, hospitalization, and death.
- E
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 interview and record review, the facility failed to offer, educate, and obtain consent for Covid-19 vaccinations for 5 of 5 residents (Residents 74, 90, 102, 108, and 120) when reviewed for immunizations. This failure denied residents the opportunity to make an informed decision regarding receiving Covid-19 vaccines and/or placed the residents at risk for complications, hospitalization, and a decreased quality of life.
- E
Keep all essential equipment working safely.
Inspectors wroteBased on observation and interview, the facility failed to maintain kitchen equipment in safe working order for a griddle/oven combo unit and 1 of 4 freestanding refrigerators when reviewed for kitchen. These failures places residents at risk of eating contaminated food, avoidable foodborne illness, fire injury, smoke inhalation, and a diminished quality of life.
- E
Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame.
Inspectors wroteBased on observation and interview, the facility failed to inspect bedrails as part of a regular maintenance program. This failure placed residents at risk of falling, entrapment, avoidable injury, and a diminished quality of life.
- 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 ensure residents were free from physical restraints with the use of a mobility device for 1 of 3 sampled residents (Resident 78) when reviewed for physical restraints. This failure placed residents at risk for avoidable injury, psychological harm, and decreased quality of life.
- D
Ensure each resident receives an accurate assessment.
Inspectors wroteBased on interview and record review, the facility failed to accurately assess a pressure ulcer/skin condition for 1 of 3 sampled residents (Resident 7) reviewed for pressure injury. This failure placed the resident at risk for health complications and diminished quality of life.
- 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 ensure services provided met professional standards of practice for 3 of 4 sampled residents (Residents 2, 88 & 28) reviewed for anticoagulant (blood thinner medication) use and/or indwelling urinary catheter (IUC, a tube inserted in the body to empty the bladder of urine) care. The facility failed to ensure Resident 28 and 88's provider's orders for IUC were in place and/or accurate, and Resident 2's anticoagulant monitoring for side effects were documented. These failures placed residents at risk of medical complications, unmet needs, and a poor quality of life.
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on observation, interview, and record review, the facility failed to provide necessary treatment to heal pressure injuries for 1 of 3 sampled residents (Resident 7) reviewed for pressure injuries. This failure placed the resident at risk for worsening pressure injury, infection, and diminished quality of life.
- D
Provide enough food/fluids to maintain a resident's health.
Inspectors wroteBased on interview and record review, the facility failed to ensure a fluid restriction for provided and monitored for 1 of 3 sampled residents (Resident 54) reviewed for nutrition. This failure placed the resident at risk of fluid overload, avoidable swelling, and a diminished quality of life.
- 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 interview and record review, the facility failed to ensure as needed (PRN) psychotropic medications (affecting the mind) were limited to 14 days for 1 of 5 sampled residents (Resident 6) when reviewed for unnecessary medications. This failure placed the residents at risk for receiving unnecessary psychotropic medication, avoidable medication side effects, and a diminished quality of life.
March 12, 2024Complaint inspection · 2 citations
- E
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on observation and interview, the facility failed to maintain the alarm function of two of three emergency exits, open to the outside and leading off the facility property, (600 hall and 700 hall) reviewed for safety/accident prevention. This failure placed cognitively impaired residents, residents who wander and have exit-seeking behaviors, at risk for being able to leave the facility unnoticed by staff, placing their safety at risk.
- E
Provide and implement an infection prevention and control program.
Inspectors wroteBased on interview and record review, the facility failed to implement an infection control and prevention program that ensured that staff were fit tested (a process for determining whether a respirator properly fits the face of the person who wears it) for N-95 respirators (a type of disposable face mask that forms a tight seal to the face and is able to filter out airborn particles and pathogens [bacteria, virus, or other microorganism that can cause disease]) upon hire, and annually thereafter, for six of six staff (Staff D, G, H, I, J, and K) reviewed for N-95 respirator fit testing. In addition, these staff were working with residents during a COVID-19 (contagious respiratory disease caused by the SARS-CoV-2 virus) outbreak in the facility. This failure placed residents and staff at risk for exposure to, and spread of, communicable diseases such as COVID-19.
December 4, 2023Complaint inspection · 1 citation
- D
Respond appropriately to all alleged violations.
Inspectors wroteBased on interviews and record reviews, facility failed to ensure a resident-to-resident altercation was identified and investigated for 1 of 4 residents (Resident 1) reviewed for abuse allegations. Failure to identify and thoroughly investigate an abuse allegation placed residents at risk for recurrence of alleged abuse and a diminished quality of life.
August 17, 2023Standard inspection · 9 citations
- 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, interviews, record review, and policy review, the facility failed to ensure the kitchen was maintained and operated in a sanitary manner to prevent the potential spread of foodborne illness to all 130 residents. Specifically, the facility failed to ensure sanitizer solutions were at the proper concentration, tray line temperatures were within safe ranges, dishes were clean, hair coverings were worn, foods were labeled, and environmental surfaces were free of excessive grime, crumbs, and black substance.
- E
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, document review, interview and facility policy review, the facility failed to ensure proper infection control in the following areas: proper infection control practices with residents on transmission-based precautions (TBP) for COVID and the timely notification of the health department of the COVID outbreak; providing diagrams for the water flow in the facility and testing waterborne pathogens; transporting uncovered clean clothing throughout the facility. These deficient practices had the potential to affect all 130 residents and to allow exposure to non-COVID residents to COVID, waterborne pathogens and their clothing to dust and germs.
- 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 interview and record review, the facility failed to ensure that an establish advanced directive (AD) was enacted as directed for 1 of 5 residents (Resident 19) reviewed for AD. This failure denied the resident the opportunity to direct their healthcare during an event when they were unable to make decisions or communicate their healthcare preferences.
- 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 observation, interview, record review, and policy review, the facility failed to notify one of 31 sampled residents (Resident (R)109) physician and family member of an injury sustained to R109's toe first discovered on 06/20/23. This resulted in a delay for a referral to the podiatrist.
- 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, record review, interview and facility policy review, the facility failed to ensure resident equipment was maintained and in good repair for four (Resident (R)11, R51, R69, and R100) of 31 sampled residents. The resident's wheelchair arms had cracked or missing protective material exposing the cloth like material. This deficient practice had the potential to allow residents with frail skin to receive soars or prevent the wheelchairs from being thoroughly clean, increasing risk of infection.
- D
PASARR screening for Mental disorders or Intellectual Disabilities
Inspectors wroteBased on interview and record review, the facility failed to refer one (Resident (R) 70) of one resident reviewed for Preadmission Screening and Resident Review (PASRR) residents for a Level II, with a qualifying diagnosis of mental illness in the sample of 31. This had the potential to cause R70 to not receive necessary mental health services.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on observation, interview, record review and policy review, the facility failed to ensure one out of one resident reviewed for non-pressure skin conditions (Resident (R)109) received adequate nursing care and services to address an injury to her toe. Specifically, the facility failed to complete an initial investigation in accordance with facility policy (Incident Report), initiate subsequent monitoring and documentation (alert charting), and determine if interventions were needed to protect the injured area and to prevent re-injury.
- D
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the use of an indwelling urinary catheter (a tube which drains urine from the bladder into a collection bag) had the catheter bag attached as ordered by the provider and a privacy bag for 1 of 1 resident (Resident 173) reviewed for urinary catheters. This failure placed the residents at risk for further complications, prolonged therapy, and unmet care needs.
- 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, interview, and record review, the facility failed to ensure that narcotics storage refrigerators were secured for 1 of 3 medication storage rooms (Ocean) and medication storage rooms were secured for 1 of 3 medication rooms (Alpine) when reviewed for medication storage. In addition, the facility failed to ensure a bottle of Virex (a germicidal / disinfectant cleaning material) was separately stored for 1 of 3 medication storage rooms (Mountain) and that personal staff hydration was not stored within a facility's medication cart (700 Hall). These failures placed residents at risk to have unintended access to drugs and biologicals that should have been locked, an increased risk of drug diversion, and potential drug misuse.
Fire safety inspections
72 fire safety citations on file: 33 on May 9, 2025, 20 on June 5, 2024, 19 on August 17, 2023.
Every fire safety citation72 citations
- F
Develop and maintain an Emergency Preparedness Program (EP).
E 4 · May 9, 2025 · Corrected (the home has a date of correction)
- F
Address patient/client population and determine types of services needed.
E 7 · May 9, 2025 · Corrected (the home has a date of correction)
- F
Include a process for Emergency Preparedness collaboration.
E 9 · May 9, 2025 · Corrected (the home has a date of correction)
- F
Address subsistence needs for staff and patients.
E 15 · May 9, 2025 · Corrected (the home has a date of correction)
- F
Establish procedures for tracking staff and patients during an emergency.
E 18 · May 9, 2025 · Corrected (the home has a date of correction)
- F
Establish policies and procedures including evacuation.
E 20 · May 9, 2025 · Corrected (the home has a date of correction)
- F
Establish policies and procedures for volunteers.
E 24 · May 9, 2025 · Corrected (the home has a date of correction)
- F
Develop a communication plan.
E 29 · May 9, 2025 · Corrected (the home has a date of correction)
- F
List the names and contact information of those in the facility.
E 30 · May 9, 2025 · Corrected (the home has a date of correction)
- F
Establish methods for sharing information.
E 33 · May 9, 2025 · Corrected (the home has a date of correction)
- F
Provide a means of sharing information on occupancy/needs.
E 34 · May 9, 2025 · Corrected (the home has a date of correction)
- F
Provide family notifications of emergency plan.
E 35 · May 9, 2025 · Corrected (the home has a date of correction)
- F
Establish emergency prep training and testing.
E 36 · May 9, 2025 · Corrected (the home has a date of correction)
- F
Establish staff and initial training requirements.
E 37 · May 9, 2025 · Corrected (the home has a date of correction)
- F
Conduct testing and exercise requirements.
E 39 · May 9, 2025 · Corrected (the home has a date of correction)
- F
Meet other general requirements.
K 100 · May 9, 2025 · Corrected (the home has a date of correction)
- F
Install emergency lighting that can last at least 1 1/2 hours.
K 291 · May 9, 2025 · Corrected (the home has a date of correction)
- F
Provide properly protected cooking facilities.
K 324 · May 9, 2025 · Corrected (the home has a date of correction)
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · May 9, 2025 · Corrected (the home has a date of correction)
- F
Follow proper procedures when the fire alarm was out of service for more than 4 hours.
K 346 · May 9, 2025 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · May 9, 2025 · Corrected (the home has a date of correction)
- F
Install corridor and hallway doors that block smoke.
K 363 · May 9, 2025 · Corrected (the home has a date of correction)
- F
Provide a written emergency evacuation plan.
K 711 · May 9, 2025 · Corrected (the home has a date of correction)
- F
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · May 9, 2025 · Corrected (the home has a date of correction)
- F
Ensure proper usage of power strips and extension cords.
K 920 · May 9, 2025 · Corrected (the home has a date of correction)
- F
Ensure that testing and maintenance of electrical equipment is performed.
K 921 · May 9, 2025 · 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 · May 9, 2025 · Corrected (the home has a date of correction)
- E
Have properly installed electrical wiring and gas equipment.
K 511 · May 9, 2025 · Corrected (the home has a date of correction)
- D
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
K 222 · May 9, 2025 · 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 · May 9, 2025 · Corrected (the home has a date of correction)
- D
Properly select, install, inspect, or maintain portable fire extinguishes.
K 355 · May 9, 2025 · Corrected (the home has a date of correction)
- D
Install smoke barrier doors that can resist smoke for at least 20 minutes.
K 374 · May 9, 2025 · Corrected (the home has a date of correction)
- D
Enure that solid fuel-burning fireplaces are not in patient sleeping areas.
K 525 · May 9, 2025 · Corrected (the home has a date of correction)
- F
Develop and maintain an Emergency Preparedness Program (EP).
E 4 · June 5, 2024 · Corrected (the home has a date of correction)
- F
Establish roles under a Waiver declared by secretary.
E 26 · June 5, 2024 · Corrected (the home has a date of correction)
- F
List the names and contact information of those in the facility.
E 30 · June 5, 2024 · Corrected (the home has a date of correction)
- F
Establish emergency prep training and testing.
E 36 · June 5, 2024 · Corrected (the home has a date of correction)
- F
Establish staff and initial training requirements.
E 37 · June 5, 2024 · Corrected (the home has a date of correction)
- F
Conduct testing and exercise requirements.
E 39 · June 5, 2024 · Corrected (the home has a date of correction)
- F
Provide properly protected cooking facilities.
K 324 · June 5, 2024 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · June 5, 2024 · Corrected (the home has a date of correction)
- F
Properly select, install, inspect, or maintain portable fire extinguishes.
K 355 · June 5, 2024 · Corrected (the home has a date of correction)
- F
Install corridor and hallway doors that block smoke.
K 363 · June 5, 2024 · Corrected (the home has a date of correction)
- F
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · June 5, 2024 · Corrected (the home has a date of correction)
- F
Have properly installed electrical wiring and gas equipment.
K 511 · June 5, 2024 · Corrected (the home has a date of correction)
- F
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
K 521 · June 5, 2024 · Corrected (the home has a date of correction)
- F
Have simulated fire drills held at unexpected times.
K 712 · June 5, 2024 · Corrected (the home has a date of correction)
- F
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
K 914 · June 5, 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 · June 5, 2024 · Corrected (the home has a date of correction)
- D
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
K 225 · June 5, 2024 · Corrected (the home has a date of correction)
- D
Have properly located and lighted "Exit" signs.
K 293 · June 5, 2024 · 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 · June 5, 2024 · Corrected (the home has a date of correction)
- D
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
K 362 · June 5, 2024 · Corrected (the home has a date of correction)
- F
Establish roles under a Waiver declared by secretary.
E 26 · August 17, 2023 · Corrected (the home has a date of correction)
- F
Establish staff and initial training requirements.
E 37 · August 17, 2023 · Corrected (the home has a date of correction)
- F
Conduct testing and exercise requirements.
E 39 · August 17, 2023 · Corrected (the home has a date of correction)
- F
Follow proper procedures when the fire alarm was out of service for more than 4 hours.
K 346 · August 17, 2023 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · August 17, 2023 · Corrected (the home has a date of correction)
- F
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
K 354 · August 17, 2023 · Corrected (the home has a date of correction)
- F
Install corridor and hallway doors that block smoke.
K 363 · August 17, 2023 · Corrected (the home has a date of correction)
- F
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · August 17, 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 · August 17, 2023 · Corrected (the home has a date of correction)
- F
Have simulated fire drills held at unexpected times.
K 712 · August 17, 2023 · Corrected (the home has a date of correction)
- F
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
K 761 · August 17, 2023 · Corrected (the home has a date of correction)
- F
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
K 914 · August 17, 2023 · Corrected (the home has a date of correction)
- F
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · August 17, 2023 · Corrected (the home has a date of correction)
- F
Ensure that testing and maintenance of electrical equipment is performed.
K 921 · August 17, 2023 · 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 · August 17, 2023 · Corrected (the home has a date of correction)
- D
Provide large enough exits.
K 231 · August 17, 2023 · Corrected (the home has a date of correction)
- D
Have properly located and lighted "Exit" signs.
K 293 · August 17, 2023 · Corrected (the home has a date of correction)
- D
Have properly installed electrical wiring and gas equipment.
K 511 · August 17, 2023 · Corrected (the home has a date of correction)
- D
Ensure proper usage of power strips and extension cords.
K 920 · August 17, 2023 · Corrected (the home has a date of correction)