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 67 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
1J
0K
0L
Actual harm
1G
0H
0I
Potential for more than minimal harm
32D
33E
0F
Potential for minimal harm
0A
0B
0C
November 25, 2025Standard inspection · 4 citations
- D
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Inspectors wroteBased on record review and interview, the facility failed to ensure a resident was provided with a written notice of transfer when transferred to a hospital for 1 (#5) 2 sampled residents reviewed for hospitalization. The DON identified 18 resident transfers in the past six months.
- 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 record review and interview, the facility failed to ensure a comprehensive care plan was created for 1 (#56) of 16 sampled residents reviewed for care plans. The DON identified 58 residents resided in the facility required MDS assessments.
- D
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Inspectors wroteBased on record review and interview, the facility failed to ensure a resident's dialysis catheter was assessed every shift for 1 (#35) of 2 sampled residents reviewed for dialysis care. The DON identified five residents in the facility received dialysis treatments.
- 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, record review, and interview, the facility failed to ensure foods were labeled, dated, and stored correctly when opened or prepared for 1 of 2 observations in the kitchen. The DON identified 58 residents received nourishment from the kitchen.
January 28, 2025Complaint inspection · 2 citations
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on record review and interview, the facility failed to ensure timely incontinent care was provided for one (#6) of three sampled residents reviewed for ADLs. The administrator identified 66 residents who resided at the facility.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure infection control was maintained and enhanced barrier precautions were followed during pressure ulcer treatment for one (#5) of three sampled reviewed for wound care. The ADON identified 10 residents who had pressure ulcers.
July 19, 2024Complaint inspection · 1 citation
- G
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Inspectors wroteBased on interview and record review, the facility failed to ensure dialysis services for one (#1) of four residents who were reviewed for dialysis services. This deficient practice resulted in Resident #1 being hospitalized with a diagnosis of metabolic acidosis from missed dialysis. The DON identified 11 residents who resided in the facility who required dialysis.
April 11, 2024Standard inspection, Complaint inspection · 25 citations
- 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 record review and interview, the facility failed to ensure an accurate code status was documented for one (#8) and residents were offered the choice to formulate an advanced directive for two (#22 and #24) of three sampled residents reviewed for advanced directives. The corporate administrator identified 53 residents who resided in the facility.
- E
Protect each resident from the wrongful use of the resident's belongings or money.
Inspectors wroteBased on record review and interview, the facility failed to ensure a missing laptop was replaced for one (#22) of one sampled resident who was reviewed for misappropriation of property. The corporate administrator identified 53 residents who resided in the facility.
- 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, record review, and interview, the facility failed to ensure comprehensive care plans were developed and/or implemented to address the residents' needs related to a urinary catheter for one (#49), pain for one (#24), and cardiovascular status for one (#22) of 24 residents whose care plans were reviewed. The corporate administrator identified 53 residents who resided in the facility. The ADON identified seven residents with a urinary catheter.
- E
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure baths and incontinent care were provided as ordered for three (#8, 16 and #43) of three residents reviewed for assistance with ADL's. The ADON identified 36 residents who required assistance with incontinent care and 39 residents who required assistance with showers.
- E
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure wound care was provided as ordered for one (#22) of one sampled resident who was observed for non pressure related wounds. The ADON identified five residents who had non pressure related wounds.
- E
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure physician orders for an indwelling urinary catheter and failed to ensure a resident with an indwelling urinary catheter received services to help prevent urinary tract infections for one (#49) of one resident reviewed for catheters. The ADON identified seven residents with an indwelling urinary catheter.
- E
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, record review, and interview, the facility failed to ensure a. the correct amount of water was administered via peg tube as ordered by the physician; b. the head of the bed was elevated during administration of water flushes and tube feeding through the peg tube; and c. a dietary recommendation was sent to the physician for one (#8) of one sampled resident who was administered nutrition through a peg tube. 1. Res #8 had diagnoses which included dysarthria (weakness in the muscles used for speech), hemiparesis and hemiplegia (Partial to complete paralysis on one side of the body) following a cerebral infarction. [...]
- 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 on record review and interview, the facility failed to provide sufficient staff to meet the needs of the residents for six (#7, 14, 16, 17, 27, and #43) of seven sampled residents who were reviewed for sufficient staffing. The corporate administrator identified 53 residents who resided in the facility.
- E
Post nurse staffing information every day.
Inspectors wroteBased on observation, record review, and interview, the facility failed to post the required staffing information. The corporate administrator identified 53 residents who resided in the facility.
- E
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Inspectors wroteBased on record review and interview, the facility failed to administer medications in accordance with physician orders for one (#22) of five sampled residents reviewed for unnecessary medications. The corporate administrator identified 53 residents resided in the facility with 17 residents receiving insulin.
- E
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Inspectors wroteBased on record review and interview, the facility failed to: a. develop and maintain policies and procedures for the monthly drug regimen review to include time frames for the different steps in the process, b. ensure a physician responded to a monthly medication review for one (#22) of five sampled residents reviewed for unnecessary medications, and c. ensure the facility followed up on requests made on the monthly medication review for one (#14) of five sampled residents reviewed for unnecessary medications. The corporate administrator identified 53 residents resided in the facility.
- E
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 record review and interview, the facility failed to ensure a resident did not receive unnecessary psychotropic medications for two (#17 and #22) of five sampled residents reviewed for unnecessary medications. The ADON identified eight residents received psychotropic medications.
- E
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Inspectors wroteBased on record review and interview, the facility failed to monitor food cooking and holding temperatures to ensure safe temperatures were maintained in the kitchen and on the steam table during meal service. The ADON reported 52 residents received services from the kitchen.
- 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, record review, and interview, the facility failed to store, prepare, and serve food in accordance with professional standards for food service safety. The ADON identified 52 residents who received meals from the kitchen.
- E
Dispose of garbage and refuse properly.
Inspectors wroteBased on observation and interview, the facility failed to ensure garbage was disposed of properly. The ADON reported 52 residents received services from the kitchen.
- E
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure: a. a surveillance system was in place to routinely identify infections and communicable diseases; b. a water management program to prevent the growth of Legionella and other opportunistic waterborne pathogens in building water systems; c. linens and laundry were processed in accordance with accepted national standards to produce hygienically clean laundry and prevent the spread of infection to the extent possible; and d. soiled linen was handled in a manner to prevent cross contamination. The corporate administrator identified 53 residents who resided in the facility.
- E
Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
Inspectors wroteBased on record review and interview, the facility failed to designate an individual as the infection preventionist. The corporate administrator identified 53 residents resided in the facility.
- E
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Inspectors wroteBased on record review and interview, the facility failed to offer influenza vaccinations for four (#17, 22, 27, and #43) of five and pneumococcal vaccinations for five (#8, 17, 22, 27, and #43) of five sampled residents reviewed for vaccinations. The corporate administrator identified 53 residents resided in the facility.
- E
Keep all essential equipment working safely.
Inspectors wroteBased on observation and interview, the facility failed to ensure a kitchen reach-in refrigerator was in good repair. The ADON reported 52 resident received services from the kitchen.
- D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteBased on observation and interview, the facility failed to ensure residents were treated with dignity for one (#44) of three residents sampled for dignity. The DON reported the census was 53.
- 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 record review and interview, the facility failed to update the care plan related to hospice services for one (#9) of two sampled resident reviewed for hospice services. The ADON identified five residents who received hospice services.
- D
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 ensure oxygen cylinders were stored properly. The DON reported the census was 53.
- D
Observe each nurse aide's job performance and give regular training.
Inspectors wroteBased on record review and interview the facility failed to complete required nurse aide yearly performance reviews for one (CNA #1) of three direct care employee files reviewed. The corporate administrator identified 53 residents who resided in the facility.
- D
Provide timely, quality laboratory services/tests to meet the needs of residents.
Inspectors wroteBased on record review and interview, the facility failed to ensure labs were completed as ordered for one (#60) of five residents reviewed for unnecessary medications. The DON reported the census was 53.
- D
Implement a program that monitors antibiotic use.
Inspectors wroteBased on record review and interview, the facility failed to maintain an antibiotic stewardship program for one (#4) of one sampled residents reviewed for antibiotic use. The ADON identified three residents were receiving antibiotics.
March 19, 2024Complaint inspection · 6 citations
- E
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Inspectors wroteBased on observations and interview, the facility failed to maintain a comfortable room temperature for three (#7, 8, and #9) of three sampled residents whose room temperatures were obtained. The Administrator identified 68 residents resided in the facility.
- E
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Inspectors wroteBased on record review and interview, the facility failed to ensure there was ongoing communication with the dialysis center for one (#1) and ongoing assessments of residents before and after dialysis treatments for three (#1, 3, and #4) of four sampled residents reviewed for dialysis care. The Administrator identified 68 residents resided in the facility. The were six residents receiving dialysis treatments.
- 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 facilitate the inclusion of residents' representative in their care plan conferences for two (#1 and #2) of three sampled residents whose care plan conferences were reviewed. The Administrator identified 68 residents resided in the facility.
- D
Reasonably accommodate the needs and preferences of each resident.
Inspectors wroteBased on observation, record review, and interview, the facility failed to accommodate a residents' need for adaptive equipment that would allow the highest possible level of physical functioning and well-being for one (#2) of one sampled resident reviewed for accommodation of needs. The Administrator identified 68 residents resided in the facility.
- 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 record review and interview, the facility failed to ensure resident representatives were notified of changes in condition for one (#1) of three sampled resident who were reviewed for notification of change. The Administrator identified 68 residents resided in the facility.
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure wound assessments were completed for one (#6) of three sampled residents whose wound assessments were reviewed and failed to follow infection control practices during wound care for one (#5) of one sampled resident whose wound care was observed. The administrator identified 68 residents resided in the facility.
February 8, 2024Complaint inspection · 7 citations
- E
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure: a. residents received baths as requested and according to schedule for two (#9 and #14) of three sampled residents reviewed for baths; b. medications were administered as ordered by a physician for two (#15 and #17) of three sampled resident reviewed for following physician orders; and c. blood sugars levels were obtained as ordered by a physician for two (#15 and #17) of three sampled residents reviewed for following physician orders. A facility census report, dated 01/31/24, documented 66 residents resided in the facility.
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on record review and interview, the facility failed to report an allegation of sexual abuse to the Oklahoma Stated Department of Health. A facility census report, dated 01/31/24, documented 66 residents resided in the facility.
- D
Respond appropriately to all alleged violations.
Inspectors wroteBased on record review and interview, the facility failed to conduct a thorough investigation of a report of alleged sexual abuse for one (#13) of three sampled residents reviewed for abuse. A facility census report, dated 01/31/24, documented 66 residents resided in the facility.
- D
Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.
Inspectors wroteBased on record review and interview, the facility failed to ensure a resident was not involuntarily discharged without notice and right to appeal and failed to document a discharge in a resident's medical record for one (#8) of three sampled resident reviewed for discharges. A facility Length of Stay By Discharge Reason Report, dated [DATE] through [DATE], documented 37 residents discharged from the facility during the specified period.
- D
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Inspectors wroteBased on record review and interview, the facility failed to provide a notice of transfer and a notice of discharge for one (#8) of three sampled residents reviewed for discharges. A facility Length of Stay By Discharge Reason Report, dated 10/01/23 through 11/30/23, documented 37 residents discharged from the facility during the specified period.
- D
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Inspectors wroteBased on record review and interview the facility failed to provide a bed hold policy to a resident prior to transfer for one (#8) of three sampled residents reviewed for discharges. A facility Length of Stay By Discharge Reason Report, dated 10/01/23 through 11/30/23, documented 37 residents discharged from the facility during the specified period.
- D
Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy.
Inspectors wroteBased on record review and interview, the facility failed to allow a resident's return to the facility after being transferred to a local hospital for a mental health evaluation for one (#8) of three sampled residents reviewed for discharges. A facility Length of Stay By Discharge Reason Report, dated 10/01/23 through 11/30/23, documented 37 residents discharged from the facility during the specified period.
February 27, 2023Standard inspection · 22 citations
- J
Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
Inspectors wroteOn [DATE], an Immediate Jeopardy (IJ) situation was determined to exist related to the facility's failure to ensure CPR was provided to Resident #66 who had a physician ordered full code status. On [DATE] at 7:30 p.m., a hospice nurse had came to evaluate Resident #66 for services and found resident without audible heart tones, absent respirations and unable to obtain palpable blood pressure. There was no documentation a facility staff member assessed the resident during this time. On interview, CMA #1 and an agency nurse had been in there 15 minutes prior to reposition resident. RN #1 stated they were alerted the resident had expired and knew the resident was a full code. CPR was not provided. On [DATE] at 9:07 a.m., The Oklahoma State Department of Health was notified and verified the existence of the IJ situation. [...]
- E
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Inspectors wroteBased on record review and interview, the facility failed to ensure staff notified residents' representatives when a change in condition occurred for two (#1 and #120) of three sampled residents reviewed for notifications. The Resident Census and Conditions of Residents report, dated 02/22/23, documented 63 residents resided in the facility.
- E
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Inspectors wroteBased on record review and interview, the facility failed to provide the appropriate liability notice prior to a resident coming off of skilled services for three (#21, 44, and #48) of three sampled residents reviewed for beneficiary notices. The DON identified 23 residents who were discharged from Medicare Part A services with benefit days remaining in the past six months.
- E
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Inspectors wroteBased on record review, observation, and interview, the facility failed to provide maintenance services necessary to ensure the following: a. floor tile was in good repair and not a trip hazard, b. wall paper was not peeling from the walls in Resident rooms and common areas, c. sheet rock was not damaged with cracks and deteriorating in common areas, and d. a clean and sanitary home like environment. The Resident Census and Condition of Residents, dated 02/22/23, documented 63 residents resided in the facility.
- E
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on record review, observation, and interview, the facility failed to: a. provide bathing assistance for two (#65 and #120) and, b, provide assistance to a dependent resident during the lunch meal service for one (#9) of 24 sampled residents reviewed for ADL assistance. The Resident Census and Condition of Residents, dated 02/22/23, documented 63 residents resided in the facility.
- E
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on observation, record review, and interviews the facility failed to: a. obtain weekly measurements of a pressure ulcer as ordered, b. ensure an effect communication for wound care orders from a third party contract provider was in place, c. provide wound care as ordered and d. assess and monitor a pressure ulcer for changes for one (#20) of three sampled resident reviewed for pressure ulcers. The Resident Census and Conditions of Residents report, dated 02/22/23, documented 15 residents with pressure ulcers.
- E
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Inspectors wroteBased on record review and interview, the facility failed to ensure an RN worked eight consecutive hours a day, seven days a week for four of 31 days reviewed in the month of January 2023. The Resident Census and Conditions of Residents report, dated 02/22/23, documented 63 residents.
- E
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Inspectors wroteBased on observation, record review, and interview, the facility failed to: a. medications were administered as ordered for two (#20 and #56) of five sampled residents reviewed for unnecessary medications, and b. controlled medications awaiting destruction were verified by two licensed staff for 15 (#17, 35, 52, 69, 70, 71, 72, 73, 75, 76, 77, 78, 79, 80 and #81) of 15 sampled residents whose discontinued medications were observed. The Resident Census and Conditions of Residents report, dated 02/22/23, documented 63 residents.
- E
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Inspectors wroteBased on record review and interview, the facility failed to ensure an effective administration for the coordination and continuity of care for one (#20) of one sampled resident reviewed for third party contract services. The Resident Census and Conditions of Residents report, dated 02/22/23, documented 63 residents.
- E
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, record review and interview, the facility failed to: a. provide wound care in a manner which prevented cross contamination for one (#20) of three sampled residents reviewed for pressure ulcers, and b. implement their infection control policy for a system for regular surveillance of all infections. The Resident Census and Conditions of Residents report, dated 02/22/23, documented 63 residents.
- E
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Inspectors wroteBased on record review and interview, the facility failed to: a. ensure residents were offered the pneumonia vaccine for one (#47) and b. ensure residents were offered the flu vaccine annually for three (#14, 21, and #47) of five sampled residents reviewed for vaccinations. The Resident Census and Conditions of Residents report, dated 02/22/23, documented 63 residents.
- E
Ensure staff are vaccinated for COVID-19
Inspectors wroteBased on record review and interview, the facility failed to implement: a. A process for tracking and securely documenting the COVID-19 vaccination status of all staff and residents The Resident Census and Conditions of Residents report, dated 02/22/23, documented 63 residents.
- D
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Inspectors wroteBased on record review and interview, the facility failed to ensure a baseline care plan had been completed within 48 hours of admission for one (#2) of three sampled residents reviewed for admission assessments. The DON identified 20 residents were admitted within the past 30 days.
- 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 record review and interview, the facility failed to develop a comprehensive care plan for dialysis for one (#47) of of one sampled resident reviewed for dialysis services. The Resident Census and Conditions of Residents report, dated 02/22/23, documented nine residents received dialysis services.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on record review and interviews, the facility failed to fully complete an admission assessment for one (#20) of three sampled residents reviewed for admission assessments. The Resident Census and Conditions of Residents report, dated 02/22/23, documented 63 residents.
- D
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Inspectors wroteBased on record review and interview, the facility failed to obtain physician ordered Pre/Post dialysis vitals and weights for one (#47) of one sampled resident reviewed for dialysis. The Resident Census and Conditions of Residents report, dated 02/22/23, documented nine residents received dialysis services.
- 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 on record review and interview, the facility failed to ensure a monthly drug regimen review was completed by a licensed pharmacist for one (#32) of five sampled residents reviewed for unnecessary medications. The Resident Census and Condition of Residents report, dated 02/22/23, documented 63 residents resided in the facility.
- 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 record review and interview, the facility failed to ensure the physician responded to a GDR for one (#37) of five sampled residents reviewed for unnecessary medications. A Resident Census and Conditions of Residents report, dated 02/22/23, documented 26 residents received psychoactive medications.
- D
Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.
Inspectors wroteBased on interview, the facility failed to conduct and document a facility-wide assessment to determine what resources were necessary to care for the residents competently during both day-to-day operations and emergencies. The Resident Census and Conditions of Residents report, dated 02/22/23, documented 63 residents.
- D
Employ or obtain outside professional resources to provide services in the nursing home when the facility does not employ a qualified professional to furnish a required service.
Inspectors wroteBased on record review and interviews, the facility failed to ensure a PICC line for IV antibiotic administration was placed in a timely manner by a third party contract service for one (#20) of one sampled resident reviewed for third party contract services. The DON identified two residents who received services from Contract Agency #1.
- D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on record review and interview, the facility failed to ensure records were accessible and complete for one (#20) of 24 sampled residents whose records were reviewed. The Resident Census and Conditions of Residents report, dated 02/22/23, documented 63 residents.
- D
Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
Inspectors wroteBased on record review and staff interview, the facility failed to maintain documentation of the vaccination status of each resident to include exemptions for unvaccinated residents for 63 residents who resided in the facility. The Resident Census and Conditions of Residents report, dated 02/22/23, documented 63 residents.
Fire safety inspections
23 fire safety citations on file: 4 on April 11, 2024, 14 on February 27, 2023, 5 on February 22, 2022.
Every fire safety citation23 citations
- F
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
K 761 · April 11, 2024 · 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 · April 11, 2024 · Corrected (the home has a date of correction)
- E
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
K 321 · April 11, 2024 · Corrected (the home has a date of correction)
- E
Provide properly protected cooking facilities.
K 324 · April 11, 2024 · Corrected (the home has a date of correction)
- F
Develop and maintain an Emergency Preparedness Program (EP).
E 4 · February 27, 2023 · Corrected (the home has a date of correction)
- F
Conduct risk assessment and an All-Hazards approach.
E 6 · February 27, 2023 · Corrected (the home has a date of correction)
- F
Conduct testing and exercise requirements.
E 39 · February 27, 2023 · Corrected (the home has a date of correction)
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · February 27, 2023 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · February 27, 2023 · Corrected (the home has a date of correction)
- F
Have simulated fire drills held at unexpected times.
K 712 · February 27, 2023 · Corrected (the home has a date of correction)
- F
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
K 761 · February 27, 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 · February 27, 2023 · Corrected (the home has a date of correction)
- E
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
K 321 · February 27, 2023 · Corrected (the home has a date of correction)
- E
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · February 27, 2023 · Corrected (the home has a date of correction)
- E
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
K 741 · February 27, 2023 · Corrected (the home has a date of correction)
- E
Have proper medical gas storage and administration areas.
K 923 · February 27, 2023 · Corrected (the home has a date of correction)
- C
Provide properly protected cooking facilities.
K 324 · February 27, 2023 · Corrected (the home has a date of correction)
- C
Properly select, install, inspect, or maintain portable fire extinguishes.
K 355 · February 27, 2023 · Corrected (the home has a date of correction)
- F
Install corridor and hallway doors that block smoke.
K 363 · February 22, 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 · February 22, 2022 · Corrected (the home has a date of correction)
- E
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
K 321 · February 22, 2022 · Corrected (the home has a date of correction)
- E
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · February 22, 2022 · Corrected (the home has a date of correction)
- E
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
K 741 · February 22, 2022 · Corrected (the home has a date of correction)