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 71 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
3J
0K
0L
Actual harm
11G
1H
0I
Potential for more than minimal harm
35D
13E
7F
Potential for minimal harm
0A
0B
1C
February 11, 2026Standard inspection · 10 citations
- G
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on observation, interview, and record review the facility failed to assess, monitor and provide interventions to prevent pressures ulcers for 3 of 3 (R1, R7, R9) residents reviewed for skin breakdown in a sample of 47. This failure resulted in R7 who was admitted to facility without a pressure acquiring an avoidable stage III pressure ulcer/injury, R1 acquiring a pressure a pressure ulcer and R9 experiencing pain from pressure ulcer.
- G
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 perform timely incontinent care for 1 of 3 (R9) residents reviewed for incontinent care in a sample of 47. This failure resulted in R9 feeling embarrassed, ashamed, and miserable. This failure also resulted in R9 obtaining opening areas to her right buttock and experiencing pain as a result. R9's Care Plan, dated 10/27/2025, documents that Resident experiences bladder incontinence. It continues Provide incontinence care after each incontinent episode. It also documents that Apply moisture barrier to skin. R9's Minimum Data Set, dated [DATE], documents that R9 is cognitively intact and dependent on staff for toileting. On 2/2/26 at 8:25 AM observed V5, Certified Nurse Assistance (CNA), provide incontinent care for R9. Upon entering room, a strong, foul urine odor in room. R9 was incontinent of bowel and bladder. [...]
- F
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 interview and record review, the Facility failed to provide the services of a Registered Nurse (RN) for at least eight hours daily. This has the potential to affect all 99 residents living in the facility.
- E
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 properly store medication and discard expired medication for 5 of 5 (R4, R12, R79, R92, R109) residents in reviewed for medication storage in a sample of 47.
- E
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Inspectors wroteBased on interview and record review, the Facility failed to offer and provide influenza and pneumococcal vaccines for 4 of 4 consenting residents (R31, R36, R64, R81) reviewed for infection control in the sample of 47.
- D
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Inspectors wroteBased on observation, record review, and interview, the facility failed to assess for use of and review the risk versus benefits for 1 of 2 (R55) resident reviewed for restraints in a sample of 47.
- D
Ensure each resident receives an accurate assessment.
Inspectors wroteBased on interview and record review the facility failed to complete quarterly smoking risk assessments for 2 of 3 residents (R5 and R88) reviewed for assessments in a sample of 47. Findings Include:1. R5's Face Sheet, admit date : [DATE] (current), documented he has diagnoses of but not limited to Chronic obstructive pulmonary disease (COPD), type II diabetes mellitus, cirrhosis of liver, and acute hepatitis C without hepatic coma. R5's Minimum Data Set (MDS), dated [DATE], documented R5 is cognitively intact with a Brief Interview for Mental Status (BIMS) of 15 out of 15 and requires supervision or touching assistance, and partial/moderate assistance with his activities of daily living (ADLs). R5's Care Plan, not dated, documented R5's preferences are to smoke while at the facility. [...]
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on observation, interview, and record review the facility failed to assess, monitor, supervise and implement interventions for 2 of 6 (R9, R31) residents reviewed for accidents and supervision in a sample of 47.
- 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 food was provided in a form to meet individual needs for 2 of 2 residents (R64, R95) reviewed for food and nutrition services in the sample of 47.
- C
Post nurse staffing information every day.
Inspectors wroteBased on observation and interview, the Facility failed to post nurse staffing information in a prominent place that was readily accessible to residents and visitors. This has the potential to affect all 99 residents living in the Facility.
October 21, 2025Complaint inspection · 5 citations
- J
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Inspectors wroteBased on interview, observation, and record review, the Facility failed to ensure residents were free from sexual abuse for 1 of 3 residents (R2) reviewed for abuse in the sample of 6. This failure resulted in R2 being sexually abused by R3 on 10/5/25 and again on 10/6/25. This Immediate Jeopardy began on 10/5/25 at 5:30 PM when V7, Certified Nursing Assistant (CNA), witnessed R3 sexually abusing R2. The Facility did not report or investigate this, and no interventions were put in place to protect R2 from R3. The following day, on 10/6/25 at approximately 9:00 AM, R3 entered R2's room and sexually abused R3 again. V1, Administrator, was notified of the Immediate Jeopardy on 10/17/25 at 12:02 PM. [...]
- G
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Inspectors wroteBased on interview, observation, and record review, the Facility failed to follow its abuse policy in preventing, reporting and investigating allegations of abuse for 1 of 3 residents (R2) reviewed for abuse in the sample of 6. This failure resulted in R2 being sexually abused on 10/6/25 after previous allegation was not reported or investigated and no interventions were put in place to prevent further abuse.
- G
Respond appropriately to all alleged violations.
Inspectors wroteBased on interview and record review, the Facility failed to investigate an allegation of sexual abuse for 1 of 3 residents (R2) reviewed for abuse in the sample of 6. This failure resulted in witnessed sexual abuse on R2 by R3 the day after a sexual abuse allegation for the same two individuals was not thoroughly investigated.
- G
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 provide adequate supervision following an allegation of sexual abuse for 1 of 3 residents (R2) reviewed for abuse in the sample of 6. This failure resulted in R3 entering R2's room without staff supervision and sexually abusing R2.
- 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 report allegation of sexual abuse for 1 of 3 residents (R2) reviewed for abuse in the sample of 6.
June 11, 2025Complaint inspection · 3 citations
- D
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Inspectors wroteBased on interview and record review, the facility failed to notify resident's representatives of a fall in 1 of 4 residents (R3) reviewed for accidents in the sample of 4.
- 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 completed physician's ordered wound care for 1 of 3 residents (R2) reviewed for wound care in the sample of 4.
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on interview and record review, the Facility failed to treat resident's pressure ulcers per physician's orders for 1 of 3 residents (R2) reviewed for pressure ulcers in the sample of 4.
May 9, 2025Complaint inspection · 1 citation
- J
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on interview and record review the Facility failed to assess and treat a change of condition for 1 of 3 residents (R2) reviewed for change of condition. This failure resulted in R2 having a significant change in condition for several hours without interventions that ultimately required an emergency transfer in which her family called 911 and R2 experienced respiratory distress, was intubated en route to the hospital and placed on a mechanical ventilator. The Immediate Jeopardy began on 5/2/2025 when R2 began to experience respiratory/breathing issues and was not sent to the hospital in a timely manner. On 5/8/2025 at 12:43 PM, V1, Administrator, V2, Director of Nursing (DON), V3, Assistant Director of Nursing (ADON), V17, Regional Nurse Consultant/ VP Clinical Services and V18, RDO/CEO (Regional Director of Operations) and CEO were notified of the Immediate Jeopardy. [...]
March 14, 2025Complaint inspection · 3 citations
- 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 report a hip fracture of unknown origin for 1 of 3 residents (R7) reviewed for abuse in the sample of 13.
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observation, interview, and record review the facility failed to provide tracheostomy care as ordered and appropriate tracheostomy supplies for 1 of 1 resident (R4) reviewed for Quality of Care in a sample of 13. Findings Include: R4's Face Sheet, undated, documents R4 was admitted [DATE] with a medical diagnosis of chronic respiratory failure with hypoxia. R4's Minimum Data Set (MDS) dated [DATE], documents R4 is cognitively intact, needs substantial/maximal assistance with personal and oral hygiene, and requires intermittent oxygen therapy, suctioning and tracheostomy (trach) care. R4's Care Plan does not address R4's tracheostomy needs. R4's Progress Note by V10, Licensed Practical Nurse (LPN), dated 3/5/25 at 4:50 AM, documents R4 was sent to hospital. R4 had pulled out trachea. [...]
- D
Ensure that the resident and his/her doctor meet face-to-face at all required visits.
Inspectors wroteBased on interview and record review, the Facility failed to ensure physician visits were completed within 30 days of admission and at least every 60 days thereafter for 3 of 3 residents (R1, R2, R5) reviewed for physician visits in the sample of 13.
February 27, 2025Standard inspection · 9 citations
- F
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 a Registered Nurse (RN) was scheduled in the facility for at least 8 consecutive hours a day, 7 days a week. This had the potential to affect all 99 residents who reside in the facility.
- 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 properly store medication, label insulins vials, and discard expired medication. This has the potential to affect all 99 residents living in the facility.
- 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 and interview, the facility failed to label and store foods appropriately, failed to wear hair restraints, perform hand hygiene in between glove changes and keep personal open drink containers away from where food was being prepared. This has the potential to affect all 99 residents living in the facility.
- E
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview and record review the Facility failed to follow their policy and prevent the potential spread of infection by not utilizing Personal Protective Equipment (PPE) while providing direct care, as well as complete hand hygiene between glove changes for 5 of 5 residents (R52, R8, R45, R27 and R60) reviewed for Transmission Based Precautions (TBP) in the sample of 59.
- E
Have policies on smoking.
Inspectors wroteBased on observation, interview and record review, the facility failed to provide storage that locks for residents smoking materials, including vapes, lighters and tobacco and failed to provide supervision during smoking times for 8 of 8 (R32, R38, R68, R69, R76, R82, R148 and R149) residents reviewed for smoking.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on interview and record review, the Facility failed to ensure blood sugar levels were documented for tracking, trending and monitoring of a chronic condition for 1 of 32 residents (R78) reviewed for medications, in the sample of 59.
- 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 perform complete incontinent care for 2 of 4 (R27, R94) residents reviewed for incontinent care, in a sample of 59.
- 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 monitor/document episodes of behaviors for which psychotropic medications were prescribed, as well as follow up on pharmacy recommendations for 1 of 3 residents (R83) reviewed for unnecessary medications in the sample of 59.
- D
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Inspectors wroteBased on interview and record review, the Facility failed to ensure preventative health vaccines such as Respiratory Syncytial Virus (RSV) and Pneumonia (PNU) were administered to those who gave consent and wished to receive them for 2 of 5 residents (R8 and R78), reviewed for immunizations, in the sample of 59.
February 20, 2025Complaint inspection · 3 citations
- G
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on the interview and record review, the facility failed to monitor and assess blood sugar levels for residents with diabetes, for 1 of 3 residents (R2) were reviewed for quality of care in the sample of 14. This failure resulted in R2 requiring emergency intervention for blood glucose level 24 and hospitalization.
- G
Provide enough food/fluids to maintain a resident's health.
Inspectors wroteBased on the interview and record review, the facility failed to implement interventions to address a significant weight loss for 1 of 3 residents (R2) who were reviewed for weight loss in a sample of 14. This failure resulted in R2 experiencing a significant weight loss of 20% over a four-month period.
- 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 the interview and record review, the facility failed to notify the physician of changes in condition related to weight loss and blood glucose readings for 1 of 3 residents (R2) reviewed for change in condition in the sample of 14.
January 24, 2025Complaint inspection · 4 citations
- 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 interview and record review the facility failed to locate and/or replace missing clothing for 1 of 1 resident reviewed for loss of property in the sample of 17. On 1/22/2025 at 1:40PM V19, R10's family member, stated Dad lost clothes, jackets, a brand-new pair of white leather shoes, hearing aids, and two blankets. I took him a blanket and the blanket disappeared. I took him another blanket and the next day that blanket was gone. It was unbelievable. On 1/22/2025 at 2:00PM V16, Social Services Director, stated I don't know anything about R10's missing clothes. I thought we found everything and returned it. On 1/22/2025 at 2:30PM V1, Administrator, stated I thought his items were found. I'm not sure. I don't think they filed a grievance. On 1/23/2025 at 2:00PM V19 stated We didn't get any missing items back from the facility. They have not contacted us for reimbursement either. [...]
- D
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Inspectors wroteBased on interview and record review the Facility failed to ensure abuse did not occur for 1 of 3 residents (R9) reviewed for abuse in the sample of 17.
- D
Respond appropriately to all alleged violations.
Inspectors wroteBased on interview and record review the facility failed to initiate and thoroughly investigate alleged violations of abuse for 1 of 3 residents (R9) reviewed for abuse in the sample of 17
- D
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 administer ordered medications to 1 of 1 resident reviewed for medications in the sample of 17. R2's Facesheet documents an admission date of 3/2/2024. Diagnosis include Osteomyelitis, Gastroesophageal Reflux Disease, Peripheral Vascular Disease, Acquired absence of other right toe(s), Chronic Kidney Disease, Acute Embolism and Thrombosis of unspecified deep veins of left lower extremity, Type 2 Diabetes. R2's Minimum Data Set, MDS, dated [DATE] documents R2 has no cognitive deficits. R2's Care Plan updated 10/24/2024 documents I have chronic pain related to Gastroesophageal Reflux Disease, Neuropathy, and Idiopathic gout. Interventions include: Report to Nurse my complaints of pain or requests for pain treatment. Pain Assessments quarterly and as needed. [...]
January 10, 2025Complaint inspection · 1 citation
- D
Ensure that residents are free from significant medication errors.
Inspectors wroteBased on interview and record review the facility failed to provide medication as ordered by the Physician. This applies to 1 resident (R1) of three reviewed for medication administration in a sample of three.
November 18, 2024Complaint inspection · 3 citations
- G
Provide safe, appropriate pain management for a resident who requires such services.
Inspectors wroteBased on observation, record review, and interview, the facility failed to assess and provide medication for pain management for 2 of 3 residents (R4 and R7) reviewed for pain in the sample of 9. This failure resulted in R4 being in pain and R7 being unable to participate in therapy.
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wrote-- Based on observation, interview, and record review, the facility failed to implement fall interventions for 1 of 3 residents (R2 ) reviewed for falls in the sample of 9.
- D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Inspectors wrote- Based on observation interviews and record reviews, the facility failed to provide medications as ordered for 2 of 3 residents (R4 and R7) who were reviewed for medications in the sample of 9.
October 25, 2024Complaint inspection · 1 citation
- E
Provide enough food/fluids to maintain a resident's health.
Inspectors wrote- A-Based on observation, interview, and record review the Facility failed to provide additional nourishment when ordered for 1 of 3 residents (R15) reviewed for weight loss in the sample of 20.
October 4, 2024Complaint inspection · 2 citations
- E
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wrote-- Based on observation, interview, and record review the Facility failed to implement current interventions and initiate progressive interventions to prevent falls for 4 of 4 (R1, R2, R4, R5) residents reviewed for falls in the sample of 5.
- 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 have pain medication available as ordered for one of three residents (R3) reviewed for pain in the sample of 5. This resulted in R3 not receiving his narcotic pain medication as ordered for 10 out of 30 days in September 2024.
September 6, 2024Complaint inspection · 3 citations
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wrote- Based on the interview and record review, the Facility failed to document necessary assessments of wound conditions per its policy, complete treatments as prescribed by a physician, and ensure the resident was assessed in a timely manner after a referral for one of three residents (R2) reviewed for wound management in the sample of 8.
- D
Provide safe, appropriate pain management for a resident who requires such services.
Inspectors wrote- Based on observation, interview, and record review, the Facility failed to ensure medications were readily available for administration per physician's orders to ensure residents' highest well-being, comfort, and pain control for 3 of 7 residents (R1, R4, and R8) reviewed for medications in the sample of 8.
- D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Inspectors wroteBased on observation, interview, and record review, the Facility failed to ensure medications were readily available for administration per physician's orders for 3 of 7 residents (R1, R4, and R8) reviewed for medications in the sample of 8.
August 15, 2024Complaint inspection · 3 citations
- F
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 allow phone access to facility and residents for 2 of 3 residents reviewed for resident rights. This has the potential to affect all 86 residents 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 treatments were completed, physician orders followed and residents repositioned timely for 1 of 3 (R2) residents reviewed for pressure ulcers.
- D
Provide safe, appropriate pain management for a resident who requires such services.
Inspectors wroteBased on interview and record review the Facility failed to ensure pain was assessed, recognizing the onset, presence, and duration of pain, and assessing the characteristics of the pain and provide pain management for 1 of 3 residents (R3) reviewed for pain. This resulted in R3 experiencing pain during dying process.
May 28, 2024Complaint inspection · 2 citations
- H
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 administer medications as ordered for residents (R1, R2, R3, R12) of 4 residents reviewed in a sample of 12. This failure resulted in R1 and R3 experiencing severe pain.
- 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 staffing on 5/20/24 for 4 of 6 (R1, R2, R3, R4) residents sampled for medications and blood glucose testing.
April 29, 2024Complaint 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 observation, interview, and record review, the facility failed to ensure fall interventions and precautions were in place for 1 of 3 residents (R7) reviewed for falls in a sample of 7.
January 31, 2024Standard inspection · 7 citations
- J
Protect each resident from the wrongful use of the resident's belongings or money.
Inspectors wroteBased on interview and record review the facility failed to protect residents from employee misappropriation of resident funds and exploitation for one of 7 residents (R51) reviewed for misappropriation of resident property in the sample of 42. This failure resulted in an Immediate Jeopardy when V22, Certified Nursing Assistant, (CNA), began using R51's debit card without his permission on March 2, 2023, accruing more than $11,000.00 in charges. When R51 became aware, he was upset and worried about taking care of future expenses and needs. The Immediate Jeopardy began on 3/02/23, when V22 began using R51's debit card without R51's permission. On 1/26/24, at 4:00 PM, V1, Administrator, V3, Assistant Director of Nursing (ADON), and V47, Registered Nurse, RN, were notified of the Immediate Jeopardy. [...]
- 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 ensure safe beverage serving temperatures to prevent thermal burns and adequate supervision to prevent falls for 3 of 9 residents (R60, R62, and R68) reviewed for accidents/hazards in the sample of 42. These failures resulted in R62 and R68 sustaining second degree abdominal burns and R60 falling and sustaining nasal fracture.
- G
Provide enough food/fluids to maintain a resident's health.
Inspectors wroteBased on interview and record review, the facility failed to adequately assess and ensure a resident receiving continuous Gastrostomy tube (G-tube) feeding did not experience significant weight loss for 1 of 2 residents (R13) reviewed for nutrition in the sample of 42. This failure resulted in R13 having an insidious significant weight loss of 12 pounds in three months while receiving nutrition via G-tube.
- 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 ensure food was stored, prepared, and distributed in a manner that prevents potential foodborne illness. This has the potential to affect all 89 residents living in the Facility.
- F
Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
Inspectors wroteBased on observation, interview and record review the facility failed to ensure an Infection Preventionist has the professional training and qualifications to perform in this role. This has the potential to affect all 89 residents living in the Facility.
- E
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Inspectors wroteBased on interview and record review, the facility failed to prevent abuse for 6 of 7 residents (R10, R49, R50, R51, R62, R293) reviewed for abuse in the sample of 42.
- D
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Inspectors wroteBased on observation, interview and record review, the facility failed to follow their policy and the resident's care plan to ensure proper placement of gastrostomy tubes (g-tubes) and ensure the correct enteral formula is provided for residents with g-tubes for 1 of 2 residents (R13) reviewed for g-tubes in the sample of 42.
December 5, 2023Complaint inspection · 1 citation
- E
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 store medication properly for 6 of 7 residents (R2, R4, R5, R6, R7, R8) reviewed for medication storage in a sample of 8.
November 22, 2023Complaint inspection · 1 citation
- 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 interview, observation and record review, the facility failed to provide incontinent care per current standards of practice to prevent Urinary Tract Infections (UTI) for 1 of 3 (R2) residents reviewed for UTI's in the sample of 3.
November 2, 2023Complaint inspection, Infection control · 2 citations
- F
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview and record review, the facility failed to enforce work restrictions for employees that were positive for COVID-19 to aid in the prevention/progression of COVID-19. This failure has the potential to affect all 90 residents residing in the facility.
- D
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Inspectors wroteBased on interview and record review, the facility failed to prevent visitor to resident mental abuse for 1 of 6 residents (R1) reviewed for abuse in the sample of 9.
October 18, 2023Complaint inspection · 1 citation
- G
Ensure that residents are free from significant medication errors.
Inspectors wroteBased on interview and record review, the facility failed to refill medications timely for 1 of 3 (R2) residents reviewed for medication administration in a sample of 10. This failure resulted in R2 being admitted to the hospital for breakthrough seizure activity.
October 5, 2023Complaint inspection · 3 citations
- E
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteBased on interview and record review, the Facility failed to answer call lights in a timely manner for 3 of 3(R1, R2, R3) residents reviewed for call lights in the sample of 12.
- 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 and interview, the Facility failed to ensure a safe, comfortable, homelike environment for 2 of 3 residents (R2, R4) reviewed for physical environment in the sample of 12.
- D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Inspectors wroteBased on observation, interview, and record review, the facility failed to administer medication to a newly admitted resident for 1(R2) of 10 residents in the sample of 12.
September 19, 2023Complaint inspection · 2 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 observation, interview and record review the facility failed to ensure the facility was clean, comfortable, and homelike for 5 of 5 residents (R7, R8, R16, R17, R19) reviewed for homelike environment in the sample of 20.
- E
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on observation, interview and record review, the facility failed to assist residents with hygiene and incontinent/toileting care for 4 of 4 residents (R7, R8, R9, R16) reviewed for assistance with activities of daily living (ADLs) in the sample of 20.
Fire safety inspections
17 fire safety citations on file: 8 on February 27, 2025, 4 on January 31, 2024, 5 on March 17, 2023.
Every fire safety citation17 citations
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · February 27, 2025 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · February 27, 2025 · Corrected (the home has a date of correction)
- F
Have simulated fire drills held at unexpected times.
K 712 · February 27, 2025 · 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, 2025 · Corrected (the home has a date of correction)
- E
Provide properly protected cooking facilities.
K 324 · February 27, 2025 · Corrected (the home has a date of correction)
- E
Install corridor and hallway doors that block smoke.
K 363 · February 27, 2025 · Corrected (the home has a date of correction)
- E
Install smoke barrier doors that can resist smoke for at least 20 minutes.
K 374 · February 27, 2025 · Corrected (the home has a date of correction)
- E
Have proper medical gas storage and administration areas.
K 923 · February 27, 2025 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · January 31, 2024 · Corrected (the home has a date of correction)
- F
Have simulated fire drills held at unexpected times.
K 712 · January 31, 2024 · Corrected (the home has a date of correction)
- E
Provide properly protected cooking facilities.
K 324 · January 31, 2024 · Corrected (the home has a date of correction)
- E
Install smoke barrier doors that can resist smoke for at least 20 minutes.
K 374 · January 31, 2024 · 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 · March 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 · March 17, 2023 · Corrected (the home has a date of correction)
- E
Install corridor and hallway doors that block smoke.
K 363 · March 17, 2023 · Corrected (the home has a date of correction)
- E
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
K 761 · March 17, 2023 · Corrected (the home has a date of correction)
- E
Have proper medical gas storage and administration areas.
K 923 · March 17, 2023 · Corrected (the home has a date of correction)