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 72 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
2J
0K
0L
Actual harm
1G
0H
0I
Potential for more than minimal harm
49D
17E
2F
Potential for minimal harm
0A
0B
1C
April 15, 2026Complaint inspection · 3 citations
- D
Respond appropriately to all alleged violations.
Inspectors wroteBased on record reviews and interviews it was determined the facility staff failed to conduct a thorough investigation. This was evident for 1 (#2801571) of 5 facility reported incidents reviewed during the survey.
- D
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Inspectors wroteBased on record review, observation and interviews it was determined that the facility staff failed to provide food that accommodated a resident's allergies, intolerances and preferences. This was evident for 1 (#10) of 14 residents reviewed during the survey.
- 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 interviews it was determined that the facility staff failed to document administration of medication at the time of administration, in accordance with accepted professional standards and practices. This was evident for 1 (#10) of 14 residents reviewed during the survey. The nursing standard of practice for medication administration includes administering time critical medication (which includes insulin) within 30 minutes before or after the scheduled time; and real time charting of when the medication was administered.
December 1, 2025Standard inspection · 13 citations
- J
Employ staff that are licensed, certified, or registered in accordance with state laws.
Inspectors wroteBased on Complaint #2625762, employee file reviews, and facility staff interviews, and facility documentation, it was determined that the facility failed to employ Licensed Practical Nurses in accordance with Maryland State laws. This was found evident for 2 (LPN #8 and LPN #14) out of 4 employees reviewed for appropriate licensures during the survey. The facility continued to employ LPN # 8 and LPN # 14 after the initial identification of non-recognized licensure on 4/3/24 through 11/21/25. Residents were at risk for improper care or negligence when their care was not provided by qualified licensed personnel, therefore The Maryland Office of Health Care Quality (OHCQ) determined this concern met the Federal definition of Immediate Jeopardy and the facility was notified in writing on 11/21/25 at 2 PM. [...]
- F
Reasonably accommodate the needs and preferences of each resident.
Inspectors wroteBased on observations and interviews it was determined that the facility staff failed to ensure that residents had their call bells to notify the staff when assistance was needed. This deficient practice was evidenced in 9 (#16, #27, #48, #51, #52, #69, #89, #112, & #116) of 33 residents screened on Patuxent Hall during the recertification survey.
- F
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observations and interviews it was determined that the facility staff failed to 1) store and process linen properly and 2)maintain effective infection prevention practices. This deficient practice had the potential to affect all the residents who were in the facility during the recertification survey.
- 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 interviews it was determined that the facility staff failed to maintain a comfortable, clean and homelike environment for the residents as evidenced of residents not having pillows and residents' clothing not being stored in the closet or armoire. This deficient practice was evidenced in 5 (#116, #40, #51, #27, & #89) of 33 residents residing on Patuxent Hall during the recertification survey.
- 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 record review and interviews it was determined that the facility staff failed to generate person centered care plans for a resident with Dementia, two residents with visual disturbances, and a resident who needed to wear a helmet to protect their brain while out of bed. This deficient practice was evidenced in 2 ( #12, #91) of 5 resident records reviewed for care plans during the recertification survey.
- 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 medical record review and interviews it was determined that the facility staff failed to complete quarterly care plan meetings. This deficient practice was evidenced in 1 (#96) of 2 resident records reviewed for care plan meetings during the recertification survey.
- D
Ensure services provided by the nursing facility meet professional standards of quality.
Inspectors wroteBased on record review and interviews it was determined that the facility staff failed to adhere to professional nursing standards as evidenced by a resident received hospice care for 12 days without a physician order, the facility staff failed to coordinate the residents' care with the hospice nurse, and a resident was prescribed psychotropic medication without behavioral monitoring or monitoring for extrapyramidal side effects. This deficient practice was evidenced in 1 (#43) of 1 hospice record reviewed and 1 (#10) of 2 records reviewed for extrapyramidal side effects/behavioral monitoring during the recertification survey.
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on medical record review, observation and resident and staff interviews it was determined the facility staff failed to ensure that dependent resident's personal hygiene needs were adequately met by offering and providing podiatry services to get their toenails trimmed on a regular basis. This was evident for 1 of 30 (#119) residents reviewed during the survey process.
- D
Assist a resident in gaining access to vision and hearing services.
Inspectors wroteBased on record review and interviews it was determined that the facility staff failed to ensure residents who had impaired vision received vision care and a recommended assistive device. This deficient practice was evidenced in 2 (#12 & #91) of 2 resident records reviewed for vision services during the recertification survey.
- 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 record review and interviews, it was determined that the facility failed to ensure that Nephrostomy drainage bag care was provided to a resident with a Nephrostomy . This was evident for 1 (#4) of 1 resident reviewed with a Nephrostomy.
- D
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on observations and interviews with facility staff, it was determined that the facility failed to maintain proper infection control procedures while serving breakfast. This was evident during the annual rectification survey.
- D
Keep all essential equipment working safely.
Inspectors wroteBased on observations and interviews it was determined that the facility staff failed to maintain the facility in a safe operating condition as evidenced by the heating/AC unit front in a resident's room was on the floor, damaged drywall in residents' rooms, a sink wasn't secured to the bathroom wall, holes in residents' bathroom door, an electrical plate was not secured to the wall, a bed control had exposed wires, an armoire with dry rotten wood, damaged tile in the shower room, a hole in the wall in the laundry room & damaged floor tile, multiple soiled ceiling tile in the stored linen room. This deficient practice was discovered in different areas in the facility during the recertification survey.
- D
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Inspectors wroteBased on observations and interviews it was determined that the facility failed to keep a sanitary environment. This was evident for 2 of 2 Residents (Residents # 64 and # 72) rooms observed during the annual recertification survey.
August 14, 2025Complaint inspection · 2 citations
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on medical record review and interview, it was determined that the facility's nursing staff failed to ensure that an newly admitted resident (resident #17) had a complete discharge summary from the local hospital. This failure to have a complete discharge summary from the local hospital led to the facility being unsure if they had the complete list of medications needed for the resident's care. This was evident for 1 of 2 residents reviewed for neglect during a complaint survey.
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on medical record review and interview, the facility's nursing staff and telehealth provider failed to ensure that a newly admitted resident with respiratory issues (resident #17) had an order for oxygen administration. This was evident for 1 of 2 residents reviewed for neglect during a complaint survey.
April 3, 2024Standard inspection, Complaint inspection · 26 citations
- E
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Inspectors wroteBased on resident interview, staff interview, and clinical record review it was determined that the facility staff failed to ensure residents received showers at least twice a week. This was evident for 4 residents (#81, #111, #116, and #28) out of 48 residents who were part of the survey sample.
- 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 medical record review and interview it was determined that the facility failed to ensure the accuracy of the Medical Orders for Life-Sustaining Treatment (MOLST) and to maintain a proper resident's Advance Directive in the resident's medical record. This was found to be evident for 7 (Resident #27, #64, #61 and #111) out of 9 residents reviewed for advance directives.
- E
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 interviews and medical record review, it was determined that the facility failed to have an effective system in place to ensure that residents and resident representatives are notified in writing of the bed hold policy upon transfer to the hospital. This was found to be evident for 4 (Residents #16, #63, #109, and #117) out of 6 residents reviewed for hospitalization during the annual survey.
- E
Ensure each resident receives an accurate assessment.
Inspectors wroteBased on staff interview and medical record review, it was determined that the facility failed to accurately document resident assessment on the MDS (Minimum Data Set) as evidenced by the inaccurate coding for residents. This was found to be evident for 4 out of 6 Residents (#13, #16, #24, & #28) reviewed for accuracy of MDS assessments.
- E
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 interviews, it was determined that the facility failed to hold care plan meetings with an interdisciplinary team for residents at the time of the Minimum Data Set (MDS) assessment. This was found evident for 3 (#97, #33, and #81) of 6 residents reviewed for care planning.
- E
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on interviews, record review, and observation it was determined that the facility failed to provide wound care treatments according to professional standards. This was found evident of 4 (Resident #101, #21, #332, and #74) of 6 Residents reviewed for skin and wound care.
- 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, interviews, and record review, it was determined that the facility failed to maintain medical records in accordance with acceptable professional standards and practices by: 1) safeguarding resident identifiable information from the public and 2) keeping accurate documentation. This was found evident in 4 of 45 (Resident #73, #101, #332, and #533) residents reviewed during the survey.
- E
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observations and interviews it was determined that the facility failed to ensure staff sanitized medical equipment between residents and failed to ensure gowns were available for staff use as posted on the Enhanced Barrier Precaution signage at the door. This was found to be evident for 1 out of 3 staff observed for infection control and for 4 rooms (#300, #336, #338, and #340) out of 10 rooms observed for Personal Protective Equipment (PPE)availability.
- 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 interviews, it was determined that the facility staff failed to ensure the dignity of the residents as evidenced by: 1) Nursing staff failed to wear a name tag and 2) Nursing staff use of a personal cell phone during Resident's (#16) care. This was found to be evident for 1 out of 1 Resident for dignity.
- D
Give the resident's representative the ability to exercise the resident's rights.
Inspectors wroteBased on interviews and record review it was determined that the facility failed to honor the rights, delegated to a Resident's Representative by informing them of changes to the plan of care. This was found evident of 1 (Resident #77) of 9 residents reviewed for advanced directive during an annual and complaint survey.
- 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 observations, interviews and documentation review it was determined the facility failed to ensure that personal property was not lost. This was found to be evident for 1 (Resident #28) out of 1 Resident observed for missing property.
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on medical record review and interview, it was determined that the facility failed to ensure that the reporting of reasonable suspicion of an abuse result in serious bodily injury was no later than 2 hours to the State Agency after informing the State Agency of the suspicion of an abuse incident. This was evident for 1 (Resident #64) out of 12 residents reviewed for the facility self-report incidents.
- 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 interviews, it was determined the facility failed to: 1) provide written notice with the reason for transfer to a Resident and 2) failed to notify the Ombudsman of residents that transferred. This was found evident of 3 of 6 (Resident #332, #63, and #109) residents reviewed for hospitalization during the survey.
- 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 interview and record review it was determined that the facility failed to develop and provide the baseline care plan to a newly admitted resident. This was found to be evident for 1(Resident #125 and #109) of 6 residents reviewed for care planning during the survey.
- D
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Inspectors wroteBased on observation, interviews and record review it was determined that the facility failed to develop a care plan for smoking. This was found to be evident for 3 (Resident #28, #125, and #111) out of 6 residents reviewed for care plans.
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on resident interview, staff interview, and observation it was determined that the facility staff failed to ensure that residents toenails were cut. This was evident for 1 (#183) out of 48 residents in the survey sample.
- D
Provide activities to meet all resident's needs.
Inspectors wroteBased on interviews and record review it was determined that the facility failed to have an activities program designed to meet the interests and needs of residents based on the resident's comprehensive assessment and care plan. This was found evident of 2 (Resident #7 and #79) of 5 residents reviewed for activity during the survey.
- D
Ensure medication error rates are not 5 percent or greater.
Inspectors wroteBased on observations, record reviews and interviews it was determined that the facility failed to ensure the medication error rate of 5% or less. This was found to be evident for the medication administration observation during the re-certification survey.
- 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 observations and staff interviews it was determined that the facility failed to maintain a safe and effective system for securing medication and treatments in designated carts on the nursing units. This was found to be evident for 1 out of 7 medication carts and 2 out of 5 treatment carts observed during random tours of the facility.
- D
Provide or obtain dental services for each resident.
Inspectors wroteBased on observation, interview and medical record review it was determined that the facility staff failed to assist the resident as necessary to make appointments for dental care or treatment. This was found to be evident for 1 (Resident # 13) out of 3 residents reviewed for dental treatments during an annual survey.
- D
Employ staff that are licensed, certified, or registered in accordance with state laws.
Inspectors wroteBased on interviews and employee file review it was determined that the facility failed to employ a Licensed Practical Nurse in accordance with Maryland State laws. This was found evident in 1 (Staff #13) out of 11 employees reviewed during the survey.
- D
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 observations and interviews it was determined that the facility failed to ensure that a resident's bed mattress was properly secured to the bed frame. This was found evident of 2 residents (Resident #85, & #97) on 4 different observations.
- D
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Inspectors wroteBased on observation and interview it was determined that the facility failed to maintain an effective pest control program as evidenced by the presence of insects. This was found to be evident for 1 out of 1 resident's (#77) room observed for pest control.
- D
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
Inspectors wroteBased on employee record review and interviews it was determined that the facility failed to monitor staff to ensure required in-service training for nurse aide staff was completed. This was found evident in 1 out of 5 Geriatric Nursing Assistants (GNA# 48) reviewed.
- D
Keep residents' personal and medical records private and confidential.
Inspectors wroteBased on a review of clinical records, staff interview, and an investigation of Intake #MD00203099 it was determined that the facility staff failed to ensure a resident's personal and medical information. That was placed in another resident's clinical record. This was evident for 1 (#382) out of 48 residents in the survey sample.
- D
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Inspectors wroteBased on record review, review of facility incidents, and interviews it was determined that the facility failed to ensure that a resident was free from verbal abuse. This was found to be evident for 2 (Resident #24 and #78) out of 9 residents reviewed for abuse.
October 2, 2023Complaint inspection · 8 citations
- J
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on medical record review and staff interview, the facility staff failed to provide adequate supervision to a resident, who received a recent Narcan administration. This was evident for 1 of 74 residents (Resident #41) reviewed during a complaint survey. As a result of these findings, an immediate jeopardy was declared on [DATE] at 12:00 PM and the immediate jeopardy tool was provided. The facility submitted several versions of a plan to abate the IJ that were rejected by the Office of Health Care Quality. The rejected plans to abate the IJ were submitted on [DATE] at the following times: 4:09 PM, 4:43 PM, 6:21 PM, 6:46 PM, 8:13 PM and 8:27 PM. The facility submitted the final plan to abate the IJ on [DATE] at 9:36 PM. On [DATE] at 10:00 PM, the facility's abatement plan was accepted by the Office of Health Care Quality. [...]
- G
Provide safe, appropriate pain management for a resident who requires such services.
Inspectors wroteBased on medical record review and staff interview, facility nursing staff failed to sufficiently manage a resident ' s pain (Resident #41), resulting in harm to the resident. This was evident for 1 of 74 residents reviewed during a complaint survey. After review of pain management staff training completed after the incident and changes to facility pain management policy the deficient practice was cited as past non-compliance. The compliance date was [DATE].
- D
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Inspectors wroteBased on a review of facility-reported incidents, employee personnel files, closed clinical record review, facility abuse policy review, and staff interview, it was determined that facility staff failed to ensure resident # 71 was free from verbal abuse. This was evident for 1 out of 3 residents reviewed during a complaint survey.
- D
Not hire anyone with a finding of abuse, neglect, exploitation, or theft.
Inspectors wroteBased on review of a facility reported incident, administrative files and staff interview, it was determined that the facility administration failed to implement the facility abuse policy by not performing a back-ground check on an employee. This was evident for 1 of 8 employee files reviewed for abuse during a complaint survey.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on review of a complaint and a closed health record, as well as staff interview, it was determined that the nursing staff failed to administer an antibiotic as ordered. This was evident for 1 (Resident #45) of 70 residents reviewed during a complaint survey.
- D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Inspectors wroteBased on complaint, reviews of a closed medical record, and staff interview, it was determined the facility failed to timely provide medication to meet the needs of the residents. This was evident for 1 (Resident #35) of 70 residents reviewed during a complaint survey.
- 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 reviews of medical records and staff interviews, it was determined that the facility staff failed to 1) have a process to ensure the clinical pharmacist's monthly medication reviews were reviewed by the physician with a documented response in the resident's medical record. This was evident for 1 (Residents #41) of 70 residents reviewed during a complaint survey.
- D
Hire a qualified full-time social worker in a facility with more than 120 beds.
Inspectors wroteBased on facility staff roster review and staff interview, it was determined that the facility has a bed capacity of 150 and did not employ a qualified social worker from January 2016 to the present on a full-time basis. This deficient practice was found during a complaint survey and has the potential to affect all residents.
March 11, 2019Standard inspection · 20 citations
- E
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 medical record review and interview with staff it was determined that the facility staff failed to provide a written notice for emergency transfers to the resident /or the resident representative and ombudsman. This was found to be evident for 5 out of 5 residents reviewed for a facility-initiated transfer during the investigative portion of the survey.
- E
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 medical record review, observation and staff interview, it was determined the facility staff failed to review and revise the interdisciplinary care plans to reveal accurate interventions for Residents (#57 and #23). This was evident for 2 of 40 residents selected for investigation during the survey process.
- E
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Inspectors wroteBased on medical record review and interview, it was determined the facility staff failed to document/obtain the blood pressure for a resident with parameters (Resident #102 and #23). This was evident for 2 of 40 residents reviewed during survey investigation.
- E
Provide timely, quality laboratory services/tests to meet the needs of residents.
Inspectors wroteBased on medical record review and interview, it was determined the facility staff failed to obtain laboratory blood specimens on Residents (#12, #23, #84, #59 and #90). This was evident for 5 of 44 residents selected for review during the survey process.
- E
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Inspectors wroteBased on resident complaints and surveyor observation it was determined the facility failed to provide food at a safe and appetizing temperature. This deficient practice has the potential to affect all residents.
- 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 interviews of facility staff, it was determined that food service employees failed to ensure that sanitary and safe food handling practices were followed to reduce the risk of foodborne illness. This deficient practice has the potential to affect all residents.
- E
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Inspectors wroteBased on observation and interview of facility staff, it was determined that the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff and the public. This deficient practice has the potential to affect all residents.
- D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteBased on record review, observation and interview, it was determined the facility staff failed to provide Resident #23 with the most dignified existence. This was evident for 1 of 44 residents selected for resident rights during the annual survey.
- D
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Inspectors wroteBased on medical record review, observation and interview, it was determined the facility staff failed to promote self-determination for Residents (#23 and #92). This was evident for 1 of 44 residents selected for review of self-determination during the annual survey process.
- 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 surveyor observation and resident interview during facility environmental observations it was determined that the facility staff failed to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior.
- D
Ensure each resident receives an accurate assessment.
Inspectors wroteBased on medical record review and staff interview it was determined the facility staff failed to document accurate assessment for Resident (#23) on the MDS. This was evident for 1 of 44 residents selected for review of MDSs assessment during the annual survey process. The MDS is a federally-mandated assessment tool that helps nursing home staff gathers information on each resident's strengths and needs. Information collected drives resident care planning decisions. MDS assessments need to be accurate to ensure each resident receives the care they need. Categories of MDS (Minimum Data Set) are: [...]
- 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 review of the medical record and interviews with staff, it was determined that the facility staff failed to develop a comprehensive care plan for a resident (#131). This was evident for 1 of 2 residents reviewed for urinary tract infections during the annual survey.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on medical record review and interview, it was determined the facility staff failed provide care to promote the highest well-being to residents. The facility staff failed to obtain an infectious disease consultation for Resident (#12) as ordered; failed to obtain a Hematology/Oncology consultation as ordered for Resident (#71) and failed to provide a dressing change as ordered for Resident (#251). This was evident for 1 of 44 residents selected for review for provision of care during the annual survey process.
- D
Provide enough food/fluids to maintain a resident's health.
Inspectors wroteBased on medical record review, observation and interview, it was determined the facility staff failed to provide Resident (#23) with a sippy cup as ordered and failed to notify the Certified Registered Nurse Practitioner (CRNP)/physician of a weight loss for Resident (#71). This was evident for 2 of 44 residents selected for review during the annual survey process.
- D
Provide safe, appropriate pain management for a resident who requires such services.
Inspectors wroteBased on medical record review and interviews with facility staff, it was determined that the facility staff failed to obtain and administer an ordered pain medication (Resident # 304) and failed to follow physician orders in administering a pain medication (Resident #84). This is evident for 2 out of 3 residents reviewed for pain management.
- D
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 medical record review and interview, it was determined the facility staff failed to have enough staffing to ensure Resident #71 was provided an escort for an appointment. This was evident for 1 of 44 residents selected for review of enough staffing during the survey process.
- D
Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder.
Inspectors wroteBased on medical record review and interview, it was determined the facility staff failed to obtain a psychiatric consultation for Resident #84 in a timely manner. This was evident for 1 of 44 residents selected for review during the annual survey process.
- 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 medical record review and interview, it was determined the consultant pharmacist failed to conduct a thorough medical record review to identify and bring to the facility staff's attention Resident #23 not receiving blood pressures and heart rate ordered by the physician. This was evident for 1 of 5 residents selected for review of un-necessary medications.
- D
Dispose of garbage and refuse properly.
Inspectors wroteBased on observation and staff interview, it was determined the facility staff failed to dispose of garbage and refuse properly.
- C
Post nurse staffing information every day.
Inspectors wroteBased on observation and staff interview it was determined that the facility staff failed to ensure staffing hours for nursing staff were posted and to ensure 18 months of posted nursing data were maintained. This was true for 4 out of 4 nursing units.
Fire safety inspections
18 fire safety citations on file: 5 on December 1, 2025, 12 on April 3, 2024, 1 on March 11, 2019.
Every fire safety citation18 citations
- F
Conduct testing and exercise requirements.
E 39 · December 1, 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 · December 1, 2025 · Corrected (the home has a date of correction)
- D
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
K 223 · December 1, 2025 · Corrected (the home has a date of correction)
- D
Inspect, test, and maintain automatic sprinkler systems.
K 353 · December 1, 2025 · Corrected (the home has a date of correction)
- D
Have simulated fire drills held at unexpected times.
K 712 · December 1, 2025 · Corrected (the home has a date of correction)
- F
Meet other general requirements.
K 200 · April 3, 2024 · Corrected (the home has a date of correction)
- F
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
K 223 · April 3, 2024 · Corrected (the home has a date of correction)
- F
Have properly located and lighted "Exit" signs.
K 293 · April 3, 2024 · Corrected (the home has a date of correction)
- F
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
K 321 · April 3, 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 · April 3, 2024 · Corrected (the home has a date of correction)
- E
Keep aisles, corridors, and exits free of obstruction in case of emergency.
K 211 · April 3, 2024 · Corrected (the home has a date of correction)
- E
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
K 225 · April 3, 2024 · Corrected (the home has a date of correction)
- E
Install corridor and hallway doors that block smoke.
K 363 · April 3, 2024 · Corrected (the home has a date of correction)
- E
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · April 3, 2024 · 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 · April 3, 2024 · Corrected (the home has a date of correction)
- D
Properly select, install, inspect, or maintain portable fire extinguishes.
K 355 · April 3, 2024 · Corrected (the home has a date of correction)
- D
Install properly constructed windows in hallway walls or doors.
K 364 · April 3, 2024 · Corrected (the home has a date of correction)
- E
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · March 11, 2019 · Corrected (the home has a date of correction)