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 55 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
2G
0H
0I
Potential for more than minimal harm
43D
6E
4F
Potential for minimal harm
0A
0B
0C
February 4, 2026Complaint inspection · 1 citation
- G
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on observation, interview, and record review, the facility failed to provide care and services to prevent accidents for one of five sampled residents (Resident 1) who has left sided hemiplegia (paralysis affecting one side of the body) and hemiparesis (one-sided weakness) when the facility failed to develop an individualized care plan that addressed Resident 1's physical limitation and failed to ensure the staff implemented appropriate interventions when certified nursing assistant (CNA 1) left the bedside table positioned on the resident's left-side, rendering necessary items inaccessible and requiring Resident 1 to reach across the body which posed a risk of Resident 1 falling off the bed. These failures resulted in Resident 1 sustaining an unwitnessed fall on 12/6/2025. [...]
August 14, 2025Complaint inspection · 2 citations
- D
Ensure that residents are free from significant medication errors.
Inspectors wroteBased on interview and record review, the facility failed to ensure 1 of 3 sampled residents (Resident 1) was free from significant medication errors when Resident 1 received two medications (solatol- used to treat heart rhythm problems and apixaban- a blood thinner that reduces blood clotting), which were intended for another resident. This failure resulted in the potential to affect Resident 1's health and well-being and placed other residents at risk for medication errors.
- D
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of four medication carts and narcotic storage boxes was locked, secured, and inaccessible to unauthorized staff, residents and visitors. This failure had the potential for visitors, residents, and unauthorized staff to access medications and narcotics stored in the medication carts.
March 21, 2025Complaint inspection · 1 citation
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on observation, interview and record review, the facility failed to report an injury of unknown origin within 24 hours for one of one sampled resident (Resident 1). This failure resulted in Resident 1's injury of unknown origin to not be reported to the state licensing/certification office, delayed the abuse investigation, and placed residents at risk for abuse.
January 30, 2025Standard inspection, Complaint inspection · 12 citations
- F
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on observation, intervention, and record review, the facility failed to follow safe food practices when: 1. The ceiling above the kitchen tray line area had peeling and bubbling paint; and, 2. Two staff members entered the kitchen without donning (to put on) hair coverings. This failure had the potential for unsanitary products to fall into resident food or onto kitchen equipment.
- 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 observation, interview, and record review, the facility failed to provide and promote a homelike atmosphere for four of 15 resident rooms (11, 19, 21, 22), within the secured unit (a specialized care unit which is locked and limits residents with memory loss and/or mental health issues from exiting the unit without supervision), when reviewed for Resident Rights. This failure had the potential for residents to feel disrespected and undervalued.
- E
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain resident rooms from environmental hazards for six of 15 rooms (12, 13, 17, 19, 20, 21), reviewed for accidents. In addition, the facility failed to provide two-person lifting assistance while transferring one of one resident (Resident 29 ) from a wheelchair to bed using a mechanical lifting device (a hydraulic devices with a sling used for transfers) with one staff, (Two staff always required for mechanical lifts). These failures had the potential for residents to sustain injuries from hazards identified in their rooms and from mechanical lifts or transfers.
- E
Have a plan that describes the process for conducting QAPI and QAA activities.
Inspectors wroteBased on interview and record review, the facility's Quality Assessment Performance Improvement (QAPI-plan developed by the QAA committee to improve conditions in the facility) failed to identify deficient practices prior to to their recertification survey when: 1) The facility did not provide education to staff related to the management of residents with post-traumatic stress disorder (PTSD- a mental condition that's caused by an extreme event - either being part of it or witnessing it) and, 2) Did not identify and correct environmental hazards which could have caused injury. These failures had the potential to negatively affect residents' health and quality of life. Findings. Cross reference : F-584, F-689, and F699. 1) A joint interview on 1/30/2025 at 2:27 P.M., with the Administrator (ADM) and the Director of Nursing (DON) was conducted. [...]
- D
Ensure each resident receives an accurate assessment.
Inspectors wroteBased on observation, interview, and record review, the facility failed to accurately assess, document, and transmit Minimum Data Set (MDS-a clinical assessment tool), information to the Center for Medicare and Medicaid Services (CMS-A federal agency that oversees health insurance) regarding a vision assessment for one of eight residents (Resident 3), reviewed for Resident Assessment. As a result, CMS was uninformed of Resident 3's impaired vision. Cross reference (F-685)
- D
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Inspectors wroteBased on observation, interview, and record review, the facility failed to develop a person-centered care plan to manage combative behavior for one of three residents (Resident 84) reviewed for ADLs (Activities of Daily Living- eating, dressing, showering, grooming and toileting). As a result, there was potential for the resident to not receive individualized care.
- D
Assist a resident in gaining access to vision and hearing services.
Inspectors wroteBased on observation, interview, and record review, the facility failed to address a residents' visual impairment in a timely manner for one of two residents (Resident 3), reviewed for Quality of Care. As a result, Resident 3 experience weight loss due to being unable to see his food. Cross Reference (F-641 and F-692)
- D
Provide enough food/fluids to maintain a resident's health.
Inspectors wroteBased on observation, interview, and record review, the facility failed to investigate and analyze the root cause for recent weight loss for one of one resident (Resident 3) reviewed for nutrition. This failure had the potential for Resident 3 to experience additional weight loss. (Cross Reference F-641, F-685, F-842)
- D
Provide care or services that was trauma informed and/or culturally competent.
Inspectors wroteBased on observation, interview and record review, the facility failed to identify triggers related to PTSD ( post-traumatic stress disorder- difficulty recovering after experiencing or witnessing a traumatic event ) for two of two residents (Resident 27 and 35) reviewed for trauma-informed care. This failure had the potential to result in re-traumatization (the reactivation of trauma symptoms via thoughts, memories, or feelings related to the past traumatic experience) that could lead to severe psychosocial harm and affect the resident's quality of life.
- D
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Inspectors wroteBased on interview and record review, the facility failed to monitor behaviors and side effects of a psychotropic medication (a drug to control thoughts and behaviors) for one of five residents (Resident 11) reviewed for unnecessary psychotropic medications. This failure placed the resident at risk for receiving unnecessary medication and having unrecognized adverse reactions.
- D
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Inspectors wroteBased on observation, interview, and record review, the facility failed to secure one of three treatment carts (East Station) and one of three medication carts (East Station), when reviewed for Pharmacy Services. This failure had the potential for residents, staff, and visitors to have access to unauthorized medications and wound supplies.
- D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on observation, interview, and record review, the facility failed to accurately document: 1. Food intake percentages (how much a resident consumes for each meal) for one of one resident (Resident 3), reviewed for nutrition; and 2. Care given to one of three residents (Resident 84) reviewed for Activities of Daily Living (ADL'S). As a result, resident records were inaccurate and did not give a clear picture of the resident's current status to other care providers. Cross Reference (F-692)
December 27, 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 implement its policy and procedure for fall prevention program for two of three sampled residents (Residents 2 and 3) who had incidents of repeated falls. This failure placed Residents 2 and 3 at risk for further falls and injuries.
October 29, 2024Complaint inspection · 1 citation
- D
Let each resident or the resident's legal representative access or purchase copies of all the resident's records.
Inspectors wroteBased on interview and record review, the facility failed to ensure resident rights were honored for 1 of 3 sample residents (1) when the Medical Record Department (MRD) could not provide evidence that Resident 1's representative received copies of the medical record requested in a timely manner. As a result, there was a delay in reviewing Resident 1's medical record.
September 24, 2024Complaint inspection · 1 citation
- D
Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy.
Inspectors wroteBased on interview and record review, the facility failed to follow appropriate discharge protocols for one of one resident (Resident 1). This failure had the potential for Resident 1 not being able to return to the facility which he considered his home and not being able to appeal the discharge.
September 17, 2024Complaint inspection · 1 citation
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on interviews and record review the facility failed to provide a medication as ordered by the physician to one (Resident 1) of three sampled residents. This failure had the potential to elevate Resident 1 ' s ammonia levels. Resident 1 ' s record was reviewed. Per Resident 1's admission Record, Resident 1 is a [AGE] year-old female admitted to the facility on [DATE]. Resident 1 ' s diagnosis included cirrhosis of the liver (scarring that prevents the liver from working properly) and hepatic encephalopathy (loss of brain function when the liver does not work properly). During a record review of Resident 1 ' s admission orders dated 8/30/24, Resident 1 was admitted with a physician's order for lactulose (a medication used to prevent and treat hepatic encephalopathy) 30 grams by mouth three times a day. [...]
August 2, 2024Complaint inspection · 1 citation
- E
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that cooks followed recipes when preparing meals. This deficient practice had the potential to impact the residents' nutritional status and not meet the residents' desires to be served food they felt was palatable and attractive.
July 18, 2024Complaint inspection · 1 citation
- D
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement an individualized care plan for one of two residents (Resident 1) reviewed for elopement (leaving the facility without permission). This failure had the potential to put Resident 1 at risk for further elopements and injury.
May 17, 2024Complaint inspection · 1 citation
- G
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on interview and record review, the facility failed to provide a safe environment for one of three residents (Resident 1) reviewed for accidents. Resident 1, who was known to have a history of suicidal attempt (the act of intentionally causing one ' s death), was left unattended during a mealtime, and swallowed part of a metal fork. As a result, Resident 1 was transferred to the hospital to remove the metal fork from her body.
May 7, 2024Complaint inspection · 1 citation
- D
Ensure services provided by the nursing facility meet professional standards of quality.
Inspectors wroteBased on interview and record review, the facility failed to ensure the clinical record was complete and accurate for 1 of 2 sampled residents to meet the standard of practice, when Resident 1 had a blood draw performed (a procedure in which a needle is used to take blood from a vein, usually for laboratory testing). As a result, Resident 1's medical record could not accurately reflect the care provided. This lack of documentation poses a potential risk to Resident 1's health, as it hinders the ability to track and monitor the effectiveness of the care provided.
March 13, 2024Complaint inspection · 1 citation
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure infection control prevention was followed when Certified Nursing Assistant (CNA) 2 was inside the isolation room without appropriate Personal Protective Equipment (PPE-equipment worn to minimize exposure to infectious agents). As a result, there was a potential for cross-contamination (physical movement or transfer of harmful bacteria or viruses from one person, object or place to another).
February 14, 2024Complaint inspection · 1 citation
- D
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Inspectors wroteBased on observation, interview, and record review the facility failed to implement interventions to prevent a fall. This failure resulted in Resident 1 sustaining a fractured clavicle (a bone of the shoulder that joins the breastbone and the shoulder blade).
October 20, 2023Complaint inspection · 1 citation
- 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 interview and record review, the facility failed to provide a proper discharge process for 1 of 2 sampled residents (1) when there was no documented evidence that the staff reviewed the personal property inventory and compared the medication list to the discharge medications. As a result, Resident 1's belongings and medications could not be accounted for.
September 13, 2023Complaint inspection · 2 citations
- D
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Inspectors wroteBased on observation, interview, and record review, the facility failed to develop person-centered care plans for one resident (Resident 1) when care plans were not developed for the use of an indwelling urinary catheter (soft, plastic or rubber tube that is inserted into the bladder to drain the urine) and the presence of a pressure ulcer (a bedsore). This failure could potentially affect the resident in the care areas that were not care planned. These included proper attention and assessment of infection for the use of an indwelling catheter and monitoring of interventions which addressed Resident 1 ' s pressure ulcer. Resident 1 was re-admitted to the facility on [DATE] with the diagnoses including Atherosclerotic Heart Disease (thickening or hardening of the arteries) according to the facility ' s admission Record. [...]
- 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 observation, interview and record review, the facility failed to ensure one of five resident ' s (Resident 8) food dislike was honored. This failure had the potential to cause Resident 8 to experience an unplanned lose weight.
June 17, 2021Standard inspection · 14 citations
- F
Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
Inspectors wroteBased on observation, interviews, and dietetic services record reviews, the facility failed to ensure safe and effective dietetic service oversight for food and nutrition services in accordance with the regulation and facility policies when: 1. One of two sampled residents (Resident 71) had a severe weight loss of 12.79 % in six months and was not adequately or timely assessed by the RD, 2. Kitchen staff were not sufficiently trained for competency in food safety and sanitation tasks, and 3. Kitchen sanitation inspections were not performed on a regular basis in accordance with facility protocols and standards of practice. These failures in dietetic services oversight placed 94 residents at risk for compromised nutrition status.
- F
Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.
Inspectors wroteBased on observation, interview and facility document review, the facility failed to ensure the food and nutrition services staff maintained current competency in dietetic task operations to safely carry out the kitchen functions in a sanitary manner according to facility policies and standards of practice when: 1. The A.M. [NAME] (CK 1) could not correctly demonstrate how to test the sanitizer concentration; 2. A Dietary Aide (DA 1) did not take the temperatures or properly store the milk served on lunch trayline; 3. The P.M. [NAME] (CK 2) did not know the correct process to cool down cooked foods. These failures had the potential to result in contamination of food, leading to widespread food borne illness for 94 residents who consume food from the kitchen. Cross Reference F 812 Findings 1. On 6/14/21 at 9:30 A.M., an interview was conducted with CK 1 and the DSS. [...]
- 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 did not ensure safe and sanitary conditions were met according to facility policy and standards of practice within the Food and Nutrition Services department when: 1. Walk-in freezer was overstocked with ice accumulation on the ceiling and cases of foods; 2. A kitchen drawer that stored loose plastic lids to rubber bowls and cups, was covered in black dirt, brown stains, and food crumbs; 3. A nurse's unit refrigerator with resident food had a temperature of 50 degrees F for two days and was dirty with brown and orange stains inside the door shelves and freezer space. These deficient practices had the potential to put residents at risk to foodborne illnesses.
- 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 consistently provide showers for 28 of 32 dependent residents (Residents 15, 19, 21, 27, 36, 37, 38, 40, 41, 48, 49, 50, 51, 52, 55, 56, 57, 58, 59, 60, 61, 63, 64, 65, 72, 75, 87, 93) reviewed for Activities of Daily Living (ADL, bathing, dressing and grooming) in the secured unit (requiring supervision). This failure had the potential for increased skin infections and a decrease in personal hygiene and socialization.
- E
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview and record review, the facility failed to ensure infection control prevention practices were followed appropriately, when: 1. Recommended COVID-19 (a contagious virus) personal protective equipment (PPE), which included the use of gowns, gloves, face shield, and N95 mask (higher level of face mask) were not worn by staff who entered the room of residents located in the yellow zone (unknown COVID-19 status for residents who were newly admitted or re-admitted to the facility), 2. Residents who smoked and were roomed in the yellow zone passed through the green zone (residents who have no exposure to COVID-19) to the smoking area; and, 3. An oxygen humidifier was resting on the floor of Resident 61's room. These failures had the potential for cross contamination of pathogens
- D
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Inspectors wroteBased on observation, interview, and record review, the facility failed to develop individualized person-centered care plans for three of 19 resident's, (Resident 63, 93, 82) reviewed for care plans when: 1. Resident 63's urinary catheter (a flexible tube that drains urine from the bladder into an external bag) preferences were not documented, 2. Resident 93's dementia (memory loss) was not identified; and, 3. Resident 83's skin condition of psoriasis (a skin disorder), was not addressed. In addition, a physician's order related to tube feeding was not followed for one of four residents (Resident 29) reviewed for medication administration. These failures had the potential for individualized care to not be consistently applied and for Resident 29 to have an alteration in nutritional status.
- 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 observation, interview, and record review, the facility failed to revise a person-centered care plan for four of 19 sampled residents (71, 345). These failures had the potential to negatively impact resident's quality of care.
- D
Provide enough food/fluids to maintain a resident's health.
Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a comprehensive and effective systematic approach was implemented to monitor and maintain acceptable parameters of nutritional status for one of two sampled residents (Resident 71). Resident 71 experienced a 12.79 percent weight loss in six months that was not addressed by the facility according to facility policy and standards of practice. As a result, Resident 71 had a severe unplanned weight loss.
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a physician's order was in place, prior to the administration of oxygen for one of two residents (Resident 61), reviewed for oxygen therapy. This failure had the potential for Resident 61 to develop oxygen toxicity (lung damage from too much oxygen being supplied).
- 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 provide pain medication to one of one residents reviewed for pain (Resident 146). As a result, Resident 146 had uncontrolled pain.
- 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 ensure a controlled substance medication (a controlled drug for pain with high abuse potential), was accounted for, for one of four residents reviewed for medication storage (Resident 29). This failure had the potential for the resident to receive more medication than ordered, and for staff diversion (theft).
- D
Ensure medication error rates are not 5 percent or greater.
Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the medication error rate was less than five percent. The facility's medication error rate was 15.63%. Out of a total of 32 opportunities, five medication errors were observed during the medication administration process for three of three randomly observed residents (84, 34). As a result, the facility could not ensure medications were correctly administered to all residents.
- D
Have a policy regarding use and storage of foods brought to residents by family and other visitors.
Inspectors wroteBased on observation, interview and record review, the facility failed to ensure safe and sanitary practices were implemented for residents' food brought in from the outside according to the facility policy. Failure to ensure safe storage and reheating procedures for residents' food from the outside has the potential to expose 94 residents to foodborne contamination in the facility.
- D
Have a plan that describes the process for conducting QAPI and QAA activities.
Inspectors wroteBased on interview and record review, the facility's Quality Assurance and Performance Improvement (QAPI), program failed to identify, implement, and evaluate systematic measures to ensure effective oversight, which were identified in the Federal recertification survey, dated 6/14/21 through 6/17/21, related to: 1. Weight loss and nutritional service (F-692) and; 2. Pharmacy services (F-755). As a result, the facility was noncompliant with deficiencies cited during the survey, which had the potential to affect the health and safety of the residents.
August 8, 2019Standard inspection · 12 citations
- D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteBased on observation, interview and record review, the facility failed to provide timely personal care for three of 19 residents (16, 40 and 51), reviewed for dignity issues. This failure had the potential to cause psychosocial harm for the residents.
- D
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Inspectors wroteBased on observation, interview, and record review, the facility failed to develop a care plan which specifically addressed a language barrier for one of two residents reviewed for communication (28). This failure had the potential for Resident 28 's needs to not be met.
- D
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Inspectors wroteBased on observation, interview, and record review, the facility failed to communicate with one of two sampled residents (28) in her preferred language. This failure had the potential for Resident 28 to not have her needs met.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on interview, observation, and record review, the facility failed to identify the needs of one of two residents reviewed for pain management (52). This failure had the potential for Resident 52's pain to go unrecognized and untreated.
- D
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 nursing staff assessed the residents' dialysis (artificial process of removing waste products and extra fluid from the body) graft (access site) for the bruit (sound associated with blood flow through the shunt) or thrill (a sensation felt over the graft indicating blood flow) presence or absence for one of one resident's (16) reviewed for dialysis care. This failure could result in complications related to dialysis treatment and infection.
- 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 interview and record review, the facility failed to provide sufficient staffing to provide care in a timely manner for four of 19 sampled residents (252,16, 40 and 51). These failures had the potential to result in resident's needs not being met in a timely manner, and to result in physical and/or psychosocial harm.
- 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 interview and record review, the facility failed to ensure concerns related to the lack of behavior monitoring for the use of an antipsychotic medication, was identified during the medication regimen review for one of five residents (29). This failure had the potential for Resident 29 to be placed on psychoactive medication unnecessarily.
- 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 observation, interview and record review, the facility failed to ensure one of five residents (29) was free from unnecessary use of psychoactive medications when: 1. An inappropriate target behavior was monitored for the use of an antipsychotic medication. 2. Behavior monitoring for the use of an antipsychotic, anti-anxiety, and a mood stabilizer medications was not consistently performed and documented. 3. A hypnotic medication was ordered and administrated without clear indications for its use. These failures had a potential for Resident 29 to experience unnecessary side effects from the psychoactive medications.
- D
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the nutritional needs of the residents when portion sizes were not followed during the lunch meal on 8/7/19. This failure had the potential for residents to not receive adequate nutrition, further compromising their medical status.
- D
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Inspectors wroteBased on observation, interview and record review, the facility failed to deliver food at appetizing temperatures. As a result, residents were at risk of foodborne illness and unplanned weight loss.
- D
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on observation, interview and record review, the facility failed to store food in a sanitary manner. As a result, residents were at risk of foodborne illness.
- D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on observation, interview, and record review, the facility failed to keep accurate medical records for two of 19 sampled residents (50, 298). This failure had the potential for: 1. Resident 50 to have improper psychiatric treatment based on incorrect information included in her psychiatric evaluation. 2. Resident 298 to have incorrect treatment based on disorganized documentation in the medical record.
Fire safety inspections
26 fire safety citations on file: 11 on January 30, 2025, 8 on June 17, 2021, 7 on August 8, 2019.
Every fire safety citation26 citations
- F
Implement emergency and standby power systems.
E 41 · January 30, 2025 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · January 30, 2025 · Corrected (the home has a date of correction)
- F
Install corridor and hallway doors that block smoke.
K 363 · January 30, 2025 · 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 · January 30, 2025 · Corrected (the home has a date of correction)
- D
Install emergency lighting that can last at least 1 1/2 hours.
K 291 · January 30, 2025 · Corrected (the home has a date of correction)
- D
Provide properly protected cooking facilities.
K 324 · January 30, 2025 · Corrected (the home has a date of correction)
- D
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
K 521 · January 30, 2025 · Corrected (the home has a date of correction)
- D
Ensure proper usage of power strips and extension cords.
K 920 · January 30, 2025 · Corrected (the home has a date of correction)
- C
Conduct testing and exercise requirements.
E 39 · January 30, 2025 · Corrected (the home has a date of correction)
- C
Have simulated fire drills held at unexpected times.
K 712 · January 30, 2025 · Corrected (the home has a date of correction)
- C
Ensure that testing and maintenance of electrical equipment is performed.
K 921 · January 30, 2025 · Corrected (the home has a date of correction)
- D
Address subsistence needs for staff and patients.
E 15 · June 17, 2021 · Corrected (the home has a date of correction)
- D
Establish policies and procedures for medical documentation.
E 23 · June 17, 2021 · Corrected (the home has a date of correction)
- D
Establish roles under a Waiver declared by secretary.
E 26 · June 17, 2021 · Corrected (the home has a date of correction)
- D
Provide emergency officials' contact information.
E 31 · June 17, 2021 · Corrected (the home has a date of correction)
- D
Provide family notifications of emergency plan.
E 35 · June 17, 2021 · Corrected (the home has a date of correction)
- D
Implement emergency and standby power systems.
E 41 · June 17, 2021 · Corrected (the home has a date of correction)
- D
Provide properly protected cooking facilities.
K 324 · June 17, 2021 · Corrected (the home has a date of correction)
- D
Meet requirements for the installation and maintenance of electrical systems.
K 911 · June 17, 2021 · Corrected (the home has a date of correction)
- D
Establish methods for sharing information.
E 33 · August 8, 2019 · Corrected (the home has a date of correction)
- D
Provide family notifications of emergency plan.
E 35 · August 8, 2019 · Corrected (the home has a date of correction)
- D
Implement emergency and standby power systems.
E 41 · August 8, 2019 · Corrected (the home has a date of correction)
- D
Keep aisles, corridors, and exits free of obstruction in case of emergency.
K 211 · August 8, 2019 · Corrected (the home has a date of correction)
- D
Properly select, install, inspect, or maintain portable fire extinguishes.
K 355 · August 8, 2019 · Corrected (the home has a date of correction)
- D
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
K 761 · August 8, 2019 · Corrected (the home has a date of correction)
- D
Ensure proper usage of power strips and extension cords.
K 920 · August 8, 2019 · Corrected (the home has a date of correction)