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 70 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
1K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
51D
18E
0F
Potential for minimal harm
0A
0B
0C
April 22, 2026Complaint inspection · 1 citation
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on interview and record review, it was determined the facility failed to follow physician orders and provide necessary treatment related to bowel care for 2 of 3 sampled residents (#s 12 and 18) reviewed for change of condition. This placed residents at risk for dehydration, incontinence and weight loss.
December 3, 2025Standard inspection, Complaint inspection · 14 citations
- E
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Inspectors wroteBased on observation and interview it was determined the facility failed to keep air temperatures between 71 and 81 degrees Fahrenheit for 2 of 4 halls reviewed for environment. This placed residents at risk for lack of a homelike environment.
- E
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview, and record review it was determined the facility failed to ensure community use CBG monitors were cleaned with an Environmental Protection Agency approved disinfectant for 2 of 5 Halls (300 Hall and 400 Hall). This placed residents at risk for cross contamination.
- D
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Inspectors wroteBased on interview and record review it was determined the facility failed to ensure a resident's advance directive was in her/his clinical record for 1 of 1 sampled resident (#3) reviewed for advance directives. This placed residents at risk for end-of-life decisions not being honored.
- D
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
Inspectors wroteBased on observation, interview, and record review it was determined the facility failed to ensure a resident's antipsychotic medication was not increased when adverse side effects were present for 1 of 4 sampled residents (# 92) reviewed for nutrition. This placed residents at risk for irreversible involuntary movements.
- D
Respond appropriately to all alleged violations.
Inspectors wroteBased on interview and record review it was determined the facility failed to ensure a resident's pressure ulcers were thoroughly investigated for 1 of 1 sampled resident (# 40) reviewed for hospice. This placed residents at risk for additional pressure ulcers.
- D
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Inspectors wroteBased on record review and interview it was determined the facility failed to ensure the Office of the State Long-Term Care Ombudsman was notified of a resident's discharge or hospitalization for 3 of 3 sampled residents (#s 11, 98, and 100) reviewed for discharge and hospitalization. This placed residents at risk for lack of knowledge regarding their rights, choices and potential financial responsibilities.
- 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 interview and record review it was determined the facility failed develop a comprehensive care plan for 1 of 1 sampled resident (#9) reviewed for dialysis. This placed residents at risk for unmet dialysis needs.
- 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 it was determined the facility failed to revise care plan interventions for 1 of 1 sampled resident (#22) reviewed for position and mobility. This placed residents at risk for unmet needs.
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on interview and record review, it was determined the facility failed to ensure a resident did not develop a pressure ulcer, failed to identify a pressure ulcer, and provide physician ordered treatments for 2 of 3 sampled residents (#s 3 and 76) reviewed for pressure ulcers. This placed residents at risk for delayed care and worsening pressure ulcers.
- 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 it was determined the facility failed to ensure residents did not have cigarettes and lighters in their rooms and a fall investigation was thoroughly completed for 3 of 10 sampled residents (#1, 11, and 110) reviewed for accidents. This placed residents at risk for accidents.
- D
Provide enough food/fluids to maintain a resident's health.
Inspectors wroteBased on interview and record review it was determined that the facility failed to implement nutritional interventions to prevent weight loss for 1 of 4 sampled residents (#40) reviewed for nutrition. This placed residents at risk for continued weight loss.
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on interview and record review it was determined the facility failed to provide sufficient respiratory services for 1 of 3 sampled residents (#11) reviewed for respiratory care. This placed residents at risk for unmet respiratory needs.
- D
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
Inspectors wroteBased on observation, interview, and record review it was determined the facility failed to ensure behavior health services were provided for 3 of 5 sampled residents (#s 9, 19, and 36) reviewed for behavioral-emotional health and hospice. This placed residents at risk for unresolved emotional needs.
- D
Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.
Inspectors wroteBased on interview and record review it was determined the facility failed to ensure a resident received thickened liquids as ordered for 1 of 4 sampled residents (#40) reviewed for nutrition. This placed residents at risk for aspiration.
April 3, 2025Complaint inspection · 4 citations
- D
Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
Inspectors wroteBased on interview and record review it was determined the facility failed to ensure residents were treated with respect and dignity for 1 of 6 sampled residents (#12) reviewed for abuse. This placed residents at risk for being treated with a lack of respect and dignity.
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on interview and record review it was determined the facility failed to accurately assess facility acquired pressure ulcers for 1 of 3 sampled residents (#11) reviewed for skin conditions. This placed residents at risk for unassessed and worsening pressure ulcers.
- D
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 it was determined the facility failed to evaluate a potential unavoidable accident of a feeding tube being dislodged to prevent recurrence for 1 of 3 sampled residents (#11) reviewed for safety. This placed residents at risk for dislodged feeding tubes.
- D
Ensure that residents are free from significant medication errors.
Inspectors wroteBased on interview and record review it was determined the facility failed to ensure residents were free from significant medication errors for 1 of 4 sampled residents (#13) reviewed for medications. This placed residents at risk for respiratory distress.
August 7, 2024Complaint inspection · 1 citation
- D
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Inspectors wroteBased on interview and record review it was determined the facility failed to ensure residents were free from sexual abuse for 2 of 3 sampled residents (#s 2 and 3) reviewed for abuse. This placed residents at risk for unwanted sexual abuse.
July 16, 2024Complaint inspection · 1 citation
- K
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 it was determined a facility employee sexually abused 6 of 10 sampled residents (#s 6, 7, 8, 9, 10 and 11) who were reviewed for sexual abuse. As a result of the pattern of sexual abuse, it was determined to be an immediate jeopardy situation and residents experienced psychosocial harm.
June 14, 2024Standard inspection, Complaint inspection · 29 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 it was determined the facility failed to ensure residents were treated with dignity and respect for 4 of 15 sampled residents (Witness 2 and Resident #s 51, 65, and 95) reviewed for dignity and abuse. This placed residents at risk for depression.
- 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 and interview it was determined the facility failed to ensure a resident's wheelchair, residents' walls and floors were in good repair and failed to provide comfortable sound levels for 5 of 13 sampled residents (#s 20, 29, 51, 90, and 137) reviewed for environment. This placed residents at risk for skin tears and unhomelike conditions.
- E
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Inspectors wroteBased on interview and record review it was determined the facility failed to provide a written grievance resolution or communicate with a resident or resident's representative regarding the resolution of a resident grievance for 6 of 14 sampled residents (#s 8, 83, 84, 86, 87, and 90) reviewed for abuse and dignity. This placed residents at risk for unaddressed concerns and grievances.
- 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 interview and record review it was determined the facility failed to revise and update a care plan intervention for 6 of 11 sampled residents (#s 16, 19, 21, 25, 49 and 51) reviewed for medications care planning, dental and respiratory. This placed residents at risk for unmet of care needs.
- E
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on interview and record review it was determined the facility failed to follow physician orders and monitor for 5 of 14 sampled residents (#s 16, 33, 51, 133, and 134) reviewed for medications, antibiotics, dialysis, and edema. This placed residents at risk for adverse side effects and constipation.
- E
Post nurse staffing information every day.
Inspectors wroteBased on observation, interview, and record review, it was determined the facility failed to post accurate and complete staffing information for 1 of 1 facility reviewed for staffing. This placed residents at risk for incomplete and inaccurate staffing information.
- E
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Inspectors wrote3. Resident 51 was admitted to the facility in 2023 with a diagnosis of Cancer. A 4/30/24 Pharmacy report recommended Resident 51's ferrous sulfate (supplement) should be discontinued because the resident's iron level was normal and docusate (treats constipation) because it was not an effective medication. A 6/2024 MAR revealed Resident 51 continued to be administered ferrous sulfate and docusate. On 6/11/24 at 2:33 PM a request was made to Staff 2 (DNS) to provide documentation Resident 51's physician declined 4/31/24 pharmacy recommendations. No additional information was provided. Based on interview and record review it was determined the facility failed to follow pharmacy recommendations for 4 of 6 sampled residents (#s 16, 33, 63, and 51) reviewed for medications. This placed residents at risk for adverse medication side effects.
- E
Ensure medication error rates are not 5 percent or greater.
Inspectors wroteBased on interview and record review it was it was determined the facility failed to ensure a medication error rate of less than 5%. The facility administration rate was 7.41% with two errors in 27 opportunities. This placed residents at risk for ineffective medication regimen.
- E
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 interview and record review it was determined the facility failed to have a system in place to ensure CNA staff received 12 hours of in-service training annually for 3 of 5 randomly selected staff members (#s 3, 5, and 6) reviewed training. This placed residents at risk for lack of competent staff.
- D
Ensure that residents are fully informed and understand their health status, care and treatments.
Inspectors wroteBased on interview and record review it was determined the facility failed to inform residents and/or resident's responsible party of the risk and benefits for the use of an antipsychotic medication and the risk and benefits of not following a prescribed diet for 3 of 6 sampled residents (#s 16, 33, and 335) reviewed for medications and diet. This placed residents' and resident responsible parties at risk for lack of informed consent and decision making.
- 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 a resident's representative of a fall for 1 of 2 sampled residents (#89) reviewed for falls. This placed resident representatives at risk for being uninformed of resident accidents.
- D
Keep residents' personal and medical records private and confidential.
Inspectors wroteBased on observation and interview it was determined the facility failed to maintain privacy and confidentiality of resident records in 1 of 1 Social Services office. This placed residents at risk for lack of privacy and confidentiality.
- D
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Inspectors wroteBased on observation, interview, and record review it was determined the facility failed to assess the use of a physical restraint for 1 of 1 sampled resident (#57) reviewed for restraints. This placed residents at risk for potential abuse or neglect.
- 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, it was determined the facility failed to report a resident to resident altercation for 2 of 11 sampled residents (#s 20 and 91 ) reviewed for abuse. This placed residents at risk for ongoing abuse. 1. Resident 20 was admitted to the facility in 2020 with a diagnosis of heart disease. A 12/16/23 Annual MDS revealed Resident 20 was cognitively impaired. Resident 20's Care Plan initiated 12/10/21 revealed Resident 20 propelled in a wheelchair. Review of Resident 20's clinical record revealed there were no resident to resident altercations identified in 11/2023. Resident 30 was admitted to the facility in 2020 with a diagnosis of seizures. Resident 30's Care Plan initiated in 2020 revealed Resident 30 was physically aggressive towards others due to a head injury. [...]
- D
Respond appropriately to all alleged violations.
Inspectors wroteBased on interview and record review it was determined the facility failed to investigate for abuse for 1 of 6 sampled residents (#65) reviewed for dignity and respect. This placed residents at risk for abuse.
- D
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Inspectors wroteBased on observation, interview and record review it was determined the facility failed to comprehensively assess residents related to behaviors for 1 of 2 sampled residents (#25) reviewed for behavioral health assessments. This placed residents at risk for unassessed behavioral emotional healthcare needs and services.
- D
Assess the resident when there is a significant change in condition
Inspectors wroteBased on interview and record review it was determined the facility failed to document and conduct a Significant Change MDS assessment within the required timeframe for 1 of 2 sampled residents (#57) reviewed for change of condition. This placed residents at risk for unassessed needs.
- D
PASARR screening for Mental disorders or Intellectual Disabilities
Inspectors wroteBased on interview and record review it was determined the facility failed to ensure residents were referred to the appropriate state-designated authority for a Level II PASARR (Pre-admission Screening and Resident Review) evaluation (evaluation for individuals with a mental disorder or intellectual disability) for 1 of 1 sampled resident (#25) reviewed for PASARR's. This placed residents at risk for not receiving specialized mental health services.
- 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 the facility failed to ensure a baseline care plan was developed for 2 of 12 sampled resident (#s 134 and 335) reviewed for dialysis, accidents, and medications. This placed residents at risk for unmet care needs.
- D
Ensure services provided by the nursing facility meet professional standards of quality.
Inspectors wroteBased on interview and record review it was determined the facility staff failed to follow professional standards of practice for a diagnosed mental disorder for 1 of 6 (#16) sampled residents reviewed for medications.
- D
Assist a resident in gaining access to vision and hearing services.
Inspectors wroteBased on observation, interview and record review it was determined the facility failed to ensure a resident had glasses for 1 of 3 sampled residents (#20) reviewed for communication-sensory. This placed residents at risk for unmet vision needs.
- 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 it was determined the facility failed to ensure a resident's environment remained free from accident hazards for 3 of 6 sampled residents (#51, 57 and 63) reviewed for accidents. This placed residents at risk for accidents.
- D
Provide enough food/fluids to maintain a resident's health.
Inspectors wroteBased on interview and record review it was determined the facility failed to ensure nutritional supplements were provided for 1 of 3 sampled residents (#19) reviewed for nutrition. This placed residents at risk for weight loss.
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observation, interview, and record review, it was determined the facility failed to obtain orders for oxygen and clean a resident's oxygen equipment for 1 of 1 sampled resident (#51) reviewed for respiratory care. This placed residents at risk for unsanitary conditions and lack of monitoring.
- D
Provide safe, appropriate pain management for a resident who requires such services.
Inspectors wroteBased on interview and record review it was determined the facility failed to ensure pain medications were available for 2 of 3 sampled residents (#85, and 339) reviewed for pain. This placed residents at risk for increased pain.
- D
Provide care or services that was trauma informed and/or culturally competent.
Inspectors wroteBased on interview and record review it was determined the facility failed to ensure a resident who was a trauma survivor received trauma-informed care in accordance with professional standards of practice and account for the residents' experiences and preferences in order to eliminate or mitigate triggers that may cause re-traumatization for 1 of 2 sampled residents (#25) reviewed for Behavioral-Emotional. This placed residents at risk for re-traumatization and a decrease in their quality of life.
- D
Provide medically-related social services to help each resident achieve the highest possible quality of life.
Inspectors wroteBased on interview and record review it was determined the facility failed to ensure a resident was transported to dialysis for 1 of 1 sampled resident (#134) reviewed for dialysis. This placed residents at risk for worsening kidney function.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview, and record review it was determined the facility failed to follow infection control standards for 1 of 5 halls (200 hall) reviewed for infection control. This placed residents at risk for cross contamination.
- D
Implement a program that monitors antibiotic use.
Inspectors wroteBased on interview and record review it was determined the facility failed to ensure a resident was not administered an antibiotic without indication for 1 of 3 sampled residents (#86) reviewed for UTI. This placed residents at risk for drug resistant infections.
March 10, 2023Standard inspection · 20 citations
- E
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Inspectors wroteBased on interview and record review it was determined the facility failed to obtain copies and provide assistance to residents who expressed interest in formulating an advance directive for 3 of 7 sampled residents (#s 6, 18, and 32) reviewed for advance directives. This placed residents at risk for not having their healthcare decisions honored.
- 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 and interview it was determined the facility failed to provide a homelike environment for 3 of 5 halls (200, 300 and 400 hall) reviewed for environment. This placed residents at risk for living in an unhomelike environment.
- E
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on observation interview and record review it was determined the facility failed to ensure physician orders and bowel protocols were followed for 4 of 16 sampled residents (#s 15, 34 and 166) reviewed for medications, ADLs and respiratory care. This placed residents at risk for adverse health consequences.
- 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 interview and record review it was determined the facility failed to ensure sufficient staffing to meet resident care needs for 4 of 5 halls (100, 200, 300 and 400) reviewed for staffing. This placed residents at risk for delayed and unmet care needs.
- E
Observe each nurse aide's job performance and give regular training.
Inspectors wroteBased on interview and record review it was determined the facility failed to ensure CNA staff annual performance reviews were completed for 4 of 4 sampled CNA staff (#s 7, 8, 9 and 10) reviewed for staffing. This placed residents at risk for a lack of competent staff.
- E
Post nurse staffing information every day.
Inspectors wroteBased on interview and record review it was determined the facility failed to ensure the Direct Care Staff Daily Reports were complete for 10 of 33 days reviewed for staffing. This placed residents at risk for incorrect staffing information.
- 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, interview and record review it was determined the facility failed to store food in accordance with professional standards for food service safety for 1 of 1 kitchen refrigerator reviewed for sanitary food storage. This placed residents at risk for exposure to harmful bacteria, reduced nutritive value and stale food products.
- D
Allow residents to self-administer drugs if determined clinically appropriate.
Inspectors wroteBased on observation, interview and record review it was determined the facility failed to ensure residents were assessed for safe self-administration of medications for 1 of 1 sampled resident (#34) reviewed for self-administration of medications. This placed residents at risk for adverse medication side effects.
- 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, it was determined the facility failed to protect the resident's right to be free from sexual abuse by Witness 3 (Alledged Perpetrator/Medical Transportation Driver) for 1 of 3 sampled residents (#54) reviewed for abuse. This placed residents at risk for abuse.
- D
Respond appropriately to all alleged violations.
Inspectors wroteBased on interview and record review it was determined the facility failed to complete a thorough investigation of an allegation of abuse for 1 of 3 sampled residents (#54) reviewed for abuse. This placed residents at risk for abuse and inaccurate investigations.
- D
Ensure each resident receives an accurate assessment.
Inspectors wroteBased on interview and record review was determined the facility failed to ensure assessments accurately reflected the residents' status for 1 of 9 sampled residents (#30) reviewed for ADLs. This placed residents at risk for inaccurate assessments.
- D
Ensure services provided by the nursing facility meet professional standards of quality.
Inspectors wroteBased on interview and record review it was determined the facility failed to ensure Staff 11 (Former Staff/RN) adhered to professional standards for medication administration. This placed residents at risk for adverse side effects of medication and hospitalization.
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on interview and record review it was determined the facility failed to provide bathing assistance to dependent residents for 2 of 7 sampled residents (#s 4 and 18) reviewed for ADLs. This placed residents at risk for lack of hygiene.
- D
Provide appropriate foot care.
Inspectors wroteBased on observation, interview and record review it was determined the facility failed to provide routine diabetic foot care for 2 of 2 sampled residents (#s 10 and 34) reviewed for foot care. This placed residents at risk for pain.
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observation, interview and record review it was determined the facility failed to ensure respiratory equipment was properly maintained for 1 of 1 sampled resident (#30) reviewed for respiratory care. This placed residents at risk for discomfort.
- D
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Inspectors wroteBased on interview and record review it was determined the facility failed to ensure residents received dialysis services consistent with the care plan for 1 of 1 sampled residents (#18) reviewed for dialysis. This placed residents at risk for potential complications in dialysis care and treatment.
- D
Provide medically-related social services to help each resident achieve the highest possible quality of life.
Inspectors wroteBased on interview and record review it was determined the facility failed to identify potential trauma and monitor psychosocial distress for 1 of 3 sampled residents (#54) reviewed for abuse. This placed residents at risk for unmet psychosocial needs.
- D
Ensure that residents are free from significant medication errors.
Inspectors wroteBased on interview and record review it was determined the facility failed to ensure residents were free from significant medication errors for 1 of 8 sampled residents (#167) reviewed for medication. This placed residents at risk for adverse side effects of medication and hospitalization.
- 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 and interview it was determined the facility failed to store treatment supplies in locked compartments for 1 of 1 treatment cart on 500 hall observed. This placed residents at risk for accidents.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation and interview it was determined the facility failed to ensure staff wore and used PPE correctly for 1 of 1 COVID unit reviewed for infection control. This placed residents and staff at risk for respiratory illnesses and infections.
Fire safety inspections
20 fire safety citations on file: 2 on December 3, 2025, 8 on October 8, 2024, 4 on June 14, 2024, 6 on March 10, 2023.
Every fire safety citation20 citations
- D
Properly select, install, inspect, or maintain portable fire extinguishes.
K 355 · December 3, 2025 · Corrected (the home has a date of correction)
- D
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
K 741 · December 3, 2025 · Corrected (the home has a date of correction)
- L
Have simulated fire drills held at unexpected times.
K 712 · October 8, 2024 · Corrected (the home has a date of correction)
- F
Develop Emergency Preparedness policies and procedures.
E 13 · October 8, 2024 · Corrected (the home has a date of correction)
- F
Establish policies and procedures including evacuation.
E 20 · October 8, 2024 · Corrected (the home has a date of correction)
- F
Establish staff and initial training requirements.
E 37 · October 8, 2024 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · October 8, 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 · October 8, 2024 · Corrected (the home has a date of correction)
- E
Keep aisles, corridors, and exits free of obstruction in case of emergency.
K 211 · October 8, 2024 · Corrected (the home has a date of correction)
- E
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · October 8, 2024 · Corrected (the home has a date of correction)
- F
Install a fire alarm system that can be heard throughout the facility.
K 341 · June 14, 2024 · Corrected (the home has a date of correction)
- F
Install an approved automatic sprinkler system.
K 351 · June 14, 2024 · Corrected (the home has a date of correction)
- D
Provide properly protected cooking facilities.
K 324 · June 14, 2024 · Corrected (the home has a date of correction)
- D
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
K 761 · June 14, 2024 · Corrected (the home has a date of correction)
- D
Keep aisles, corridors, and exits free of obstruction in case of emergency.
K 211 · March 10, 2023 · 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 · March 10, 2023 · Corrected (the home has a date of correction)
- D
Ensure that suites are correctly sub-divided by noncombustible or limited-combustible construction.
K 255 · March 10, 2023 · Corrected (the home has a date of correction)
- D
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
K 741 · March 10, 2023 · Corrected (the home has a date of correction)
- D
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
K 761 · March 10, 2023 · Corrected (the home has a date of correction)
- D
Ensure proper usage of power strips and extension cords.
K 920 · March 10, 2023 · Corrected (the home has a date of correction)