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 68 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
1K
0L
Actual harm
1G
0H
0I
Potential for more than minimal harm
54D
11E
1F
Potential for minimal harm
0A
0B
0C
May 7, 2025Standard inspection, Complaint inspection · 32 citations
- K
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wrote7. The facility staff failed to ensure Resident #90's insulin was ordered and/or administered to address the resident's diabetic needs. Resident #90's Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 1/26/25, was signed as completed on 1/29/25. Resident #90 was assessed as usually able to make self understood and as usually able to understand others. Resident #90's Brief Interview for Mental Status (BIMS) summary score was documented as a 15 out of 15; this indicated intact or borderline cognition. Resident #90's clinical documentation indicated the resident arrived at the facility on 1/22/25 at 4:10 p.m. A DIET REQUISITION FORM for the resident to receive a no salt added, CCHO diet was used to communicate the resident's dietary needs to the dietary department on 1/22/25. [...]
- G
Provide safe, appropriate pain management for a resident who requires such services.
Inspectors wroteBased on staff interview, clinical record review and facility document review, the facility staff failed to ensure that pain management is provided to residents consistent with professional standards of practice and the person-centered comprehensive care plan for 1 (one) of 30 residents in the survey sample, resident #448 (R448).
- 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 interviews, clinical record reviews, and facility document review facility staff failed to implement a process that ensured all residents were provided written information concerning the right to formulate an advance directive for 11 of 30 sampled residents. (Resident #4, #39, #45, #62, #63, #65, #67, #77, #89, #198, #348).
- E
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Inspectors wroteBased on staff interviews, clinical record reviews, and facility document review, the facility staff failed to implement a process that ensured a baseline care plan was developed for every resident within 48 hours of admission and failed to provide the resident and their representative with a summary of that baseline care plan for 7 of 30 residents. (Resident #1, #32, #39, #65, #77, #89, and #348).
- E
Ensure services provided by the nursing facility meet professional standards of quality.
Inspectors wrote3. The facility staff failed to follow professional standards of practice related to documenting the pronouncement of death for Resident #95. Resident #95's Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 3/6/25, was signed as completed on 3/10/25. Resident #95 was assessed as usually able to make self understood and as usually able to understand others. Resident #95's Brief Interview for Mental Status (BIMS) summary score was documented as a 9 out of 15; this indicated moderate cognitive impairment. On the morning of 5/2/25, the following information was found in Resident #95's clinical record, as part of a licensed practical nurse's progress note dated 4/10/25 at 4:01 a.m.: Resident presents with no signs of life, no blood pressure, no pulse, no respirations. Resident is a DNR. Post mortem care provided by CNAs. [...]
- 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 staff interview, clinical record review, and facility document review, the facility staff failed to ensure sufficient licensed nursing staff to provide services to assure residents attain or maintain the highest practicable physical wellbeing of each resident.
- E
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Inspectors wroteBased on staff interview and facility document review, the facility staff failed to ensure the Director of Nursing (DON) did not serve as a charge nurse.
- E
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on resident interview, family interview, staff interview, clinical record review, and facility document review, the facility staff failed to maintain complete and/or accurate clinical records for two (2) of 30 sampled residents (Resident #39 and Resident #63).
- E
Provide behavior health training consistent with the requirements and as determined by a facility assessment.
Inspectors wroteBased on staff interview and facility document review, the facility staff failed to provide behavioral health training for 5 of 5 sampled Certified Nursing Assistants (CNAs) #1, #2, #3, #4, and #5.
- D
Allow residents to self-administer drugs if determined clinically appropriate.
Inspectors wroteBased on observation, resident interview, staff interview, and clinical record review, the facility staff failed to ensure 1 of 19 residents was assessed for self-administration of medications, Resident #119.
- 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 staff interviews, clinical record review, and facility document review, the facility staff failed to notify the medical provider of a change in condition for 1 of 30 sampled residents (Resident #65).
- D
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Inspectors wroteBased on interviews and facility document review, the facility staff failed to provide a Skilled Nursing Facility (SNF) Advanced Beneficiary Notice of Non-coverage (ABN) notification for one (1) of three (3) residents selected for SNF Beneficiary Notification Review (Resident #100).
- D
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Inspectors wrote3. The facility staff failed to notify the ombudsman of Resident #90's transfer/discharge to a local hospital. Resident #90's Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 1/26/25, was signed as completed on 1/29/25. Resident #90 was assessed as usually able to make self understood and as usually able to understand others. Resident #90's Brief Interview for Mental Status (BIMS) summary score was documented as a 15 out of 15; this indicated intact or borderline cognition. Resident #90's clinical documentation indicated the resident was admitted to a local hospital on 1/26/25. No evidence was found by or provided to the surveyor to indicate the ombudsman had been notified of this discharge/transfer. The following information was found in a facility policy titled Transfer or Discharge, Preparing a Resident for (with a revised date of December 2016): [...]
- D
Prepare residents for a safe transfer or discharge from the nursing home.
Inspectors wroteBased on staff interview, clinical record review, and facility document review, the facility staff failed to provide and document sufficient preparation and orientation to the resident to ensure a safe and orderly transfer/discharge from the facility for (1) of (30) sampled residents, (Resident #65).
- D
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Inspectors wroteBased on staff interview, clinical record review, and facility document review, the facility staff failed to provide residents and/or resident's representative with a facility bed hold policy upon transfer for one (1) of thirty (30) sampled residents, (Resident #65)
- D
Ensure each resident receives an accurate assessment.
Inspectors wroteBased on observation, staff interview, and clinical record review, the facility staff failed to ensure accurate minimum data set (MDS) assessments for one (1) of 30 sampled residents (Resident #59).
- 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, staff interview, resident interview, clinical record review and facility document review the facility staff failed to develop and implement a care plan for 2 of 30 residents, Resident #51 and Resident #77.
- 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 staff interview, resident interview, clinical record review and facility document review, the facility staff failed to review and revise the comprehensive care plan for 2 of 30 residents, Resident #51, Resident #85.
- D
Provide enough food/fluids to maintain a resident's health.
Inspectors wroteBased on staff interview, clinical record review, and facility document review, the facility staff failed to document tube feeding residuals for one (1) of 30 sampled residents (Resident #67).
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observation, staff interview, resident interview, clinical record review and facility document review the facility staff failed to provide respiratory services per the physician's orders for 1 of 30 residents, Resident #51.
- D
Provide care or services that was trauma informed and/or culturally competent.
Inspectors wroteBased on staff interview, clinical record review, and facility document review, the facility staff failed to provide appropriate care and services to address trauma-informed care in accordance with professional standards of practice for (1) one of (30) thirty sampled residents, (Resident #77)
- D
Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit.
Inspectors wroteBased on interviews, clinical record review, and facility document review, the facility staff failed to ensure medical provider orders were signed by the ordering provider when the orders were entered into residents' clinical records by non-prescribing facility staff members for 1 of 30 sampled residents (Resident #90).
- D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Inspectors wroteBased on observations, staff interview, facility document review, and during a medication pass and pour observation, the facility staff failed to maintain an accurate record of controlled drugs for (2) two of (30) sampled residents, (Resident #201 and Resident #51).
- 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 staff interview, clinical record review, and facility document review the facility staff failed to ensure the medical provider reviewed medication regimen reviews in a timely manner for (1) one of (30) sampled residents, (Resident #36).
- D
Ensure that residents are free from significant medication errors.
Inspectors wroteBased on staff interview and clinical record review, the facility staff failed to ensure residents were free of significant medication errors for 3 of 30 sampled residents (Resident #26, Resident #62, and Resident #4).
- 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, staff interview, and facility document review, the facility staff failed to ensure the safe and secure storage of medications and biologicals for (1) one of (5) five facility medication carts.
- D
Provide timely, quality laboratory services/tests to meet the needs of residents.
Inspectors wroteBased on resident interview, staff interview, clinical record review, and facility document review, the facility staff failed to obtain laboratory services to meet the needs of 2 of 30 sampled residents, Resident #348 and #77.
- D
Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.
Inspectors wroteBased on staff interview, record review and facility document review the facility staff failed to promptly notify the ordering provider of laboratory results that fell outside clinical reference ranges, in accordance with facility policies and procedures for notification of a practitioner or per the ordering physician's orders for 1 (one) of 30 residents in the survey sample, resident # 15 (R15).
- D
Provide timely, approved x-ray services, or have an agreement with an approved provider to obtain them.
Inspectors wroteBased on staff interview, clinical record review, and facility document review, the facility staff failed to obtain timely diagnostic services to meet the needs of the residents for 1 of 30 sampled residents (Resident #4).
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, staff interview, and facility document review, the facility staff failed to maintain infection prevention and control practices during medication administration for 1 of 2 nursing units.
- D
Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members.
Inspectors wroteBased on staff interview and facility document review, the facility staff failed to provide effective communication training for one of five sampled direct care staff members, Certified Nursing Assistant (CNA) #1.
- D
Employ staff that are licensed, certified, or registered in accordance with state laws.
Inspectors wroteBased on staff interview and facility document review, the facility staff failed to ensure professional staff had a valid license to practice in accordance with applicable state laws for 1 of 6 sampled licensed nurses, Licensed Practical Nurse (LPN) #12.
February 2, 2024Complaint inspection · 15 citations
- F
Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit.
Inspectors wroteBased on staff interviews, clinical record review, and facility document review, the facility staff failed to ensure that medical providers co-signed verbal orders, telephone orders, and/or orders documented in the Rounding Binders.
- 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 staff interviews, clinical record review, and facility document review, the facility staff failed to notify a medical provider and/or a responsible party of a change in condition for two (2) of 12 sampled residents (Resident #2 and Resident #11).
- D
Assess the resident when there is a significant change in condition
Inspectors wroteBased on staff interviews, clinical record review, and facility document review, the facility staff failed to complete a significant change Minimum Data Set (MDS) assessment for one (1) of 12 sampled residents (Resident #11).
- 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 staff interview, clinical record review, and facility document review, the facility staff failed to review and revise the comprehensive care plan for one of 12 residents in the survey sample.
- D
Ensure services provided by the nursing facility meet professional standards of quality.
Inspectors wroteBased on staff interviews, clinical record review, and facility document review the facility staff failed to follow professional standards of practice for 1 of 12 residents sampled, Resident #1.
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on staff interview, clinical record review and facility document review, the facility staff failed to provide activities of daily living (ADL) care to two of 12 residents, resident # 10 and resident # 12.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on staff interviews, clinical record reviews, and facility document review, the facility staff failed to provide treatment and care to address residents' needs for three (3) of 12 sampled residents.
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on staff interview, clinical record review and facility document review, the facility failed to provide an environment free from accidents and hazards for two of 12 residents, resident # 10 and # 12.
- D
Provide enough food/fluids to maintain a resident's health.
Inspectors wroteBased on staff interview, clinical record review and facility document review, the facility staff failed to ensure residents maintained, to the extent possible, acceptable parameters of nutritional status.
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on interviews, clinical record review, and facility document review, the facility staff failed to provide respiratory care and/or treatment to address the needs of one (1) of 12 sampled residents (Resident #5).
- D
Provide medically-related social services to help each resident achieve the highest possible quality of life.
Inspectors wroteBased on staff interviews, clinical record review, and facility document review, the facility staff failed to provide social services according to a medical provider's guidance for one (1) of twelve sampled residents (Resident #11).
- D
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Inspectors wroteBased on staff interviews, clinical record review, and facility document review, the facility staff failed to ensure a resident was free of an unnecessary medication for one (1) of 12 sampled residents (Resident #11).
- D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on staff interviews, facility document review, and clinical record review, the facility staff failed to maintain complete and/or accurate clinical records for two (2) of 12 sampled residents (Resident #5 and Resident #10).
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observations, staff interviews, clinical record review, and facility document review, (a) the facility staff failed to correctly perform hand hygiene during wound care for one (1) of 12 sampled residents (Resident #4) and (b) the facility staff failed to store residents' nebulizer equipment in a sanitary manner for three (3) of four (4) residents observed with nebulizer equipment (Resident #5, Resident #6, and Resident #8).
- D
Keep all essential equipment working safely.
Inspectors wroteBased on observations, staff interviews, and document review, the facility staff failed to maintain residents' nebulizer equipment according to manufacturer's directions for use.
May 12, 2022Standard inspection · 3 citations
- 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 staff interview and clinical record review, the facility staff failed to complete drug regimen reviews for 2 of 18 Residents Resident #28 and #42 and failed to act upon recommendations for 1 of 18 resident #28. The facility staff failed to provide the surveyor with evidence of drug regimen reviews that were completed in March 2022 for Resident #28 and #42 and failed to follow up on pharmacy recommendations for Residents #28.
- D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on staff interview, clinical record review and facility document review, the facility staff failed to ensure a complete, and accurately documented clinical record for 1 of 18 residents in the survey sample (Resident #45). For Resident #45, the facility staff failed to document the resident's blood glucose readings.
- D
Perform COVID19 testing on residents and staff.
Inspectors wroteBased on observation, interviews, and document review the facility staff failed to properly implement COVID-19 testing processes and/or procedures for 1 of 1 COVID-19 staff testing observations, CNA#1. An observation of the staffing coordinator (CNA#1) obtaining a COVID-19 nasal swab test for one licensed practical nurse (LPN) identified the specimen was not collected according to manufacturer's instructions.
June 7, 2019Standard inspection · 18 citations
- E
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on resident interview, staff interview, facility document review, and clinical record review, the facility staff failed to follow the bowel protocol for 1 of 25 residents (Resident #17).
- E
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Inspectors wroteBased on staff interview, facility document review, and clinical record review, the facility staff failed to ensure 4 of 25 residents were free of an unnecessary psychotropic medication (Resident #87, Resident #26, Resident #62, and Resident #105).
- E
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Inspectors wroteBased on observation and staff interview, the facility staff failed to dispose of expired medications on 2 of 2 units.
- E
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Inspectors wroteBased on observation, resident interview, staff interview, and clinical record review, the facility staff failed to ensure food was palatable and served at an appetizing temperature on one of two units (unit B).
- D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteBased on observation, resident interview, staff interview, and clinical record review, the facility staff failed to provide a dignified dining experience for 3 of 25 residents (Resident # 87, Resident #62, and Resident #40) and failed to knock or announce themselves before entering residents rooms for 1 of 25 residents (Resident #17).
- 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 staff interview and clinical record review the facility staff failed to notify the physician of a change in condition and failed to inform a resident that he would not receive ferrous sulfate during his morning medication pass for 2 of 25 residents in the survey sample (Residents #17 and #59).
- D
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Inspectors wroteBased on observation, staff interview, facility document review, and clinical record review, the facility staff failed to ensure a clean, comfortable, homelike environment for 1of 25 residents (Resident #26).
- D
Ensure each resident receives an accurate assessment.
Inspectors wroteBased on staff interview and clinical record review, facility staff failed to ensure accuracy of Minimum Data Set assessments for 2 of 26 residents in the survey sample (Resident #104 and supplemental resident #1). 1. For Resident #104, facility staff failed to ensure the admission minimum data set assessment accurately documented hospice and hemodialysis status. Resident #104 was admitted to the facility on [DATE] 04:05 PM. Diagnoses included hypertension, end stage Alzheimer's disease, malnutrition, anxiety, and depression. On the admission Minimum Data Set assessment with Assessment Reference Date 5/20/19, the resident was assessed with short and long-term memory deficits, severely impaired decision-making ability, fluctuating signs of delirium, and without signs of psychosis or delirium. The resident was admitted with an order for hospice (5/9/19). The MD'S was not coded for hospice. [...]
- 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 clinical record review and staff interview, the facility staff failed to review and revise the comprehensive plan of care for 1 of 26 Residents in the survey sample, Resident # 41.
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on observation, resident interview, family interview, staff interview and clinical record review, the facility staff failed to provide nail care to 1 of 25 dependent residents (Resident #62).
- D
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Inspectors wroteBased on observation, staff interview, facility document review, and clinical record review, the facility staff failed to follow the physician's orders for 1 of 25 residents (Resident #40) for the care of an indwelling Foley catheters.
- D
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Inspectors wroteBased on clinical record review, staff interview, and facility document review, the facility staff failed to ensure that 1 of 26 Residents in the survey sample received port-a-cath care consistent with professional standards of practice, Resident # 41.
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observation, staff interview, Resident interview, facility document review, and clinical record review the facility staff failed to properly maintain oxygen equipment or to deliver the ordered dose for 3 of 26 Residents, Resident #52, Resident #59. and Resident #62).
- D
Provide safe, appropriate pain management for a resident who requires such services.
Inspectors wroteBased on resident interview, staff interview, facility document review, and clinical record review, the facility staff failed to provide pain management to 1 of 25 residents (Resident #17).
- D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Inspectors wroteBased on resident interview, staff interview, clinical record review, and facility document review, failed to ensure physician ordered medications were available for 1 out of 25 residents (Resident #17).1. The facility staff failed to ensure physician ordered medications were available for Resident #17. Methadone, Oxycodone, and a Nicoderm patch were not available for administration. The clinical record of Resident #17 was reviewed 6/4/19 through 6/7/19. Resident #17 was admitted to the facility 3/23/18 with diagnoses, that included but not limited to multiple sclerosis, urinary tract infection, cellulitis and abscess of the mouth, major depressive disorder, chronic pain syndrome, anxiety, insomnia, slow transit constipation, tobacco use, nicotine dependence, iron deficiency anemia, and dysuria. [...]
- D
Ensure medication error rates are not 5 percent or greater.
Inspectors wroteBased on clinical record review, and medication pass and pour observation the facility staff failed to ensure a medication error rate of less than 5%. There were 3 errors in 31 opportunities resulting in a medication error rate of 9.68 %. Medication errors affected Resident # 76, Resident # 83, and Resident # 59.
- D
Ensure that residents are free from significant medication errors.
Inspectors wroteBased on staff interview and clinical record review the facility staff failed to ensure three of 26 Residents were free of significant medication errors, Resident #33, Resident #25 and Resident #40.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, resident interview, staff interview, facility document review and clinical record review facility staff failed to ensure infection treatment as ordered for 1 of 26 residents in the survey sample (Resident #77) and proper hand-washing. Resident #77 Infections (not UTI or Respiratory) 06/05/19 11:36 AM resident reported that staff had run out of his antibiotic while he was here. He is on nafcillin 2 gm in 50 ml ns at 50 ml/hr every 4 hours for 8 weeks from 4/22-6/14. MAR indicated 'N' on 6/2 at 9AM, 1 PM, 5 PM, and 9 PM and on 6/3 at 1 AM; in May MAR indicated 'N' on 5/7 at 5 PM, and many other times. Notes indicate the medication will be administered when meds are available or that the medication was not available. [...]
Fire safety inspections
24 fire safety citations on file: 7 on May 7, 2025, 13 on May 12, 2022, 4 on June 7, 2019.
Every fire safety citation24 citations
- E
Address patient/client population and determine types of services needed.
E 7 · May 7, 2025 · Corrected (the home has a date of correction)
- E
Address subsistence needs for staff and patients.
E 15 · May 7, 2025 · Corrected (the home has a date of correction)
- E
Establish policies and procedures for volunteers.
E 24 · May 7, 2025 · Corrected (the home has a date of correction)
- E
Establish staff and initial training requirements.
E 37 · May 7, 2025 · Corrected (the home has a date of correction)
- E
Conduct testing and exercise requirements.
E 39 · May 7, 2025 · Corrected (the home has a date of correction)
- E
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
K 761 · May 7, 2025 · Corrected (the home has a date of correction)
- E
Meet other general requirements.
K 932 · May 7, 2025 · Corrected (the home has a date of correction)
- F
Have properly installed electrical wiring and gas equipment.
K 511 · May 12, 2022 · Waiver
- F
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
K 761 · May 12, 2022 · Waiver
- E
Use approved construction type or materials.
K 161 · May 12, 2022 · Corrected (the home has a date of correction)
- E
Provide rooms that can be unlocked from inside without a key.
K 221 · May 12, 2022 · Corrected (the home has a date of correction)
- E
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
K 222 · May 12, 2022 · Corrected (the home has a date of correction)
- E
Have properly located and lighted "Exit" signs.
K 293 · May 12, 2022 · Corrected (the home has a date of correction)
- E
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · May 12, 2022 · Corrected (the home has a date of correction)
- E
Inspect, test, and maintain automatic sprinkler systems.
K 353 · May 12, 2022 · Corrected (the home has a date of correction)
- E
Install corridor and hallway doors that block smoke.
K 363 · May 12, 2022 · Corrected (the home has a date of correction)
- E
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
K 521 · May 12, 2022 · Waiver
- E
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
K 914 · May 12, 2022 · Corrected (the home has a date of correction)
- E
Ensure proper usage of power strips and extension cords.
K 920 · May 12, 2022 · Corrected (the home has a date of correction)
- D
Provide a written emergency evacuation plan.
K 711 · May 12, 2022 · 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 · June 7, 2019 · Corrected (the home has a date of correction)
- F
Install an approved automatic sprinkler system.
K 351 · June 7, 2019 · Corrected (the home has a date of correction)
- E
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
K 222 · June 7, 2019 · Corrected (the home has a date of correction)
- D
Have properly installed electrical wiring and gas equipment.
K 511 · June 7, 2019 · Corrected (the home has a date of correction)