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 57 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
1J
0K
1L
Actual harm
4G
0H
0I
Potential for more than minimal harm
31D
12E
8F
Potential for minimal harm
0A
0B
0C
July 2, 2026Complaint inspection · 1 citation
- F
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 ensure sufficient staff to meet residents' needs in a timely manner. This has the potential to affect all 108 residents currently residing at the facility. Findings Include:1. R9's admission Record documented an original admission to the facility on [DATE] and included diagnoses of acute respiratory failure, diabetes mellitus 2, anemia, anxiety disorder, and cognitive communication deficit. R9's Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 15, indicating cognition is intact. R9's current Care Plan includes the following Focus areas of, 1. R9 has a functional self-care deficit related to impaired balance, muscoskeletal impairment related to left femur fracture, pain and activity intolerance. R9 is dependent on staff for some functional tasks. [...]
May 19, 2026Complaint inspection · 5 citations
- L
Respond appropriately to all alleged violations.
Inspectors wroteBased on interview and record review, the facility failed to conduct a thorough investigation and report factual information of an injury of unknown origin that resulted in R1's death for 1 of 1 (R1) resident and failed to investigate allegations of sexual abuse for 2 of 6 residents (R3 and R10) reviewed for abuse in a sample of 46. The facility's failure has the potential to affect all 114 residents residing in the facility by failing to protect them from potential abuse. The Immediate Jeopardy began on [DATE] at 12:00 PM when R1 was found expired in the floor next to her bed with her head in a trash can and a plastic trash bag covering her face. V1 (Administrator) and V3 (Regional Clinical Director) were notified of the Immediate Jeopardy on [DATE] at 1:00 PM. [...]
- F
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 abuse timely to the State Agency and to local law enforcement for 2 (R1 and R3) of 6 residents reviewed for abuse out of a sample of 46. This failure has the potential to affect all 114 residents residing in the facility.
- F
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Inspectors wroteBased on interview and record review, the facility Administrator failed to follow policy and procedures to effectively and efficiently investigate an incident resulting in the death of 1 of 3 residents (R1) reviewed for death in a sample of 46. This has the potential to affect all 114 residents living in the facility.
- 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 timely and factually notify family and the physician of an incident of injury of unknown origin resulting in death for 1 of 6 (R1) residents reviewed for abuse in of a sample of 46.
- D
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Inspectors wroteBased on observation, interview, and record review, the facility failed to protect the resident's right to be free from sexual abuse for 2 (R3 and R10) of 6 residents reviewed for abuse in a sample of 46. This failure resulted in R10 feeling intimidated and scared for her safety.
April 22, 2026Complaint inspection · 1 citation
- D
Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.
Inspectors wroteBased on interview and record review, the facility failed to notify the physician with a critical lab value in a timely manner for 1 of 3 (R4) residents reviewed for labs in a sample of 6.
April 8, 2026Complaint inspection · 2 citations
- E
Ensure each resident receives and the facility provides drinks consistent with resident needs and preferences and sufficient to maintain resident hydration.
Inspectors wroteBased on interview and observation, the facility failed to provide access to drinking water at the bedside for 4 (R18, R19, R20, R21) of 5 residents reviewed for access to drinking water in a sample of 29. On 3/31/26 at 2:28 PM, there were no water pitchers for R18 and R19 on or near their overbed tables in their room. There were empty cups sitting on the overbed tables of both R18 and R19 with only drops of clear liquid in the bottom. On 3/31/26 at 2:33 PM, there were no water pitchers or cups for R20 and R21 on or near their overbed tables in their room. On 4/1/26 at 8:50 AM, there were no water pitchers for R18 and R19 on or near their overbed tables in their room. There were also no empty or full cups of liquid on or near the overbed table of R18 and R19. On 4/1/26 at 8:55 AM, there were no water pitchers or cups on or near the overbed tables in the room of R20 and R21. [...]
- D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Inspectors wroteBased on observation, interview, and record review, the facility failed to secure medications at the bedside for 1 (R22) of 3 residents reviewed for medications secured at the bedside in the sample of 29.
January 30, 2026Complaint inspection · 2 citations
- E
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteBased on interview and record review, the facility failed to answer call lights timely for 6 (R2, R10, R11, R12, R13, R14) of 6 residents reviewed for call lights in the sample of 14.
- D
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Inspectors wroteBased on interview and record review, the facility failed to clean a newly admitted resident's room after one resident was moved out and he was moved in for 1 (R2) of 3 residents reviewed for environment in a sample of 9.
December 9, 2025Complaint inspection · 6 citations
- F
Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure meals were served in a timely manner. This failure has the potential to affect all 112 residents residing in the facility. Findings Include:On 11/21/25 at 2:19PM, R1 was alert and oriented and was asked how his meals were and if they were they served on time. R1 stated, It seems like we have a lot of reruns on the meals, but I think they try to follow the menu the best they can. R1 stated the meals are sometimes late and he wasn't sure why. When asked if the food and time the meals were served was ok, R1 stated, Well, that is debatable. On 11/21/25 at 3:30PM, V5 (Head Cook) stated there was a no call/no show for the shift so they are running way behind on everything. V5 said they usually have all the dishes from lunch done by now. [...]
- D
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Inspectors wroteBased on interview and record review, the facility failed to ensure a resident was free from intimidation/verbal abuse for 1 (R11) of 3 residents reviewed for abuse in the sample of 13.
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on interview and record review, the facility failed to report an allegation of verbal abuse to the State Agency and local law enforcement within 24 hours for 1 (R11) of 3 residents reviewed for reporting alleged violations in the sample of 13.
- D
Respond appropriately to all alleged violations.
Inspectors wroteBased on interviews and record review, the facility failed to complete a thorough investigation in response to an allegation of staff to resident verbal abuse for 1 (R11) of 3 residents reviewed for abuse in the sample of 13.
- D
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 ensure timely incontinence care and repositioning services were provided for 3 (R4, R5, and R10) of 5 dependent residents reviewed for Activities of Daily Living (ADL) care in the sample of 13.
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure interventions were developed and implemented for the prevention of pressure ulcers for 1 (R5) of 3 residents reviewed for pressure ulcers in the sample of 13.
November 12, 2025Complaint 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 interview and record review, the facility failed to provide adequate supervision to prevent an elopement for 1 of 3 residents (R1) reviewed for elopement risk in the sample of 15. This past noncompliance occurred from 10/19/2025 to 10/20/25.
August 15, 2025Complaint inspection · 2 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, interview, and record review, the facility failed to keep the dry storage free of contamination of rodents and rodent droppings. This failure has the potential to affect all 94 residents residing in the facility.
- F
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the facility was free of rodents. This failure has the potential to affect all 94 residents residing in the facility.
August 11, 2025Complaint inspection · 5 citations
- G
Provide safe, appropriate pain management for a resident who requires such services.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure pain was treated for 1 of 1 (R3) resident reviewed for pain in the sample of 19. This failure resulted in R3 experiencing severe pain with no treatment for the first 24 hours of admission, resulting in a lack of sleep and emotional distress. Findings Include:R3's facility admission Record, with a print date of 8/4/25, documents R3 was admitted to the facility on [DATE], with diagnoses that include sacroiliitis, surgical aftercare, diabetes, asthma, anemia, restless leg syndrome, Alzheimer's disease, and radiculopathy of lumbar region. R3's Baseline Care Plan, dated 7/30/25, documents R3 is alert with cognitive impairment. This Care Plan documents, family states resident gets confused at times. Under Pain, this Care Plan documents R3 is in pain with no pain level documented. [...]
- E
Ensure each resident receives and the facility provides drinks consistent with resident needs and preferences and sufficient to maintain resident hydration.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents had water available to them in their rooms for 4 of 4 (R1, R2, R6, R7) residents reviewed for hydration in the sample of 19. Findings Include: 1. R2's facility admission Record, with a print date of 08/07/2025, documents R2 was admitted to the facility on [DATE], with diagnoses that include cerebral palsy, acute kidney failure, diabetes, and hypertension. R2's MDS (Minimum Date Set), dated 07/22/2025, documents R2 has a BIMS score of 12, indicating a moderate cognitive deficit. R2's current Care Plan documents a Focus area of, (R2) has potential for nutritional complications r/t (related to) obesity and dietary restrictions secondary to therapeutic diet .(R2) is on an LCS (low concentrate sugars), regular texture diet, with thin liquids. Date Initiated: 04/18/2025. [...]
- E
Make sure that a working call system is available in each resident's bathroom and bathing area.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure they had a working call system for 5 of 5 residents (R1, R2, R4, R6, R7) reviewed for call lights in the sample of 19. Findings Include:1. R1's facility admission Record, with a print date of 8/4/25, documents R1 was admitted to the facility on [DATE], with diagnoses that include right femur fracture, generalized anxiety disorder, muscle weakness, and difficulty walking. R1's MDS (Minimum Data Set), dated 7/27/25, documents a BIMS (Brief Interview for Mental Status) score of 15, indicating R1 is cognitively intact. R1's current Care Plan documents a Focus area of, Transferring: (R1) has a self care deficit in transferring r/t (related to) recent fall with R (right) femur fx (fracture), WBAT (weight bearing as tolerated) status to RLE (right lower extremity), and deconditioning. Date Initiated: 07/23/2025. [...]
- D
Reasonably accommodate the needs and preferences of each resident.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure call lights were within reach for 1 of 1 (R1) resident reviewed for accommodation of needs in the sample of 19. Findings Include:1. R1's facility admission Record, with a print date of 8/4/25, documents R1 was admitted to the facility on [DATE], with diagnoses that include right femur fracture, generalized anxiety disorder, muscle weakness, and difficulty walking. R1's MDS (Minimum Data Set), dated 7/27/25, documents a BIMS (Brief Interview for Mental Status) score of 15, indicating R1 is cognitively intact. R1's current Care Plan documents a Focus area of, Transferring: (R1) has a self care deficit in transferring r/t (related to) recent fall with R (right) femur fx (fracture), WBAT (weight bearing as tolerated) status to RLE (right lower extremity), and deconditioning. Date Initiated: 07/23/2025. [...]
- D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications were available as ordered by the physician for 1 of 1 (R3) residents reviewed for pharmacy services in the sample of 19. Findings Include:R3's facility admission Record, with a print date of 8/4/25, documents R3 was admitted to the facility on [DATE], with diagnoses that include sacroiliitis, surgical aftercare, diabetes, asthma, anemia, restless leg syndrome, Alzheimer's disease, and radiculopathy of lumbar region. R3's Baseline Care Plan, dated 7/30/25, documents R3 is alert with cognitive impairment. This Care Plan documents, family states resident gets confused at times. Under Pain, this Care Plan documents R3 is in pain with no pain level documented. R3's Order Summary Report documents the following physician orders were started on 7/30/25: [...]
July 9, 2025Complaint inspection · 1 citation
- D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteBased on interview, record review and observation, the facility failed to protect and promote residents rights for 1 of 3 (R1) residents reviewed for resident rights in a sample of 12.
June 16, 2025Standard inspection, Complaint inspection · 17 citations
- J
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteDeficiencies at this level require more than one Deficient Practice Statements A. Based on interview and record review, the facility failed to prevent the development of unstageable ulcers, identify and assess newly developed ulcers, consistently implement interventions to promote healing of the ulcers, and implement physician orders to treat ulcers for 1 (R149) of 7 residents reviewed for ulcers in the sample of 52. This failure resulted in R149 developing unstageable ulcers to bilateral heels and subsequently being admitted to the hospital with diagnoses of sepsis, gangrene, and necrosis of the bone, tendon, and surrounding tissue. R149 underwent surgery to debride the ulcers on bilateral heels. Post surgery, R149 was placed on hospice and died on 6/9/25. [...]
- G
Provide safe, appropriate pain management for a resident who requires such services.
Inspectors wroteBased on interview, observation, and record review, the facility failed to manage pain for 1 of 2 residents (R81) reviewed for pain in a sample of 52. This failure resulted is R81 experiencing decreased mobility and participation in daily activities related to uncontrolled severe pain.
- F
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 ensure adequate staffing to meet the needs of the residents timely. This has the potential to affect all 96 residents who currently reside at the facility. Findings Include: The facility Resident Matrix dated 6/2/25 documents 96 residents currently reside at the facility. 1. R43's admission Record documented R43 was readmitted to this facility on 5/28/2024. with diagnoses of type 2 Diabetes Mellitus with neuropathy and foot ulcer, need for assistance with personal care and muscle weakness among others. R43's MDS (Minimum Data Set), dated 4/8/2025, documented R43 with a BIMS (Brief Interview for Mental Status) score of 15 out of 15, which indicates R43 is cognitively intact. This same MDS documented R43 is dependent on staff for toileting and personal hygiene and needs moderate assistance with transferring. [...]
- F
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on interview, observation, and record review, the facility failed to store, handle, and sanitize food and food contact surfaces to prevent contamination. This failure has the potential to affect all 96 residents residing in the facility.
- E
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 interview, observation, and record review, the facility failed to provide food portions as directed by the dietary spreadsheet approved by the registered dietician for 4 (R17, R53, R61, and R63) of 17 residents reviewed for dining in a sample of 52.
- E
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Inspectors wroteBased on interview, observation, and record review, the facility failed to serve food at a preferred palatable temperature for 4 of 17 residents (R17, R53, R61, R63) reviewed dining in a sample of 52.
- E
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
Inspectors wroteBased on interview, observation, and record review, the facility failed to provide food in a texture according to physician orders for 4 (R10, R22, R28, and R56) of 17 residents reviewed for dining in a sample of 52.
- 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 answer call lights for residents needing assistance in a timely manner to promote dignity for 3 residents (R36, R43, R55) of 24 residents reviewed for dignity in the sample of 52. Findings including: 1. R43's admission record documented R43 was readmitted to this facility on 5/28/2024, with diagnoses of type 2 Diabetes Mellitus with neuropathy and foot ulcer, need for assistance with personal care, and muscle weakness, among others. R43's MDS (Minimum Data Set), dated 4/8/2025, documented R43 with a BIMS (Brief Interview for Mental Status) score of 15 out of 15, which indicates R43 is cognitively intact. This same MDS documented R43 is dependent on staff for toileting and personal hygiene, and needs moderate assistance with transferring. On 06/03/25 at 08:43 AM, R43 said, Call lights take forever to get answered. [...]
- 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, the facility failed to formulate or offer to formulate an Advanced Directive for 2 of 24 residents (R57, R300) reviewed for Advanced Directives in a sample of 52.
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on interview and record review, the facility failed to ensure allegations of peer-to-peer abuse were reported to the Administrator timely for 1 of 1 (R37) resident reviewed for abuse in the sample of 52. Findings Include: R37's admission Record, with a print date of 6/9/25, documents R37 was admitted to the facility on [DATE], with diagnoses that include metabolic encephalopathy, schizoaffective disorder, vascular dementia, and altered mental status. R37's MDS (Minimum Data Set), dated 3/23/25, documents a BIMS (Brief Interview for Mental Status) score of 07, which indicates R37 has a severe cognitive deficit. R37's current Care Plan documents a Focus initiated 5/21/2019 of, (R37) has impaired cognitive function/impaired thought processes r/t (related to) metabolic encephalopathy and vascular dementia. [...]
- D
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Inspectors wroteBased on interview and record review, the facility failed to provide a copy of the bed hold policy to residents or their representatives for a resident who had been hospitalized for 2 of 2 residents (R28, R88) reviewed for hospitalizations in the sample of 52.
- D
PASARR screening for Mental disorders or Intellectual Disabilities
Inspectors wroteBased on interview and record review, the facility failed to ensure a current PASSR (Preadmission Screening and Resident Review Evaluation) 2 screening was in place for 1 of 5 (R36) residents reviewed for PASSR's in the sample of 52. Findings Include: R36's admission Record, with a print date of 6/4/25, documents R36 was admitted to the facility on [DATE], with diagnoses that include schizoaffective disorder, agoraphobia with panic disorder, insomnia, major depressive disorder, and anxiety disorder. R36's MDS (Minimum Data Set), dated 3/24/25, documents a BIMS (Brief Interview for Mental Status) score of 14, which indicates R36 is cognitively intact. [...]
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on observation, interview, and record review, the facility failed to assist resident with dietary needs for 3 residents of 17 (R10, R22, and R61) residents reviewed for dining in a sample of 52.
- D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications were stored using current standards of practice for 1 of 1 resident (R68) reviewed for medication storage in the sample of 52. Findings Include: R68's admission Record, with a print date of 6/4/25, documents R68 was admitted to the facility on [DATE], with diagnoses that include alcohol dependence with withdrawal, chronic obstructive pulmonary edema, hypertension, anxiety disorder, and major depressive disorder. R68's Minimum Data Set, dated [DATE], documents a Brief Interview for Mental Status score of 15, which indicates R68 is cognitively intact. R68's current Care Plan documents a Focus area of, (R68) uses psychotropic medications r/t (related to) depression and anxiety. Date Initiated: 04/06/2023. [...]
- D
Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs.
Inspectors wroteBased on interview, observation, and record review, the facility failed to provide a meal for 1 of 17 residents (R12) reviewed for dining in a sample of 52.
- 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 follow the resident's dietary preferences for 3 of 17 (R17, R54 and R63) residents reviewed for dining in a sample 52.
- D
Provide special eating equipment and utensils for residents who need them and appropriate assistance.
Inspectors wroteBased on interview, observation, and record review, the facility failed to provide adaptive equipment for 2 (R53 and R56) of 17 residents reviewed for dining in a sample of 52.
March 18, 2025Complaint 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 adjust the type and frequency of interventions and needed level of supervision for a resident with a history of self inflicted burns with hot liquids for one resident (R1) of four residents reviewed for incidents/accidents in the sample of four. This failure resulted in R1 spilling hot water onto his groin, sustaining second degree burns to nine percent of his body, causing pain and the need for increased pain medication, and requiring placement of an indwelling catheter to prevent urine from irritating the wounds. Findings Include: R1's Face Sheet documented an admission Date of 4/5/24, and listed Diagnoses including Spinal Stenosis with Fusion of the Lumbar Spine, Schizoaffective Disorder, and Diabetes Type 2. [...]
January 21, 2025Complaint inspection · 1 citation
- 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 resident's medications were administered per facility policy for 1 (R1) of 3 residents reviewed for medication administration in the sample of 7. This past noncompliance occurred from 1/14/25 to 1/15/25.
September 12, 2024Complaint inspection · 1 citation
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure fall interventions were implemented for 1 (R2) of 3 residents reviewed for falls in the sample of 11. Findings Include: R2's admission Record documents R2 was admitted to the facility on [DATE], with diagnoses that included Parkinson's disease, adult failure to thrive, repeated falls, weakness, diabetes, major depressive disorder, hypertension, peripheral vascular disease, difficulty walking, syncope and collapse. R2's Minimum Data Set (MDS), dated [DATE], documents a Brief Interview for Mental Status (BIMS) score of 12, which indicates R2 has a moderate cognitive deficit. R2's current Care Plan documents a Focus area of, (R2) is at risk for falls r/t (related to) Deconditioning, Gait/balance problems. Date Initiated: 02/27/2024. The interventions for this Focus area are documented as follows. [...]
July 19, 2024Standard inspection · 4 citations
- E
Provide enough food/fluids to maintain a resident's health.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure supplements and double portions were given as ordered for 6 (R49, R52, R59, R62, R67, and R74) of 20 residents reviewed for therapeutic diets in a sample of 48.
- E
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Inspectors wroteBased on observation, interview, and record review, the facility failed to label insulin with open dates for 4 of 10 residents (R25, R62, R81, R244) reviewed for medication labeling and storage in a sample of 48.
- E
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 provide pureed diets per facility recipes for 13 (R3, R7, R19, R26, R30, R31, R40, R51, R54, R65, R84, R89, and R245) of 20 residents reviewed for dietary needs out of a sample of 48.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on observation, interview, and record review, the facility failed to follow physicians orders for the treatment of scalp and facial wounds for one of 48 residents (R61) reviewed for quality of care in the sample of 48.
April 24, 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, observation, and record review, the facility failed to develop and implement appropriate fall interventions for one of three residents (R2) reviewed for falls in the sample of 4. This failure resulted in a repeated fall for R2 on 3/28/24, resulting in a left patellar fracture.
November 13, 2023Complaint inspection · 1 citation
- D
Provide appropriate foot care.
Inspectors wroteBased on interview and record review, the facility failed to provide podiatry/toenail care for a resident with Diabetes Mellitus for 1 of 4 (R1) residents reviewed for foot care in a sample of 7.
November 3, 2023Complaint inspection · 1 citation
- E
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 observation, interview, and record review, the facility failed to follow mechanically altered diet orders and special diet orders for 46 of 46 residents (R2 and R4-R48) reviewed for special diets in the sample of 48.
July 14, 2023Standard inspection · 4 citations
- E
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 and interview, the facility failed to ensure pureed diets were prepared to correct consistency for 1 of 8 residents (R5, R7, R26, R41, R43, R62, R70 and R247) reviewed for a pureed diet in the sample of 39.
- D
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Inspectors wroteBased on record review and interview, the facility failed to provide written notice of a hospital transfer for 1 of 1 (R64) residents reviewed for transfer in the sample of 39. The Findings Include: R64's face sheet documents a date of birth of [DATE], admit date of 10/10/22, and diagnosis included: cerebral infarction, cognitive communication deficit, and altered mental status. R64's quarterly Minimum Data Assessment, dated 4/12/23, documents a Brief Interview for Mental Status of 3, indicating a severe cognitive impairment. Nursing progress notes, dated 3/10/23, document R64 was transferred out to the emergency room per resident request. On 7/13/23 at 9:30 AM, V1 (Administrator) stated they did not send a transfer form in the mail to V14 (Family Member) when R64 was sent the the emergency room on 3/10/23; they always call to alert them.
- 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 record review and interview, the facility failed to provide written notice of bed hold for 1 of 1 (R64) residents reviewed for transfer in the sample of 39. The Findings Include: R64's face sheet documents a date of birth of [DATE], and diagnosis included: cerebral infarction, cognitive communication deficit, and altered mental status. R64's quarterly Minimum Data Assessment, dated 4/12/23, documents a Brief Interview for Mental Status of 3, indicating a severe cognitive impairment. Nursing progress notes, dated 3/10/23, document R64 was transferred out to the emergency room per resident request. On 7/13/23 at 9:30 AM, V1 (Administrator) stated they did not send the bed hold form in the mail to V14 (Family Member) when R64 was sent the the emergency room on 3/10/23; they always call to alert them.
- D
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Inspectors wroteBased on interview and record review, the facility failed to refer residents for a level II Pre-admission Screening and Resident Review (PASARR) assessment for 3 (R40, R44, R64) of 3 residents reviewed for PASARR screenings in a sample of 39. The Findings Include: 1. R40's face sheet documents admission to this facility on 01/12/18, with diagnoses to include anxiety, hyperglycemia, and osteoarthritis. R40's initial PASARR screening, dated 01/15/18, indicate she is appropriate for nursing services. R40's diagnosis sheet confirms she was newly diagnosed with schizophrenia on 03/04/19, major depressive disorder on 03/09/19, and severe dementia with behavioral disturbance on 10/01/22. There is no documentation in the record of R40 being referred for a PASARR II assessment. 2. [...]
Fire safety inspections
33 fire safety citations on file: 9 on June 16, 2025, 13 on July 19, 2024, 11 on July 14, 2023.
Every fire safety citation33 citations
- F
Establish staff and initial training requirements.
E 37 · June 16, 2025 · Corrected (the home has a date of correction)
- F
Have properly located and lighted "Exit" signs.
K 293 · June 16, 2025 · Corrected (the home has a date of correction)
- F
Follow proper procedures when the fire alarm was out of service for more than 4 hours.
K 346 · June 16, 2025 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · June 16, 2025 · deficient, provider has
- F
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
K 354 · June 16, 2025 · Corrected (the home has a date of correction)
- F
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · June 16, 2025 · Corrected (the home has a date of correction)
- E
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
K 321 · June 16, 2025 · Corrected (the home has a date of correction)
- E
Install an approved automatic sprinkler system.
K 351 · June 16, 2025 · Corrected (the home has a date of correction)
- E
Ensure proper usage of power strips and extension cords.
K 920 · June 16, 2025 · Corrected (the home has a date of correction)
- F
Develop and maintain an Emergency Preparedness Program (EP).
E 4 · July 19, 2024 · Corrected (the home has a date of correction)
- F
Create arrangements with other facilities to receive patients.
E 25 · July 19, 2024 · Corrected (the home has a date of correction)
- F
Establish roles under a Waiver declared by secretary.
E 26 · July 19, 2024 · Corrected (the home has a date of correction)
- F
Establish staff and initial training requirements.
E 37 · July 19, 2024 · Corrected (the home has a date of correction)
- F
Conduct testing and exercise requirements.
E 39 · July 19, 2024 · Corrected (the home has a date of correction)
- F
Follow proper procedures when the fire alarm was out of service for more than 4 hours.
K 346 · July 19, 2024 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · July 19, 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 · July 19, 2024 · Corrected (the home has a date of correction)
- F
Provide a written emergency evacuation plan.
K 711 · July 19, 2024 · Corrected (the home has a date of correction)
- E
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
K 321 · July 19, 2024 · Corrected (the home has a date of correction)
- E
Properly select, install, inspect, or maintain portable fire extinguishes.
K 355 · July 19, 2024 · Corrected (the home has a date of correction)
- E
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
K 741 · July 19, 2024 · Corrected (the home has a date of correction)
- E
Ensure proper usage of power strips and extension cords.
K 920 · July 19, 2024 · Corrected (the home has a date of correction)
- F
Develop and maintain an Emergency Preparedness Program (EP).
E 4 · July 14, 2023 · Corrected (the home has a date of correction)
- F
Establish policies and procedures for volunteers.
E 24 · July 14, 2023 · Corrected (the home has a date of correction)
- F
Establish roles under a Waiver declared by secretary.
E 26 · July 14, 2023 · Corrected (the home has a date of correction)
- F
Conduct testing and exercise requirements.
E 39 · July 14, 2023 · Corrected (the home has a date of correction)
- F
Follow proper procedures when the fire alarm was out of service for more than 4 hours.
K 346 · July 14, 2023 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · July 14, 2023 · 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 · July 14, 2023 · 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 · July 14, 2023 · Corrected (the home has a date of correction)
- E
Provide properly protected cooking facilities.
K 324 · July 14, 2023 · 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 · July 14, 2023 · Corrected (the home has a date of correction)
- E
Ensure proper usage of power strips and extension cords.
K 920 · July 14, 2023 · Corrected (the home has a date of correction)