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
0K
0L
Actual harm
2G
0H
0I
Potential for more than minimal harm
47D
11E
7F
Potential for minimal harm
0A
1B
0C
April 30, 2026Complaint inspection · 1 citation
- G
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on a review of facility's policy, facility documentation, clinical records, and staff interview, it was determined the facility failed to follow wound physician's treatment orders/recommendations and provide consistent and appropriate treatment for an Unstageable Pressure Ulcer on the right heel (obscured full-thickness skin and tissue loss), resulting in wound deterioration and actual harm for one of four residents reviewed. (Resident 1)
March 17, 2026Complaint inspection · 1 citation
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on clinical records review and staff interview, it was determined that the facility failed to follow the physician's order for one of four residents reviewed (Resident 1).
January 29, 2026Complaint inspection · 2 citations
- G
Ensure that residents are free from significant medication errors.
Inspectors wroteBased on observation, record review, and staff interviews, the facility failed to ensure residents were free from significant medication errors, resulting in actual harm when Resident R1 required transfer to the hospital with the need for intubation and admission to the Intensive Care Unit, this was found to be a past noncompliance incident for one of 15 residents reviewed. (Resident R1)
- 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 facility policy review, observations and staff interview it was determined the facility failed to properly store medications for one resident reviewed. (Resident R6)
July 18, 2025Standard inspection · 6 citations
- D
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Inspectors wroteBased on interviews, policy reviews, and clinical closed record review, it was determined the facility failed to ensure ombudsman notification procedures were followed for one of one resident reviewed. (Resident 6), and to document return of personal items upon discharge or death for two of three residents reviewed (Resident 139 and 140). Findings Include: Review of Resident 6’s clinical record revealed diagnoses including pulmonary embolism. (A pulmonary embolism (PE) is a blood clot in one of the blood vessels in your lung.) Interview with Director of Nursing on [DATE] at 10:02 AM confirmed no notification was sent to ombudsman Review of facility policy titled Personal Property: Patient's revealed, personnel will identify and record the resident's belongings upon admission to the facility. [...]
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on a review of facility policy, clinical records and staff interviews, it was determined that the facility failed to properly follow physician orders for two of 32 residents reviewed (Resident 6 and 29).
- D
Provide enough food/fluids to maintain a resident's health.
Inspectors wroteBased upon review of facility policy and procedure and review of clinical records, it was determined the facility failed to ensure weight loss and weight gain was adequately monitored for two of 15 residents reviewed (Resident 8, Resident 60).
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on clinical record review, and policy and procedures review, it was determined the facility failed to follow a physician's order for oxygen therapy for one of three residents reviewed (Resident 10).
- D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Inspectors wroteBased on facility policy, observations and interviews, it was determined that the facility failed to document medication disposition for one of three discharged residents. (Resident 139).
- D
Keep all essential equipment working safely.
Inspectors wroteBased on observations, review of facility records and staff interviews, it was determined that the facility failed to maintain kitchen equipment (dishwasher and sink faucet) in safe, operating condition.
January 29, 2025Complaint inspection · 1 citation
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on interviews and clinical record reviews, it was determined that the facility failed to report one resident's hospital transfer due to consumption of a liquid soap product. (Resident 2)
August 15, 2024Standard inspection · 22 citations
- F
Develop, implement, and/or maintain an effective training program for all new and existing staff members.
Inspectors wroteBased on review of facility policy, facility documentation, facility personnel records, and staff interviews it was determined that the facility failed to implement and maintain an effective training program for new hires and existing staff.
- F
Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members.
Inspectors wroteBased on review of facility documents, and staff interview, it was determined that the facility failed to provide training on effective communication for four out of five staff members (Employee E3, Employee E4, Employee E5, Employee E6,).
- F
Ensure that staff members are educated on resident rights and facility responsibilities to properly care for its residents.
Inspectors wroteBased on review of new hire personnel records and interviews, it was determined that the facility failed to provide training on Resident Rights for four out of five staff members (Employee E3, Employee E4, Employee E5, Employee E6, Employee E7).
- F
Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.
Inspectors wroteBased on staff interviews and a review of facility training and orientation records, it was determined that the facility failed to provide training on the facility's abuse prohibition policy and facility specific procedures for one out of five new hires (Employee E6).
- F
Include as part of its infection prevention and control program, mandatory training that includes written standards, policies, and procedures for the program.
Inspectors wroteBased on review personnel records, and staff interview, it was determined that the facility failed to provide training on Infection Control for four out of five new hires (Employee E3, Employee E4, Employee E5, and Employee E6).
- F
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 review of personnel file for nursing assistants employed by the facility, it was determined the facility failed to ensure consistent in-service training and competencies were completed as required for one of five personnel files reviewed. (Employee E13)
- F
Provide behavior health training consistent with the requirements and as determined by a facility assessment.
Inspectors wroteBased on review of facility documents, employee education records, and staff interview, it was determined that the facility failed to provide training on behavioral health for four out of five staff members (Employee E3, Employee E4, Employee E5, and Employee E6)
- D
Respond appropriately to all alleged violations.
Inspectors wroteBased on review of the facility's policy, clinical records, and staff interview, it was determined that the facility failed to thoroughly investigate an allegation of physical abuse for one of the 29 residents reviewed (Resident 54).
- 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 clinical record review and staff interview, it was determined that the facility failed to notify the Office of the State Long-Term Care Ombudsman of a transfer to the hospital for four of eight residents reviewed (Residents 17, 96, 332, and 333).
- D
Ensure each resident receives an accurate assessment.
Inspectors wroteBased on review of the Resident Assessment Instrument User's Manual and clinical records, as well as staff interviews, it was determined that the facility failed to complete accurate Minimum Data Set assessments for one of 32 residents reviewed (Residents 25).
- 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 clinical record reviews and interviews with residents and staff, it was determined that the facility failed to develop a baseline care plan within 48 hours of a resident's admission that included the minimum information necessary to properly care for a resident, for one of eight residents reviewed (Resident 333).
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on clinical record review and staff interview it as determined the facility failed to administer medications as ordered to one of 24 residents reviewed. (Resident 20) Findings Include: Review of Resident 20's physician orders revealed an order for Midodrine (increases blood pressure) 5 milligrams (mg) three times a day (TID) for hypotension (low blood pressure) hold for systolic blood pressure greater than 140. Review of Resident 20's Medications Administration Record (MAR) from August 1-13 2024 revealed the resident received the midodrine four times when the systolic blood pressure was above 140. Review of Resident 20's MAR for the entire month of July 2024 revealed the resident received the midodrine 13 times when the systolic blood pressure was above 140. Interview with the Director of Nursing on August 15, 2024 at 11:30 a.m. [...]
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on a review of the facility's policy, clinical records review, and staff interview, it was determined the facility failed to ensure that treatments for pressure ulcers were provided as ordered by the physician for two of the 29 residents reviewed (Resident 54 and 127).
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on Facility policy and procedure review, clinical record review and staff interview it was determined the facility failed to provide interventions to prevent a potential elopement for one of two residents reviewed. (Resident 101) Findings Include: Review of Facility policy and procedure titled Wandering, last revised May 1, 2022, revealed wandering behavior symptoms will be documented on the Behavior Monitoring and Intervention Flow Record or Behavior Tracking Form. Forms will be reviewed to determine triggers associated with the behavior and effectiveness of non-pharmacological interventions. Behavior symptoms will be addressed in the care/service plan. Review of Resident 101's progress notes revealed a social service entry dated July 26, 2024 at 2:17 p.m. [...]
- 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 clinical record review, facility policy and procedure review, observations, and staff interview it was determined the facility failed to provide care and services for foley catheters for one of five residents reviewed. (Resident 20) Findings Include: Review of facility policy and procedure titled Catheter: Urinary-Justification for Use, last revised August 7, 2023, revealed Patients who have urinary catheters upon admission or subsequently receive one will be assessed for removal of the catheter as soon as possible unless the patients clinical condition demonstrates that catheterization is necessary. If the patients condition meets any of the indwelling catheter criteria, obtain a physician order, include in care plan. Observation of Resident 20 on August 12, 2024 at 9:30 a.m. revealed the resdient had a Foley Catheter (tube placed into the bladder to drain urine). [...]
- D
Provide enough food/fluids to maintain a resident's health.
Inspectors wroteBased on review of the facility's policy, clinical records review, and staff interview, it was determined the facility failed to appropriately monitor, provide appropriate interventions, and timely notify the physician of a significant weight change for two of 29 residents reviewed (Residents 85 and 127).
- D
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Inspectors wroteBased on Clinical record review and staff interview it was determined the facility failed to provide enteral nutrition (feeding delivered through a feeding tube) as ordered by the physician for one of eight residents reviewed. (Resident 332)
- D
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Inspectors wroteBased on clinical record review, facility policy and procedure review and staff interview it was determined the facility failed to ensure residents did not receive unnecessary psychotropic medications for two of six residents reviewed. (Residents 65 and 101) Findings Include: Review of facility policy and procedure titled Behaviors: Management of Symptoms last reviewed July 1, 2024 revealed, when medication sis ordered for behavior symptoms completed the Psychotropic/Therapeutic Medication use evaluation when a patient is newly prescribed psychotherapeutic medication and then quarterly. Complete the Abnormal Involuntary Movement Scale (AIMS) per nursing schedule for patient receiving antipsychotic medications. [...]
- 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 clinical record review, observations, facility policy and procedure review and staff interview it was determined the facility failed to date and label insulin pens on two medications carts and reconcile medications on discharge for one of three residents. (Resident: 131) Findings Include: Review of facility policy and procedure Insulin Pens, last reviewed July 1, 2024, revealed Insulin Pens will be clearly labeled with the patient name, physician name, date used; a new pen must be ordered from the pharmacy. Observations of the medication cart 1 on the skilled nursing unit on August 15, 2024 at 9:15 a.m. revealed four insulin pens that were opened and being used but had no date of when they were opened or when they were to be discarded. [...]
- D
Provide timely, quality laboratory services/tests to meet the needs of residents.
Inspectors wroteBased on clinical record review and staff interview it was determined the facility failed to obtain laboratory studies as ordered for one of 24 residents reviewed. (Resident 20) Findings Include: Review of Resident 20's physician orders revealed an order dated August 1, 2024 for a CBC (comprehensive blood count- count of all the cells in the blood) and a CMP (comprehensive metabolic panel- a routine blood test that measures 14 different substances in a sample of your blood). Review of resident 20's Results for laboratory studies revealed these lab studies were not completed as ordered. Review of Resident 20's physician orders revealed an order dated July 5, 2024 for a CBC and a CMP and a tacrolimus level (measures the amount of drug in the blood to determine whether concentrations have reached therapeutic levels). [...]
- D
Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.
Inspectors wroteBased on clinical record review and staff interview it was determined the facility performed laboratory studies without a physician order for one of 24 residents reviewed. (Resident 24) Findings Include: Review of Resident 20's laboratory results revealed the results for a Magnesium level (blood test to determine the amount of magnesium in the blood), BMP (Basic Metabolic Panel- a test that measures eight different substances in your blood) and a CBC (comprehensive blood count- count of all the cells in the blood) completed on August 12, 2024. Review of resident 20's physician orders revealed there was no order for these laboratory studies. Review of Resident 20's laboratory results revealed the results for a CBC completed on June 24, 2024. Review of resident 20's physician orders revealed there was no order for this laboratory study. [...]
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on clinical record review, observations, and staff interviews, it was determined that the facility failed ensure infection control management was implemented during a tracheostomy care and failed to follow policy related transmissions-based precautions and use of personal protective equipment for two of 32 sampled residents. (Resident 4 and Resident 85).
April 17, 2024Complaint inspection · 3 citations
- D
Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
Inspectors wroteBased on observations and interviews, it was determined the facility failed to ensure treatment with dignity and respect for one of five residents observed (Resident R1)
- D
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Inspectors wroteBased on observations and interviews with staff it was determined that the facility failed to provide hot water for all residents residing in the facility for two of two days observed, April 16, 2024, and April 17, 2024.
- 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 and staff interview, it was determined that the facility failed ensure three medication carts were locked and secured out of six medication carts observed.
January 29, 2024Complaint inspection · 1 citation
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on clinical record review and staff interview it was determined the facility failed to follow physician orders for one of 3 residents reviewed. (Resident R1) Findings Include: Review of Resident R1's physician orders revealed an order dated January 20, 2024 for Oxycodone (narcotic pain reliever) 10mg, give one tablet by mouth every 8 hours as needed for severe pain. Review of Resident R1's Medication Administration Record for January 2024 revealed Resident R1 received a dose on January 27, 2024 at 4:29 p.m. and the next dose administered was on January 28, 2024 at 8:30 p.m. Review of Resident R1's Progress Notes revealed a nursing entry on January 29, 2024 at 9:26 a.m. [...]
September 29, 2023Standard inspection, Complaint inspection · 30 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 observations and interviews with residents and staff, it was determined that the facility failed to provide a clean and homelike environment on one of four nursing units.
- E
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on clinical record reviews, as well as resident and staff interviews, it was determined that the facility failed to ensure that residents were provided with showers as scheduled for 13 of 56 residents reviewed (Residents 18, 24, 27, 32, 33, 54, 64, 71, 84, 95, 101, 103, 112).
- E
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on review of clinical records and staff interviews, it was determined that the facility failed to ensure that physician's orders were followed for four of 56 residents reviewed (Residents 23, 29, 88, 96).
- E
Provide enough food/fluids to maintain a resident's health.
Inspectors wroteBased on clinical record reviews and staff interviews, it was determined that the facility failed to ensure that there was timely physician notification and intervention for a significant weight loss for one of 56 residents reviewed (Resident 27).
- E
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Inspectors wroteBased on clinical record reviews, observations, and staff interviews, it was determined that the facility failed to ensure that residents who were receiving tube feedings received appropriate treatment and services to prevent complications for one of 56 residents reviewed (Resident 79).
- E
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on clinical record reviews, observations, and staff interviews, it was determined that the facility failed to ensure that respiratory care was provided as ordered for one of 56 residents reviewed (Resident 29).
- 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 clinical record reviews and staff interviews, it was determined that the facility failed to ensure that residents were free from unnecessary psychotropic medications, by failing to ensure that non-pharmacological (non-medication) interventions were attempted prior to the administration of as needed antianxiety medications for one of 56 residents reviewed (Resident 101).
- E
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Inspectors wroteBased on review of facility policies, observations, as well as resident and staff interviews, it was determined that the facility failed to serve food items at appetizing temperatures.
- E
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on a review of policies, observations, and staff interviews, it was determined that the facility failed to store and prepare food in accordance with professional standards of food service safety by failing to properly label and date stored foods and maintain a sanitary environment in the kitchen.
- E
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on review of clinical records, as well as resident and staff interviews, it was determined that the facility failed to maintain clinical records that were complete and accurately documented for one of 56 residents reviewed (Resident 64).
- E
Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.
Inspectors wroteBased on review of facility policies and staff training records, as well as staff interviews, it was determined that the facility failed to provide annual abuse training for two of five employees (Licensed Practical Nurse 15, Registered Nurse 16).
- D
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Inspectors wroteBased on review of policies and employee files, as well as staff interviews, it was determined that the facility failed to implement its written abuse prevention policies, by failing to ensure that reference checks were obtained prior to hire for one of five employee files reviewed (Nurse Aide 12).
- D
Assure that each resident’s assessment is updated at least once every 3 months.
Inspectors wroteBased on review of the Resident Assessment Instrument Manual and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that quarterly Minimum Data Set assessments were completed within the required time frame for nine of 56 residents reviewed (Residents 8, 22, 23, 24, 27, 28, 49, 50, 51).
- 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 a review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that a baseline care plan was developed and implemented for one of 56 residents reviewed (Resident 106).
- D
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Inspectors wroteBased on review of policies, clinical records, and staff interviews, it was determined that the facility failed to develop comprehensive care plans that included specific and individualized interventions to address the care needs for two of 56 residents reviewed (Residents 88, 95).
- 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 review of facility policy and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that a resident's care plan was updated/revised to reflect the resident's specific care needs for one of 56 residents reviewed (Resident 84).
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on review of clinical records and staff interviews, it was determined that the facility failed to ensure that treatments for pressure ulcers were provided as ordered by the physician for one of 56 residents reviewed (Resident 81).
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on clinical record reviews, observations, and staff interviews, it was determined that the facility failed to ensure that each resident received assistance devices to prevent accidents for two of 56 residents reviewed (Residents 23, 41).
- D
Ensure that the resident and his/her doctor meet face-to-face at all required visits.
Inspectors wroteBased on clinical record reviews and staff interviews, it was determined that the facility failed to ensure that a physician performed the initial comprehensive visit with the resident and was seen by the physician at least once every 30 days for the first 90 days after admission for one of 56 residents reviewed (Resident 102).
- D
Observe each nurse aide's job performance and give regular training.
Inspectors wroteBased on review of personnel files, as well as staff interviews, it was determined that the facility failed to ensure that nurse aide performance evaluations were completed annually based on hire dates for three of three nurse aides reviewed (Nurse Aides 6, 7, 8).
- D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Inspectors wroteBased on review of clinical records, as well as staff interviews, it was determined that the facility failed to maintain accountability for controlled medications (drugs with the potential to be abused) for one of 56 residents reviewed (Resident 84).
- D
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Inspectors wroteBased on review of clinical records, as well as staff interviews, it was determined that the facility failed to ensure that residents were free from unnecessary drugs that were used for a longer duration than what was ordered by the physician for one of 56 residents reviewed (Resident 81).
- D
Ensure that residents are free from significant medication errors.
Inspectors wroteBased on review of clinical records and staff interviews, it was determined that the facility failed to provide medication as ordered by the physician, resulting in significant medication errors for two of 56 residents reviewed (Residents 29, 88).
- D
Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.
Inspectors wroteBased on review of facility documentation and staff interviews, it was determined that the facility failed to ensure that the Facility Assessment was completed, and reviewed and revised, as needed, at least annually.
- D
Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
Inspectors wroteBased on clinical record reviews and staff interviews, it was determined that the facility failed to ensure that the designated interdisciplinary team member obtained the required information from the contracted hospice provider for three of 56 residents reviewed who were receiving hospice services (Residents 40, 84, 95).
- D
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Inspectors wroteBased on review of the facility's plans of correction for previous surveys, and the results of the current survey, it was determined that the facility's Quality Assurance Performance Improvement (QAPI) committee failed to correct quality deficiencies and ensure that plans to improve the delivery of care and services effectively addressed recurring deficiencies.
- D
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
Inspectors wroteBased on review of facility documentation and staff interview, it was determined that the facility failed to ensure that the Quality Assurance Committee met quarterly for two of three quarters reviewed (first and second quarter 2023).
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on review of policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that the water management policy was implemented for the detection and/or prevention of Legionella within the facility's water systems.
- D
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
Inspectors wroteBased on review of personnel files and staff interviews, it was determined that based on nurse aides' hire dates, the facility failed to ensure that nurse aides completed at least 12 hours of inservice education annually for three of three nurse aides reviewed (Nurse Aides 6, 7, 8).
- B
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Inspectors wroteBased on clinical record reviews and staff interviews, it was determined that the facility failed to provide the required notice to the resident or the resident's representative following the end of their Medicare coverage, or failed to provide 48-hour advanced notice, for one of three residents reviewed (Resident 122).
September 3, 2023Complaint inspection · 1 citation
- D
Reasonably accommodate the needs and preferences of each resident.
Inspectors wroteBased on clinical record review and resident interview, it was determined that the facility failed to ensure residents received prescribed insulin timely for one of six residents reviewed (Resident R1).
Fire safety inspections
45 fire safety citations on file: 7 on July 18, 2025, 20 on August 15, 2024, 18 on September 29, 2023.
Every fire safety citation45 citations
- F
Conduct testing and exercise requirements.
E 39 · July 18, 2025 · Corrected (the home has a date of correction)
- E
Install a two-hour-resistant firewall separation.
K 133 · July 18, 2025 · Corrected (the home has a date of correction)
- E
Install corridor and hallway doors that block smoke.
K 363 · July 18, 2025 · Corrected (the home has a date of correction)
- E
Have properly installed electrical wiring and gas equipment.
K 511 · July 18, 2025 · 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 · July 18, 2025 · Corrected (the home has a date of correction)
- E
Ensure proper usage of power strips and extension cords.
K 920 · July 18, 2025 · Corrected (the home has a date of correction)
- E
Have proper medical gas storage and administration areas.
K 923 · July 18, 2025 · Corrected (the home has a date of correction)
- F
Install emergency lighting that can last at least 1 1/2 hours.
K 291 · August 15, 2024 · Corrected (the home has a date of correction)
- F
Have properly located and lighted "Exit" signs.
K 293 · August 15, 2024 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · August 15, 2024 · Corrected (the home has a date of correction)
- F
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
K 521 · August 15, 2024 · Corrected (the home has a date of correction)
- E
Meet requirements for sections of health care facilities separated by fire resistive construction.
K 131 · August 15, 2024 · Corrected (the home has a date of correction)
- E
Meet other general requirements.
K 200 · August 15, 2024 · Corrected (the home has a date of correction)
- E
Keep aisles, corridors, and exits free of obstruction in case of emergency.
K 211 · August 15, 2024 · 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 · August 15, 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 · August 15, 2024 · Corrected (the home has a date of correction)
- E
Provide properly protected cooking facilities.
K 324 · August 15, 2024 · Corrected (the home has a date of correction)
- E
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · August 15, 2024 · Corrected (the home has a date of correction)
- E
Properly provide smoke detection systems in areas open to corridors.
K 347 · August 15, 2024 · Corrected (the home has a date of correction)
- E
Have properly installed electrical wiring and gas equipment.
K 511 · August 15, 2024 · Corrected (the home has a date of correction)
- E
Have simulated fire drills held at unexpected times.
K 712 · August 15, 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 · August 15, 2024 · Corrected (the home has a date of correction)
- E
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · August 15, 2024 · Corrected (the home has a date of correction)
- E
Ensure proper usage of power strips and extension cords.
K 920 · August 15, 2024 · Corrected (the home has a date of correction)
- E
Have proper medical gas storage and administration areas.
K 923 · August 15, 2024 · Corrected (the home has a date of correction)
- C
Meet other general requirements.
K 100 · August 15, 2024 · Corrected (the home has a date of correction)
- C
Properly select, install, inspect, or maintain portable fire extinguishes.
K 355 · August 15, 2024 · Corrected (the home has a date of correction)
- F
Provide properly protected cooking facilities.
K 324 · September 29, 2023 · Corrected (the home has a date of correction)
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · September 29, 2023 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · September 29, 2023 · Corrected (the home has a date of correction)
- F
Have simulated fire drills held at unexpected times.
K 712 · September 29, 2023 · Corrected (the home has a date of correction)
- F
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
K 761 · September 29, 2023 · Corrected (the home has a date of correction)
- F
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
K 914 · September 29, 2023 · Corrected (the home has a date of correction)
- F
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · September 29, 2023 · Corrected (the home has a date of correction)
- E
Keep aisles, corridors, and exits free of obstruction in case of emergency.
K 211 · September 29, 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 · September 29, 2023 · Corrected (the home has a date of correction)
- E
Properly select, install, inspect, or maintain portable fire extinguishes.
K 355 · September 29, 2023 · Corrected (the home has a date of correction)
- E
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · September 29, 2023 · Corrected (the home has a date of correction)
- E
Have properly installed electrical wiring and gas equipment.
K 511 · September 29, 2023 · Corrected (the home has a date of correction)
- C
Develop and maintain an Emergency Preparedness Program (EP).
E 4 · September 29, 2023 · Corrected (the home has a date of correction)
- C
Develop Emergency Preparedness policies and procedures.
E 13 · September 29, 2023 · Corrected (the home has a date of correction)
- C
Meet other general requirements.
K 100 · September 29, 2023 · Corrected (the home has a date of correction)
- C
Install emergency lighting that can last at least 1 1/2 hours.
K 291 · September 29, 2023 · Corrected (the home has a date of correction)
- C
Have properly located and lighted "Exit" signs.
K 293 · September 29, 2023 · Corrected (the home has a date of correction)
- C
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
K 521 · September 29, 2023 · Corrected (the home has a date of correction)