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 62 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
3G
0H
0I
Potential for more than minimal harm
45D
11E
3F
Potential for minimal harm
0A
0B
0C
June 16, 2026Complaint inspection · 1 citation
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on interview and record review, the facility failed to complete timely and comprehensive vital-sign assessments (measurements of the body's most basic functions), specifically blood-glucose (sugar) level and temperature, for 2 of 3 residents (Residents 1 & 2) during changes in condition, reviewed for quality of care. This failure placed the residents at risk for unrecognized medical complications, unmet care needs and a diminished quality of life.
March 23, 2026Complaint inspection · 1 citation
- 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 an allegation of neglect was reported to the State Agency within the required timeframe for 1 of 4 residents (Resident 1), reviewed for abuse reporting. This failure placed the resident at risk for potential unidentified neglect and lack of protection from neglect.
November 26, 2025Standard inspection · 14 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 store food in accordance with professional standards for food safety when expired food items were not discarded for 1 of 1 dry storage room (Kitchen Dry Storage Room), reviewed for food services. In addition, the facility failed to ensure expired paper tests strips (designed to check the level of chlorine [a chemical that kills germs] in the water used to sanitize the dishware during the dishwasher rinsing phase) were discarded. These failures placed the residents at risk for foodborne illness (caused by the ingestion of contaminated food or beverages).
- E
Post nurse staffing information every day.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the posted daily nurse staffing information included the actual hours worked by registered and licensed nursing staff directly responsible for resident care per shift for 4 of 7 days, reviewed for posted nurse staffing information. The failure to post a complete and accurate form daily prevented the residents, family members, and visitors from exercising their rights to know the actual nursing staff hours worked in the facility.
- 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 ensure expired medications were discarded for 2 of 3 medication carts (Cascade Medication Cart & Olympic Medication Cart), and for 1 of 2 medication rooms (Central Supply Room), reviewed for medication storage and labeling. This failure placed the residents at risk for receiving compromised and ineffective medications.
- E
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure proper transport of clean linens was followed for 1 of 1 staff (Staff U), reviewed for infection control. In addition, the facility failed to ensure hand hygiene practices and/or proper use of gloves were followed during medication administration for 2 of 4 staff (Staff O & Staff N). These failures placed the residents, visitors, and staff at risk for infection and related complications.
- E
Implement a program that monitors antibiotic use.
Inspectors wroteBased on interview and record review, the facility failed to implement an Antibiotic Stewardship Program (a coordinated effort to optimize the use of antibiotics [medicine that prevents or treats infection] to ensure their appropriate and necessary use) for 1 of 2 residents (Resident 51), reviewed for antibiotic stewardship. The failure to conduct assessment to confirm presence of an infection prior to initiation of antibiotic placed the resident at risk for receiving unnecessary medication and a diminished quality of life.
- 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 ensure a copy of the advance directive (a written document describing a resident's wishes for care if they became incapacitated such as a living will or Durable Power of Attorney [DPOA- a document delegating to an agent the authority to make health care decisions in case the individual delegating the authority subsequently becomes incapable to do so]) for health care was obtained for 1 of 1 resident (Resident 21), reviewed for advance directive. This failure placed the resident at risk for losing their right to have their preferences honored regarding care.
- D
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Inspectors wroteBased on interview and record review, the facility failed to provide the required Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN-a written notice that informs a Medicare [government health insurance program] that a service may not be covered and that resident may be responsible for the cost if they remained in the facility after their Medicare Part A skilled nursing and rehabilitation services ended) for 2 of 3 residents (Residents 104 & 105), reviewed for liability notices. This failure placed the residents and/or their representatives at risk of not having adequate information to make financial decisions related to continued stay in the facility.
- 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 bed hold and transfer notices to the residents and/or their representatives in writing for 2 of 2 residents (Residents 69 & 94), reviewed for hospitalization. In addition, the facility failed to ensure a copy of the transfer notice was sent timely to the State Long Term Care Ombudsman (an advocate for residents of nursing homes who protect and promote resident rights under federal and state law and regulations) office describing the reason for the transfer and/or the location. These failures placed the residents at risk of not having an opportunity to make an informed decision about their transfers.
- D
Ensure each resident receives an accurate assessment.
Inspectors wroteBased on interview and record review, the facility failed to accurately assess 1 of 21 residents (Resident 5), reviewed for Minimum Data Set (MDS-an assessment tool). The failure to ensure resident assessment was completed accurately on the MDS regarding medications placed the resident at risk for unidentified and/or unmet care needs, and a diminished quality of life.
- D
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Inspectors wroteBased on interview and record review, the facility failed to include the dialysis (a treatment to remove extra fluid and waste when kidneys fail) days, transportation arrangement and contact information of the dialysis center in the comprehensive care plan for 1 of 1 resident (Resident 31), reviewed for dialysis. This failure placed the resident at risk for unmet care needs and a diminished quality of life.
- 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 ensure safety hazards such as a lighter and a box cutter were properly stored for 1 of 2 residents (Resident 13), reviewed for accident hazards. This failure placed the resident at risk for injury, and a diminished quality of life.
- D
Provide safe, appropriate pain management for a resident who requires such services.
Inspectors wroteBased on interview and record review, the facility failed to initiate non-pharmacological interventions for pain management prior to administering as needed (PRN) pain medication for 1 of 1 resident (Resident 21), reviewed for pain management. This failure placed the resident at risk for unnecessary medications and incomplete pain control.
- 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 controlled medications were accurately reconciled for 1 of 3 medication carts (Olympic Medication Cart), reviewed for controlled medication storage/reconciliation. This failure placed the facility at risk for potential loss and/or drug diversion of the controlled medication.
- D
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Inspectors wroteBased on interview and record review, the facility failed to ensure influenza vaccine (used to prevent influenza [an infection of the nose, throat, and lungs]) were offered for 2 of 5 residents (Residents 6 & 10), reviewed for immunizations. This failure placed the residents at risk of acquiring, transmitting, and/or experiencing potentially avoidable complications from influenza disease.
August 29, 2025Complaint inspection · 3 citations
- G
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on observation, interview, and record review, the facility failed to accurately assess, provide timely treatment, and implement pressure relieving interventions to prevent worsening of skin condition for 1 of 3 residents (Resident 1), reviewed for pressure injury (localized damage to the skin and/or underlying tissue that occurs due to prolonged pressure on the skin). [...]
- D
Respond appropriately to all alleged violations.
Inspectors wroteBased on interview and record review, the facility failed to conduct a thorough investigation for 1 of 3 residents (Resident 3), reviewed for abuse investigations. This failure placed the resident at risk for repeated incidents, unidentified abuse, and inappropriate corrective actions.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure hand hygiene practices and/or proper use of personal protective equipment (PPE-glove/gown use) were followed for 2 of 3 residents (Residents 1 & 2), reviewed for infection control. These failures placed the residents, visitors, and staff at an increased risk for infection and related complications.
May 9, 2025Complaint inspection · 1 citation
- 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 interview and record review, the facility failed to provide a written summary of the baseline care plan to the residents and/or their representatives for 4 of 4 residents (Residents 1, 2, 3 & 4), reviewed for baseline care plan. This failure placed the residents at risk for unmet care needs, and a diminished quality of life.
April 8, 2025Complaint inspection · 2 citations
- E
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff used N95 masks (a device designed to protect the wearer against particles and help prevent the spread of germs) correctly for 4 of 4 staff (Staff G, F, E & H), and were fit-tested (a test protocol conducted to verify that a respirator provides the wearer with the expected protection) timely for 2 of 4 staff (Staff F & G), reviewed for infection control. In addition, the facility failed to ensure Enhanced Barrier Precautions (EBP- precaution to protect residents from Multidrug-Resistant Organism (a germ that is resistant to medications that treat infections) practices were followed for 1 of 3 residents (Resident 2), reviewed for infection control. These failures placed the residents, staff, and visitors at risk for facility acquired or healthcare-associated infections and related complications.
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on interview and record review, the facility failed to provide necessary assistance with Activities of Daily Living (ADL) for 1 of 4 residents (Resident 1), reviewed for ADLs. The failure to provide the resident who was dependent on staff for assistance with toileting placed the resident at risk for unmet care needs and a diminished quality of life.
March 17, 2025Complaint inspection · 1 citation
- D
Plan the resident's discharge to meet the resident's goals and needs.
Inspectors wroteBased on interview and record review, the facility failed to ensure a resident centered discharge plan was in place for 1 of 5 residents (Resident 1), reviewed for discharge planning. The failure to begin the discharge planning process at admission placed the resident at risk for unmet care needs and a diminished quality of life.
November 7, 2024Complaint inspection · 2 citations
- 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 timely reporting of an allegation of neglect to the State Agency for 1 of 3 resident (Resident 1), reviewed for abuse/neglect reporting. This failure placed the resident at risk for potential unidentified and ongoing abuse/neglect and lack of protection from abuse/neglect.
- D
Respond appropriately to all alleged violations.
Inspectors wroteBased on interview and record review, the facility failed to ensure allegation of neglect was thoroughly investigated for 1 of 3 resident (Resident 1), reviewed for abuse/neglect investigations. This failure placed the resident at risk for unidentified abuse and/or neglect, and a diminished quality of life.
September 26, 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 interview and record review the facility failed to provide necessary/adequate supervision for 1 of 1 resident (Resident 1), reviewed for elopement. This failure allowed Resident 1 to exit the facility unnoticed and placed the resident at risk for serious injury and a diminished quality of life.
September 6, 2024Standard inspection, Complaint inspection · 17 citations
- E
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Inspectors wroteBased on observation, interview, and record review, the facility failed to develop comprehensive care plans for 5 of 21 residents (Residents 9, 65, 68, 3 and 54), reviewed for care plans. The failure to develop care plans for nutrition, pressure ulcer (bed sore), Continuous Positive Airway Pressure (CPAP - a therapy that pumps air into the lungs through the nose or nose and mouth that keeps the airway open), antiplatelet (a medications that prevent blood clots), communication, and oxygen placed the residents at risk for unmet care needs, related complications, and a diminished quality of life.
- 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 appropriately label and store drugs and/or biologicals for 2 of 2 medication carts (Cascade medication cart & [NAME] medication cart), reviewed for medication storage. This failure placed the residents at risk for receiving compromised, incorrect, and/or ineffective medications.
- E
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure foods were handled appropriately in accordance with professional standards of food safety for 1 of 1 kitchen, and for 1 of 1 dining room (Baker Dining Room), reviewed for food services. The failure to label and date food items, perform hand hygiene between glove use, and use appropriate food handling when assisting residents placed the residents at risk for food borne illness (caused by the ingestion of contaminated food or beverages), cross contamination, and a diminished quality of life.
- D
Reasonably accommodate the needs and preferences of each resident.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a call light (an alerting device for staff to assist residents in need) was within reach for 1 of 6 residents (Resident 3), reviewed for accommodation of needs. This failure placed the resident at risk for delayed care, accidents/falls, and a diminished quality of life.
- 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 suspected allegations of abuse and/or neglect to the State Agency for 1 of 4 residents (Resident 75), reviewed for abuse/neglect reporting. This failure placed the residents at risk for potential unidentified and ongoing abuse/neglect and lack of protection from abuse.
- D
Respond appropriately to all alleged violations.
Inspectors wroteBased on interview and record review the facility failed to ensure allegations of abuse and/or neglect was thoroughly investigated for 1 of 4 residents (Residents 75), reviewed for abuse/neglect investigations. This failure placed the resident at risk for unidentified abuse and/or neglect, and a diminished quality of life.
- 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 interview and record review, the facility failed to provide a written transfer/discharge notice to the resident and/or their representative describing the reason for transfer for 1 of 1 resident (Resident 65), reviewed for hospitalization. This failure placed the resident at risk of not having the opportunity to make informed decisions about transfers/discharges.
- D
Assess the resident when there is a significant change in condition
Inspectors wroteBased on interview and record review, the facility failed to ensure a Significant Change in Status Assessment (SCSA) Minimum Data Set (MDS - an assessment tool) was completed for 1 of 3 residents (Resident 9), reviewed for SCSA. This failure placed the resident at risk for delayed care planning, unmet care needs, and a diminished quality of life.
- D
Assure that each resident’s assessment is updated at least once every 3 months.
Inspectors wroteBased on interview and record review, the facility failed to complete quarterly Minimum Data Set (MDS- an assessment tool) timely within 14 days from the Assessment Reference Date (ARD or assessment period) for 1 of 7 residents (Resident 32), reviewed for Resident Assessments. This failure placed the resident at risk for delayed and/or unidentified care needs.
- D
Ensure each resident receives an accurate assessment.
Inspectors wroteBased on interview and record review, the facility failed to accurately assess 4 of 21 residents (Residents 11, 3, 95 & 8), reviewed for Minimum Data Set (MDS-an assessment tool). The failure to ensure accurate assessments regarding change in behavior, bladder/bowel continence status, discharge status, and use of insulin (medication/hormone that regulates blood sugar levels) injections placed the residents at risk for unidentified and/or unmet care needs, and a diminished quality of life.
- D
PASARR screening for Mental disorders or Intellectual Disabilities
Inspectors wroteBased on interview and record review, the facility failed to ensure the Level I Pre-admission Screening and Resident Review (PASRR- an assessment used to identify people [resident] referred to nursing facilities with Serious Mental Illness [SMI], intellectual disabilities, or related conditions are not inappropriately placed in nursing facility for long term care) had the required referral for PASRR Level II evaluation (a comprehensive evaluation required as a result of a positive Level I screening. A Level II is necessary to confirm the indicated diagnosis noted in the Level I screening and to determine whether placement or continued stay in a nursing facility is appropriate) for 1 of 5 residents (Resident 11), reviewed for PASRR. In addition, the facility failed to ensure a new PASRR Level I was completed when Resident 11 had a significant change in condition. [...]
- D
Ensure services provided by the nursing facility meet professional standards of quality.
Inspectors wroteBased on observation, interview, and record review, the facility failed to clarify a physician's order for 1 of 4 residents (Resident 55) and failed to ensure staff documented medications in accordance with professional standards for 1 of 4 residents (Resident 2), reviewed for medication administration. In addition, the facility failed to ensure insulin (a hormone that regulates blood sugar level) administration was documented for 1 of 3 residents (Resident 3), reviewed for insulin administration. These failures placed the residents at risk for medication errors, negative outcomes, and a diminished quality of life.
- 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 bathing/shower and personal hygiene were consistently provided according to plan of care for 1 of 4 residents (Resident 9), reviewed for Activities of Daily Living (ADL). This failure placed the resident at risk for poor hygiene, decreased self-esteem, and a diminished quality of life.
- 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 observation, interview, and record review, the facility failed to ensure appropriate treatment and services related to enteral tube feeding (a medical device used to provide nutrients through a tube directly into the stomach) were followed for 1 of 1 resident (Resident 55), reviewed for tube feeding management. The failure to label/date and discard tube feeding syringes placed the resident at risk for infection and related complications.
- D
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
Inspectors wroteBased on observation, interview and record review, the facility failed to provide the necessary behavioral care and services for 1 of 1 resident (Resident 11), reviewed for behavioral health services. This failure placed the resident at risk for unmet care needs and a diminished quality of life.
- D
Ensure medication error rates are not 5 percent or greater.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a medication error rate of less than 5 Percent (%). The failure to properly administer 2 of 31 medications for 2 of 4 residents (Residents 2 & 55), observed during medication pass resulted in a medication error rate of 6.45%. This failure placed the residents at risk for not receiving the correct dose or receiving less than the intended therapeutic effects of physician ordered medication.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure Enhanced Barrier Precautions (EBP - precaution to protect residents from multidrug-resistant organism [a germ that is resistant to medications that treat infections]) practices were followed for 1 of 7 residents (Resident 55), reviewed for infection control. In addition, the facility failed to ensure hand hygiene practices and/or proper use of gloves were followed before, during, and after resident care and medication administration for 2 of 12 staff (Staff EE & Staff M), reviewed for infection control. These failures placed the residents, visitors, and staff at an increased risk for infection and related complications.
April 24, 2024Complaint inspection · 5 citations
- D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteBased on observation, interview, and record review, the facility failed to provide care and services in a manner that maintained and promoted residents' dignity related to use of urinary catheter (a flexible tube inserted into the bladder, which drains urine into a collection/drainage bag outside the body) for 3 of 4 residents (Residents 4, 5 & 6), reviewed for resident rights. This failure placed the residents at risk for embarrassment, decreased self-worth, and a diminished quality of life.
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure allegation of abuse was reported to the State Agency and/or law enforcement for 1 of 3 residents (Resident 1), reviewed for abuse allegations. This failure placed the resident at risk for potential unidentified abuse and lack of protection from abuse.
- D
Respond appropriately to all alleged violations.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure allegation of abuse was thoroughly investigated for 1 of 3 residents (Resident 1), reviewed for abuse investigations. This failure placed the resident at risk for repeated incidents, unidentified abuse, and a diminished quality of life.
- 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 ensure residents received skin care and treatments in accordance with professional standards of practice for 3 of 4 residents (Residents 1, 2 & 3), reviewed for skin conditions. This failure placed the residents at risk for not receiving the necessary skin care treatment, unmet care needs, and a diminished quality of life.
- 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, interview, and record review, the facility failed to ensure urinary catheters (a flexible tube inserted into the bladder, which drains urine into a collection/drainage bag outside the body) were positioned off the floor for 2 of 4 residents (Resident 1 & 2), reviewed for urinary catheter use. This failure placed the residents at risk for urinary tract/bladder infections and related complications.
April 3, 2024Complaint inspection · 2 citations
- F
Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
Inspectors wroteBased on interview and record review, the facility failed to designate a qualified staff person to serve as an Infection Preventionist (IP) to oversee the facility's infection prevention and control program. This failure placed the residents, staff, and visitors at risk for contracting COVID-19 (an infectious disease-causing respiratory illness) during a facility outbreak, unmet infection control issues, and lack of oversite of infection control practices.
- E
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure hand hygiene practices were followed for 1 of 3 staff (Staff E), failed to appropriately disinfect medical equipment for 1of 2 staff (Staff E), and failed to do proper use and disinfection/disposal of personal protective equipment (PPE-gown, gloves, face shield, N95 respirators [a device/mask designed to protect the wearer against particles and help prevent the spread of germs]) for 2 of 7 staff (Staff E & F), reviewed for infection control. In addition, the facility failed to ensure staff were fit tested (a test protocol conducted to verify that a respirator provides the wearer with the expected protection) for N95 masks for 13 of 18 staff (Staff E, F, D, G, J, K, L, M, N, O, H, I & P), reviewed for transmission based precautions (measures to prevent the spread of infection). [...]
March 13, 2024Complaint inspection · 1 citation
- D
Provide enough food/fluids to maintain a resident's health.
Inspectors wroteBased on interview and record review, the facility failed to provide adequate nutritional care and services including assessments and interventions to address significant weight loss for 1 of 3 residents (Resident 1), reviewed for nutrition/hydration. This failure placed the resident at risk for decline in nutritional status, nutrition related complications, and a diminished quality of life.
February 1, 2024Complaint inspection · 1 citation
- G
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on interview and record review, the facility failed to provide necessary care and services timely to treat and prevent further skin breakdown from a pressure ulcer/pressure injury (PU/PI - an injury to skin and underlying tissue resulting from prolonged pressure on the skin) and failed to initiate timely antibiotic medication to treat PU/PI wound infection for 1 of 2 residents (Resident 1), reviewed for PU/PI. Resident 1 experienced harm when they had a rapid deterioration of multiple PU/PIs that became infected and required hospitalization related to bacteremia (presence of bacteria in the blood), and placed other residents at risk for wound infection, delayed wound healing, and a diminished quality of life.
December 5, 2023Complaint inspection · 1 citation
- D
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure resident was free from physical abuse for 1 of 3 residents (Resident 1), reviewed for abuse investigations. This failure placed the resident at risk for serious harm and injury and a diminished quality of life.
May 4, 2023Standard inspection · 9 citations
- G
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on record review and interview, the facility failed to ensure professional standards of practice were followed for 2 of 9 residents (Resident 39 & 146) reviewed for removal of Coban dressing (self-adherent elastic wrap, used to secure dressings, compress, or protect wound sites), weekly skin assessment, and conducting neurological/neuro checks (an assessment to monitor level of consciousness, movement of the eye, facial symmetry, motor assessment of the arms/legs) after an unwitnessed fall. [...]
- 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 air dry drinking glasses before stacking and a fan was blowing over food being prepared on the tray line. These failures placed all the residents at risk for developing food borne illness (caused by ingestion of contaminated food and beverages).
- E
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Inspectors wroteBased on interview and record review, the facility failed to electronically transmit Minimum Data Set (MDS) data to the CMS [Center for Medicare and Medicaid] system within the required time frames for 4 of 24 residents (Residents 74, 15, 35 and 7) reviewed for timeliness in transmitting 5 day and/or discharge MDS assessments. This failure placed the residents at risk for unmet care needs and a diminished quality of life.
- 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 recognize and ensure that injuries of unknown source were reported to the state agency for 1 of 4 residents (Resident 146) reviewed for closed record review. This failure placed the resident at risk for abuse and neglect.
- D
Respond appropriately to all alleged violations.
Inspectors wroteBased on interview and record review, the facility failed to investigate multiple bruises of unknown origin to determine the cause, rule out abuse, and implement interventions to prevent reoccurrence of incidents reported for 1 of 4 residents (Resident 146) reviewed for closed record review. The failure to initiate and/or conduct a thorough investigation placed the resident at risk for delayed identification of potential injury/harm, abuse and neglect, and a diminished quality of life.
- D
PASARR screening for Mental disorders or Intellectual Disabilities
Inspectors wroteBased on record review, interview, and policy review, the facility failed to conduct a Level II Pre-admission Screening and Resident Review (PASARR) for 1 of 3 residents (Resident 29) reviewed for PASARR. This failure placed the resident at risk for not receiving timely specialized health services, unmet care needs, and a diminished quality of life.
- 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 observation, interview, record review, the facility failed to provide appropriate services for administering medications via gastrostomy tube (G-tube, tube inserted through the belly that brings nutrition directly to the stomach) for 1 of 2 residents (Residents 69) reviewed for administration of G-tube medications. This failure placed the resident at risk for drug interactions and complications.
- D
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure appropriate treatment and services were provided to 1 of 1 resident (Resident 5) reviewed for dementia care. This failure placed the resident at risk for unmet care needs and a diminished quality of life.
- D
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Inspectors wroteBased on interview and record review, the facility failed to complete an Abnormal Involuntary Movement Scale (AIMS - a test that rates involuntary muscle movements on residents who are administered antipsychotic [mind-altering] medications) assessment, upon admission for 1 of 5 residents (Residents 298) reviewed for unnecessary medications. This failure placed the resident at risk for unrecognized side effects and a diminished quality of life.
Fire safety inspections
31 fire safety citations on file: 12 on November 26, 2025, 8 on September 6, 2024, 11 on May 4, 2023.
Every fire safety citation31 citations
- F
Have exits that are accessible at all times.
K 271 · November 26, 2025 · Corrected (the home has a date of correction)
- F
Install emergency lighting that can last at least 1 1/2 hours.
K 291 · November 26, 2025 · Corrected (the home has a date of correction)
- F
Provide properly protected cooking facilities.
K 324 · November 26, 2025 · Corrected (the home has a date of correction)
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · November 26, 2025 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · November 26, 2025 · Corrected (the home has a date of correction)
- F
Have simulated fire drills held at unexpected times.
K 712 · November 26, 2025 · Corrected (the home has a date of correction)
- F
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
K 761 · November 26, 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 · November 26, 2025 · Corrected (the home has a date of correction)
- F
Ensure that testing and maintenance of electrical equipment is performed.
K 921 · November 26, 2025 · Corrected (the home has a date of correction)
- E
Have properly installed electrical wiring and gas equipment.
K 511 · November 26, 2025 · Corrected (the home has a date of correction)
- E
Ensure proper usage of power strips and extension cords.
K 920 · November 26, 2025 · Corrected (the home has a date of correction)
- D
Have properly located and lighted "Exit" signs.
K 293 · November 26, 2025 · Corrected (the home has a date of correction)
- F
Address patient/client population and determine types of services needed.
E 7 · September 6, 2024 · Corrected (the home has a date of correction)
- F
Address subsistence needs for staff and patients.
E 15 · September 6, 2024 · Corrected (the home has a date of correction)
- F
Conduct testing and exercise requirements.
E 39 · September 6, 2024 · Corrected (the home has a date of correction)
- E
Ensure that waiting areas, nurse’s stations, gift shops, and cooking facilities, open to the corridor are properly protected.
K 361 · September 6, 2024 · Corrected (the home has a date of correction)
- D
Keep aisles, corridors, and exits free of obstruction in case of emergency.
K 211 · September 6, 2024 · Corrected (the home has a date of correction)
- D
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 6, 2024 · Corrected (the home has a date of correction)
- D
Inspect, test, and maintain automatic sprinkler systems.
K 353 · September 6, 2024 · Corrected (the home has a date of correction)
- D
Have properly installed electrical wiring and gas equipment.
K 511 · September 6, 2024 · Corrected (the home has a date of correction)
- F
Provide properly protected cooking facilities.
K 324 · May 4, 2023 · Corrected (the home has a date of correction)
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · May 4, 2023 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · May 4, 2023 · Waiver
- F
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
K 914 · May 4, 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 · May 4, 2023 · Corrected (the home has a date of correction)
- F
Ensure that testing and maintenance of electrical equipment is performed.
K 921 · May 4, 2023 · Corrected (the home has a date of correction)
- F
Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk.
K 926 · May 4, 2023 · Corrected (the home has a date of correction)
- E
Have properly located and lighted "Exit" signs.
K 293 · May 4, 2023 · Corrected (the home has a date of correction)
- E
Properly select, install, inspect, or maintain portable fire extinguishes.
K 355 · May 4, 2023 · Corrected (the home has a date of correction)
- D
Install corridor and hallway doors that block smoke.
K 363 · May 4, 2023 · Corrected (the home has a date of correction)
- D
Ensure proper usage of power strips and extension cords.
K 920 · May 4, 2023 · Corrected (the home has a date of correction)