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 48 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
1G
0H
0I
Potential for more than minimal harm
32D
11E
1F
Potential for minimal harm
0A
3B
0C
May 19, 2026Complaint inspection · 1 citation
- B
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on interview, and medical record review, the facility failed to ensure complete and accurate medical records for two of four sampled residents (Residents 2 and 3). * Resident 2's neurological assessments were incomplete, and the resident's IDT Note was completed three days after the IDT meeting was conducted. * Resident 3's Physician Progress Note was dated as completed one week after the resident had been transferred to the acute care hospital and was no longer in the facility. These failures resulted in medical records that contained incomplete or inaccurate information, which could negatively affect continuity of care.
April 24, 2026Standard inspection · 20 citations
- E
Ensure that residents are fully informed and understand their health status, care and treatments.
Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure five of five final sampled residents reviewed for unnecessary medications (Residents 2, 4, 11, 75, and 95) and one final sampled resident (Resident 13) reviewed for informed consents were provided the right to self-determination regarding the use of psychotropic medications and treatments. * The facility failed to ensure the informed consents for the quetiapine (antipsychotic) and mirtazapine (antidepressant) medications included the indication of use and manifested behavior for Resident 2. * The facility failed to ensure the informed consent for the quetiapine medication included the indication for the use and manifested behavior for Resident 4. [...]
- E
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the respiratory care and services were provided in accordance with the professional standards for two of three final sampled residents (Residents 57 and 83) reviewed for respiratory care. * The facility failed to ensure Resident 57's nasal cannula was placed properly positioned and the oxygen concentrator was functioning properly. * The facility failed to ensure Resident 83's Yankauer suction tubing was labeled. These failures had the potential to result in the residents not receiving appropriate respiratory care and increased risks of the infection.
- E
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Inspectors wroteBased on interview and medical record review, the facility failed to ensure the residents were free from unnecessary medications for one of five sampled residents reviewed for unnecessary medications (Resident 11) and two of 19 final sampled residents (Residents 13 and 57). * The facility failed to ensure Resident 57's heart rate was monitored prior to administering the amlodipine (blood pressure medication) and lisinopril (blood pressure medication), as prescribed by the physician. * The facility failed to ensure Resident 13's heart rate was monitored prior to administering the diltiazem (blood pressure medication) and hydralazine (blood pressure medication), as prescribed by the physician. * The facility failed to ensure Resident 11's heart rate was monitored prior to administering the amlodipine (blood pressure medication), as prescribed by the physician. [...]
- 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, facility document review, and facility P&P review, the facility failed to maintain sanitary conditions in the kitchen and food storage areas. * Red tape marking the food-preparation area was placed too far inward, allowing staff and visitors access to milk without wearing required hair restraints. * One cup of milk was uncovered and contained a black particle floating on the surface. * A hair restraint was not worn to cover Maintenance Supervisor's chin beard while inside the kitchen. * A dusty portable fan was blowing air into the storage rack containing clean plate lids. * Two cutting boards in the food preparation area were heavily marred. * Brownish particles were observed inside the oven, located between two glass casings. * A 70% vegetable oil container stored inside the walk-in refrigerator was not labeled with an open date. [...]
- E
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to maintain the infection control program and practices. * The facility failed to ensure the staff members' personal items were not stored in the clean linen area. * The facility failed to conduct a facility-wide risk assessment to identify areas where Legionella and other opportunistic waterborne pathogens (e.g. Pseudomonas, Acinetobacter, Burkholderia, Stenotrophomonas, nontuberculous mycobacteria, and fungi) could grow and spread within the facility water system. * The facility failed to protect the residents' clean personal clothing from dust and contamination during transport and Laundry Aide 2 failed to performed hand hygiene when entering and leaving EBP rooms. [...]
- D
Reasonably accommodate the needs and preferences of each resident.
Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to provide a reasonable accommodations to meet the needs of one of 19 final sampled residents (Resident 108). * The facility failed to ensure Resident 108's call light was within the resident's reach. This failure had the potential to negatively impact the resident's psychosocial well-being and cause delays in receiving needed care.
- 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, medical record review, and facility P&P review, the facility failed to provide the written information and follow up assistance regarding the formulation of an advance directive for one of three final sampled residents (Resident 95) reviewed for advanced directives. * The facility failed to provide Resident 95 with written information on how to formulate an advanced directive. In addition, the facility failed to follow up and assist Resident 95 in completing an advanced directive. This failure had the potential for Resident 95 to receive care or emergency treatment that did not align with the resident's expressed wishes.
- D
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure two of five final sampled residents (Residents 2 and 11) were free from unnecessary psychotropic medication. * The facility failed to ensure accurate monitoring of meal intake related to the use of mirtazapine (antidepressant) for Residents 2 and 11. This failure had the potential to result in unnecessary medication use and ineffective monitoring for the use of psychotropic medications, which could negatively affect the well-being of Residents 2 and 11.
- D
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to provide a copy of the notification of the transfer/discharge to the Office of the State Long-Term Care Ombudsman for one of the three residents (Resident 105) reviewed for closed records. * The facility failed to ensure copy of the transfer discharge notification was sent to the Ombudsman when Resident 105 was transferred to the acute care hospital. This failure had the potential to result in the resident not receiving accurate information regarding transfer/discharge status and the right to appeal.
- D
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to develop a comprehensive person-centered care plan for one of 19 final sampled residents (Resident 5). * The facility failed to develop a care plan problem to address Resident 5's use of LAL mattress with bolster (a medical grade mattress designed to prevent and treat pressure injuries by reducing moisture and heat buildup, with raised foam edges to support positioning and prevent rolling out of bed). This failure posed the risk of not providing appropriate, consistent, and individualized care for Resident 5.
- 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 interview, medical record review, and facility P&P review, the facility failed to revise the comprehensive, person-centered care plan for three of 19 final sampled residents (Residents 5, 11, and 87). * The facility failed to revise Resident 5's care plan when the order for Foley Catheter (a thin, flexible, indwelling tube inserted through the urethra - a tube that transports urine from the bladder to the opening of penis in male and vulva in female, into the bladder to drain urine into a bag, held in place by a small balloon) was discontinued. This posed the risk of not providing the resident with individualized and person-centered care. * The facility failed to revise the plan of care for Residents 11 and 87 to address the adjustments to the APP mattress settings made for the residents' comfort. [...]
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary care and services for one of 19 final sampled residents (Resident 5). * The facility failed to identify and notify the physician and the resident's representative of Resident 5's eye redness with discharge. In addition, the facility failed to ensure the dark purplish discoloration on the resident's right dorsal (back side) hand and the light purplish discoloration on the left posterior lower arm were monitored and reported to the physician and responsible party. This failure had the potential for Resident 5 not to receive appropriate care and treatment.
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on observation, interview, medical record review, and facility document review, the facility failed to ensure the necessary care and services were provided to prevent the development of pressure injuries for one of three final sampled residents (Resident 9) reviewed for pressure injuries. * The facility failed to ensure Resident 9's LAL mattress was used correctly and was not covered by an additional foam mattress topper. This failure had the potential to contribute to the development of new pressure injuries or worsening of existing pressure injuries for Resident 9.
- D
Provide safe, appropriate pain management for a resident who requires such services.
Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure an appropriate pain management were provided for one of one final sampled resident (Resident 4) reviewed for pain management. * The facility failed to ensure the nonpharmacological interventions for pain management were provided before the administration of the pain medication for Resident 4. This failure had the potential to result in Resident 4 not receiving appropriate and comprehensive pain management.
- D
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the nursing staff demonstrated competency in providing care and identifying changes in condition for Residents 5 and 87. * The facility failed to ensure LVN 1 was competent in identifying eye redness with discharge in Resident 5 and notifying the physician and responsible party. * The facility failed to ensure LVN 2 was adequately trained and competent in the use of the APP machine for Resident 87. These failures had the potential to result in Residents 5 and 87 not receiving care and treatment in a safe and competent manner.
- D
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Inspectors wroteBased on observation, interview, and facility P&P review, the facility failed to provide the necessary pharmacy services were provided to maintain proper medication storage for one of three medication carts (Medication Cart A) inspected. * The facility failed to ensure the orally administered medications were stored separately from the externally used medications. This failure had the potential to have negative impact the residents' well-being, and the potential for the medications to be contaminated, lose stability, and effectiveness.
- D
Have a policy regarding use and storage of foods brought to residents by family and other visitors.
Inspectors wroteBased on observation, interview, and facility P&P review, the facility failed to ensure safe food handling of food brought for the residents from outside sources. * The facility failed to ensure two staff (CNA 3 and LVN 5) were knowledgeable regarding the facility's P&P for food brought in by families or visitors. In addition, the facility failed to follow its P&P requiring outside food be stored in a designated unit to ensure safety. These failures posed the risk of the residents not being able to enjoy foods brought from outside in a safe and accessible manner.
- 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 interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure coordination and consistency between the facility and hospice provider for one of one final sampled resident (Resident 13) reviewed on hospice services. * The facility failed to ensure the current frequencies of hospice staff visits as shown in the hospice plan of care were transcribed into Resident 13's physician's orders. In addition, the facility failed to ensure the hospice aide visit notes were maintained in the resident's medical record. These failures placed Resident 13 at risk for a breakdown in hospice care coordination and recordkeeping and could potentially result in delays in providing hospice care and services to Resident 13.
- D
Keep all essential equipment working safely.
Inspectors wroteBased on observation, interview, facility document review, and the facility P&P review, the facility failed to ensure the essential equipment was maintained in safe and operating condition for one of three glucometers (a device which measures the amount of sugar in the blood) inspected. * The facility failed to ensure the glucometer in Medication Cart A was calibrated and had quality control testing performed on 4/21/26. This failure had to result in inaccurate blood glucose readings for the residents of the facility requiring blood glucose monitoring.
- D
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Inspectors wroteBased on observation and interview, the facility failed to ensure for a safe and comfortable environment for the staff, vendors, and visitors as evidenced by: * The facility failed to ensure hot water temperatures at one kitchen handwash sink and the two compartment manual dishwashing sink were maintained at a safe and comfortable temperature level. This failure posed the risk of burn injuries to the staff, vendors, and visitors.
March 19, 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 medical record review, the facility failed to ensure one of two sampled residents (Resident 1) remain free from the accident hazards. * The facility failed to ensure Resident 1 was provided with two-person assistance for transfers. This failure had the potential to place the resident at risk for serious injuries.
February 7, 2025Standard inspection · 13 citations
- E
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure six of six final sampled residents (Residents 11, 28, 32, 37, 44, and 685) reviewed for respiratory care were provided with the appropriate respiratory care and services when: * The facility failed to ensure Residents 11, 32, 37, 44, and 685 were receiving the correct rate of oxygen as per the physician's order. * The facility failed to ensure Resident 28's nebulizer set-up was changed weekly as per the facility's P&P. These failures had the potential to affect the respiratory health and well-being of the residents in the facility.
- 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, facility document review, and facility P&P review, the facility failed to ensure the sanitary requirements were met in the kitchen. * The facility failed to ensure Dietary Aide 1 performed handwashing in between glove changes and performed proper hand hygiene and glove changes between dirty and clean areas during dishwashing. * The facility failed to ensure the rusty cooling steel racks were not stored with clean kitchen utensils. * The facility failed to ensure a spatula stored in a drawer had a smooth, easily cleanable surface. * The facility failed to ensure the plate lowerator and microwave were clean. * The facility failed to ensure kitchen employee belongings were not stored on a shelf used to store paper cups. * The facility failed to ensure the kitchen thermometers were calibrated properly. [...]
- E
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview, medical record review, and facility document review, the facility failed to maintain the infection control program and practices as evidenced by: * Room A did not have a receptacle to dispose of used or soiled gowns. * The infection surveillance logs failed to accurately document the infections in the facility. * Mapping for infections did not accurately reflect all the HAIs. * The facility failed to ensure Resident 44's nasal cannula was stored in a sanitary manner. * The facility failed to ensure the medication carts were kept clean. * The facility failed to ensure the facility staff followed the EBP for Resident 688 as per the physician's order. These failures posed the risk for transmission and development of disease-causing microorganisms.
- E
Implement a program that monitors antibiotic use.
Inspectors wroteBased on interview and medical record review, the facility failed to ensure the McGeer's Criteria for Infection Surveillance Checklist were completed for one of 20 final sampled residents (Resident 685) reviewed for antibiotic medication use. This failure posed the risk of the continued use of unnecessary antibiotics, potentially resulting in adverse reactions associated with antibiotics and the development of antibiotic resistant bacteria.
- D
Allow residents to self-administer drugs if determined clinically appropriate.
Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure one of 20 final sampled residents (Resident 389) was safe to self-administer the medications found at the bedside. * The facility failed to ensure the bottles of ibuprofen (NSAIDs), and Advil (NSAIDs), several tablets of alpha-chymotrypsin (a digestive enzyme supplement), a tube of arthritis relief pain ointment (NSAIDs), and a bottle of dry relief eye drops (used to relieve irritation and discomfort caused by dry eyes) were not at Resident 389's bedside table. Resident 389 stated she administered the medications herself, however, Resident 389 was not assessed for safe self-administration of medications per her admission assessment. [...]
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to provide the necessary care and services to attain or maintain the highest practicable well-being for two of three final sampled residents (Residents 7 and 685) reviewed for falls. * The facility failed to ensure Resident 685's post fall neurological assessment was accurately completed after the resident had an unwitnessed fall on 2/4/25. * The facility failed to ensure Resident 7's post fall neurological assessment was accurately completed after the resident had a fall on 1/23/25. These failures had the potential for a delay in providing care to these residents.
- 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 facility P&P review, the facility failed to ensure the necessary care and services were provided to prevent further falls and/or injuries for one two of three final sampled residents (Resident 7) reviewed for falls. * The facility failed to implement Resident 7's care plan interventions to address the resident's risk for falls, including the resident fall risk monitoring, star sticker to the resident's room, and colored arm band. This failure post the risk for the resident to sustain further falls and/or injuries.
- D
Provide enough food/fluids to maintain a resident's health.
Inspectors wroteBased on interview, medical record review, and the facility P&P review, the facility failed to maintain the acceptable parameters for fluid intake for one of one final sampled resident (Resident 9) reviewed for hydration status. * The facility failed to ensure Resident 9 was monitored when her fluid intake was above the parameter as documented by the CNAs. In addition, the facility failed to ensure the I&O Record documentation was accurate. This failure had the potential for Resident 9 to have fluid overload and negatively impact the resident's well-being.
- D
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to provide adequate monitoring for the signs and symptoms of bleeding to ensure two of four final sampled residents (Residents 39 and 84) reviewed for anticoagulant (prevents blood clots) medication use were free from unnecessary drugs. * Residents 39 and 44 were administered with apixaban (Eliquis, blood thinner medication) without monitoring for the signs and symptoms of bleeding. These failures had the potential for the residents to develop significant side effects of bleeding and negatively affect the residents' health condition and well-being.
- 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 medical record review, the facility failed to ensure one of five final sampled residents (Resident 9) reviewed for unnecessary medications was free from the unnecessary psychotropic medication. * The facility failed to ensure the monitoring of Resident 9's meal intake related to the use of mirtazapine (antidepressant medication) medication was accurate. In addition, the facility failed to ensure the monthly behavior summary related to the use of mirtazapine medication was completed. These failures had to potential to result in unnecessary use and ineffective monitoring for the use of psychotropic medication that could negatively affect Resident 9's well-being.
- D
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Inspectors wroteBased on observation, interview, and facility P&P review, the facility failed to ensure for the safe storage of the medications and supplies. * The facility failed to ensure Medication Cart F was not left unlocked and unattended. In addition, the facility failed to ensure the containers of the bleach wipes were not stored with a box of tuberculin syringe. * The facility failed to ensure the vitamin A&D ointment (barrier cream/ointment) was not kept at Resident 9's bedside. * The facility failed to ensure the eye and rectal medications were not stored together. These failures had the potential to result in the unsafe administration of medications, and cross-contamination of the medications.
- D
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, facility document review, and facility P&P review, the facility failed to ensure the menus were followed. * The pureed mixed vegetable was not the same as the regular mixed vegetable with tofu. * The pureed beef was not served with a ladle of sauce per the recipe. These failures had the potential for residents on pureed diet not receiving adequate nutrition, and negatively affect their well-being.
- D
Have a policy regarding use and storage of foods brought to residents by family and other visitors.
Inspectors wroteBased on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the facility staff assisted the residents regarding the use and storage of food brought in by the family member or visitors for the residents. * The facility failed to ensure the safe handling and storage of food from outside sources to be included in the facility's P&P. This failure had the potential to cause foodborne illnesses to the medically vulnerable resident population who consume food brought from outside sources.
August 27, 2024Complaint inspection · 1 citation
- G
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Inspectors wroteBased on interview, medical record review, facility document review, and facility P&P review, the facility failed to protect the resident's rights to be free from the physical abuse by the facility staff for one of three sampled residents (Resident 1). * Resident 1 was slapped on the face by CNA 1 and sustained a redness to the right cheek. This failure had violated the resident's rights to be free from the abuse and negatively affected the resident's psychological well-being.
January 24, 2024Complaint inspection · 2 citations
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on observations, interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure one of two sampled residents (Resident 1) was promptly assessed and notified to the physician and responsible party after a COC was identified as per the facility's P&P. This failure had the potential for the resident to not receive adequate care and risk for adverse complications.
- B
Reasonably accommodate the needs and preferences of each resident.
Inspectors wroteBased on observations, interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure the call light was within reach for one of two sampled residents (Resident 2). This failure had the potential for Resident 2 to not receive care and assistance when needed.
March 23, 2023Standard inspection · 10 citations
- F
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 facility P&P review, the facility failed to ensure the proper administration, storage, and disposal of the medications in a safe manner as evidenced by the following: * The facility failed to ensure the medications were not left unattended. * The facility failed to ensure the discontinued medications were properly stored and disposed. * The facility failed to ensure the expired lemon glycerin swab sticks and used sterile wound dressing supplies were disposed from the treatment cart. These failures had the potential to cause unsafe handling and storage of the residents' medications.
- 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, facility P&P review, and facility document review, the facility failed to ensure the puree recipes were followed during the puree food preparation for 18 of 96 residents who received puree diets. This failure posed the risk for the inconsistent puree product which could alter the quality and nutrient content of the puree food for the residents receiving puree diets.
- 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, facility's P&P review, and facility document review, the facility failed to ensure the food preparation, storage, and sanitary requirements were met in the kitchen. * The facility failed to ensure the cutting boards were in the sanitary conditions. * The facility failed to ensure the meat slicer was in the sanitary conditions. * The facility failed to ensure that cooked items were properly stored, labeled, and dated. * The facility failed to ensure the temperature of beverages were checked prior distributing to the residents. * The facility failed to ensure the dietary staff maintained proper handling of dirty to clean plates and utensils. * The facility failed to ensure the dietary staff maintained proper hand hygiene. [...]
- D
Ensure that residents are fully informed and understand their health status, care and treatments.
Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure one of 20 final sampled residents (Resident 5) was informed and provided education on mirtazapine (an antidepressant that affects a person's mental state) and quetiapine (an antipsychotic that affects a person's mental state) use prior to signing the informed consent. This failure had the potential to violate the resident's rights to be fully inform of the psychotropic medications use for Resident 5.
- D
Reasonably accommodate the needs and preferences of each resident.
Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to accommodate the individual needs and preferences for two of 20 final sampled residents (Residents 36 and 72) when the call lights button were placed out of the residents' reach. This failure could delay in providing the residents assistance to meet their needs.
- 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, medical record review, and facility P&P review, the facility failed to ensure one of 20 final sampled residents (Resident 5)'s care plan was developed to be comprehensive and person-centered to address Resident 5's psychotropic medication use. This failure had the potential to cause unnecessary use of mirtazapine and quetiapine for Resident 5.
- 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, medical record review, and facility P&P review, the facility failed to ensure one of six nonsampled residents (Resident 4) was provided accurate doses of prescribed vitamin C (supplement). This failure had the potential to cause harm to Resident 4.
- 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, medical record review, and facility P&P review, the facility failed to ensure one of 20 final sampled residents (Resident 5) was provided the comprehensive assessment and management for the use of psychotropic medications. * The facility failed to ensure the physician's assessment and diagnose of Resident 5 were completed and documented for the use of mirtazapine and quetiapine. * The facility failed to document the non-pharmacological interventions attempted prior to the administration of mirtazapine and quetiapine for Resident 5. These failures had the potential to cause harm to Resident 5.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview, and facility P&P review, the facility failed to ensure the hand hygiene practices were performed before patient contact and after glove use. This failure posed the risk of spreading infectious organism to residents in the facility.
- B
Ensure each resident receives an accurate assessment.
Inspectors wroteBased on interview and medical record review, the facility failed to ensure the MDS assessments were accurately completed for two of 20 final sampled residents (Residents 5 and 91). This posed the risk of the residents not receiving an individualized plan of care based on the residents' specific needs.
Fire safety inspections
9 fire safety citations on file: 2 on April 24, 2026, 5 on February 7, 2025, 2 on March 23, 2023.
Every fire safety citation9 citations
- D
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
K 223 · April 24, 2026 · Corrected (the home has a date of correction)
- D
Inspect, test, and maintain automatic sprinkler systems.
K 353 · April 24, 2026 · Corrected (the home has a date of correction)
- F
Have power receptacles that are properly grounded.
K 912 · February 7, 2025 · Corrected (the home has a date of correction)
- D
Have properly located and lighted "Exit" signs.
K 293 · February 7, 2025 · Corrected (the home has a date of correction)
- D
Provide properly protected cooking facilities.
K 324 · February 7, 2025 · Corrected (the home has a date of correction)
- D
Have properly installed electrical wiring and gas equipment.
K 511 · February 7, 2025 · Corrected (the home has a date of correction)
- C
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · February 7, 2025 · Corrected (the home has a date of correction)
- D
Inspect, test, and maintain automatic sprinkler systems.
K 353 · March 23, 2023 · Corrected (the home has a date of correction)
- D
Ensure that testing and maintenance of electrical equipment is performed.
K 921 · March 23, 2023 · Corrected (the home has a date of correction)