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 51 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
38D
11E
2F
Potential for minimal harm
0A
0B
0C
December 9, 2025Complaint inspection · 1 citation
- D
Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder.
Inspectors wroteBased on review of medical records, observation, interview, policy review and review of provided videos and pictures, the facility failed to ensure residents with trauma received the appropriate treatment and services to attain or maintain his or her highest practicable physical, mental, and psychosocial well-being. This affected one resident (#55) out of three residents reviewed for abuse. [...]
July 29, 2025Standard inspection, Complaint inspection · 26 citations
- F
Provide and implement an infection prevention and control program.
Inspectors wroteBased on review of resident medical record, observations, staff interview, CDC website review, and review of facility policies, the facility failed to serve food in a safe and sanitary manner. This had the potential to affect 116 out of 117 residents who ate food from the kitchen. The facility identified one resident (Resident #72) as not eating food from the kitchen. The facility also failed to thoroughly perform legionella surveillance. This had the potential to affect all 117 residents residing in the facility. The facility also failed to provide designated disposal bins for used personal protective equipment in a resident's room when the resident was under contact precautions. This affected one resident (#125) out of three residents (#48, #72 and #125) reviewed for transmission-based precautions. The facility census was 117.
- E
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
Inspectors wroteBased on medical record review, interviews and facility policy review, the facility failed to ensure an appropriate diagnosis for the use of antipsychotic medications and to identify target behaviors and monitor the target behaviors for the use of antipsychotic medications. This affected five residents (#12, #45, #71, #93 and #106) of five residents reviewed for unnecessary medications. The facility census was 117. Findings Include: 1. Review of the medical record for Resident #45 revealed an initial admission date of 02/23/25 with the diagnoses including but not limited to diabetes mellitus, chronic kidney disease, dependence on wheelchair, dementia, idiopathic peripheral autonomic neuropathy, atrial fibrillation, hypertension, restless leg syndrome, major depressive disorder, constipation, overactive bladder, insomnia and gastro-esophageal reflux disease. [...]
- E
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Inspectors wroteBased on staff interview, record review and facility policy review, the facility failed to ensure accurate coordination with the Pre-admission Screening and Resident Review (PASARR) process by submitting an incorrect list of mental health diagnoses. This affected four (Resident #6, #12, #79 and #90) out of five residents reviewed for PASARR. The facility census was 117.
- E
Notify the appropriate authorities when residents with MD or ID services has a significant change in condition.
Inspectors wroteBased on record review, facility policy review, and staff interview, the facility failed to ensure the state mental health authority was notified of updated and accurate mental health diagnoses. This affected four (Resident #6, #12, #79 and #90) out of five residents reviewed for Pre-admission Screening and Resident Review (PASRR). The facility census was 117.
- E
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure proper skin monitoring for Residents #79, #95, and #58; failed to remove medication patches as ordered for Resident #50; failed to ensure Geri sleeves and related care plans were implemented for Resident #58; and failed to monitor and implement dental care recommendations following the extraction of seven teeth for Resident #49. These failures affected five (Residents #79, #95, #58, #50, and #49) out of 26 residents reviewed for quality of care. The facility census was 117.
- E
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on interview, observation, and record reviews, the facility failed to ensure air mattress bed settings were appropriate and ordered for four (Residents #2, #8, #53 and #70) of four residents who were at risk for developing pressure ulcers. The facility census was 117.
- E
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on review of resident medical records, observations, staff interviews and review of company policies, the facility failed to provide supervision with dining for residents that were identified as choking risks. This affected two residents (Resident #4 and 18) out of thirty three residents that the facility identified as at risk for choking. The facility also failed to ensure that transfers were completed as required for Resident #116 and that the call light cord wiring was not exposed for Resident #79. These affected two residents (Resident #79 and #116) out of six residents that were reviewed for accidents. The facility census was 117 residents.
- E
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Inspectors wroteBased on observation, record review, interview and facility policy review, the facility failed to ensure pain management monitoring, evaluations and indication for usage for residents. This affected four (Resident #58, #9, #50 and #13) out of five residents reviewed for pain. The facility also failed to ensure Dexcom (continuous glucose monitoring system) was not expired, this affected one (Resident #114) out of one reviewed for insulin usage. The facility census was 117.
- E
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on observations, staff interview and review of facility policy, the facility failed to store food in a safe and sanitary method. This had the potential to affect 116 residents who ate food from the kitchen. The facility identified one resident (Resident #72) who did not eat food from the kitchen. The facility census was 117 residents.
- E
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, interview, and record review, the facility failed to maintain a clean, sanitary, and homelike environment in multiple resident areas. This affected one (Resident #50) out of six residents reviewed for environmental concerns. Additionally the facility failed to maintain the cleanliness of common areas this had the potential to affect 40 residents (#40, #14, #58, #2, #41, #93, #85, #24, #95, #13, #75, #114, #115, #99, #30, #80, #97, #10, #89, #49, #131, #6, #73, #69, #104, #86, #1, #51, #76, #71, #26, #9, #62, #34, #21, #60, #79, #50, #64, and #74) identified using the affected areas. The facility census was 117.
- D
Reasonably accommodate the needs and preferences of each resident.
Inspectors wroteBased on observation, interview, record review and facility policy review, the facility failed to ensure the call light was in reach for Resident #03. This affected one resident (#03) of four residents reviewed for call light accessibility. The facility census was 117.
- D
Keep residents' personal and medical records private and confidential.
Inspectors wroteBased on observation, interview, record review and facility policy review, the facility failed to ensure private medical record information for Resident #03 was not visible to facility visitors. This affected one resident (#03) of four residents reviewed for privacy concerns. The facility census was 117.
- D
Respond appropriately to all alleged violations.
Inspectors wroteBased on review of resident medical record, family interview, staff interviews, dentist interview, review of facility self-reported incident investigation, review of hospital notes, and review of facility policies, the facility failed to complete a thorough investigation of an injury of unknown origin. This affected one resident (Resident #48) that was reviewed for abuse. The facility census was 117 residents.
- D
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Inspectors wroteBased on medical record review, staff interview and review of facility policy, the facility failed to perform oral assessments on a resident. This affected one resident out (Resident #58) out of twenty nine residents reviewed. The facility census was 117 residents.
- D
Ensure each resident receives an accurate assessment.
Inspectors wroteBased on interview and record review the facility failed to ensure documented diagnoses were accurate for Resident #12. This affected one resident (#12) out of five residents reviewed. Facility census was 117.
- D
PASARR screening for Mental disorders or Intellectual Disabilities
Inspectors wroteBased on interview and record review, the facility failed to ensure accurate Preadmission screening and resident review (PASRR) Level I screenings for residents with qualifying mental health diagnoses. This affected one (Resident #90) out of five residents reviewed for PASRR screenings accuracy. The facility census was 117.
- 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, record review and policy review, the facility failed to ensure care plans reflected resident care needs. This affected three residents (#12, #45, and #114) out of four reviewed for care plans. The facility census was 117.1. Review of the medical record for Resident #12 revealed resident was originally admitted to the facility on [DATE] and was readmitted to the facility on [DATE] after a weeklong hospitalization. On 07/24/25 at 8:46 A.M., a review of the medical record via the electronic charting system Point Click Care (PCC) revealed Resident #12 had a primary ICD admitting diagnosis F28 which was listed as, other psychotic disorder not due to a substance or known physiological condition with a start date of 05/07/24 and entry date of 05/09/25. Additional diagnoses included spinal stenosis; [...]
- D
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Inspectors wroteBased on interviews, observations, record review and facility policy review, the facility failed to ensure shaving needs were completed for two residents (#79 and #120) who required assistance with needs for personal care. Four residents were reviewed for activities of daily living. The facility census was 117.
- D
Provide activities to meet all resident's needs.
Inspectors wroteBased on medical record review, interview and facility policy review, the facility failed to develop an individualized activity program to meet one resident (#45) needs. This affected one (Resident #45) of two residents reviewed for activities. The facility census was 117. Findings Include:Review of the medical record for Resident #45 revealed an initial admission date of 02/23/25 with the diagnoses including but not limited to diabetes mellitus, chronic kidney disease, dependence on wheelchair, dementia, idiopathic peripheral autonomic neuropathy, atrial fibrillation, hypertension, restless leg syndrome, major depressive disorder, constipation, overactive bladder, insomnia and gastro-esophageal reflux disease. [...]
- D
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Inspectors wroteBased on interview, observation, and record review, the facility failed to ensure treatment for a contracture and plan of care was in place for one Resident (#95) of one that was reviewed for position and mobility. The facility census was 117.
- D
Provide enough food/fluids to maintain a resident's health.
Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure nutritional supplements were provided as ordered by the physician for one (Resident #48) of four residents reviewed for nutritional support. The facility also failed to obtain weekly weights as ordered for two (Residents #9 and #13) of four residents reviewed for nutritional support. The facility census was 117.
- 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 resident record review, observations, staff interview, and review of facility policy, the facility failed to administer an enteral feeding per physician's orders. The facility also did not date the enteral formula container with the hang date and/or time. This affected one (Resident #72) out of two residents reviewed for tube feedings. The facility census was 117 residents.
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observation, record review and interview, the facility failed to ensure the nebulizer medication delivery system as stored in a manner to prevent contamination. This affected one (Resident #116) of one resident reviewed for respiratory care. The facility census was 117. Findings Include:Review of the medical record for Resident #116 revealed an initial admission date of 06/01/21 with the diagnoses including but not limited to polyosteoarthritis, zoster, atrial fibrillation, chronic kidney disease, anemia, congestive heart failure, asthma, dry eye syndrome, myopia, presbyopia, constipation, abdominal aortic aneurysm, seasonal allergic allergies, hyperlipidemia, aortic valve stenosis, overactive bladder, insomnia, presence of cardiac pacemaker, peripheral vascular disease, hypertension and obstructive sleep apnea. [...]
- D
Provide safe, appropriate pain management for a resident who requires such services.
Inspectors wroteBased on closed record review, interview and facility policy review, the facility failed to ensure long-acting narcotic pain medication was available for administration. This affected one resident (Resident #15) out of five residents reviewed for pain. The facility census was 117.
- D
Ensure medication error rates are not 5 percent or greater.
Inspectors wroteBased on observation, record review, interview and facility policy review, the facility failed to ensure a medication error rate was below 5%. This affected two (Resident #6 and #48) out of four residents observed during medication administration. 27 opportunities of medication administration were observed and 2 of the 27 medications were not administered in accordance with physician's orders, resulting in a medication error rate of 7.41%. The facility census was 117.
- D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on closed record review, interview and facility policy review, the facility failed to ensure the transfer was documented in the resident's medical record. This affected one resident (#49) of three residents reviewed. The facility census was 117. Findings Include:Review of the closed medical record for Resident #49 revealed an initial admission date of [DATE] with the diagnoses including but not limited to dementia with psychotic disturbances, dysphagia, cerebrovascular accident with left sided hemiplegia, gastro-esophageal reflux disease, hypertension, congestive heart failure, insomnia, major depressive disorder, presence of cardiac pacemaker, hyperlipidemia, anemia, constipation, chronic pain, atrial fibrillation and hypothyroidism. The resident expired on [DATE] at the facility. [...]
June 3, 2025Complaint 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 wroteTHE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on record review, interview and policy review, the faciliy failed to ensure residents were free from abuse. This affected one (Resident #8) of seven residents reviewed for abuse. The facility census was 116.
May 6, 2025Complaint inspection · 1 citation
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, staff interview, record review, document review, and policy review the facility failed to provide a safe and sanitary environment to help prevent the development and transmission of disease and infections when they failed to follow droplet precautions for Resident #90 and failed to properly clean a blood glucose monitoring machine for Resident #3. This had the potential to affect four (Resident #3, #76, #78, and #79) Residents who received blood glucose monitoring on the two East hallway The facility census was 106.
June 4, 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 record review, review of hospital reports, review of facility investigation, and interview, the facility failed to ensure a safe and proper wheelchair transport resulting in a fall. This affected one resident (#7) of three residents reviewed for falls. The facility census was 113.
March 28, 2024Complaint inspection · 1 citation
- D
Ensure medication error rates are not 5 percent or greater.
Inspectors wroteBased on observation, medical record review, policy review and interview, the facility failed to ensure a medication error rate of not 5 percent or greater. This affected four (Resident #67, #111, #113 and #131) of six residents observed for medication administration. Five errors were observed out of 35 opportunities resulting in a medication error rate of 14.2%. The census was 111.
September 28, 2023Standard 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 review of facility policy, the facility failed to ensure the satellite kitchens were maintained in a sanitary manner. This had the potential to affect 113 of 113 residents who consumed food from the kitchen.
- E
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Inspectors wroteBased on record review, observation and interviews the facility failed to ensure pharmacy recommendations were dated and appropriate rationale was provided regarding gradual dose reductions. This affected three residents (Resident #43, #74 and #85) of five residents reviewed for unnecessary medications. The facility census was 116.
- E
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 record review the facility failed to maintain complete and accurate medical records. This affected five residents (#23, #88, #71, #66, and #85) of 24 resident records reviewed. The facility census was 116.
- D
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Inspectors wroteBased on medical record review and staff interview, the facility failed to provide skilled nursing facility advanced beneficiary notices (SNFABN) with estimated costs upon discharge from Medicare Part A skilled services for two (#101 and #87) of three residents reviewed for beneficiary protection notification review. The facility census was 116.
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on observations, resident and staff interviews, medical record review, review of shower sheets, and facility policy review, the facility failed to ensure one resident's (Resident #85) hair was washed and one resident's (Resident #88) unwanted facial hair was removed. This affected two (Residents #85 and #88) of eight residents reviewed for activities of daily living (ADLs). The facility census was 116. Findings Include: 1. Review of the medical record for Resident #85 revealed an initial admission date on 03/22/21 and a readmission date on 04/09/21. Medical diagnoses included chronic obstructive pulmonary disease (COPD), Type II diabetes mellitus with polyneuropathy, stroke, essential hypertension (high blood pressure), colostomy status, fibromyalgia, other chronic pain, major depressive disorder, anxiety disorder, and drug induced subacute dyskinesia (abnormal movements). [...]
- D
Provide activities to meet all resident's needs.
Inspectors wroteBased on observation, interview, and record review the facility failed to have weekend activities and daily independent activities available. This affected two residents (#41 and #62) of two residents reviewed for activities. The facility census was 116.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on medical record review, staff interview, review of pharmacy delivery receipts, and facility policy review, the facility failed to ensure hospice notes were kept on-site and readily available to staff for one resident (Resident #89). The facility failed to administer as needed (PRN) blood pressure medication as ordered to one resident (Resident #67). The facility failed to timely treat tardive dyskinesia (involuntary, repetitive movements often caused by long-term use of some psychiatric medications) for one resident (Resident #85). This affected one (Resident #89) of two residents reviewed for hospice services and two (Residents #67 and #85) of five residents reviewed for medications. The facility census was 116. Findings Include: 1. Review of the medical record for Resident #89 revealed an original admission date on 06/17/22 and a readmission date on 07/13/23. [...]
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure pressure reducing interventions were in place for Resident #41. This affected one resident (#41) of two residents reviewed for pressure ulcers. The facility census was 116.
- D
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Inspectors wroteBased on record review, observation, interview and policy review the facility failed to complete assessments for continuation of an appropriate restorative program. This affected two residents (Resident #43 and Resident #74) of two residents reviewed for Restorative Therapy. The facility census was 116.
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on record review, staff interviews, and facility policy review, the facility failed to conduct a thorough investigation following a choking episode for one resident (Resident #89). This affected one (Resident #89) of three residents reviewed for accidents. The facility census was 116. Findings Include: Review of the medical record for Resident #89 revealed an original admission date on 06/17/22 and a readmission date on 07/13/23. Diagnoses included Parkinson's Disease, dementia, pneumonia (07/14/23), esophageal obstruction (07/14/23), type II diabetes mellitus without complications, heart disease, and encounter for palliative care. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #89 has impaired cognition and scored six out of 15 on the Brief Interview for Mental Status (BIMS) assessment. [...]
- 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 record review, observation, and interview, the facility failed to ensure physician orders were in place for an indwelling urinary catheter. This affected one resident (Resident #361) of one residents reviewed for indwelling urinary catheter. The facility census was 116.
- D
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Inspectors wroteBased on medical record review, staff interview, review of medication administration records, and facility policy review, the facility failed to attempt a variety of non-pharmacological interventions and did not include parameters for administering as needed (PRN) pain medications to one resident (Resident #85). The facility also failed to ensure appropriate monitoring for antipsychotic medication side effects was completed. This affected two residents (Resident #5 and #85) of five residents reviewed for unnecessary medications. The facility census was 116. Findings Include: 1. Review of the medical record for Resident #85 revealed an initial admission date on 03/22/21 and a readmission date on 04/09/21. [...]
- D
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Inspectors wroteBased on resident interview, observation, and staff interview the facility failed to ensure one resident (#71) with a documented lactose intolerance received food free from dairy products containing lactose. This affected one resident (#71) out of one resident reviewed for food allergies or food intolerances. The facility census was 116.
- D
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Inspectors wroteBased on record review and interview the facility failed to maintain accurate resident influenza and pneumonia immunization records. This affected two residents (Resident #88 and Resident #361) out of five residents reviewed for accurate immunization documentation. The census was 116. 1. Review of Resident #88 medical record revealed Resident #88 was admitted to the facility on [DATE] with the admitting diagnosis including dementia, type two diabetes mellitus, depression, anxiety, dysphagia, and weakness. Further review revealed Resident #88 had impaired cognition and impaired hearing. Review of Resident #88 immunization record revealed there was no current influenza vaccine received date or a signed refusal consent by Resident #88 or Power of Attorney (POA) for Resident #88. 2. [...]
June 7, 2021Standard inspection · 6 citations
- D
Reasonably accommodate the needs and preferences of each resident.
Inspectors wroteBased on medical record review and staff interview, the facility failed to provide all necessary and reasonable accommodations for a resident with mobility impairments. This affected one (Resident #63) of two residents reviewed for mobility. Findings Include: Record review revealed Resident #63 was admitted to the facility on [DATE]. Her diagnoses were unspecified fracture of left humerus, moderate protein calorie malnutrition, peripheral vascular disease, venous insufficiency, chronic kidney disease, unspecified dementia, tremor, anxiety disorder, anemia, osteoarthritis, hypertension, hypothyroidism, hypokalemia, and glaucoma. Her Brief Interview for Mental Status (BIMS) score was not calculated due to her inability to answer the questions, which indicated she had a severe cognitive impairment. The assessment was completed on 04/21/21. [...]
- D
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Inspectors wroteBased on record review and staff interview, the facility failed to update and submit new Preadmission Screening and Resident Review (PASRR) screenings when one resident (Resident #82) was diagnosed with additional mental health diagnoses. Additionally, the facility failed to ensure an accurate PASRR screening was completed for one resident (Resident #43). This affected two residents (Residents #43 and #82) out of four residents reviewed for PASRR screenings.
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on medical record review and staff interview, the facility failed to thoroughly investigate a resident fall. This affected one (Resident #63) of two residents reviewed for falls. The census was 100. Findings Include: Medical record review revealed Resident #63 was admitted to the facility on [DATE]. Her diagnoses were unspecified fracture of left humerus, moderate protein calorie malnutrition, peripheral vascular disease, venous insufficiency, chronic kidney disease, unspecified dementia, tremor, anxiety disorder, anemia, osteoarthritis, hypertension, hypothyroidism, hypokalemia, and glaucoma. Her Brief Interview for Mental Status (BIMS) score was not calculated due to her inability to answer the questions, which indicated she had a severe cognitive impairment. The assessment was completed on 04/21/21. [...]
- D
Ensure that residents are free from significant medication errors.
Inspectors wroteBased on medical record review, staff interview, and facility policy and procedure review, the facility failed to ensure medications were administered without significant medication errors when one resident (Resident #20) was administered an improper dosage of Coumadin (a blood thinning medication) which resulted in a critically high international normalized ratio (INR). This affected one resident (Resident #20) out of five residents reviewed for unnecessary medications. Findings Include: [...]
- 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, policy review, and staff interview the facility failed to ensure insulin was discarded appropriately after being opened. This affected three residents (Residents #1, #6 and #79) and had the potential to affect fifteen residents (#1, #6, #13, #15, #20, #35, #42, #50, #52, #55, #59, #60, #79, #294, #347) who receive insulin in the facility. The facility census is 100.
- 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 review of resident diets, review of dietary spreadsheets, observation, staff interview, and facility policy review, the facility failed to follow the dietary spreadsheet when plain chicken with brown gravy instead of barbeque chicken was served to residents who were prescribed a pureed or mechanical soft diet. This had the potential to affect 26 residents (Residents #2, #3, #4, #9, #10, #12, #13, #16, #26, #27, #31, #33, #34, #35, #43, #47, #50, #51, #54, #57, #62, #65, #75, #83, #86, #92) who received a pureed diet, a mechanical soft diet, or ground/pureed meats. The facility census was 100. Findings Include: Review of the Diet Order Tally Report-All Special Diets, dated 06/01/21, revealed there were 13 residents on a mechanical soft diet (Residents #2, #3, #9, #13, #16, #26, #33, #34, #43, #47, #50, #57, and #62). [...]
Fire safety inspections
19 fire safety citations on file: 11 on July 29, 2025, 6 on September 28, 2023, 2 on June 7, 2021.
Every fire safety citation19 citations
- F
Have properly located and lighted "Exit" signs.
K 293 · July 29, 2025 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · July 29, 2025 · Corrected (the home has a date of correction)
- F
Install corridor and hallway doors that block smoke.
K 363 · July 29, 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 · July 29, 2025 · Corrected (the home has a date of correction)
- E
Have exits that are accessible at all times.
K 271 · July 29, 2025 · Corrected (the home has a date of correction)
- E
Provide properly protected cooking facilities.
K 324 · July 29, 2025 · Corrected (the home has a date of correction)
- E
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · July 29, 2025 · Corrected (the home has a date of correction)
- E
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
K 761 · July 29, 2025 · Corrected (the home has a date of correction)
- E
Have restrictions on the use of portable space heaters.
K 781 · July 29, 2025 · Corrected (the home has a date of correction)
- E
Ensure proper usage of power strips and extension cords.
K 920 · July 29, 2025 · Corrected (the home has a date of correction)
- C
Conduct testing and exercise requirements.
E 39 · July 29, 2025 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · September 28, 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 28, 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 28, 2023 · Corrected (the home has a date of correction)
- E
Provide properly protected cooking facilities.
K 324 · September 28, 2023 · Corrected (the home has a date of correction)
- E
Install smoke barrier doors that can resist smoke for at least 20 minutes.
K 374 · September 28, 2023 · Corrected (the home has a date of correction)
- E
Have proper medical gas storage and administration areas.
K 923 · September 28, 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 · June 7, 2021 · Corrected (the home has a date of correction)
- E
Inspect, test, and maintain automatic sprinkler systems.
K 353 · June 7, 2021 · Corrected (the home has a date of correction)