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 46 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
4G
0H
0I
Potential for more than minimal harm
24D
16E
2F
Potential for minimal harm
0A
0B
0C
July 29, 2026Complaint inspection · 2 citations
- E
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Inspectors wroteBased on observation, interview, and record review the facility failed to provide a comfortable, home like environment when the facility's cooling system was not able to maintain comfortable temperatures for the residents, causing two residents with lung disorders to have increased difficulty breathing; and two residents to be uncomfortable in their rooms. This deficient practice affected four (Resident #3, #4, #5, and #6) of four sampled residents. The facility census was 172. Review of the facility policy titled, Extreme Weather, dated 10/24/22, showed:-The purpose of the policy was to provide residents, visitors, and staff with comfortable and safe environment during extreme weather; -The facility responds to extreme weather in a prompt manner to protect the health and safety of residents; [...]
- 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 to the State Survey agency when one resident (Resident #1) was found with skin tears to his/her mouth, right arm and right ring finger of unknown origin. This affected one of seven sampled residents. The facility census is 172. Review of the facility's Abuse Prevention and Prohibition Program policy, dated 10/24/22, showed:-Unexplained injuries are promptly and thoroughly investigated by the Director of Nursing Services and/or other staff person designated by the Administrator, to ensure resident safety is not compromised and action is taken whenever, to avoid future occurrences. -Facility staff are mandatory reporters. [...]
January 26, 2026Complaint inspection · 2 citations
- E
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Inspectors wroteBased on observation, interview, and record review the facility failed to provide a safe and comfortable home like environment when the facility's heating system was not able to maintain comfortable temperatures for the residents. This deficient practice affected four (Resident #2, #3, #4, and #5) of five sampled residents. The facility census was 158. Review of the facility policy titled, Extreme Weather, dated 08/25/23, showed:-The purpose of the policy was to provide residents, visitors, and staff with comfortable and safe environment during extreme weather; -The facility responds to extreme weather in a prompt manner to protect the health and safety of residents; [...]
- D
Ensure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge.
Inspectors wroteBased on interview and record review, the facility failed to provide a discharge notice to the resident and his/her Durable Power of Attorney (DPOA) and follow appropriate discharge procedures and complete discharge documentation, for one resident (Resident #1) of five sampled residents. The census was 158. Review of the facility policy titled, Transfer and Discharge, dated 10/24/2022, showed:-The purpose of the policy is to ensure that residents are transferred and discharged from the Facility in compliance with state and federal laws and to provide complete, safe and appropriate discharge planning and necessary information to the continuing care provider; -The facility may transfer or discharge a resident for the following reasons: The discharge is necessary for the resident's welfare and resident's needs cannot be met in the facility; [...]
January 6, 2026Complaint inspection · 1 citation
- F
Ensure services provided by the nursing facility meet professional standards of quality.
Inspectors wroteBased on interview and record review the facility failed to ensure that licensed staff's responsibilities were completed according to acceptable standards of professional clinical practice when two licensed nurses RN-A, LPN-A and the Social Worker (SSD) failed to document a change or update of one resident's condition in the clinical medical record (the clinical medical record is accessible to all facility nursing staff and providers) that would have allowed other clinical staff to know what changes or updates had been done for one Resident (Resident #1), when Resident #1 had a critical potassium lab level and refused to be taken to the hospital for potassium to be replaced, and then unexpectedly died three days later. [...]
December 31, 2025Complaint 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 follow their policy and ensure an alleged allegation of sexual abuse of Resident #1 was reported to law enforcement and the state survey agency within two hours. The facility census was 161. Review of the facility policy titled, Abuse Prevention and Prohibition Program, dated 10/24/2022, showed:-The purpose of this policy is to ensure the Facility establishes, operationalizes, and maintains an Abuse Prevention and Prohibition Program designed to screen and train employees, protect residents, and to ensure a standardized methodology for the prevention, identification, investigation, and reporting of abuse, neglect, mistreatment, misappropriation of property, and crime in accordance with federal and state requirements; [...]
- D
Respond appropriately to all alleged violations.
Inspectors wroteBased on interview and record review, the facility failed to follow their policy and ensure an alleged allegation of sexual abuse of Resident #1 was investigated. The facility census was 161. Review of the facility policy titled, Abuse Prevention and Prohibition Program, dated 10/24/2022, showed:-Each resident has the right to be free from abuse; -The Facility has zero-tolerance for abuse, staff must not permit anyone to engage in sexual abuse;-The Facility is committed to protecting residents from abuse by anyone, including other residents, -The Administrator is responsible for coordinating and implementing the Facility's abuse prevention policies, procedures, training programs, and systems. -Investigation: [...]
November 21, 2025Complaint inspection · 3 citations
- E
Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
Inspectors wroteBased on observation, interview, and record review, the facility failed to treat residents with dignity and respect when staff allowed Resident #7 to scream and yell in the halls and dining room of the facility. This affected two sampled residents (Resident #2 and Resident #5). The facility census was 158. Review of the facility's policy titled, Resident Rights, dated 5/1/23, showed:-All residents have a right to a dignified existence, self-determination;-The facility must treat each resident with respect and dignity;-The facility will protect the rights of the resident. Review of the facility's policy titled, Privacy and Dignity, dated 10/24/22, showed the facility will promote resident care in a manner that maintains or enhances dignity and respect, in full recognition of each resident's individuality.1. [...]
- E
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 provide basic Activities of Daily Living (ADLs: tasks completed in a day to care for oneself) to ensure residents were clean, dry, and free of odor. The facility failed to provide incontinence care in a timely manner for four sampled residents (Resident #10, #1, #4, and #3); failed to ensure four residents were free of offensive body odor (Resident #10, #1, #4, #3) out of 28 sampled residents. The facility census was 158. Review of the facility provided policy titled, Perineal Care, dated October 24, 2022 showed: -Purpose is to maintain cleanliness, reduce odor and prevent skin breakdown;-Perineal care is provided as part of a resident's hygienic program, a minimum of once daily and per resident need; [...]
- 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 one resident with potential for skin breakdown was free of preventable pressure ulcers when Resident #10 was not provided timely incontinent care and had open area to his/her buttocks. The facility census was 158. Review of the facility provided policy titled, Perineal Care, dated 10/24/2022 showed the purpose was to maintain cleanliness and prevent skin breakdown. Review of the facility provided policy titled, Care and Services, dated 10/24/2022 showed the facility will have sufficient staff to provide services to residents, to provide nursing and related services to assure resident's attain or maintain highest practicable physical well being. [...]
September 26, 2025Complaint inspection · 2 citations
- G
Ensure services provided by the nursing facility meet professional standards of quality.
Inspectors wroteBased on observation, interview and record review the facility failed to ensure appropriate wound dressing orders were obtained and in place for one resident (Resident #2), when a negative pressure wound dressing (Wound Vac) was left in place from September 9, 2025 until September 19, 2025, causing the wound to open and bleed excessively when the dressing was removed. This effected one of four sampled residents. Facility census was 152. Review of the facility provided policy titled, Wound Management, dated October 24, 2022 showed:-Purpose is to provide a system for treatment and management of residents with wounds including pressure and non-pressure ulcers; -A resident who has a wound will receive necessary treatment and services to promote healing, prevent infection and prevent new pressure ulcers from developing; [...]
- G
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 protect Resident #1's safety when he/she eloped from the facility and was later found in the facility parking lot with a laceration to the forehead. The facility census was 152. On November 17, 2025 , the Administrator was notified of the past noncompliance incident which occurred on September 7, 2025. [...]
June 19, 2025Standard inspection · 4 citations
- E
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 dependent residents who were unable to carry out activities of daily living (ADLs) received the necessary services to maintain good personal hygiene when staff failed to ensure they provided perineal to meet the needs of three residents (Resident #72, #56, and #103), out of the sampled 32 Residents. The facility census was 162. Review of the facility's Care and Services Policy, revised 10/24/22, showed: -Care and services are provided a in manner that consistently enhances self esteem and self worth. Review of the facility's Perineal Care Policy, revised 10/24/22, showed: -Perineal care is provided to maintain cleanliness of the resident and to reduce odor, prevent infection and reduce skin breakdown; -Perineal care is provided as part of a resident's care; [...]
- E
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observation, interview and record review, the facility failed provide proper respiratory care when staff failed to document the date when oxygen tubing was cleaned and failed to properly store oxygen accesories at the bedside for three residents (Residents #119, #126, and #253) resulting in possible exposure to bacteria during oxygen usage. This affected three of 32 sampled residents. The facility census was 162. Review of the facility's Oxygen administration policy not provided; 1. Review of Resident #253's Care Plan, dated 6/9/25, showed: - Resident has COPD (lung disease) with risk of shortness of breath. Maintain resident's O2 levels with a flow rate of two liters per minute via a nasal cannula as needed to maintain oxygen saturation levels above 90%; - Check O2 saturation every shift and as needed; [...]
- 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 store, prepare and serve food in accordance with professional standards of food safety when staff failed to dispose of expired food items, failed to properly label and seal opened food items, failed to wear hairnets and failed to maintain cleanliness in the refrigerators, freezer, and storerooms. This affected all residents by putting them at risk for food borne illness. The facility census was 162. Review of facility policy, Cleaning Schedule Dietary Services, revised 10/24/22, showed: - The dietary staff will maintain a sanitary environment in the dietary department by complying with the routine cleaning schedule developed by the Dietary Manager; - The cleaning schedule includes tasks assigned to specific positions within the dietary department; [...]
- D
Provide care or services that was trauma informed and/or culturally competent.
Inspectors wroteBased on interview, and record review, the facility failed to, provide supportive services, or develop a care plan that directed interventions for facility staff to utilize to protect the resident and prevent trauma from recurring for one resident who was identified as having a past traumatic life event (Resident #26), out of 32 sampled residents. The facility census was 162. Review of the facility's Care and Services Policy, revised 10/24/22, showed: -Care and services are provided a in manner that consistently enhances self esteem and self worth; -Behavior health encompasses and residence whole emotional and mental well-being which includes the identification of needed care and services; -A resident who is diagnosed with mental disorder or psychosocial adjustment difficulty will receive appropriate treatment in accordance with assessed behavioral needs. [...]
May 2, 2025Complaint inspection · 1 citation
- D
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Inspectors wroteBased on interviews and record review, the facility failed to provide an appropriate discharge when staff failed to provide written notice of discharge that included the date and location the resident would be discharge to, statement of appeal rights and the name, address, or telephone number of the Office of the State Long Term Care Ombudsman (advocates for the residents in nursing facilities) to one sampled resident (Reisdent #1). The facility's census was 161. Review of facility policy regarding Transfer and Discharge, revised 10/24/22, showed: - The facility may not transfer or discharge a resident while the appeal to the notice of transfer/discharge is pending, unless it is documented that failure to transfer or discharge the resident would endanger the health or safety of the resident or other individuals; [...]
March 26, 2025Complaint 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 interviews and record review, the facility failed to protect the resident's right to be free from physical abuse when Resident #1 hit and restrained Resident #2 resulting in a scratch to Resident #2's left cheek, redness to his/her right eye, abrasion to right eyebrow, and redness and bruises to the right forearm and bicep. The facility census was 153. Review of the facility's Abuse Prevention and Prohibition Program, revised 10/24/22, showed: - Each resident has the right to be free from abuse. The facility has zero-tolerance for abuse. Staff must not permit anyone to engage in verbal, mental, sexual, or physical abuse of residents; - The facility maintains adequate staffing on all shifts to ensure that the needs of each resident are met; [...]
April 11, 2024Standard inspection, Complaint inspection · 13 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 facility policy review, the facility failed to ensure air vents were clean, stored food was dated after opening and sealed from contamination, and staff wore hair restraints while in the kitchen. This had the potential to affect 98 of 99 residents who resided in the facility and consumed food prepared from the facility's kitchen.
- D
Ensure that residents are fully informed and understand their health status, care and treatments.
Inspectors wroteBased on interview and record review, the facility failed to ensure one resident and/or representative of five residents (Resident (R) 78) reviewed for unnecessary medications, out of a total sample of 25 residents, was informed of the risk and benefits of a physician ordered antipsychotic medication. This failure placed the resident and/or representative at risk of not knowing the risks and benefits of the use of medications.
- D
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a clean and comfortable environment for one of 25 sample residents (Resident (R) 67).
- D
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Inspectors wroteBased on record review, interview, and policy review, the facility failed to protect the resident's right to be free from physical abuse by a resident for one resident of four residents (Resident (R) 51) reviewed for abuse out of a sample of 25 residents. R96 bit R51's arm after R51 reached for a blanket R96 was using.
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on record review, interview, and policy review, the facility failed to report an injury of unknown origin to the State Survey Agency (SSA) and failed to report a resident-to-resident altercation to the Abuse Coordinator and the SSA within two hours for two residents out of four residents (Resident (R) 96 and R51) reviewed for abuse out of a sample of 25.
- D
Respond appropriately to all alleged violations.
Inspectors wroteBased on record review, interview, and policy review, the facility failed to conduct a thorough investigation for an injury of unknown origin and a resident-to-resident altercation for two residents of four residents (Resident (R) 96 and R51) reviewed for abuse out 25 sampled residents. Failure to thoroughly investigate injuries of unknown origin and resident-to-resident altercations could place vulnerable residents at risk.
- 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 record review, interview, and facility policy, the facility failed to revise the care plan of two of 25 sampled residents (Resident (R) 66 and R55). R66 did not have a revision to the care plan for a diagnosis of Post Traumatic Stress Disorder (PTSD). R55's care plan was not updated to include the use of her specialized wheelchair. This failure created an increased risk for the residents to receive care and services not appropriate for their current clinical condition.
- 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 two residents of 25 sampled residents (Resident (R) 55 and R67) received care and treatment in accordance with professional standards of practice. The facility failed to ensure a wheelchair headrest was placed to support R55's head and that the foot pedal was applied to support her left leg. In addition, the facility failed to obtain a dermatology appointment for R67 in a timely manner, due to a skin condition that caused excessive itching.
- 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 observation, interview, record review, review of the facility policy, the facility failed to ensure one of four residents (Resident (R) 34) reviewed for range of motion (ROM) limitation out of 25 sample residents received appropriate services to increase her ROM and/or prevent a decrease in her ROM. This failure placed the resident at risk for increased contractures and a diminished quality of life.
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of two residents (Resident (R) 44) reviewed for respiratory care out of 25 sampled residents received care consistent with professional standards of practice. The facility failed to ensure R44's nebulizer tubing and pipe were placed into a covered bag to minimize spread of pathogens. This failure placed R44 at risk for infection.
- 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, record review, and review of facility policy, the facility failed to complete an Abnormal Involuntary Movement Scale (AIMS-a test that rates involuntary muscle movements on residents who are administered antipsychotic medications) assessment for one resident (Resident (R) 78) and failed to have a stop date and diagnosis for use of an as needed (PRN) psychotropic medication for one resident (R59) out of five residents reviewed for unnecessary medications in a total sample of 25 residents. This failure placed residents at risk for unrecognized side effects and a diminished quality of life.
- 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, record review, and review of facility policy, the facility failed to ensure an insulin pen was removed from one medication cart after 28 days for one of 18 Kwik pens (Resident (R) 46) that were observed for open date and expiration date on three of three nurse medications. This failure to ensure insulin pens were removed from the medication cart timely, placed the resident at risk for receiving ineffective medication and health complications.
- D
Keep all essential equipment working safely.
Inspectors wroteBased on observation and staff interview, the facility failed to ensure the reach-in refrigerator was properly maintained. This had the potential to affect 98 of the 99 residents who consume food from the kitchen.
February 13, 2024Complaint inspection · 1 citation
- G
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on observation, interview and record review, the facility failed to provide supervision and protective oversight for one sampled resident (Resident #1) when he/she was found with an acute oblique (break is at an angle) fracture to the right femur. The facility census was 105. Review of the facility's Positioning Policy/Procedure, dated March 2021, showed: -Any resident is an appropriate candidate for the Positioning Program if he/she: -Is unable to turn and get into position independently -Needs assistance in turning or positioning due to any mental or physical limitation. -Before determining which Positioning Program best meets the resident's needs, caregivers should assess: -Resident ability to assist with positioning and turning. -The need for learning specific positioning techniques. -Risk factors such as: contractures, fracture, confusion. 1. [...]
September 29, 2022Standard inspection · 14 citations
- E
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteBased on observation and interview, the facility staff failed to sit next to residents while assisting them to eat, rather than standing over them for two sampled residents (Resident #68 and #52), honor resident preferred choices in meal preferences for one sampled resident (Resident #19), and failed to provide meals to all residents at a table at the same time for three residents (Resident #58. #68 and #72); failed to provide oral care for one resident (Resident #30) and failed to provide one resident a table to sit at during meals (Resident #52) . The facility failed to ensure one of 22 sampled residents. The facility census was 110. Review of the facility's policy for resident choices and preferences, revised 1/21, showed, in part: - The residents have the right to make choices about aspects of their lives that are significant to them; [...]
- E
Reasonably accommodate the needs and preferences of each resident.
Inspectors wroteBased on observations, interviews, and record review the facility failed to provide reasonable accommodation of needs when they did not provide ease of access for three residents (Resident's #42, Resident #5 and Resident #96) out of the 22 sampled residents, to enter in and exit out of the facility's courtyard area independently. The facility census was 110. Review of the facility's Resident's Rights policy revised January 2021 showed: - It is the facility's responsibility to accommodate individual needs, and preferences of and abide by the resident's right of choice and self -determination will be balanced against protecting the resident. The responsibility to respect a residents choice is balanced by considering the potential impact of these choices on other individuals and on the the facility's obligation to protect the residents from harm. [...]
- E
Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home.
Inspectors wroteBased on record review and interview, the facility failed to ensure they kept resident's money separated from the facility's operating account. This effected six additionally sampled residents. The facility census was 110. Review of the facility policy titled Guidelines for Maintaining the Resident Trust Fund Account, dated 12/18/18, included the following: - This facility will establish and maintain a system that assures full, complete and separate accountings of each resident ' s personal funds entrusted to the facility on the resident ' s behalf. A separate statement will be maintained for each resident that will show every disbursement and every deposit made on the resident's behalf; [...]
- E
Ensure services provided by the nursing facility meet professional standards of quality.
Inspectors wroteBased on record review and interviews, the facility failed to follow acceptable standards of practice for two sampled residents (Resident #51 and #37), when the staff failed to administer medications per the physician's order; and failed to obtain an order for bed cane rails for four residents (Resident #30, #69, #103 and #79) out of 22 sampled residents. The facility census was 110. Review of the facility's medication administration policy, updated on 1/2021 showed: -It is the policy of the facility to retain, store, administer, and document compliance with Federal and State regulations and in accordance with current standards of practice and guidelines for medication management. -Physician's medication orders must be reviewed and renewed. -Orders must be signed and dated when ordered and maintained in chronological order. [...]
- E
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure the safety of residents that use U-rails (rails installed at the head of the bed on one or both sides of the bed that is in the shape of an upside-down U), failed to do an entrapment assessment when the rails where initiated, failed to review the risks and benefits of the rails and obtain consent for the use of the rails, for four of 22 sampled residents, (Resident #30, #69, #79, and #103). The facility census was 110. The facility did not provide a policy for cane bed rails. 1. Review of Resident #30's significant change in status Minimum Data Set, (MDS) a federally mandated assessment instrument completed by facility staff, dated 7/8/22 showed: - Cognitive skills severely impaired; - Physical behavior directed at others occurred one to three days; - Rejected care occurred one to three days; [...]
- E
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Inspectors wroteBased on observations, interviews, and record review, the facility failed to assure staff served food that is of a safe and acceptable temperature to the residents. The facility census was 110. Review of the facility's Food Temperatures policy, dated May 2015, showed: -The Dietary Services Manager or designee is responsible for seeing that all food is the proper serving temperature(s) before trays are assembled. -Hot food should be at least 120 degrees Fahrenheit when served to the resident. Observation of the lunch meal preparations on 9/28/2022 showed: -11:19 A.M.: Dietary Staff B began preparing the plates for the residents on Unit 1. Plates were placed into the portable heated transport rack uncovered. -11:31 A.M.: The test tray is completed and placed into the portable heated transport rack. -11:36 A.M.: The portable heated transport rack arrives on Unit 1. [...]
- 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, interviews and record review, the facility failed to store food in a safe sanitary manner and failed to maintain the kitchen in a sanitary manner. This has the potential to affect all facility residents who receive food from the facility kitchen. The facility census was 110. Review of the facility's Safe Food Handling policy, dated May 2015, showed: -All food should be tightly sealed with an identifying label and date. Observation of the kitchen on 9/26/2022 at 11:26 A.M., showed: -Walk-in Refrigerator: -Large pan of meatballs, covered with plastic wrap, no label or date. -Two aerosol cans of whipped cream, no date. -One open bag of shredded mozzarella cheese, no date. -Two door Fridge: -Open package of sliced cheese, no label or date. -Walk-in Freezer -Twelve cookies, individually bagged, no label or date. [...]
- E
Provide and implement an infection prevention and control program.
Inspectors wroteBased on record review and interview, the facility failed to maintain an infection prevention and control program designed to help prevent the development and transmission of communicable diseases and infections, when the facility failed to implement their policy regarding employee tuberculosis testing when they did not provide a second step of the test timely. The facility census was 110. Review of the facility's undated policy titled Tuberculosis (TB) Control included the following: - All employees will be screened for TB; - Once the decision has been made to employ an individual, the individual will be asked for documentation of a prior purified protein derivative (PPD) TB Test: o If the employee does not have documentation of a prior PPD; [...]
- E
Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame.
Inspectors wroteBased on observation, interview, and record review, facility staff failed to complete entrapment assessments for four residents with side rails (Residents #30, #69, #103 and #79) to ensure the environment remained safe and free of accident hazards. The facility census was 110. Facility did not have a policy regarding bed canes. 1. Review of Resident #69's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by staff, dated 8/5/22 showed: -Brief Interview for Mental Status (BIMS, an interview conducted by staff to determine the residents ability to answer questions appropriately and make decisions) of 4; the resident is unable to make decisions and answer questions appropriately; -Extensive assistance of one staff member for transfers and bed mobility; [...]
- D
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Inspectors wroteBased on observation and interviews, the facility failed to provide a safe, clean, and homelike environment for residents. The facility census was 110. 1. Observation on 9/28/22 beginning at 7:45 A.M. showed the following: - room [ROOM NUMBER]- Three broken tiles by the bed; - room [ROOM NUMBER]- Large scratches and gouges on the wall behind the bed; - ¾ inch () by four inch crack on the wall by the exit to from unit 1; - #303- large area of the wall behind door damaged, the from the door opener at the top. - room [ROOM NUMBER]- large gouges in about a thee foot by four foot area behind the bed; - 316 - a 2 to 3 hole in the bathroom door; - 317 - area of the laminate floor missing by the toilet approximate size of a baseball; - Unit 3 shower room- 2 by 4 area on the ceiling where the ceiling texture was peeling; [...]
- D
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Inspectors wroteBased on interview and record review, the facility failed to issue written notice of transfer for one residents (Resident #86). The facility census was 110. Review of the facility Bed-hold Notice and Return/readmission policy, dated January 2022, showed: -It is the policy of this facility to to provide written bed hold policy when a resident is admitted and upon transfer to a hospital or goes on therapeutic leave. -These bed hold policies apply to all residents and require that two notices are issued relation to the bed-hold policies: -The first notice of bed-hold policy is given well in advance of any transfer, usually at admission. -The second notice, which specifies the duration of the bed-hold policy, will be issued at the time of transfer. [...]
- 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 observations, interviews, and record review, the facility failed to maintain medication storage when loose pills were found in the medication cart and expired medication was found in the medication room; failed to date an opened vial of insulin and ensure staff were able to read the opened and expiration date on a vial of insulin for one (Resident #9) of 22 sampled residents, The facility census was 110. Review of the facility's undated policy for storage of medications, showed, in part: - Medications must be stored in the container in which they were received; - No discontinued, outdated, or deteriorated drugs or biological's may be retained for use. All such drugs must be returned to the issuing Pharmacy or destroyed in accordance with established guidelines. 1. Observation and interview on 9/28/22 at 11:11 A.M., in the medication room for Unit 1 showed: [...]
- D
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
Inspectors wroteBased on observations and interview, the facility failed to ensure the pureed food was prepared to a smooth and appropriate consistency. This had the potential to affect all residents in the facility who receive a pureed diet (a texture-modified diet in which all foods have a soft, pudding-like consistency). The facility census was 110. Review of the facility's Types of Diets policy, dated May 2015, showed: -Pureed Diet: This diet is for the edentulous resident and residents with swallowing difficulties. Foods are blended to a mashed potato consistency or altered to meet the needs of the resident, using as little liquid as possible. Observation of lunch meal preparation on 9/28/2022 at 10:45 A.M., showed: -Dietary staff C began preparing the pureed lunch meal. -He/she placed cut up pieces of breaded chicken breast into the food processor. [...]
- D
Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
Inspectors wroteBased on record review and interview, the facility failed to employ an infection preventionist (IP) on at least a part-time basis. The facility census was 110. Review of the facility's Infection Surveillance policy, dated May 2016, showed: -The IP will be the hub of the Antibiotic Stewardship Program (ASP). They will have the knowledge and expertise to effectively develop, implement and monitor the ASP. -The IP or designee will be responsible to audit the clinical assessment documentation at the time of antibiotic prescription. -The IP or designee will be responsible for auditing the completeness of antibiotic prescribing documentation to include dose, route, start date, end date, days of therapy, and indication. -The IP or designee will monitor antibiotic imitation. -The IP or designee will track antibiotic resistant infections. [...]
Fire safety inspections
41 fire safety citations on file: 1 on November 21, 2025, 11 on June 19, 2025, 7 on April 11, 2024, 22 on September 29, 2022.
Every fire safety citation41 citations
- D
Address subsistence needs for staff and patients.
E 15 · November 21, 2025 · Corrected (the home has a date of correction)
- F
Provide properly protected cooking facilities.
K 324 · June 19, 2025 · Corrected (the home has a date of correction)
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · June 19, 2025 · Corrected (the home has a date of correction)
- F
Have simulated fire drills held at unexpected times.
K 712 · June 19, 2025 · 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 19, 2025 · Corrected (the home has a date of correction)
- F
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · June 19, 2025 · Corrected (the home has a date of correction)
- F
Ensure proper usage of power strips and extension cords.
K 920 · June 19, 2025 · Corrected (the home has a date of correction)
- E
Keep aisles, corridors, and exits free of obstruction in case of emergency.
K 211 · June 19, 2025 · Corrected (the home has a date of correction)
- E
Have properly located and lighted "Exit" signs.
K 293 · June 19, 2025 · Corrected (the home has a date of correction)
- E
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
K 321 · June 19, 2025 · Corrected (the home has a date of correction)
- E
Properly select, install, inspect, or maintain portable fire extinguishes.
K 355 · June 19, 2025 · Corrected (the home has a date of correction)
- E
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · June 19, 2025 · Corrected (the home has a date of correction)
- F
Have exits that are accessible at all times.
K 271 · April 11, 2024 · Waiver
- F
Install emergency lighting that can last at least 1 1/2 hours.
K 291 · April 11, 2024 · Corrected (the home has a date of correction)
- F
Have an enclosure around a vertical opening shaft.
K 311 · April 11, 2024 · Waiver
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · April 11, 2024 · Corrected (the home has a date of correction)
- F
Ensure that waiting areas, nurse’s stations, gift shops, and cooking facilities, open to the corridor are properly protected.
K 361 · April 11, 2024 · Corrected (the home has a date of correction)
- F
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
K 761 · April 11, 2024 · Corrected (the home has a date of correction)
- E
Have properly installed electrical wiring and gas equipment.
K 511 · April 11, 2024 · Corrected (the home has a date of correction)
- F
Conduct testing and exercise requirements.
E 39 · September 29, 2022 · Corrected (the home has a date of correction)
- F
Ensure that building systems meet requirements determined by risk assessment procedures performed by qualified personnel.
K 901 · September 29, 2022 · Corrected (the home has a date of correction)
- F
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
K 914 · September 29, 2022 · Corrected (the home has a date of correction)
- E
Develop and maintain an Emergency Preparedness Program (EP).
E 4 · September 29, 2022 · Corrected (the home has a date of correction)
- E
Address subsistence needs for staff and patients.
E 15 · September 29, 2022 · Corrected (the home has a date of correction)
- E
Use approved construction type or materials.
K 161 · September 29, 2022 · Corrected (the home has a date of correction)
- E
Keep aisles, corridors, and exits free of obstruction in case of emergency.
K 211 · September 29, 2022 · Corrected (the home has a date of correction)
- E
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
K 225 · September 29, 2022 · Corrected (the home has a date of correction)
- E
Install emergency lighting that can last at least 1 1/2 hours.
K 291 · September 29, 2022 · Corrected (the home has a date of correction)
- E
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
K 321 · September 29, 2022 · Corrected (the home has a date of correction)
- E
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · September 29, 2022 · Corrected (the home has a date of correction)
- E
Inspect, test, and maintain automatic sprinkler systems.
K 353 · September 29, 2022 · Corrected (the home has a date of correction)
- E
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
K 354 · September 29, 2022 · Corrected (the home has a date of correction)
- E
Install corridor and hallway doors that block smoke.
K 363 · September 29, 2022 · Corrected (the home has a date of correction)
- E
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · September 29, 2022 · Waiver
- E
Have properly installed electrical wiring and gas equipment.
K 511 · September 29, 2022 · Corrected (the home has a date of correction)
- E
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
K 521 · September 29, 2022 · Corrected (the home has a date of correction)
- E
Have elevators that firefighters can control in the event of a fire.
K 531 · September 29, 2022 · Corrected (the home has a date of correction)
- E
Provide a written emergency evacuation plan.
K 711 · September 29, 2022 · Corrected (the home has a date of correction)
- E
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
K 761 · September 29, 2022 · Corrected (the home has a date of correction)
- E
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · September 29, 2022 · Corrected (the home has a date of correction)
- E
Ensure proper usage of power strips and extension cords.
K 920 · September 29, 2022 · Corrected (the home has a date of correction)