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 53 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
1J
2K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
22D
24E
3F
Potential for minimal harm
0A
0B
1C
October 16, 2025Complaint inspection · 1 citation
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on medical record review, observation, and staff interview, the facility failed to ensure Resident's received treatment and care in accordance with professional standards of practice. Specifically, physician's orders were not followed. Resident #87. Facility census: 94.a) Resident #87A review of Resident #87's medical record revealed, a Physicians order for: --Check residual prior to each tube feed. If >200ml hold feed and re-check in 1 hour. If >500ml notify MD. every shift with order date 4/24/2024.--Check placement before med administration or feedingevery shift with order date 4/24/2024. An observation on 10/15/25 at 930 AM of Resident #87s tube feeding revealed Licensed Practical Nurse #1 (LPN) failed to check residual prior to this tube feed. During an interview 10/15/25 at 930 AM, LPN #1 stated that there was not an order to check residual prior to feeding. [...]
August 27, 2025Standard inspection, Complaint inspection · 6 citations
- F
Dispose of garbage and refuse properly.
Inspectors wroteBased on observation, policy review, and staff interview the facility failed to properly contain kitchen waste in garbage dumpsters in a safe and sanitary manner. Facility Census: 93. Findings Included:On 08/20/25 at 10:15 AM, facility dumpsters were observed overflowing, lids would not close on any dumpster, soiled gloves, bags and miscellaneous trash were around all sides of the dumpster. On 08/20/25 at 10:21 AM, the Administrator was notified and confirmed the dumpsters were overflowing, lids would not close and miscellaneous trash was around dumpsters. The Administrator stated, I'll call them they will make a special trip .they usually come on Tuesdays, Thursdays and Saturdays. Document titled Food-Related Garbage and Refuse Disposal was reviewed and revealed the following: Policy: Food-related garbage and refuse are disposed of in accordance with current state laws. [...]
- 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 resident interview, staff interview and observation the facility failed to provide a safe, clean, comfortable, homelike environment for residents. This is true for residents #58, #79, #87, and #40. Facility Census 93. Findings Included:a) Resident #58 Interview with Resident # 58 on 08/20/2025 at 2:38 PM who reported a black area on the tile on and around the base of the wall behind resident’s toilet. Observed area around resident's toilet at 2:41 PM and Nurse Aide (NA) #35 acknowledged the area and agreed to notify housekeeping/maintenance. b) Resident #79 On 08/20/2025 at 10:47 AM during an interview with Resident #79, he stated pieces of dry wall had been removed from the bathroom wall around the pipes to the toilet for approximately one month. The toilet is now working but he did not have access to his toilet for two weeks, he had to use the toilet at the nurse’s station. [...]
- 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 and staff interview the kitchen failed to store food in accordance to professional standards for food safety. Facility census: 93. Findings Included: a) During initial kitchen walk through on 08/20/25 the following items we found in the walk-in refrigerator: six (6) quarts of cranberry juice with a use by date of 08/08/25 five (5) Fruit Punch pitcher use by date of 08/18/25 three (3) grape drinks use by 08/15/25 four (4) sugar free drink use by 08/18/25 Unsweet tea use by 08/18/25 Interview with Kitchen Manager at 7:50 AM who acknowledged the drinks found in the walk-in refrigerator. Review of document titled, Receiving and Storage of Food, Policy: Foods shall be received and stored in a manner that complies with safe food handling practices. Specific Procedures/Guidance, Number eight (8) states the following: [...]
- D
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Inspectors wroteBased on record review, policy review, resident representative interview, and staff interview, the facility failed to notify Resident #97's legal representative when he passed away in the facility and notify the resident representative of a new medication. This was a random opportunity for discovery. Resident identifiers: #97 and #76. Facility census: 93.
- 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 provide a Pre-admission Screening (PAS) which included all psychiatric diagnoses for Resident #10. This was true for one (1) of three (3) residents reviewed during the survey process. Resident Identifier: #10. Facility Census: 93. Findings Include: Based on record review and staff interview, the facility failed to provide a Pre-admission Screening (PAS) which included all psychiatric diagnoses for Resident #10. This was true for one (1) of three (3) residents reviewed during the survey process. Resident Identifier: #10. Facility Census: 93. Findings Include: a) Resident #10 On 08/25/25 at 2:00 PM, a record review was completed for Resident #10. The review found the PAS dated 07/01/24 did not include the diagnosis of generalized anxiety disorder (GAD). [...]
- D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on record review and staff interview, the facility failed to provide an accurate and complete medical record for Resident #5. This was true for one (1) of five (5) residents reviewed under the care area of unnecessary medications. Resident Identifier: #5. Facility Census: 93. On 08/25/25 at 2:30 PM, a record review was completed for Resident #5. The review found a physician's order for Lamictal 200mg (milligram) one (1) tablet by mouth at bedtime for seizures. A review of the resident's diagnoses did not find the diagnosis of seizures. On 08/25/25 at 3:30 PM, the Minimum Data Set (MDS) Licensed Practical Nurse (LPN) #13 confirmed the resident did not have seizures and the correct diagnosis should be mood disorder. On 08/25/25 at 3:45 PM, the MDS LPN #13 stated, We will get this corrected.
June 11, 2024Standard inspection, Complaint inspection · 27 citations
- K
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, resident interview, and staff interview, the facility failed to prevent verbal abuse. The state agency determined the failure to address verbal threats from Resident #61 placed all residents in the facility in an immediate jeopardy situation. The residents making the threats could physically harm other residents. Psychological harm, such as fear and anxiety. could occur for other residents who were threatened by the residents or overheard the threats. Residents with post-traumatic stress disorder could be triggered. Resident identifier: #61. Facility census: 86.
- K
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on observation, facility record review, and staff interview the facility failed to follow Manufacturer's instructions regarding dishwasher temperature. Overall, commercial dishwasher temperature requirements are important to maintaining a safe and sanitary food service environment. This failed practice had the potential to affect every resident that gets their nutrition from the kitchen. This created an immediate jeopardy situation. Facility Census: 86.
- J
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 record review and staff interview, the facility failed to ensure that a resident who is diagnosed with a mental disorder receives appropriate treatment and services to correct the assessed problem or to attain the highest practicable mental and psychosocial well-being. Failure to provide one (1) of one (1) residents with essential menal health services and treatemnt created an immediate jeopardy sitauiton. Resident #61 did not receive the appropriate treatment and services for diagnoses paranoid schizophrenia, depression and unspecified dementia with moderate agitation. Resident #61 had documented violent behaviors that placed more than an limited number of residents at risk for serious harm. Resident identifier: #61. Facility census: 86.
- F
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation and staff interview the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, comfortable environment and to help prevent the development and transmission of communicable diseases and infections with regards to readily available PPE. This was a random opportunity for discovery. This had the potential to affect more than a limited number of residents. Facility census: 86.
- E
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteb) Resident #60 On 6/03/24 at 12:00 AM, an observation of the facility dining area was performed. During this observation, Resident #60 was noted to be seated at a table wearing a facility gown that was not tied at the neck or waist. The front of the gown was exposing Resident #60's upper chest, shoulders and the right side of Resident #60's back. It was noted that several facility staff walked by Resident #60 without offering to adjust or tie Resident #60's gown to cover Resident #60's exposed body areas. On 06/03/24 at 12:12 PM, a staff interview was conducted with Employee #96. During this interview, Employee #96 acknowledged that Resident #60's gown should be tied and that Resident #60's upper chest, shoulders and back of Resident #60's body should not be exposed. Employee #96 then went and tied Resident #60's gown. [...]
- E
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Inspectors wroteBased on interviews, and document review, the facility failed to ensure that residents' food preferences and choices were honored. This failed policy had the potential to affect more than a limited number of residents. Resident identifiers: #17, #14, and #9. Facility Census 86.
- E
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Inspectors wroteBased on record review, resident interview and staff interview, the facility failed to identify verbal complaints/concerns as a grievance. This was a random opportunity for discovery.
- E
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on resident interview, record review and staff interview, the facility failed to report allegations of verbal abuse, neglect, and possible crime to all required stated agencies. This deficient practice had the potential to affect three (3) of 11 residents reviewed for the care area of abuse. Resident identifiers: #79, #29, and #86. Facility census: 86.
- E
PASARR screening for Mental disorders or Intellectual Disabilities
Inspectors wroteBased on record review and staff interviews, the facility failed to ensure that the resident's Pre-admission Screening (PAS) reflected a pre-admission mental health diagnosis for three (3) of six (6) residents reviewed for the category of PASARR (Pre-admission Screening and Resident Review). The lack of pre-screening resulted in the residents' conditions not being evaluated through the Level II PASARR process. Resident identifier: #79, #61, and #58. Facility census: 86.
- E
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Inspectors wroteBased on record review and staff interview, the facility failed to ensure each resident had a person-centered comprehensive care plan developed and implemented to meet his or her preferences and goals, and address the resident's medical, physical, mental, and psychosocial needs. This was true for five (5) of 26 residents reviewed in the Long-Term Care Survey Process. Resident identifiers: #82, #190, #191, #54, and #61. Facility census: 86.
- E
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on resident interview, record review, and staff interview, the facility failed to ensure activities of daily living (ADL) care was provided to dependent residents. This deficient practice had the potential to affect one (1) of three (3) residents reviewed for the care area of activities of daily living. Resident identifier: #29. Facility census: 86.
- E
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on record review and staff interview the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices. This was true for 3 (three) of 11 residents reviewed for the Long-Term Survey Process. Resident identifiers: #39, #41, #191. Facility census: 86.
- E
Provide safe, appropriate pain management for a resident who requires such services.
Inspectors wroteBased on record review and staff interview the facility failed to ensure that a resident received the treatment and care in accordance with professional standards of practice in regard to monitoring pain levels. This was true for two (2) of four (4) residents reviewed for pain during a revisit survey. Resident Identifier: #69 and #80. Facility census: 86.
- E
Dispose of garbage and refuse properly.
Inspectors wroteBased on observation and staff interview the facility failed to store garbage and refuse in a proper manner. The dumpster area was polluted with uncovered garbage and medical supplies. This had the potential to affect all residents that reside in the facility. Facility census: 88.
- E
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on record review and staff interview, the facility failed to ensure a complete and accurate medical record for residents. The facility failed to maintain an accurate medical record for two (2) of 26 sampled residents reviewed during the Long-Term Care Survey process. The facility failed to ensure Physician Orders for Scope of Treatment (POST) forms were legally valid and matched other physician orders. Resident identifiers: #79, #54, and #3. Facility census: 86.
- E
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Inspectors wroteBased on record review and staff interview, the facility failed to develop and implement policies and procedures which addressed establishing priorities for performance improvement activities that focused on resident safety, quality of care, and high-volume and/or problem-prone areas. This had the potential to affect an unlimited number of residents. Facility census: 86.
- E
Keep all essential equipment working safely.
Inspectors wroteBased on observation and interview the facility failed to maintain essential equipment in safe operating condition according to manufacturer's recommendations. This had the potential to affect all residents who get their nutrition from the kitchen. Facility census: 88.
- E
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Inspectors wroteBased on observation and staff interview the facility failed to incorporate an effective pest control program. This has the potential to affect all residents residing in the facility. Facility census: 88.
- D
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Inspectors wroteBased on record review and staff interview, the facility failed to provide the required Notification of Medicare Non-Coverage (NOMNC) and the Skilled Nursing Facility Advanced Beneficiary Notice (SNF ABN) on non-coverage liability notices in a timely fashion for one (1) of three (3) residents reviewed for beneficiary protection notification throughout the Long-Term Care Survey Process. This failure placed the resident at risk of not being informed of her appeal rights prior to the end of Medicare covered services. Resident identifier: #25. Facility census: 86.
- D
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Inspectors wroteBased on record review, resident interview, and staff interview, the facility failed to implement their abuse policies for reporting neglect. This deficient practice had the potential to affect one (1) of 11 residents reviewed for the care area of abuse. Resident identifier: #29. Facility census: 86.
- D
Respond appropriately to all alleged violations.
Inspectors wroteb) Resident #29 During an interview on 06/03/24 at 1:39 PM, Resident #29 stated she had been left outside alone in the courtyard four (4) times following smoke breaks. Resident #29 stated she is unable to propel her wheelchair independently due to tremors and was unable to reenter the facility on her own. Resident #29 further stated there was no way to notify staff that she was outside and wanted to come in. The resident stated she was left out in the hot sun for two (2) hours on one day. Resident #29 also stated she had a history of falling from her wheelchair. Review of facility grievance forms showed a grievance on 05/13/24 which stated, Resident went outside with staff assistance for 1 pm smoke break. At end of smoke break as everyone returned inside [Nursing Assistant (NA) #5] said to this patient, If you can't bring yourself outside or inside, you shouldn't be able to smoke. [...]
- D
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Inspectors wroteBased on medical record review and staff interview, the facility failed to provide evidence that a resident/resident's representative was provided a written Notice of Transfer for an acute hospital transfer/discharge and failed to notify the long-term care Ombudsman of the transfer. This was true for two (2) of three (3) residents reviewed under the hospitalization pathway in the annual Long-Term Care Survey Process. Resident identifiers: #191,and #39. Facility census: 86.
- 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 wroteb) Resident #34 Medical Record review on 06/10/24 revealed resident #34 was discharged to the hospital on [DATE]. Subsequent review of Resident #34's medical record showed it did not contain documentation that the Notice of Transfer or Discharge was provided to the Resident Representative, or the Ombudsman was notified of the discharges on 06/02/24. On 06/11/24 at 9:50 AM during an interview the Social Worker verified, there was no evidence that the Notice of Transfer or Discharge was completed and provided to the Resident's Representative for the discharges on 06/02/24. The Social Worker also confirmed the Ombudsman was not notified of the discharges on 06/02/24. Based on medical record review and staff interview, the facility failed to provide evidence that a resident/resident's representative was provided a written Bed Hold notice for an acute hospital transfer. [...]
- 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 the PASARR for Resident #3, after the resident was diagnosed with a major mental disorder after admission to the facility. This was true for one (1) of six (6) residents reviewed for PASARRs during the survey process. Resident Identifier: 3. Facility census: 86.
- D
Provide timely, quality laboratory services/tests to meet the needs of residents.
Inspectors wroteBased on record review and staff interview the facility failed to obtain laboratory services as ordered by the physician to meet the needs of its residents. This was true for one (1) of 1 resident reviewed for the Long-Term Survey Process. Resident identifier: #41. Facility census: 86. a) Resident #41 On 06/04/24 at 01:00 PM, a review of Resident #41's medical record was performed. During the review of the physician's orders, it was noted that Resident #41 had orders as follows: * Novolog Injection Solution (Insulin Aspart) Inject as per sliding scale: if 201- 250 = 4; 251- 300 = 6; 301- 350 = 8; 351- 400 = 10; 401- 450 = 12; 451 + = 15. Notify Medical Doctor (MD) if blood sugar (BS) is less than 60 or above 450, subcutaneously before meals and at bedtime for Diabetes Mellitus (DM) II. Order date: 01/29/24 * Complete Blood Count (CBC)/Glycated hemoglobin (HgbA 1c) every 6 (six) months. [...]
- 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, resident interview, and staff interview, the facility failed to ensure a safe, clean, comfortable, homelike environment. The ceiling in room B6 was damaged. This was a random opportunity for discovery. Facility census: 86.
- C
Post nurse staffing information every day.
Inspectors wroteBased on observation and staff interview, the facility failed to post the daily nurse staffing in a prominent place readily accessible to residents and visitors on a daily basis. This was a random opportunity for discovery. Facility census: 86.
March 21, 2024Complaint inspection · 2 citations
- 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 medical record review and staff interview, the facility failed to ensure Advance Directive paperwork was part of Resident #11's medical record. This was a random opportunity for discovery in the complaint process. Resident identifier: #11. Facility census: 78.
- D
Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs.
Inspectors wroteBased on medical record review and staff interview, the facility failed to provide a resident with a well-balanced diet that met her daily nutritional and special dietary needs. The facility failed to offer a diverticulosis diet to Resident #11 who had an identified diagnosis of diverticulosis upon admission to the facility. This was a random opportunity for discovery in the complaint process. Resident identifier: #11. Facility census: 78.
September 14, 2022Standard inspection · 17 citations
- F
Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
Inspectors wroteBased on review of facility documents and staff interview, the facility failed to ensure the designated individual acting as the Infection Preventionist completed a specialized training in infection prevention and control. This failed practice had the potential to affect all residents residing in the facility. Census:
- 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 staff interview, the facility failed to ensure residents were served meals in a dignified manner. Residents seated at the same table did not receive meals simultaneously. This failed practice was observed as a random opportunity for discovery and had the potential to affect more than a limited number of residents. Resident Identifiers: Resident #37, #139, and #6. Census:
- E
Honor the resident's right to organize and participate in resident/family groups in the facility.
Inspectors wroteBased on a policy review, review of resident council minutes, resident interview and staff interview the facility failed to consider the voiced concerns of residents in resident council. The facility failed to act promptly to investigate resident grievances concerning issues of call lights and staffing attitudes. This practice has the potential to affect more than a limited number of residents living in the facility. Facility census: 89. Findings Included: A review of the facility policy titled Grievance/Concern with a revision date of 06/01/22 found the following. .Policy Center leadership will investigate, document and follow up on all concerns and grievances registered by any patient or patient representative a) Call lights The following Resident Council Meeting Minutes From 01/24/22 to 08/29/22 found the following documentation related to call lights concerns. [...]
- 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 resident interview, observation, resident council meeting and staff interview, the facility failed to provide residents with a safe clean, comfortable and homelike environment. The facility failed to eliminate the institutional practices by the overhead paging of frequent announcements. The facility also failed to provide residents with furniture in good repair and resident walls in good repair . This had a potential to affect an unlimited amount of residents living in the facility. Resident Identifiers: #16 and #119. Facility Census: 89. Findings Included: a) Overhead paging During an interview on 09/12/22 at 11:37 AM Resident #16 stated That thing goes off all the time, (the overhead paging made announcement). I have hearing problems, so I can only imagine how loud it is to the other patients that live here. [...]
- E
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Inspectors wroteBased on observation, resident council meeting, and staff interviews the facility failed to make grievances forms accessible to residents to file a grievance anonymously. This practice has the potential to affect more than a limited number of residents living in the facility. Facility census: 89 Findings Included: a) Grievance Forms Accessibility A review of the facility policy titled Grievance/Concern with a revision date of 06/01/22 found the following. .Process . 2.1 The right to file grievances orally (meaning spoken) or in writing, the right to file grievances anonymously; . During a Resident Council meeting held on 09/13/22 at 2:38 PM by two (2) state surveyors the following question was asked; Do you know how to file a Grievance? --I think there was forms in the dining room, but have not seen them in there. [...]
- E
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on record review and staff interview the facility failed to ensure that resident centered care and services were provided in accordance with professional standards of practice. This was true for six (6) of ten (10) records reviewed for nutrition. Resident Identifiers: #30, #68, #2, #49, #78, #70. Facility Census: 89 Findings Included: a) Resident #30 On 9/14/22 at 11:30 AM record review shows the facility did not re-weigh resident #30 when he had a weight change of five (5) pounds (increase or decrease) from the last weight. According to staff interview with the Director of Nursing (DON) on 9/13/22 at 12:26 PM, staff is to re-weigh the Resident if there is a difference of a five (5) pound increase or decrease in the Residents weight. This was not performed on 3/10/22, 5/31/22, 6/20/22 and 7/06/22. This was confirmed with the DON 9/14/22 at 12:45 PM. [...]
- E
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Inspectors wroteBased on anonymous resident interviews, anonymous staff interviews, resident council minutes, a resident council meeting held during the long-term care survey, and interviews with Administration, the facility failed to ensure sufficient qualified nursing staff were available at all times to provide nursing and related services to meet the residents' needs safely and in a manner that promoted resident rights, physical, mental and psychosocial well-being. Facility census: 89. Findings Included: a) Anonymous Resident Interviews During an anonymous resident interview on 09/12/22 at 11:06 AM, Resident #301 stated the facility doesn't have enough staff. It would be the resident's preference to get up and be dressed earlier, but there simply isn't enough staff available to honor that preference. [...]
- E
Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
Inspectors wroteBased on observation and staff interview the facility failed to employ a clinically qualified nutrition professional on a full time basis to manage the daily function of the kitchen. This had the potential to affect all the residents that receive nutrition from the kitchen. Facility Census: 89. Findings Included: a) a) Qualified Nutrition Professional An observation of the kitchen office on 09/13/22 at 9:04 AM, revealed no certified licensed professional certificates. During an interview on 09/13/22 at 9:04 AM, Dietary Manager #34, stated I am enrolled in the Dietary Mangers class, I will be testing in February. During an interview on 09/13/22 at 9:04 AM interview District Manager of Dietary #112 stated, we do not have a full time certified dietary manager, I am here a few days a month and the dietician is here two (2) to three (3) days a week.
- 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 and staff interview the facility failed to store food in a safe and sanitary manner in accordance with professional standards for food service safety. The facility failed to keep kitchen equipment clean and rust free. The failed practice had the potential to affect all residents currently receiving nutrition from the facility's kitchen. Facility Census: 89. Findings Included: a) Ice Machine A review of the facility policy titled 4.0 Cleaning Standards with a revision date of 06/15/18 found the following. .Cleaning Procedure Ice Machine ( Bin type) When: Monthly On 09/12/22 at 9:50 AM a tour of the kitchen with Dietician #111, the ice machine in the main dining room revealed to have black substance in the inside of the machine. The Dietician #111 acknowledged the black substance. [...]
- D
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Inspectors wroteBased on record review and staff interview, the facility failed to provide evidence the required Notification of Medicare Non-Coverage (NOMNC) notice was issued in a timely fashion for one (1) of three (3) residents reviewed for beneficiary protection notification. This failure had the potential to place the resident at risk of not being informed of their rights prior to the end of Medicare Part A covered services. Resident identifier: #192. Facility census: 89.
- D
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Inspectors wroteBased on medical record review and staff interview, the facility failed to provide evidence a resident/resident's representative was provided a written Notice of Transfer for an acute hospital transfer. This was true for one (1) of two (2) residents reviewed for hospitalizations/discharges during the long-term care survey process. Resident identifier: #78. Facility census: 89.
- 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 medical record review and staff interview, the facility failed to provide evidence a resident/resident's representative was provided a written Bed Hold Notice for a hospital transfer. This was true for two (2) of five (5) residents reviewed for hospitalizations during the long-term care survey process. Resident identifiers: #78 and #80. Facility census: 89.
- 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, record review, resident and staff interview, the facility failed to develop a comprehensive person-centered care plan for each resident to meet the resident's needs that were identified in the comprehensive assessment for one (1) of 29 residents reviewed during the Long Term Care Survey Process (LTCSP). Resident identifier: Resident # 69.
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on observation, record review and staff interview, the facility failed to provide care to residents with pressure ulcers consistent with professional standards of practice to promote healing, prevent infection and prevent new pressure ulcers from developing for one (1) of six (6) residents reviewed for pressure ulcers during the LTCSP. Resident identifier: Resident #81.
- D
Provide special eating equipment and utensils for residents who need them and appropriate assistance.
Inspectors wroteBased on observation, record review and staff interview the facility failed to provide appropriate assistive devices to Resident #56 in order for him to drink independently. This was a random opportunity of discovery. Resident Identifier: #56 Facility Census:
- D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on record review and staff interview, the facility failed to ensure two (2) of 26 residents reviewed during the long-term care survey process had a complete and accurate medical record. Resident #75 and #52 had Physician Orders for Scope of Treatment (POST) forms completed incorrectly per directions specified by the [NAME] Virginia Center for End-of-Life Care in conjunction with the [NAME] Virginia Health Care Decisions Act (16-30-1). Resident identifiers: #75 and #52. Facility census: 89.
- D
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
Inspectors wroteBased on record review and staff interview, the facility failed to maintain a Quality Assessment and Assurance (QAA) committee consisting, at a minimum, of the Director of Nursing (DON); the Medical Director or his/her designee; and at least three other members of the facility's staff, at least one of who must be the administrator, owner, a board member, or other individual in a leadership role. Facility census: 89.
Fire safety inspections
13 fire safety citations on file: 3 on August 27, 2025, 5 on June 11, 2024, 5 on September 14, 2022.
Every fire safety citation13 citations
- F
Have simulated fire drills held at unexpected times.
K 712 · August 27, 2025 · Corrected (the home has a date of correction)
- F
Ensure that testing and maintenance of electrical equipment is performed.
K 921 · August 27, 2025 · Corrected (the home has a date of correction)
- D
Construct fire resistant interior walls.
K 331 · August 27, 2025 · Corrected (the home has a date of correction)
- F
Keep aisles, corridors, and exits free of obstruction in case of emergency.
K 211 · June 11, 2024 · Corrected (the home has a date of correction)
- F
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 11, 2024 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · June 11, 2024 · Corrected (the home has a date of correction)
- F
Ensure that testing and maintenance of electrical equipment is performed.
K 921 · June 11, 2024 · Corrected (the home has a date of correction)
- C
Have simulated fire drills held at unexpected times.
K 712 · June 11, 2024 · Corrected (the home has a date of correction)
- F
Keep aisles, corridors, and exits free of obstruction in case of emergency.
K 211 · September 14, 2022 · Corrected (the home has a date of correction)
- F
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · September 14, 2022 · Corrected (the home has a date of correction)
- D
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 14, 2022 · Corrected (the home has a date of correction)
- D
Inspect, test, and maintain automatic sprinkler systems.
K 353 · September 14, 2022 · Corrected (the home has a date of correction)
- D
Have properly installed electrical wiring and gas equipment.
K 511 · September 14, 2022 · Corrected (the home has a date of correction)