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 72 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
1J
0K
0L
Actual harm
1G
0H
0I
Potential for more than minimal harm
52D
7E
8F
Potential for minimal harm
0A
2B
1C
December 12, 2025Standard inspection, Complaint inspection · 25 citations
- F
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Inspectors wroteBased on record review and interview, it was determined that the facility failed to ensure that licensed nurses had specific competencies and skill sets necessary to care for residents' needs. This was evident for 5 (Staff #12, #13, #14, #15, and #16) of 5 randomly selected Licensed Practical Nurses (LPNs) during the Staffing task portion of the annual survey.
- F
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Inspectors wroteBased on record review and interview, it was determined that the facility failed to ensure there was a Registered Nurse (RN) for at least 8 consecutive hours every day. This was evident for 2 days (11/23/25, 12/03/25) of 22 days reviewed for federal staffing compliance during the annual survey.
- F
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 interviews, it was determined that the facility failed to ensure that the Quality Assurance and Performance Improvement (QAPI) committee maintained a comprehensive, data-driven program. This failure was evident for one of one QAPI program reviewed during the Quality Assurance task.
- F
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Inspectors wroteBased on observations, interviews, and record review, it was determined that the facility failed to maintain sidewalks and patios in a manner that was safe for residents, staff, and the public. This failure was evident for three of three sidewalks observed and one of one patio observed during the Environmental task.
- 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 medical record review, interview, and observation it was determined that the facility failed to develop a comprehensive person-centered care plan and failed to ensure that care plan interventions were implemented. This was found to be evident for two (Resident's # 3 and #2) out of two residents reviewed for accidents and for one (Resident #49) of two residents reviewed for Respiratory Care.
- E
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
Inspectors wroteBased on record review and interview it was determined that the facility failed to provide Geriatric Nursing Assistants (GNAs) required training. This was evident for 3 of 5 GNAs (GNA #8, GNA #9, GNA #10) reviewed for evidence of required training during the Staffing task portion of the annual survey.
- D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteBased on observations, record review, and interviews, it was determined that the facility failed to ensure that a resident who required assistance with self-care was groomed in a manner that preserved the Resident's dignity. This was evident for 1 (Resident #12) of 1 resident reviewed for dignity.
- D
Ensure that residents are fully informed and understand their health status, care and treatments.
Inspectors wroteBased on medical record review and interview it was determined that the facility failed to ensure the risks and benefits of a psychoactive medication was discussed with the resident and or the responsible representative prior to the start of treatment with psychoactive medication. This was found to be evident for one (Resident #20) out of five resident's reviewed for unnecessary medications.
- 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 interview it was determined that the facility failed to ensure residents, and or responsible representatives, were asked about advance directives and that responsible decision makers were involved in the determination of orders regarding cardiopulmonary resuscitation (CPR) and other life-sustaining treatment options. This was found to be evident for one (Resident #3) out of three residents reviewed for Advance Directives.
- 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 medical record review and interview it was determined that the facility failed to ensure the primary care physician and the registered dietitian were made aware of the identification of continued significant weight loss in a timely manner. This was found to be evident for one (Resident #3) out of three residents reviewed for nutrition.
- D
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 interviews, observations, and record review, it was determined that the facility failed to enter, investigate, and follow up on grievance in a timely manner. This failure was identified while performing the Resident Council task and was evident for 1 of 1 grievance reviewed in the facility's grievance log.
- D
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Inspectors wroteBased on medical record review and interview it was determined that the facility failed to ensure written transfer notice and bed hold policy information was provided to the resident and the responsible party when the resident was transferred to the hospital. This was found to be evident for two (Resident #2 and #5) of the three residents reviewed for hospitalizations.
- D
Ensure each resident receives an accurate assessment.
Inspectors wroteBased on observations, record review, and interviews, it was determined that the facility failed to ensure that Minimum Data Set (MDS) assessments were accurately recorded. This was evident for 1 (Resident #6) out of 1 resident reviewed for position and mobility.
- D
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Inspectors wroteBased on review of medical records and interviews it was determined that the facility failed to ensure baseline care plan information was provided to the resident and or the responsible representative. This was found to be evident for 3 (Resident #3, #20 and #55) out of the 15 residents included in the survey sample.
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on observations, record reviews, and interviews, it was determined that the facility failed to ensure that residents who were dependent on staff for Activities of Daily Living (ADL) received oral care. This was evident for 1 (Resident #6) of 2 residents reviewed for ADL.
- D
Provide activities to meet all resident's needs.
Inspectors wroteBased on interviews, observations, and record review, it was determined that the facility failed to provide an ongoing program of activities that met residents' needs and preferences. This was evident for 1 (Resident #6) out of 3 residents reviewed for activities.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on observation, record review, and interviews, it was determined that the facility failed to ensure appropriate follow-up care after a hospital discharge; and failed to ensure there were orders or care plan interventions for the use and monitoring of an air mattress. This failure was evident for one (Resident #1) of two residents reviewed for catheter use; and one (Resident #53) out of one resident reviewed for skin issues.
- 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, record review, and interviews, it was determined that the facility failed to ensure that a resident with a limited range of motion received treatment and services to prevent further decline in his/her range of motion. This was evident for 1 (Resident #6) out of 1 resident reviewed for position and mobility.
- D
Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services.
Inspectors wroteBased on record reviews and interviews, it was determined that the facility failed to ensure that residents' colostomy care was provided by appropriately trained, competent, skilled nursing staff. This was evident for 1 (Resident #6) of 1 resident reviewed for colostomy care.
- 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 record reviews, observations, and interviews, it was determined that the facility failed to provide appropriate treatment and services to residents receiving tube feedings. This was evident for 1 (Resident #6) of 1 resident reviewed for tube feeding.
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observations, record reviews, and interviews, it was determined that the facility failed to follow an attending physician's order to administer oxygen to a resident. This was evident for 1 (Resident #49) of 2 residents reviewed for Respiratory Care.
- D
Provide safe, appropriate pain management for a resident who requires such services.
Inspectors wroteBased on interviews, observations, and record review, it was determined that the facility failed to manage Residents' pain. This was evident for 2 (Residents #6, #59) of 2 residents reviewed for pain management.
- D
Ensure that the resident and his/her doctor meet face-to-face at all required visits.
Inspectors wroteBased on medical record review and interview it was determined that the facility failed to ensure the resident was seen by the primary care provider every 30 days for the first 90 days of admission. This was found to be evident for one (Resident #3) out of three resident reviewed for nutrition.
- 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 and interview it was determined that the facility failed to have separately locked, permanently affixed compartments for the storage of controlled drugs that required refrigeration. This was found to evident in two out of the two medication storage rooms in the facility.
- D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on medical record review, observation and interview it was determined that the facility failed to ensure the medical record accurately reflected the resident's need for and use of supplemental oxygen. This was found to be evident for one (Resident #3) out of two residents reviewed for respiratory care.
August 1, 2025Complaint inspection · 5 citations
- J
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on record review, interview, facility document review, and facility policy review, the facility failed to ensure an alarm on the fire exit door of the secured unit sounded to prevent elopement for 1 (Resident #7) of 1 resident reviewed for elopement. The failure resulted in Resident #7 exiting the facility on the morning of 07/28/2024 at 6:10 AM and being found by staff approximately one-half mile from the facility at approximately 7:00 AM. It was determined the facility's non-compliance with one or more requirements of participation had caused or was likely to cause serious injury, serious harm, serious impairment, or death to one or more facility residents. The Immediate Jeopardy (IJ) was related to 42 CFR 483.25(d), F689, Supervision to Prevent Accidents at a scope and severity of J. [...]
- G
Provide enough food/fluids to maintain a resident's health.
Inspectors wroteBased on interview, record review, and facility document and policy review, the facility failed to monitor and assess a resident's oral fluid intake, notify the physician of changes in intake, and put interventions in place to maintain adequate hydration for 1 (Resident #3) of 3 residents reviewed for dehydration. Specifically, the facility failed to identify and address Resident #3's inadequate fluid intake, which resulted in actual harm to Resident #3 who required hospitalization with diagnoses of encephalopathy and dehydration.
- E
Keep all essential equipment working safely.
Inspectors wroteBased on interview, facility document review, and policy review, the facility failed to check the automated external defibrillator (AED) daily for 157 days out of 421 days (37%).
- 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, observation, interview, facility document review, and facility policy, the facility failed to protect residents from verbal and physical abuse for 2 (Resident #4 and Resident #5) of 7 residents reviewed for abuse.
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on facility document review, staff interview, and facility policy review, the facility failed to submit an initial allegation of a bruise of unknown origin and failed to submit a five-day follow-up report of verbal abuse timely for Resident #5. Additionally, the facility failed to submit a five-day follow-up report of misappropriation of property timely for Resident #6. These failures affected 2 (Resident #5 and Resident #6) of 7 residents reviewed for abuse.
June 7, 2023Standard inspection · 26 citations
- F
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Inspectors wroteBased on a review of staffing sheets and interview, it was determined that the facility failed to ensure that a registered nurse was onsite at the facility at least 8 consecutive hours a day, 7 days a week. This practice has the potential to affect the health and safety of all residents.
- 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 of the kitchen and staff interview, it was determined that the facility failed to follow professional standards for food service safety. This deficient practice has the potential to affect all residents.
- D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteBased on observation, record review, and interview, facility staff failed to treat residents with respect and dignity during meal time. This was evident for 2 (# 31 and #10) of 9 residents observed in Unit 1 Dining Room.
- D
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, record reviews, and observations, it was determined that the facility failed to honor a resident's bathing preference. This was evident for 1 resident (Resident #24) out of 1 resident reviewed for choices during an annual survey.
- 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 medical record review and interview, it was determined that the facility failed to ensure that significant weight losses were reported to the physician, registered dietitian and family in a timely manner. This was found to be evident for 2 (Resident #23, #39) out of 5 residents reviewed for nutrition.
- 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, it was determined that the facility failed to provide a home-like environment to residents. This was evident for 2 of 2 nursing units reviewed for environment.
- D
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Inspectors wroteBased on record review and interview, it was determined the facility failed to develop and implement abuse policies and procedures. This was evident for 1 of 1 abuse policies reviewed.
- D
Respond appropriately to all alleged violations.
Inspectors wroteBased on record review and interview, it was determined that facility staff failed to conduct a thorough investigation of an allegation of abuse and failed to further protect the residents until the investigation had been completed. This was evident for 1( Resident #250) of 5 residents reviewed for neglect.
- 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, it was determined that the facility failed to: 1) notify the resident/resident representative in writing of a transfer/discharge of a resident along with the reason for the transfer. This was evident for 1 (#42) of 4 residents reviewed for hospitalization.
- 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 record review, and interview, it was determined that the facility failed to provide a resident's representative with a written bed hold policy when the resident was transferred to the hospital. This was evident for 1 resident (Resident # 9) out of 4 residents reviewed for hospitalizations during an annual survey.
- D
Ensure each resident receives an accurate assessment.
Inspectors wroteBased on observation, record review, and interview, it was determined that facility staff failed to code the Minimum Data Set (MDS) assessments accurately. This was evident for 1(# 36) of 4 residents reviewed for limited range of motion and 1 (#39) of 5 residents reviewed for unnecessary medications.
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on observation, interviews, and record reviews, it was determined that the facility failed to provide the necessary care to ensure that a resident was kept well-groomed with clean hair. This was evident for 1 resident (Resident #24) out of 1 resident reviewed for choices.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on record review, and interviews, it was determined the facility 1) failed to ensure that a newly admitted resident was provided the appropriate medications upon admission to the facility. This was evident for 1 (# 257) of 1 resident reviewed for general concerns. This was evident for 1 (#246) of 8 residents reviewed for complaints.
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on medical records reviews, observations, and interviews, the facility failed to establish a process to safely monitor residents in the dining room without staff supervision nor were residents in the dining room provided with a means to communicate with the staff in case of an emergency and or routine requests. This was evident for two out two observations made during the investigation phase of the annual survey.
- D
Provide enough food/fluids to maintain a resident's health.
Inspectors wroteBased on medical record review and interview, it was determined that the facility failed to evaluate and implement measures to address the resident's nutritional needs as evidenced by 1) failing to ensure resident weights were obtained timely following readmission to the facility and weights were obtained as recommended by the dietician, 2) failing to ensure that a resident's significant weight loss was confirmed and reported to the dietician and physician so it could be addressed in a timely manner, 3) failing to ensure the physician addressed a resident's significant weight loss, 4) failing to ensure the dietician recommendations were implemented, and 4) failing to ensure the resident's representative was notified when the resident had a significant weight loss. This was evident for 3 (#246, #23, #24) of 5 residents reviewed for nutrition.
- D
Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit.
Inspectors wroteBased on medical record review, it was determined that the physician failed to address a residents' recent significant weight loss in the progress notes. This was found to be evident for 1 (Resident #23) out of 5 residents reviewed for nutrition.
- D
Ensure that the resident and his/her doctor meet face-to-face at all required visits.
Inspectors wroteBased on medical record review and staff interview, it was determined the physician failed to see residents every 60 days at a minimum. This was evident for 1 (#246) of 5 residents reviewed for nutrition.
- D
Observe each nurse aide's job performance and give regular training.
Inspectors wroteBased on review of Geriatric Nursing Assistant (GNA) personnel files and staff interview, it was determined the facility failed to conduct yearly performance reviews at least every 12 months. This was found to be evident for all of the GNA's working in the facility. Based on review of employee files and staff interview, it was determined that the facility staff failed to put a system in place to ensure that Geriatric Nursing Assistants (GNA) were evaluated annually and provided appropriate re-education based on the outcome of these evaluations. This was found to be evident for 3 of 3 GNA (#14, #20, #23) reviewed for annual evaluations. This deficient practice has the potential to affect all the residents in the facility.
- D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Inspectors wroteBased on record review, and interviews, it was determined that the facility 1) failed to ensure a resident had a continuous supply of their prescribed medications. This was evident for 1 (Resident # 25) out of 5 residents reviewed for unnecessary medications, and 2) failed to ensure staff followed porcedures related to the accounting of controlled substances. This was found to be evident on 2 of 2 nursing unit.
- D
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 medical record review and interview, it was determined that the pharmacist failed to identify an order that was over the maximum recommended dose of a medication. This was found to be evident for 1 (Resident #39) out of 5 residents reviewed for unnecessary medications during the survey.
- D
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Inspectors wroteBased on medical record review and interview, it was determined that the facility failed to ensure a resident was free from excessive dose of a medication. This was found to be evident for 1 (Resident #39) out of 5 residents reviewed for unnecessary medications during the survey.
- 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, review of pertinent documentation and interviews it was determined that the facility failed to ensure medications were stored according to accepted professional standards. This was found to be evident for two out of two nursing units.
- D
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Inspectors wroteBased on resident interview, observation, and staff interview, it was determined that the facility failed to serve residents a meal that was appetizing in appearance and at the appropriate temperature. This was evident for 1 (#35) of 1 resident reviewed for food concerns.
- 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, it was determined that the facility failed to maintain complete medical records for residents. This was evident for 1 (#35) of 3 residents reviewed for hospitalization and 1 (#36) of 9 residents reviewed for abuse.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, and interview, it was determined that the facility failed to ensure that appropriate hand hygiene was maintained during wound care. This was evident for 1 resident (Resident #25) reviewed for pressure injury during an annual survey.
- D
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Inspectors wroteBased on observation and interview with facility staff, it was determined that the facility failed to maintain sidewalks and patios in a way that they were safe for the residents, staff, and the public to use. This was evident for 3 of 3 sidewalks and 1 of 1 patio observed during the survey.
March 15, 2019Standard inspection · 16 citations
- F
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 review of the medical record, it was determined that the facility staff failed to review and revise resident's care plans after each Minimum Data Set (MDS) Assessment and as needed. This was evident for 1 (#10) of 1 resident reviewed for pressure ulcers and infections, 1 (#26) of 5 residents reviewed for unnecessary medications, 1 (#38) of 2 residents reviewed for activities of daily living, and 1 (#17) of 2 residents reviewed for care plans. A care plan is a guide that addresses the unique needs of each resident. It is used to plan, assess, and evaluate the effectiveness of the resident's care.
- F
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 interview with staff and review of the medical record, the facility failed to ensure that there were sufficient nursing staff to assure resident safety, to attain or maintain the highest practical well-being of each resident, and to administer medications in accordance with the standards of professional practice. This deficient practice had the potential to affect all residents.
- E
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteBased on resident and staff interviews, it was determined that the facility failed to treat residents with dignity and respect by failing to answer call bells in a timely manner. This was evident for 1 (Resident #46) out of 16 residents interviewed the first day.
- 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 interview with the resident and review of the medical record, it was determined that the facility staff failed to develop and implement person-centered care plans for each resident that included measurable objectives and timeframes. This was evident for 1 (Resident #10) of 1 resident reviewed for pressure ulcers and infections, 1 (Resident #26) of 5 residents reviewed for unnecessary medications, and 1 (Resident #17) of 2 residents reviewed for care plans. A care plan is a guide that addresses the unique needs of each resident. It is used to plan, assess and evaluate the effectiveness of the resident's care.
- E
Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit.
Inspectors wroteBased on medical record review and staff interview, it was determined that the facility staff failed to ensure physician medical visit notes were in residents' medical records on the day the residents were seen. This was evident for 1 (#26) of 5 residents reviewed for unnecessary medications and 1 (#38) of 2 residents reviewed for activities of daily living.
- E
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Inspectors wroteBased on review of facility documentation and interviews with the facility staff, it was determined that the facility failed to ensure that effective quality assessment and assurance performance improvement interventions were implemented to address deficiencies from a previous survey. This was evident during review of the Quality Assurance program.
- D
Allow resident to participate in the development and implementation of his or her person-centered plan of care.
Inspectors wroteBased on resident and staff interview and medical record review, it was determined the facility failed to include the resident and the resident's representative in the development and implementation of the resident's person-centered care plan. This was evident for 1 (#14) of 2 residents reviewed for care plans.
- D
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Inspectors wroteBased on observation, record review, and resident interview, it was determined that the facility failed to allow a resident to participate in choosing fall prevention measures. This was evident for 1 (#42) of 2 residents reviewed for Activities of Daily Living (ADLs).
- D
Ensure each resident receives an accurate assessment.
Inspectors wroteBased on medical record review and staff interview, it was determined that the facility staff failed to ensure that Minimum Data Set (MDS) assessments were accurately coded. This was evident for 1 (#26) of 5 residents reviewed for unnecessary medications.
- D
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Inspectors wroteBased on resident interview and record review, it was determined that facility staff failed to implement a baseline care plan to ensure that Resident #68's pain was managed. This was evident for 1 (#68) of 2 residents reviewed for pain management.
- D
Provide safe, appropriate pain management for a resident who requires such services.
Inspectors wroteBased on medical record review and interview with facility staff, it was determined that the facility failed to ensure physician orders for as-needed pain medication contained parameters for nursing administration of the medication. This was evident for 1 (#25) of 2 residents reviewed for pain management.
- D
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Inspectors wroteBased on observation, medical record review, and interview with residents and facility staff, it was determined that the facility failed to ensure that residents received medication from competent nursing staff in a way that followed the standards of medication administration and assured resident safety. This was evident for 1 of 3 medication observations.
- D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on review of medical record and interview with facility staff, it was determined that the facility failed to ensure that resident medical records were complete and accurate. This was evident for 2 (Residents #66 & #9) of 6 residents reviewed for unnecessary medication.
- C
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, it was determined the facility failed to notify the resident/resident representative in writing of a transfer/discharge of a resident along with the reason for the transfer. Additionally, the facility failed to routinely notify the Office of the State Long-Term Care Ombudsman of transfer/discharges of residents. This was evident for 3 (#69, #42, and #66) of 3 residents reviewed that were transferred to an acute care facility.
- B
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 wrote2) A medical record review conducted on 3/15/19, of Resident #42's progress notes revealed resident was sent to an acute care facility on 2/20/19 and there was no documentation that the resident's responsible party was notified, in writing, of the facility's bed hold policy. Based on medical record review and staff interview, it was determined the facility failed to notify the resident/resident representative in writing of the bed hold policy when the resident was transferred to an acute care facility. This was evident for 2 (#66, #42) of 3 residents reviewed that were transferred to an acute care facility.
- B
Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
Inspectors wroteBased on medical record review and interview with facility staff, it was determined that the facility failed to ensure that discharge summaries were completed for all discharge residents within a reasonable period of time. This was evident for 2 (#70, #71) of 3 residents reviewed for discharge.
Fire safety inspections
26 fire safety citations on file: 15 on December 12, 2025, 8 on June 7, 2023, 3 on March 15, 2019.
Every fire safety citation26 citations
- F
Develop and maintain an Emergency Preparedness Program (EP).
E 4 · December 12, 2025 · Corrected (the home has a date of correction)
- F
Address patient/client population and determine types of services needed.
E 7 · December 12, 2025 · Corrected (the home has a date of correction)
- F
Conduct testing and exercise requirements.
E 39 · December 12, 2025 · Corrected (the home has a date of correction)
- F
Meet other general requirements.
K 100 · December 12, 2025 · Corrected (the home has a date of correction)
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · December 12, 2025 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · December 12, 2025 · Corrected (the home has a date of correction)
- F
Have simulated fire drills held at unexpected times.
K 712 · December 12, 2025 · Corrected (the home has a date of correction)
- F
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
K 761 · December 12, 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 · December 12, 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 · December 12, 2025 · Corrected (the home has a date of correction)
- F
Ensure that testing and maintenance of electrical equipment is performed.
K 921 · December 12, 2025 · Corrected (the home has a date of correction)
- E
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
K 223 · December 12, 2025 · Corrected (the home has a date of correction)
- E
Have exits that are accessible at all times.
K 271 · December 12, 2025 · Corrected (the home has a date of correction)
- E
Install corridor and hallway doors that block smoke.
K 363 · December 12, 2025 · Corrected (the home has a date of correction)
- E
Ensure proper usage of power strips and extension cords.
K 920 · December 12, 2025 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · June 7, 2023 · Corrected (the home has a date of correction)
- F
Have simulated fire drills held at unexpected times.
K 712 · June 7, 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 · June 7, 2023 · Corrected (the home has a date of correction)
- D
Develop and maintain an Emergency Preparedness Program (EP).
E 4 · June 7, 2023 · Corrected (the home has a date of correction)
- D
Conduct risk assessment and an All-Hazards approach.
E 6 · June 7, 2023 · Corrected (the home has a date of correction)
- D
Keep aisles, corridors, and exits free of obstruction in case of emergency.
K 211 · June 7, 2023 · Corrected (the home has a date of correction)
- D
Have exits that are accessible at all times.
K 271 · June 7, 2023 · Corrected (the home has a date of correction)
- D
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
K 761 · June 7, 2023 · 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 · March 15, 2019 · Corrected (the home has a date of correction)
- C
Ensure that testing and maintenance of electrical equipment is performed.
K 921 · March 15, 2019 · Corrected (the home has a date of correction)
- C
Have proper medical gas storage and administration areas.
K 923 · March 15, 2019 · Corrected (the home has a date of correction)