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 62 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
1K
0L
Actual harm
1G
0H
0I
Potential for more than minimal harm
41D
15E
1F
Potential for minimal harm
0A
0B
3C
May 7, 2026Complaint inspection · 1 citation
- D
Ensure services provided by the nursing facility meet professional standards of quality.
Inspectors wroteBased on review of the clinical record and staff interviews, the facility staff failed to conduct and document a thorough assessment for 1 of 27 residents (Resident #125) in the survey sample.
February 20, 2026Standard inspection · 15 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 interview, record review, and review of the facility's policy, the facility failed to ensure residents were free from sexual abuse for two of nine residents reviewed for abuse (Resident (R) 2 and R122) out of 41 sampled residents. R2 experienced repeat sexual victimization when she was sexually abused by her Power of Attorney (POA2) in the facility, R121, and R100. Additionally, R122 was sexually abused by R99. Even though the facility was aware of R121's, R100's, and R99's incidents of sexual abuse and sexual behavior, the facility failed to put measures in place to protect R2, R122, and other vulnerable residents from sexual abuse, which constituted immediate jeopardy (IJ).
- G
Protect each resident from the wrongful use of the resident's belongings or money.
Inspectors wroteBased on interviews, record review, and review of the facility's policy, the facility failed to ensure residents were free from misappropriation for one of three residents (Resident (R) 120) reviewed for misappropriation out of 41 sampled residents. The Business Office Manager (BOM) used the resident's credit card for personal use, totaling over $10,000. This failure resulted in more than minimum consequence harming Resident #120 by deliberately misusing and exploiting significant amounts of money without consent which constituted Immediate Jeopardy past non-compliance.
- F
Provide and implement an infection prevention and control program.
Inspectors wroteBased on interviews, record review, and facility policy review, the facility failed to complete an assessment of the building to determine where Legionella and other opportunistic waterborne pathogens can grow and spread. Additionally, the facility failed to ensure staff adhered to Transmission Based Precautions (TBP) for one of 41 sampled residents (Resident (R) 51). These failures had the potential for some of the areas at risk for Legionella growth not to be monitored in the building and placed residents at risk for the spread of infections.
- E
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to report alleged abuse violations timely for five of five Residents (Resident (R) 2, R99, R100, R121 and R122) reviewed for abuse out of a total sample of 41 residents. This had the potential for continued abuse.
- E
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Inspectors wroteBased on interview, record review, and policy review, the facility failed to ensure residents and/or resident representatives were provided with written notices of transfer and bed hold notices for four of five residents (Residents (R) 5, R8, R51, and R99) reviewed for hospitalizations out of a total sample of 41. This failure had the potential for residents and/or resident representatives (RP) not to have the necessary information to make informed decisions regarding bed holds and to not be informed of the reasons for transfers.
- D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteBased on observation, interview, and facility policy review, the facility failed to provide a dignified dining experience for two Residents (Resident (R)8 and R30) of two observed during dining. R30 was left waiting for her meal set up after being delivered his tray. This failed practice had the potential to affect and resident who ate their meals in the dining room.
- D
Respond appropriately to all alleged violations.
Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to complete a thorough investigation of resident-to-resident abuse involving one resident (Resident (R)7) out of nine residents reviewed for abuse out of a total sample of 41 residents. This had the potential for unrevealed concerns and the potential for continued abuse.
- D
PASARR screening for Mental disorders or Intellectual Disabilities
Inspectors wroteBased on record review, interview, and policy review, the facility failed to ensure the Pre-admission Screening and Resident Review (PASARR) level one screen was completed accurately prior to admission for two residents (Resident (R) 8 and R105) of four residents reviewed for PASARR out of 41 sampled residents. This created a potential failure to identify what specialized or rehabilitative services the residents needed and whether placement in the facility was appropriate prior to admission.
- D
Ensure services provided by the nursing facility meet professional standards of quality.
Inspectors wroteBased on review of the clinical record and staff interviews, the facility staff failed to conduct and document a thorough assessment for 1 of 27 residents (Resident #125) in the survey sample.
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure residents were provided with foot care for one of one resident (Resident (R) 77) reviewed for activities of daily living (ADLs) out of 41 sample residents. This failure had the potential to affect resident care including personal hygiene in the facility.
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on interviews, and record review, the facility failed to monitor a resident for safety during a physician's appointment for one of five residents reviewed for accidents/hazards out of 41 sampled residents (Resident (R) 119). This failure had the potential to result in the resident experiencing an accident without an escort to the appointment.
- D
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 observation, interview, record review, and facility policy review, the facility failed to ensure alternative measures were attempted prior to the use of side rails, educated on the risks and benefits of side rail use, and failed to obtain a consent for the side rails for one of one Resident (Resident (R)63) out of 41 sampled residents. These failures placed the resident at risk of accidents and hazards related to side rail use.
- D
Ensure medication error rates are not 5 percent or greater.
Inspectors wroteBased on observation, interview, record review, and review of facility policy, the facility failed to ensure a medication error rate below five percent. During medication administration three medication errors for three residents (Resident (R) 5, R10, and R62) were made of 27 opportunities resulting in a medication error rate of 11.11 percent. These failures had the potential to increase or decrease the effectiveness of these medications.
- D
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Inspectors wroteBased on document review, observation, interview, and facility policy review, the facility failed to ensure one Resident (Resident (R)23) of one observed out of a total of 41 sampled residents received the meal that was posted on the menu. The facility further failed to ensure the meal that was served to R23 was pureed. This had the potential for the resident not to have nutritional needs met.
- D
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Inspectors wroteBased on observation, interview, and review of the test tray, the facility failed to ensure foods were served at palatable food temperatures for three of 96 residents (Resident (R) 8, R51, and R77) who received meals from the facility's kitchen. This had potential to dissatisfaction with meals and potential weight loss.
March 3, 2022Standard inspection · 31 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, and staff interview the facility staff failed to ensure resident rooms were maintained in a safe comfortable and homelike environment.
- E
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Inspectors wroteBased on review of facility documents, staff interview and the facility's policy; the facility staff failed to implement their abuse policy regarding the screening of employees for 25 of 25 employee records reviewed.
- E
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Inspectors wroteBased on observation, resident interview, staff interview, clinical record review, the facility staff failed to have ongoing communication, coordination and collaboration with the dialysis center regarding acute changes in the resident's status for 1 of 35 residents (Resident #64), in the survey sample.
- E
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Inspectors wroteBased on observation, clinical record review and staff interview the facility, the failed to ensure 3 of 35 residents, Residents (#30, #55 and #6) in the survey sample was seen by the pharmacist for Medication Regimen Review (MRR) on a monthly basis.
- E
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 staff interviews, clinical record review and facility documentation, the facility staff failed to ensure the recommendation for do a Gradual Dose Reduction (GDR) made on 01/20/22 by the facility's Nurses Practitioner (NP) for 1 of 35 resident (Resident #30) in the survey sample. Resident #30 received 41 extra doses of the unnecessary psychotropic medication Zyprexa 5 mg.
- E
Keep complete, dated laboratory records in the resident's record.
Inspectors wroteBased on observation, resident interview, staff interview, and clinical record review, the facility staff failed to have laboratory reports filed in the resident's clinical record for 1 of 35 residents (Resident #64), in the survey sample.
- E
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on observations and staff interviews, the facility staff failed to store utensils in a clean and sanitary manner.
- E
Implement a program that monitors antibiotic use.
Inspectors wroteBased on staff interview and facility document review, and it was determined that the facility staff failed to maintain an effective antibiotic stewardship program.
- E
Perform COVID19 testing on residents and staff.
Inspectors wroteBased on staff interviews, facility document and facility documentation, the facility staff failed to provide evidence of the facility's COVID-19 staff testing for an unvaccinated employee based on the level of community transmission according for the recommended frequency of twice a week.
- D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteBased on observation, resident interview and staff interview, the facility's staff failed to ensure 1 resident was treated with dignity and respect while receiving wound care. For 1 of 35 Residents (Resident #22), in the survey sample.
- D
Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
Inspectors wroteBased on observation, resident interview and staff interview and during the course of a complaint investigation, the facility's staff failed to ensure privacy while providing wound care for 1 of 35 residents (Resident #31) in the survey sample.
- D
Honor the resident's right to manage his or her financial affairs.
Inspectors wroteBased on a resident personal funds review, resident interview, staff interview and facility document review the facility staff failed to ensure that 1 resident out of 35 residents, (Resident #14) in the survey sample was afforded the right to manage their personal funds.
- D
Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home.
Inspectors wroteBased on a resident personal funds review, resident interview, staff interview and facility document review the facility staff failed to ensure that 1 resident out of 35 residents (Resident #14) in the survey sample was afforded the right to manage their personal funds.
- 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 resident interview, staff interviews, clinical record reviews and facility documentation review, the facility staff failed to ensure 2 of 35 residents in the survey sample, (Resident #55 and #3) were given the opportunity to formulate an advance directive.
- 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 staff interview and clinical record review; the facility staff failed to ensure the physician and resident representative were informed the medication (Zyprexa) was not decreased from 5 mg to 2.5 mg as ordered for 1 of 35 residents (Resident #30), and the facility staff failed to notify the resident representative and physician of a change in condition in a timely manner for 1 of 35 residents (Resident #316), in the survey sample. The Findings Included: 1. The facility staff failed to notify the physician/Nurse Practitioner (NP) and Resident Representative (RR) that Resident #30's psychotropic medication (Zyprexa 5 mg) was not decreased to 2.5 mg as recommended by the (NP) on 01/20/22. Resident #30 received 41 extra doses of the psychotropic medication Zyprexa. Resident #30 was admitted to the facility on [DATE]. [...]
- D
Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.
Inspectors wroteBased on staff interviews, clinical record review and facility documentation review the facility staff failed to ensure Comprehensive Care Plan Goals were sent upon transfer to the hospital for 1 out of 35 residents in the survey sample, Resident #3. The facility staff failed to ensure Resident #3's Comprehensive Care Plan Goals were sent upon transfer to the hospital on [DATE].
- 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 staff interviews, clinical record review and facility documentation review the facility staff failed to ensure a Bedhold notice was sent upon transfer to the hospital for 1 out of 35 residents in the survey sample, Resident #3. The facility staff failed to ensure Resident #3's Bedhold notice was sent upon transfer to the hospital on [DATE].
- D
PASARR screening for Mental disorders or Intellectual Disabilities
Inspectors wroteBased on observations, clinical record review, and staff interviews the facility staff failed to ensure that a Level I Preadmission Screening and Resident Review (PASARR) was conducted prior to admission or within 30 days of admission to the nursing facility for 1 of 35 residents in the survey sample, Resident #3. The facility staff failed to ensure a Level I Preadmission Screening and Resident Review (PASARR) was conducted prior to admission or within 30 days of Resident #3's admission to the facility on 7/23/19.
- 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, resident interview, staff interview and clinical record review the facility staff failed to include anticoagulation in the comprehensive care plan, for 1 of 35 resident (Resident #55), in the survey sample.
- 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 observations, resident interviews, staff interviews, and clinical record review, the facility staff failed to review and revise the care plan after the resident's dentures were broken for 1 of 35 residents (Resident #65) in the survey sample.
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on observation, resident interview, staff interview, clinical record review, and review of facility documents, the facility's staff failed to ensure a resident who is unable to carry out activities of daily living receives the necessary services to maintain grooming, and personal hygiene for 2 of 35 residents (Resident #31 and #14), in the survey sample.
- 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 observations, family interviews, staff interviews, and clinical record review, the facility staff failed to ensure a resident with limited range of motion of the left arm received application of the left arm splint as ordered to prevent further decrease in range of motion for 1 of 35 residents, (Resident #13), in the survey sample.
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on clinical record reviews, staff and resident interviews and during the course of a complaint investigation, the facility staff failed to ensure 1 of 35 residents (Resident #316), in the survey sample was free of accident hazards. Activities of daily Living (ADL) assistance was not provided for a resident that was care planned to have the assistance of one person while bathing/showering which placed the resident at risk for falls. This is a closed record resident.
- D
Provide safe, appropriate pain management for a resident who requires such services.
Inspectors wroteBased on observations, resident interview, staff interview, and clinical record review, the facility staff failed to address, assess and treat a resident's pain for 1 of 35 residents (Resident #6), in the survey sample.
- D
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 information obtained during the Sufficient and Competent Nurse Staffing task, the facility staff failed to staff a Registered Nurse (RN) for eight consecutive hours a day on 2/27/22, which could potentially affect all residents care.
- 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, clinical record review, staff interviews, and facility document review the facility staff failed to ensure a medication was securely stored for 1 of 35 residents in the survey sample, Resident #53. The facility staff failed to securely store a respiratory inhaler that was observed at the bedside of Resident #53.
- D
Provide special eating equipment and utensils for residents who need them and appropriate assistance.
Inspectors wroteBased on observations, interviews, medical record review and facility document review the facility staff failed to ensure assistive devices for meal consumption was provided for 1 of 35 resident's in the survey sample, Resident #3. The facility staff failed to ensure Resident # 3's issued built up weighted rocker knife and foam built up fork for self feeding were provided on each meal tray.
- D
Dispose of garbage and refuse properly.
Inspectors wroteBased on observations and staff interviews the facility staff failed to ensure garbage and refuse were disposed of properly.
- D
Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
Inspectors wroteBased on observation, staff interview and facility documentation, the facility staff failed to designate at least one qualified staff member as the facility's Infection Preventionist (IP).
- D
Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
Inspectors wroteBased on resident interview, staff interviews and clinical record review, the facility staff failed to ensure 1 out of 35 resident (Resident #35) in the survey sample, was given the opportunity to either refuse or accept a COVID-19 vaccine.
- C
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
Inspectors wroteBased on staff interview and review of facility documents, the facility staff failed to maintain a quality assessment and assurance committee which meets at least quarterly.
March 1, 2019Standard inspection · 15 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, group interview, staff interview and facility records, the facility staff failed to maintain hot water temperatures in resident rooms.
- E
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on observations, resident interview, clinical record review, and staff interviews, the facility staff failed to provide needed hygienic care for a dependent resident for 1 of 43 residents (Residents #57), in the survey sample. The facility staff failed to provide necessary oral hygiene to remove adhered food and plaque from Resident #57's teeth; and the facility staff failed to provide basic hygienic care to Resident #57's feet to prevent severe dryness and flakiness.
- E
Ensure that residents are free from significant medication errors.
Inspectors wroteBased on staff interview, resident interviews, clinical record review, and facility document review and in the course of a complaint investigation, the facility staff failed to ensure 1 of 43 residents in the survey sample, Resident #93, was free from a medication timing error. Resident #93 received his pain medication 60 or more minutes later than the prescribed time which interfered with the resident's pain control.
- E
Provide and implement an infection prevention and control program.
Inspectors wroteBased on information revealed during the Infection Prevention and Control Program review and staff interview, the facility staff failed to have an current and active Infection Prevention and Control Program. The facility staff failed to sign the Infection Prevention and Control Program policy into effect, effective 1/1/2019, and establish an infection control program which investigates collected data to track trends, prevent the onset and the spread of infections or use the data to educate the staff.
- D
Allow residents to self-administer drugs if determined clinically appropriate.
Inspectors wroteBased on observation, staff interview, clinical record review, and facility documentation review, the facility staff failed for one (Resident #51) of 43 residents in the survey sample to determine if the resident was capable of self-administering medication. Resident #51 was not assessed or approved to self-administer eye drops.
- D
Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.
Inspectors wroteBased on clinical record review, staff interviews and facility document review the facility staff failed to ensure a Plan of Care Summary was sent upon transfer to the hospital for 3 of 43 Residents in the survey sample, Resident # 73, Resident #87 and Resident #57. 1. The facility staff failed to ensure that Resident #73's Plan of Care Summary was sent to the receiving facility upon transfer to the hospital on 1/16/19. 2. The facility staff failed to ensure that Resident #87's Plan of Care Summary was sent to the receiving facility upon transfer to the hospital on 2/25/19. 3. The facility staff failed to ensure that Resident #57's Plan of Care Summary was sent to the receiving facility upon transfer to the hospital on 5/31/18
- 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 clinical record review, staff interviews and facility document review the facility staff failed to ensure a written notice of Bed-Hold Policy Notice was sent upon transfer to the hospital for 2 of 43 Residents in the survey sample, Resident # 73, and Resident #87. 1. The facility staff failed to ensure that Resident #73 received a written notice of Bed-Hold Policy Notice upon transfer to hospital on 1/16/19. 2. The facility staff failed to ensure that Resident #87 received a written notice of Bed-Hold Policy Notice upon transfer to hospital on 2/25/19.
- D
Ensure each resident receives an accurate assessment.
Inspectors wroteBased on observations, clinical record review, staff interview and review of the facility's policy, the facility staff failed to accurately code the Minimum Data Set (MDS) assessment for 1 of 43 residents (Residents #57), in the survey sample. The facility staff failed to accurately code Resident #57's Annual Minimum Data Set assessment dated [DATE], in section L (Oral/Dental Status).
- D
Ensure services provided by the nursing facility meet professional standards of quality.
Inspectors wroteBased on clinical record review, staff interview and review of the facility's policy, the facility staff failed to assure that services provided met professional standards, for 1 of 43 residents (Residents #71), in the survey sample. The facility staff failed to transcribe Resident #71's antibiotic order on 2/1/19.
- D
Provide appropriate foot care.
Inspectors wroteBased on observation, resident interview, staff interview and a review of clinical records, the facility staff failed to provide podiatry services for 3 residents out of a survey sample of 43 residents. (Resident # 47, # 28 & #57)
- D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Inspectors wroteBased on observations, resident record review, resident interviews, staff interviews, and facility document review the facility staff failed to provide pharmaceutical services to include administering medications to 2 of 43 Resident's in the Survey Sample (Resident #67 and #51). 1. The facility staff failed to ensure that Resident #67's medications were consumed on 2/25/19 instead of being left on the bedside table unattended. 2. The facility staff failed to administer Resident #51 ophthalmic drops according to the prescriber's orders. The facility staff allowed Resident #51 to self-administer Refresh eye drops while contaminating the vial.
- D
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Inspectors wroteBased on information obtained during a complaint investigation, a closed record review, and a staff interview, the facility staff failed to ensure a resident's drug regimen was free from unnecessary medications for 1 of 43 residents (Resident #92), in the survey sample. The facility staff administered three doses of Keflex (an antibiotic) to Resident #92, secondary to a medication transcription error.
- D
Provide or obtain dental services for each resident.
Inspectors wroteBased on observations, resident interview, clinical record review, and staff interview, the facility staff failed to assure residents received needed dental services for 1 of 43 residents (Residents #57), in the survey sample. The facility staff failed to assist Resident #57 obtain needed dental services for decayed teeth and dental caries (cavities).
- 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 clinical record review, staff interview, facility document review and the facility's policy, the facility staff failed to notify the Office of the State Long-Term Care Ombudsman in writing of a hospital discharge for 2 of 43 residents (Resident #57 and 73) in the survey sample. 1. The facility staff failed to notify the Long-Term Care Ombudsman of Resident #57's discharge and admission to a local acute care hospital, 5/31/18. 2. The facility staff failed to notify the Office of the State Long-Term Care Ombudsman of Resident #73's discharge to the hospital on 1/16/19.
- C
Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
Inspectors wroteBased on a complaint investigation, staff interviews and facility document review the facility staff failed to accurately submit mandatory Payroll Based Journal Quarterly data to include direct care staffing information. The facility staff failed to accurately submit mandatory Payroll Based Journal Quarterly data to include direct care staffing hours for the Director of Nursing for July-September 2018.
Fire safety inspections
46 fire safety citations on file: 6 on February 20, 2026, 25 on March 3, 2022, 15 on March 1, 2019.
Every fire safety citation46 citations
- E
Install corridor and hallway doors that block smoke.
K 363 · February 20, 2026 · Corrected (the home has a date of correction)
- E
Ensure that periodic evaluations are made of hazards that could be encountered during surgical procedures, and fire prevention procedures are established.
K 933 · February 20, 2026 · Corrected (the home has a date of correction)
- D
Inspect, test, and maintain automatic sprinkler systems.
K 353 · February 20, 2026 · Corrected (the home has a date of correction)
- D
Properly select, install, inspect, or maintain portable fire extinguishes.
K 355 · February 20, 2026 · Corrected (the home has a date of correction)
- D
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
K 761 · February 20, 2026 · Corrected (the home has a date of correction)
- D
Meet other general requirements.
K 932 · February 20, 2026 · Corrected (the home has a date of correction)
- D
Install proper backup exit lighting.
K 281 · March 3, 2022 · Corrected (the home has a date of correction)
- D
Meet requirements for operating features, such as evacuation plans, fire drills, smoking regulations, draperies, decorations and the inspection, testing and maintenance of fire doors.
K 700 · March 3, 2022 · Corrected (the home has a date of correction)
- D
Have simulated fire drills held at unexpected times.
K 712 · March 3, 2022 · Corrected (the home has a date of correction)
- D
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
K 761 · March 3, 2022 · Corrected (the home has a date of correction)
- D
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · March 3, 2022 · Corrected (the home has a date of correction)
- C
Conduct risk assessment and an All-Hazards approach.
E 6 · March 3, 2022 · Corrected (the home has a date of correction)
- C
Address patient/client population and determine types of services needed.
E 7 · March 3, 2022 · Corrected (the home has a date of correction)
- C
Develop Emergency Preparedness policies and procedures.
E 13 · March 3, 2022 · Corrected (the home has a date of correction)
- C
Address subsistence needs for staff and patients.
E 15 · March 3, 2022 · Corrected (the home has a date of correction)
- C
Establish procedures for tracking staff and patients during an emergency.
E 18 · March 3, 2022 · Corrected (the home has a date of correction)
- C
Establish policies and procedures including evacuation.
E 20 · March 3, 2022 · Corrected (the home has a date of correction)
- C
Establish policies and procedures for sheltering.
E 22 · March 3, 2022 · Corrected (the home has a date of correction)
- C
Establish policies and procedures for medical documentation.
E 23 · March 3, 2022 · Corrected (the home has a date of correction)
- C
Establish policies and procedures for volunteers.
E 24 · March 3, 2022 · Corrected (the home has a date of correction)
- C
Create arrangements with other facilities to receive patients.
E 25 · March 3, 2022 · Corrected (the home has a date of correction)
- C
Establish roles under a Waiver declared by secretary.
E 26 · March 3, 2022 · Corrected (the home has a date of correction)
- C
List the names and contact information of those in the facility.
E 30 · March 3, 2022 · Corrected (the home has a date of correction)
- C
Provide emergency officials' contact information.
E 31 · March 3, 2022 · Corrected (the home has a date of correction)
- C
Provide primary/alternate means for communication.
E 32 · March 3, 2022 · Corrected (the home has a date of correction)
- C
Establish methods for sharing information.
E 33 · March 3, 2022 · Corrected (the home has a date of correction)
- C
Provide a means of sharing information on occupancy/needs.
E 34 · March 3, 2022 · Corrected (the home has a date of correction)
- C
Provide family notifications of emergency plan.
E 35 · March 3, 2022 · Corrected (the home has a date of correction)
- C
Establish emergency prep training and testing.
E 36 · March 3, 2022 · Corrected (the home has a date of correction)
- C
Establish staff and initial training requirements.
E 37 · March 3, 2022 · Corrected (the home has a date of correction)
- C
Conduct testing and exercise requirements.
E 39 · March 3, 2022 · Corrected (the home has a date of correction)
- E
Inspect, test, and maintain automatic sprinkler systems.
K 353 · March 1, 2019 · 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 · March 1, 2019 · Corrected (the home has a date of correction)
- C
Address patient/client population and determine types of services needed.
E 7 · March 1, 2019 · Corrected (the home has a date of correction)
- C
Address subsistence needs for staff and patients.
E 15 · March 1, 2019 · Corrected (the home has a date of correction)
- C
Establish procedures for tracking staff and patients during an emergency.
E 18 · March 1, 2019 · Corrected (the home has a date of correction)
- C
Establish policies and procedures including evacuation.
E 20 · March 1, 2019 · Corrected (the home has a date of correction)
- C
Establish policies and procedures for sheltering.
E 22 · March 1, 2019 · Corrected (the home has a date of correction)
- C
Establish policies and procedures for medical documentation.
E 23 · March 1, 2019 · Corrected (the home has a date of correction)
- C
Establish policies and procedures for volunteers.
E 24 · March 1, 2019 · Corrected (the home has a date of correction)
- C
Establish roles under a Waiver declared by secretary.
E 26 · March 1, 2019 · Corrected (the home has a date of correction)
- C
List the names and contact information of those in the facility.
E 30 · March 1, 2019 · Corrected (the home has a date of correction)
- C
Establish methods for sharing information.
E 33 · March 1, 2019 · Corrected (the home has a date of correction)
- C
Provide family notifications of emergency plan.
E 35 · March 1, 2019 · Corrected (the home has a date of correction)
- C
Establish emergency prep training and testing.
E 36 · March 1, 2019 · Corrected (the home has a date of correction)
- C
Establish staff and initial training requirements.
E 37 · March 1, 2019 · Corrected (the home has a date of correction)