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 66 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
3J
0K
0L
Actual harm
2G
0H
0I
Potential for more than minimal harm
39D
19E
3F
Potential for minimal harm
0A
0B
0C
April 10, 2026Complaint inspection · 1 citation
- E
Make sure that a working call system is available in each resident's bathroom and bathing area.
Inspectors wroteBased on observation, and interview, the facility failed to ensure residents' call lights were within reach, for 4 of 10 sampled residents, (#5, #6, #7, and #9).
October 15, 2025Complaint inspection · 2 citations
- G
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Inspectors wroteBased on observation, interview and record review, the facility failed to protect the resident's right to be free from physical abuse by a Certified Nursing Assistant (CNA) for 1 of 5 residents reviewed for abuse, of a total sample of 12 residents, (#6). The facility's failure to protect resident #6 resulted in actual harm when the resident sustained injuries to his right hand and left forearm.
- E
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on observation, interview and record review, the facility failed to report an allegation of physical abuse to the Agency for Health Care Administration (AHCA) in a timely manner for 1 of 5 residents reviewed for abuse, of a total sample of 12 residents, (#6). The failure to immediately report prevented prompt protective measures to residents and delayed the reporting to state authorities.
June 20, 2025Standard inspection · 20 citations
- F
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wrote6. On 6/18/25 at 11:15 AM, kitchen staff prepared for the lunch meal and set up of the tray line. At 11:20 AM, there was Dietary Aide ZZ was in the preparation area near an upright refrigerator. He donned his facial hair restraint incorrectly, so that his mustache was exposed. He remained silent when he asked about the correct way to wear a facial hair restraint. Dietary Aide YY was seen washing dishes at the three compartment sink and had donned his facial hair restraint incorrectly, as well. His beard was sticking out and the facial hair restraint was under his chin. Approximately 3-4 minutes later, Dietary Aide XX was assisting with the lunch tray line set up. He was wearing gloves and adjusted his facial hair restraint, touching his face and underneath his nose. [...]
- E
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wrote6. Resident #349 was admitted to the facility on [DATE] with diagnoses to include respiratory failure with hypoxia (low O2), pulmonary embolism (clot in lung), encephalopathy (brain disorder), and tracheostomy status. Review of the Medication Review Report (physician orders) revealed the following orders: Tracheostomy size 6 Shiley, tracheostomy care daily and as needed. Clean the inner cannula and replace. Maintain Ambu bag at bedside and replacement tracheostomy of equal size and one size down at bedside every shift for preventative measure, dated 3/13/25. On 8/18/25 at 5:55 PM, resident #349 was in bed; at bedside there was no Ambu bag, and no size 5 or 6 replacement tracheostomy set seen. On 6/18/25 at 5:57 PM, Licensed Practical Nurse (LPN) J verified the Ambu bag and replacement tracheostomy required to be at the bedside for resident #349 was not present. [...]
- E
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 observation, interview, and record review, the facility failed to follow the menus for portion sizes. The non-compliance found had the potential to affect 263 residents, out of a total resident population of 350 residents that ate meals at the facility.
- E
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Inspectors wroteBased on observation, interview, and record review, the facility failed to demonstrate sustained performance improvement with respect to identified Quality Deficiencies and ensure the deficiencies were not repeated.
- D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteBased on observation, and interview, and record review, the facility failed to ensure residents were afforded dignity during meals for 2 of 20 residents reviewed for dining, of a total sample of 103, (#99, & #206).
- D
Allow resident to participate in the development and implementation of his or her person-centered plan of care.
Inspectors wroteBased on interview, and record review, the facility failed to provide an opportunity to participate in the development and implementation of a person-centered plan of care for 1 of 2 residents reviewed for care planning, of a total sample of 103 residents, (#327).
- D
Allow residents to self-administer drugs if determined clinically appropriate.
Inspectors wrote2. Resident #332 was admitted on [DATE] for dysphagia (trouble swallowing), sepsis, severe protein-calorie malnutrition, and hypertensive heart disease. The quarterly MDS dated [DATE] indicated resident #332 had a BIMS score of 15/15, which reflected no cognitive impairment. On 6/16/25 at 9:47 AM, three medications including a container of Naproxen, 220 milligram (mg) tablets, a tube of triple antibiotic gel, and a tube of Muscle Rub, were on the resident's bedside table. The resident stated he had these medications in his room since he was admitted and took them for pain as needed. At 9:54 AM, the A wing UM verified the medications on the resident's bedside table. She removed the medications and told the resident the facility would need to administer the medications to him per the physician's orders. [...]
- 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 interview, and record review, the facility failed to ensure prompt efforts were made to resolve grievances for 1 of 20 sampled residents regarding choices, of a total sample of 103 residents, (#120).
- D
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Inspectors wrote2. Resident #56 was a long-term care resident who admitted to the facility on [DATE]. Review of the level I PASARR dated 9/20/13, noted section 1A was blank and did not include any diagnoses of potential mental illness or intellectual disability. Review of the resident's current diagnoses included dementia, epilepsy, depression, anxiety and psychotic disorder. Record review revealed during a session with the Psychologist on 4/28/25, the resident was noted with a depressed mood and expressed feelings of being overwhelmed. There was not any evidence in the medical record that the level I PASARR had been updated. On 6/19/25 the Social Service Director was ask to provide a copy of the resident's level I PASARR. On 6/20/25 at 1:35 PM, the Social Service Director provided the requested copy of the PASARR dated 9/20/13 and a copy of a new PASARR which was updated on 6/19/25. [...]
- D
PASARR screening for Mental disorders or Intellectual Disabilities
Inspectors wroteBased on interview, and record review, the facility failed to request a Preadmission Screening and Resident Review (PASARR) level I and level II evaluation for 2 of 5 residents reviewed for PASARR, of a total sample of 103 residents, (#70, and #123).
- D
Provide activities to meet all resident's needs.
Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a resident centered activities program to meet the needs of residents who required 1:1 in room activities for 5 of 6 residents reviewed for in room activities, of a total sample of 103 residents, ( #152, #174, #345, #349, & #359).
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on interview, and record review, the facility failed to timely provide coordination of care for diagnostic imaging/laboratory services and a specialty gastrointestinal (GI) consult for 2 of 2 residents reviewed for coordination of care, (#159 and #22); and failed to obtain physician's wound treatment orders and complete weekly wound measurement assessments for 1 of 5 residents reviewed for non- pressure skin condition concerns, (#120), of a total of 103 sampled residents.
- D
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Inspectors wroteBased on observation, interview, and record review, the facility failed to provide care and services related to management and application of orthotic devices to prevent worsening of contractures and promote skin integrity for 1 of 1 residents reviewed for limited range of motion (ROM) and reduced mobility, of a total sample of 103 residents, (#249).
- D
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Inspectors wroteBased on observation, interview, and record review the facilty failed to provide care and services for a Peripherally Inserted Central Catheter (PICC) intravenous (IV) line for 1 of 1 residents reviewed for central line catheters, of a total sample of 103 residents, (#922).
- D
Provide safe, appropriate pain management for a resident who requires such services.
Inspectors wroteBased on interview, and record review, the facility failed to address a resident's pain timely for 1 of 2 residents reviewed for pain, of a total sample of 103 residents, (#250).
- D
Provide care or services that was trauma informed and/or culturally competent.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that residents who experienced trauma received trauma-informed care for 1 of 4 residents reviewed for behavioral-emotional concerns, of a total sample of 103 residents, (#251).
- 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 interview, and record review, the facility failed to act upon the pharmacist medication recommendations made for one of five residents reviewed for pharmacist recommendations, of a total sample of 103 residents, (#256).
- D
Ensure that residents are free from significant medication errors.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications were administered according to physician orders to prevent medication errors for 1 of 5 residents observed during the medication administration task, of a total sample of 103 residents, (#1).
- D
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Inspectors wroteBased on observation, interview, and record review, the facility failed to honor food preferences and accommodate residents who required alternate meal times due to appointments/procedures/treatments for 1 of 1 residents reviewed for renal dialysis, of a total sample of 103 residents, (#358).
- D
Provide and implement an infection prevention and control program.
Inspectors wrote3. Resident #99 was admitted to the facility on [DATE] with diagnoses of dementia, disorder of the brain, aphasia (inability to speak) and schizophrenia. The annual Minimum Data Set (MDS) dated [DATE] indicated the Brief Interview for Mental Status (BIMS) evaluation was not conducted as resident #99 was rarely or never understood and her cognitive abilities were severely impaired. The Care Plan indicated resident #99 was totally dependent on staff for eating and most other Activities of Daily Living (ADL's). 4. Resident #206 was admitted on [DATE] with diagnoses of disorders of muscle, type II diabetes mellitus with polyneuropathy, heart failure, chronic obstructive pulmonary disease, end stage renal disease, and dysphagia (trouble swallowing). [...]
August 22, 2024Complaint inspection · 1 citation
- E
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications were administered as per physician orders and according to professional standards of practice for 2 out of 5 residents reviewed for medication administration, (#2, #3)
March 8, 2024Standard inspection, Complaint inspection · 33 citations
- J
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Inspectors wroteBased on observation, interview and record review, the facility neglected to provide adequate oversight of staff to provide appropriate admission orders and skin assessments; and neglected to provide maintenance care and services for a peripherally inserted central line intravenous catheter (PICC) per standards of care for 1 of 1 resident reviewed for PICC lines, of a total sample of 109 residents, (#72). Resident #72 was readmitted to the facility from the hospital on 1/10/24 with a peripherally inserted central line catheter in his left upper arm. The 3008 Agency for Healthcare Administration Transfer and Discharge form dated 1/10/24 detailed the double lumen PICC, but the form did not give the date it was inserted, the date the dressing was last changed or the location. [...]
- J
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on observation, interview, and record review, the facility failed to provide adequate care and services in accordance with accepted professional standards to identify, obtain and implement physician orders for a peripherally inserted intravenous central line catheter (PICC) for 1 of 1 resident reviewed for PICC lines, (#72), failed to change intravenous line dressings as per orders for 1 of 6 residents reviewed for medication administration (#435), and failed to monitor blood glucose levels as per physician orders for 1 of 3 residents reviewed for (#584) insulin use out of a total sample of 109 residents, (#72). Resident #72 was readmitted to the facility from the hospital on 1/10/24 with a peripherally inserted central line catheter in his left upper arm. [...]
- J
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, interview, and record review the facility failed to ensure licensed nurses were knowledgeable and demonstrated competency to provide care and services per standards of care for a peripherally inserted intravenous central line catheter (PICC) for 1 of 1 resident reviewed for PICC lines, out of a total sample of 109 residents (#72) and failed to ensure licensed nurses were competent to follow physician orders for medication parameters, topical ointments and diabetes management for 4 of 102 licensed nurses, (Registered Nurses D, K, E and GG). Resident #72 was readmitted to the facility from the hospital on 1/10/24 with a peripherally inserted central line catheter in his left upper arm. [...]
- G
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 wrote5. Resident #85 was admitted to the facility on [DATE], with diagnoses that included multiple sclerosis, schizoaffective disorder, bipolar disorder, delusional disorders, foot drop right/left foot, and chronic pain. Review of the MDS quarterly assessment with Assessment Reference Date (ARD) of 12/08/23, revealed the resident's cognition was intact, with BIMS score of 14 out of 15. The assessment noted the resident had impairment in functional limitation in ROM on both sides of her upper and lower extremities and was dependent on staff assistance for transfer and personal hygiene. A physician order dated 4/18/22 noted left resting hand splint for 2 hours with skin integrity daily. On 3/04/24 at 10:07 AM, and on 3/05/24 at 9:56 AM, resident #85 was sitting up in bed watching television. Her left hand was contracted, and no splint was noted. [...]
- 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 and interview, the facility failed to ensure food was stored, prepared, and served in a safe and sanitary manner to prevent foodborne illness in the main kitchen and 4 out of 6 pantries.
- E
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 record review, the facility failed to ensure 32 of 32 dependent residents on the memory care unit reviewed for dining were provided a homelike environment during mealtimes, of a total sample of 109 residents.
- 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 interview, the facility failed to provide housekeeping and maintenance services necessary to ensure shower rooms were clean, sanitary, and homelike on 3 of 6 units (A wing, C Wing, G-Wing), failed to ensure Air Condition (AC) units were clean and in good repair in 5 rooms on the C Wing (C-09, 10, 12, 13, 25), failed to provide a comfortable interior in 2 rooms on the H-Wing, (1205, 1211) and failed to ensure return of residents clothing from the laundry for 3 of 10 residents reviewed for personal property (#4, #7, #307) of a total sample of 109 residents
- E
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 interview, and record review, the facility failed to provide written Notification of Transfer or Discharge forms to the residents or their representative, and the state Ombudsman for 6 of 7 residents reviewed for hospitalizations out of a total sample of 109 residents, (#58, #198, #727, #155, #3, and #61).
- E
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on observation, interview, and record review the facility failed to provide Activities of Daily Living (ADL) care with respect to oral care, bathing, grooming, nail care and change of clothing for 9 of 18 residents identified to have concerns with lack of ADL care in a total sample of 109 residents, (#300, #246, #110, #87, #435, #29, #434, #238, #137).
- E
Provide activities to meet all resident's needs.
Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a resident centered activities program which met the individual interests and needs of the resident, which encouraged both independent and group interactions for 11 out 17 residents identified not to have any meaningful activities of a total sample of 109 residents, (#246, #107, #309, #202, #137, #435, #434, #47, #238, #285 and #7).
- E
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Inspectors wroteBased on observation, interview and record review, the facility failed to obtain a physician's order for removal and care of an indwelling urinary catheter for 1 of 2 residents observed for indwelling catheters of a total sample of 109 residents, (#136).
- E
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Inspectors wroteBased on observation, interview, and record review, the facility failed to provide pharmaceutical services related to accurate interpretation of a physician order, (#437); proper acquisition, storage, and administration of medication, (#586); appropriate storage of medications at bedside, (#256); and safe administration of medication according to professional standards, (#284), for 4 of 109 sampled residents.
- E
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Inspectors wroteBased on interview, and review of facility documentation, the facility failed to ensure implementation of policies to the extent of including thorough monitoring of previously identified areas of concern and adequately tracking performance to ensure prior improvement measures were realized and sustained.
- E
Keep all essential equipment working safely.
Inspectors wroteBased on observation, and interview, the facility failed to maintain mechanical, and electrical equipment in the kitchen in safe operating condition.
- D
Allow residents to self-administer drugs if determined clinically appropriate.
Inspectors wroteBased on observation, interview, and record review, the facility failed to conduct medication self-administration assessment to ensure safety for 3 of 3 residents reviewed for self-administration of medications, out of a total sample of 109 residents, (#256, #284 and #586).
- D
Protect a residents' right to refuse some types of non-requested transfers within the nursing home.
Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure residents and/or their representatives had the opportunity to refuse room transfers for 1 of 11 residents identified to have concerns related to resident rights, in a total sample of 109 residents, (#122).
- 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 interview, and record review, the facility failed to promote resident rights related to choice of type and frequency of baths for 1 of 17 residents reviewed for choices, out of a total sample of 109 residents, (#156).
- 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 interview and record review, the facility failed to conduct thorough, periodic reviews of Advance Directives to ensure resuscitation status related to Do Not Resuscitate Orders (DNROs) was appropriately documented in the medical record to effectively communicate choices regarding withholding life-sustaining measures for 3 of 4 residents reviewed for Advance Directives, out of a total sample of 109 residents, (#184, #246, and #165).
- 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 interview and record review, the facility failed to follow their grievance process related to homelike environment for 1 of 1 resident reviewed for grievances in a total sample of 109 residents, (#267).
- D
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Inspectors wroteBased on observation, interview, and record review, the facility failed to complete a Preadmission Screening and Resident Review (PASARR) for a newly diagnosed Serious Mental Illness (SMI) for 1 of 10 residents reviewed for PASARR from a total sample of 109 residents, (#138).
- D
PASARR screening for Mental disorders or Intellectual Disabilities
Inspectors wroteBased on interview, and record review, the facility failed to request a Preadmission Screening and Resident Review (PASARR) level 1 and level II evaluations for 1 of 10 residents reviewed for PASARR from a total sample of 109 residents, (#12).
- 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 interview, and record review, the facility failed to ensure the opportunity to participate in the development, implementation, and evaluation of their care plan was provided to 1 of 3 residents reviewed for care planning, of a total sample of 109 residents, (#29).
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on observation, interview, and record review, the facility failed to provide appropriate care and treatment to promote healing of a pressure ulcer for 1 of 1 resident reviewed for pressure ulcers of a total sample of 109 residents, (#295).
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the resident's environment was free of accident hazards related to an unsecured oxygen cylinder for 1 of 10 residents reviewed for accidents, out of a total sample of 109 residents, (#71).
- 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 observation, interview, and record review, the facility failed to provide appropriate care and services as per physician orders for 1 of 1 resident reviewed for gastric tube feeding out of a total sample of 109 residents, (#222).
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observation, interview and record review, the facility failed to maintain oxygen flow rate as ordered by the physician for 2 of 5 residents reviewed for respiratory care from a total sample of 109 residents, (#137 and #157).
- D
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain adequate communication with the dialysis center, follow the comprehensive person-centered care plan and ensure post-dialysis assessments were completed for 3 of 4 resident reviewed for dialysis of a total sample of 109 residents, (#109, #220, and #313).
- D
Ensure medication error rates are not 5 percent or greater.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications were administered according to physician orders to prevent medication errors for 2 of 6 residents observed during the medication administration task, out of a total sample of 109 residents, (#437 and #584). There were 2 errors in 25 opportunities for a medication error rate of 8%.
- 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 observation, interview, and record review, the facility failed to provide meals and alternatives that met nutritional needs and food preferences for 1 of 4 residents reviewed for dialysis, (#109); and failed to provide fortified foods to meet nutritional adequacy according to the plan of care for 1 of 10 residents reviewed for food and nutrition services, (#238), out of a total sample of 109 residents.
- D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on interview and record review, the facility failed to ensure the medical record reflected actual medication administration time for 1 of 4 residents reviewed for dialysis, (#109), and accurate blood glucose level and insulin administration time for 1 of 6 residents reviewed during the medication administration task, (#584), out of a total sample of 109 residents.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview, and record review, the facility failed to adhere to proper infection control practices related to hand hygiene during lunch meal service on 1 of 6 units, (B Wing).
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on interview, and record review, the facility failed to ensure investigation for alleged neglect was submitted to the State Survey Agency, within 5 working days of the incident for 1 of 2 residents reviewed for neglect, of a total sample of 109 residents, (#67).
- D
Respond appropriately to all alleged violations.
Inspectors wroteBased on interview, and record review, the facility failed to ensure a thorough investigation was completed pertaining to a fall for 1 of 11 residents reviewed for accidents, of a total sample of 109 residents, (#436).
May 5, 2022Standard inspection · 9 citations
- F
Dispose of garbage and refuse properly.
Inspectors wroteBased on observation and interview, the facility failed to dispose of garbage properly and maintain the garbage storage area in a sanitary manner.
- E
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 record review and interview, the facility failed to provide written notification to the Office of the State Long-Term Care Ombudsman regarding transfers and discharges for 5 of 6 residents reviewed for transfer/discharge status, of a total sample of 95 residents, (#409, #229, #173, #230 & #291).
- 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 interview and record review, the facility's Consultant Pharmacist failed to identify and report irregularities related to use of a medication contrary to a physician's order for 1 of 5 residents reviewed for unnecessary medications, of a total sample of 95 residents (#142).
- E
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Inspectors wroteBased on interview and medical record review, the facility gave a prescribed medication without adequate indications for use to 1 of 5 sampled residents reviewed for medication administration, of a total sample of 95 residents (#142).
- 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, record review and interview the facility failed to ensure dietary staff utilized hair restraints, stored food correctly, maintained kitchenware and equipment in a clean, sanitary and functional manner.
- 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 observation, interview, and record review, the facility failed to develop a baseline care plan in a timely manner related to intravenous (IV) services and treatments for1 of 1 newly readmitted residents reviewed for IV therapy services, of a total sample of 95 residents (#716).
- 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, interview, and record review, the facility failed to develop a comprehensive care plan for continuous oxygen (O2) therapy via a nasal cannula and oxygen concentrator for 1 of 5 residents reviewed for respiratory care services, of a total sample of 95 residents (#120).
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observation, interview, and record review, the facility failed to obtain physician orders for continuous oxygen (O2) therapy for 1 of 5 residents reviewed for respiratory care services of a total sample of 95 residents (#120).
- D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Inspectors wroteBased on observation, interview and record review, the facility failed to provide pharmaceutical services to ensure medications were administered according to physician orders for 1 of 5 residents reviewed for medication administration, of a total sample of 95 residents (#716).
Fire safety inspections
8 fire safety citations on file: 4 on June 20, 2025, 4 on March 8, 2024.
Every fire safety citation8 citations
- F
Develop and maintain an Emergency Preparedness Program (EP).
E 4 · June 20, 2025 · Corrected (the home has a date of correction)
- E
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
K 761 · June 20, 2025 · Corrected (the home has a date of correction)
- E
Have power receptacles that are properly grounded.
K 912 · June 20, 2025 · Corrected (the home has a date of correction)
- E
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
K 914 · June 20, 2025 · Corrected (the home has a date of correction)
- E
Keep aisles, corridors, and exits free of obstruction in case of emergency.
K 211 · March 8, 2024 · Corrected (the home has a date of correction)
- E
Install an approved automatic sprinkler system.
K 351 · March 8, 2024 · Corrected (the home has a date of correction)
- E
Install corridor and hallway doors that block smoke.
K 363 · March 8, 2024 · Corrected (the home has a date of correction)
- E
Have power receptacles that are properly grounded.
K 912 · March 8, 2024 · Corrected (the home has a date of correction)