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 100 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
1J
0K
0L
Actual harm
1G
0H
0I
Potential for more than minimal harm
76D
20E
0F
Potential for minimal harm
0A
2B
0C
July 16, 2026Complaint inspection · 1 citation
- D
Provide enough food/fluids to maintain a resident's health.
Inspectors wroteBased on interview and record review, the facility failed to ensure one of 3 residents (Resident 1) who suffered weight loss received adequate nutrition by failing to:Carry out the Registered Dietitian's (RD, a licensed healthcare professional specialized in providing nutrition therapy to help residents meet their health needs) nutritional recommendations. Administer the correct gastric tube feeding (GT, a tube surgically placed directly into the stomach to administer liquid feeding and medications) formula, as recommended by the RD.These failures had the potential to result in the resident's continued weight loss, leading to complications like malnutrition, dehydration, including hospitalization.
July 2, 2026Complaint inspection · 1 citation
- D
Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.
Inspectors wroteBased on observation, interview and record review, the facility failed to ensure, one of three sample residents' (Resident 1), received the therapeutic diet (meal plan prescribed by a healthcare professional [doctor or dietitian] to manage a specific medical condition, treat an illness, or improve overall health) ordered by the physician. This deficient practice resulted in Resident 1's high blood sugar levels, placing the resident at risk for complications like diabetic coma (life-threating, temporary state of unconsciousness caused by extreme high blood sugar levels).
May 22, 2026Complaint inspection · 1 citation
- E
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure three of three sampled residents (Residents 1, 2, and 3), received treatment and care in accordance with professional standards of practice by failing to ensure:Residents 1, 2, and 3 were turned every two hours according to the Resident's Care Plans. Resident 2 and 3's Care Plans were updated to reflect the Resident's preference not to use pillows when repositionedThe facility followed its policy and procedure (P&P) titled, Skin Integrity Management, which indicated the facility will perform skin inspections, wound observations and measurements weekly. These failures had the potential to result in the worsening of Resident 1 and 2's skin conditions, skin breakdown for Resident 3 and could negatively affect the Resident's health and well-being.
May 6, 2026Complaint inspection · 1 citation
- D
Ensure services provided by the nursing facility meet professional standards of quality.
Inspectors wroteBased on interview and record review, the facility failed to report to the physician, one of four sampled residents' (Resident 1) elevated blood glucose levels (amount of sugar circulating in the person's blood stream) on 4/25/2026, 4/26/2026 and 5/3/2026 to 5/5/2026. This deficient practice placed Resident 1 at risk for hyperglycemia (high blood glucose) and serious health complications like heart disease, stroke, including hospitalization.
April 29, 2026Complaint inspection · 2 citations
- 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 interview and record review, the facility failed to implement intervention by monitoring and recording all meal intakes completely, as indicated in the resident's care plan titled, Resident as at nutritional risk, for one of four sampled residents' (Resident 1). This failure had the potential to delay in identifying the resident's nutritional status and interventions being met and at risk for complications of lack of nutrition such as hospitalization.
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on interview and record review, the facility failed to implement its policy and procedure (P&P) titled, Fall Management, which indicated, patients should be assessed for fall risk and receive appropriate interventions to reduce risk and minimize injury, review, revise or update new care plan to reflect new interventions, for one of four sampled residents (Resident 1). This failure placed Resident 1 at risk for recurring fall and had the potential to sustain injuries, hospitalization, and death.
April 1, 2026Complaint inspection · 1 citation
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on interview and record review, the facility failed to follow the facility's policy and procedure for Out On Pass for one of three sampled residents (Resident 1) when Resident 1 left the facility without being assessed, someone accompanying him, and signing out in the Out on Pass log. This deficient practice has the potential for Resident 1 to be injured while outside the facility's premises without the facility's knowledge.
February 6, 2026Complaint inspection · 1 citation
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview and record review, the facility failed to:1. Ensure Certified Nursing Assistant (CNA) 1 discarded personal protective equipment (PPE) in a designated trash bin. This failure had the potential to increase the risk of infection and cross-contamination (the transfer of bacteria, viruses, microorganisms, or other harmful substances from one surface to another through improper or unsanitary equipment, procedures, or products) among residents.
January 9, 2026Complaint inspection · 2 citations
- D
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Inspectors wroteBased on observation, interview, and record review, the facility failed to exercise reasonable care for the protection of one of three sampled residents' (Resident 1) personal property by failing to: 1. Ensure Resident 1's Inventory of Personal Effects (personal belonging inventory list) was completed on admission to the facility. This failure had the potential to result in Resident 1's belongings getting lost or stolen and negatively affecting the resident's psychosocial well-being.
- 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 meet residents' needs for one of three sampled residents (Resident 1) by failing to:1. Ensure the alprazolam (medication to treat anxiety) was available to be administered according to the physician's order for Resident 1. This failure had the potential for Resident 1 to feel frustrated and result in worsening of the Resident's anxiety.
December 12, 2025Complaint inspection · 6 citations
- 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 interview and record review, the facility failed to create a baseline care plan (initial instructions that addresses resident-specific health and safety concerns immediately upon admission, including needs for supervision, behavioral interventions, and assistance with activities of daily living) within 48 hours of admission, for one of four residents (Resident 1), as indicated in the facility's policy and procedure (P&P) titled Care Plan - Baseline. This failure had the potential to result in Resident 1's care team not aware of Resident 1's needs and placed the resident at risk for not receiving the necessary care and services safely.
- 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 ensure care was provided in accordance with professional standards of practice and the resident's comprehensive person-centered care plan for one of three residents (Resident 1) who was admitted to the facility with a left hip surgical incision/wound received treatment. The facility failed to ensure:1). Resident 1's left hip surgical site/ wound was monitored for signs of infections like pustules (a small blister or pimple on the skin containing pus) and inflammation (a condition in which a part of the body becomes reddened, swollen, hot, and often painful, especially as a reaction to injury or infection) as indicated in Resident 1's care plan titled, Resident has skin breakdown related to surgical site.2). [...]
- D
Provide safe, appropriate pain management for a resident who requires such services.
Inspectors wroteBased on an interview and record review, the facility failed to implement the physician's order for pain management for one of four sampled residents (Resident 1). This failure had the potential to result in Resident 1 becoming dependent on pain medication. This failure had the potential for Resident 1 to reduce her capacity to manage and cope with her pain.
- 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 pork sausage patty in the breakfast tray, for two of four sampled residents (Residents 2 and 3), as indicated on the menu and meal tickets (the diet order that matched the dietitian approved menu, honoring resident food preferences). This failure resulted in Resident 2 and Resident 3 not receiving the adequate protein and calories, potentially worsening their protein and calorie malnutrition (undernutrition).
- 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 ensure one of four sampled residents (Resident 2) was not served in her breakfast tray, orange juice and hot cereal as indicated in the resident's meal ticket. This failure resulted in a violation in Resident 2's rights, which caused her to feel angry and distressed.
- 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 accurate documentation was maintained for one of four resident's (Resident 1). This failure had the potential for miscommunication and inaccurate clinical decision-making and could result in delayed identification of condition changes and providing care.
November 18, 2025Complaint inspection · 2 citations
- D
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 ensure 1 of 3 sampled residents (Resident 1) did not have a diaper and bed linen soaked with urine. This failure placed Resident 1 at risk for skin breakdown.
- D
Post nurse staffing information every day.
Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a current Direct Care Service Hours Per Patient Day (DHPPD- a staffing standard used in California's skilled nursing facilities, that measures the average number of actual hours of direct care provided to each patient in a 24-hour period) containing an updated census and number of staff on duty to ensure residents receive adequate level of direct care), was posted on 9/29/2025 at Nursing Station 1. This failure had the potential the facility did not meet the staffing requirements and placed the residents' care needs at risk of not being met.
June 13, 2025Standard inspection, Complaint inspection · 14 citations
- E
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the safe provision of pharmacy services for two of three sampled residents (Resident 94 and 17) when: 1. Resident 94 ' s supplements were not labeled with resident ' s name and date of birth . 2. Resident 17 ' s box of morphine medication was labeled with another resident ' s medication label This failure had the potential to result in medication errors.
- E
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on observation, interview, and record review the facility failed to: 1. Ensure one of five sampled residents (Resident 29) physician orders were updated when the Licensed staff received a telephone order. This deficient practice of not updating physician orders had the potential to cause the Licensed staff to administer the medication the incorrect route. 2. Complete an initial Body Check for one of three sampled residents (Resident 88), by not documenting the status of her skin upon admission. This deficient practice of failing to do an initial skin assessment, caused Resident 88's medical records to be incomplete.
- E
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview and record review, the facility failed to ensure staff disposed of a used protective personal equipment (PPE, clothing and equipment that is worn or used to provide protection against hazardous substances and/or environments) inside the resident ' s room instead of the hallway. This failure had the potential to increase the chances of acquiring infections and for germs to be transmitted in between residents.
- E
Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.
Inspectors wroteBased on observation, interview and record review, the facility failed to ensure 23 of 36 resident's rooms (rooms 2, 3, 4, 5, 7, 8, 9, 10, 11, 12, 13, 22, 23, 24, 28, 29, 30, 31, 32, 33, 34, 35, 36) met the requirement of 80 square feet (sq. ft.) per resident in a multiple resident room. This deficient practice had the potential for inadequate space for resident care and personal property and the inability to move around the room easily.
- 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 record review, the facility failed to ensure all residents had access to the weekly menu and list of alternative choices to the weekly menu, by posting them outside the kitchen, excluding access to residents who are bed or chair bound affecting two of three sampled residents (Resident 12 and Resident 36). The deficient practice of failing to provide menus to residents limited their choice of food due to their physical limitations.
- D
Reasonably accommodate the needs and preferences of each resident.
Inspectors wroteBased on observation, interview, and record review the facility failed to ensure one out of five residents (Resident 22) call light was within reach. This failure had the potential for Resident 22 needs not being met.
- D
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 ensure one out of three sampled residents (Resident 58): 1. Resident 58 was free from mental abuse. 2. To follow facility's policy and procedure (P&P) titled, Abuse Prohibition Policy and Procedure, dated 2/2021, the P&P indicated mental abuse were prohibited threats verbal or nonverbal conduct which can cause or had the potential for the patient to experience intimidation or fear. This deficient practice of not preventing mental abuse for Resident 58 had the potential for Resident 58 to feel unsafe and uncomfortable.
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on interview and record review, the facility failed to report a femur (thigh bone) fracture of an unknown origin to the California Department of Public Health (CDPH) for one of one sampled residents (Resident 57). This failure resulted in a delay of an investigation by the CDPH.
- 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 one out of five sampled residents (Resident 29) had a revised care plan for medication administration to be taken by mouth. The deficient practice had the potential for repeat occurrences.
- D
Ensure services provided by the nursing facility meet professional standards of quality.
Inspectors wroteBased on interview, and record review the facility failed to follow the physician's orders to not give losartan (a medication used to control blood pressure) for one out of one resident (Resident 84) when the systolic blood pressure (SBP- the top number of a blood pressure reading) was less than 110 millimeters of mercury (mmHg- unit of measurement). This deficient practice had the potential for Resident 84 to experience adverse effects related to receiving losartan when her blood pressure was too low and could result in dizziness and falls.
- D
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Inspectors wroteBased on observations, interview, and record review the facility failed to ensure one out of five sampled residents (Resident 77) was allowed to eat meals out of her bed. This deficient practice of not taking Resident 77 out of bed during mealtimes had the potential for the resident to decline in mobility (a patient's ability to move and change body positions, encompassing the physical capacity to perform functional movements and the independence to carry out daily activities) during activities of daily living ([ADL] -routine tasks/activities to perform daily care for themselves).
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on interview, and record review, the facility failed to ensure certified nurse assistant (CNA) 5 placed the low air loss mattress ([LALM]- an air mattress used to prevent pressure sores) on static mode (mattress setting that provides a firm, even surface for the user by inflating all air cells) and provide two-person assistance when changing Resident 97 on a LALM. This deficient practiced resulted in Resident 97 rolling off the bed while being changed by CNA 5.
- 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 ensure the Medication Regimen Review (MRR- a review of medications to identify problems/errors) for one of two sampled residents (Resident 24) was reviewed by the doctor to approve or not approve the pharmacist's recommendation for the month of May. This failure had the potential to result in side effects that could go undetected by licensed staff and delay for the physician to act upon irregularities.
- D
Ensure that residents are free from significant medication errors.
Inspectors wroteBased on interview and record review, the facility failed to ensure residents were free from significant medication error by failing to administer clonidine (a medicine used to treat high blood pressure) within the administration parameters (instructions in the medication order to give the medication if the blood pressure reading is high) a total of 33 times between 3/19/2025 and 6/11/2025 affecting one of three residents sampled for unnecessary medications (Resident 12.) The deficient practice of failing to administer clonidine as ordered had a potential to place Resident 12 at risk for adverse effects of uncontrolled high blood pressure such as heart attack, stroke, vision loss or other serious complications.
May 30, 2025Complaint inspection · 2 citations
- D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Inspectors wroteBased on interview and record review, the facility failed to: 1. Ensure one of seven sampled residents (Resident 4) had timely documentation of his medications. This deficient practice had the potential to result in a duplicate dose of the medication being given due to no indication the resident received it.
- D
Ensure that residents are free from significant medication errors.
Inspectors wroteBased on interview and record review, the facility failed to: 1. Ensure one of seven sampled residents (Resident 4) received their scheduled dose of Lispro ([insulin]- a fast-acting medication that lowers the blood sugar) on time. This deficient practice had the potential to result in Resident 4 having a dangerously high blood sugar requiring medical attention.
May 5, 2025Complaint inspection · 4 citations
- D
Honor each resident's preferences, choices, values and beliefs.
Inspectors wroteBased on observation, interview and record review, the facility failed to provide the care and services necessary to relieve the pain for one of three sampled residents ' , Resident 1. This deficient practice resulted in the resident ' s discomforts, affecting his participation with physical therapy (PT) and his activities of daily living and had the potential to affect the resident ' s quality of life and recovery.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the care and services of one of three sampled residents (Resident 2) needed for the suprapubic catheter (a type of urinary catheter inserted into the bladder through a small incision in the lower abdomen, rather than through the urethra, to drain urine) was provided promptly. This deficient practice resulted in Resident 1 experiencing bladder spasm and discomfort.
- D
Provide safe, appropriate pain management for a resident who requires such services.
Inspectors wroteBased on observation, interview and record review, the facility failed to thoroughly assess one of three sampled residents ' (Resident 1), who had an indwelling foley catheter ([FC] a thin, flexible tube inserted into the urethra and into the urinary bladder to drain urine) pain and provide interventions to alleviate the pain. This failure resulted in not identifying the cause of the resident ' s pain, resulting in delayed interventions to alleviate the pain. This failure had the potential to affect in maintaining the highest practicable, physical, mental and psychosocial well-being of the resident.
- 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, interview and record review, the facility failed to ensure staff was competent to apply a device to secure the foley catheter ([FC] a thin, flexible tube inserted into the bladder to drain urine) from moving or pulled. This failure resulted in the delay of securing Resident 1 ' s FC, causing more pain and discomfort to the affected resident.
May 1, 2025Complaint inspection · 3 citations
- 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 observation, interview, and record review, the facility failed to report a change in behavior for one of three sampled residents (Resident 1). This failure had the potential for delay in identifying the underlying cause of change in behavior in Resident 1 and receiving treatment.
- 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, interview, and record review the facility failed to ensure licensed nurses had the competencies and skill sets necessary to safely administer medications as ordered for one of three sample residents (Residents 5 and 2) when: 1. Licensed Vocational Nurse (LVN) 1 did not check Resident 5's blood pressure in a supine (lying flat on the person's back) position as indicated, prior to administering Droxidopa (medication to treat orthostatic hypotension [low blood pressure (BP) that happens when standing up from a sitting or lying position). 2. Resident 2 blood sugar was not checked on 4/21/2025 at 9:00 p.m. and 4/24/2025 at 6:30 a.m., who had an order to administer insulin (a hormone that removes excess sugar from the blood, can be produced by the body or given artificially via medication). [...]
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview and record review the facility failed to implement its infection prevention and control measures for one of three sampled residents (Resident 5) by failing to perform hand hygiene washing hands or using an alcohol-based hand-sanitizer) after removing personal Protective Equipment (PPE- clothing and equipment worn or used to provide protection against hazardous substances and/or environments). This deficient practice had the potential for contamination (transfer of harmful bacteria or viruses from one place, object or person to another) and transmission of disease-causing organisms leading to illness to Resident 5.
April 25, 2025Complaint inspection · 5 citations
- J
Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
Inspectors wroteBased on interview and record review, the facility failed to implement its Policy and Procedure (P/P) titled, Emergency Procedure -Cardiopulmonary Resuscitation (CPR- an emergency procedure to restart a person's heart and breathing after one or both suddenly stop) which indicated staff are trained to initiate CPR, BLS (Basic life Support-medical care for residents experiencing cardiac arrest [when the heart stops beating] or respiratory distress [difficulty in breathing), and defibrillation ([Automated External Defibrillation (AED)- an electrical current to help your heart return to a normal heart beat in someone experiencing cardiac arrest or severe arrhythmias [improper beating of the heart), for one of one sampled Resident (Resident 1), who had a full code status (when a medical personnel performs life-saving measures in a medical emergency), was observed unresponsive in bed as [...]
- D
Reasonably accommodate the needs and preferences of each resident.
Inspectors wroteBased on observation, interview and record review, the facility failed to ensure three of the nine sampled residents (Resident 4, Resident 5 and Resident 6) call lightswere placed within reach. This deficient practice had the potential for the residents to not call for help in case of emergency and for any needs, and can negatively impact the physical, medical and psychosocial well-being of the resident when provision of services were delayed.
- 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 monitor one of one sampled resident (Resident 1) for signs and symptoms (s/s) of hypoglycemia (a condition where the level of sugar in the blood is too low) and hyperglycemia (a condition where the level of sugar in the blood is too high) who had a history of diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing) and refusal of blood sugar level checks. This deficiency practice had the potential for a delay in care for Resident 1, leading to complications related to hypoglycemia and hyperglycemia such as seizures, loss of consciousness and death.
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on observation, interview and record review, for one of 9 sampled residents (Resident 1), the facility failed to: 1. Follow the physician ' s order for Resident 1 ' s wound care. 2. Document the treatment provided to Resident 1 in the Treatment administration record (TAR) on 4/19/2025, 4/20/2025, 4/21/2025, 4/22/2025, 4/23/2025 and 4/24/2025. These deficient practices placed Resident 1 at risk of poor wound healing process and wound infection.
- D
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 ensure one out of nine sampled Residents (Resident 1), who had a suprapubic foley catheter ([FC] a type of catheter inserted through the urethra, inserted through a hole in the abdomen and then directly into the bladder) was free of signs of urinary tract infection (UTI) like sediments (happens when crystals, bacteria, or blood exit through the urine as a result of dehydration, urinary tract infections, or other conditions) and cloudiness (looks milky or hazy) in the urinary drainage bag. This deficient practice had the potential for Resident 1 to have UTI.
February 28, 2025Complaint inspection · 3 citations
- E
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Inspectors wroteBased in observation, interview and record review, the facility failed to ensure the Licensed Vocational Nurses (LVN) working in the facility were able to administer all the medications for two of five sampled residents (Residents 1 and 2), timely, as ordered by the physician and as per standards of practice. This deficient practice had the potential to cause these residents not to maintain the therapeutic level of the medication and to not receive the full benefit of the ordered medications.
- E
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Inspectors wroteBased in observation, interview and records review, facility failed to: 1. Provide medications, to four of five sampled residents (Residents 2,3,4, and 5), in a timely manner and as ordered by the physician. 2. Ensure Licensed staff did not crush Resident 2 ' s three medications and mixed with apple source before administering it to Resident 2. This deficient practice had the potential to cause drug interaction when two medications could not be mixed together and could lead to staff not being able to identify each medicine in the case resident refused to take any of the medications. [...]
- 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, interview and records review, the facility failed to ensure, 1 of 5 sampled residents ' (Resident 2) medications were administered, as ordered by the physician. The facility failed to ensure: 1. The facility staff did not crush Resident 2 ' s three medications together without physicians ' order. 2. The facility staff did not crush Resident 2 ' s extended-release medication (medications designed to release an active ingredient over a specific duration gradually) prior to its administration. These deficient practices placed Resident 2 at risk for high level of the medication in her system, as crushing extended-release medication, converts it to immediate release (developed to dissolve without delaying or prolonging dissolution or absorption of the drug).
February 14, 2025Complaint inspection · 2 citations
- 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 interviews and record review, the facility failed to create a baseline care plan (a care plan developed within 48 hours of admission that included minimum healthcare information necessary to properly care for each resident immediately upon their admission) for diabetes (DM-a disease that result in too much sugar in the blood) for one of three sampled residents, (Resident 1). This failure had a potential to cause Resident 1 to not have the appropriate interventions for diabetes. [...]
- D
Ensure services provided by the nursing facility meet professional standards of quality.
Inspectors wroteBased on interviews and record review, the facility failed to follow professional standards of practice for one of three sampled residents (Resident 1), who was receiving insulin (a medication to lower blood sugar) injections, by not ensuring a physician order for blood sugar monitoring was obtained and monitored, as indicated in the resident's care plan. This deficient practice had the potential for Resident 1's blood sugar not being adequately monitored and managed.
January 29, 2025Complaint inspection · 1 citation
- D
Ensure services provided by the nursing facility meet professional standards of quality.
Inspectors wroteBased on interview and record review, the facility failed to record the respiratory rate, temperature, and oxygen saturation (O2 sat- a measurement of how much oxygen the blood is carrying as a percentage) for one of two residents (Resident 2). This deficient practice had the potential for Resident 2 to experience a delay in interventions if the resident had fluctuating respiratory rate, temperature, and O2 sat.
November 27, 2024Complaint inspection · 4 citations
- E
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Inspectors wroteBased on interview and record review, the facility failed to provide pharmaceutical services to one of one sampled resident (Resident 1) by failing to: 1. Ensure the licensed nurses followed the facility's policy and procedure (P&P) titled, Administering Medications to administer medications within one hour of their prescribed time. This deficient practice placed Resident 1 at risk for mismanagement of medication regimen.
- D
Let each resident or the resident's legal representative access or purchase copies of all the resident's records.
Inspectors wroteBased on interview and record review, the facility failed to: 1. Ensure a request for access to medical records and provide copies to resident representative was fulfilled in a timely manner for one of one sampled resident (Resident 1). This deficient practice had the potential to result in Resident 1 feeling frustrated and violated resident rights to obtain medical records.
- 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 ensure residents received treatment and care in accordance with professional standards of practice, by failing to: 1. Follow-up with orthopedic (a medical specialty that focuses on the diagnosis, treatment, and prevention of injuries and diseases affecting the musculoskeletal system) surgeon in a timely manner for resident with bilateral (having or involving two sides) knee immobilizer (a medical device that restricts movement of the knee joint) for one of one sampled resident (Resident 1). This deficient practice had the potential for Resident 1 to have decline in mobility and range of motion.
- D
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Inspectors wroteBased on interview and record review, the facility failed to: 1. Administer influenza vaccine (a vaccine that protects against the influenza virus) to one of one sampled resident (Resident 1). This deficient practice placed Resident 1 at risk for acquiring influenza virus.
November 12, 2024Complaint inspection · 1 citation
- 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 interview and record review, the facility failed to complete a care plan for one of three sampled residents (Resident 1) to address the resident's losing belongings at the facility. This deficient practice had the potential to result in recurring loss, theft, and psychosocial harm for Resident 1.
October 17, 2024Complaint inspection · 1 citation
- 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 interview and record review, the facility failed to develop a Care Plan for one out of four sampled residents (Resident 1) who was admitted with a wound to the sacrum [bone located at the base of the spine). This deficient practice had the potential to result in Resident 1 ' s needs not being met and unidentified interventions to address the resident ' s wound.
August 19, 2024Complaint inspection · 1 citation
- E
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on observation, interview and record review, the facility failed to ensure three (3) of 3 emergency crash carts ([crash cart] cart containing medical emergency equipment and medications) contained emergency oxygen tanks (e-tank). This failure had the potential to affect the quality of care and emergency medical interventions residents may need, in cases of emergency medical crisis (a point in a disease where a significant change [like cardiac and respiratory arrest-unexpected loss of heart function, breathing, and consciousness] occurs which can lead to either recovery or death) affecting the recovery and survival chance of the affected resident.
July 5, 2024Complaint inspection · 4 citations
- D
Keep residents' personal and medical records private and confidential.
Inspectors wroteBased on observation, interview and record review, the facility failed to implement its policy and procedure (P&P) titled, Protected Health Information (PHI), Management and Protection, which indicated all personnel who have access to residents information are responsible to ensure information are managed and protected to prevent unauthorized release or disclosure of personal informations. This failure had the potential to result in unauthorized exposure of resident ' s confidential information to other personnel not involved in the residents' care and had the potential to violate residents' rights to privacy and confidentiality.
- 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 provide a safe environment for one of six residents (Resident 5), who was at risk for elopement (when a resident leaves the premises without authorization), by failing to ensure 3 of 4 emergency door alarms (a sound alerting staff when emergency door is opened) were turned on. This failure had the potential for residents at risk for elopement leave the facility successfully, resulting in accidents, injuries, hospitalization and death.
- D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Inspectors wroteBased on interview, and record review, the facility failed to ensure a system was in place for the accurate reconciliation and turnover of controlled drugs (drugs controlled by the government with the potential for abuse and addiction) by licensed staff at each change of shifts (when current nurse goes off, and an incoming nurse start work). This failure had the potential to result in drug diversion (illegal distribution or abuse of prescription drugs or their use for purposes not intended by the prescriber) within the facility.
- D
Keep all essential equipment working safely.
Inspectors wroteBased on observation, interview and record review, the facility did not maintain resident equipment in good working condition, by failing to: 1. Ensure 4 of 12 screens doors were maintained in good working condition. 2. Ensure toilet and sink in one of 3 resident (Resident 3) rooms were not leaking. This failure had the potential to cause resident injuries.
June 14, 2024Standard inspection · 14 citations
- E
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: 1. Ensure two of six sampled residents (Resident 41 and 138) the Physician Orders for Life-Sustaining Treatment ([POLST] patients treatment wishes so that emergency personnel know what treatments the patient wants in the event of a medical emergency) form was completed. This deficient practice had the potential for not following the residents desired health care decisions when they become unable to make decisions for themselves.
- 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 and record review the facility failed to: 1. Ensure two of six Residents (Resident 41 and 138) had a comprehensive care plan for a Physician Orders for Life-Sustaining Treatment ([POLST] patients treatment wishes so that emergency personnel know what treatments the patient wants in the event of a medical emergency) form was completed. This deficient practice of not having a comprehensive care plan for the POLST had the potential of Resident 41 and 138 wishes not being carried out.
- E
Ensure services provided by the nursing facility meet professional standards of quality.
Inspectors wroteBased on interview and record review, the facility failed to: 1. Ensure one of five sampled residents (Resident 61) had weekly documented summaries. 2. Ensure one of one sampled residents (Resident 25) weekly weights were completed as ordered by the physician. This failure had the potential for the staff to not be aware if Resident 61's health status is improving or deteriorating.
- E
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on interview and record review, the facility failed to: 1. Ensure two of five sampled residents ( Residents 2 and 61) had restorative nursing aide (RNA) services provided five times per week, as ordered. This deficient practice had the potential for Resident 2 and Resident 61 to experience a decline in functional mobility (ability to move independently and safely to accomplish tasks).
- E
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Remove two boxes of expired influenza vaccinations from the medication refrigerator in the medication storage room. This deficient practice had the potential to result in the use of ineffective vaccines for the residents. 2. Label a bottle of Latanoprost (medication to treat glaucoma [eye disease that damages the nerve]) and Dorzolamide (medication to treat high eye pressure) eye drops with the open date for Resident 20. This deficient practice had the potential to result in using outdated medication for the resident.
- E
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Inspectors wroteBased on interview and record review the facility failed to: 1. Ensure three of six sampled residents (Resident 138, 81, and 141) had a consent for influenza, pneumococcal vaccine, and education about the vaccines. This deficient practice of not having a consent for influenza, pneumococcal vaccine, and education placed Residents 138, 81, and 141 at risk for being misinformed the risk and benefits of having vaccinations.
- 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: 1. Ensure interdisciplinary team meetings ([IDT]- group of healthcare individuals with expertise in different areas who work together to achieve goals for the residents) were held for one of five sampled residents, (Resident 61) to participate in IDT meetings to discuss his care and discharge goals. This deficient practice had the potential to violate Resident 61's right to be an active participant in his care.
- D
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Ensure the bedrails were free of debris for one of one sampled resident (Resident 34). This deficient practice had the potential to result in cross contamination (the movement of germs from one place to another) while providing care to Resident 34.
- D
PASARR screening for Mental disorders or Intellectual Disabilities
Inspectors wroteBased on interview and record review the facility failed to: 1. Ensure one of six sampled resident (Resident 41) had an PASARR ([Preadmission Screening and Resident Review] to determine if facility practices are in place to identify residents with mental disorders) screening for a new diagnosis for mental disorder. This deficient practice of not initiating a PASARR screening for a new diagnosis placed Resident 41 at risk for receiving proper care.
- D
Assist a resident in gaining access to vision and hearing services.
Inspectors wroteBased on interview and record review the facility failed to: 1. Ensure one of six sampled Residents (Resident 41) had eyeglasses. This deficient practice had the potential in Resident 41 being unable to see necessary objects.
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Follow the doctor's order to document the oxygen saturation (measurement of how much oxygen is circulating in the blood) level for one of one sampled resident (Resident 73), every shift. 2. Clarify the doctor's order for one of one sampled resident (Resident 73's) continuous supplemental oxygen when Resident 73 was only using oxygen as needed. These deficient practices had the potential to cause complications associated with oxygen therapy.
- 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 wroteThe facility failed to: 1. Ensure Medication Regimen Review (review of medications to identify problems/errors) recommendations were reported to the physician for one of one sampled resident (Resident 77). This failure had the potential to result in a dangerously low blood sugar for Resident 77.
- 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: 1. Offer a replacement meal for one of one sampled residents (Resident 34) on subsequent days. This failure had the potential to result in low blood sugar or weight loss.
- B
Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.
Inspectors wroteBased on observation, interview and record review, the facility failed to: 1. Ensure 23 of 36 resident's rooms (rooms 2, 3, 4, 5, 7, 8, 9, 10, 11, 12, 13, 22, 23, 24, 28, 29, 30, 31, 32, 33, 34, 35, 36) met the requirement of 80 square feet (sq. ft.) per resident in a multiple resident room. This deficient practice had the potential for inadequate space for resident care and personal property and the inability to move around the room easily.
May 7, 2024Complaint inspection · 1 citation
- D
Make sure that a working call system is available in each resident's bathroom and bathing area.
Inspectors wroteBased on observation, interview, and record review the facility failed to: 1. Ensure one of three sampled residents (Resident 1's) call light was working. This deficient practice increased the risk for Resident 1 to be unable to call for staff for assistance.
December 4, 2023Complaint inspection · 1 citation
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview and record review, the facility failed to implement infection control measures by failing to clean and sanitize two vending machines during a Coronavirus Disease ([Covid-19], a highly contagious respiratory infection caused by a virus that could easily spread from person to person) outbreak. This deficient practice had the potential to spread Covid-19 to residents, staff, and the community.
November 14, 2023Complaint inspection · 1 citation
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure assistance with activities of daily living (ADLS, activities related to personal care, that includes bathing or showering, dressing, getting in and out of bed or a chair, walking, using the toilet, and eating) was provided to 1 of 4 sampled residents, Resident 1. This failure resulted in Resident 1 sitting on a soiled undergarments for several hours and had the potential to cause skin irritation and damage.
October 19, 2023Complaint inspection · 2 citations
- D
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 abuse allegation for two of four sampled residents (Resident 1 and Resident 2) within two hours after being made aware of the allegation. This deficient practice had the potential to result in unidentified abuse in the facility and a failure to protect residents from further abuse.
- 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 two-person assistance was provided during provision of care for one of four sampled residents (Resident 3). This deficiency had the potential for avoidable harm to Resident 3, who was placed at an increased risk for falls and subsequent injuries related to falls.
September 8, 2023Complaint 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 interview and record review the facility failed to ensure one of three sampled residents (Resident 1) was free from sexual abuse. On 8/23/2023, Resident 2 was found by Certified Nurse Assistant (CNA) 2, inside Resident 1's room, touching Resident 1 on her thighs and Resident 1 stated Resident 2 touched her (Resident 1) vagina. This failure resulted in Resident 2 going into Resident 1's room and touched Resident 1 on her thighs and vagina. Resident 1 felt scared, anxious, had trouble sleeping, had difficulty relaxing, and does not feel safe at the facility.
- E
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on observation, interview, and record review, the facility failed to provide monitoring and supervision for three of three sampled residents (Resident 1, 2 and 3) per facility policies and care plans. These deficient practices resulted in Resident 1 and Resident 3 to experience emotional distress due to the lack of staff supervision and monitoring Resident 2.
March 24, 2022Standard inspection · 16 citations
- 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 observation, interview, and record review, the facility failed to develop and/or implement an individualized person-centered plan of care with measurable objectives, timeframes, and interventions to meet residents' needs for four out of 18 sampled residents (Resident 5, 54, 59, and 228) by failing to: 1. Develop a baseline care plan addressing the diagnosis of major depressive disorder (a mental health disorder characterized by a persistent sad mood or loss of interest in activities, causing significant impairment in daily life) for Resident 5 and 59. 2. Develop an individualized/person- centered care plan to address Resident 54's oxygen use. 3. Implement Resident 228's plan of care, interventions, and how to monitor for signs and symptoms of a urinary tract infection. [...]
- E
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 residents were included in the comprehensive care plan for 3 of 18 sampled residents (Residents 54, 77, and 228). These deficient practices had the potential for the residents to not receive appropriate care treatment and/or services.
- E
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Follow the manufactures requirements to remove from use one expired insulin pen for Resident 43 in one of two inspected medications carts (Medication Cart 2). 2. Follow the manufactures requirements to remove from use one expired insulin vial for Resident 12 in one of two inspected medication carts (Medication Carts 3). 3. Refrigerate and label with a date an unopened vial of Novolog insulin (a medication used to regulate blood sugar levels) for Resident 27 in accordance with the manufacturer's requirements in one of two inspected medication carts (Medication Cart 2). 4. Refrigerate and label with a date one unopened container of Latanoprost (medication used to treat [glaucoma] condition where the nerve connecting the eye to the brain is damaged, usually due to high eye pressure) eyedrops for Resident 67. [...]
- E
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview, and record review, the facility failed to implement interventions to prevent and control the spread of the coronavirus ([COVID-19] a severe respiratory illness caused by a virus and spread from person to person) disease and infection in accordance with its infection prevention and control program by failing to ensure: 1. Certified Nurse Assistant (CNA) 1 performed hand hygiene before and after providing care to one of one sampled resident (Resident 31). 2. Staff was fit tested (a test performed to ensure a respirator (mask) forms a tight seal around the wearer's face to prevent the spread of infection) to determine the correct respirator to wear in a timely manner for five of five staff (Housekeeping [HK] 3, CNA 10, CNA 13, CNA 14, CNA 15) and failed to fit test two of two staff (CNAs 11 and 12). [...]
- 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 record review, the facility failed to maintain the confidentiality of the electronic medical record for one of 18 sampled residents (Resident 27). This deficient practice violated Resident 27's right to privacy and confidentiality of her personal information.
- D
PASARR screening for Mental disorders or Intellectual Disabilities
Inspectors wroteBased on observation, interview, and record review, the facility failed to accurately complete the Preadmission Screening and Resident Review (PASRR) for one of eighteen sampled residents (Resident 77) who was diagnosed with a mental illness. This deficient practice resulted in not triggering recommendations to obtain PASRR level II evaluation and had the potential for inappropriate placement and unidentified specialized services for Resident 77.
- D
Ensure services provided by the nursing facility meet professional standards of quality.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure Licensed Vocational Nurse (LVN) 1 administered medications in accordance with professional standards of quality to one of 18 sampled residents by ensuring LVN 1 did not leave Resident 29's room until she was sure the resident had taken his medications. LVN 1 left five medications (amiodarone, Nephro-Vite multivitamin, sevelamer, simethicone and Vitamin D3 5000) unattended on the bedside table of one of 18 sampled residents (Resident 29) and told the resident to take the medications later one hour before he leaves for dialysis. This deficient practice had the potential to cause harm to Resident 29 if he did not take the medication in a timely manner and had the potential to cause harm to other residents who may consume the unattended medications.
- D
Honor each resident's preferences, choices, values and beliefs.
Inspectors wroteBased on observation, interview, and record review, the facility failed to provide necessary care and services by not placing a call light within reach for two of 18 sampled residents (Resident 5 and 17). This deficient practice has the potential to cause a negative impact on the resident 5's psychosocial well-being.
- D
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Inspectors wroteBased on observation, interview, and record review the facility failed to provide translation services to one of eighteen (18) sampled residents (Resident 129), who's primary language was Spanish. This deficient practice resulted in Resident 129 feeling frustrated, and anxious with the care and therapy he was receiving.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for two of 18 sampled residents (Resident 5, 39) by not providing proper positioning care (turn every two hours) to Resident 5 and 39, who are dependent on staff for positioning. These deficient practices had the potential to negatively affect Resident 5 and 39's physical comfort, skin integrity, and psychosocial wellbeing.
- D
Provide safe, appropriate pain management for a resident who requires such services.
Inspectors wroteBased on observation, interview, and record review the license nurses failed to adequately manage pain level for 1 of eighteen (18) sampled Residents. For Resident 42, license nurses did not administer pain medication when resident stated she had pain level of 8 on her right thigh. This deficient practice resulted in Resident 42 being left through the night with a pain level of 8 causing anxiety and distress.
- 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: 1. To provide pharmaceutical services that meet the needs for one of 18 sampled residents (Resident 29). Licensed Vocational Nurse (LVN) 1 did not wait for Resident 29 to take five medications and medications were left unattended on Resident 29's bedside table. This deficient practice had the potential to cause harm to Resident 29 and other residents as medications were left unsupervised at the bedside of the resident. 2. To ensure licensed nurses followed policies and procedures to count controlled medications every (prescription medication that is controlled and monitored by the government) shift with two licensed nurses for one of two inspected medication carts (Medication Cart 3). [...]
- D
Ensure that residents are free from significant medication errors.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure licensed nurses did not administer doses of expired insulin (a medication used to control high blood sugar) to residents (Resident 43 and 12). This deficient practice increased the risk for Resident 43 and Resident 12 to potentially experience harmful side effects related to the administration of expired insulin, which could have resulted in medical complications possibly leading to hyperglycemia, coma, hospitalization, or death.
- 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 assure a menu was developed and prepared to meet resident choices including their religious, cultural, and ethnic needs for one of 18 sampled residents (Resident 50). This deficient practice prevented Resident 50 from practicing his religious beliefs by not honoring his food preferences.
- D
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 one of four dietary staff wore an N95 mask (a respirator mask used to prevent the spread of an airborne illness) and one of one cook (Cook 1) wore gloves during tray line food preparation. These deficient practices had the potential to cause food-borne illnesses.
- B
Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.
Inspectors wroteBased on observation, interview and record review, the facility failed to ensure 27 of 36 resident's bedrooms (rooms 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 15, 18, 20, 22, 23, 24, 28, 29, 30, 31, 32, 33, 34, 35, and 36) met the requirement of 80 square foot (sq. ft.) per resident in a multiple resident bedroom. This deficient practice had the potential for inadequate space during resident care, inability to access or use personal assistive devices, furniture, and for visitors to visit the residents.
Fire safety inspections
14 fire safety citations on file: 10 on June 13, 2025, 2 on June 14, 2024, 2 on March 24, 2022.
Every fire safety citation14 citations
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · June 13, 2025 · Corrected (the home has a date of correction)
- F
Have simulated fire drills held at unexpected times.
K 712 · June 13, 2025 · Corrected (the home has a date of correction)
- E
Install an approved automatic sprinkler system.
K 351 · June 13, 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 13, 2025 · Corrected (the home has a date of correction)
- E
Ensure proper usage of power strips and extension cords.
K 920 · June 13, 2025 · Corrected (the home has a date of correction)
- D
Keep aisles, corridors, and exits free of obstruction in case of emergency.
K 211 · June 13, 2025 · Corrected (the home has a date of correction)
- D
Have a complete alarm system manually initiated and initiated by fire sprinkler system connection.
K 342 · June 13, 2025 · Corrected (the home has a date of correction)
- D
Properly select, install, inspect, or maintain portable fire extinguishes.
K 355 · June 13, 2025 · Corrected (the home has a date of correction)
- D
Install corridor and hallway doors that block smoke.
K 363 · June 13, 2025 · Corrected (the home has a date of correction)
- D
Have properly installed electrical wiring and gas equipment.
K 511 · June 13, 2025 · Corrected (the home has a date of correction)
- D
Implement emergency and standby power systems.
E 41 · June 14, 2024 · Corrected (the home has a date of correction)
- D
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
K 761 · June 14, 2024 · Corrected (the home has a date of correction)
- E
Inspect, test, and maintain automatic sprinkler systems.
K 353 · March 24, 2022 · Corrected (the home has a date of correction)
- D
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
K 741 · March 24, 2022 · Corrected (the home has a date of correction)