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 37 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
20D
13E
3F
Potential for minimal harm
0A
0B
1C
January 15, 2026Standard inspection · 4 citations
- E
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Inspectors wroteBased on interview, record review, facility policy review, and review of the Centers for Disease Control and Prevention (CDC) guidelines, the facility failed to offer three of eight residents (Residents (R) 80, R17, and R86) reviewed for pneumonia vaccinations, and/or their representatives, the opportunity for the residents to be vaccinated in accordance with nationally recognized standards out of 61 residents sampled. This practice had the potential to increase the risk for residents to contract pneumonia. In addition, the facility policy did not reflect current CDC recommendations. 1. Review of R80's electronic medical record (EMR) titled admission Record located under the Profile tab indicated the facility admitted the resident on 02/21/22. The resident was over the age of 65 at the time of his/her admission. [...]
- D
Allow resident to participate in the development and implementation of his or her person-centered plan of care.
Inspectors wroteBased on interviews, record reviews, and review of the facility's policy, the facility failed to ensure one of one resident (Residents (R) 17), out of a survey sample of 61, was afforded the right to participate in their care planning process. This failure placed the residents at risk of not being aware of the goals and outcomes of their care and for their care plan not to be person centered.
- 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, record review, interview, and review of the facility's abuse policy, the facility failed to ensure one of 42 sampled residents (Resident # 62) was free from resident-to-resident abuse from Resident # 52. This resulted in harm when Resident # 52 hit Resident # 62 causing a swollen lip and two teeth being knocked out.
- D
Assist a resident in gaining access to vision and hearing services.
Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure that one of one resident (Resident (R) 41) reviewed for vision out of a total sample of 61 residents had an appointment made for cataract removal. This failure had the potential for the resident's vision to decline.
November 21, 2025Complaint inspection · 7 citations
- E
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteComplaint # : 185875 Based on observations, interviews, record reviews, and policy reviews, the facility failed to ensure that resident rights were respected for residents who smoke and/or desire to go outside the facility.
- 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 wroteComplaint #: 185875 and 182189Based on observation, interviews, record review, and policy review, the facility failed to ensure the residents' environment remained clean, comfortable, and homelike for three of the three floors (first, second, and third floors). Specifically, the facility failed to provide overall facility cleanliness; clean and repair resident wheelchairs, electric wheelchairs, and geri chairs; repair scraped and scuffed air conditioning units; clean ceiling vents; clean and repair rusty and dirty door jams; provide ceiling vent covers in the shower rooms; and provide window screens that were without rips and tears.
- E
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteComplaint # : 178254 and 179036 Based on observations, record review, and interviews, the facility failed to ensure the ceiling vents, ice machine vent, and equipment were kept clean and/or in good repair. The failure had the potential to affect 149 of 153 residents who received meals prepared in the facility kitchen.
- E
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Inspectors wroteComplaint # : 185875 Based on record review, observations, staff interviews, and review of facility policy, the facility failed to ensure an effective pest control program within the facility. Flies were observed in multiple areas of the building during the complaint investigation process. This failure created the potential for cross contamination related to the fly infestation. A total of 34 residents were reviewed in the sample.
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteComplaint # 2587860 and 187900Based on review of facility policy, record review, and interviews, the facility failed to ensure timely reporting of allegations of potential exploitation and/or abuse to the State Agency for four Sampled Residents (Resident (R ) R1, R2, R15 and R16) out of a total sample of 34 residents. This failure created the potential for this and other residents to experience further exploitation and/or abuse.
- D
Respond appropriately to all alleged violations.
Inspectors wroteComplaint # : 2587860 and 187900 Based on review of facility policy, record review, and interviews, the facility failed to ensure a thorough investigation was completed related to allegations of potential exploitation and/or abuse two sampled residents (Resident (R) R1and R2) out of a total sample of 34 residents. This failure created the potential for these and other residents to experience further exploitation and/or abuse.
- D
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Inspectors wroteComplaint # 179036Based on record review, interviews, and policy review, the facility failed to develop a comprehensive care plan for one of two residents (Resident (R) 8) sampled for the use of a Life Vest, (a wearable defibrillator).
February 10, 2025Complaint inspection · 1 citation
- 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 wroteComplaint #: NJ180849 Based on observations, interviews, and review of other facility documentation on 2/10/2025, it was determined that the facility failed to maintain a clean and homelike environment for the residents. This deficient practice was identified for 2 of 3 units, (Pavilion 2 and Pavilion 3) and was evidenced by the following: During a tour of the 2nd floor unit (Pavilion 2) on 2/10/2025 at 10:08 AM, the surveyor observed the following: 1.) Inside resident room [ROOM NUMBER], a brown stain on the ceiling tile and a build-up of dust and unknown debris in the heater vent. 2.) Inside resident room [ROOM NUMBER], four small holes in the wall behind the television for Bed-B and chipped paint on the walls. 3.) Inside resident room [ROOM NUMBER], two holes in the wall next to the bathroom door, a build-up of unknown debris in the heater vent, and chipped paint on the heater. [...]
August 14, 2024Standard inspection, Complaint inspection · 13 citations
- F
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Inspectors wroteComplaint # NJ 158956, 166158, 170632 Based on interview, and review of other facility documentation, it was determined the facility failed to ensure there was sufficient nursing staff on a 24-hour basis to provide nursing care to the residents. This deficient practice was evidenced by the following: A review of the provided Facility Assessment dated March 2024 included .our approach to ensure adequate staff based on our resident population and their needs for care . for Certified Nurse Aides 1:8 Residents for days, 1:10 evenings, 1:14 nights, one Restorative Aide day shift weekdays and one Restorative Aide Day shift weekends. During resident Council meeting on 08/08/2024 at 11:00 AM, a resident stated nights are short staffed, and wait time is long. Only two were on 2nd floor last night. 2 of 5 residents stated they have waited 4 to 5 hours for an aide. [...]
- E
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Inspectors wroteBased on observation, interview, review of the medical record, and review of pertinent facility records it was determined that the facility failed to follow through on recommendations made by the consultant pharmacist (CP) during their monthly medication regimen review (MRR) in a consistent and timely manner. This deficient practice was identified for 2 of 5 residents reviewed for unnecessary medications, (Resident #55 and Resident #89) and was evidenced by the following: The surveyor reviewed the facility policy on 08/13/2024 at 10:45 AM, titled Medication Regimen Review Policy NO: ROP-32, Reviewed: 6/2/2024. The following was revealed under POLICY: It is the facilities policy to provide a Medication regimen review (MRR) for all residents admitted to the nursing facility. The following was revealed under Policy Explanation and Compliance Guidelines: 1. [...]
- 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, interview, and record review, it was determined that the facility failed to handle potentially hazardous foods and maintain sanitation in a safe and consistent manner to prevent food borne illness. This deficient practice was evidenced by the following: The surveyor reviewed a facility policy on 08/05/2024 at 12:02 PM, titled [company name] Dining Services Food Storage, undated. The following was revealed under Canned Fruits: Dented or bulging cans shall be placed on Damaged Goods Shelf and returned for credit. The following was revealed under Canned Vegetables: Dented or bulging cans shall be placed on Damaged Goods Shelf and returned for credit. The surveyor reviewed a facility policy on 08/05/2024 at 12:02 PM, titled [facility name] Dining Services Pots and Pans - Sanitizing Solution, undated. The following was revealed under the heading SANITATION OF EQUIPMENT: [...]
- 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 review of other facility documentation, it was determined that the facility failed to ensure the transport of a non-ambulatory resident was provided in a manner to promote the dignity and respect of the resident. This deficient practice was identified for 1 of 32 residents reviewed for dignity, (Resident #27) and was evidenced by the following: A review of a facility policy titled Resident Rights, Created: 2/2024, revealed the following under Policy Explanation and Compliance Guidelines: 10. All residents will be treated equally regardless of age, race, ethnicity, religion, culture, language, physical or mental disability, socioeconomic status, sex, sexual orientation, or gender identity or expression. 11. [...]
- 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.
- 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, record review, and review of other facility documentation, it was determined the facility failed to develop and implement a comprehensive person-centered care plan that included measurable objectives, timelines, and interventions to meet resident's medical and nursing needs for 1 out of 4 residents investigated for Respiratory Care. A review of a facility policy reviewed on 08/08/2024 at 11:05 AM, titled, Care Plan, dated June 2024, revealed the following statement, It is the policy of [facility name] that all residents admitted to the facility will have adequate person-centered care plans that provide for all their needs in a timely manner. Under Procedures, #1. Baseline Care Plans for all new admissions will be initiated within 48 hours of admission. Under #2. [...]
- D
Ensure services provided by the nursing facility meet professional standards of quality.
Inspectors wroteBased on interview, review of the Electronic Medical Record (EMR), and review of other facility documentation, it was determined that the facility failed to ensure a resident had a Physician Order (PO) for transfer to the hospital. This deficient practice was identified for 2 of 2 residents reviewed for hospitalizations (Resident # 126 and Resident # 137) and was evidenced by the following: On 08/14/2024 at 9:52 AM, a review of the facility's Transfer or Discharge, Emergency policy dated revised June 2024, included, Should it become necessary to make an emergency transfer or discharge to a hospital . Notify the resident's attending physician; place order for transfer per attending physician/NP (nurse practitioner)/PA .(physician assistant) On 08/06/2024 at 11:42 AM, a review of the Electronic Medical Record (EMR) revealed the following: 1. [...]
- 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, review of the medical record and other facility documentation, it was determined that the facility failed to follow physician orders specifically to change the piston set (a device intended for medical purposes that consists of a calibrated hollow barrel and a movable plunger) every 24 hours for 1 of 3 residents reviewed for Tube Feeding, (Resident #54). This deficient practice was evidenced by the following: On 08/12/2024 at 12:10 PM, a review of a facility policy titled Enteral Tubes with a last revised date of 06/3/2024, revealed under the Procedure section: 16. Rinse Thoroughly with tap water and place in a labeled dry plastic bag to remain at bedside. *Change syringe and bag every 24 hours. During the initial tour of Pavilion 2 on 08/05/2024 at 10:58 AM, Resident # 54's piston set was observed on the bed side table. [...]
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observation, interview, review of the Electronic Medical Record (EMR) and review of other facility documentation, it was determined that the facility failed to ensure a resident who used Oxygen therapy at night, had a Physician Order. This deficient practice was identified for 1 of 4 residents reviewed for Respiratory Care (Resident #117) and was evidenced by the following: During the initial tour of the facility on 08/05/2024 at 10:29 AM, the surveyor observed oxygen tubing next to the resident in bed. The tubing was not dated. Resident #117 said he/she uses it at night. There was no observed oxygen sign outside the room. On 08/08/2024 at 01:10 PM, a review of a facility policy titled Oxygen Administration with a revised date of January 2024, revealed under the Policy section: Oxygen administration will be carried out only with a physician order. [...]
- D
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Inspectors wroteBased on observation, interview, review of medical records and other facility documentation, it was determined that the facility failed to complete the dialysis communication book for a resident on dialysis (Resident #94). This deficient practice was identified for 1 of 1 residents reviewed for dialysis. The evidence was as follows: On 8/16/2024 at 12:00 PM the surveyor reviewed the facility's Dialysis Management (Hemodialysis) policy with a revised date of 6/2024 included . If Dialysis is provided at off-site Dialysis Center .Assure facility completed Dialysis communication form accompanies resident to dialysis on treatment days, to communicate resident information and coordinate care between Dialysis center and facility .Dialysis center personnel to complete Dialysis communication form and return and return to the facility . [...]
- D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Inspectors wroteCross Reference F867 Based on observation, interview, record review and review of other facility documentation, it was determined that the facility failed to ensure: a) a discontinued and expired medication (pantoprazole, used to treat gastroesophogeal reflux disease /GERD, a condition in which stomach acid repeatedly flows back up into the tube connecting the mouth and stomach) was removed from active inventory b) maintain an accurate accountability for controlled substances within the medication administration cart c) a controlled medication that was expired was removed from an automated medication dispensing system. This deficient practice was identified for 1 of 3 medication carts, and 1 of 1 automated medication dispensing system reviewed during the medication storage task. A review of the facility policy, Medication Administration (Reviewed 06/24) revealed the following: [...]
- D
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Inspectors wroteCross Reference F755 Based on observation, interview, and review of pertinent facility records, it was determined that the facility Quality Assessment and Performance Improvement (QAPI) committee failed to utilize the Facility Performance Improvement Plan (PIP) to follow the facility process to measure and utilize data for checking medication carts three times weekly for expired medications. This deficient practice was evidenced by the following: On 08/13/2024 at 09:51 AM, the surveyor reviewed the facility policy titled Quality Assurance Performance Improvement, Date Reviewed/Revised: 9/14/23. The following was revealed under Purpose: Our Quality Assurance and Performance Improvement Program (QAPI) represent our facility's commitment to continuous quality improvement. [...]
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interviews, and review of pertinent facility documentation, it was determined that the facility failed to a.)properly store and maintain both sterile and non-sterile medical supplies in a safe and sanitary manner and b.) ensure that laundry staff used the appropriate personal protective equipment while handling items that were likely contaminated with infectious bodily fluids. This deficient practice was identified for 2 of 2 medication storage rooms reviewed for the medication storage task and 1 of 1 laundry staff and was evidenced by the following: On 08/07/2024 at 9:41 AM, during the inspection of the Pavilion Three Medication Storage Room, in the presence of Licensed Practical Nurse Unit Manager (LPN/UM #1) the surveyor observed: three enema kits, two packages of heel booties, and a box of wound treatment supplies which included: [...]
December 16, 2022Standard inspection · 12 citations
- F
Provide and implement an infection prevention and control program.
Inspectors wroteBased on interview and review of other pertinent documents, it was determined that the facility who had been in an active COVID-19 outbreak since 11/18/22, failed to: a) follow the facility policy and conduct complete and thorough contact tracing to prevent the spread of COVID-19 (a potentially, deadly virus) and b) implement measures to prevent the growth of Legionella (bacterium that causes legionnaires' disease, a type of pneumonia caused by legionella bacteria that spreads through mist such as through air conditioning units and can also occur in potable water) and other waterborne pathogens in the facility's water systems. This deficient practice was identified for 1 (one) of 1 (one) sampled COVID-19 positive resident (Resident #107) and a review of 1 (one) of 1(one) COVID-19 positive staff member (Certified Nursing Assistant (CNA) #4) and was evidenced by the following: Reference: [...]
- F
Perform COVID19 testing on residents and staff.
Inspectors wroteBased on interviews, and review of pertinent documents, it was determined that the facility failed to: a) conduct immediate, comprehensive resident and staff COVID-19 (a potentially, deadly virus) testing upon the identification of a single positive resident or staff member in accordance with the facility policy b) ensure that comprehensive COVID-19 testing was completed and accurately documented during a COVID-19 outbreak that began on 11/18/22, in accordance with current Federal, State and Centers for Disease Control guidelines. This deficient practice was identified for 1 (one) of 1 (one) COVID-19 positive resident (Resident #107), 1 (one) of 1 (one) COVID-19 staff members (Certified Nursing Assistant (CNA #4) on 3 (three) of 3 (three) nursing units, and was evidenced by the following: Reference: [...]
- 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, it was determined that the facility failed to update the resident's comprehensive care plan in a timely manner. This deficient practice was identified for 2 of 34 residents (Residents #119 and #141) reviewed for care plans and was evidenced by the following: 1. On 12/07/22 at 12:00 PM, 12/08/22 at 10:14 AM and 12/09/22 at 12:30 PM, the surveyor observed the resident seated at a table in the dayroom. The surveyor observed that Resident #119 had a palm guard applied to the left hand at the time of each observation. According to the admission Record, Resident #119 was admitted with diagnoses which included, but were not limited to, contracture of the muscle to the left hand. [...]
- E
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on observation, interview, review of medical records and other pertinent facility documentation, it was determined that the facility failed to a.) accurately identify a wound type from first identification of the wound on 09/07/22 until 12/15/22 and b.) clarify the implementation of a diagnostic study recommended by a wound care consultant. This deficient practice was identified for 1 (one) of 2 (two) residents (Resident #15) reviewed for pressure ulcers and was evidenced by the following: On 12/07/22 at 10:54 AM, during initial tour, the surveyor observed Resident #15 sitting in a chair at his/her bedside. The resident was observed with an anti-pressure cushion on the wheelchair and an anti-pressure mattress on the bed. [...]
- E
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Inspectors wroteBased on observation, interview, review of the medical record and review of other facility documentation, it was determined that the facility failed to adequately monitor the target behaviors for the use of psychotropic medications (mood altering medications) for 2 of 5 residents (Resident #86 and #115) reviewed for mood/behavior. This deficient practice was evidenced by the following: 1. On 12/08/22 at 11:29 AM, the surveyor observed Resident #86 seated in a wheelchair in the dayroom while an activity was being held. On 12/08/22 at 12:23 PM, the surveyor reviewed Resident #86's electronic medical record (eMR). A review of the admission Record face sheet (an admission summary) reflected that the resident was admitted to the facility with diagnoses which included but were not limited to dementia without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety. [...]
- E
Ensure that residents are free from significant medication errors.
Inspectors wroteBased on interview, review of the medical record, and other facility documentation, it was determined that the facility failed to verify and accurately transcribe readmission medications. The deficient practice was identified for 1 of 5 residents (Resident #80) reviewed for unnecessary medications and was evidenced by the following: According to the admission Record, Resident #80 was admitted with diagnoses that included, but were not limited to, psychosis, anxiety disorder, and depression. Review of Resident #80's Quarterly Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 09/10/22, included the resident had a Brief Interview for Mental Status of 15, which indicated that the resident was cognitively intact. Further review of the MDS revealed the resident received antidepressant medication for the last 7 days. [...]
- 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, interview, and review of facility documentation, it was determined that the facility failed to handle potentially hazardous foods and maintain sanitation in a safe, consistent manner designed to prevent foodborne illness. This deficient practice was evidenced by the following: On 12/07/22 at 10:54 AM, the surveyor, in the presence of the Food Service Director (FSD), observed the following during the kitchen tour: 1. A stack of 18-inch sheet pans was stored on a multi-tiered cart. The surveyor observed the top sheet pans were wetnesting. When interviewed, the FSD stated the sheet pan should not have been stacked while wet. 2. In the dry storage room, an opened, undated container of beef base wrapped in plastic was stored on a shelf. When interviewed, the FSD stated the container should have been dated when opened. 3. [...]
- D
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to complete a resident assessment that accurately reflected the resident's status. This was identified during a review of the quarterly Minimum Data Set (MDS), an assessment tool to facilitate the management of care, for 1 of 31 residents reviewed (Resident #15). This deficient practice was evidenced by the following: On 12/07/22 at 10:54 AM, during tour, the surveyor observed Resident #15 sitting in a chair at bedside. The resident was observed with an anti-pressure cushion on the wheelchair and an anti-pressure mattress on the bed. The surveyor interviewed the resident at that time and Resident #15 stated that he/she had a sore on the right foot and pointed to the planter area of the right foot. The resident was washed and dressed and had socks on both feet. [...]
- D
Ensure services provided by the nursing facility meet professional standards of quality.
Inspectors wroteBased on interview, record review, and other pertinent facility documentation it was determined that the facility failed to a.) accurately document neuro checks (a nurse assessment to document an individual's neurological functions, motor and sensory response and level of consciousness) in accordance with professional standards of practice for one resident who sustained a fall b.) follow physician orders for the application of compression stockings. This deficient practice was identified for 1 of 5 residents (Resident #37) reviewed for hospitalizations and 1 of 1 (Resident #15) reviewed for edema (swelling) and was evidenced by the following: Reference: New Jersey Statutes, Annotated Title 45, Chapter 11. Nursing Board The nurse practice act for the State of New Jersey states; [...]
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on observation, interview and review of the medical record and other facility documentation, it was determined that the facility failed to provide finger nail care to a resident that was dependent on the staff for hygiene for (one)1 of 31 residents (Residents #64). This deficient practice was evidenced by the following: According to the admission Record, Resident #64 was admitted to the facility with the diagnoses which included but was not limited to: vascular dementia, neuropathy, depression, and glaucoma. The quarterly Minimum Data Set (MDS), an assessment tool used facilitate the management of a resident's care, dated 09/13/22, indicated that Resident #64 had severe cognitive impairment and required extensive assistance with personal hygiene and total dependence on staff for bathing. [...]
- D
Dispose of garbage and refuse properly.
Inspectors wroteBased on observation, interview and review of other facility documents, it was determined that the facility failed to provide a sanitary environment for residents, staff and the public by failing to keep the garbage compacter area free of garbage and debris and failed to have the doors to the trash compactor closed for 1 of 1 trash compactor. This deficient practice was evidenced by the following: On 12/07/22 at 10:54 AM, the surveyor toured the kitchen with the Food Service Director (FSD) and requested to see the outside garbage receptacle area. The surveyor observed a trash compactor (TC) on a cement pad. The surveyor further observed that both the left-side and right-side doors of the TC open exposing multiple trash bags inside. [...]
- C
Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.
Inspectors wroteBased on interview and review of other pertinent facility documentation, it was determined that the facility failed to ensure that the Facility Assessment included the resources required to establish policies and procedures for the management of an active COVID-19 (a potentially deadly virus) outbreak. This deficient practice was identified by the following. Reference F880, F886 On 12/07/22 at 9:30 AM during the entrance conference, both the Administrator and the Director of Nursing (DON) stated that the facility was in an active outbreak of COVID-19 and confirmed that there were no active cases of COVID-19, or persons under investigation (PUI) for signs and symptoms of COVID-19. [...]
Fire safety inspections
25 fire safety citations on file: 12 on January 15, 2026, 9 on August 14, 2024, 4 on December 16, 2022.
Every fire safety citation25 citations
- F
Keep aisles, corridors, and exits free of obstruction in case of emergency.
K 211 · January 15, 2026 · Corrected (the home has a date of correction)
- F
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
K 222 · January 15, 2026 · Corrected (the home has a date of correction)
- F
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
K 225 · January 15, 2026 · Corrected (the home has a date of correction)
- F
Install proper backup exit lighting.
K 281 · January 15, 2026 · Corrected (the home has a date of correction)
- F
Have properly located and lighted "Exit" signs.
K 293 · January 15, 2026 · Corrected (the home has a date of correction)
- F
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
K 321 · January 15, 2026 · Corrected (the home has a date of correction)
- F
Provide properly protected cooking facilities.
K 324 · January 15, 2026 · Corrected (the home has a date of correction)
- F
Properly select, install, inspect, or maintain portable fire extinguishes.
K 355 · January 15, 2026 · Corrected (the home has a date of correction)
- F
Have properly installed electrical wiring and gas equipment.
K 511 · January 15, 2026 · Corrected (the home has a date of correction)
- F
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
K 521 · January 15, 2026 · Corrected (the home has a date of correction)
- F
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
K 741 · January 15, 2026 · Corrected (the home has a date of correction)
- E
Inspect, test, and maintain automatic sprinkler systems.
K 353 · January 15, 2026 · Corrected (the home has a date of correction)
- F
Keep aisles, corridors, and exits free of obstruction in case of emergency.
K 211 · August 14, 2024 · Corrected (the home has a date of correction)
- F
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
K 222 · August 14, 2024 · Corrected (the home has a date of correction)
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · August 14, 2024 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · August 14, 2024 · Corrected (the home has a date of correction)
- F
Install corridor and hallway doors that block smoke.
K 363 · August 14, 2024 · Corrected (the home has a date of correction)
- F
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
K 521 · August 14, 2024 · Corrected (the home has a date of correction)
- F
Have elevators that firefighters can control in the event of a fire.
K 531 · August 14, 2024 · Corrected (the home has a date of correction)
- F
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · August 14, 2024 · Corrected (the home has a date of correction)
- F
Have proper medical gas storage and administration areas.
K 923 · August 14, 2024 · Corrected (the home has a date of correction)
- F
Meet other general requirements.
K 200 · December 16, 2022 · Corrected (the home has a date of correction)
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · December 16, 2022 · Corrected (the home has a date of correction)
- E
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
K 223 · December 16, 2022 · Corrected (the home has a date of correction)
- E
Have an enclosure around a vertical opening shaft.
K 311 · December 16, 2022 · Corrected (the home has a date of correction)