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 73 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
3J
0K
0L
Actual harm
1G
0H
0I
Potential for more than minimal harm
54D
13E
2F
Potential for minimal harm
0A
0B
0C
May 15, 2026Complaint inspection · 8 citations
- J
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on a review of a complaint, medical records, interviews, and facility investigative documents, it was determined that the facility failed to have an effective system to prevent 2 residents with cognitive impairment, exit-seeking behavior, and an assessed risk for elopement from leaving the facility without appropriate supervision. This failure placed both residents at risk for harm due to hazards, including no sidewalk, which forced them into a road, which led them to a heavily traveled road and one resident not being properly dressed. These actions resulted in an Immediate Jeopardy (cited as past non-compliance). This was evident for 2 (Resident #6, #7) out of 8 residents reviewed for elopement/wandering risk during a complaint survey. The facility implemented effective and thorough corrective measures following this incident prior to the start of this survey. [...]
- F
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
Inspectors wroteBased on documentation review and interview, it was determined the facility failed to ensure nurse aide competency training occurred no less than 12 hours per year as determined in nurse aides' performance reviews. This was evident for 5 of 5 personnel files reviewed during the complaint survey.
- D
Keep residents' personal and medical records private and confidential.
Inspectors wroteBased on medical record review, observation and interview, the facility staff failed to ensure residents had a curtain to maintain privacy during care. This was evident for 2 (Resident #10 and #13) of 25 residents observed during a complaint survey.
- D
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Inspectors wroteBased on medical record review, facility documentation review and interview, it was determined the facility failed to maintain an effective grievance system for residents. This was evident for 1 (Resident #10) of 4 residents reviewed for complaints during a complaint survey.
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on complaint, record review, and staff interview, it was determined the facility failed to report an incident of elopement to the state survey agency, the Office of Health Care Quality. This was evident for 2 (Resident #6, #7) of 8 residents reviewed for elopement during the complaint survey.
- D
Ensure each resident receives an accurate assessment.
Inspectors wroteBased on medical record review and staff interview, it was determined the facility staff failed to ensure Minimum Data Set (MDS) assessments were accurately coded. This was evident for 3 (#6, #2, #17) of 24 residents reviewed during a complaint survey.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on medical record review and interview, the facility staff failed to 1) assess a resident's wounds weekly to include measurements and 2) failed to follow wound care provider's orders for a resident. This was evident for 1 (Resident #8) of 3 residents reviewed for wound care during a complaint survey.
- D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on complaint, medical record review and interview, it was determined the facility failed to maintain complete and accurate medical records in accordance with accepted professional standards. This was evident for 3 (#6, #7, #10) of 10 residents reviewed for complaints during a complaint survey.
November 21, 2025Standard inspection · 15 citations
- 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 and interview it was determined the facility failed to serve food in a sanitary manner. This was evident during the initial tour of the kitchen during the recertification/complaint survey.
- E
Have a plan that describes the process for conducting QAPI and QAA activities.
Inspectors wroteBased on staff interviews and record reviews, it was determined that the facility failed to ensure governing body oversight of the facility's Quality Assurance and Performance Improvement (QAPI) Program and activities. This was evident during the recertification/complaint survey.
- E
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Inspectors wroteBased on surveyor observations and interviews with facility staff, it was determined that the facility failed to maintain an effective pest control program. This was found to be evident during the facility's recertification/complaint survey.
- D
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Inspectors wroteBased on record review and interviews, it was determined that the facility failed to notify the resident's physician and resident representatives of a facility acquired pressure ulcer. This was true for 1 (Resident #9) of 2 residents reviewed for pressure ulcer during the recertification/complaint survey process.
- D
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Inspectors wroteBased on interviews and record reviews it was determined that the facility failed to notify the resident and/or resident's representative of the facility policy for bed hold, including reserve bed payment. This was evident for 1(Resident #10) of 3 residents reviewed for hospitalization during the recertification/complaint survey.
- 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 Observation, record review and facility staff interviews, it was determined that the facility 1) failed to update the care plan of Resident #2 who is on isolation precaution to reflect the actual status of the isolation and, 2) failed to conduct care plan meetings of the interdisciplinary team for Resident #11 at the time of the quarterly revision of their care plan. This was evident for 2 (Resident #2 and #11) out of 56 residents reviewed for care plans during this recertification/complaint survey.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on a complaint, record review and staff interviews, it was determined that the facility failed to administer medications to a resident timely, and as ordered by the physician. This was evident for 1 (Resident #105) of 5 residents reviewed for unnecessary medications during the recertification/complaint survey.
- D
Provide enough food/fluids to maintain a resident's health.
Inspectors wroteBased on observation, record review, and interview it was determined the facility failed to assist with feeding for a resident at risk for aspiration. This was evident for 1 (Resident #16) of 2 residents reviewed for Nutrition during the recertification/complaint survey.
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observation, medical record review, and interviews, it was determined that the facility failed to 1) maintain a nasal cannula in a sanitary manner and administer Oxygen according to the prescribed physician order (Residents #6), and 2) failed to provide necessary respiratory care services for Resident #30. This was evident for 2 (Residents #6 and #30) of 3 residents reviewed for respiratory care during the recertification/complaint survey.
- D
Provide safe, appropriate pain management for a resident who requires such services.
Inspectors wroteBased on clinical record review and staff interview it was determined that the facility staff failed to ensure parameters used to determine if a resident was to be administered pain medication was adhered to by nursing staff, and failed to have a physician's order for non- pharmacological interventions for residents on pain medications. This was evident for 3 (Resident #6 and #84, #4) out of 3 residents reviewed for pain during the recertification/complaint survey.
- 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 record review and staff interviews, it was determined that the facility failed to report irregularities identified by the pharmacist to the attending physician for follow up. This was evident for 1 (Resident #7) of 5 residents reviewed for unnecessary medication during the recertification/complaint survey.
- D
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Inspectors wroteBased on observation and interview it was determined that the facility staff failed to 1) ensure treatment carts were locked and secure, and 2) failed to store all drugs in a locked compartment as required. This was evident for 1 out of the 4 nursing units observed in the facility during the recertification/complaint survey.
- D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on medical record review and interview, it was determined the facility staff failed to 1) maintain a medical record in the most accurate form for residents and 2) maintain medical records for residents from other licenses professionals. This was evident for 2 (Resident #12 and #11) out of 46 residents reviewed during the facility's recertification/complaint survey.
- D
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Inspectors wroteBased on record review and interview with facility staff, it was determined that the facility staff failed to ensure residents and/or residents' representative (RP) were provided education regarding the benefits and potential side effects of the pneumococcal and/or influenza immunization. This was evident for 2 (Resident #26 and #12) out of the 5 residents reviewed for immunizations during the facility's recertification/complaint survey.
- D
Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
Inspectors wroteBased on record review and interview with facility staff, it was determined that the facility failed to ensure staff were provided education regarding the benefits and potential side effects associated with the COVID-19 vaccine. This was evident for 1 (Staff #30) out of 5 staff members reviewed for immunizations during the facility's recertification/complaint survey.
February 2, 2024Standard inspection, Complaint inspection · 36 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 review of medical records and other pertinent documentation and interviews, it was determined that the facility failed to have an effective system in place to ensure that a resident's wishes regarding cardiopulmonary resuscitation (CPR) were clearly and accurately communicated to facility staff. This was found to be evident for 3 out of 7 residents reviewed for advance directives or death. (#184, #53, and #91) This failure resulted in an Immediate Jeopardy for Resident #184.
- F
Assure that each resident’s assessment is updated at least once every 3 months.
Inspectors wroteBased on record review and interviews, it was determined that the facility failed to complete Quarterly Minimum Data Set (MDS) assessments for residents within the regulatory time frames to facilitate appropriate care planning and maintain current assessment records. This was evident for 11 (#85, #28, #65, #183, #59, #54, #43, #77, #18, #63, #3) of 67 residents reviewed during the survey.
- E
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Inspectors wroteBased on observation and interview, it was determined that the facility failed to have an effective system in place to ensure that maintenance concerns are reported and addressed. This was found to be evident for rooms in 3 out of the 4 units in the facility.
- E
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Inspectors wroteBased on record review and staff interviews, it was determined that the facility staff 1) failed to complete comprehensive Minimum Data Set (MDS) assessments within the regulatory time frames to facilitate appropriate care planning and maintain current and accurate assessment records, and 2) failed to failed to assess a resident's cognition and mood on comprehensive and quarterly MDS assessments. This was evident for 8 (#98, #281, #130, #245, #282, #235, #241 and #54) of 67 residents reviewed during the survey.
- E
Ensure each resident receives an accurate assessment.
Inspectors wroteBased on medical record review and staff interview, it was determined the facility staff failed to ensure Minimum Data Set (MDS) assessments were accurately coded. This was evident for 1 (#91) of 2 residents reviewed for dental status, 1 (#98) of 3 residents reviewed for resident assessment, 2 (#65, #54) of 5 residents reviewed for unnecessary medications and 1 (#129) of 4 residents reviewed for hospitalization.
- E
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Inspectors wroteBased on medical record review and staff interview, it was determined that facility staff failed to develop and implement comprehensive, person-centered care plans, with measurable goals and non-pharmacological approaches. This was found to be evident for for 1 (#63) of 4 residents reviewed for position and mobility, and 2 (#54, #21) of 5 residents reviewed for unnecessary medications
- 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 medical record review and staff interview, it was determined that facility 1) failed to ensure interdisciplinary team meetings to review and revise the care plans following each assessment, 2) failed to evaluate and update a resident's plan of care after each assessment and 3) failed to ensure that a resident and resident representative, if applicable, had the opportunity to participate in the development, review, and revision of his/her care plan after each assessment. This was evident for 4 (#53, #59, #54, #235) of 6 residents reviewed for care plan timing and revision, 1 (#68) of 6 residents reviewed for communication and sensory problems, and 1 (#106) of 2 residents reviewed for behavioral and emotional status and 1 (#21) of 5 residents reviewed for unnecessary medications.
- E
Provide activities to meet all resident's needs.
Inspectors wroteBased on observations, medical record review, and interviews with the staff, it was determined that the facility failed to develop and implement an activities program to meet the needs and preferences of residents. This was evident for 4(#43, #71, #63, #91) of 6 residents reviewed for activites.
- 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 medical record review and interview, it was determined that the facility failed to have an effective system in place to ensure that the attending physician reviewed and responded to pharmacist identified irregularities and recommendations in a timely manner. This was evident for 1 (#65) of 5 residents reviewed for unnecessary medications, and 1 (#53) of 2 residents reviewed for insulin
- E
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on medical record review and interview, it was determined that the facility failed to ensure that primary care and specialty provider notes were placed in the medical record for review by other health care professionals. This was found to be evident for 1 (#106) of 2 residents reviewed for behavioral and emotional status, 2 (#63, #59) of 6 residents reveiwed for communication and sensory problems, 1 (#53) of 2 residents reviewed for insulin, and 2 (#184, #183) of 20 residents reviewed for facility reported incidents.
- D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteBased on observation, record review, and interview with staff, it was determined that the facility failed to ensure that a dependent resident was groomed in a manner that preserved the resident's dignity. This was evident for 1 (# 71) of 2 residents reviewed for dignity.
- D
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Inspectors wroteBased on medical record review and staff interviews, it was determined that the facility 1) failed to ensure that the resident was informed of their right to formulate an advance directive. This was evident for 2 (#54, and #235) of 5 residents reviewed for advance directives.
- D
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Inspectors wroteBased on record review and interviews, it was determined that the facility staff 1) failed to notify a provider of a blood sugar level outside an order's acceptable range for a resident, and 2) failed to notify the physician immediately following an accident that had the potential for requiring physician intervention. This was evident for 1 (#65) of 5 residents reviewed for unnecessary medications, and 1 (#245) of 5 residents reviewed for accidents.
- D
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Inspectors wroteBased on record review and interviews, it was determined that the facility failed to provide the Skilled Nursing Facility Advance Beneficiary Notice (SNFABN) to residents who were discharged from Medicare Part A services but had benefit days remaining and intended to remain at the nursing facility receiving non-skilled care. This was evident for 2 (#31, #106) of 3 residents reviewed for Skilled Nursing Facility Beneficiary Protection Notification.
- D
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Inspectors wroteBased on medical record review and staff interview, it was determined the facility failed to notify the resident/resident representative in writing of a transfer/discharge of a resident along with the reason for the transfer. This was evident for 1 (#132) of 5 residents reviewed for accidents, and 1 (#241) of 4 residents reviewed for hospitalization.
- D
Prepare residents for a safe transfer or discharge from the nursing home.
Inspectors wroteBased on medical record review and staff interview, it was determined the facility failed to document what preparation and orientation was given to residents to ensure an orderly transfer to an acute care facility. This was evident for 1 (#241) of 4 residents reviewed for hospitalization.
- D
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Inspectors wroteBased on medical record review, it was determined the facility failed to notify the resident and/or the resident representative in writing of the bed-hold policy upon transfer of the resident to an acute care facility. This was evident for 1 (#132) of 5 residents reviewed for accidents, and 1 (#241) of 4 residents reviewed for hospitalizations.
- D
PASARR screening for Mental disorders or Intellectual Disabilities
Inspectors wroteBased on medical record review and interview, it was determined that the facility failed to ensure a new Preadmission Screening and Resident Review (PASRR) was completed when it was determined that a resident would remain in the facility for long term care. This was found to be evident for 1 (Resident #63) out of 1 resident reviewed for PASRR during the survey.
- 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 medical record review and resident and staff interview, it was determined the facility failed to provide a resident and/or a resident's representative with a summary of the baseline care plan that included a summary of the resident's medications. This was evident for 2 (#54, #235) of 6 residents reviewed careplanning.
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on interviews and pertinent document review, it was determined that the facility failed to provide incontinent care to a dependent resident. This was evident for 1 (#282) of 3 residents reviewed for pressure injury.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wrote3) Review of Resident #183's medical record revealed the resident was originally admitted in February 2023 with a brief re-hospitalization in March 2023. The resident's diagnosis included, but was not limited to, multiple myeloma (blood cancer), Parkinson's disease, diabetes, heart disease and blindness. Review of the 3/11/23 hospital discharge report revealed one of the medications at the time of discharge was pomalidomide 4 MG take one capsule by mouth daily for 21 days followed by a 7 day rest period. Pomalidomide, also known as Pomalyst, is an anticancer medication used to treat multiple myeloma. Review of the Medication Administration Record (MAR) for March 2023 revealed there was an order to start Pomalidomide 4 mg one time a day for cancer until 4/1/23, take for for 21 days and rest 7 days. This medication was not administered on 3/12/23 and was discontinued on 3/13/23. [...]
- D
Assist a resident in gaining access to vision and hearing services.
Inspectors wroteBased on medical record review and interviews, it was determined that the facility failed to have an effective system in place to ensure that orders for eye doctor and audiology appointments were scheduled in a timely manner. This was found to be evident for 2 (Resident #68 and #59) of 5 residents reviewed for vision and hearing.
- D
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Inspectors wroteBased on observation, record review, and interviews, it was determined that the facility 1) failed to ensure splints for the prevention of contracture development were re-implemented after a resident was re-admitted after a brief hospitalization, and 2) failed to ensure that a resident with a limited range of motion received treatment and services as ordered by the attending provider to prevent further decline in the range of motion. This was evident for 2 (#63, #43) of 4 residents reviewed for position and mobility.
- 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 pertinent document review and interviews, it was determined that the facility failed to accurately document and address a physician's recommendation for a resident to receive a urology consult. This was evident for 1 ( #38) of 1 resident reviewed for urinary catheter.
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observation, record review, and interview, it was determined that the facility failed to maintain respiratory care equipment for a resident who required continuous oxygen via nasal cannula. This was evident for 1 (#85) out of 4 residents reviewed for respiratory care.
- D
Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit.
Inspectors wroteBased on medical record review and staff interview, it was determined that a facility provider failed to make their visit notes available after a visit with a resident (resident #515). This was evident for 1 (#515) of 4 residents reviewed for provider visit note availability during a facility's revisit survey.
- D
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
Inspectors wroteBased on medical record review, observation and interview, it was determined that the facility failed to ensure recommendations from the psychiatric provider was reported to the primary care provider and failed to ensure abnormal behaviors were reported to either the primary care provider or the psychiatric provider in a timely manner. This was found to be evident for 1(#106) of two residents reviewed for behavioral health services during the survey.
- D
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Inspectors wroteBased on medical record review and staff interview, it was determined the facility failed to keep a resident's drug regimen free from unnecessary drugs by 1) failing to ensure orders for a topical anesthetic patch included the duration the patch should be applied, and 2) failing to implement physician orders for blood pressure and pulse parameters prior to administering a blood pressure medication. This was evident for 1 (#21) of 5 residents reviewed for unnecessary medications.
- D
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 medical record review and staff interviews, it was determined that the facility staff failed to ensure that a resident's medication regimen was free from unnecessary medication by administering psychotropic medications without adequate monitoring for behavior. This was evident for 2 (#54, #21) of 5 residents reviewed for unnecessary medications.
- D
Ensure medication error rates are not 5 percent or greater.
Inspectors wroteBased on observation, interview and pertinent document review, the facility staff failed to ensure a medication error rate of less than 5 percent for 3 (#287, #292, #42) of 5 residents observed with 31 medication administration opportunities which resulted in a error rate of 9.6 percent.
- D
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Inspectors wroteBased on observation and interview, it was determined that the facility failed to maintain locked carts where medications were stored. This was evident for 3 carts out of 9 carts observed during the survey.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, record review, and interviews, it was determined that the facility failed to 1) have a physical barrier between the clean and soiled areas of the laundry room to prevent cross-contamination and 2) clean/replace a dirty nebulizer mask. This was evident for 2 out of 2 observations of the laundry room and 1 ( #65) of 2 residents observed for oxygen use.
- J
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Inspectors wroteBased on a review of facility self report MD00181520 investigation documentation, medical records, observations, and interviews, it was determined that the facility failed to ensure nursing staff had the appropriate competencies and skills to access a permacath for the IV administration of antibiotics. This was found to be evident for 1 (#184) of 2 residents reviewed for death during the survey. This deficient practice led to an immediate jeopardy for Resident #184. The facility implemented effective and thorough corrective measures following this incident. The facility's plan and action were verified during this survey, therefore this deficiency will be cited as past noncompliance. The date of correction was 8/14/22.
- G
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Inspectors wroteBased on interviews and record review it was determined that the facility failed to provide residents with an environment that was free from abuse. Due to this deficient practice Resident #505 suffered physical and psychosocial harm. This was evident for 1 (MD00204162) of 2 facility reported incidents of abuse.
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on review of facility documents and staff interview, it was determined the facility 1) failed to report an allegation of abuse to the State Agency, the Office of Health Care Quality (OHCQ), immediately but not later than 2 hours of the allegation. This was evident for 2 (#235, #383) of 21 residents reviewed for abuse.
- D
Respond appropriately to all alleged violations.
Inspectors wroteBased on review of facility investigation documentation, medical records and interviews, it was determined the facility failed to ensure that abuse allegations were thoroughly investigated. This was found to be evident for 2 (Resident #3, #34) of 21 residents reviewed for abuse.
March 29, 2019Standard inspection · 14 citations
- E
Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit.
Inspectors wroteBased on medical record review and interview, the physician failed to show evidence of admission assessment for 4 Residents. This is evident for 4 of 6 resident's (Resident #46, #59, #66 and #82) reviewed during the annual survey for physician services.
- E
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on medical record review and interview, it was determined the facility staff failed to maintain a medical record in the most accurate form for a resident. This was evident for 1 of 1 resident (Resident #59) reviewed for accurate medical records.
- D
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Inspectors wroteBased on resident interview, staff interview, and observation, it was determined that the facility failed to ensure a resident received meal services at a time that would allow full participation in dialysis treatment. This was true for 1 out of 2 residents (Resident #145) reviewed for dialysis.
- D
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Inspectors wroteBased on medical record review and interview, it was determined the facility staff failed to notify the physician the results of a potentially toxic Keppra blood level in a timely manner for a resident. This was evident for 1 of 56 residents (Resident #254) selected for review during the survey process.
- 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 surveyor observation, staff interview and resident interview it was determined that the facility staff failed to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior. This was observed on 2 of 4 resident units.
- D
PASARR screening for Mental disorders or Intellectual Disabilities
Inspectors wroteBased on clinical record review and staff interview it was determined that the facility staff failed to ensure a Pre-admission Screening and Resident Review (PASARR) was completed in a timely fashion. This was true for 1 out of the 56 residents (Resident #145) selected for review.
- 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 medical record review and interview, it was determined the facility staff failed to initiate, provide and implement comprehensive care plans for residents. This was evident for 2 of 56 residents (Residents #70 and #93) selected for review of care plans during the annual survey process.
- D
Honor each resident's preferences, choices, values and beliefs.
Inspectors wroteBased on medical record review and interview, it was determined the facility staff failed to thoroughly review dental recommendations for Resident #23 and act upon those recommendations. This was evident for 1 of 56 residents selected for dental review.
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on observation, medical record review and interview it was determined the facility staff failed to aid with meals for Residents #26 and #29 and failed to provide thorough grooming and personal hygiene services for Resident #68. This is evident for 3 of 3 residents selected for review for ADL care during the annual survey process.
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on clinical record review, facility incident report review, resident interview, and staff interview it was determined that the facility staff failed to ensure a resident was free from an accident or hazard. This was true for 3 out of 5 residents (Resident #256, #16 and #78) reviewed for a complaint.
- D
Provide enough food/fluids to maintain a resident's health.
Inspectors wroteBased on medical record review, observation and interview, it was determined the facility staff the failed to provide Resident #35 with the physician ordered diet. This was evident for 1 of 10 residents selected for review of nutrition and during the annual survey process.
- D
Provide safe, appropriate pain management for a resident who requires such services.
Inspectors wroteBased on a review of the clinical records and staff interview it was determined that the facility staff failed to document the administration of pain medication and monitor the effectiveness. This was true for 1 out of the 6 residents (Resident #255) reviewed for pain management during an annual recertification survey.
- D
Provide or obtain dental services for each resident.
Inspectors wroteBased upon staff interview and medical record review it was determined the facility staff failed to assist a resident in obtaining routine dental care and failed to ensure the recommendations of the dentist were carried out. This was evident for 1 of 3 residents (Resident #29) selected for review of dental services during the annual survey.
- D
Keep all essential equipment working safely.
Inspectors wroteBased on observation, staff interview and record review it was determined that the facility failed to maintain kitchen equipment in safe operating condition.
Fire safety inspections
32 fire safety citations on file: 10 on November 21, 2025, 21 on February 2, 2024, 1 on March 29, 2019.
Every fire safety citation32 citations
- F
Conduct testing and exercise requirements.
E 39 · November 21, 2025 · Corrected (the home has a date of correction)
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · November 21, 2025 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · November 21, 2025 · Corrected (the home has a date of correction)
- F
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
K 761 · November 21, 2025 · Corrected (the home has a date of correction)
- F
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · November 21, 2025 · Corrected (the home has a date of correction)
- E
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
K 223 · November 21, 2025 · Corrected (the home has a date of correction)
- E
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
K 362 · November 21, 2025 · Corrected (the home has a date of correction)
- E
Install corridor and hallway doors that block smoke.
K 363 · November 21, 2025 · Corrected (the home has a date of correction)
- E
Have restrictions on the use of portable space heaters.
K 781 · November 21, 2025 · Corrected (the home has a date of correction)
- E
Ensure proper usage of power strips and extension cords.
K 920 · November 21, 2025 · Corrected (the home has a date of correction)
- F
Develop and maintain an Emergency Preparedness Program (EP).
E 4 · February 2, 2024 · Corrected (the home has a date of correction)
- F
Address patient/client population and determine types of services needed.
E 7 · February 2, 2024 · Corrected (the home has a date of correction)
- F
Include a process for Emergency Preparedness collaboration.
E 9 · February 2, 2024 · Corrected (the home has a date of correction)
- F
Address subsistence needs for staff and patients.
E 15 · February 2, 2024 · Corrected (the home has a date of correction)
- F
Establish policies and procedures for volunteers.
E 24 · February 2, 2024 · Corrected (the home has a date of correction)
- F
Provide a means of sharing information on occupancy/needs.
E 34 · February 2, 2024 · Corrected (the home has a date of correction)
- F
Establish emergency prep training and testing.
E 36 · February 2, 2024 · Corrected (the home has a date of correction)
- F
Establish staff and initial training requirements.
E 37 · February 2, 2024 · Corrected (the home has a date of correction)
- F
Conduct testing and exercise requirements.
E 39 · February 2, 2024 · Corrected (the home has a date of correction)
- F
Provide properly protected cooking facilities.
K 324 · February 2, 2024 · Corrected (the home has a date of correction)
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · February 2, 2024 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · February 2, 2024 · Corrected (the home has a date of correction)
- F
Provide a written emergency evacuation plan.
K 711 · February 2, 2024 · Corrected (the home has a date of correction)
- F
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
K 761 · February 2, 2024 · Corrected (the home has a date of correction)
- F
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
K 914 · February 2, 2024 · Corrected (the home has a date of correction)
- D
Properly select, install, inspect, or maintain portable fire extinguishes.
K 355 · February 2, 2024 · Corrected (the home has a date of correction)
- D
Meet other general requirements that are deficient.
K 500 · February 2, 2024 · 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 · February 2, 2024 · Corrected (the home has a date of correction)
- D
Ensure gas and vacuum piping is labeled.
K 909 · February 2, 2024 · Corrected (the home has a date of correction)
- D
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · February 2, 2024 · Corrected (the home has a date of correction)
- D
Have proper medical gas storage and administration areas.
K 923 · February 2, 2024 · Corrected (the home has a date of correction)
- D
Install an approved automatic sprinkler system.
K 351 · March 29, 2019 · Corrected (the home has a date of correction)