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 48 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
37D
10E
0F
Potential for minimal harm
0A
0B
1C
April 9, 2026Complaint inspection · 3 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 interview and record review, the facility failed to ensure a comprehensive individualized care plan was developed with specific information for that resident for 4 of 7 sampled residents (1, 4, 5, and 6) reviewed for care plans. This failure placed residents at risk for unmet care needs and a diminished quality of life.
- E
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 errors when medications were not administered in accordance with provider orders and/or within the standard practice administration parameters for 3 of 7 sampled residents (Resident 1, 2, and 6) reviewed for significant medication errors. This failure placed residents at risk of adverse medical conditions, a change in health conditions, and a diminished quality of life.
- D
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Inspectors wroteBased on interview and record review, the facility failed to consistently conduct and document pre and post dialysis (a life sustaining treatment for kidney failure) assessments designed to ensure consistent ongoing communication and collaboration with the dialysis facility and failed to follow physicians' orders pertaining to dialysis treatment, for 1 of 1 resident (Resident 3) reviewed for dialysis. This failure had the potential to place residents who receive dialysis at risk for unmet care needs and dialysis related complications.
January 9, 2026Standard inspection · 15 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 expired and/or BUE (beyond-use date) medications were discarded when expired from 2 of 5 medication carts (Cart B & Cart E) reviewed. The facility also failed to store medication in residents' room in a locked container for 1 of 1 resident reviewed (Resident 80). This failure placed residents at risk of not receiving the full benefits of the medication, equipment, supplies, and at risk for accessing unsecured medication.
- 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, the facility failed to ensure staff performed hand hygiene during the lunch hallway meal pass for 1 of 5 hallways (C-Wing) reviewed for lunch meal pass. This failure to perform proper hand hygiene placed residents at risk of cross-contamination, food borne illness and a diminished quality of life.
- D
Ensure that residents are fully informed and understand their health status, care and treatments.
Inspectors wroteBased on interview and record review, the facility failed to obtain a signed consent before administering a psychotropic medication (medications capable of affecting the mind, emotions, and behaviors) for 1 of 5 residents (Resident 6) reviewed for unnecessary medications. This failure placed the resident at risk of not being fully informed of the risks and benefits before making decisions about medications, and a diminished quality of life.
- D
Honor the resident's right to manage his or her financial affairs.
Inspectors wroteBased on interview and record review, the facility failed to ensure residents who had personal fund accounts established, received accrued interest on those accounts for 3 of 3 sampled residents (Residents 16, 76, and 98) reviewed for Trust Funds interest accrued. This failure placed residents at risk not to receive or have access to monies owed to them.
- D
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Inspectors wroteBased on interview and record review, the facility failed to provide a Medicare Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNF ABN - a notice of Medicare non-coverage and residents assumption of financial responsibility) to 1 of 3 residents (Resident 16) reviewed for beneficiary notification. This failure placed residents at risk of not being informed of services and related changesFindings included. Resident 16 was re-admitted to the facility on [DATE]. The Annual Minimum Data Set, an assessment tool, dated 12/31/2025, documented Resident 16 was severely cognitively impaired. Record review of Resident 16's Notice of Medicare Non-Coverage (NOMNC) form, dated 09/03/2025, showed Resident 16's representative received a call on 09/03/2025, informing them that Resident 16's Medicare Part A coverage would end on 09/05/2025. [...]
- 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 interview, observation and record review, the facility failed to maintain a clean homelike environment by not ensuring resident rooms were cleaned for 1 of 11 rooms (C Wing, room [ROOM NUMBER]) reviewed for environment. This failure placed residents at risk for a diminished quality of life.
- D
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
Inspectors wroteBased on interview and record review, the facility failed to complete an AIMS (Abnormal Involuntary Movement Scale) test (a rating scale used to assess the severity of involuntary movements that sometimes develop as a side effect of treatment with antipsychotic medications [drugs used primarily to treat symptoms such as hallucinations and delusions]) for 2 of 5 sampled residents (Resident 4 &118) reviewed for unnecessary medications. This failure placed residents at risk for adverse medication side-effects, medical complications, and a diminished quality of life.
- D
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Inspectors wroteBased on interview and record review, the facility failed to ensure a written transfer/discharge notice was provided to the resident or the resident representative in a language and manner they understood for 1 of 1 residents (Resident 115) reviewed for hospitalization. This failure placed the resident at risk for not knowing the reason for their transfer or have the opportunity to make decisions about their transfer/discharge rights.
- D
Ensure each resident receives an accurate assessment.
Inspectors wroteBased on interview and record review, the facility failed to ensure the Minimum Data Set (MDS, an assessment tool) was completed accurately to reflect a resident's health status and/or care needs for 2 of 2 sampled residents (Residents 39 and 22) reviewed for resident assessment. This failure placed residents at risk for unidentified and/or unmet care needs and a diminished quality of life.
- 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 comprehensive care plan for 1 of 1 sampled resident (Resident 116) reviewed for comfort care (medical focus shifts from curing an illness to providing relief from pain and symptoms). This failure placed residents at risk of unmet care needs and a diminished quality of life.
- 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 provide assistance with grooming for 1 of 4 residents (Resident 80) reviewed for activities of daily living. This failure placed residents at risk of unmet care needs and a diminished quality of life.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on interviews and record reviews, the facility failed to ensure bowel interventions were initiated for 1 of 8 sampled residents (Resident 74) reviewed for quality of care and failed to perform ordered weights for 1 of 5 residents (Resident 13) reviewed for weights. This failure placed residents at risk for discomfort, health complications and a diminished quality of life.
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observation, interview, and record review, the facility failed to obtain physician orders for oxygen use for 1 of 2 sampled residents (Resident 83) reviewed for respiratory care. This failure placed residents at risk for worsening health complications, unmet care needs, and a diminished quality of life. Findings Included. Record review of the facility's policy titled, Oxygen Administration, undated, documented .1. Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration. Resident 83 was admitted to the facility on [DATE], discharged return anticipated on 12/19/2025, and re-admitted on [DATE] on hospice. The admission Minimum Data Set, (an assessment tool) dated 11/11/2025, showed Resident 83 was cognitively intact and was on oxygen therapy. [...]
- D
Post nurse staffing information every day.
Inspectors wroteBased on interview and record review, the facility failed to ensure resident census and nursing hours were accurately posted and/or updated daily for 30 of 30 days reviewed for nurse staff postings. This failure placed residents, resident representatives, and visitors at risk of not being fully informed of the current staffing levels and resident census information.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff properly donned (putting on) personal protective equipment (PPE) for 1 of 3 sampled resident rooms (room [ROOM NUMBER]) reviewed for infection prevention and control. This failure placed residents at risk for the spread of infection transmission in the facility and a diminished quality of life.
January 5, 2026Complaint inspection · 3 citations
- E
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Inspectors wroteBased on interview and record review, the facility failed to provide activities of daily living (ADL's) for resident's dependent on staff assistance related to bathing for two of three sampled residents (Resident 1 & 2) reviewed for ADLs. This failure placed residents at risk for unmet needs, poor hygiene, and a diminished quality of life.
- E
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 errors when medications were not administered in accordance with provider orders for 2 of 5 sampled residents (Residents 2 &4) reviewed for significant medication errors. This failure placed residents at risk of adverse medical conditions, a change in health condition, and a diminished quality of life.
- D
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Inspectors wroteBased on interview and record review, the facility failed to ensure prescriptions provided on discharge accurately reflected the residents reconciled medication list in the discharge summary for 1 of 5 sample residents (Resident 3) reviewed. This facility failure placed residents at risk for adverse medication side effects, changes in health conditions, and a diminished quality of life.
November 18, 2025Complaint inspection · 1 citation
- 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 medication and/ or treatment errors when medications and or treatments were not administered in accordance with provider orders for 1 of 3 sampled residents (Resident 1) reviewed for medication errors. This failure placed residents at risk of adverse medical conditions, a change in health conditions, and a diminished quality of life.
July 31, 2025Complaint inspection · 4 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 interview and records review, the facility failed to inform the physician about a significant change in the residents' physical condition for 1 of 3 residents (Resident 1) reviewed for notice of changes. This failure placed residents at risk of adverse medical conditions and a diminished quality of life.
- D
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Inspectors wroteBased on interview and record review, the facility failed to provide bathing assistance for 1 of 3 (Resident 1) residents reviewed for Activities of Daily Living care. This failure placed residents at risk of adverse medical conditions and a diminished quality of life.
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on interview and record review, the facility failed to assess and accurately document a residents wound for 1 of 3 residents (Resident 1) sampled for wound care. This failure placed residents at risk of adverse medical conditions and a diminished quality of life.
- D
Ensure that residents are free from significant medication errors.
Inspectors wroteBased on interview and record review, the facility failed to ensure Resident 1 was free from significant medication errors when medications were not administered in accordance with provider orders for 1 of 3 sampled residents (Resident 1) reviewed for significant medication errors. This failure placed residents at risk of adverse medical conditions, a change in health conditions, and a diminished quality of life.
October 25, 2024Standard inspection · 7 citations
- D
Ensure that residents are fully informed and understand their health status, care and treatments.
Inspectors wroteBased on interview and record review, the facility failed to ensure residents received information about the risk and benefits and failed to obtain the resident's informed consent prior to the administration of psychotropic medications for 2 of 6 sampled residents (32 & 78) reviewed for right to be informed and make treatment decisions. These failures placed residents and/or their representatives at risk of not being fully informed about the care and treatment related to the risks and benefits associated with psychotropic medications and a diminished quality of life.
- D
Ensure each resident receives an accurate assessment.
Inspectors wroteBased on observations, interviews, and record review the facility failed to accurately assess significant weight loss for 1 of 1 sampled resident (71) reviewed for assessment accuracy. This failure placed residents at risk for nutritional and functional decline in overall health status and a diminished quality of life.
- D
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Inspectors wroteBased on interview and record review, the facility failed to ensure the recommendations of the Preadmission Screen and Resident Review (PASARR) Level II were followed for 1 of 1 sampled resident (23) reviewed for PASARR. This failure placed residents at risk of not receiving the necessary mental health services and a diminished quality of care.
- D
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Inspectors wroteBased on observation, interview and record review, the facility failed to a baseline care plan was not developed to address falls and communication for 2 of 8 sampled residents (66 & 82) reviewed for baseline care plans. This failure placed residents at risk for unmet care needs and a diminished quality of life.
- 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 ongoing neurological assessments (assess the nervous system and identify any abnormalities that affect function and activities of daily living) were performed after an unwitnessed fall for 1 of 2 sampled residents (66); failed to ensure daily weights were obtained for 2 of 9 sampled residents (75 & 288) reviewed for weight management; failed to ensure the bowel protocol was initiated for 2 of 7 sampled residents (24 & 73) and failed to ensure dental services were obtained for 1 of 1 sampled resident (53) reviewed for quality of care related to neurological assessments, weight management, bowel management, and dental services. These failures placed residents at risk for worsening conditions, health complications and diminished quality of life.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview, and record review, the facility failed to implement Enhanced Barrier Precautions (EBP) when providing medical device care and wound care for 4 of 5 sampled residents (62, 240, 241 & 339) reviewed for infection prevention and control. These failures placed residents, staff, and visitors at risk for contracting infectious diseases and a decreased quality of life.
- D
Report COVID19 data to residents and families.
Inspectors wroteBased on interview and record review, the facility failed to notify a resident's family and/or representative of a positive COVID-19 (Coronavirus - a contagious disease) results for 1 of 5 sampled residents (75) reviewed for infection prevention and control. This failure placed residents and/or resident's representative at risk of not being knowledgeable to make decisions about their care in relation to the facility's COVID-19 management plan and a diminished quality of care.
August 23, 2024Complaint inspection · 2 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 interview and record review, the facility failed to ensure a comprehensive individualized care plan was developed with specific information for that resident for 6 of 6 sampled residents (1, 2, 3, 4, 5, and 6) reviewed for care plans. This failure placed residents at risk for unmet care needs and a diminished quality of life.
- E
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 errors when medications were not administered in accordance with provider orders for 4 of 6 sampled residents (Residents 1, 2, 5, & 6) reviewed for significant medication errors. This failure placed residents at risk of adverse medical conditions, a change in health condition and a diminished quality of life.
July 8, 2024Complaint 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 ensure fall mats (a cushioned surface used for the purpose of reducing injuries from falls) were in place on either side of the resident's bed, as directed in the comprehensive care plan, for 1 of 3 sampled residents (Resident 1) reviewed for accident hazards. This failure placed residents at risk of a fall with injury and a diminished quality of life.
March 18, 2024Complaint inspection · 1 citation
- 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 medication errors when medication orders for bedside administration were not followed for 1 of 7 sampled residents (1) reviewed for medication errors. This failure placed residents at risk for a decline in medical condition and a diminished quality of life.
December 8, 2023Standard inspection, Complaint inspection · 10 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 medication refrigerator temperature logs were consistently maintained in 2 of 2 sampled medication rooms (1st Floor and 2nd Floor) reviewed for medication storage. This failure placed residents at risk for receiving compromised or ineffective medications with unknown potency.
- D
Ensure that residents are fully informed and understand their health status, care and treatments.
Inspectors wroteBased on interview and record review, the facility failed to ensure residents and/or resident representatives were informed and provided consent before administering a psychotropic (mind altering) medication for 2 of 5 sampled residents (29 & 21) reviewed for right to be informed and make treatment decisions related to unnecessary medications. This failure placed residents and/or resident representatives at risk of not being fully informed of the risks and benefits before making decisions about psychotropic medications and a diminished quality of life.
- D
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Inspectors wroteBased on interview and record review, the facility failed to obtain, provide, and/or assist with completing advanced directives (ADs) for 3 of 16 sampled residents (38, 54, and 278) reviewed for ADs. This failure placed residents at risk for losing their right to have their health care preferences and/or have their decisions honored.
- 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 interview and record review, the facility failed to provide a written notice of transfer to the resident and/or the resident's representative describing the reason for transfer for 2 of 5 sampled residents (10 & 33) reviewed for transfer notification requirement. This failure placed residents at risk of not being informed of their condition, unmet care needs and a diminished quality of life.
- 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 interview and record review, the facility failed to provide a written Bed-Hold notice to the resident or resident's representative at the time of transfer to the hospital for 4 of 5 sampled residents (10, 40, 13 & 33) reviewed for bed hold notifications. This failure placed residents at risk for lack of knowledge regarding their right to hold their bed while in the hospital.
- 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 a care plan related to nephrostomy tube (a tube that drains urine from the kidney to an external bag) for 1 of 3 sampled residents (13) reviewed for comprehensive care plans. catheter care. This failure placed residents at risk of unmet care needs, delayed care, and a decreased quality of life.
- 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 initiate bowel interventions for 2 of 2 sampled residents (10 & 268) and failed to perform ongoing neurological assessments (assesses the nervous system and identifies abnormalities affecting function and activities of daily living) for a resident after an unwitnessed falls for 2 of 5 sampled residents (21 & 26) reviewed for quality care related to bowel management and neurological assessments. These failures placed residents at risk for interventions not be intimated, discomfort, health complications and a diminished qualify of life.
- D
Provide enough food/fluids to maintain a resident's health.
Inspectors wroteBased on interview and record review, the facility failed to ensure resident weights were monitored per physician orders for 1 of 5 sampled residents (13) reviewed for nutrition. This failure placed residents at risk of malnutrition, delayed wound-healing, and a decreased quality of life.
- D
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Inspectors wroteBased on interview and record review, the facility failed to ensure consistent and ongoing communication and collaboration with the dialysis facility regarding dialysis treatment and care for 1 of 2 sampled residents (26) reviewed for dialysis. This failure placed residents at risk of unidentified medical complications and a diminished quality of life.
- C
Post nurse staffing information every day.
Inspectors wroteBased on interview and record review, the facility failed to ensure nursing hours were posted daily for 22 of 30 days reviewed for nurse staff posting. This failure placed residents, resident representatives, and visitors at risk of not being fully informed of the current staffing levels and census.
September 20, 2023Complaint inspection · 1 citation
- E
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on interview and record review, the facility failed to ensure activities of daily living (ADLs) for residents dependent on staff assistance were provided related to bathing for 7 of 10 sampled residents (1, 2, 3, 4, 5, 6 & 7) reviewed for ADLs for dependent residents. This failure placed residents at risk for poor hygiene and a diminished quality of life.
Fire safety inspections
44 fire safety citations on file: 5 on January 9, 2026, 11 on October 25, 2024, 28 on December 8, 2023.
Every fire safety citation44 citations
- F
Install corridor and hallway doors that block smoke.
K 363 · January 9, 2026 · Corrected (the home has a date of correction)
- F
Ensure that testing and maintenance of electrical equipment is performed.
K 921 · January 9, 2026 · Corrected (the home has a date of correction)
- E
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 9, 2026 · Corrected (the home has a date of correction)
- D
Have an enclosure around a vertical opening shaft.
K 311 · January 9, 2026 · Corrected (the home has a date of correction)
- D
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
K 521 · January 9, 2026 · Corrected (the home has a date of correction)
- F
Develop and maintain an Emergency Preparedness Program (EP).
E 4 · October 25, 2024 · Corrected (the home has a date of correction)
- F
Address patient/client population and determine types of services needed.
E 7 · October 25, 2024 · Corrected (the home has a date of correction)
- F
List the names and contact information of those in the facility.
E 30 · October 25, 2024 · Corrected (the home has a date of correction)
- F
Meet other general requirements.
K 100 · October 25, 2024 · Corrected (the home has a date of correction)
- F
Provide properly protected cooking facilities.
K 324 · October 25, 2024 · Corrected (the home has a date of correction)
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · October 25, 2024 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · October 25, 2024 · Corrected (the home has a date of correction)
- F
Install corridor and hallway doors that block smoke.
K 363 · October 25, 2024 · Corrected (the home has a date of correction)
- F
Have simulated fire drills held at unexpected times.
K 712 · October 25, 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 · October 25, 2024 · Corrected (the home has a date of correction)
- F
Ensure that testing and maintenance of electrical equipment is performed.
K 921 · October 25, 2024 · Corrected (the home has a date of correction)
- F
Develop and maintain an Emergency Preparedness Program (EP).
E 4 · December 8, 2023 · Corrected (the home has a date of correction)
- F
Conduct risk assessment and an All-Hazards approach.
E 6 · December 8, 2023 · Corrected (the home has a date of correction)
- F
Address patient/client population and determine types of services needed.
E 7 · December 8, 2023 · Corrected (the home has a date of correction)
- F
Include a process for Emergency Preparedness collaboration.
E 9 · December 8, 2023 · Corrected (the home has a date of correction)
- F
Develop Emergency Preparedness policies and procedures.
E 13 · December 8, 2023 · Corrected (the home has a date of correction)
- F
Address subsistence needs for staff and patients.
E 15 · December 8, 2023 · Corrected (the home has a date of correction)
- F
Establish procedures for tracking staff and patients during an emergency.
E 18 · December 8, 2023 · Corrected (the home has a date of correction)
- F
Establish policies and procedures including evacuation.
E 20 · December 8, 2023 · Corrected (the home has a date of correction)
- F
Establish policies and procedures for sheltering.
E 22 · December 8, 2023 · Corrected (the home has a date of correction)
- F
Establish policies and procedures for medical documentation.
E 23 · December 8, 2023 · Corrected (the home has a date of correction)
- F
Establish policies and procedures for volunteers.
E 24 · December 8, 2023 · Corrected (the home has a date of correction)
- F
Create arrangements with other facilities to receive patients.
E 25 · December 8, 2023 · Corrected (the home has a date of correction)
- F
Establish roles under a Waiver declared by secretary.
E 26 · December 8, 2023 · Corrected (the home has a date of correction)
- F
Develop a communication plan.
E 29 · December 8, 2023 · Corrected (the home has a date of correction)
- F
List the names and contact information of those in the facility.
E 30 · December 8, 2023 · Corrected (the home has a date of correction)
- F
Provide emergency officials' contact information.
E 31 · December 8, 2023 · Corrected (the home has a date of correction)
- F
Provide primary/alternate means for communication.
E 32 · December 8, 2023 · Corrected (the home has a date of correction)
- F
Establish methods for sharing information.
E 33 · December 8, 2023 · Corrected (the home has a date of correction)
- F
Provide a means of sharing information on occupancy/needs.
E 34 · December 8, 2023 · Corrected (the home has a date of correction)
- F
Provide family notifications of emergency plan.
E 35 · December 8, 2023 · Corrected (the home has a date of correction)
- F
Establish emergency prep training and testing.
E 36 · December 8, 2023 · Corrected (the home has a date of correction)
- F
Establish staff and initial training requirements.
E 37 · December 8, 2023 · Corrected (the home has a date of correction)
- F
Conduct testing and exercise requirements.
E 39 · December 8, 2023 · 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 · December 8, 2023 · Corrected (the home has a date of correction)
- F
Provide properly protected cooking facilities.
K 324 · December 8, 2023 · Corrected (the home has a date of correction)
- F
Have restrictions on the use of flammable curtains.
K 751 · December 8, 2023 · Corrected (the home has a date of correction)
- F
Have proper medical gas storage and administration areas.
K 923 · December 8, 2023 · Corrected (the home has a date of correction)
- F
Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk.
K 926 · December 8, 2023 · Corrected (the home has a date of correction)