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 49 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
1J
0K
0L
Actual harm
1G
0H
0I
Potential for more than minimal harm
13D
16E
16F
Potential for minimal harm
0A
1B
1C
July 1, 2026Complaint inspection · 2 citations
- E
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on record review, observation, and interview, the facility failed to provide respiratory care in accordance with professional standards for 4 (R #2, R #3, R #5, and R #6) of 4 (R #2, R #3, R #5, and R #6) residents reviewed for respiratory care when the staff failed to:1. Ensure medical orders included the amount of oxygen (a specific flow rate; measurement of the volume of liquid or gas moving per unit of time) and the delivery method (i.e. Nasal canula, simple mask, or non-rebreather mask) for R #6.2. Ensure oxygen tubing included a label with a date indicating when tubing was changed for R #2, R #3, and R #5). These deficient practices are likely to result in residents receiving too much, not enough oxygen, and increase their risk of infection which can lead to worsening of their conditions.
- D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Inspectors wroteBased on interview and record review, the facility failed to ensure timely acquisition and provision of ordered narcotic pain medication for 1 (R #6) of 1(R #6) resident who required post operative pain management. This failure resulted in a delay in receiving prescribed narcotic medication which has the potential to cause the resident unnecessary pain and anguish.
November 18, 2025Complaint inspection · 1 citation
- E
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Inspectors wroteBased on record review and interview, the facility failed to ensure each resident's drug regimen was free from unnecessary drugs by ensuring adequate indication of use for medications based off of the residents' diagnosis for 3 (R #1, R #2, and R #3) of 3 (R #1, R #2, and R #3) residents reviewed for unnecessary medications. This deficient practice could likely lead to adverse drug effects and poor patient outcomes.
August 14, 2025Standard inspection · 11 citations
- F
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, the facility failed to ensure safe medication storage practices by not ensuring the following:1. The medication carts were locked while unattended, 2. The medical supply storage rooms were kept free of expired medications, 3. Supplies and medications were stored according to manufacturer's temperature instructions. These deficient practices have the potential to affect all 61 residents as identified by the census provided by the Activities Coordinator on 08/10/25. If the facility does not ensure safe storage practices, then residents are at risk for unauthorized persons to have access to medications and adverse effects due to improper storage.
- F
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Inspectors wroteBased on observation, record review, and interviews, the facility failed to ensure the nutritional needs and preferences were met for all 61 residents listed on the facility census provided by the Administrator (ADM) on 08/10/25, when staff failed to complete the following: 1. Serve food items that were listed on the menu. 2. Provide residents with the opportunity to select their choice from the menu or alternate menu in advance of meal service. These deficient practices are likely to lead to residents experiencing frustration, depression, and weight loss due to not knowing what food is being served or being able to choose what they eat.
- F
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on observation and interview, the facility failed to maintain the kitchen in a sanitary manner when staff failed to complete the following: 1. Maintain the ice machine in a manner to prevent contamination and foodborne pathogens, 2. Maintain the coffee, juice, and tea machines in a clean and sanitary manner, 3. Properly store food items,4. Maintain the kitchen environment in a clean and sanitary manner. These failures have the potential to result in cross contamination, the growth of foodborne pathogens, and foodborne illnesses.
- F
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, record review, and interview, the facility failed to develop and implement an ongoing infection prevention and control program (a program that is used to prevent, recognize, and control the onset and spread of infections) by not providing the following:Enhanced Barrier (EBP) signs not visible outside of rooms with precautions,Hand Sanitizing,This failed practice has the potential to result in the spread of infectious diseases and residents to be at risk of contracting infections, hospitalization, and death.
- F
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, the facility failed to maintain documentation related to staff COVID-19 (an acute respiratory disease in humans characterized mainly by fever and cough and capable of progressing to severe symptoms and in some cases death, especially in older people and those with underlying health conditions) vaccinations (treatment with a vaccine to produce immunity to a particular infections disease or pathogen) for 4 (CNA #1, CNA #2, CNA #3, and CNA #4) of 4 (CNA #1, CNA #2, CNA #3, and CNA #4) staff members reviewed for COVID-19 vaccinations and at a minimum provide the following:1. Staff were given education of the COVID-19 vaccination regarding the benefits and potential risks associated with COVID-19 vaccine,2. Staff were offered the COVID-19 vaccine or information on obtaining COVID-19 vaccine. 3. [...]
- F
Keep all essential equipment working safely.
Inspectors wroteBased on observation and interview, the facility failed to ensure essential equipment was in safe operating condition by not cleaning, repairing, or replacing the following: 1. The cleaning solution dispenser above the three-compartment sink.2. The walk-in refrigerator. 3. The freezer located in the kitchen. 4. The water heater located in the kitchen. If the facility does not keep essential equipment in the kitchen in safe operating condition, then all 61 residents residing in the facility (according to the facility census that was provided by the administrator (ADM) on 08/10/25) could experience increase in foodborne illnesses and food not being prepared properly.
- E
Respond appropriately to all alleged violations.
Inspectors wroteBased on record review and interview, the facility failed to report the results of all investigations to the State Survey Agency within five working days of an incident for 2 (R #32 and R #64) of 2 (R #32 and R #64) residents reviewed for abuse or neglect. If the facility is not submitting the summary of the facility's investigation to the State Survey Agency, then the State Survey Agency is unable to appropriately triage (review) the allegation for further investigation.
- D
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Inspectors wroteBased on observation, interview, and record review, the facility failed to keep residents free from physical restraints for 1 (R #4) of 1 (R #4) resident reviewed for restrictions when staff used a wander guard (wearable technology used to keep residents from wandering or eloping from the facility unattended) for a resident that no longer needs a wander guard. This deficient practice could likely result in R #4 being unnecessarily restricted.
- 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, interview, and record review, the facility failed to ensure staff revised the care plan for 1 (R #32) of 3 (R #9, R #32, and R #65) residents reviewed when staff failed revise R #34's care plan to include elopement risk and use of a wander guard (wearable technology used to keep residents from wandering or eloping from the facility unattended). This deficient practice is likely to result in residents' care and needs not being addressed.
- D
Post nurse staffing information every day.
Inspectors wroteBased on observation and interview, the facility failed to post nurse staffing data daily, at the beginning of the shift that included the following: 1. Facility name. 2. The current date. 3. The total number and the actual hours worked by the following categories of licensed and unlicensed nursing staff directly responsible for resident care per shift: 1. Registered nurses. 2. Licensed practical nurses. 3. Certified nurse aides. 4. Resident census. This deficient practice could likely result in residents and visitors not having the staffing information readily available.
- D
Ensure that residents are free from significant medication errors.
Inspectors wroteBased observation, record review, and interviews, the facility failed to ensure residents were free from significant medication errors by not administering medications as ordered for 1 (R #2) of 1 (R #2) resident reviewed for medication administration. This deficient practice could likely lead to severe negative effects on the residents.
May 29, 2025Complaint inspection · 10 citations
- F
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 record review and interview, the facility failed to conduct an in-dept investigation, correct the grievance allegations, and notify residents of the outcome of their grievances. These deficient practices have the potential to affect all 62 residents (residents were identified using the census provided by the Administrator on 05/28/25) residing in the facility. If the facility is not investigating, correcting, and notifying residents of their grievance allegations then residents are likely to feel unheard and unimportant.
- F
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, the facility failed to secure medications in a medication cart and a treatment cart for all 62 residents living in the facility (residents were identified by the census list provided by the Administrator on 05/28/25). This deficient practice could result in residents obtaining medication not prescribed to them resulting in adverse side effects.
- F
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Inspectors wroteBased on record review, interview, and observation, the facility failed to serve food that is palatable, attractive, and at a safe and appetizing temperature. This deficient practice has the potential to affect all 62 residents' ability to eat and enjoy their meals, may decrease their quality of life, and could likely lose weight.
- 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 interviews, the facility failed to provide a comfortable and homelike environment by: 1. Not repairing the peeling and chipped paint, 2. Not repainting areas of repair to match the rest of the wall, 3. Handrails in the 200-hall appeared worn and needed repair/refinishing, 4. Using an overhead paging system to announce phone calls for staff members and to call staff members to the office. These deficient practices could affect everyone that lives in the 200-hall as identified by the Daily Census provided by the Administrator (ADM) on 05/28/25 and will likely cause residents to feel like they are not living in a comfortable home-like environment and make them feel they are not valued.
- E
Respond appropriately to all alleged violations.
Inspectors wroteBased on interview, the facility failed to have evidence that all allegations of abuse, neglect, exploitation or mistreatment were thoroughly investigated to prevent further incidents from occurring. This deficient practice could likely affect all 62 residents residing in the facility according to the census provided by the Administrator (ADM) on 05/28/25. If the facility is not thoroughly investigating and maintaining evidence of the investigations then residents are at a higher risk of being abused, neglected, exploited, or mistreated.
- 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 interviews and record reviews, the facility failed to ensure the comprehensive care plan was accurate for 2 (R #1 and R #7) of 2 (R #1 and R #7) residents reviewed for care plan accuracy. This deficient practice could likely result in staff not understanding and implementing the most appropriate interventions and treatments for the residents.
- E
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on record review and interview, the facility failed to provide activities of daily living ADL; (activities related to personal care such as bathing, showering, dressing, walking, toileting, and eating) assistance for baths and showers for 1 (R #7) of 1 (R #7) dependent resident sampled for ADLs. If the facility is not assisting the residents to bathe or shower, then residents are likely to feel unimportant, dirty and could develop further or worsening health issues.
- E
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on observation, record review, and interview, the facility failed to keep residents free from accidents for 2 (R #5 and R #7) of 2 (R #5 and R #7) residents reviewed for accidents when staff failed to: 1. Put interventions in place to reduce the risk of falls for R #5. 2. Implement appropriate post-fall interventions (ensure the health and safety of residents after a fall by completing actions such as neurochecks) for R #5 and R #7. These deficient practices could likely result in residents getting injured during falls or injuries going unnoticed after a fall.
- E
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observation, record review, and interview, the facility failed to provide respiratory care in accordance with professional standards for 3 (R #2, R #3, and R #4) of 3 (R #2, R #3, and R #4) residents reviewed for respiratory care when staff failed to change the oxygen concentrator (a medical device that provides extra oxygen) tubing. If the facility fails to provide new, clean tubing for oxygen concentrators then residents are at risk of becoming ill.
- 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 record review and interview, the facility failed to update the resident's medical chart and to ensure the resident's current advance directive and New Mexico Orders for Scope of Treatment (MOST) form (a document which provides an individual's wishes for emergency and lifesaving care) matched the order in the electronic health record (EHR) for 1 (R #7) of 2 (R #1 and R #7) residents reviewed for advance directives when staff failed to update the resident's code status. This deficient practice is likely to result in confusion, delay, and residents not having their wishes honored if a life-threatening event occurred.
January 2, 2025Complaint inspection · 2 citations
- G
Provide safe, appropriate pain management for a resident who requires such services.
Inspectors wroteBased on record review and interview, the facility failed to provide pain relief for 8 hours since admission to the facility for 1 (R #1) of 3 (R #1, R #5, and R #8) residents reviewed for pain. This deficient practice likely resulted in R #1 experiencing significant pain which led to her calling 911 for relief and discharging from the facility against medical advice.
- B
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Inspectors wroteBased on interview, observation and record review the facility failed to ensure staff served meals that were attractive and palatable (pleasant to taste) for 4 (R #2, #5, #6, and #7) of 6 (R #2, #4, #5, #6, #7 and #8) residents reviewed for meal quality. This deficient practice could likely reduce residents' ability to eat and enjoy meals, decrease their quality of life, and they could lose weight.
October 30, 2024Complaint inspection · 2 citations
- D
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Inspectors wroteBased on record review and interview, the facility failed to develop an accurate, person-centered comprehensive care plan for 1 (R #1) of 3 (R #1, R #2, and R #3) residents reviewed. If the facility is not updating the care plan to reflect the treatment needs for wound care, then the residents could likely experience a worsening of existing wounds or the development of new wounds.
- D
Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
Inspectors wroteBased on record review and interview, the facility failed to provide a discharge summary that included a recapitulation (a summary describing the resident's course of treatment while residing in the facility) and a reconciliation of all medications at the time of discharge for 1 (R #1) of 1 (R #1) resident reviewed for discharge. This deficient practice could likely lead to the receiving facility, community agency, or family member not knowing what the current care needs and/or current medications are for the resident.
July 26, 2024Standard inspection · 9 citations
- J
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to: 1. Ensure the environment was free of accident hazards when water temperatures were not maintained at a safe temperature level for six of 20 residents (Resident (R) 31, R23, R43, R22, R18, and R41) residing on the dementia care unit. 0n 07/19/24, water temperatures at the hand washing sinks on the dementia care unit were recorded to be 123.4 degrees Fahrenheit (F). Water temperatures were adjusted but no monitoring occurred. On 07/24/24, water temperatures in two resident bathrooms were noted to be 122 degrees F and 125 degrees F. The water temperatures were not adjusted after water was measured to be in excess of 120-degree F. The failure to maintain water temperatures at a safe level had the potential to cause serious burns or injuries for the residents, and 2. [...]
- F
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on observations, interviews, and documentation review, the facility failed to ensure food was stored and served in a sanitary manner. This had the potential to result in the spread of infections and food born illnesses for 59 of 59 residents residing in the facility.
- F
Keep all essential equipment working safely.
Inspectors wroteBased on observation, interview, and review of facility documents and policies, the facility failed to maintain the walk-in refrigerator to ensure it functioned properly and maintained a safe operating temperature. This had the potential to result in food-borne illness as the result of not holding food at a safe temperature level. This had the potential to affect 59 of 59 residents in the facility.
- E
Ensure services provided by the nursing facility meet professional standards of quality.
Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure restorative services were provided as ordered by the physician for five of eight residents (Residents (R) 47, R54, R46, R11, and R34) reviewed for restorative services out of a total sample of 23. This had the potential to cause avoidable decline in the residents' functional abilities.
- E
Provide activities to meet all resident's needs.
Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to provide an ongoing program of activities to meet the needs and interests of five of six residents (Resident (R) 43, R38, R47, R22, and R42) reviewed for activities out of a total sample of 23. This failure had the potential to cause diminished quality of life for all residents who resided on the dementia care unit.
- E
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Inspectors wroteBased on observation, interview, record review, and facility policy review, it was determined the facility failed to maintain an environment free of flies. Flies were observed in resident rooms, dining rooms, hallways, and in the therapy room, landing on residents and their food. This had the potential to affect 59 of 59 residents who resided at the facility, and the potential to result in food borne illness and the spread of infection and diseases.
- D
Allow resident to participate in the development and implementation of his or her person-centered plan of care.
Inspectors wroteBased on an interview, record review, and facility policy review, the facility failed to ensure the resident's right to participate in the care planning process for two of two residents (Resident (R) 32 and R48) reviewed for care plans out of a total sample of 23. This failure placed the residents at risk for unmet care needs due to a lack of resident involvement in their care. Findings Include: 1. Review of R32's admission Record, located under the Profile tab of the electronic medical record (EMR), revealed R32 was admitted to the facility on [DATE] with diagnoses that included bipolar disease. It was recorded R32 was her own representative. [...]
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview, record review, and review of facility policy, the facility failed to administer medications in a manner to prevent cross contamination for five of eight residents (Resident (R) 18, R43, R9, R42, and R5) residents observed receiving medications out of a total census of 59 and failed to complete wound care in a manner to prevent cross contamination for one of one resident (R11) reviewed for pressure ulcers out of a total sample of 23. The failure had the potential to cause residents to be exposed to pathogens and increased the risk of infection.
- C
Post nurse staffing information every day.
Inspectors wroteBased on interview and facility policy review, the facility failed to post the actual hours worked for the licensed and unlicensed nursing staff, including Registered Nurses, Licensed Nurses, and Nursing Assistants. This had the potential to affect 59 of 59 residents who resided at the facility and any visitors to the facility. This had the potential to cause residents and staff to be uninformed of the facility's staffing data.
June 15, 2023Standard inspection · 12 citations
- F
Give residents a notice of rights, rules, services and charges.
Inspectors wroteBased on record review and interview, the facility failed to ensure that staff reviewed Resident's Rights during the resident's stay or Resident Council Meetings for 11 (R #1, R #5, R #6, R #13, R #14, R #18, R #19, R #32, R #35, R #41, and R #42) of 11 (R #1, R #5, R #6, R #13, R #14, R #18, R #19, R #32, R #35, R #41, and R #42) residents sampled during a Resident's Council meeting. This deficient practice could likely result in residents feeling uninformed, not respected, vulnerable and susceptible to abuse or neglect.
- F
Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.
Inspectors wroteBased on observation and interview, the facility failed to ensure that the most recent survey results completed by Federal and State Surveyors and any plans of correction in effect is readily and easily accessible for residents, visitors, and their legal representatives. This deficient practice has the potential of affecting all 49 residents identified on the facility census list provided by the Administrator on 06/11/23.
- F
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 record review and interview, the facility failed to ensure that five (5) Certified Nursing Aides (CNA's) (CNA's #2, #3, #5, #7 and #8) of 5 (CNA's #2, #3, #5, #7 and #8) CNA's had documented and demonstrated competencies (ability of an individual to do a job properly), before they worked with the residents. All 49 residents, as identified by the facility census provided by the Administrator on 06/11/23, residents could likely be affected by this deficient practice, which could lead to the residents not receiving the care and services as described on their care plan and making them susceptible to improper care.
- F
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on observation, record review, and interview, the facility failed to store and maintain foods under sanitary conditions by not ensuring food items in the dry storage, refrigerator, and freezer were properly labeled and/or dated. These deficient practices are likely to affect all 49 residents listed on the resident census list provided by the Director of Nursing (DON) on 06/11/23, and could lead to foodborne illnesses in residents if food is not being stored properly and safe food handling practices are not adhered to.
- F
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Inspectors wroteBased on observation, record review, and interview, the facility failed to provide a safe, functional, and comfortable environment for all 49 residents, as identified by the facility census provided by the Administrator on 06/11/23, by failing to maintain, repair and resurface building/walls and the hand rail system. This deficient practice is likely to affect their safety and psychosocial well being.
- E
Honor the resident's right to organize and participate in resident/family groups in the facility.
Inspectors wroteBased on record review and interview, the facility failed to notify residents of the findings of their grievances. This deficient practice could likely affect all 49 residents who reside at the facility grievances. If the facility does not provide responses to grievances, then residents may not feel that their concerns are being resolved or important to the facility administration.
- 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 record review, observation, and interview, the facility failed to develop a comprehensive care plan and implement a comprehensive care plan for 3 (R #7, 22, and 47) of 4 (R #7, 22, 47, and 49) residents reviewed for comprehensive care plans: Develop a comprehensive care plan for R #7 and R #47 residents; Implement a comprehensive care plan for R #22. This failure is likely to delay residents in receiving benefits from, or improving, related to plans of care that are effective for their optimal well-being.
- E
Ensure services provided by the nursing facility meet professional standards of quality.
Inspectors wroteBased on observation, record review, and interview, the facility failed to have physician orders for 1 (R #7) of 1 (R #7) resident by administering oxygen without a physician's order. If the facility fails to obtain orders for the administering of oxygen, it could likely cause the resident to not receive the therapeutic benefits, resulting in possible harm to the resident.
- E
Keep all essential equipment working safely.
Inspectors wroteBased on observation and interview, the facility failed to ensure kitchen equipment is in safe operating condition. This failure is likely to cause residents to not receive meals as scheduled, or be served at appetizing temperatures, or be stored in accordance with industry standards.
- 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 record review and interview, the facility failed to ensure that a care plan had been revised for 1 (R #21) of 1 (R #21) resident reviewed for care plans. The facility failed to update the care plan to include removal of a catheter (device used to drain the bladder). This deficient practice is likely to result in residents care and needs not being addressed if care plans are not updated.
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on record review, observation, and interview, the facility failed to provide a Wanderguard (a device worn by a resident used to notify the facility of resident trying to leave the facility) to prevent accidents for 1 (R #45) of 1 (R #45) resident reviewed for accidents. If the facility does not implement safety devices, accidents could occur, resulting in injury to residents.
- D
Dispose of garbage and refuse properly.
Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure garbage can lids on garbage cans were closed completely or had a lid within the kitchen area. A. On 06/17/23 at 11:00 am, during observation of the kitchen, a trash can on wheels was sitting uncovered in the kitchen area, by the back door. B. On 06/17/23 at 11:01 am, during an interview with Dietary Services Director (DSD), when asked if the garbage cans in the kitchen needed to be covered, she replied yes. She then picked up the lid from next to the trash can and placed it on the trash can. C. Record review of Trash Removal policy dated 07/15/22 revealed the following: Policy Title: Trash Removal . Process: . 2. Covered trash containers are used for collection. 5. Trash containers and lids are cleaned when visibly soiled and disinfected at least monthly. 6. [...]
Fire safety inspections
35 fire safety citations on file: 25 on August 14, 2025, 5 on July 26, 2024, 5 on June 15, 2023.
Every fire safety citation35 citations
- F
Establish procedures for tracking staff and patients during an emergency.
E 18 · August 14, 2025 · Corrected (the home has a date of correction)
- F
Establish methods for sharing information.
E 33 · August 14, 2025 · Corrected (the home has a date of correction)
- F
Provide a means of sharing information on occupancy/needs.
E 34 · August 14, 2025 · Corrected (the home has a date of correction)
- F
Conduct testing and exercise requirements.
E 39 · August 14, 2025 · 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, 2025 · Corrected (the home has a date of correction)
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · August 14, 2025 · Corrected (the home has a date of correction)
- F
Follow proper procedures when the fire alarm was out of service for more than 4 hours.
K 346 · August 14, 2025 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · August 14, 2025 · Corrected (the home has a date of correction)
- F
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
K 354 · August 14, 2025 · Corrected (the home has a date of correction)
- F
Have properly installed electrical wiring and gas equipment.
K 511 · August 14, 2025 · Corrected (the home has a date of correction)
- F
Have simulated fire drills held at unexpected times.
K 712 · August 14, 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 · August 14, 2025 · 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 · August 14, 2025 · Corrected (the home has a date of correction)
- E
Keep aisles, corridors, and exits free of obstruction in case of emergency.
K 211 · August 14, 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 · August 14, 2025 · Corrected (the home has a date of correction)
- E
Ensure proper usage of power strips and extension cords.
K 920 · August 14, 2025 · Corrected (the home has a date of correction)
- D
Have properly located and lighted "Exit" signs.
K 293 · August 14, 2025 · Corrected (the home has a date of correction)
- D
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
K 321 · August 14, 2025 · Corrected (the home has a date of correction)
- D
Provide properly protected cooking facilities.
K 324 · August 14, 2025 · Corrected (the home has a date of correction)
- D
Install an approved automatic sprinkler system.
K 351 · August 14, 2025 · Corrected (the home has a date of correction)
- D
Properly select, install, inspect, or maintain portable fire extinguishes.
K 355 · August 14, 2025 · Corrected (the home has a date of correction)
- D
Install corridor and hallway doors that block smoke.
K 363 · August 14, 2025 · 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 · August 14, 2025 · Corrected (the home has a date of correction)
- D
Meet requirements for the installation and maintenance of electrical systems.
K 911 · August 14, 2025 · Corrected (the home has a date of correction)
- D
Have proper medical gas storage and administration areas.
K 923 · August 14, 2025 · Corrected (the home has a date of correction)
- F
Address patient/client population and determine types of services needed.
E 7 · July 26, 2024 · Corrected (the home has a date of correction)
- F
Establish staff and initial training requirements.
E 37 · July 26, 2024 · Corrected (the home has a date of correction)
- F
Conduct testing and exercise requirements.
E 39 · July 26, 2024 · Corrected (the home has a date of correction)
- E
Inspect, test, and maintain automatic sprinkler systems.
K 353 · July 26, 2024 · Corrected (the home has a date of correction)
- E
Meet requirements for the installation and maintenance of electrical systems.
K 911 · July 26, 2024 · Corrected (the home has a date of correction)
- F
Address patient/client population and determine types of services needed.
E 7 · June 15, 2023 · Corrected (the home has a date of correction)
- F
Provide family notifications of emergency plan.
E 35 · June 15, 2023 · Corrected (the home has a date of correction)
- F
Establish emergency prep training and testing.
E 36 · June 15, 2023 · 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 · June 15, 2023 · Corrected (the home has a date of correction)
- E
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · June 15, 2023 · Corrected (the home has a date of correction)