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 32 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
11D
21E
0F
Potential for minimal harm
0A
0B
0C
March 5, 2025Complaint inspection · 1 citation
- 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 interview, the facility failed to notify the physician of a resident leaving AMA for 1 (#4) of 1 sampled resident reviewed for leaving the facility AMA. The administrator identified 62 residents resided in the facility.
March 15, 2024Standard inspection · 11 citations
- E
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 interview the facility failed to notify the physician when fingerstick blood sugar results were greater than 501 for one (#57) of one sampled resident reviewed for change in condition. The Administrator identified 66 residents resided in the facility.
- E
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on observation, record review, and interview, the facility failed to prevent development of new pressure ulcers for one (#15) of one sampled residents reviewed for pressure ulcers. Corporate consult RN #1 identified six residents resided in the facility with pressure ulcers.
- E
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observation, record review, and interview, the facility failed to obtain orders for continuous oxygen and failed to ensure oxygen tubing was changed and dated per physician orders for two (#1 and #9) of two sampled residents reviewed for oxygen administration. Corporate consult RN #1 identified 13 residents received oxygen in the facility.
- E
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Inspectors wroteBased on record review and interview, the facility failed to ensure there was ongoing assessment of a resident on dialysis for one (#54) of one sampled resident reviewed for dialysis services. The administrator identified two residents received dialysis services.
- E
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Inspectors wroteBased on observation, record review and interview, the facility failed to ensure medications were administered according to physician orders for one (#12) of five sampled residents reviewed for unnecessary mediations. The administrator identified 66 residents resided in the facility.
- E
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Inspectors wroteBased on record review and interview the facility failed to monitor for side effects related to the use of Warfarin for one (#62) of one sampled resident reviewed anticoagulant use. The Administrator identified 66 residents resided in the facility.
- E
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Inspectors wrote2. Res #9 had diagnoses which included anxiety disorder. A physician order, dated 04/13/23, documented to administer Ativan oral tablet 0.5 mg every 12 hours as needed for anxiety. A monthly medication review, dated 05/01/23, documented the pharmacist's request to add a stop date to the as needed Ativan order per regulations. There was no documented stop date to the order until 08/05/23. A MAR for May 2023 documented Res #9 received the as needed Ativan 33 times. A MAR for June 2023 documented Res #9 received the as needed Ativan 25 times. A MAR for July 2023 documented Res #9 received the as needed Ativan 29 times. A MAR for August 2023 documented Res #9 received the as needed Ativan four times. The order was discontinued on 08/05/23. On 03/14/24 at 3:00 p.m. Corporate consult RN #1 stated a 14 day stop date was not added to the order. [...]
- E
Provide timely, quality laboratory services/tests to meet the needs of residents.
Inspectors wroteBased on record review and interview the facility failed to obtain laboratory studies as ordered for one (#5) of five sampled residents reviewed for unnecessary medications. The administrator identified 66 residents resided in the facility.
- D
Assess the resident when there is a significant change in condition
Inspectors wroteBased on record review and interview, the facility failed to complete a significant change assessment for a resident with declines in ADLs for one (#48) of two sampled residents reviewed for ADLs. The administrator identified 66 residents resided in the facility.
- 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 update a care plan with smoking interventions for one #57) of one sampled resident reviewed for smoking. The Administrator identified 66 residents resided in the facility and the list of smoking residents documented eleven residents smoked.
- 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 interview, the facility failed to ensure a medication regimen review was responded to timely for one (#9) of five sampled residents reviewed for unnecessary medications. The administrator identified 66 residents resided in the facility.
January 27, 2023Standard inspection · 10 citations
- E
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteBased on record review, observation and interview, the facility failed to ensure residents were treated with respect and dignity, and care in a timely manner for two (#23 and #26) of 24 residents reviewed for dignity and respect. The Resident Census and Conditions of Residents form documented 73 residents resident in the facility.
- E
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Inspectors wroteBased on record review, observation, and interview, the facility failed to maintain a safe, clean, comfortable, homelike environment regarding wheelchair maintenance and air temperatures. The Resident Census and Conditions of Residents report documented 73 residents resided in the facility.
- E
Notify the appropriate authorities when residents with MD or ID services has a significant change in condition.
Inspectors wroteBased on record review and interview, the facility failed to ensure the OHCA was notified after a resident received a significant mental health diagnoses for two (#17 and #37) of three residents reviewed for PASRR. The Resident Census and Conditions of Residents report, documented 72 residents who reside in the facility.
- 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 person-centered care plan for two (#6 and #11) of 23 residents whose care plans were reviewed. The facility failed to develop a care plan: a. related to wandering behaviors for Res #11 and b. related to ADL care including refusals to bathe for Res #6. The Resident Census and Conditions of Residents form documented 73 residents resided at the facility.
- E
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on record review, observation, and interview, the facility failed to ensure bathing was provided to dependent residents for six (#2, 17, 21, 23, 30, and #124) of six residents reviewed for ADL care. The Resident Census and Conditions of Residents report documented 73 residents resided in the facility.
- E
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Inspectors wroteBased on record review, observation, and interview, the facility failed to ensure there was sufficient nursing staff to provide care in accordance with resident care plans for eight (#2, 13, 17, 21, 23, 30, 49, and #124) of 24 residents reviewed for staffing. The Resident Census and Conditions of Residents form documented 73 residents resided at the facility.
- E
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Inspectors wroteBased on record review, observation, and interview, the facility failed to obtain blood pressures for one (#30) of five residents reviewed for unnecessary medications. The Resident Census and Conditions of Residents report documented 73 residents resided in the facility.
- D
Reasonably accommodate the needs and preferences of each resident.
Inspectors wroteBased on record review, observation, and interview, the facility failed to ensure resident call lights were in reach for one (#23) of 24 residents observed for call lights. The Resident Census and Conditions of Residents form documented 73 residents resided in the facility.
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on record review, observation, and interview, the facility filed to ensure an allegation of abuse was reported to the State Survey Agency no later than two hours after the allegation was made for one (#21) of one resident reviewed for abuse. The Resident Census and Conditions of Residents report documented 73 residents resided in the facility.
- 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 ensure a resident received adequate supervision and/or failed to implement interventions to prevent wandering into other resident rooms for one (#11) of one resident reviewed for wandering. The Resident Census and Conditions of Residents report documented 73 residents residing in the facility.
October 10, 2019Standard inspection · 10 citations
- E
Respond appropriately to all alleged violations.
Inspectors wroteBased on record review and interview, it was determined the facility failed to ensure allegations of abuse were thoroughly investigated for one (#15) of two sampled residents who were reviewed for thorough investigations. The resident census and condition report identified 76 residents resided in the facility.
- E
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on observations, record review and interview, it was determined the facility failed to ensure assistance with activities of daily living was provided in a timely manner for three (#44, #59 and #61) of three sampled residents who were reviewed for activities of daily living. The facility identified 69 residents who required assistance with bathing and 49 residents who required assistance with toileting.
- 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 interviews, it was determined the facility failed to ensure: ~ supervision was provided to prevent elopements for one (#33) of one sampled resident who was reviewed for eleopements; ~ smoking assessments were completed and supervision was provided to ensure residents did not smoke in their rooms for one (#3) of one sampled resident who smoked; and ~ safe transfers with a lift were provided with the assistance of two staff members for one (#23) of one sampled resident who was reviewed for transfers using a lift. The facility identified 15 residents who smoked and 76 residents who resided in the facility.
- E
Provide safe, appropriate pain management for a resident who requires such services.
Inspectors wroteBased on observation, record review and interview, it was determined the facility failed to ensure pain medication was administered in a timely manner for one (#27) of three sampled residents who were reviewed for pain. The facility identified 76 residents who resided in the facility.
- E
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Inspectors wroteBased on observation, record review and interview, it was determined the facility failed to provide sufficient nurse staff to ensure care was provided in a timely manner for three (#44, #59 and #61) of 14 sampled residents who were reviewed for staffing. The facility identified 76 residents who resided in the facility.
- E
Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.
Inspectors wroteBased on observation, record review and interview, it was determined the facility failed to ensure a sufficient amount of bedtime snacks were available and offered to residents. The facility identified 75 residents who received meals from the kitchen, and 25 residents were identified as diabetic.
- 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 record review, it was determined the facility failed to notify the physician and the family in a timely manner after a fall for one (#68) of two sampled residents who were reviewed for falls. The resident census and condition report documented 76 residents resided in the facility.
- 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, it was determined the facility failed to develop a care plan related to smoking for one (#33) of four sampled residents who smoked. The facility identified 15 residents who smoked.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on interview and record review, it was determined the facility failed to assess a resident in a timely manner after a fall for one (#68) of two sampled residents who were reviewed for falls. The resident census and condition report documented 76 residents resided in the facility.
- D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on interview and record review, it was determined the facility failed to document a fall in the clinical record in a timely manner for one (#68) of two sampled residents who were reviewed for falls. The resident census and condition report documented 76 residents resided in the facility.
Fire safety inspections
16 fire safety citations on file: 6 on March 15, 2024, 5 on January 27, 2023, 5 on October 10, 2019.
Every fire safety citation16 citations
- F
Install emergency lighting that can last at least 1 1/2 hours.
K 291 · March 15, 2024 · Corrected (the home has a date of correction)
- F
Have properly located and lighted "Exit" signs.
K 293 · March 15, 2024 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · March 15, 2024 · Corrected (the home has a date of correction)
- F
Have simulated fire drills held at unexpected times.
K 712 · March 15, 2024 · 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 · March 15, 2024 · Corrected (the home has a date of correction)
- E
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · March 15, 2024 · Corrected (the home has a date of correction)
- E
Keep aisles, corridors, and exits free of obstruction in case of emergency.
K 211 · January 27, 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 · January 27, 2023 · Corrected (the home has a date of correction)
- E
Install smoke barrier doors that can resist smoke for at least 20 minutes.
K 374 · January 27, 2023 · Corrected (the home has a date of correction)
- E
Have restrictions on the use of portable space heaters.
K 781 · January 27, 2023 · Corrected (the home has a date of correction)
- E
Have proper medical gas storage and administration areas.
K 923 · January 27, 2023 · Corrected (the home has a date of correction)
- F
Have simulated fire drills held at unexpected times.
K 712 · October 10, 2019 · Corrected (the home has a date of correction)
- F
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
K 761 · October 10, 2019 · Corrected (the home has a date of correction)
- E
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 · October 10, 2019 · 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 · October 10, 2019 · Corrected (the home has a date of correction)
- E
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · October 10, 2019 · Corrected (the home has a date of correction)