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 88 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
7G
0H
0I
Potential for more than minimal harm
44D
21E
15F
Potential for minimal harm
0A
0B
1C
July 31, 2026Complaint inspection · 2 citations
- G
Provide safe, appropriate pain management for a resident who requires such services.
Inspectors wroteBased on observation, interview and record review, the facility failed to ensure pain medication supply was available for administration for two residents (R1 and R2), failed to clarify a physician order for a pain medication dose for one resident (R2), and failed to initiate a care plan for pain triggered on a Care Area Assessment (CAA) for one resident (R2). These failures affected two (R1 and R2) of three residents reviewed for pain on the sample list of three residents. This failure resulted in R1, going without needed Morphine narcotic pain medications, during end-of-life (Hospice) comfort focused care, for greater than 24 hours. This failure resulted in R2 going without Lidocaine (topical numbing agent, for nerve ending) patch for pain, continually for five days which prevented R2's ability to sleep comfortably. 1. [...]
- G
Ensure that residents are free from significant medication errors.
Inspectors wroteBased on observation, interview and record review the facility failed to obtain physician ordered medications in a timely manner, which resulted in significant medication errors due to repeated, missed administration of medication. These failures affected two (R1 and R2) of three residents reviewed for medication on the sample list of three residents. This failure resulted in R1, going without needed Morphine narcotic pain medications, during end-of-life (Hospice) comfort focused care, for greater than 24 hours. This failure resulted in R2 going without Lidocaine (topical numbing agent, for nerve ending) patch, for pain, continually for five days which prevented R2's ability to sleep comfortably and going without Mirabegron Urinary Antispasmodic medication for seven days, which increased frequency of urgency to urinate. 1. [...]
May 20, 2026Complaint inspection · 1 citation
- E
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Inspectors wroteFailures at this level required more than one Deficient Practice Statement. A. Based on interview, observation and record review, the facility failed to keep resident rooms at comfortable temperatures for seven of nine (R19, R22, R25, R27, R28, R31, R57) residents reviewed for safe, clean, comfortable homelike environment, in a sample of 40. B. Based upon observation, interview, and record review, the facility failed to provide a clean and sanitary environment for one of nine residents (R16) reviewed for safe, clean, comfortable homelike environment, in a sample of 40.
February 4, 2026Complaint inspection · 1 citation
- G
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on observation, interview, and record review the facility failed to utilize footrests when transporting a dependent resident in a wheelchair resulting in entrapment of lower extremities in front wheels and the staff member transporting the resident failed to report the incident resulting in a two day delay of care for one (R1) of three residents reviewed for accidents in a sample of three residents. This failure caused R1 to suffer a fractured left tibia. Findings Include:R1's Care Plan, updated on 12/17/25, lists the following diagnoses: Congestive Heart Failure, Chronic Kidney Disease Stage III, Paroxysmal Atrial Fibrillation, Lymphedema and Chronic Venous Insufficiency of the lower extremities, unsteady gait, muscle wasting, and difficulty walking. [...]
December 28, 2025Complaint inspection · 2 citations
- F
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Inspectors wroteBased on interview and record review the facility failed to provide the services of a registered nurse for eight consecutive hours seven days a week every twenty-four hours. This failure has the potential to affect all 47 residents who reside in the facility.
- 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 observation, interview, and record review, the facility failed to provide and ensure the use of the correct size incontinence brief for three of three residents (R3, R4, R5) reviewed for insufficient supplies on a sample list of five residents. This failure placed the residents at risk for skin breakdown.
August 26, 2025Complaint inspection · 2 citations
- G
Provide enough food/fluids to maintain a resident's health.
Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that each resident's nutritional and hydration status was maintained for two (R1, R3) of three residents reviewed for weight loss.
- G
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, interview, and record review the facility failed to provide a bedtime snack and breakfast for two (R1, R3) of three residents reviewed for food services on a sample list of six.
March 4, 2025Complaint inspection · 2 citations
- G
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 effectively supervise R1 to prevent a traumatic fall and thoroughly investigate a fall. This failure resulted in R1 striking R1's head on a closet door during a fall to the floor and sustaining a brain bleed requiring emergency medical evaluation and treatment at two hospitals. R1 is one of three residents reviewed for accidents in the sample list of three.
- 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, the facility failed to report a resident fall to the resident's representative and provider for one (R1) of three residents reviewed for accidents in the sample list of three.
January 28, 2025Standard inspection · 14 citations
- F
Ensure residents have reasonable access to and privacy in their use of communication methods.
Inspectors wroteBased on interview and record review the facility failed to deliver mail on Saturdays to five (R8, R9, R23, R35, and R37) of six residents reviewed for mail and package delivery on Saturdays from a sample list of 32. This failure also has the potential to affect all 38 residents residing in the facility.
- F
Verify that a nurse aide has been trained; and if they haven't worked as a nurse aide for 2 years, receive retraining.
Inspectors wroteBased on interview and record review the facility failed to verify eligibility for employment through the healthcare workers registry prior to commencing employment for two Certified Nurse's Aides of five Certified Nurse's Aides reviewed for Healthcare Worker Background checks in a sample list of 32. This failure has the potential to affect all 38 residents residing at the facility. Findings Include: The facility's Long-Term Care Facility Application for Medicare and Medicaid dated 1/26/25 documents the facility census as 38. The facility's employee roster documents V20, CNA (Certified Nurse's Aide) began employment at the facility on 11/15/24. The registry verification documents eligibility was verified as of 11/19/24. The facility's employee roster documents V21, CNA (Certified Nurse's Aide) began employment at the facility on 11/18/24. [...]
- 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, interview, and record review the facility failed to ensure foods were labeled and stored appropriately. This failure has the potential to affect all 38 residents in the facility.
- F
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview and record review the facility failed to implement COVID-19 transmission based precautions for one of three residents (R14) reviewed for infection control in the sample list of 32. The facility also failed to ensure COVID-19 (human coronavirus) symptomatic employees were restricted from work and tested timely for COVID-19. This failure has the potential to affect all 38 residents in the facility.
- E
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observation, interview, and record review the facility failed to implement orders, maintain supplies, provide hygienic care, accurately complete assessments and develop care plans for oxygen, nebulizer, continuous positive airway pressure (CPAP), and humidifier use for for four of six residents (R1, R4, R28, R33) reviewed for respiratory care in the sample of 32.
- E
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Inspectors wroteBased on interview and record review the facility failed to provide the services of a registered nurse for eight consecutive hours seven days a week every twenty-four hours and failed to employ a full time Director of Nursing. This failure has the potential to affect all 38 residents who reside in 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 interview and record review the facility failed to administer medications as ordered for four (R2, R9 R28 and R33) of four residents reviewed for medication administration from a total sample list of 32 residents.
- E
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Inspectors wroteBased on interview and record review the facility failed to offer pneumococcal vaccination to four of five residents (R1, R4, R28, R31) reviewed for immunizations in the sample list of 32.
- D
Allow residents to self-administer drugs if determined clinically appropriate.
Inspectors wroteBased on observation, interview, and record review the facility failed to assess for the ability to self administer medications for one of one resident (R4) reviewed for self administration of medications in the sample list of 32.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on observation, interview and record review the facility failed to ensure the correct size brief was available for a resident to prevent skin breakdown for one of one resident (R33) reviewed for skin care from a total sample list of 32 residents.
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on observation, interview, and record review the facility failed to complete a safe full mechanical lift transfer, thoroughly investigate a fall and document details of a fall and physician notification in the resident's medical record for one of two residents (R31) reviewed for falls in the sample list of 32.
- 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 observation, interview, and record review the facility failed to provide hygienic incontinence care to one (R7) of one residents reviewed for incontinence care from a total sample list of 29 residents.
- D
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Inspectors wroteBased on interview and record review the facility failed to monitor an enteral feeding including inputs and outputs and failed to monitor the weights of a resident receiving enteral feedings for one (R30) of one resident reviewed for enteral feedings from a total sample list of 32 residents.
- 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 interview and record review the facility failed to implement a gradual dose reduction for one (R1) resident of five residents reviewed for psychotropic medications from a total sample list of 32 residents.
November 14, 2024Complaint inspection · 1 citation
- E
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Inspectors wroteBased on observation, interview, and record review the facility failed to ensure three residents (R1, R3, R4) were free from abuse by another resident (R2). This failure affects five (R1, R2, R3, R4, R5) residents reviewed for abuse in the sample of four. Findings Include: 1.) R2's Minimum Data Set (MDS) dated [DATE] documents R2 was severely cognitively impaired and was independently mobile with a wheelchair. R2's Care plan reviewed 8/15/24 documents R2 has behavioral problem: Physical behaviors related to Parkinson's Disease. The facility's Incident Report dated 10/21/24 documents (R1) alleged (R2) struck (R1) with (R2's) foot on the front porch. Residents immediately separated pending investigation. All parties notified. R2's AIMS for Wellness note dated 10/25/24 documents, transferred to hospital for increased aggressive behaviors. [...]
October 30, 2024Complaint inspection · 3 citations
- 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 a dependent resident with dressing assistance of compression stocking for one of four residents (R1) reviewed for wounds/activities of daily living assistance on the sample list of four.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on observation, interview and record review the facility failed to prevent cross contamination between wounds, during wound treatment for one of four residents (R3) reviewed for wounds on the sample list of four.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview, and record review the facility failed post infection control/contact isolation precaution sign to alert staff and visitors to wear personal protective equipment, and failed to wear personal protective gowns during high risk personal care care These failures affected one of four (R3) residents reviewed for wound/infection control on the sample list of four.
August 16, 2024Complaint inspection · 5 citations
- E
Ensure that the resident and his/her doctor meet face-to-face at all required visits.
Inspectors wroteBased on observation, interview and record review the facility failed to ensure five (R1, R2, R5, R6, R7) residents received timely Physician visits out of five residents reviewed for Physician visits in a sample list of seven residents.
- D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteBased on observation, interview and record review the facility failed to maintain a residents' dignity by not providing timely incontinence care for one (R1) of three residents reviewed for incontinence care in a sample of seven residents.
- D
Reasonably accommodate the needs and preferences of each resident.
Inspectors wroteBased on observation, interview and record review the facility failed to ensure a residents' preferences for personal care (toileting) were honored. This failure affects one (R5) of three residents reviewed for dignity in a sample list of seven residents.
- 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 timely incontinence care for a resident dependent on staff assistance with toileting and a history of skin breakdown. This failure affects one (R1) of three residents reviewed for incontinence care in a sample of seven residents.
- 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 observation, interview and record review the facility failed to prevent cross contamination during incontinence care for one (R1) resident out of three residents reviewed for incontinence care in a sample list of seven residents.
June 9, 2024Complaint inspection · 4 citations
- 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, interview and record review the facility failed to ensure four (R1, R2, R3, ,R4) residents have a homelike, clean environment out of four residents reviewed for Physical Environment in a sample list of six residents.
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on interview and record review the facility failed to report an allegation of staff to resident mental abuse to the State Agency for one (R5) of three residents reviewed for abuse in a sample list of six residents.
- D
Respond appropriately to all alleged violations.
Inspectors wroteBased on interview and record review the facility failed to thoroughly/timely investigate an allegation of staff to resident mental abuse and failed to remove the accused staff member from resident care during the investigation for one of three residents (R5) reviewed for abuse on the sample of six residents.
- D
Make sure that a working call system is available in each resident's bathroom and bathing area.
Inspectors wroteBased on observation, interview and record review the facility failed to provide individual functioning call lights to two (R1, R2) residents out of six residents reviewed for call lights in a sample list of six residents.
May 1, 2024Complaint inspection · 5 citations
- F
Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
Inspectors wroteBased on observation, interview, and record review the facility failed to employ a clinically qualified director of food and nutrition services. This failure has the potential to affect all 38 residents residing in the facility.
- F
Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.
Inspectors wroteBased on observation, interview, and record review the facility failed to employ dietary staff who had completed safe food handling training. This failure has the potential to affect all 38 residents residing in facility.
- 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, interview and record review the facility failed to ensure expired food products were disposed of and not served to residents, monitor food temperatures, monitor freezer and refrigerator temperatures, prevent cross contamination during food service, properly label and store foods, maintain a sanitary kitchen environment, store chemicals and soiled cleaning equipment away from food storage areas, and monitor temperatures/sanitizer levels for the dishwasher to ensure dishes were sanitized prior to resident use. These failures have the potential to affect all 38 residents residing in the facility.
- E
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Inspectors wroteBased on observation, interview, and record review the facility failed to serve foods that were palatable to five (R1, R2, R3, R5, R9) residents out of five residents reviewed for Dietary Services in a sample list of nine residents.
- D
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
Inspectors wroteBased on observation, interview, and record review the facility failed to prepare the safe texture of pureed food for three residents (R6, R7, R8) out of three residents reviewed for pureed diet orders in the sample list of nine.
February 22, 2024Standard inspection · 25 citations
- F
Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
Inspectors wroteBased on observation, interview, and record review the facility failed to employer a clinically qualified Director of Food and Nutrition. This failure has the potential to affect all 47 residents residing in the facility.
- F
Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.
Inspectors wroteBased on observation, interview and record review the facility failed to have sufficient dietary staff to provide meals in a timely manner. This failure has the potential to affect all 47 residents who reside at the facility.
- 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, interview, and record review, the facility failed to properly label opened refrigerator items, check steam table food temperatures for safety (TCS) foods (R5, R8, R10, R12, R26, R31 and R36) properly label time and temperature control for safety (TCS) foods, test the dishwasher for sanitation purposes and use pasteurized eggs when serving soft, cooked eggs (R4, R9, R31). These failures have the potential to affect 10 (R5, R8, R10, R12, R26, R31, R4, R9, R31 and R36) of 10 residents reviewed for altered diets on the sample list of 36 and all 47 residents residing in the facility.
- F
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
Inspectors wroteBased on interview and record review the facility failed to have an Infection Preventionist attend quarterly quality meetings. This failure has the potential to affect all 47 residents in the facility.
- F
Provide and implement an infection prevention and control program.
Inspectors wroteBased on interview and record review the facility failed to trend the facility's monthly infections. This failure has the potential to affect all 47 residents residing in the facility.
- E
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Inspectors wroteBased on interview and record review the facility failed to timely submit Minimum Data Sets (MDSs) for six (R43, R39, R27, R16, R33, R32) of 36 residents reviewed for MDS in the sample list of 36.
- E
Provide enough food/fluids to maintain a resident's health.
Inspectors wroteBased on observation, interview, and record review the facility failed to implement physician ordered nutritional supplements, document supplement intakes, and update a care plan with weight loss and nutritional interventions for four (R198, R13, R39, R4) of four residents reviewed for nutrition in the sample list of 36.
- E
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Inspectors wroteBased on interview and record review the facility failed to complete psychotropic assessments, ensure psychotropic assessments were accurate, care plan for behaviors and interventions, and document behaviors to justify increasing psychotropic medications for four (R8, R24, R45, R41) of five residents reviewed for unnecessary medications in the sample list of 36.
- 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 document an open date of insulin upon opening a new pen/vial for five of five residents (R32, R18, R17, R22, R28) reviewed for medication storage in the sample list of 36.
- E
Provide or get specialized rehabilitative services as required for a resident.
Inspectors wroteBased on observation, interview, and record review the facility failed to ensure therapy services were provided for five of six residents (R17, R41, R44, R148, R149) reviewed for therapy services on the sample list of 36.
- E
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Inspectors wroteBased on interview and record review the facility failed to determine vaccinations status and offer influenza and pneumococcal vaccinations upon admission for four (R45, R41, R44, and R35) of five residents reviewed for immunizations on the sample list of 36.
- 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 psychotropic medication consents for one (R8) of five residents reviewed for unnecessary medications in the sample list of 36.
- D
Allow residents to self-administer drugs if determined clinically appropriate.
Inspectors wroteBased on observation, interview and record review the facility failed to observe a resident consume medications during medication administration for one of one resident (R4) reviewed for self-administration of medication in the sample list of 36.
- D
Reasonably accommodate the needs and preferences of each resident.
Inspectors wroteBased on observation, interview, and record review the facility failed to provide an individualized fitting wheelchair and commode for one (R45) of 16 residents reviewed for accommodation of needs on the sample list of 36.
- D
Respond appropriately to all alleged violations.
Inspectors wroteBased on interview and record review, the facility failed to investigate an injury of unknown origin for one resident (R21) of one resident reviewed for abuse in the sample list of 36.
- 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 comprehensive care plans for two (R6, R45) of 16 residents reviewed for care plans on the sample list of 36.
- D
Provide care by qualified persons according to each resident's written plan of care.
Inspectors wroteBased on observation, interview and record review the facility failed to administer a medication according to physician's orders and manufacturers recommendations for one of one resident (R4) reviewed for following physician's orders in the sample list of 36.
- D
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Inspectors wroteBased on observation, interview, and record review, the facility failed to provide methods for communication for a resident who has limited English proficiency and failed to provide a call light (to alert staff of resident needs) to be within the resident's reach for one resident (R39) of four residents in the sample list of 36.
- 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 obtain daily weights and failed to follow up with the medical doctor for weight gain for 2 residents (R21, R22) of two residents reviewed for daily weights in the sample list of 36.
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on observation, interview, and record review the facility failed to document wound measurements upon admission, document weekly skin checks, document weekly wound measurements, document that a treatment was provided as ordered by the physician and develop a pressure ulcer plan of care for one (R45) of one resident reviewed for pressure ulcers on the sample list of 36.
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on observation, interview, and record review the facility failed to complete a smoking assessment and develop a plan of care for smoking for one of one (R6) resident reviewed for smoking on the sample list of 36.
- 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 observation, interview, and record review the facility failed to provide toileting for two (R6, R45) of 16 residents reviewed for toileting on the sample list of 36.
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observation, interview, and record review the facility failed to change oxygen and nebulizer tubing for one (R10) of two residents reviewed for respiratory care in the sample list of 36.
- D
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
Inspectors wroteBased on observation, interview and record review the facility failed to provide the correct consistency for a pureed diet for two (R13 and R15) of two residents reviewed for pureed diets in the sample list of 36.
- 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 interview and record review the facility failed to offer COVID boosters for two (R45, R44) of five residents reviewed for vaccinations on the sample list of 36.
January 25, 2024Complaint inspection · 1 citation
- D
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Inspectors wroteBased on interview and record review, the facility failed to protect the residents right to be free from physical abuse by another resident for one of three residents (R1) reviewed for physical abuse on the sample list of three.
October 31, 2023Complaint inspection · 6 citations
- G
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 interview and record review the facility failed to timely obtain a urinalysis and follow up with the physician to treat a urinary tract infection for one (R1) of three residents reviewed for change in condition in the sample list of ten. This failure resulted in R1 being hospitalized with Acute Encephalopathy secondary to Urinary Tract Infection and Sepsis.
- E
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview, and record review the facility failed to implement infection control measures to prevent the spread of COVID-19 (Human Coronavirus) during an outbreak by failing to post isolation signage to identify COVID-19 positive rooms, ensure staff wore appropriate Personal Protective Equipment (PPE) in COVID-19 positive rooms, ensure staff change PPE upon leaving COVID-19 positive rooms, and keep COVID-19 positive room doors closed. These failures affect nine (R1, R2, R3, R5, R6, R7, R8, R9, R10) of ten residents reviewed for infections in the sample list of ten residents.
- 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 the facility failed to report a resident's (R2) weight gain and laboratory results to the physician. R2 is one of three residents reviewed for change in condition in a sample list of ten.
- 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 care plan with problems, goals, and interventions to address Congestive Heart Failure for two (R2, R3) of three residents reviewed for changes in condition in the sample list of ten.
- 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 accurately transcribe physician orders for three (R1, R2, R3) of three residents reviewed for physician's orders in the sample list of ten.
- D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a COVID-19 medication was available to be administered as ordered for two (R1, R2) of three residents reviewed for physician's orders in the sample list of ten.
January 11, 2023Standard inspection · 14 citations
- F
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
Inspectors wroteBased on interview and record review, the facility failed to ensure the required quarterly Quality Assessment and Assurance (QAA) committee meetings were completed. This failure has the potential to affect all 44 residents in the facility.
- F
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation record review the facility failed to follow their COVID-19 Control Measure policy by failing to ensure nursing staff were wearing masks and eye protection while working in the facility. This failure had the potential to affect all 44 residents residing in the facility.
- E
Assure that each resident’s assessment is updated at least once every 3 months.
Inspectors wroteBased on interview and record review the facility failed to complete quarterly Minimum Data Set assessments every three months for seven (R8, R13, R14, R21, R22, R23, and R28) of 26 residents reviewed for quarterly assessments on the sample list of 26.
- E
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Inspectors wroteR86's Physician Order Sheet dated January 2023 documents R86 was admitted to the facility on [DATE]. R86's Baseline Care Plan is dated 12/16/22. R86 does not have a Comprehensive Care Plan. On 1/9/23 at 2:30 PM, V3 Care Plan Coordinator confirmed R86's Comprehensive Care Plans should have been completed. R24's Physician Order Sheet dated January 2023 documents R24 was admitted to the facility on [DATE]. R24's Baseline Care Plan is dated 9/26/22. R24 does not have a Comprehensive Care Plan. On 1/9/23 at 2:30 PM V3 Care Plan Coordinator confirmed R24's Comprehensive Care Plans should have been completed. Based on interview and record review the facility failed to develop a Comprehensive Care Plan for four residents (R139, R136, R24, R86) the facility also failed to develop a Care Plan for Pressure Ulcers, Anticoagulant, and Pain for two residents (R17, R25). [...]
- 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 interview and record review the facility failed to revise and update resident's Comprehensive Care Plans. This failure affected four of thirteen residents (R9, R11, R14, R25) reviewed for Care Plans on the sample list of 26.
- E
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
Inspectors wroteBased on observation, interview, and record review the facility failed to assess the risk of entrapment for four of four residents (R9, R25, R15, R136) reviewed for side rails on the sample list of 26.
- E
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Inspectors wroteBased on interview and record review the facility failed to complete initial and quarterly Psychotropic Medication assessments. This failure effected five of five residents (R11, R86, R9, R22, R25) reviewed for unnecessary medications on the sample list of 13.
- D
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Inspectors wroteBased on interview and record review the facility failed to complete timely admission and Annual Minimum Data Set (MDS) Assessments (Resident Assessment Instrument/RAI) for two of 13 residents (R136, R9) reviewed for MDS assessments in the sample list of 26.
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on observation, interview and record review the facility failed to prevent cross contamination during Pressure Ulcer dressing changes and failed to complete dressing changes as ordered for two of three residents (R139, R17) reviewed for Pressure Ulcers in the sample list of 26.
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on observation, interview and record review the facility failed to secure an Oxygen tank for one of one resident (R6) reviewed for Oxygen in the sample list of 26.
- 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 observation, interview and record review the facility failed to prevent cross contamination during incontinence care for one of one resident (R136) reviewed for incontinence care in the sample list of 26.
- 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 interview and record review the facility failed to address pharmacy recommendations for one (R25) of 13 residents reviewed for medication monitoring reviews on the sample list of 26.
- D
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Inspectors wroteBased on interview and record review the facility failed to review a resident's medication orders to prevent duplicate therapy and the potential for excess dosage for one of 13 residents (R136) reviewed for medications in the sample list of 26.
- C
Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
Inspectors wroteBased on interview and record review the facility failed to accurately submit payroll data. This failure has the potential to affect all 44 residents residing in the facility.
Fire safety inspections
28 fire safety citations on file: 16 on January 28, 2025, 5 on February 22, 2024, 7 on January 11, 2023.
Every fire safety citation28 citations
- F
Develop and maintain an Emergency Preparedness Program (EP).
E 4 · January 28, 2025 · Corrected (the home has a date of correction)
- F
Develop Emergency Preparedness policies and procedures.
E 13 · January 28, 2025 · Corrected (the home has a date of correction)
- F
Develop a communication plan.
E 29 · January 28, 2025 · Corrected (the home has a date of correction)
- F
Establish emergency prep training and testing.
E 36 · January 28, 2025 · Corrected (the home has a date of correction)
- F
Establish staff and initial training requirements.
E 37 · January 28, 2025 · Corrected (the home has a date of correction)
- F
Conduct testing and exercise requirements.
E 39 · January 28, 2025 · Corrected (the home has a date of correction)
- F
Install a fire alarm system that can be heard throughout the facility.
K 341 · January 28, 2025 · Corrected (the home has a date of correction)
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · January 28, 2025 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · January 28, 2025 · Corrected (the home has a date of correction)
- F
Have simulated fire drills held at unexpected times.
K 712 · January 28, 2025 · Corrected (the home has a date of correction)
- F
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
K 741 · January 28, 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 · January 28, 2025 · 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 28, 2025 · Corrected (the home has a date of correction)
- E
Provide properly protected cooking facilities.
K 324 · January 28, 2025 · Corrected (the home has a date of correction)
- E
Ensure proper usage of power strips and extension cords.
K 920 · January 28, 2025 · Corrected (the home has a date of correction)
- E
Have proper medical gas storage and administration areas.
K 923 · January 28, 2025 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · February 22, 2024 · Corrected (the home has a date of correction)
- F
Properly select, install, inspect, or maintain portable fire extinguishes.
K 355 · February 22, 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 22, 2024 · Corrected (the home has a date of correction)
- E
Provide properly protected cooking facilities.
K 324 · February 22, 2024 · Corrected (the home has a date of correction)
- E
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · February 22, 2024 · Corrected (the home has a date of correction)
- F
Conduct risk assessment and an All-Hazards approach.
E 6 · January 11, 2023 · Corrected (the home has a date of correction)
- F
Provide a means of sharing information on occupancy/needs.
E 34 · January 11, 2023 · Corrected (the home has a date of correction)
- F
Provide family notifications of emergency plan.
E 35 · January 11, 2023 · Corrected (the home has a date of correction)
- F
Conduct testing and exercise requirements.
E 39 · January 11, 2023 · Corrected (the home has a date of correction)
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · January 11, 2023 · Corrected (the home has a date of correction)
- F
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · January 11, 2023 · Corrected (the home has a date of correction)
- E
Inspect, test, and maintain automatic sprinkler systems.
K 353 · January 11, 2023 · Corrected (the home has a date of correction)