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 66 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
1G
0H
0I
Potential for more than minimal harm
40D
20E
5F
Potential for minimal harm
0A
0B
0C
July 14, 2026Complaint inspection · 6 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 record review and staff interview, it was determined that the facility failed to ensure there was a Registered Nurse working at least 8 hours a day. This was evident in 3 out of 14 days reviewed during the Staffing task in the recertification survey.
- 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 resident interview, observations, and staff interview, it was determined that the facility failed to maintain a functional and comfortable environment. This was evident on 4 out of 4 units reviewed for environment.
- E
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteBased on interviews, record reviews, and observations, it was determined that the facility failed to promote and maintain resident dignity by failing to answer residents' call lights promptly to address residents basic care needs. This was evident for 4 (Resident #17, #2, #60 and #22) out of 8 residents reviewed for dignity during the recertification survey.
- E
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Inspectors wroteBased on observations and staff interviews, it was determined that the facility failed to maintain a clean and homelike environment. This was evident in 4 out of 4 units observed for environment.
- E
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Inspectors wroteBased on interviews and record reviews, it was determined that the facility failed to administer medications in accordance with professional standards. This was evident for 5 (Resident #46, #2, #60, #59 and #64) out of 5 residents reviewed for medication administration.
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on record review, observations, and staff interview, it was determined that the facility failed to supervise a resident (#49) to prevent them from hazards. This was evident for 1 out 3 residents reviewed for accidents and supervision.
February 24, 2026Complaint inspection · 1 citation
- 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 medical record review and interview, the facility failed to update the resident's care plan after the resident had a change in condition. This was evident in 1 of 3 residents (Resident #3) reviewed during a complaint survey.
October 17, 2025Complaint inspection · 3 citations
- F
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 observations, record reviews, and interviews, it was determined that the facility failed to ensure adequate nursing staff coverage as required and failed to ensure that call bells were answered in a timely manner. This deficient practice was evident for all four nursing units during the complaint survey.
- D
Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.
Inspectors wroteBased on record reviews and interviews, it was determined that the facility failed to ensure that the facility's assessment accurately reflected the facility's staffing requirements. This deficient practice was evident during the complaint survey.
- D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on review of complaint #2611976, record reviews, and staff interviews, it was determined that the facility failed to ensure a resident's clinical record was accurately documented regarding the date and acquisition of pressure injuries. This was evident for 1 out of 2 complaints reviewed during the complaint survey.
July 23, 2025Standard inspection, Complaint inspection · 11 citations
- 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 record reviews, observations, and interviews it was determined that the facility failed to perform bed rail assessments and obtain resident consent for bedrails. This was evident for 4 (Resident #17, # 21, #68, and #64) out of 5 residents reviewed for bedrails during the survey.
- E
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on observation and interview with staff, it was determined that the facility failed to maintain proper infection control procedures and failed to store and prepare food in a manner that maintains professional standards of food service safety. This practice was evident for 2 of 4 kitchens that prepare food for residents within the facility.
- E
Make sure that a working call system is available in each resident's bathroom and bathing area.
Inspectors wroteBased on observations, record review, and interviews with residents and staff, it was determined that the facility failed to ensure a system was in place to timely respond to the needs of a resident (Resident #21) reviewed for accommodation of needs during the survey.
- D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteBased on administrative record review and interviews with the residents, family and facility staff, it was determined the facility staff failed to provide an environment that promotes dignity and respect for residents who require assistance with their daily care. This was found to be evident for 1(Resident #49) of 5 residents reviewed for abuse allegations during the survey.
- D
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Inspectors wroteBased on medical record review and interviews with facility staff, it was determined the facility failed to ensure that a resident and /or the resident representative (RP) received notice in a timely manner regarding notification and explanation of their rights pending discharge from Medicare. This was found to be evident for 1 (Resident # 67) of 4 residents reviewed regarding liability notices during the survey.
- D
Respond appropriately to all alleged violations.
Inspectors wroteBased on interview and record review, it was determined that the facility failed to maintain documentation related to an allegation of abuse. This was evident for 2 of 6 facility reports reviewed during the annual recertification survey.
- D
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Inspectors wroteBased on record review and interview with staff, it was determined that the facility failed to ensure a resident's person-centered care plan was reviewed and revised to reflect the resident's current code status. This was evident for 1 (Resident #68) out of 2 residents reviewed for care planning during the survey.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on observations, record review, and interviews with residents and staff, it was determined that the facility failed to ensure a physician's order for tube feeding was accurately followed (Resident #12) who was reviewed for tube feeding.
- D
Provide safe, appropriate pain management for a resident who requires such services.
Inspectors wroteBased on reviews of medical records, interviews with residents, and interviews with facility staff, it was determined that facility staff failed to document administration of as needed (PRN) pain medications in a resident's medication administration record. This was evident for 1 (Resident #66) of two residents reviewed for pain management during the survey.
- D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on reviews of medical records, interviews with residents, and interviews with facility staff, it was determined that facility staff failed to maintain complete and accurate medical records in accordance with acceptable professional standards. This was evident for 1 of 2 residents (Resident #66) reviewed for pain management and 1 of out of 4 residents (Resident #68) reviewed for accidents during the survey.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, record review, and interview with staff, it was determined that the facility failed to ensure staff donned appropriate personal protective equipment for enhanced barrier precautions and failed to ensure a resident's order for enhanced barrier precautions was maintained and followed. This was evident for 2 (Resident #21 and #32) out of 14 residents reviewed for enhanced barrier precautions during the survey.
January 23, 2023Standard inspection · 28 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 medical record review, observations, and interview with facility staff, it was determined that the facility failed to address and implement interventions for a resident admitted with a suprapubic catheter. This was identified during the review of 1 of 1 residents with suprapubic catheters.
- E
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Inspectors wroteBased on medical record review and staff interviewed it was determined that the facility failed to ensure the resident, and/or their responsible party, received written notification of a transfer to the hospital, including appeal rights and ombudsman contact information (Residents #19, #201 and #202). This was found to be evident for 3 out of 6 residents reviewed for hospitalization during an annual survey.
- E
Ensure each resident receives an accurate assessment.
Inspectors wroteBased on medical record review and interview with resident and facility staff, it was determined that the facility staff failed to 1. appropriately code a residents suprapubic catheter on the quarterly Minimum Data Set (MDS). This was evident during the review of 1 of 1 residents identified as having suprapubic catheters (Resident #20). 2. accurately code significant weight loss (Resident #7), 3. accurately code the use of oxygen (Resident #35) and 4. accurately code the use of antibiotics (Resident #28). This was evident for 4 out of 50 residents reviewed during an annual survey. The MDS is a federally mandated assessment tool used by nursing home staff to gather information on each resident's strengths and needs. Information collected drives resident care planning decisions. MDS assessments need to be accurate to ensure each resident receives the care they need.
- E
Ensure a qualified health professional conducts resident assessments.
Inspectors wroteBased on medical record review and staff interview, it was determined the facility staff completed MDS (Minimum Data Set) assessments without the proper qualifications (Residents #7, #17, #31, #37, #53, #201, #202). This was evident for 7 of 50 residents reviewed during an annual survey.
- E
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Inspectors wroteBased on medical record review and interview, it was determined the facility staff failed to develop and/or implement a resident's interdisciplinary care plan (Residents #29, #37, #201). This was evident for 3 of 50 residents reviewed during an annual survey. A care plan is a guide that addresses the unique needs of each resident. It is used to plan, assess and evaluate the effectiveness of the resident's care.
- 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 clinical record review, staff interview, and resident interview it was determined that the facility staff failed to ensure care plan meetings were held. This was evident for 4 (#28, #29, #37, #202) out of 50 residents that were part of the survey sample.
- E
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on medical record review and interview, the facility staff failed to provide treatment/services to prevent/heal pressures ulcers (Resident #7, #46 and #201). This is evident for 3 of 4 residents reviewed for pressure ulcers during an annual survey. A pressure ulcer also known as pressure sore or decubitus ulcer is any lesion caused by unrelieved pressure that results in damage to the underlying tissue. [...]
- E
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on medical record review, observation and staff interview, the facility staff failed to provide supervision to prevent an accident (Resident #201, #29) and failed to ensure a resident room was safe (Resident #151). This was evident for 3 out of 50 residents reviewed during an annual survey.
- E
Provide enough food/fluids to maintain a resident's health.
Inspectors wroteBased on medical record review, observation and interview, it was determined the facility staff failed to failed to obtain weights on Resident #37 as recommended by the dietitian and facility staff failed to thoroughly monitor and add interventions timely when the facility staff documented a significant weight loss for a resident Resident #7. This was evident for 2 of 5 residents selected for review for nutrition during the annual survey.
- E
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
Inspectors wroteBased on clinical record reviews, resident interviews, and staff interviews, it was determined that the facility staff failed to provide a comprehensive psychiatric evaluation and consultation for (#3), 6 months out of 12 possible months in 2022. This was evident in 1 out of 50 residents sampled as part of this survey.
- E
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on the tour of the four kitchens, observation, and staff interview it was determined that the facility staff failed to ensure food is stored and prepared in a properly maintained kitchen. This was evident for 4 out of the 4 kitchens.
- E
Employ or obtain outside professional resources to provide services in the nursing home when the facility does not employ a qualified professional to furnish a required service.
Inspectors wroteBased upon interview and record review, the facility failed to 1. failed to follow the recommendations of a consultant (Resident #40) 2. ensure timely consult reports from the use of outside resources (Resident #17) 3. failed to ensure urology consults were obtained and recommendations followed (Resident #20), 4. failed to follow up and implement interventions for a resident with an identified impaired nutritional status (Resident #7). This was evident for 4 out of 12 residents with outside consults during the annual survey.
- E
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on medical record review and interview, it was determined the facility staff failed to maintain the medical record in the most complete and accurate form for Residents (#17, #19, #24, #54 and #201). This was evident for 5 of 50 residents selected for medical record review during the annual survey process.
- E
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Inspectors wroteBased on a revisit of previous annual surveys and deficient practices identified during this survey, it was determined that the facility failed to have an effective Quality Assurance Program as evidenced by the identification of 7 repeat deficiencies. The failure to identify and develop appropriate plans of correction to correct quality deficiencies places all residents at risk.
- E
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Inspectors wroteBased on observation of the residents and facility, and a review of the facility pest control records, it was determined that the facility staff failed to maintain an effective pest control program, specifically concerning fly control (Resident #7), 2nd 3rd, and 4th floors of the facility.
- D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteBased upon observations and interview, the facility failed to ensure Resident #40 had laundered personal clothing available to wear in accordance with this resident's wishes in order to maintain the resident's dignity. On 01/05/2023 at 08:00 AM, Resident #40 was observed dressed in a hospital gown in the hallway, verbalizing that they had no clothes to wear. Staff #26: GNA (geriatric nursing assistant) #4, was seen in the hall by the laundry room and acknowledged the resident's clothes were in the laundry and not ready. On 01/05/2023 at 09:35 AM, the resident was observed by surveyors sitting in a chair in the community area dressed in the hospital gown and pants verbalizing that his/her own clothes were preferred but were not laundered yet. On 01/10/2023 at 08:30 AM, Resident #40 was observed sitting in a chair in the community area with an upset facial expression. [...]
- D
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Inspectors wroteBased on an initial observation prior to and of dining the facility failed to provide the residents with and environment that included comfortable sound levels with appropriate entertainment. This was evident during the first observation of dining occurring on the 4th floor.
- D
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Inspectors wroteBased on a review of the medical record and staff interview, it was determined that the facility staff failed to provide the resident and their representative with written notice of bed hold policy, at the time of the resident's transfer for hospitalization. This was evident for 2 (Residents #19 and #48) of 6 residents reviewed for hospitalization during an annual recertification survey.
- D
Ensure services provided by the nursing facility meet professional standards of quality.
Inspectors wroteBased on the medical record review and interview, the facility failed to follow the standard of practice during medication administration for the care of the resident (Resident # 55). This was evident for 1 of 50 residents selected for review during the annual survey.
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on medical record review, observation and interview, it was determined the facility staff failed to provide grooming and personal hygiene services for a resident (Resident #204). This was evident for 1 out of 50 residents reviewed during an annual survey.
- D
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, resident interview, and staff interview it was determined that the facility staff failed to ensure a resident's bed had a complete pair of siderails. This was evident for 1 out of the 50 residents selected for the survey sample.
- D
Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care.
Inspectors wroteBased on medical record review and interview with facility staff, it was determined that the physician progress notes did not contain or address pertinent issues that were relevant at the time the notes were completed. This was evident during the review of 1 of 26 resident physician notes. (#7)
- D
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 the review of employee files and interview with facility staff, it was determined that the facility failed to have competency skills list provided and available for Geriatric Nursing Assistance (GNA) upon hire. This was evident for 2 of 4 GNA employee files reviewed.
- D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Inspectors wroteBased on medical record review, observation and interview it was determined that the facility failed to ensure medications were destroyed after a resident expired or the medications were discontinued; and secure a medication storage room and properly label resident medication. This was found to be evident during observation of two of four medication storage rooms.
- 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 clinical record review and staff interview it was determined that the facility staff failed to ensure a resident's medication regimen was reviewed monthly (#19). This was true for 1 out of 50 residents that were part of the survey sample.
- D
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Inspectors wroteBased on random observations it was determined that the facility failed on multiple occasions to ensure that the code cart and the medication carts were secure. This was observed on different occasions and locations.
- D
Provide routine and 24-hour emergency dental care for each resident.
Inspectors wroteBased on clinical record review, observation, resident interview, and staff interview it was determined that the facility staff failed to ensure a resident was screened for dental services (#28). This was evident for 1 out of 50 residents reviewed as part of the survey sample.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, it was determined that the facility staff failed to follow infection control practices and guidelines by failing to maintain a sanitary environment to prevent the development and transmission of disease-causing organisms from exposed foam and underneath padding due to torn and cracked vinyl on stools.
March 11, 2019Standard inspection · 17 citations
- F
Provide and implement an infection prevention and control program.
Inspectors wroteBased on record review and staff interview it was determined that the facility failed to implement an Infection Prevention Control Program (IPCP) to provide appropriate infection surveillance, an effective antibiotic stewardship program for residents, and review the IPCP annually . This deficient practice has the potential to affect all residents, staff, and visitors in the facility.
- F
Implement a program that monitors antibiotic use.
Inspectors wroteBased on review of pertinent documentation and interview with facility staff, it was determined that the facility failed to have an active antibiotic stewardship program in place for the past year. This was evident after the attempted review of the facility's antibiotic stewardship program. This deficient practice has the potential to affect all residents.
- D
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Inspectors wroteBased on medical record review and interview with the facility staff, it was determined that the facility failed to: 1.) provide notice to residents informing them that Medicare may deny payments for procedures or treatments and that residents may be personally responsible for full payment, and 2.) provide notification to residents that their Medicare coverage was ending within the required time frame. This was evident in 3 of 3, residents (Resident #247, #248 and #21) reviewed during beneficiary protection notification.
- D
Respond appropriately to all alleged violations.
Inspectors wroteBased on review of medical records and other pertinent documentation as well as staff interviews it was determined that the facility failed to ensure resident safety while an investigation was in process and failed to complete thorough investigations as evidenced by allowing an accused employee to work with residents prior to the completion of the investigation and failure to interview potential witnesses. This was found to be evident for 3 out of 4 residents (Resident #96, #297 and #146) reviewed for abuse during the survey.
- D
Ensure each resident receives an accurate assessment.
Inspectors wroteBased on medical record review and interview with facility staff it was determined that the facility failed to accurately code a resident on the Minimum Data Set (MDS) regarding antipsychotic and anxiolytic usage. This was evident in the review of 2 of 6 residents (Resident #42 and #31) reviewed for unnecessary medications.
- D
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Inspectors wroteBased on review of the medical record and staff interview it was determined that the facility failed to have a system in place to provide a summary of the Baseline Plan of Care to the resident or responsible party. This was found to be evident for 1 out of 6 residents (Resident #39) reviewed for care planning in the investigative section of the survey process.
- D
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Inspectors wroteBased on medical record review, observation, and interview it was determined that the facility failed to ensure the development and implementation of comprehensive care plans as evidenced by: 1.) failure to update care plan to reflect that restorative services were on hold, 2.) failure to establish a care plan for restorative nursing services, 3.) failure to include safety measures in regard to dining precautions, 4.) failure to develop an individualized care plan related to a residents diagnosis of congestive heart failure (CHF), and 5.) failure to follow the resident care plan by ensuring that regularly scheduled medications were available to administer to the resident. This was found to be evident for 5 of 23 residents (Resident #28, #9, #25, #31, and #23) investigated during the survey.
- D
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Inspectors wroteBased on medical record review and interview with staff it was determined that the facility failed to have an effective system in place to ensure restorative nursing services were provided as ordered. This was found to be evident for 1 out of 3 residents (Resident #9) reviewed for activities of daily living.
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on medical record review, interview and observation it was determined that the facility failed to ensure a resident received 1:1 supervision during meals as ordered by the physician, and failed to implement the speech therapist recommendation of no straws for a resident with a swallowing dysfunction. This was found to be evident for 1 out of 1 resident (Resident #25) reviewed for potential accidents. The facility also failed to ensure pureed food was of a smooth pudding like consistency. This was found to be evident for 1 out of 1 pureed test tray obtained during the survey but has the potential to affect any resident receiving a pureed diet.
- D
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 administrative record review and interviews with the resident and facility staff it was determined the facility failed to have enough staff to: 1.) ensure that a resident's regularly scheduled medication was available as ordered as to prevent missing doses at the time of administration, and 2.) provide physician ordered meal supervision. This was found to be evident for 2 of 23 residents (Resident #23 and #25) reviewed during the facility's annual Medicare/Medicaid survey.
- D
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 review of employee files and staff interviews it was determined that the facility failed to have an effective system in place to ensure both nurses and geriatric nursing assistants (GNA) demonstrated skills competency prior to working independently with residents. This was found to be evident for 2 out of 3 recently hired GNA's (GNA #10 and #11) and 2 out of 2 recently hired nurses (Nurse #12 and #13).
- D
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 review of employee files and staff interview it was determined that the facility failed to have an effective system in place to ensure geriatric nursing assistants (GNA) were currently certified. This was found to be evident for 1 out of 4 GNA's (GNA #20) files reviewed for GNA's that had worked at the facility for more than one year.
- 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 medical record review and interview with staff it was determined that the staff failed to have a system in place to ensure that the pharmacist recommendations were reviewed/addressed by the physicians in a timely manner and failed to ensure that a prn (as needed) order for an anti-psychotic medication was limited to 14 days and then obtain a new order for the medication only after evaluation from the physician. This was evident for 1 of 6 residents (Resident #12) reviewed for unnecessary medications in the investigative stage of the survey process.
- D
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Inspectors wroteBased on medical record review and interview with facility staff, it was determined that the facility staff failed to administer medication according to physician orders. This was evident during the review of 1 of 6 unnecessary medications (Resident #21).
- D
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Inspectors wroteBased on medical record review and interview with staff it was determined that the facility failed to ensure that a PRN (as needed) order for an anti-psychotic medication was limited to 14 days and then obtain a new order for the medication only after evaluation from the physician. This was found to be evident for 1 out of 7 residents (Resident #12) reviewed for unnecessary medications during the investigative stage of the survey.
- D
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Inspectors wroteBased on review and observation of medical records, Controlled Drug Count Verification sheets, observation of the medication room refrigerators, and interview with staff it was determined that the facility failed to ensure the temperature on the medication refrigerator was documented daily. This was found to be evident for 3 out of the 3 nursing medication room refrigerators.
- D
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Inspectors wroteBased on medical record review and interview with staff it was determined that the facility failed to ensure residents were offered the flu vaccine annually. This was found to be evident for one out of five residents (Resident #3) reviewed for immunizations during survey.
Fire safety inspections
48 fire safety citations on file: 4 on March 11, 2026, 6 on July 23, 2025, 31 on January 23, 2023, 7 on March 11, 2019.
Every fire safety citation48 citations
- E
Install a fire alarm system that can be heard throughout the facility.
K 341 · March 11, 2026 · Corrected (the home has a date of correction)
- E
Have restrictions on the use of portable space heaters.
K 781 · March 11, 2026 · Past noncompliance: already fixed when inspectors found it
- D
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 · March 11, 2026 · Corrected (the home has a date of correction)
- D
Properly select, install, inspect, or maintain portable fire extinguishes.
K 355 · March 11, 2026 · Corrected (the home has a date of correction)
- F
Develop and maintain an Emergency Preparedness Program (EP).
E 4 · July 23, 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 · July 23, 2025 · Corrected (the home has a date of correction)
- D
Keep aisles, corridors, and exits free of obstruction in case of emergency.
K 211 · July 23, 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 · July 23, 2025 · Corrected (the home has a date of correction)
- D
Install a fire alarm system that can be heard throughout the facility.
K 341 · July 23, 2025 · Corrected (the home has a date of correction)
- D
Have proper medical gas storage and administration areas.
K 923 · July 23, 2025 · Corrected (the home has a date of correction)
- F
Establish an Emergency Preparedness Program (EP).
E 1 · January 23, 2023 · Corrected (the home has a date of correction)
- F
Develop and maintain an Emergency Preparedness Program (EP).
E 4 · January 23, 2023 · Corrected (the home has a date of correction)
- F
Establish procedures for tracking staff and patients during an emergency.
E 18 · January 23, 2023 · Corrected (the home has a date of correction)
- F
Create arrangements with other facilities to receive patients.
E 25 · January 23, 2023 · Corrected (the home has a date of correction)
- F
Develop a communication plan.
E 29 · January 23, 2023 · Corrected (the home has a date of correction)
- F
List the names and contact information of those in the facility.
E 30 · January 23, 2023 · Corrected (the home has a date of correction)
- F
Provide emergency officials' contact information.
E 31 · January 23, 2023 · Corrected (the home has a date of correction)
- F
Establish staff and initial training requirements.
E 37 · January 23, 2023 · Corrected (the home has a date of correction)
- F
Conduct testing and exercise requirements.
E 39 · January 23, 2023 · Corrected (the home has a date of correction)
- F
Implement emergency and standby power systems.
E 41 · January 23, 2023 · Corrected (the home has a date of correction)
- F
Provide properly protected cooking facilities.
K 324 · January 23, 2023 · Corrected (the home has a date of correction)
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · January 23, 2023 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · January 23, 2023 · Corrected (the home has a date of correction)
- F
Provide a written emergency evacuation plan.
K 711 · January 23, 2023 · Corrected (the home has a date of correction)
- F
Have simulated fire drills held at unexpected times.
K 712 · January 23, 2023 · Corrected (the home has a date of correction)
- F
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
K 761 · January 23, 2023 · Corrected (the home has a date of correction)
- F
Ensure that building systems meet requirements determined by risk assessment procedures performed by qualified personnel.
K 901 · January 23, 2023 · 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 · January 23, 2023 · Corrected (the home has a date of correction)
- F
Have a battery powered remote alarm panel in a location accessible by operating personnel.
K 916 · January 23, 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 23, 2023 · Corrected (the home has a date of correction)
- E
Keep aisles, corridors, and exits free of obstruction in case of emergency.
K 211 · January 23, 2023 · 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 · January 23, 2023 · 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 · January 23, 2023 · Corrected (the home has a date of correction)
- E
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
K 225 · January 23, 2023 · Corrected (the home has a date of correction)
- E
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
K 362 · January 23, 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 23, 2023 · Corrected (the home has a date of correction)
- E
Have properly installed electrical wiring and gas equipment.
K 511 · January 23, 2023 · Corrected (the home has a date of correction)
- D
Meet other general requirements.
K 100 · January 23, 2023 · Corrected (the home has a date of correction)
- D
Have properly installed hallway dispensers for alcohol-based hand rub.
K 325 · January 23, 2023 · Corrected (the home has a date of correction)
- D
Properly select, install, inspect, or maintain portable fire extinguishes.
K 355 · January 23, 2023 · Corrected (the home has a date of correction)
- D
Have proper medical gas storage and administration areas.
K 923 · January 23, 2023 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · March 11, 2019 · Corrected (the home has a date of correction)
- F
Meet other general requirements that are deficient.
K 500 · March 11, 2019 · Corrected (the home has a date of correction)
- F
Have simulated fire drills held at unexpected times.
K 712 · March 11, 2019 · Corrected (the home has a date of correction)
- F
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · March 11, 2019 · Corrected (the home has a date of correction)
- E
Provide properly protected cooking facilities.
K 324 · March 11, 2019 · Corrected (the home has a date of correction)
- E
Have properly installed electrical wiring and gas equipment.
K 511 · March 11, 2019 · Corrected (the home has a date of correction)
- D
Have proper medical gas storage and administration areas.
K 923 · March 11, 2019 · Corrected (the home has a date of correction)