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 44 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
34D
10E
0F
Potential for minimal harm
0A
0B
0C
February 3, 2026Complaint inspection · 2 citations
- D
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Inspectors wroteBased on record review, and interviews during an abbreviated survey (2603474), the facility did not ensure a comprehensive care plan was developed and implemented to maintain the Resident's highest practicable physical, mental, and psychosocial well-being for two (2) of three (3) residents (Resident #1, #4) reviewed for behaviors. Specifically, 1) Resident # 1 had severe cognitive impairment with documented nursing progress notes of wandering behavior, physical and verbal aggression and refusal of cares had no behavior care plan initiated There was no behavior care plan documented in the Electronic Medical Record during the survey. When requested the Facility did not provide a behavioral care plan for the resident. [...]
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on record review and interviews during an abbreviated survey (2603474) the facility did not ensure the resident environment was free of accident hazards and that each resident received adequate supervision to prevent elopement for 1(Resident #1) out of 3 residents reviewed for elopement. Specifically, on 8/11/2025 the resident was found off their unit in the kitchen by a dietary staff resident was placed on 15-minute visual checks and identified on the elopement risk assessment to be a high risk for elopement. On 8/27/2025, Resident# 1 was captured on video surveillance exiting the building through the fire exit doors at 3:04pm and returned into the building at 3:15pm. The facility's resident monitoring: [...]
July 22, 2025Standard inspection, Complaint inspection · 15 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 and interview during the recertification survey conducted from 7/15/25 to 7/25/25, the facility did not ensure that a clean, comfortable, and homelike environment was provided. Specifically, during observation of the Forest Unit, resident rooms [ROOM NUMBERS] had leaking radiator units. Wallpaper throughout the Forest Unit hallways and common areas was torn or missing, ceiling trim had rust stains and a baseboard in room [ROOM NUMBER]B was missing. The Forest Unit shower room had low water pressure and low hot water temperature. During observation of the Town Hall Common area, approximately 25% of the ceiling fluorescent light fixtures were non-functioning.
- 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, record review and interview conducted during the recertification survey from 7/15/25-7/22/25, the facility did not ensure that staff evaluated the effectiveness of interventions and/or provided immediate interventions to assure the safety of residents to prevent abuse for 1 of 3 residents (Resident #218) reviewed for Abuse and prevent the potential for abuse for 1 of 6 residents (Resident #145) reviewed for Accidents. Specifically, 1. on 4/25/24 Resident # 218 with a history of wandering in/out of other resident rooms was found seated in the bed in Resident #147's room, while Resident #147 stood/masturbated in front of and pushed their penis against the face/mouth of Resident #218. Additionally, after the 4/25/24 incident, staff did not consistently document 15-minute visuals for Resident #218 as per the 4/25/24 incident and accident report/physician order and 2. [...]
- E
Respond appropriately to all alleged violations.
Inspectors wroteBased on record review and interviews the facility did not ensure that they initiated and completed a thorough investigation of alleged violations of abuse to prevent further potential abuse for one of three residents (#218) reviewed for abuse and three of four residents (#19, #99 and #25) reviewed for resident rights. Specifically, 1) on 4/25/24 at 4:30 PM, Registered Nurse # 30 was looking for Resident #218 and located them in Resident's #147's room. Resident #147 was standing in front of Resident #218 masturbating in their face. There was no documented evidence the Accident/Incident Report was completed until 6/19/24 and 2) the facility did not complete an investigation after Resident #19 reported a missing ring and 3) Resident #99 reported a missing purse. [...]
- 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 conducted during the recertification survey from 7/15/2025 to 7/22/2025, the facility did not ensure proper storage in accordance with professional standards for food safety. Specifically, multiple containers of unmarked, undated food were observed in facility refrigerators and freezers, multiple containers of food were in the dry storage area without a date to indicate when they had been opened, a kitchen staff's personal drink item was observed in a refrigerator which stored resident foods, and a malodor was present in the meat refrigerator where food was stored.
- E
Keep all essential equipment working safely.
Inspectors wroteBased on observation and interview conducted during the recertification survey from 7/15/25 to 7/22/25, the facility did not ensure all mechanical and electrical equipment was in safe operating condition. Specifically, water was observed leaking from the kitchen dishwasher which allowed standing water to be present on the floor in and around the dishwasher.
- D
Reasonably accommodate the needs and preferences of each resident.
Inspectors wroteBased on observation, interview, and record review during the Recertification Survey from 7/15/2025-7/22/2025, the facility did not ensure reasonable accommodation of resident needs and preferences. Specifically, one of four residents (Resident #187) reviewed for accommodation of needs and one of five residents (Resident #119) reviewed for call devices, were observed on multiple occasions with the call bell device not within the resident's reach.
- D
Protect each resident from the wrongful use of the resident's belongings or money.
Inspectors wroteBased on observations, interviews, and record reviews conducted during a recertification survey the facility did not ensure each resident was free from misappropriation of resident property for two of four residents (#19, and #99) reviewed for resident rights. Specifically, 1) Resident #19 reported a missing ring and 2) Resident #99 reported a missing purse which contained rosary beads, a twenty dollar bill, debit card and pacemaker card.
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on observation, interview, and record review conducted during the recertification from 7/15/25 to 7/22/25, the facility did not ensure all alleged violations of abuse were reported immediately, but not later than 2 hours to the state survey agency for 1 of 3 residents reviewed for Abuse (Resident #218). Specifically, there was no documented evidence that an allegation of abuse was reported to the facility Administrator or to the state survey agency after a 4/25/24 incident where Resident # 218 with a history of wandering in/out of other resident rooms was found seated in the bed in Resident #147's room, while Resident #147 stood and masturbated in front of Resident #218.
- 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 observation, interview and record review conducted during a recertification survey, from 7/15/2025-7/22/2025 the facility did not ensure that comprehensive person-centered care plans were developed and/or implemented for each resident to meet the resident's medical and/or nursing needs for 1 of 4 residents (#214) reviewed for range of motion. Specifically, for Resident #214 with muscle weakness a care plan was not developed to address left-hand contracture and/or the use of a left-hand roll as per occupational therapy recommendation
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on observation, interview, and record review during the Recertification Survey from 7/15/2025-7/22/2025, the facility did not ensure that residents receive treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan for one of three residents (#6) reviewed for mood and behavior and one of four residents (#171) reviewed for positioning. Specifically, 1) Resident #6 did not receive follow up psychiatric services as ordered and recommended by the physician and 2) Resident #171 was observed seated in their wheelchair with their legs/feet unsupported and dangling above the footrests.
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on observation, record review, and interview during the recertification survey conducted 7/15/2025 to 7/22/2025, the facility did not ensure residents received care, consistent with professional standards of practice, to prevent pressure ulcers for one of three residents (Residents #171) reviewed for pressure ulcers. Specifically, heel booties were not applied as per physician order and care plan for Resident #171 who was assessed at risk for pressure ulcers.
- D
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Inspectors wroteBased on observation, record review, and interviews conducted during the Recertification Survey from 07/15/2025 to 07/22/2025, the facility did not ensure a resident with limited range of motion received appropriate treatment and services to prevent further decrease in range of motion for 1 of 4 residents (Resident #10) reviewed for Position/Mobility. Specifically, Resident #10 with functional limitation in range of motion was observed on multiple occasions without the use of a left-hand splint as per Occupational Therapy recommendation.
- D
Ensure medication error rates are not 5 percent or greater.
Inspectors wroteBased on observation, record review, and interview during the Recertification Survey conducted from 07/15/2025- 07/22/2025, the facility did not ensure that residents were free of medication error rates less than 5% for 1 of 4 residents (Resident #114) reviewed for Medication Administration. Specifically, Licensed Practical Nurse #11 crushed 3 medications and administered them all at once via gastrostomy tube, then combined 3 liquid medications and administered them all at once to for Resident #114 via gastrostomy tube.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation and interview conducted during the recertification survey from 7/15/25 to 722/25, the facility did not ensure infection control prevention practices were maintained to prevent the development and transmission of infection for 1 of 4 residents reviewed for nutrition. Specifically, Licensed Practical Nurse #12 was observed without the use of a gown when they administered medications via gastrostomy tube to Resident #14 who was on enhanced barrier precautions.
- 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 interview, and record review conducted during the recertification and abbreviated survey (813417) from 7/15/25 - 7/22/25, the facility did not ensure Comprehensive Care Plans were revised to reflect the resident's current condition for 1 of 6 residents (Resident #227) reviewed for Accidents. Specifically, for Resident #227, there was no documented evidence that comprehensive care plans were reviewed and/or revised to include safety interventions recommended by occupational therapy after a 1/18/2024 fall.
July 1, 2025Complaint inspection · 3 citations
- 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 observations, record review and interviews conducted during the Abbreviated Surveys (NY00342238 and NY00364422), the facility did not ensure that there was sufficient nursing staff to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Specifically, 1) The facility did not provide adequate staffing to meet the needs of the residents, and as per their Facility assessment dated 6/2018 and revised on 4/9/2025; 2) Upon review of the nursing staffing schedule on 6/2/2024 (3pm-11pm), there were a total of 27 Certified Nurse Aides and a total of 5 Licensed Practical Nurses in the facility and the Facility Assessment documented that there must be 29-32 Certified Nurse Aides and 6-9 Licensed Practical Nurses in the building on the evening shift,; [...]
- D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteBased on observations, record review and interviews conducted during the Abbreviated Surveys (NY00342238 and NY00364422), the facility did not ensure that residents had the right to a dignified existence by promoting resident independence and dignity while dining for 1(Resident #6) of 3 residents observed for residents' rights. Specifically, Licensed Practical Nurse #7 was observed standing over Resident #6 while assisting them to eat their dinner.
- 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 and interviews conducted during the Abbreviated Surveys (NY00342238 and NY00364422), the facility did not ensure that a facility-wide assessment was conducted to thoroughly assess the needs of its residents and to determine the required resources to provide the care and services to its residents during its day-to-day operations, did not address what is considered sufficient, particularly on the weekends, how the care required on a weekend shift is different than the care required on other shifts, and did not include behavioral health services necessary to meet resident needs. Additionally, the facility assessment did not have the date that it was reviewed with Quality Assurance and Performance Improvement (QAPI). [...]
April 12, 2024Complaint inspection · 1 citation
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on interview and record review conducted during an abbreviated survey (NY00318168), the facility did not ensure adequate supervision was provided and residents environment remained free of accidents hazards as possible for 1 of 3 residents reviewed for accidents. Specifically, on 6/10/2023, Resident #1 who had a wander guard in place exited the facility through the north hall exit undetected by staff. Resident #1 was found by staff outside the facility up the hill by the roadway and was returned to the facility by Nurse Care Supervisor. The north hall exit sensor did not alarm/sound when Resident #1 exited.
June 8, 2023Standard inspection · 13 citations
- E
Ensure residents have reasonable access to and privacy in their use of communication methods.
Inspectors wroteBased on observation, staff and resident interviews conducted during the recertification survey from 6/1/2023 to 6/8/2023, the facility did not ensure the rights of citizenship, including the right to receive mail, were maintained for all residents. Specifically, mail was not delivered to residents on Saturdays, thereby denying all residents the same rights provided to other citizens of the general community.
- E
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on record review and interview conducted during the 6/1/2023 - 6/8/2023 recertification and abbreviated surveys (NY00301182, NY00298858), the facility did not ensure that all alleged violations involving an injury of unknown origin or allegations of abuse were reported to the New York State Department of Health (NYSDOH) within 2 hours of occurrence for 4 out of 5 residents (Resident #39, #55, #173 #175) reviewed for abuse. Specifically, 1)Resident #173 had left shin swelling and left ankle swelling identified on 3/15/23, an X-ray was completed on 3/16/23 and revealed an acute spiral fracture of the distal tibia, the incident was not reported to the NYSDOH. 2) Resident #175 sustained a fracture of unknown origin and the incident was not reported to the NYSDOH. [...]
- 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 during the 6/1/2023 to 6/8/2023 recertification and abbreviated surveys (#NY00301182), the facility did not promptly notify the resident's representative of a need to alter treatment for 1 of 1 resident (Resident #39) reviewed for notification. Specifically, on 8/22/2022 Resident #39 was found to have new bruising and pain to their right upper right arm, x-rays were ordered, and there was no documented evidence that the resident's Health Care Proxy (HCP) was notified until 8/23/2022.
- D
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Inspectors wroteBased on observation, record review and interviews conducted during the recertification survey from 6/1/23 to 6/8/23, the facility did not ensure residents were free from physical restraints for 2 of 2 residents (#91 and #190) reviewed for physical restraints. Specifically, Resident #190 did not have a thorough restraint assessment and re-assessments were not completed to address the continued use of a lap tray while in the wheelchair, and for Resident # 91 the lap tray was not removed every 2 hours and with meals as ordered.
- D
Respond appropriately to all alleged violations.
Inspectors wroteBased on record review and interview conducted during the recertification and abbreviated surveys (NY00298858) from 6/1/2023 to 6/8/2023, the facility did not ensure all alleged violations involving physical abuse including injuries of unknown source were thoroughly investigated and did not prevent the potential for further abuse while an investigation was in progress . This was evident for 2 out of 5 residents (Residents #55 and #173) reviewed for abuse. Specifically, 1) Certified Nurse Aide (CNA) #14 was accused of slapping Resident #55 and was not immediately removed from resident care while the investigation was in progress. 2) When an injury of unknown origin was identified for Resident #173, and then diagnosed as a spiral fracture of the distal tibia, there was no documented evidence that the incident was investigated.
- 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 interview and record review conducted during the recertification survey of 6/1/2023 - 6/8/23 the facility did not ensure that a Baseline Care Plan was developed and implemented within 48 hours for a resident admitted with an indwelling catheter. This was evident for 1 (Resident #211) of 3 residents reviewed for urinary catheter/urinary tract infection. Specifically, Resident #211's baseline care plan did not include the instructions needed and the physician orders for care of the resident's urinary indwelling catheter.
- 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 interviews and record review conducted during the Recertification survey from 06/01/23-06/08/23, the facility did not develop and implement a comprehensive person-centered care plan for 1 of 2 residents (Resident #54) reviewed for pressure ulcers. Specifically, Resident #54 did not have a care plan developed to address a Stage 4 pressure ulcer.
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on observations, record reviews, and interviews conducted during the recertification survey 6/1/23-6/8/23, the facility did not ensure 1 (Resident #54) of 2 residents reviewed for pressure ulcers received care and services to promote healing and to prevent new pressure ulcers from developing. Specifically, Resident #54 had a Stage 4 pressure ulcer and interventions were not implemented as ordered.
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on observations, record review and interviews during the recertification survey from 6/1/23-6/8/23, the facility did not ensure the resident environment remained free of accident hazards and each resident received adequate supervision to prevent accidents for 1 (Resident #182) of 3 residents reviewed for accidents. Specifically, Resident #182, with a history of wandering, was not provided supervision to prevent the ingestion of medicated cream and the resident's level of supervision was not reassessed for ongoing unsafe wandering.
- 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 record review and interview during the 6/1/2023 to 6/8/2023 recertification survey, the facility did not ensure for 1 of 3 residents (Resident #211) reviewed for urinary catheter or urinary tract infection (UTI) that a urinary indwelling (Foley) catheter was discontinued as soon as it was clinically possible. Specifically, Resident #211 was admitted to the facility with a Foley catheter for a diagnosis of other retention of urine and no services were provided to the resident in order to restore or improve as much bladder function to the extent possible.
- 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 observations, record reviews and interviews during a recertification survey, the facility did not ensure drugs and biologicals were stored in locked compartments for 2 of 3 residents (Residents #72 and #128) reviewed for medication storage. Specifically, 1) medicated creams and ointments for Resident #72 were found in a dresser drawer and 2) medicated powder was observed on a dresser top in Resident #128 room. Both residents were on units with other resident who had known wandering behaviors.
- D
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 conducted during a recertification survey, the facility did not ensure that residents were consistently offered and provided with evening snacks. Specifically, 8 out of 8 residents from that attended the resident council meeting stated that they were not offered a snack, or if they asked for a snack, they were not provided with an evening snack.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observations, interviews and record review during a recertification survey from 6/1/23-6/8/23, the facility did not ensure that Infection Control practices and procedures were maintained. Specifically, 1) Staff did not practice proper hand hygiene during a pressure ulcer dressing change for Resident #54 and contaminated the clean dressing field with dirty gloves, 2) A dirty linen cart was positioned next to a clean linen cart on the Echo unit, and 3) Resident #211's Foley catheter was observed on the floor without the use of a barrier.
August 9, 2019Standard inspection · 10 citations
- E
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 interview and record review conducted during the recertification survey, the facility did not ensure that staff received proper training to provide competent care for 1 resident (Resident #314) reviewed for safe transfer using a sliding Board. Specifically, the facility did not provide evidence to show that 2 Certified Nursing Assistants (CNAs) were trained effectively on how to transfer a resident out of bed with a sliding board.
- E
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Inspectors wroteBased on observation, interviews and record review, the facility did not ensure that an effective pest control program was in place. Specifically, gnats were found in the kitchen dry storage room. Chapter 1 of the State Sanitary Code, subpart 14-1, states the premises are to be free from insects, rodents, harborage, and insect or rodent breeding conditions.
- D
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Inspectors wroteBased on observation, interview and record review conducted during the recertification survey, the facility did not ensure that staff documented specific instructions or implemented interventions on the use of seat belts for safety and prevention of falls. This was evident for 1 resident (Residents # 172) reviewed for restraints. Specifically, 1. Residents # 172 - no specific instructions were provided in the care guide on the use of a Velcro seat belt.
- 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 conducted during the recertification survey, the facility did not ensure that the care plan was updated and did not develop appropriate interventions to address changes in the resident's current health status. Specifically , a care plan for constipation was not revised to address issues related to a resident's hospitalization. This was evident for 1 resident reviewed for quality of care. (Resident #269).
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on record review and interview conducted during the recertification survey the facility did not ensure that care was provided in accordance with professional standards of practice. Specifically , the physician's orders for the treatment of constipation were not consistently implemented. This was evident for 1 resident reviewed for hospitalization. (Resident #269).
- 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 conducted during the recertification survey, it cannot be ensured that the facility's environment remained as free of accidents as possible, Specifically 2 of 2 residents (Residents #159 and #314) reviewed for accidents.
- D
Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs.
Inspectors wroteBased on interview and observation conducted during the recertification survey, the facility did not ensure adequate holding temperatures for cold foods in accordance with professional standards of food safety practice. According to the Food Safety and Inspection Service of the US Department of Agriculture (www.fsis.usda.gov), cold foods should be held at or below 40 degrees Fahrenheit (F) and placed in containers on ice.
- D
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 conducted during the recertification survey, the facility did not ensure proper storage, preparation, distribution and service of food in accordance with professional standards for food safety. Specifically, 1. the facility did not ensure food contact equipment and kitchenware were maintained in sanitary condition, and 2. the concentration of quaternary ammonium compound chemical sanitizing rinse (QAC) was less than required by the manufacturer. Chapter 1 Sub-Part 14-1 of the State Sanitary Code states that food contact surfaces are to be washed, rinsed and sanitized after each use and when contaminated.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview, and record review conducted during the recertification survey, the facility did not provide a safe, sanitary environment to help prevent the transmission and development of communicable diseases and infections. Specifically, 1) the facility did not ensure that the potable water system was tested as required by public health laws and regulations, to determine the presence of Legionella and/or other opportunistic waterborne pathogens and 2) the facility did not ensure that staff followed proper hand hygiene to prevent cross contamination and the spread of infection for 3 residents (Residents #24, #46, and #196) observed during the lunch meal observation.
- D
Make sure that a working call system is available in each resident's bathroom and bathing area.
Inspectors wroteBased on interview and observations conducted during the recertification survey, the facility did not ensure that residents consistently had a means of directly contacting staff for assistance.
Fire safety inspections
29 fire safety citations on file: 12 on July 22, 2025, 8 on June 8, 2023, 9 on August 9, 2019.
Every fire safety citation29 citations
- F
Have properly located and lighted "Exit" signs.
K 293 · July 22, 2025 · Corrected (the home has a date of correction)
- F
Install an approved automatic sprinkler system.
K 351 · July 22, 2025 · Corrected (the home has a date of correction)
- F
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
K 761 · July 22, 2025 · 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 · July 22, 2025 · Corrected (the home has a date of correction)
- F
Ensure that testing and maintenance of electrical equipment is performed.
K 921 · July 22, 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 · July 22, 2025 · Corrected (the home has a date of correction)
- E
Inspect, test, and maintain automatic sprinkler systems.
K 353 · July 22, 2025 · Corrected (the home has a date of correction)
- D
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
K 225 · July 22, 2025 · Corrected (the home has a date of correction)
- D
Have exits that are accessible at all times.
K 271 · July 22, 2025 · Corrected (the home has a date of correction)
- D
Install emergency lighting that can last at least 1 1/2 hours.
K 291 · July 22, 2025 · Corrected (the home has a date of correction)
- D
Properly select, install, inspect, or maintain portable fire extinguishes.
K 355 · July 22, 2025 · Corrected (the home has a date of correction)
- D
Ensure proper usage of power strips and extension cords.
K 920 · July 22, 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 · June 8, 2023 · Corrected (the home has a date of correction)
- E
Follow proper procedures when the fire alarm was out of service for more than 4 hours.
K 346 · June 8, 2023 · Corrected (the home has a date of correction)
- E
Install corridor and hallway doors that block smoke.
K 363 · June 8, 2023 · Corrected (the home has a date of correction)
- E
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
K 521 · June 8, 2023 · Corrected (the home has a date of correction)
- E
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · June 8, 2023 · Corrected (the home has a date of correction)
- D
Ensure that waiting areas, nurse’s stations, gift shops, and cooking facilities, open to the corridor are properly protected.
K 361 · June 8, 2023 · Corrected (the home has a date of correction)
- C
Install an approved automatic sprinkler system.
K 351 · June 8, 2023 · Corrected (the home has a date of correction)
- C
Inspect, test, and maintain automatic sprinkler systems.
K 353 · June 8, 2023 · Corrected (the home has a date of correction)
- E
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
K 225 · August 9, 2019 · Corrected (the home has a date of correction)
- E
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · August 9, 2019 · Corrected (the home has a date of correction)
- E
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
K 521 · August 9, 2019 · Corrected (the home has a date of correction)
- E
Have simulated fire drills held at unexpected times.
K 712 · August 9, 2019 · Corrected (the home has a date of correction)
- E
Meet requirements for the installation and maintenance of electrical systems.
K 911 · August 9, 2019 · Corrected (the home has a date of correction)
- E
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · August 9, 2019 · Corrected (the home has a date of correction)
- D
Have exits that are accessible at all times.
K 271 · August 9, 2019 · Corrected (the home has a date of correction)
- D
Have an enclosure around a vertical opening shaft.
K 311 · August 9, 2019 · Corrected (the home has a date of correction)
- D
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
K 321 · August 9, 2019 · Corrected (the home has a date of correction)