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 59 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
2J
0K
0L
Actual harm
1G
0H
0I
Potential for more than minimal harm
47D
7E
1F
Potential for minimal harm
0A
0B
1C
March 3, 2026Complaint inspection · 4 citations
- 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 document review the facility failed to report a change in condition to the provider and family for 1 of 3 residents (R2) when R2 had an acute episode of hypoxemia (low levels of oxygen in the blood characterized by symptoms that may include shortness of breath and bluish lips) during a combined physical and occupational therapy assessment.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on interviews and document review, the facility failed to assess and monitor 1 of 3 residents (R2) per the provider orders on admission and failed to comprehensively assess and monitor 1 of 3 residents (R2) after a change in condition when R2 participated in therapy, his lips turned blue and had a significant decrease in oxygen saturation rate.
- D
Provide safe, appropriate pain management for a resident who requires such services.
Inspectors wroteBased on interview and document review the facility failed to sufficiently manage pain for 1 of 3 residents (R2) when R2 reported severe pain and was not provided with pain medications until more than 24 hours later.
- D
Ensure that residents are free from significant medication errors.
Inspectors wroteBased on interview and document review the facility failed to verify and accurately transcribe orders for 1 of 3 residents (R1) when a blood pressure medication with conflicting dose and types were prescribed for R1 and then then transcribed incorrectly. Additionally, the facility failed to timely administer prescribed pain medication for 1 of 3 residents (R2) who was admitted post-surgically after a cervical (neck) spinal fusion.
January 27, 2026Complaint inspection · 2 citations
- J
Ensure that residents are free from significant medication errors.
Inspectors wroteBased on interview and document review, the facility failed to ensure a medication was available for administration for 1 of 3 residents (R1) reviewed for medication errors. This resulted in immediate jeopardy (IJ) when R1 was not administered physician prescribed anti-seizure medication which resulted in hospital intensive care unit (ICU) admission for medical management and treatment. The IJ began on 1/17/26 when the facility failed to ensure R1 received scheduled dose Lacosamide (anti-seizure medication) on 1/17/26, 1/18/26, and 1/19/2026 (six doses) and an additional dose not administered on morning of 1/20/26 this caused R1 to have 3 seizures over the span of 7 minutes resulting in hospital ICU admission where R1 remains. The administrator, the director of nursing, and the regional director of operations were notified of the IJ on 1/27/26 at 4:40 p.m. [...]
- 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, the facility failed to review and revise the comprehensive care plan in a timely manner following a verbal altercation for 1 of 3 residents (R2) reviewed for abuse. This failure placed R2 at risk for psychosocial distress and potential recurrence of resident-to-resident conflict.
December 2, 2025Complaint inspection · 3 citations
- D
Provide activities to meet all resident's needs.
Inspectors wroteBased on observation, interview, and record review, the facility failed to support the facility-sponsored and individual activities for residents' preference to support their physical, mental, and psychosocial well-being for 2 of 3 residents (R1 & R2) who were dependent on staff for activities.
- 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 a resident received treatment and care professional standards of practice for 1 of 3 residents (R1) reviewed for quality of care. R1 received treatments that were not ordered and R1 was simultaneously seeing an outpatient wound clinic and the facilities inhouse wound care team who both prescribed different wound care orders leading to inconsistent treatment for R1's wound including missed treatments and inaccurate assessments. Based on observation, interview, and record review the facility failed to ensure a resident received treatment and care professional standards of practice for 1 of 3 residents (R1) reviewed for quality of care. [...]
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview, and record review the facility failed to follow enhanced barrier precautions (an infection control intervention designed to reduce transmission of multidrug-resident organisms that employs targeted gown and glove use during high contact resident activities) for 1 of 3 residents reviewed (R1). In addition, during a wound care dressing change staff failed to follow proper infection control protocol.
August 5, 2025Complaint inspection · 1 citation
- G
Provide enough food/fluids to maintain a resident's health.
Inspectors wroteBased on interview and document review, the facility failed to comprehensively and accurately re-assess, develop and implement interventions to reduce/prevent significant and continued weight loss for 1 of 3 resident (R2) reviewed for weight loss. This resulted in actual harm when R2 was hospitalized for malnutrition. Findings Include: Center for Medicare & Medicaid Services (CMS) considers weight loss 'significant' if it exceeds 5 percent (%) within one month, 7.5% within three months, or 10% within six months. R2's admission Minimum Data Set (MDS) assessment dated [DATE], identified an admission date of 3/13/25, indicated R2 was severely cognitively impaired and had diagnoses of cerebral palsy, depression, and enlarged prostate know as benign prostatic hyperplasia (BPH), obstructive uropathy (blockage hindering urine flow), and Rhabdomyolysis (muscle breakdown). [...]
July 15, 2025Complaint inspection · 6 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 observation, interview, and record review the facility failed to attempt alternative devices before using bedrails on residents beds. The failed to accurately assess the residents for risk of entrapment by assessing residents medical diagnosis, size and weight, cognition, communication and mobility for 5 of 7 residents (R1, R2, R3, R6 and R7) reviewed for bed rails. In addition, R6 had side rails used in conjunction with an air mattress. Based on observation, interview, and record review the facility failed to attempt alternative devices before using bedrails on residents beds. The failed to accurately assess the residents for risk of entrapment by assessing residents medical diagnosis, size and weight, cognition, communication and mobility for 5 of 7 residents (R1, R2, R3, R6 and R7) reviewed for bed rails. [...]
- E
Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame.
Inspectors wroteBased on observation, interview, and record review the facility failed to conduct regular inspections of all bed frames, mattresses, and bed rails as a part of the regular maintenance program to identify areas of possible entrapment for 6 of 7 residents (R1, R2, R3, R4, R6 and R7) reviewed. The bed manufacturer guidelines indicated to visually inspect the bed and accessories monthly and indicated to follow the FDA guidance.
- 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 the facility failed to develop a care and furnish services according to the providers orders for 1 of 3 residents (R4) reviewed. R4 was ordered to wear compression stocking and an abdominal binder. These services were not being completed.
- D
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Inspectors wroteBased on interview, and record review the facility failed to provide the necessary services recommended by physical therapy to maintain or improve a residents ability to carry out her own activities of daily living for 1 of 3 residents (R4) reviewed. R4 was ordered a functional maintenance program when her physical therapy treatment period ended, and the facility did not initiate the program delaying R4's discharge goals. Based on interview, and record review the facility failed to provide the necessary services recommended by physical therapy to maintain or improve a residents ability to carry out her own activities of daily living for 1 of 3 residents (R4) reviewed. R4 was ordered a functional maintenance program when her physical therapy treatment period ended, and the facility did not initiate the program delaying R4's discharge goals.
- 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 observation, interview, and record review the facility failed to ensure sufficient nursing staff available at all times to provide nursing services to meet the residents needs for 3 of 3 residents (R1, R2 and R4) reviewed when staff were unavailable to provide necessary care and services according to assessed needs leading to long wait times for incontinence cares.
- 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 ensure call lights, or another means to request assistance were accessible for 3 of 3 (R2, R5, and R7) residents who were dependent on staff for activities of daily living.
June 26, 2025Complaint inspection · 2 citations
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on interview and document review, the facility failed to ensure an allegation of potential abuse was reported timely to the administrator and to the State agency (SA) in accordance with established policies and procedures for 1 of 1 residents (R1) who was reviewed for an allegation of abuse.
- D
Respond appropriately to all alleged violations.
Inspectors wroteBased on interview and document review, the facility failed to ensure an allegation of potential verbal/ physical abuse was thoroughly investigated and protection was provided when the alleged perpetrator was allowed to continue to work with residents after the allegation was identified for 1 of 1 resident (R1) reviewed for an allegation of abuse.
May 14, 2025Complaint inspection · 1 citation
- D
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Inspectors wroteBased on interview and document review, the facility failed to ensure the physician was notified timely of elevated blood sugars and a change condition for 1 of 2 residents (R2) reviewed for change of condition.
April 3, 2025Complaint inspection · 2 citations
- D
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a peripherally inserted central catheter (PICC) was appropriately managed based on professional standards of practice and in accordance with physician orders for 1 of 1 resident (R1) reviewed for intravenous (IV) medications.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview, and record review the facility failed to follow infection control protocols to ensure proper handwashing was implemented for 2 of 4 residents (R1, R2); failed to ensure proper enhanced barrier precautions (EBP) were utilized appropriately for 2 of 2 residents (R1, R3); and failed to disinfect vital sign machine after use for 1 of 1 residents (R1).
December 5, 2024Complaint inspection · 1 citation
- D
Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
Inspectors wroteBased on interview and document review, the facility failed to ensure discharge summary requirements were met for 1 of 3 residents (R1) reviewed for discharge. R1 discharged from the facility against medical advice (AMA), R1's medical record did not include a recapitulation of resident's stay (a concise summary of the resident's stay and course of treatment in the facility) and a final summary of the resident's status at discharge.
November 7, 2024Complaint inspection · 3 citations
- J
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on interview and record review, the facility failed to monitor and notify the physician following a change in condition for one of three residents, (R1) who had multiple episodes of vomiting that began on [DATE] and continued through [DATE] when R1 died. This resulted in an Immediate Jeopardy (IJ) for R1. The IJ began on [DATE] when R1's had a change in condition was not monitored, nor was the physician notified of R1's change in condition that started on the evening of [DATE] and continued through the morning of [DATE] when R1 passed away. The IJ was identified on [DATE]. The administrator and the director of nursing were notified of the immediate jeopardy at 10:47 a.m. on [DATE]. The immediate jeopardy was removed on [DATE] and the deficient practice was corrected on [DATE], prior to the start of the survey and was therefore past non-compliance.
- 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 allegations of neglect to the state agency immediately, but not later than two hours for one of one resident (R1) reviewed when R1's change in condition was not assessed, the physician was not notified, and R1's change in condition was not monitored by licensed nurses. R1 began vomiting on [DATE] and died in the facility on [DATE].
- 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 comprehensive care plan for one of three residents (R1) reviewed when R1 had a history of gastrointestinal bleeds that was not identified on her care plan.
September 19, 2024Standard inspection · 9 citations
- F
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview, and record review the facility failed to ensure personal protection equipment (PPE) was used when sorting dirty laundry. This had the potential to impact all 82 residents who reside in the facility.
- 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 resident privacy and dignity 2 of 3 residents (R46, R11) reviewed for dignity. R46 R46's admission (MDS) dated [DATE], indicated R46 had moderate cognitive impairment and required substantial and/or maximal assistance with most activities of daily living (ADLs), such as hygiene, dressing, and transfers. During observation on 9/18/24 at 7:30 a.m., R46 had their call light on. At 7:32 a.m., the social services designee (SS)-A knocked on R46's door and stated they would let them [the staff] know as they walked out of R46's room. At 7:34 a.m., SS-A stated loudly down the hall to nursing assistant (NA)-A R46 needed a check and change. During interview on 9/18/24 at 8:48 a.m., NA-A stated SS-A always does that when questioned about SS-A's statement in the hall. [...]
- D
Allow residents to self-administer drugs if determined clinically appropriate.
Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure a self-administration of medications (SAM) assessment was completed to allow 1 of 1 resident (R30) to safely administer their own non-oral medications.
- D
Reasonably accommodate the needs and preferences of each resident.
Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure resident use of shared toilet for 1 of 1 resident (R62) reviewed for accommodation of needs.
- 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 observation, interview, and document review, the facility failed to ensure an enteral feeding pump, tube feeding pole, and supporting legs were cleaned and in sanitary condition for 1 of 2 residents (R11) reviewed for tube feeding. Furthermore, the facility failed to keep the building clean for 1 of 1 bathroom with an unclean exhaust fan and 1 of 1 room with an unclean wall vent and ceiling tiles. Also, the facility failed to keep furniture in good condition for 1 of 2 residents (R30) who had an extended table from a dresser in their room.
- 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 observation, the facility failed to ensure a comprehensive and individualized care plan was developed for 1 of 1 resident (R49) reviewed for constipation.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on observation, interview, and document review, the facility failed to comprehensively assess and monitor non-pressure related skin conditions for 1 of 1 resident (R49) reviewed for skin concerns.
- 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, interview, and document review, the facility failed to provide routine range of motion for 1 of 2 residents (R11) reviewed for range of motion (ROM). Further, the facility failed to implement a walking program for 1 of 1 resident (R62) reviewed for walking program.
- D
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Inspectors wroteBased on interview and record review the facility failed to ensure the current pneumococcal vaccination was offered for 1 of 5 residents (R47) reviewed for immunizations.
August 13, 2024Complaint inspection · 1 citation
- D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on interview and document review, the facility failed to ensure accurate documentation of medications and treatments when residents were hospitalized for 2 of 3 (R1, R3) residents reviewed for documentation.
November 16, 2023Complaint inspection · 1 citation
- D
Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.
Inspectors wroteBased on interview and document review the facility failed to ensure required information was documented and communicated to a receiving healthcare facility to ensure continuity of care when transferred to the hospital emergently for 1 of 3 residents (R1) reviewed for change in condition.
July 14, 2023Standard inspection · 13 citations
- E
Allow resident to participate in the development and implementation of his or her person-centered plan of care.
Inspectors wroteBased on interview and document review, the facility failed to provide an opportunity to participate in care planning for 4 of 4 residents (R21, R29, R73, R56) reviewed for care conferences.
- E
Honor the resident's right to organize and participate in resident/family groups in the facility.
Inspectors wroteBased on interview and document review the facility failed to ensure resident council concerns were addressed or followed-up on in a timely manner. This had the potential to affect 12 residents who attended the resident council meetings in the previous six months.
- E
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on observation, interview and document review, the facility failed to complete a comprehensive fall analysis to determine root cause, develop and implement resident-centric interventions, and monitor for post-fall complications following a fall for 1 of 1 residents (R73) reviewed for falls. In addition, the facility failed to ensure the environment was free from hazards to prevent falls and accidents for 4 of 4 residents (R39, R27, R31, R55) in the locked, memory care unit.
- 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 document review, the facility failed to notify resident representatives and/or a provider for 3 of 3 residents (R27, R39, R238) who had a change in condition and/or were involved in incidents resulting in potential or actual harm.
- D
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 document review, the facility failed to minimize verbal resident-to-resident abuse for 1 of 1 resident (R30) reviewed who was verbally abused by another resident (R58) .
- D
Respond appropriately to all alleged violations.
Inspectors wroteBased on interview and document review the facility failed to thoroughly investigate an allegation of resident-to-resident sexual abuse for 1 of 1 residents (R39).
- D
PASARR screening for Mental disorders or Intellectual Disabilities
Inspectors wroteBased on interview and document review the facility failed to ensure a level I Pre-admission Screening and Resident Review (PASRR) level I was completed and accurate prior to admission to the facility for 1 of 1 residents (R27).
- D
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Inspectors wroteBased on observation, interview, and document review the facility failed to comprehensively assess, update, and implements a care plan for 1 of 1 resident (R55) who continued to have behaviors with no new interventions.
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on observation, interview and document review, the facility failed to provide timely assistance with incontinence cares for 1 of 3 residents (R25) who were dependent upon staff for incontinence cares.
- D
Provide activities to meet all resident's needs.
Inspectors wroteBased on observation, interview, and document review, the facility failed to comprehensively assess, develop, and implement meaningful and engaging activities for 2 of 2 residents (R27, R39) in the memory care unit. This had the potential to affect all 20 residents residing in the memory care unit.
- D
Provide enough food/fluids to maintain a resident's health.
Inspectors wroteBased on interview and document review the facility failed to comprehensively assess, develop, and implement interventions for ongoing and unplanned weight gain for 1 of 1 residents (R27) who had sudden and continued weight gain.
- 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, interview, and document review the facility failed to adequately maintain bed rails to minimize the risk of entrapment for 1 of 1 resident (R73) reviewed who had bed rails attached to their bed.
- D
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure a safe, functional environment for 1 of 1 resident (R73) reviewed whose bed did not lock and bed controller did not work. R73's quarterly MDS dated [DATE], indicated he was moderately cognitively impaired, required extensive assistance of two staff for bed mobility, transfers, and toilet use. The MDS indicated he did not have any falls since the most recent assessment. R73's Medical Diagnosis list included bilateral below-the-knee leg amputations (BKA), diabetes, weakness, and lung disease. R73's Falls Care Area assessment dated [DATE], indicated he was at risk for falls due to changes in mobility and medications. A progress note dated 3/3/23, indicated R73 had an unwitnessed fall after attempting to self-transfer. [...]
September 17, 2021Standard inspection · 10 citations
- E
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview, and document review, the facility failed to follow the Centers for Disease Control (CDC) guidelines to prevent and/or minimize the transmission of COVID-19 related to the proper utilization of personal protective equipment (PPE) including facemasks and eye protection. This had the potential to affect 22 residents who resided on the [NAME] neighborhood.
- E
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure privacy curtains, resident walls, and fall mats were clean and/or in good repair for 4 of 4 residents (R42, R33, R28, R10) reviewed for environment.
- D
Allow residents to self-administer drugs if determined clinically appropriate.
Inspectors wroteBased on observation, interview, and document review the facility failed to ensure a self-administration of medication assessment was completed for 1 of 1 resident (R10) who was observed with medications at her bedside.
- 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 document review, the facility failed to ensure the physician was notified of a pattern of increased blood glucose levels for 1 of 1 resident (R10) reviewed who received insulin.
- 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 document review, the facility failed to develop a comprehensive person-centered care plan to reflect individualized goals for 1 of 4 residents (R38) reviewed for care planning.
- 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 document review, the facility failed to ensure assistance was provided with removing facial hair and dressing and/or bathing was for 2 of 4 residents (R58, R3) reviewed who required staff assistance with activities of daily living (ADL). R58's quarterly Minimum Data Set (MDS) dated [DATE], identified R58 had diagnoses of chronic kidney failure, heart failure, and diabetes. R58 had intact cognition, used a walker for mobility, and required set up assistance with bathing. R58's Active Order Summary dated 9/16/21, indicated R58 received dialysis on Tuesday, Thursday, and Saturday. R58's dialysis dressing was to be removed the day after dialysis. R58's care plan dated 3/25/21, indicated R58 would continue to make daily preferences/choices which were important to him. R58's care plan lacked evidence of bathing preferences. [...]
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on observation, interview, and document review, the facility failed to provide assistance removing facial hair for 2 of 2 residents reviewed who were dependent upon staff for hygiene assistance.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on interview and document review, the facility failed to ensure daily weights were obtained for 2 of 2 residents (R85, R443) reviewed whom had daily weights ordered.
- 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 document review, the facility failed to ensure a urinary drainage bag and catheter tubing was kept off the floor to prevent cross contamination and potential infection for 1 of 1 residents (R42) reviewed for catheters.
- C
Post nurse staffing information every day.
Inspectors wroteBased on interview and document review, the facility failed to ensure the posted nurse staffing hours accurately reflected the hours worked each day. This had the potential to affect all 92 residents who resided at the facility.
Fire safety inspections
13 fire safety citations on file: 8 on September 19, 2024, 4 on July 14, 2023, 1 on September 17, 2021.
Every fire safety citation13 citations
- F
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · September 19, 2024 · Corrected (the home has a date of correction)
- D
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 · September 19, 2024 · Corrected (the home has a date of correction)
- D
Install corridor and hallway doors that block smoke.
K 363 · September 19, 2024 · Corrected (the home has a date of correction)
- D
Install smoke barrier doors that can resist smoke for at least 20 minutes.
K 374 · September 19, 2024 · Corrected (the home has a date of correction)
- D
Ensure proper usage of power strips and extension cords.
K 920 · September 19, 2024 · Corrected (the home has a date of correction)
- C
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · September 19, 2024 · Corrected (the home has a date of correction)
- C
Provide a written emergency evacuation plan.
K 711 · September 19, 2024 · Corrected (the home has a date of correction)
- C
Have simulated fire drills held at unexpected times.
K 712 · September 19, 2024 · Corrected (the home has a date of correction)
- F
Install a fire alarm system that can be heard throughout the facility.
K 341 · July 14, 2023 · Corrected (the home has a date of correction)
- D
Keep aisles, corridors, and exits free of obstruction in case of emergency.
K 211 · July 14, 2023 · 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 14, 2023 · Corrected (the home has a date of correction)
- D
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · July 14, 2023 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · September 17, 2021 · Corrected (the home has a date of correction)