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
59D
5E
1F
Potential for minimal harm
0A
0B
0C
June 5, 2026Complaint inspection · 5 citations
- 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 interview, observation, and document review, the facility failed to:1) Maintain sufficient and adequate linen supplies;2) Ensure a sanitary, clean and homelike environment of resident rooms;3) Maintain the cleanliness of shower rooms and resident care areas; and4) Ensure resident equipment, including a footboard, was maintained in good repair. This deficient practice had had the potential to encourage pathogen growth, spread infection, compromise resident comfort, dignity, and hygiene, and could interfere with the provision of timely and appropriate care.
- D
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Inspectors wroteBased on interview, record review, and document review the facility failed to implement its Drug Diversion Risk Tool for missing narcotics, for 1 of 64 sampled residents (Resident 272). The deficient practice had the potential to put residents at risk of physical harm.
- D
Ensure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge.
Inspectors wroteBased on interview, record review and document review, the facility failed to ensure skilled services were maintained for a resident with an approved appeal for 1 of 64 Residents (Resident 276). The deficient practice had the potential for a resident not to receive the necessary skilled services to attain maximum potential and prevention from hospital readmission.
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on interview, record review and document review, the facility failed to provide the documented evidence showers were provided to a resident for 1 of 64 sampled resident (Resident 228). The deficient practice had the potential to prevent resident from skin infections and exposing unhygienic conditions which can affect a resident's mental health, dignity, and overall immune response.
- D
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Inspectors wroteBased on observation, interview, record review and document review, the facility failed to ensure 1) enteral feeding bottle and hydration bag were labeled in accordance with facility policy for 1 of 64 sampled residents (Resident 245), and 2) a physician order was obtained for an enteral feeding tube de-clogging procedure for 1 of 64 sampled patients (Resident 5). The deficient practice placed the resident at risk for complications and for the resident's physician not to be aware of the enteral feeding tube clogging event and providing clinical oversight of the medical situation.
March 20, 2026Complaint inspection · 2 citations
- D
Keep residents' personal and medical records private and confidential.
Inspectors wroteBased on interview, record review and document review, the facility failed to ensure residents did not feel like their privacy rights were violated related to an unauthorized video recording and subsequent social media release by a resident's family member for 10 of 21 sampled residents (Resident 1, 2, 3, 7, 10, 11, 15, 18, 19, and 21). The deficient practice placed residents and/or representatives at risk for exploitation.
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on observation, interview, record review and document review, the facility failed to ensure a 1) fire incident and 2) an incident of unauthorized video recording and social media release of multiple residents by a resident's family member were reported timely to the state agency. The deficient practice placed residents at risk for delayed emergency response and potential violation of privacy.
March 6, 2026Complaint inspection · 1 citation
- D
Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility.
Inspectors wroteBased on interview, record review, and document review, the governing body of the facility failed to oversee services performed by a contracted vendor, including ensuring the accuracy of documentation of resident behaviors, for 2 of 13 sampled residents (Resident 4 and 6). This deficient practice had the potential to result in inappropriate tiering and state payments for residents in the Medicaid Behaviorally Complex Care Program.
March 4, 2026Complaint inspection · 1 citation
- D
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Inspectors wroteBased on interview, record review, and document review, the facility failed to ensure target behaviors and side effects were monitored with regards to use of an anti-psychotic medication for 1 of 7 sampled residents (Resident 1). The deficient practice had the potential to place the residents at risk for receiving unnecessary medications.
December 31, 2025Complaint inspection · 2 citations
- D
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Inspectors wroteBased on observation, record review, interview and document review the facility failed to provide bathing as scheduled for 1 of 6 sampled residents (Resident 1). The deficient practice had the potential to negatively impact the resident's overall well-being.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on record review and staff interviews, the facility failed to ensure physician orders for monthly weights were followed for 1 of 6 sample residents (Resident 6). This deficient had the potential to impact monitoring of the resident's changes in weight (loss or gain), nutritional assessment, and delay dietary interventions. Findings Include: Resident 6 (R6) was admitted to the facility on [DATE] with diagnoses including Parkinson's disease without dyskinesia, dementia, and major depressive disorder. A physician order summary dated 07/03/2025, documented monthly weight one time a day starting on the 1st and ending on the 7th every month for monitoring. A physician/nurse practitioner progress note dated 12/11/2025 documented R6 had an eight-pound weight loss from August of 2025. [...]
April 24, 2025Complaint inspection · 1 citation
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on observation, interview, record review and document review the facility failed to ensure an orthopedic consult was obtained as per physician order for 1of 5 sampled residents (Resident 1). The deficient practice had the potential to delay treatment and healing of a fracture.
March 28, 2025Standard inspection, Complaint inspection · 17 citations
- G
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on observation, interview, record review and document review, the facility failed to ensure: 1. The plan of care was followed regarding transfers and the staff was provided with transfer training after a resident fall for 1 of 35 sampled residents (Resident 25) and, 2. An Oxygen tank was secured for 1 of 35 sampled residents (Resident 98). The deficient practice led to a resident's fall with injury and had the potential to cause a resident injury due to an unsecured Oxygen tank.
- E
Have a plan that describes the process for conducting QAPI and QAA activities.
Inspectors wroteBased on interview and document review, the facility failed to maintain documentation and demonstrate evidence of its ongoing Quality Assurance and Performance Improvement (QAPI) program. This deficient practice has the potential to negatively affect the outcomes of resident care and the quality of each resident's life.
- E
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
Inspectors wroteBased on interview and document review, the facility failed to maintain documented evidence of maintaining a Quality Assurance and Performance Improvement (QAPI) Committee consisting at a minimum of: the Director of Nursing services; the Medical Director or his/her designee; at least three other members of the facility's staff, at least one of who must be the administrator, owner, or board member; and the infection preventionist. The facility also failed to maintain documentation of evidence of the committee meeting at least quarterly. This deficient practice has the potential to negatively affect the outcomes of resident care and the quality of each resident's life.
- D
Allow residents to self-administer drugs if determined clinically appropriate.
Inspectors wroteBased on observation, interview, record review and document review, the facility failed to ensure a physician's order was obtained, an assessment was completed, and care plan was developed for the self-administration of medication for one unsampled resident (Resident 38). The deficient practice had the potential for the resident's unsafe administration of medication or adverse reactions to medication.
- D
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure residents have a right to make choices about aspects of their life in the facility which are significant to the resident for 1 of 35 sampled residents (Resident 102). The failure to accommodate the residents' preferences and choices had the potential risk to cause psychosocial distress to the residents.
- D
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 document a written response including rationale to address complaints brought forth in the resident council. The deficient practice had the potential to cause resident concerns to remain unresolved.
- D
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Inspectors wroteBased on interview, record review and document review, the facility failed to ensure a resident was kept safe from physical abuse for 1 of 35 sampled residents (Resident #43). The deficient practice had the potential for the resident to experience emotional and physical harm.
- D
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Inspectors wroteBased on observations, record reviews, staff interviews, and facility policy reviews, the facility failed to ensure 1 of 35 sampled residents (Resident 168) remained free from restraints not needed to treat a medical symptom, identify the use of lower bed rails as a restraint, and follow policies and procedures in assessing the use of a physical restraint or alternatives considered prior to implementing a physical restraint. The deficient practice could have resulted in a decline in activities of daily living, loss of dignity, and physical and psychosocial harm to the resident.
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on interview, record review and document review, the facility failed to ensure an alleged incident of physical abuse was reported to the State Agency (SA) within the required timeframes for 1 of 35 sampled residents (Resident #43). The deficient practice had the potential to place residents at risk for incidents of physical abuse to not be adequately protected.
- 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 observations, interview, record review, and document review the facility failed to ensure a resident-centered care plan was revised and physician order obtained for use of side rails for 1 of 35 sampled residents (Resident 6). The deficient practice had the potential to put the resident at risk for harm due to lack of communication between staff.
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on observation, interview, record review and document review, the facility failed to provide incontinent care for 2 of 35 sampled residents (Resident 25 and Resident 417) and 1 unsampled resident (Resident 468). The deficient practice had the potential for the resident's skin integrity to be compromised.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased observation, interview, record review and document review, the facility failed to ensure physician orders were followed in medication administration and orders clarified for medication for 1 of 3 closed record sampled residents (Resident 469), a medication was administered per the physician's order for one unsampled resident (Resident 219), and staff administered medication in a timely manner for 2 of 35 sampled residents (Residents 210 and 147) and 2 unsampled residents (Residents 27 and 137). The deficient practice had the potential for the resident not achieving the therapeutic effect (specific and desired effect) of the medication.
- D
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Inspectors wroteBased on observation, interview, record review, and document review, the facility failed to obtain a physician's order for the removal or use of an intravenous (IV) access, including assessing and monitoring the site, for 1 of 35 sampled residents (Resident 90). This deficient practice had the potential to cause complications such as infection, infiltration, phlebitis, or impaired venous access.
- 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 observations, record reviews, staff interviews, and facility policy reviews, the facility failed to ensure 1 of 35 sampled residents (Resident 168) was assessed and reviewed for risk and benefits, appropriate alternatives were attempted prior to installing the bed rail, and physician orders were obtained for bed rails. The deficient practice had the potential to place the resident at risk of injury such as falls, entrapment, and broken bones.
- 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 observation, document review and interview, the facility failed to ensure pre-made foods were stored, labeled, dated, and used within seven days in the refrigerator. This deficient practice posed a potential risk to safety and health standards which could lead to food spoilage and place residents at risk of foodborne illness.
- D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on interview and record review, the facility failed to ensure the medical records were complete and accurate for 1 of 35 sampled residents (Resident 98) and 2 unsampled residents (Resident 467 and Resident 469). The deficient practice had the potential for residents not to receive timely interventions needed and for the facility missing the opportunity to identify care issues.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview, record review and document review, the facility failed to ensure infection control practices were maintained for 1 of 35 sampled residents (Resident 25). The deficient practice had the potential to increase risk of cross-contamination, spread infectious diseases, and compromise health and safety for residents.
December 6, 2024Complaint inspection · 9 citations
- F
Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
Inspectors wroteBased on interview and document review the facility failed to ensure 1.) the Infection Preventionist had specialized training in infection control prior to appointment to the position; 2.) a COVID-19 outbreak was reported to the appropriate state agency; and 3.) N-95 respirator fit testing was completed, documented and staff training was provided per facility policy. The deficient practice had the potential for the facility's infection prevention program to be ineffective.
- D
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Inspectors wroteBased on interview, record review and document review, the facility failed to ensure a grievance report was initiated and followed through for 1 of 37 sampled residents (Resident 1). The deficient practice had the potential to result in a resident having an unresolved grievance.
- D
Provide doctor's orders for the resident's immediate care at the time the resident was admitted.
Inspectors wroteBased on interview and record review, the facility failed to vancomycin medication was initiated upon admission for 1 of 37 sampled residents (Resident 20). The deficient practice had the potential prevent the continuation of a resident's medicine regimen for a serios infection.
- D
Plan the resident's discharge to meet the resident's goals and needs.
Inspectors wroteBased on interview, record review, and document review, the facility failed to provide documented evidence discharge planning was provided to 1 of 37 sampled residents (Resident 10). The deficient practice had a potential for inadequate post management and coordination of the continuation of care for a resident. Findings Include: Resident 10 (R10) was admitted on [DATE] for short term rehabilitation for open heart surgery. R10 was discharged on 03/01/2024. R10's medical record lacked documented evidence of a case manager's assessment for discharge needs during the resident's short-term stay. On 12/03/2024 at 1:19 PM, the Licensed Social Worker indicated case management oversaw discharge planning for short term skilled residents. [...]
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on interview, record review, and document review, the facility failed to provide documented evidence assistance with activities of daily living (ADL) was provided for 1 of 37 sampled residents (Resident 3). The deficient practice had the potential for the resident's skin integrity to be compromised.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on interview, record review and document review, the facility failed to ensure weekly wound evaluations were completed and weekly skin observations were documented accurately for 1 of 37 sampled residents (Resident 1) and failed to implement a physician order for a psychiatric consultatin for 1 of 37 sampled residents (Resident 32). The deficient practice had the potential to delay the assessment and treatment of residents' skin condition and management of a resident's mental health.
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on interview, record review and document review, the facility failed to ensure weekly wound evaluations were completed and weekly skin observations were documented accurately for 1 of 37 sampled residents (Resident 2). The deficient practice had the potential to delay the assessment and treatment of residents' skin condition.
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on observation, interviews, and documentation review, the facility failed to provide a safe environment free from accident hazards by ensuring the sharps containers were replaced after it reached the manufacture fill line, used razors and syringes were disposed in an appropriate sharps container in a common shower room (Hall 600), residents were assessed for smoking, and the designated smoking area was under supervision. The deficient practice had the potential for increased risk of needle stick and compromised the resident's overall safety and well-being.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview, record review, and document review, the facility failed to ensure staff did not use personal blood pressure monitors to take vital signs for residents in transmission-based precautions when disposable blood pressure cuffs were available. The deficient practice had the potential to increase the risk of cross-contamination.
February 9, 2024Standard inspection, Complaint inspection · 13 citations
- E
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on observation, interview, record review and document review, the facility failed to ensure, 1) Oxygen tanks were stored appropriately, 2) medications were not left at bedside, 3) storage rooms were secured, 4) a respiratory cart and medication cart were secured, and 5) the facility's smoking policy was followed when residents were allowed to have possession of smoking supplies. The deficient practice had the potential to place residents at risk for harm or injury.
- E
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Inspectors wroteBased on observation, interview and document review, the facility failed to ensure medications were not left unsecured in a medication cart at the 800-900-Hall nursing station, and medications were not left at bedside. The deficient practice posed a risk for resident's safety of obtaining medications not prescribed and not taking ordered medications.
- E
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview, record review and document review, the facility failed to ensure: 1) residents with suspected scabies were placed on contact precautions for 1 of 35 sampled residents (Resident 112), 2) a staff member who was assigned to provide care to residents with unconfirmed rashes and who themself was undergoing treatment for scabies, was not assigned to another unit, 3) laundry items of residents with unconfirmed rashes were handled in accordance with the facility's policy, 4) the wound care team was notified of residents with unconfirmed rashes and 5) suspected resident and staff scabies cases were reported to the health department. The deficient practice placed other residents and staff at risk of contracting scabies.
- 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 observation, interview, record review and document review, the facility failed to ensure a baseline care plan was completed for a resident who was admitted with a surgical wound (Resident 635) and a resident with a contracture (Resident 108). The deficient practice had the potential the residents would not receive the wound care or contracture care the residents required.
- 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, record review and document review, the facility failed to develop a care plan for a resident with bed rails (Resident 95). The deficient practice placed the resident at a risk for safety.
- 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 administer medications timely in accordance with the facility's policy for 1 of 35 sampled residents (Resident 42). The deficient practice had the potential to cause physical and psychosocial harm to the resident. Findings including: Resident 42 (R42) R42 was admitted on [DATE] with diagnoses including chronic pain syndrome, mononeuropathy, and anxiety disorder. On 02/07/24 at 7:52 AM, R42 indicated scheduled medication for pain and anxiety were frequently administered late. A review of the medical record documented: - A physician order for Lorazepam oral tablet 1 milligram (mg), give 1 mg by mouth three times a day for anxiety. [...]
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on observation, interview, record review and document review, the facility failed to ensure a physician's order for a pressure redistributing mattress was implemented for a resident with a stage four coccyx pressure ulcer. The deficient practice potentially resulted in the worsening of the resident's coccyx pressure ulcer.
- 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, record review and document review, the facility failed to ensure restorative nursing services (RNA) was provided to residents in accordance with therapy recommendations for 3 of 35 sampled residents (Residents 34, 108 and 110). The failure to provide RNA services had the potential for the resident's further decline in mobility.
- 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, record review and document review, the facility failed to ensure care orders were obtained and implemented for a resident who was admitted with an indwelling catheter for 1 of 35 sampled residents (Resident 182). Specifically, a physician's order was not obtained when the resident's catheter had to be replaced and perineal (area between the anus and posterior part of external genitalia) wash was not performed routinely in accordance with the facility's policy. The deficient practice placed the resident at risk for a recurrent urinary tract infection (UTI).
- 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, record review and document review, the facility failed to ensure assessment for entrapment was completed, alternatives were attempted, and informed consent was obtained prior to installation of side rails for 1 of 35 sampled residents (Resident 95). Resident 95 (R95) R95 was admitted to the facility on [DATE] and re-admitted on [DATE], with diagnoses including encephalopathy, unspecified, personal history of traumatic brain injury and seizure disorder. On 02/06/24 at 10:21 AM, R95 was in bed with the upper side rails in the up position on both sides of the bed. On 02/08/24 at 9:15 AM, R95 was in bed with the upper side rails in the up position on both sides of the bed. On 02/08/24 at 10:23 AM, a Certified Practical Nurse (CNA) confirmed R95 had upper side rails in the up position on both sides of the bed. [...]
- D
Provide medically-related social services to help each resident achieve the highest possible quality of life.
Inspectors wroteBased on interview, record review and document review, the facility failed to ensure: 1) an admission and quarterly social services assessment was completed for 1 of 35 sampled residents (Resident 182), 2) the Social Worker followed-up with the acute care hospital and the onsite dental services regarding the missing dentures for 1 of 35 sampled residents (Resident 53), and 3) there were sufficient number of social services staff members in accordance with the facility assessment. The deficient practice had the potential for the facility not meeting the social services needs of the residents.
- 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, interview and document review, the facility failed to 1) label and date food items, and 2) discard potentially hazardous foods. The deficient practice had the potential to expose resident to foodborne illness.
- D
Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
Inspectors wroteBased on observation, interview, record review and document review, the facility failed to ensure the hospice physician's order to place a resident on transmission-based precautions for possible scabies infection was followed for 1 of 35 sampled residents (Resident 112). The deficient practice placed other residents and staff at risk for spreading scabies.
November 1, 2023Complaint inspection · 8 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, record review and document review, the facility failed to ensure a dislodgement of a urinary indwelling catheter that resulted in urethral trauma and hematuria was promptly reported to the attending physician for 1 of the 33 sampled residents (Resident #1). The deficient practice had the potential to prevent the resident from receiving the treatments to prevent urinary complications.
- 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 record review, interview, and document review, the facility failed to ensure a baseline care plan was developed for the care of surgical wounds for 1 of 33 sampled residents (Resident #1). The deficient practice had the potential to deprive the resident for receiving wound care services in a timely manner.
- 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, interview and document review, the facility failed to develop and implement a comprehensive care plan to manage the pain for a resident with communication problems related to ventilator-dependent respiratory failure for 1 of 33 sampled residents (Resident #32). The deficient practice had the potential to deprive the resident for receiving effective pain management and treatment.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on record review, interviews, and document review, the facility failure to perform the initial assessment for wound care, obtain physician orders for wound care, and provide treatment for surgical wounds in timely manner for 1 of 33 sampled residents (Resident #1). The deficient practice placed residents at risk for unmet treatment care needs that could have resulted in surgical site complications such as infection, improper healing, and pain.
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on interview, record review and document review, the facility failed to ensure 1) wound treatments were provided per physician's order and 2) wound assessments were conducted on a weekly basis in accordance with facility policy for a resident with an existing pressure ulcer for 1 of 33 sampled residents (Resident 6). The deficient practice placed the resident at risk for wound complications such as wound deterioration, infection, and pain.
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on interview, record review and document review, the facility failed to ensure post fall protocol was implemented for 1 of 33 sampled residents (Resident 22). The deficient practice had the potential for inaccurate assessment and monitoring following an unwitnessed fall, impacting the quality of life of the resident.
- D
Provide safe, appropriate pain management for a resident who requires such services.
Inspectors wroteBased on record review, interview and document review, the facility failed to accurately assess the pain for a resident with communication problems related to ventilator-dependent respiratory failure for 1 of 33 sampled residents (Resident #33). The deficient practice had the potential to deprive the resident of receiving effective pain management and treatment.
- D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Inspectors wroteBased on interview and document review, the facility failed to account for narcotics signed out on the controlled drug record for 1 of 33 sampled residents (R29). The deficient practice had the potential to delay a resident's pain management and increase risk for physical and psychosocial harm.
November 18, 2022Standard inspection · 7 citations
- 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 physician orders were followed for Oxygen therapy for 1 of 32 sampled residents (Resident 14), and administration of a stool softener for one unsampled resident (Resident 271). The failure to follow physician orders had the potential for the resident's treatment plan to be ineffective.
- 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, record review, and document review, the facility failed to report signs of possible urinary tract infection (UTI) to the physician in a timely manner for 2 of 32 sampled residents (Residents 7 and 96) and ensure there was a medical justification for the continued use of a urinary catheter for 1 of 32 sample residents (Resident 134). The failure could potentially increase the risk of complications related to urinary catheters.
- D
Ensure that the resident and his/her doctor meet face-to-face at all required visits.
Inspectors wroteBased on interview and record review, the facility failed to ensure an attending physician personally visited a resident for 1 of 32 sampled residents (Resident 4). The failure denied the resident the right to be seen by a physician.
- D
Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.
Inspectors wroteBased on interview, record review and document review, the facility failed to ensure there was documented evidence a physician was notified of the laboratory results timely for 1 of 32 sampled residents (Resident 109). The failure could potentially delay treatments and interventions.
- D
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Inspectors wroteBased on observation, interview, record review and document review, the facility failed to ensure the resident's food preferences were honored for one unsampled resident (Resident 31). The failure resulted in the resident being offered disliked foods.
- D
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure burned Brussels sprouts were not served to residents. The failure to provide a palatable meal had the potential to cause a decrease in the residents' appetite and, as a result, the alteration in nutritional parameters such as weight.
- D
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Inspectors wroteBased on interview, record review and document review, the facility failed to ensure the pneumococcal vaccine was offered and re-offered to 1 of 32 sampled resident (Resident 134) and two unsampled residents (Residents 49 and 78). The failure prevented the residents/representatives to decline or avail the vaccine.
Fire safety inspections
45 fire safety citations on file: 14 on March 28, 2025, 17 on February 9, 2024, 14 on November 18, 2022.
Every fire safety citation45 citations
- J
Have properly installed electrical wiring and gas equipment.
K 511 · March 28, 2025 · Corrected (the home has a date of correction)
- F
Address subsistence needs for staff and patients.
E 15 · March 28, 2025 · Corrected (the home has a date of correction)
- E
Develop and maintain an Emergency Preparedness Program (EP).
E 4 · March 28, 2025 · Corrected (the home has a date of correction)
- E
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
K 321 · March 28, 2025 · Corrected (the home has a date of correction)
- E
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · March 28, 2025 · Corrected (the home has a date of correction)
- E
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
K 741 · March 28, 2025 · Corrected (the home has a date of correction)
- E
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
K 761 · March 28, 2025 · Corrected (the home has a date of correction)
- D
Establish staff and initial training requirements.
E 37 · March 28, 2025 · Corrected (the home has a date of correction)
- D
Have properly located and lighted "Exit" signs.
K 293 · March 28, 2025 · Corrected (the home has a date of correction)
- D
Have an alternate power supply for its alarm system.
K 344 · March 28, 2025 · Corrected (the home has a date of correction)
- D
Inspect, test, and maintain automatic sprinkler systems.
K 353 · March 28, 2025 · Corrected (the home has a date of correction)
- D
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · March 28, 2025 · Corrected (the home has a date of correction)
- D
Ensure that testing and maintenance of electrical equipment is performed.
K 921 · March 28, 2025 · Corrected (the home has a date of correction)
- D
Have proper medical gas storage and administration areas.
K 923 · March 28, 2025 · Corrected (the home has a date of correction)
- F
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
K 521 · February 9, 2024 · Corrected (the home has a date of correction)
- F
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
K 761 · February 9, 2024 · Corrected (the home has a date of correction)
- F
Ensure gas and vacuum systems are inspected and tested as part of a maintenance program.
K 908 · February 9, 2024 · Corrected (the home has a date of correction)
- F
Ensure that testing and maintenance of electrical equipment is performed.
K 921 · February 9, 2024 · Corrected (the home has a date of correction)
- E
Address subsistence needs for staff and patients.
E 15 · February 9, 2024 · Corrected (the home has a date of correction)
- E
Develop a communication plan.
E 29 · February 9, 2024 · Corrected (the home has a date of correction)
- E
Establish emergency prep training and testing.
E 36 · February 9, 2024 · Corrected (the home has a date of correction)
- E
Install emergency lighting that can last at least 1 1/2 hours.
K 291 · February 9, 2024 · Corrected (the home has a date of correction)
- E
Inspect, test, and maintain automatic sprinkler systems.
K 353 · February 9, 2024 · Corrected (the home has a date of correction)
- E
Have properly installed electrical wiring and gas equipment.
K 511 · February 9, 2024 · Corrected (the home has a date of correction)
- E
Provide a written emergency evacuation plan.
K 711 · February 9, 2024 · Corrected (the home has a date of correction)
- E
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
K 741 · February 9, 2024 · Corrected (the home has a date of correction)
- E
Have restrictions on the use of flammable curtains.
K 751 · February 9, 2024 · Corrected (the home has a date of correction)
- D
Include a process for Emergency Preparedness collaboration.
E 9 · February 9, 2024 · Corrected (the home has a date of correction)
- D
Implement emergency and standby power systems.
E 41 · February 9, 2024 · Corrected (the home has a date of correction)
- D
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · February 9, 2024 · Corrected (the home has a date of correction)
- D
Ensure proper usage of power strips and extension cords.
K 920 · February 9, 2024 · Corrected (the home has a date of correction)
- F
Address subsistence needs for staff and patients.
E 15 · November 18, 2022 · Corrected (the home has a date of correction)
- F
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 · November 18, 2022 · Corrected (the home has a date of correction)
- E
Establish roles under a Waiver declared by secretary.
E 26 · November 18, 2022 · Corrected (the home has a date of correction)
- E
Conduct testing and exercise requirements.
E 39 · November 18, 2022 · Corrected (the home has a date of correction)
- E
Implement emergency and standby power systems.
E 41 · November 18, 2022 · Corrected (the home has a date of correction)
- E
Install emergency lighting that can last at least 1 1/2 hours.
K 291 · November 18, 2022 · Corrected (the home has a date of correction)
- E
Inspect, test, and maintain automatic sprinkler systems.
K 353 · November 18, 2022 · Corrected (the home has a date of correction)
- E
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · November 18, 2022 · Corrected (the home has a date of correction)
- E
Have properly installed electrical wiring and gas equipment.
K 511 · November 18, 2022 · 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 · November 18, 2022 · Corrected (the home has a date of correction)
- E
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
K 761 · November 18, 2022 · Corrected (the home has a date of correction)
- E
Meet Health Care Facilities Code mechanical requirements.
K 900 · November 18, 2022 · Corrected (the home has a date of correction)
- E
Ensure that testing and maintenance of electrical equipment is performed.
K 921 · November 18, 2022 · Corrected (the home has a date of correction)
- D
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · November 18, 2022 · Corrected (the home has a date of correction)