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 85 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
50D
30E
2F
Potential for minimal harm
0A
0B
3C
July 22, 2026Complaint inspection · 1 citation
- E
Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made.
Inspectors wroteBased on closed clinical record review, clinical record review and staff interview it was determined that the facility failed to provide written notice to a resident or resident's responsible party before the resident's room change for three of five residents reviewed (Residents CR1, 3, 4).
June 26, 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 observations and staff interview, it was determined that the facility failed to provide a clean, comfortable, homelike environment on two of six nursing units (Sycamore Boulevard and Maple Lane; Resident 2), and provide a safe and clean environment in the common intersection between Maple Lane, [NAME] Lane, and Little League Boulevard.
- 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 clinical record review, observation, and staff interview, it was determined that the facility failed to develop and implement a comprehensive person-centered care plan regarding denture care for one of two residents reviewed (Resident 2). Findings Include: During an interview with Resident 2 on June 26, 2026, at 11:35 AM, they indicated that they had dentures. The resident showed their mouth and revealed they had a full set of upper dentures and a lower partial in place. Clinical record review for Resident 2 revealed they had been admitted on [DATE]. Further review revealed that the resident had no care plan (an outline of an individual's health needs, specific care requirements, and the actions necessary to achieve desired health outcomes) implemented since admission relating to denture care. [...]
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on review of select facility policies and procedures, observation, clinical record review, and resident and staff interview, it was determined that the facility failed to provide a dependent resident with activities of daily living assistance for one of one resident reviewed (Resident 4).
- D
Provide enough food/fluids to maintain a resident's health.
Inspectors wroteBased on clinical record review and staff interview, it was determined that the facility failed to implement interventions to maintain nutritional status for one of three residents reviewed for nutritional concerns (Resident 3).
- 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, review of facility documents, and resident and staff interview, it was determined that the facility failed to provide menu items as indicated for three of three residents reviewed (Residents 2, 3 and 4).
April 16, 2026Complaint inspection · 2 citations
- E
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Inspectors wroteBased on review of select facility policies, clinical record review, and staff interview, it was determined that the facility failed to ensure medication availability for two of six residents reviewed (Residents 2 and 3).
- D
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Inspectors wroteBased on review of select facility policies and procedures, clinical record review, and family and staff interview, it was determined that the facility failed to ensure that a resident was free from physical restraint for one of six residents reviewed (Resident 4).
March 13, 2026Standard inspection, Complaint inspection · 27 citations
- F
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on observation and staff interview, it was determined that the facility failed to store food items in a safe and sanitary manner and maintain equipment in a sanitary condition, in the main kitchen of the facility, main dining room, and on one of six nursing units (Little League Nursing Unit).
- E
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Inspectors wroteBased on clinical record review, observation, and resident and staff interview, it was determined that the facility failed to ensure that residents could make choices regarding aspects of their lives that were significant to them, such as smoking, for three of three residents reviewed for concerns related to resident choices (Residents 28, 39, and 101).
- E
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
Inspectors wroteBased on clinical record review and staff interview, it was determined that the facility failed to monitor the use of psychotropic medications for three of five residents reviewed for potentially unnecessary medications (Residents 4, 14, and 15).
- E
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Inspectors wroteBased on a review of select facility policies and procedures, clinical record review, review of employee personnel records, and staff interview, it was determined that the facility failed to develop written procedures for screening potential employees that included all necessary components, maintain documentation of potential employee employment history screening for three of five newly hired employees (Employees 5, 6, and 7), and failed to thoroughly investigate an injury of unknown origin for one of 24 residents reviewed (Resident 15).
- E
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on clinical record review, review of facility documentation, and staff and resident interview, it was determined that the facility failed to provide the highest practical care regarding physician ordered medications and/or devices for four of 24 residents reviewed (Residents 4, 11, and 12); and implement resident-directed care and treatment consistent with the resident's care plan for one of 24 residents reviewed (Resident 101).
- E
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on review of select facility policies and procedures, clinical record review, and staff interview, it was determined that the facility failed to thoroughly investigate and implement interventions to prevent falls for three of eight residents reviewed for fall concerns (Residents 14, 39, and 101).
- 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 a review of select facility policies and procedures, clinical record review, observation, and resident and staff interview, it was determined that the facility failed to assess all potential risks for entrapment for four of 13 residents reviewed for accident hazards (Residents 5, 8, 9, and 16) and failed to conduct ongoing assessments to assure appropriate maintenance with bedrail usage for two of 13 residents reviewed (Residents 8 and 16).
- 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 review of facility documentation and staff interview, it was determined that the facility failed to ensure that nursing staff possessed the appropriate competencies and skill sets related to the care and assessment of residents with enteral tube feeding, who utilize a lift, catheter care, medication administration, donning and doffing PPE (personal protective equipment), and dressing changes for four of four employees reviewed for competencies (Employees 13,14, 10, and 16).
- E
Ensure medication error rates are not 5 percent or greater.
Inspectors wroteBased on observation, clinical record review, and staff interview, it was determined that the facility failed to ensure a medication error rate of less than five percent (Resident 51).
- E
Provide and implement an infection prevention and control program.
Inspectors wroteBased on a review of select facility policies and procedures, observation, and staff interview, it was determined that the facility failed to ensure an environment free from the potential spread of infection on three of five nursing units (Maple Court, Sycamore, and Little League; Residents 4, 11, 15, 37, 51).
- E
Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
Inspectors wroteBased on staff interview it was determined that the facility failed to maintain documentation of staff COVID-19 vaccination status, and provide evidence that staff were offered the COVID-19 vaccine or information on obtaining the COVID-19 vaccine for three of three staff reviewed. (Employees 11, 18, and 19)
- D
Reasonably accommodate the needs and preferences of each resident.
Inspectors wroteBased on observation, and staff and resident interview, it was determined that the facility failed to accommodate resident needs, creating a homelike environment for one of 24 residents reviewed (Resident 7).
- 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 review of select facility policies and procedures, clinical record review, review of the facility's grievance log, and staff interview, it was determined that the facility failed to address a grievance promptly and implement effective actions to resolve the reported grievance for one of 24 residents reviewed (Resident 90).
- D
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Inspectors wroteBased on clinical record review and family and staff interview it was determined that the facility failed to provide written notice of transfer that included all the necessary contents to residents' responsible parties at the time of transfer for four of eight residents reviewed for hospitalizations (Residents 4, 5, 9, and 7); failed to provide timely written notice of the facility bed-hold policy to residents' responsible parties at the time of transfer for three of eight residents reviewed for hospitalizations (Resident 5, 9, and 7); and failed to notify the Office of the State Long-Term Care Ombudsman upon transfer to the hospital for three of eight residents reviewed for hospitalizations (Residents 5, 9, and 7).
- D
Ensure each resident receives an accurate assessment.
Inspectors wroteBased on clinical record review and staff interview, it was determined that the facility failed to ensure assessments accurately reflected a resident's status for one of 24 residents reviewed (Resident 43).
- 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 clinical record review, observation, and resident and staff interview, it was determined that the facility failed to revise a resident's comprehensive care plan for one of 24 residents reviewed (Resident 3) and failed to invite and ensure resident and/or responsible party participation in care plan meetings for 1 of 24 residents reviewed (Resident 28).
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on observation, clinical record review, and resident and staff interview, it was determined that the facility failed to provide a dependent resident with activities of daily living assistance for one of four residents reviewed (Resident 7).
- 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 clinical record review and resident and staff interview, it was determined that the facility failed to provide services to maintain a resident's range of motion for two of seven residents reviewed for ROM concerns (Resident 3 and 45).
- 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 clinical record review, review and staff interview, it was determined that the facility failed to provide appropriate treatment and services regarding incontinence management for one of one resident reviewed (Resident 3).
- D
Provide enough food/fluids to maintain a resident's health.
Inspectors wroteBased on clinical record review, observation, and family and staff interview, it was determined that the facility failed to implement interventions to maintain nutritional status for one of seven residents reviewed for nutritional concerns (Resident 9).
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on clinical record review, observation, and staff interview, it was determined that the facility failed to provide respiratory care consistent with professional standards of practice for one of one resident reviewed with oxygen concerns (Resident 7) and maintain respiratory related equipment supplies in a safe and sanitary manner in one of one dining room observed (main dining room).
- D
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Inspectors wroteBased on clinical record review, observation, and resident and staff interview, it was determined that the facility failed to implement appropriate care and services related to dialysis care for one of one resident reviewed for dialysis concerns (Resident 28).
- D
Provide care or services that was trauma informed and/or culturally competent.
Inspectors wroteBased on clinical record review and staff interview, it was determined that the facility failed to identify triggers related to a resident's diagnosis of Post-Traumatic Stress Disorder, to provide culturally, competent, trauma-informed care, and to eliminate or mitigate re-traumatization for two of two residents reviewed for mood and behaviors (Residents 12 and 43).
- 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 observation and staff interview, it was determined that the facility failed to properly store resident medications on two of six nursing units reviewed (Little League Nursing Unit and Sycamore Nursing Unit).
- D
Keep all essential equipment working safely.
Inspectors wroteBased on observation and staff interview, it was determined that the facility failed to assure essential kitchen equipment is maintained in a safe, operating condition in the facility's main kitchen.
- C
Post nurse staffing information every day.
Inspectors wroteBased on observation, review of posted daily nurse staffing data, and staff interview, it was determined that the facility failed to accurately post information regarding daily nurse staffing data as required.
- C
Dispose of garbage and refuse properly.
Inspectors wroteBased on observation and staff interview, it was determined that the facility failed to properly contain and dispose of garbage at the observed facility trash dumpster.
December 13, 2025Complaint inspection · 2 citations
- E
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Inspectors wroteBased on review of select policies and procedures, observation, and resident and staff interview, it was determined that the facility failed to serve food that is palatable on four of six nursing units (Nursing Units [NAME], Little League, Sycamore, and Grampian; Residents 1, 2, 3, 4, 5, 6, and 7).
- 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 observations and interview with residents and staff, it was determined the facility failed to reasonably accommodate residents who may wish to eat outside of scheduled meal service times on six of six nursing units (Residents 1, 2, and 4).
May 13, 2025Complaint inspection · 1 citation
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on a review of select facility policies and procedures, clinical record review, and staff interview, it was determined that the facility failed to provide the highest practicable care regarding neurological assessments for one of five residents reviewed.
February 21, 2025Standard inspection, Complaint inspection · 25 citations
- E
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Inspectors wroteBased on clinical record review and staff interview it was determined that the facility failed to provide required notification to a resident whose payment coverage changed for three of three residents reviewed (Residents 72, 101, and CR119).
- E
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on clinical record review, observation, and staff and resident interview, it was determined that the facility failed to provide bathing assistance for residents dependent on staff assistance for 5 of 6 residents sampled for activities of daily living (Residents 22, 92, 7, 43, and 70).
- E
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on clinical record review, observation and resident and staff interview, it was determined that the facility failed to provide the highest practicable care regarding physician orders, medications, and treatments for six of 22 residents reviewed (Residents 22, 33, 42, 70, 109, 112, and 114).
- E
Provide safe, appropriate pain management for a resident who requires such services.
Inspectors wroteBased on clinical record review and staff interview, it was determined that the facility failed to provide the highest practicable care regarding physician ordered pain medications for two of three residents reviewed (Residents 6 and 43)
- 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, clinical record review, and staff interview, it was determined that the facility failed to review the risk and benefits of side rail utilization with the resident or resident representative and receive consent for the use of side rails for four of five residents reviewed for accident hazards (Residents 33, 42, 70, and 109), and properly assess all zones that pose a risk for entrapment from bed rails on two of five residents reviewed (Residents 33 and 109).
- E
Observe each nurse aide's job performance and give regular training.
Inspectors wroteBased on review of facility documentation and staff interview, it was determined that the facility failed to ensure that nurse aides received an annual performance review and at least 12 hours of in-service education annually for three of three nurse aides reviewed (Employees 10, 11, and 12). Findings Include: Review of available personnel documentation for Employee 10 (nurse aide) revealed that the facility hired her on September 12, 2023. Interview with the Nursing Home Administrator on February 20, 2025, at 2:38 PM revealed that the facility could not provide evidence of an annual performance review (due September 2024) for Employee 10. Review of available personnel documentation for Employee 11 (nurse aide) revealed that the facility hired him on November 15, 2022. [...]
- E
Keep complete, dated laboratory records in the resident's record.
Inspectors wroteBased on clinical record review and staff interview, it was determined that the facility failed to ensure laboratory reports were in residents clinical records for 3 of 22 residents reviewed (Residents 22, 92, and 46).
- 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 staff interview, it was determined that the facility failed to store food in accordance with professional standards for food service safety in the facility's main kitchen.
- E
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation and resident and staff interview, it was determined that the facility failed to ensure an environment free from the potential spread of infection on two of five nursing units (Grampian: Residents 109, 112, 113, and 223; and Sycamore: Resident 22).
- D
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Inspectors wroteBased on clinical record review and staff interview, it was determined that the facility failed to honor advance directive choices for one of 22 residents reviewed (Resident 53).
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on review of select facility policies and procedures, clinical record review, and staff interview, it was determined that the facility failed to report an allegation of misappropriation of resident property for one of three closed records reviewed (Resident 118, Employee 2).
- D
Ensure each resident receives an accurate assessment.
Inspectors wroteBased on clinical record review and staff and resident interview it was determined that the facility failed to ensure assessments accurately reflected a resident's status for one of 22 residents reviewed (Resident 113).
- D
Provide activities to meet all resident's needs.
Inspectors wroteBased on clinical record review, facility documentation, and staff interview, it was determined that the facility failed to provide an ongoing program of activities designed to meet the individual needs and interests for one of one resident reviewed for activities (Resident 7).
- 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 clinical record review and staff interview, it was determined that the facility failed to provide services to maintain a resident's range of motion for one of four residents reviewed for ROM concerns (Resident 7).
- 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 clinical record review and staff interview, it was determined that the facility failed to assess and implement individualized interventions to promote bowel and bladder continence for one of one resident reviewed for incontinence (Resident 55).
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observation, clinical record review, and staff interview, it was determined that the facility failed to provide appropriate respiratory care and services for three of three residents reviewed (Residents 22, 6, and 70).
- D
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Inspectors wroteBased on clinical record review, observation, and resident and staff interview, it was determined that the facility failed to implement care to prevent potential complications from a dialysis access site for one of one resident reviewed for dialysis concerns (Resident 112).
- D
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Inspectors wroteBased on review of facility documentation, clinical record review, and staff interview, it was determined that the facility failed to ensure that nursing staff possessed the specific competencies and skill sets related to the care and assessment of residents with indwelling urinary catheters, cardiac pacemaker devices, and central venous catheters, for three of three employees reviewed for competencies (Employees 2, 8, and 9; Residents 112 and 114).
- D
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
Inspectors wroteBased on clinical record review and family and staff interview, it was determined that the facility failed to provide behavior health care that was individualized to attain or maintain the highest practical physical, mental, or psychosocial well-being for one of two residents reviewed for mood and behavior concerns (Resident 221).
- D
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Inspectors wroteBased on clinical record review and staff interview, it was determined that the facility failed to develop and implement individualized person-centered care plans to address dementia and cognitive loss displayed by one of three residents reviewed (Resident 91).
- D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Inspectors wroteBased on closed clinical record review, review of select policies and procedures, and staff interview, it was determined that the facility failed to ensure the proper disposal and documentation of controlled medications for one of three discharged residents reviewed (Resident 118).
- 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 clinical record review, observation, and staff interview, it was determined that the facility failed to ensure that medication labeling was in accordance with currently accepted professional standards and active physician orders for one of eight residents reviewed for medication administration (Resident 221).
- D
Provide or obtain dental services for each resident.
Inspectors wroteBased on clinical record review, observation, and staff interview, it was determined that the facility failed to assist a resident to obtain routine dental care for one of one resident reviewed for dental concerns (Resident 46).
- D
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
Inspectors wroteBased on a review of Quality Assessment and Assurance (QAA) meeting attendance and staff interview it was determined that the facility failed to ensure the committee consisted of the minimum members (medical director and Director of Nursing) at least quarterly.
- D
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Inspectors wroteBased on clinical record review and staff interview, it was determined that the facility failed to ensure that a residents medical record included documentation that the residents representative was provided education regarding the risks and benefits of the influenza immunization for one of five residents reviewed for immunization concerns (Resident 92).
December 9, 2024Complaint inspection · 1 citation
- D
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Inspectors wroteBased on a review of facility staffing documents and staff interview, it was determined that the facility failed to designate a registered nurse (RN) as the Director of Nursing on a full time basis from November 11, 2024, to December 7, 2024.
October 19, 2024Complaint inspection · 2 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 clinical record review and staff interview, it was determined that the facility failed to notify the responsible party of a resident's change in condition requiring interventions for one of six residents reviewed (Resident CR1).
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on observations, clinical record review, and staff interview, it was determined that the facility failed to provide the necessary treatment and services consistent with professional standards of practice for the prevention of a pressure ulcer for one of five residents reviewed for pressure ulcers (Resident 3).
March 15, 2024Standard inspection · 18 citations
- F
Observe each nurse aide's job performance and give regular training.
Inspectors wroteBased on staff interviews and review of facility documentation, it was determined that the facility failed to ensure that nurse aides received an annual performance review for three of three nurse aides reviewed (Employees 3, 4, and 5). Findings Include: Review of the facility's list of active nurse aide staff revealed Employee 3 had a hire date of November 15, 2022. Employee 3 should have had an annual performance review by November 15, 2023. Employee 4 had a hire date of November 15, 2022. Employee 4 should have had an annual performance review by November 15, 2023. Employee 5 had a hire date of November 15, 2022. Employee 5 should have had an annual performance review by November 15, 2023. Requests to review Employees 3, 4, and 5's performance reviews revealed no documented evidence that the facility completed the reviews at least once every 12 months. [...]
- E
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Inspectors wroteBased on clinical record review and staff interview, it was determined that the facility failed to ensure that the resident or resident representative received written notice of the facility's bed hold policy at the time of transfer for six of 10 residents reviewed for hospitalizations (Residents 3, 10, 44, 45, 62, and 69).
- E
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on clinical record review, observation, and staff interview, it was determined that the facility failed to provide the highest practicable care regarding physician-ordered vital signs, medications, and interventions for two of 22 residents (Residents 8 and 52) and integrated hospice care and services for two of four residents reviewed (Residents 34 and 75).
- E
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on clinical record review, observation, and staff interview, it was determined that the facility failed to assess and implement treatment and services to prevent development and promote healing of pressure ulcers for four of six residents reviewed for pressure ulcer concerns (Residents 15, 22, 34 and 260).
- 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 the review of facility documentation, four employee files and staff interviews, it was determined that the facility failed to ensure that nursing staff possessed the appropriate competencies and skill sets related to the care and assessment of resident tracheostomy, peg tube, and catheter care.
- E
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Inspectors wroteBased on clinical record review and staff interview, it was determined that the facility failed to develop and implement an individualized person-centered care plan to address dementia and cognitive loss displayed by four of five residents reviewed (Residents 33, 50, 8, and 75).
- E
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Inspectors wroteBased on clinical record review, and staff interview, it was determined that the facility failed to ensure that the resident's attending physician addressed and responded appropriately to pharmacy recommendations for four of six residents reviewed (Resident 64, 33, 50, and 75) and failed to ensure that the consulting pharmacy identified potential appropriateness for psychoactive medications for one of six residents reviewed (Resident 64).
- E
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Inspectors wroteBased on clinical record review and staff interview, it was determined that the facility failed to ensure a resident's medication regime was free from potentially unnecessary medications for three of five residents reviewed (Residents 2, 8, and 64).
- 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 clinical record review and staff interview, it was determined that the facility failed to implement a comprehensive person-centered care plan regarding cognitive loss and psychotropic medication use with behaviors for two of 22 residents reviewed (Resident 64 and 75). Findings Include: Review of Resident 64's clinical record revealed a Minimum Data Set Assessment (MDS, an assessment done at specific intervals to determine care needs) dated May 12, 2023, revealed that the facility assessed Resident 64 as having cognitive loss and determined that a plan of care would be developed to address her cognitive loss. Review of Resident 64's current plan of care revealed that the facility did not develop a plan of care to address her cognitive loss until March 12, 2024. Interview with the Director of Nursing on March 15, 2024, at 9:32 AM, confirmed the above findings for Resident 64. [...]
- 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 review of select facility policies, clinical record review, and staff and resident interview, it was determined that the facility failed to invite and ensure resident and responsible party attendance and to hold care plan conferences for three of 22 residents reviewed (Resident 8, 62, and 66).
- 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 clinical record review and staff interview, it was determined that the facility failed to provide services to maintain a resident's range of motion (ROM, movement of the body to maintain a resident's ability) for three of 10 residents reviewed (Residents 69, 66, and 20).
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on clinical record review, and staff interview it was determined that the facility failed to thoroughly investigate a resident elopement for one of 22 residents sampled (Resident 44)
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observation, clinical record review, and staff interview, it was determined that the facility failed to provide appropriate respiratory care and services for one of two residents reviewed (Resident 8).
- D
Provide safe, appropriate pain management for a resident who requires such services.
Inspectors wroteBased on clinical record review, resident and staff interview, it was determined that the facility failed to ensure the highest practicable pain management for one of six residents reviewed (Resident 103).
- D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Inspectors wroteBased on clinical record review, review of select policies and procedures, and resident and staff interview, it was determined that the facility failed to ensure accurate acquiring and dispensing of medications for one of 22 residents reviewed (Resident 103).
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation and staff interviews, it was determined that the facility failed to prevent the potential spread of infection to one of five residents reviewed for infection control. (Residents 10).
- D
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, clinical record review, and staff interview, it was determined that the facility failed to perform an assessment for possible entrapment after installation of enabler bars and/or side rails for two of two residents reviewed (Residents 22 and 66).
- C
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Inspectors wroteBased on clinical record review and staff interview, it was determined that the facility failed to notify a resident and/or the resident's responsible party in writing of a transfer to the hospital for seven of 10 residents reviewed (Residents 3, 34, 69, 44, 62, 45, and 10). The facility also failed to notify the Office of the State Long-Term Care Ombudsman of a transfer to the hospital for 3 of 10 residents reviewed (Residents 34, 44, and 69).
November 2, 2023Complaint inspection · 1 citation
- E
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on clinical record review and staff interview, it was determined that the facility failed to provide the highest practicable care regarding physician-ordered treatments for four of five residents reviewed (Residents 1, 2, 4, and 5).
Fire safety inspections
21 fire safety citations on file: 10 on March 13, 2026, 4 on February 21, 2025, 7 on March 15, 2024.
Every fire safety citation21 citations
- F
Keep aisles, corridors, and exits free of obstruction in case of emergency.
K 211 · March 13, 2026 · Corrected (the home has a date of correction)
- E
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
K 222 · March 13, 2026 · 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 13, 2026 · Corrected (the home has a date of correction)
- E
Inspect, test, and maintain automatic sprinkler systems.
K 353 · March 13, 2026 · Corrected (the home has a date of correction)
- E
Install corridor and hallway doors that block smoke.
K 363 · March 13, 2026 · Corrected (the home has a date of correction)
- E
Install properly constructed and protected linen or trash chutes.
K 541 · March 13, 2026 · Corrected (the home has a date of correction)
- C
Provide properly protected cooking facilities.
K 324 · March 13, 2026 · Corrected (the home has a date of correction)
- C
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · March 13, 2026 · Corrected (the home has a date of correction)
- C
Have simulated fire drills held at unexpected times.
K 712 · March 13, 2026 · Corrected (the home has a date of correction)
- C
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
K 914 · March 13, 2026 · Corrected (the home has a date of correction)
- E
Inspect, test, and maintain automatic sprinkler systems.
K 353 · February 21, 2025 · Corrected (the home has a date of correction)
- E
Install corridor and hallway doors that block smoke.
K 363 · February 21, 2025 · Corrected (the home has a date of correction)
- E
Install smoke barrier doors that can resist smoke for at least 20 minutes.
K 374 · February 21, 2025 · Corrected (the home has a date of correction)
- E
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
K 761 · February 21, 2025 · Corrected (the home has a date of correction)
- E
Install a two-hour-resistant firewall separation.
K 133 · March 15, 2024 · Corrected (the home has a date of correction)
- E
Use approved construction type or materials.
K 161 · March 15, 2024 · 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 15, 2024 · Corrected (the home has a date of correction)
- E
Inspect, test, and maintain automatic sprinkler systems.
K 353 · March 15, 2024 · Corrected (the home has a date of correction)
- E
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
K 362 · March 15, 2024 · Corrected (the home has a date of correction)
- E
Install corridor and hallway doors that block smoke.
K 363 · March 15, 2024 · Corrected (the home has a date of correction)
- E
Meet requirements for the use of electrical equipment.
K 919 · March 15, 2024 · Corrected (the home has a date of correction)