Where the Heart is

Facility unable to provide documentation for annual forward flow test.

New kitchen stove has a shelf blocking the nozzle flow of the suppression system.

Facility unable to provide documentation for required sensitivity testing and has not maintained a nuisance log; 3 failed tests require repair.

The facility failed to provide its Medicaid policy to five residents, resulting in those residents not having a signed policy on file regarding facility acceptance of Medicaid as a payment source. Previously cited on October 24, 2025.

The facility failed to include assessed needs and the facility's roles and responsibilities in the Negotiated Service Agreement (NSA) regarding medications and their management for one resident. Previously cited on October 24, 2025.

Facility failed to include assessed needs and facility's roles/responsibilities regarding medication management in the Negotiated Service Agreement (NSA) for 1 of 5 residents.

Facility failed to follow controlled substance management policy; 3 of 3 narcotic books (1, 3, and 4) were not signed by staff during shift changes due to lack of overlap time.

Facility failed to include medication management information in the Negotiated Service Agreement for Resident 5.

Facility failed to complete full assessments within 14 days of admission for Resident 7, and failed to adequately assess medication management for Residents 3, 4, 5, and 6, or preferences regarding hobbies/activities for all residents reviewed.

Facility failed to provide nursing services as disclosed in the Disclosure of Services document (failed to schedule RN hours).

Facility failed to maintain an adequate supply of gloves, disinfecting wipes, and trash bags in communities 3 and 4, forcing staff to purchase their own supplies.

Facility failed to provide written disclosure of their Medicaid policy to 7 of 7 residents.

Facility failed to provide their Medicaid policy to 5 of 5 residents, resulting in no signed Medicaid policy on file for those residents.

Facility failed to maintain cold food temperatures at 41 degrees F or less in communities 3 and 4; multiple food items measured between 45.8 and 49.7 degrees F.

Facility failed to conduct or retain preadmission assessments for Residents 2 and 7.

Facility unable to provide documentation for annual forward flow test.

No signage to indicate location of fire department connection.

Facility cannot provide documentation for the completion of 12 planned and unannounced fire drills in previous 12 months (Quarter 3 missing for all shifts).

Power strip plugged into another power strip in community 1 nurses office.

Facility unable to provide documentation for semi-annual kitchen suppression system servicing.

Facility unable to provide documentation for monthly carbon monoxide detector testing.

Cross-corridor fire doors to community #3 and #4 had inoperative door-closing coordinators.

Facility unable to provide documentation for monthly single station smoke alarm testing.

Cart blocking emergency exit near the kitchen.

Fire/Smoke damper inspection deficiencies (7 fusible links, 1 spring) not corrected.

Fire department connection located behind a fence without a gate to access from the street.

Facility unable to provide documentation for monthly 30-second activation test for emergency lights.

Facility failed to ensure violations for 2 Fire and Life Safety annual inspections (10/09/2024 and 01/14/2025) were corrected, including IFC 706.1 duct/air transfer opening deficiencies and IFC 904.13.5.2 annual forward flow test for the sprinkler system.

Facility unable to provide documentation for the annual forward flow test in accordance with NFPA 25.

Fire/Smoke damper inspection from 1/23/23 showed 7 fusible links and 1 spring needing replacement; these were not corrected.

Facility failed to have a nurse on site as disclosed, resulting in a lack of nursing oversight for a resident's pressure sore, blood sugar fluctuations, and general health decline.

Facility failed to follow its own policy regarding weekly high-risk resident meetings for Resident 1, failing to address deteriorating health conditions.

Facility failed to coordinate services with medical providers in a timely manner, allowing 21 days to pass between initial medical alerts for a resident and necessary emergency intervention.

The facility failed to report to the CRU hotline and law enforcement when staff noted signs that Resident 1 was potentially being abused by a staff member.

The facility failed to conduct an investigation and failed to protect the resident during an allegation of abuse by a staff member.