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 65 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
2G
0H
0I
Potential for more than minimal harm
33D
26E
2F
Potential for minimal harm
0A
0B
2C
May 28, 2026Complaint inspection · 3 citations
- D
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure ongoing communication was maintained for 1 of 2 resident reviewed for dialysis services. Dialysis communication forms or any other documented dialysis visit notes could not be retrieved by the facility and Director of Nursing was not aware that the dialysis center had changed a resident's prescribed dialysis schedule from three (3) days per week to two (2) days per week. (Resident B)
- 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 record review, the facility failed to ensure adequate pharmaceutical services were available to provide physician prescribed routine medications to 2 of 3 residents reviewed for pharmacy services. Residents did not receive routine physician prescribed medications due to the medications not being available and new physician prescribed medication was not started timely following a readmission from the hospital. (Resident B, Resident C)
- D
Provide timely, quality laboratory services/tests to meet the needs of residents.
Inspectors wroteBased on interview and record review, the facility failed to ensure laboratory services were provided for 1 of 3 residents reviewed for quality of care. Labs were not completed per the physician's order. (Resident B)
March 26, 2026Standard inspection, Complaint inspection · 12 citations
- E
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Inspectors wroteBased on interview and record review, the facility failed to ensure clinical records contained bed hold policy, completed transfer/discharge forms, and documentation that a representative of the Office of the State Long-Term Care Ombudsman was notified of transfer/discharge for 7 of 7 residents reviewed for hospitalizations. The clinical records lacked documentation of bed hold, transfer/discharge forms, and notification to Ombudsman for residents reviewed. (Resident 12, Resident D, Resident 4, Resident B, Resident 3, Resident 1, Resident 6)
- E
Ensure each resident receives an accurate assessment.
Inspectors wroteBased on interview and record review, the facility failed to ensure accuracy of the Minimum Data Set (MDS) assessments for 1 of 1 residents reviewed for hospice, 1 of 5 reviewed for unnecessary medications, 1 of 1 reviewed for medication side effects, and 1 of 1 reviewed for Preadmission Screening and Resident Reviews (PASRR). Residents who received hospice services were marked as not getting them, a resident with a diagnosis of dementia was not identified as having that diagnosis, and a resident's PASRR was not marked on their MDS assessment. (Resident 4, Resident 24, Resident 63, Resident 12)
- E
Ensure services provided by the nursing facility meet professional standards of quality.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure physician orders were followed for 4 of 5 residents reviewed for nutrition and hospitalizations, and 1 of 3 residents reviewed for pressure ulcers . Weekly weights were not completed as ordered and medications were not reviewed by the primary care physician when the resident returned from the hospital. (Resident 6, Resident 24, Resident 35, Resident 4, Resident 3)
- E
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that dependent residents were receiving Activities of Daily Living (ADL) services for 3 of 4 residents reviewed for ADLs and 3 of 3 residents in Resident Council. Resident's did not receive showers and oral care. (Resident B, Resident C, Resident D)
- 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 record review, the facility failed to ensure safe medication storage for 1 of 3 hall carts observed. Medication carts were left unlocked and unsupervised, and medications were left unsupervised on the top of a medication cart. (D Hall Medication Cart)
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on interview and record review, the facility failed to ensure physician orders were followed leading to a discontinuance of an anticonvulsant medication for 1 of 1 residents reviewed for medication side effects. A resident's anticonvulsant medication was discontinued despite a physician's contraindication to discontinue. The physician nor family were notified of the medication discontinuance. (Resident 63)
- 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 interview and record review, the facility failed to ensure a resident with an indwelling urinary catheter received care to prevent a urinary tract infection for 1 of 1 resident's reviewed for urinary catheters. A resident did not receive routine catheter care and was hospitalized for a Catheter Associated Urinary Tract Infection (CAUTI). (Resident B)
- D
Provide safe, appropriate pain management for a resident who requires such services.
Inspectors wroteBased on interview, observation, and record review, the facility failed to ensure a plan was in place to control a resident's pain for 1 of 1 resident reviewed for pain management. A resident indicated his pain was not controlled, staff were not giving routine pain medication as ordered, documentation lacked pain characteristics, non pharmacological interventions were not in place, and notification to the Medical Doctor was not consistently documented.
- D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure accurate documentation in resident clinical records for 2 of 2 records reviewed. A resident that was in the hospital had a progress note with vital signs documented in the clinical record. A resident had a shower documented when it was not given. (Resident D, Resident C)
- 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, and record review, the facility failed to ensure hospice communication and documentation was occurring between the facility and the hospice company for 1 of 1 residents reviewed for hospice. The clinical record lacked hospice communication. (Resident 4)
- C
Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the past 3 years of state survey results were readily available to visitors, residents, and other individuals without them having to ask to review them for 2 of 2 days reviewed for the survey period.
- C
Post nurse staffing information every day.
Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the posted nurse staffing form was posted on all entrances of the facility for 8 of 8 days reviewed for the survey. (3/17/26, 3/18/26, 3/19/26, 3/20/26, 3/23/26, 3/24/26, 3/25/26, 3/26/26).
October 22, 2025Complaint inspection · 1 citation
- 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 interview and record review, the facility failed to ensure residents received end of life care for 2 of 3 residents reviewed for hospice care. A collaborative plan of care was not established for residents who received hospice services and routine assessments, and physician orders were not completed. (Resident B, Resident C)1. During record review on 10/20/25 at 1:15 P.M., Resident B's diagnoses included but were not limited to chronic kidney disease and malignant cancer. Resident B's most recent Minimum Data Set (MDS) assessment, dated 9/3/25, indicated the resident had not received hospice services. [...]
September 23, 2025Complaint inspection · 2 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, and record review, the facility failed to ensure a resident was free from accident hazards for 1 of 3 residents reviewed for accidents. Staff provided hot water to a resident without monitoring or checking the temperature of the water. The resident spilled the hot water which resulted in second-degree burns to the resident's abdomen, left hip, and lower back. This deficient practice resulted from a failure to follow the facility's procedure for serving hot beverages and contributed the development of second-degree burns that required routine treatment and the resident pain rated at a 5 on a scale of 0 - 10 (zero indicating no pain and 10 indicating the most pain). (Resident C)
- E
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a safe, sanitary, and homelike environment in 1 of 3 resident units observed and 1 of 2 dining rooms observed. Resident areas had missing paint on the walls, missing cove base, plywood covering a window, and a dark decolorization to dining room vaulted ceiling. (C/D halls, room [ROOM NUMBER], room [ROOM NUMBER] and C/D dining room)
July 31, 2025Complaint inspection · 1 citation
- 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, interview, and record review, the facility failed to ensure a sanitary environment was maintained in accordance with professional standards for food services safety during 1 of 1 kitchen observations. Containers of food were stored on the dry food storage room floor and on the walk-in freezer floor, and a buildup of dust and debris was observed over the cookstove hood, on the ceiling in and around the vents above the dishwashing area, on top of the dishwasher, and along the base of the walls and floor.
February 13, 2025Standard inspection, Complaint inspection · 19 citations
- G
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure necessary treatment and services were provided to prevent and promote healing of facility acquired pressure injuries for 3 of 8 residents reviewed for pressure ulcers. Specific care plans were not developed, physician orders and other interventions not followed, and assessments were not completed thoroughly or accurately. This deficient practice resulted in facility acquired unstageable, Stage 3, and Stage 4 pressure ulcers. (Resident 20, Resident 7, Resident 25)
- F
Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
Inspectors wroteBased on interview and record review, the facility failed to employ sufficient staff with the appropriate competencies and skills set to carry out the functions of the food and nutrition service for 1 of 1 kitchens observed. The Dietary Manager was not certified. (Dietary Manager)
- E
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 interview and record review, the facility failed to ensure a notice of transfer or discharge was given to residents or resident representatives for 5 of 5 residents reviewed for hospitalizations and transfers. There was no documentation of a resident or representative receiving a notice of transfer or discharge at the time of hospitalization. (Resident D, Resident B, Resident 79, Resident 48, Resident 30)
- 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 interview and record review, the facility failed to ensure a bed hold policy was given to residents or resident representatives for 5 of 5 residents reviewed for hospitalizations and transfers. There was no documentation of a resident or representative receiving a bed hold policy at the time of hospitalization. (Resident D, Resident B, Resident 79, Resident 48, Resident 30)
- E
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure comprehensive care plans were reviewed and revised by the interdisciplinary team (IDT) after each assessment, including both the comprehensive and quarterly review assessments. Care plans weren't revised for residents that were nothing by mouth (NPO), had a bed alarm, had a catheter removed, and a decline in activities of daily living (ADLs). (Resident C, Resident 73, Resident 79, Resident 4)
- E
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a resident who displayed or was diagnosed with dementia, received the appropriate treatment and services to attain or maintain his highest practicable physical, mental, and psychosocial well-being for 1 of 5 residents reviewed on the dementia unit. A Certified Nurse Aide (CNA) failed to provide appropriate Activities of Daily Living (ADL) care for a resident on the dementia unit along with other concerns on the hall with 15 men. (Resident B, men's hall)
- 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 record review, the facility failed to follow facility policy by ensuring safe and secure storage of medications for 5 residents during 2 random observations of the medication carts. Medications had been pre-prepared and held in medication cups in the medication cart prior to administration. (Resident B, Resident G, Resident 76, Resident 34, Resident 19)
- E
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 interview and record review, the facility failed to ensure menus were being followed by dietary staff for 1 of 1 kitchens reviewed. (Kitchen)
- E
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe and sanitary environment to help prevent the development and transmission of communicable diseases and infections for 4 of 6 residents observed for infection control. Staff did not clean the shared glucometer prior to use, staff was not using proper personal protective equipment (PPE) or signage, and hands were not sanitized between glove use. (Resident C, Resident D, Resident G, Resident H)
- D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure each resident was treated with respect and dignity for 2 of 3 residents reviewed for dignity concerns and one random observation. Residents felt like staff were rude and not in a hurry to provide care and staff made unkind comments about a resident within hearing distance of that resident. (Resident C, Resident E, Resident F)
- D
Allow resident to participate in the development and implementation of his or her person-centered plan of care.
Inspectors wroteBased on interview and record review, the facility failed to ensure timely care plan conferences with residents and/or their representatives for 3 of 7 residents reviewed for care plan conferences. Care plan conferences were not held quarterly for residents and/or their representatives to participate in planning of care. (Resident D, Resident 4, Resident 35)
- 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 interview and record review, the facility failed to clarify a Resident's code status for 1 of 1 residents reviewed for advanced directives. A resident's current facesheet and Physician's Order did not match the signed Indiana Physician Orders for Scope of Treatment form. (Resident B)
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on interview and record review, the facility failed to ensure an incident report contained an explanation of the circumstances for an alleged incident. The incident report lacked details related to the actual incident reported involving a Certified Nurse Aide (CNA) and resident. (CNA 31, Resident B)
- D
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Inspectors wroteBased on observation, interview and record review, the facility failed to develop a care plan for 2 of 5 residents reviewed for Unnecessary Medications, and 1 of 1 residents reviewed for hospice services. A resident was administered an anticoagulant and an antiplatelet and did not have a care plan related to the medication. A resident received hospice services but lacked a care plan. (Resident D, Resident 79, Resident 67)
- D
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents with indwelling urinary catheters received appropriate orders and services to prevent urinary tract infections (UTI) for 2 of 3 residents reviewed for catheter care. A resident's urinary catheter bag was not placed lower then his bladder and a resident with a urinary catheter did not have an order. (Resident D, Resident 48)
- 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 record review, the facility failed to ensure pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) met the needs of each resident for 1 of 1 residents reviewed for antibiotic use. A resident's antibiotics (taken for multiple infections) were not continued in a timely manner after discharge from the hospital. (Resident D)
- D
Ensure medication error rates are not 5 percent or greater.
Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure it was free of a medication error rate of greater than 5 percent for 2 of 3 residents (Residents 6, Resident D) observed during medication pass. Two medication errors were observed during 31 opportunities for error in medication administration. This resulted in a medication error rate of 6.45 percent.
- D
Ensure that residents are free from significant medication errors.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure prevention of a significant medication error for 1 of 3 residents observed for medication administration. A dose of insulin was not given resulting in an increase of blood sugar. (Resident 6)
- D
Have policies on smoking.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure smoking policies related to smoking safety were enforced for 2 of 2 random observation of smoking. (Resident K, Resident 51, Resident 20)
December 6, 2024Complaint inspection · 3 citations
- 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, interview, and record review, the facility failed to ensure a sanitary environment was maintained in accordance with professional standards for food services safety during 2 of 2 kitchen observations. Kitchen staffs' hair was not fully contained within a hairnet, and kitchen staff failed to complete proper hand hygiene.
- E
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a safe, sanitary, and homelike environment in 2 of 6 resident halls observed. Resident areas had holes in walls, floors appeared dirty and unmopped, bedpans were stored uncovered, cove base was missing from a resident restroom, a vent fan was missing a cover in a resident restroom, used Styrofoam cups were not removed from a resident's room, and resident wheelchairs had not been cleaned. (C/D Halls, Resident D, Resident F, room [ROOM NUMBER], room [ROOM NUMBER], Resident H, Resident G, Resident M)
- 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 resident records were accurate and complete for 1 of 3 residents reviewed for pressure wounds and 1 of 3 residents reviewed for diabetic care. Medication Administration Records (MAR) and Treatment Administration Records (TAR) were not documented completely. (Resident D)
August 16, 2024Complaint inspection · 2 citations
- E
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a safe, sanitary, and homelike environment in 3 of 4 resident halls observed and 2 of 3 shared restrooms observed. Resident rooms were missing window trim, had stained toilet bowels, and were missing thresholds between doorways, shared shower rooms were missing light covers, cove base, corner trim, had cracked or broken tiles, had a broken switch plate, and had old screw holes in the walls, and hall floors were missing baseboard and had worn spots and paint splatters. (C/D Halls and shower rooms, GHI shower room, room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER])
- D
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure routine catheter care and ostomy care was completed for 3 of 3 residents reviewed for catheter/ostomy care. Routine catheter and ostomy care was not provided per the residents' plan of care. (Resident C, Resident D, Resident F)
April 19, 2024Complaint inspection · 3 citations
- D
Allow residents to self-administer drugs if determined clinically appropriate.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that a resident was clinically appropriate to administer their own medications without supervision by qualified staff during a random observation during the survey. A resident was alone in their room with a cup of medications sitting at their bedside table. (Resident F)
- D
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident's plan of care was followed for 1 of 4 resident care plans reviewed. A resident did not receive care from at least 2 staff members according to the resident's plan of care, resulting in an allegation of staff negligence. (Resident B)
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on observation, interview, and record review, the facility failed to provide assistance with bathing for 2 of 3 residents reviewed for activities of daily living (ADLs). Residents did not receive assistance with ADL's (bathing) according to the plan of care and bathing schedule. (Resident B, Resident C)
January 26, 2024Standard inspection, Complaint inspection · 19 citations
- F
Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.
Inspectors wroteBased on interview and record review, the facility failed to ensure a complete and accurate facility assessment for 1 of 1 reviewed based on the resident population and identification of resources needed to provide the necessary care and services required for their residents.
- E
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteBased on observation, interview and record review, the facility failed to ensure each resident was treated with respect and dignity for 1 of 6 residents observed for care, and 3 of 3 random observations. A staff member was observed speaking to a resident in an undignified manner, a resident waited on a meal for over 22 minutes after other residents were served, a resident was observed wearing clothing belonging to a recently deceased resident, and staff opened a window during care against the resident's wishes. (Resident 30, Resident 55, Resident 127, Anonymous Resident)
- E
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure care was provided in accordance with the written plan of care for 5 of 5 residents reviewed. Care plan interventions and orders were not followed or implemented for the following: fluid restriction, skin assessment, prescribed antibiotics, hand splints, and performance of household chores. (Resident 7, Resident 45, Resident 58, Resident 60, Resident 127)
- E
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Inspectors wroteBased on observation, interview, and record review, the facility failed to develop a care plan for 2 of 5 residents reviewed for development of care plans and failed to provide care plan conferences with residents and residents' representatives for 5 of 5 residents reviewed for care plan conferences. A resident lacked a care plan for dialysis and dementia. A resident lacked a care plan for smoking. (Resident 17, Resident 24, Resident 31, Resident 57, Resident 58)
- E
Provide activities to meet all resident's needs.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure an ongoing program to support residents in their choice of activities for 2 of 7 halls reviewed. A and B Halls lacked activities in accordance with the activity calendar. (Locked Dementia Unit A and B Hall)
- E
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure each resident received adequate supervision to prevent accidents for 4 of 5 residents reviewed for accidents. A resident was found smoking several times in his room/bathroom and was still allowed to carry his smoking supplies on his person. Residents' care plan interventions were not followed and alarms were not working. (Resident 57, Resident 25, Resident 127, Resident 178)
- E
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure sufficient and competent nursing staff was provided for 1 of 3 units reviewed, 2 of 6 resident council meetings reviewed, and 2 of 2 resident grievances reviewed. Incontinence care was not completed, hospice orders were not in place, interventions were not followed resulting in falls, notification was not completed following significant changes, and the unit was observed to not be sufficiently staffed. (A/B Unit)
- E
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on observation and interview the facility failed to ensure all the freezers in the kitchen had thermometers in them and temperature logs filled out for 1 of 1 kitchen observations. The ice cream freezer did not have a thermometer in it and the freezer in dry storage lacked a temperature log for January 2024. (Kitchen)
- E
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure infection control practices were followed for 5 of 9 residents during observation of perineal care. Gloves were not changed between dirty and clean tasks during peri care, staff dropped gloves on the floor and picked them up and used them to perform peri care. Staff failed to sanitize hands between dirty and clean tasks and after completing peri care (Resident 16, Resident 66, Resident B, Resident 55, Resident E)
- E
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a sanitary environment for resident rooms and halls. The outside of the building had paint peeled off the frame and window frames. The water temperature on the dementia unit was hot. (A wing, B wing, C wing, D wing, E wing, I wing)
- 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 observation, interview, and record review, the facility failed to ensure notification to a resident's healthcare provider following a significant change for 1 of 2 residents reviewed for nutrition. The Registered Dietician (RD) was not notified following a significant weight loss, and the physician was not notified of a significant weight loss or medication recommendation. (Resident 54)
- D
Ensure services provided by the nursing facility meet professional standards of quality.
Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a new diagnosis of schizophrenia was reviewed for appropriateness for 1 of 5 residents reviewed for unnecessary medications. (Resident 63)
- D
Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
Inspectors wroteBased on interview and record review, the facility failed to provide emergency basic life support immediately when needed, including CPR (cardiopulmonary resuscitation) for 1 of 1 resident reviewed for CPR. Staff did not immediately provide services to a resident that required emergency care and CPR. (Resident 178)
- D
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents with limited mobility received appropriate services and assistance to prevent further decrease in range of motion for 2 of 2 residents reviewed for the restorative nursing program. (Resident 7, Resident 29)
- D
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents incontinent of urine received incontinence services and assistance. Residents were observed saturated with urine at the end of night shift for 2 of 5 residents reviewed for incontinence care. (Resident B, Resident E)
- D
Ensure that residents are free from significant medication errors.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were free of significant medication errors for 1 of 1 insulin administration. The nurse failed to prime the insulin pen before administering insulin to a resident. (Resident 60)
- D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure complete and accurate documentation of resident records for 1 of 2 residents reviewed for nutrition, and 1 of 2 residents reviewed for restorative nursing program. (Resident 54, Resident 7)
- 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, and record review, the facility failed to follow 2 of 2 hospice contracts to ensure communication from the Hospice providers were available for the facility staff. Hospice diet orders were not put into place when ordered, and hospice communication was not available for review on a unit with a Hospice resident. (Resident 28, Resident 178)
- D
Have policies on smoking.
Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the smoking policy was followed for 1 of 1 residents reviewed for smoking. A resident has been caught smoking in his room and was still considered a safe smoker and allowed to keep his smoking supplies on his person. (Resident 57)
Fire safety inspections
35 fire safety citations on file: 6 on March 26, 2026, 9 on February 13, 2025, 20 on January 26, 2024.
Every fire safety citation35 citations
- F
Conduct testing and exercise requirements.
E 39 · March 26, 2026 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · March 26, 2026 · Corrected (the home has a date of correction)
- E
Install an approved automatic sprinkler system.
K 351 · March 26, 2026 · Corrected (the home has a date of correction)
- E
Have proper fire barriers, ventilation and signs for the transfilling of oxygen.
K 927 · March 26, 2026 · Corrected (the home has a date of correction)
- C
Implement emergency and standby power systems.
E 41 · March 26, 2026 · Corrected (the home has a date of correction)
- C
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · March 26, 2026 · Corrected (the home has a date of correction)
- F
Install emergency lighting that can last at least 1 1/2 hours.
K 291 · February 13, 2025 · Corrected (the home has a date of correction)
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · February 13, 2025 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · February 13, 2025 · Corrected (the home has a date of correction)
- F
Have simulated fire drills held at unexpected times.
K 712 · February 13, 2025 · Corrected (the home has a date of correction)
- F
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
K 914 · February 13, 2025 · Corrected (the home has a date of correction)
- F
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · February 13, 2025 · deficient, provider has
- E
Have properly located and lighted "Exit" signs.
K 293 · February 13, 2025 · Corrected (the home has a date of correction)
- E
Meet other general requirements that are deficient.
K 500 · February 13, 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 · February 13, 2025 · Corrected (the home has a date of correction)
- F
Establish methods for sharing information.
E 33 · January 26, 2024 · Corrected (the home has a date of correction)
- F
Provide a means of sharing information on occupancy/needs.
E 34 · January 26, 2024 · Corrected (the home has a date of correction)
- F
Provide family notifications of emergency plan.
E 35 · January 26, 2024 · Corrected (the home has a date of correction)
- F
Conduct testing and exercise requirements.
E 39 · January 26, 2024 · Corrected (the home has a date of correction)
- F
Implement emergency and standby power systems.
E 41 · January 26, 2024 · Corrected (the home has a date of correction)
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · January 26, 2024 · Corrected (the home has a date of correction)
- F
Provide a written emergency evacuation plan.
K 711 · January 26, 2024 · Corrected (the home has a date of correction)
- F
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
K 761 · January 26, 2024 · Corrected (the home has a date of correction)
- F
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · January 26, 2024 · Corrected (the home has a date of correction)
- E
Have exits that are accessible at all times.
K 271 · January 26, 2024 · Waiver
- E
Install proper backup exit lighting.
K 281 · January 26, 2024 · Corrected (the home has a date of correction)
- E
Have properly located and lighted "Exit" signs.
K 293 · January 26, 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 · January 26, 2024 · Corrected (the home has a date of correction)
- E
Inspect, test, and maintain automatic sprinkler systems.
K 353 · January 26, 2024 · Corrected (the home has a date of correction)
- E
Install corridor and hallway doors that block smoke.
K 363 · January 26, 2024 · Corrected (the home has a date of correction)
- E
Meet other general requirements that are deficient.
K 500 · January 26, 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 · January 26, 2024 · Corrected (the home has a date of correction)
- D
Have properly installed electrical wiring and gas equipment.
K 511 · January 26, 2024 · Corrected (the home has a date of correction)
- D
Ensure proper usage of power strips and extension cords.
K 920 · January 26, 2024 · Corrected (the home has a date of correction)
- C
Have simulated fire drills held at unexpected times.
K 712 · January 26, 2024 · Corrected (the home has a date of correction)