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 39 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
2J
0K
0L
Actual harm
2G
0H
0I
Potential for more than minimal harm
22D
8E
5F
Potential for minimal harm
0A
0B
0C
January 8, 2026Complaint inspection · 4 citations
- J
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Inspectors wroteBased on staff interviews, record review, and review of the facility's policy titled, Abuse Prohibition Policy and Procedures and Identifying Sexual Abuse and Capacity to Consent, Facility B failed to ensure one of three Residents (R) (R1) was protected from sexual assault by R2. Specifically, R2 was found in R1's room sitting next to her bed. R1 was naked from the waist down with blood noted to her vaginal area and R2 was later found to have blood on his right middle finger. Subsequently, R1 was sent to the hospital after the sexual assault by R2 resulting in a one-centimeter laceration to her left vaginal wall. The facility's failure to ensure protection from the sexual assault had the potential to result in physical, mental, or psychosocial harm. [...]
- J
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Inspectors wroteBased on staff interviews, record reviews, and review of the facility's policy titled Resident Rights, Standards of Performance Nursing Home Administrator (PPNH), and Standards of Performance Director of Nursing (PPNH), Facility B failed to ensure one of three Residents (R) (R1) was protected from sexual assault by R2. Specifically, Administration failed ensure R1 maintain an environment free from abuse in a manner that efficiently maintained the highest practicable physical, mental, and psychosocial well-being for the resident. The facility's failure to ensure protection from the sexual assault had the potential to result in physical, mental, or psychosocial harm. An Immediate Jeopardy (IJ) was identified on 12/29/2025 at 5:00 pm and was determined to have existed on 11/29/2025 at appropriately 6:09 pm. [...]
- E
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on staff interviews, record reviews, and review of the facility's policy titled Falls and Falls Risk Management, Facility A failed to ensure four of four Residents (R) (R1, R2, R3, R4) reviewed for falls had fall risk assessments, 3 (three)-day post fall follow-up, and/or neurological checks completed to prevent the risks and minimize complications from falls.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, staff interview, record review and review of the facility's policy titled Perineal Care, Facility A failed to ensure one of four Residents (R) (R8) with pressure ulcers was provided perineal care in a sanitary manner to prevent cross contamination of loose stool to a clean area. This deficient practice had the potential to place the resident at risk for infection.
September 10, 2025Complaint inspection · 2 citations
- E
Ensure medication error rates are not 5 percent or greater.
Inspectors wroteBased on observations, interviews, record review, and review of the facilities' policy titled Administering Medications, Facility B failed to ensure that one of three nurses (Licensed Practical Nurse (LPN) FF) observed during medication administration observation did not pre-set medications in labeled cups for one hall of four halls (100-Hall) resulting in medication error rate of 55.56%.
- 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 observations, interviews, and review of the facilities' policy titled Storage of Medications, Facility A failed to ensure one of one medication storage room did not have expired over the counter (OTC) medications on the shelf and failed to ensure two of two medication carts (Long Hall and the Short Hall) did not have expired medications. In addition, Facility B failed to ensure one of two medication storage rooms (located on Bluebird hall) did not have expired medication on the shelf and failed to ensure one of four medication carts (100-Hall) did not have expired medications.
May 16, 2025Standard inspection · 17 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, staff interview, and facility policy review, Facility B failed to ensure kitchen staff thoroughly cleaned and air-dried pans prior to storage. This failure had the potential to increase the risk of foodborne illness and had the potential to affect residents in one of two buildings (Facility B) who received dietary services. Facility failed to ensure that soap was dispensing into the dishwasher after replacing the dish detergent. These failures had the potential to affect all residents in building B, who consumed food from the kitchen.
- F
Dispose of garbage and refuse properly.
Inspectors wroteBased on observation, interview, and policy review, Facility A failed to ensure garbage was properly disposed of and contained which would affect all the residents and staff in one of two buildings (building B).
- F
Provide and implement an infection prevention and control program.
Inspectors wroteBased on interviews and review of facility policy, Facility B failed to maintain a Legionella Water Management Program. This deficient practice has the potential to affect all residents in the facility.
- F
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 interviews, Facility B failed to maintain staff documentation of current COVID-19 vaccination status. This failure had the potential to affect all 132 residents in the facility and all staff.
- E
Implement a program that monitors antibiotic use.
Inspectors wroteBased on interview, record review, review of Center for Disease Control (CDC) guidance and policy review, the facility failed to monitor and evaluate antibiotic usage for five of seven residents (Resident (R) 117, R100, R47, R119 and R95) reviewed for antibiotic usage out of 31 sampled residents. This failure had the potential to affect residents in the facility safety related to antibiotic usage.
- D
Ensure that residents are fully informed and understand their health status, care and treatments.
Inspectors wroteBased on interview, record review, and review of the facility's policy, the facility failed to ensure residents were informed of the risk versus the benefits of psychotropic medication use prior to being administered psychoactive medications for two of five (Resident (R) 79, and R38) reviewed for unnecessary medications out of 31 sampled residents. This failures placed the residents at risk for receiving unnecessary medications.
- D
Allow resident to participate in the development and implementation of his or her person-centered plan of care.
Inspectors wroteBased on interview, record review, and review of the facility's policy, Facility B failed to ensure residents were informed in advance of their right to attend and participate in their care plan conference for two of four residents reviewed for care planning (Resident (R) 28 and R79) out of 31 sampled residents. This failure placed the residents at risk for their care plans not being person centered.
- D
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Inspectors wroteBased on interview, record review, and facility policy review, Facility A failed to obtain the CMS-10055 (Centers for Medicaid and Medicare Services) Skilled Nursing Facility Advance Beneficiary Notice (SNFABN) and CMS-10123 Notice of Medicare Non-Coverage (NOMNC) for one of five residents (Resident (R) 136) when Part A Medicare services ended. This failure prevented R136 or responsible party from appealing the decision of the facility and/or making an informed decision related to the cost of continued therapy services.
- D
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Inspectors wroteBased on interviews, record reviews, and review of the Centers for Medicare and Medicaid Services (CMS) Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual, Facility A failed to provide a timely quarterly Minimum Data Set (MDS) Assessment data submission for one (Resident (R)78) of one resident reviewed for MDS over 120 days old out of a total sample of 31 residents.
- 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 review of the facility's policy, Facility B failed to develop care plans related to bed rail use for two of four residents reviewed for care planning (Resident (R) 28 and R75) out of 31 sampled residents. This failure placed the resident at risk for unmet care needs and increased risks of accidents.
- D
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Inspectors wroteBased on interview, record review, and review of the facility's policy, Facility B failed to review and revise residents' care plans for one of four residents review for care planning (Resident (R) 50). R50's care plan was not revised to reflect his current status. This failure placed the resident at risk for unmet care needs.
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on interview, record review, and review of the facility's policy, Facility B failed to ensure residents who were dependent on staff for activities of daily living (ADLs) received showers for one of two residents (Resident (R) 28) reviewed for ADLs out of 31 sampled residents. This failure placed the resident at risk for an undignified quality of life.
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on interview, record review, and policy review, Facility A failed to ensure one of four residents (Resident (R) 73) reviewed for pressure ulcers out of a sample of 31 residents did not develop facility acquired pressure ulcers. This failure to not identify a pressure ulcer until it was a Stage II had the potential to escalate to a higher level causing the resident pain and discomfort.
- D
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, Facility A failed to monitor a resident's bathroom door protector to ensure it did not injure the resident until the door was replaced for one of seven residents reviewed for accidents out of 31 sampled residents (Resident (R) 64). This failure had the potential to cause injury to the resident.
- 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 review of the facility's policy, Facility B failed to assess residents for the use of bed rails, review the risks and benefits of bed rail use and obtain informed consent prior to the installation of bed rails for two of seven residents (Resident (R) 28 and R75) reviewed for accidents and hazards out of 31 sampled residents. These failures placed the residents at risk for injury and restraint.
- D
Ensure medication error rates are not 5 percent or greater.
Inspectors wroteBased on observation, interview, record review, review of facility policy, and review of manufacturer's pharmaceutical recommendations, Facility B failed to ensure a medication error rate below five percent. During medication administration for three (Resident (R)10, R51, R108) in the medication administration observation. These failures caused three medication errors out of 25 opportunities for error, or a medication error rate of 12%. These failures had the potential to increase or decrease the effectiveness of these medications.
- D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on record review, interview, and facility policy review, Facility A failed to document a resident's decline, death, and disposition of one of one resident (Resident (R) 141) reviewed for facility death out of a total sample of 31 residents.
May 11, 2023Standard inspection · 6 citations
- G
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 observations, staff interviews, record review, and a review of the facility's policy titled, Care planning- IDT, Facility A failed to follow residents' baseline care plans directing staff to medicate residents for pain related to wound care for one of three residents (R#402) who received wound care. Actual harm was identified on 5/10/23 when the Wound Care Nurse (WCN) failed to assess and administer medication to R#402 prior to providing wound care treatment, which resulted in pain.
- G
Provide safe, appropriate pain management for a resident who requires such services.
Inspectors wroteBased on observation, record review, interview, and review of facility policy Pain Assessment and Management, Facility A failed to stop and address verbal and facial expressions of pain during wound care for one of three residents (R) (R#402) observed for wound care resulting in harm. Actual harm was identified on 5/10/23 when the Wound Care Nurse (WCN) failed to assess and administer pain medication to R#402 prior to providing wound care treatment, which resulted in pain during the treatment.
- F
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on observations, interviews, and review of the policy titled Sanitation and Infection Prevention/Control, facility A failed to discard expired food in the walk-in refrigerator and walk-in freezer; label and date opened food items in the walk-in refrigerator and dry storage area; store cooking grease in proper container; ensure serving pans and bowls were stacked and stored dry; maintain an updated cleaning log; maintain the cleanliness of the icemaker; ensure the floors and walls in the walk-in refrigerator, dry storage and kitchen area were kept clean; and repair damaged ceiling in the dry storage area. The deficient practices had the potential to adversely affect 41of 44 residents who received oral diets.
- 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, interviews, and review of the facility policy titled, Administering Medications, facility A failed to ensure that one of three medication carts (Long Hall medication cart) and the treatment cart was locked and secured when the cart was out of view of the nurse. Specifically, the facility A failed to ensure the treatment cart and the medication cart on the Long Hall medication cart was locked and medications secured when not in use for two of three carts.
- D
Allow residents to self-administer drugs if determined clinically appropriate.
Inspectors wroteBased on observation, record review, interviews, and review of the policy titled Self Administration of Medication, Facility A failed to ensure one resident (R) (R#110) of 51 sampled residents, was assessed to safely self-administer medications.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on observations, record review, interviews, and review of policy titled Dressing Change Policy, the facility failed to ensure quality of care and services in accordance with professional standards related to not receiving physician orders for treatment/wound care for one of one resident (R#65) with a cancer lesion on her right wrist. The sample size was 51.
July 30, 2021Standard inspection · 10 citations
- E
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 wrote3. During the tour of Facility B on 7/27/2021 at 12:00 p.m. and 7/28/2021 at 11:30 a.m. the following was observed: In room [ROOM NUMBER] an oxygen tank filter had a large amount of dust build up. The dust buildup was found at the back of oxygen tank and had a brownish gray color. The resident of room [ROOM NUMBER] was currently using the oxygen tank when the dust buildup was observed. In room [ROOM NUMBER] the cream-colored blinds had brown and black spots embedded into them. In room [ROOM NUMBER] the cream-colored blinds had brown and black spots embedded into them. In room [ROOM NUMBER] the cream-colored blinds had brown and black spots embedded into them. In room [ROOM NUMBER] the cream-colored blinds had brown and black spots embedded into them. In room [ROOM NUMBER] there were two ceiling vents with black and brown spots. During the tour on 7/29/2021 at 8:34 a.m. [...]
- E
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on interview, observations, and review of policy titled Foods Brought by Family/Visitors and Food and Supply Storage, facility A failed to discard expired items, failed to label and date items in the refrigerator and freezer of the resident food pantry, and failed to monitor freezer temperatures for the freezer in the resident food pantry. This deficient practice affected one of one resident food pantry for facility A.
- E
Provide bedrooms that don't allow residents to see each other when privacy is needed.
Inspectors wroteBased on observations and staff interviews, the facility (Facility A) failed to ensure that privacy curtains provided full visual privacy for a total of 11 of 21 resident shared bedrooms (rooms: 2, 3, 5,8, 9,14, 16, 26, 27, 28, and 29).
- D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteBased on observations, record review, staff interviews, Facility A failed to maintain dignity by ensuring a dignity bag was provided for one of two residents (R) #113) who had an indwelling foley catheter. The facility sample size was 27 Residents.
- 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 observations, record reviews, and staff interview, the facility policy titled Care Plans-Baseline, facility failed to develop a person-centered baseline care plan which included Transmission Based Precautions (TBP) interventions for one of four newly admitted residents (R) #182) at facility A.
- 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 observations, interviews, record reviews, and review of the facility policy titled Care Plans, Comprehensive Person-Centered, Facility A failed to develop a care plan for one resident (R) R#71) related to use of a knee immobilizer and skin assessments and failed to implement a care plan for one resident, R#90, related to a nutritional supplement. The sample size was 27.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on observation, record review, and staff interview facility A failed to ensure that physician orders were followed related to Magic cup being served at each meal, for one of 10 residents, (R) R#90), with an order for Magic cup.
- 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 observations, record review, staff interviews, and the facility policy titled Catheter Care, Urinary the facility (Facility A) failed to ensure that the urinary drainage for R#113 was positioned lower than the level of the bladder to prevent unobstructed urine flow and tension for one resident (R#113). The sample size was 27 Residents.
- 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 observations, record reviews, staff interview, and the facility policy Storage of Medication, facility A failed to ensure disposal of expired medications and supplies by appropriate expiration dates on one of the two medication carts and one of the one medication storage unit room. The facility census was 137 Residents.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observations, record review, and staff interviews, and review of the Department of Public Health Interim Guidance for Long-Term Care (LTC) Facilities Admitting Residents from a Hospital the facility (Facility A) failed to ensure that the door to the room, for one of one unvaccinated resident (R#182) on Transmission Based Precautions for MRSA (Methicillin Resistant Staphylococcus Aureus) and as a newly admitted resident was kept closed at all times. In addition, the facility failed sanitize one of three Hoyer lifts between resident use and failed to use separate gauze or cloths during wound care.
Fire safety inspections
6 fire safety citations on file: 2 on May 16, 2025, 2 on May 11, 2023, 2 on July 30, 2021.
Every fire safety citation6 citations
- D
Inspect, test, and maintain automatic sprinkler systems.
K 353 · May 16, 2025 · Corrected (the home has a date of correction)
- D
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · May 16, 2025 · Corrected (the home has a date of correction)
- D
Inspect, test, and maintain automatic sprinkler systems.
K 353 · May 11, 2023 · Corrected (the home has a date of correction)
- D
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · May 11, 2023 · Corrected (the home has a date of correction)
- F
Keep aisles, corridors, and exits free of obstruction in case of emergency.
K 211 · July 30, 2021 · Corrected (the home has a date of correction)
- D
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · July 30, 2021 · Corrected (the home has a date of correction)