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 36 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
1J
0K
0L
Actual harm
1G
0H
0I
Potential for more than minimal harm
24D
9E
1F
Potential for minimal harm
0A
0B
0C
January 26, 2026Standard inspection · 11 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 provide 3 of 3 sampled residents (Resident 3, 58, and 63) with a notice of transfer/discharge which outlined their specific rights related to their transfer/discharge and failed to notify the Long-Term Care Ombudsman for 2 of 3 residents (Resident 58 and 63) for discharge from the facility as soon as reasonably able. These failures placed residents at risk of not knowing their rights and limited their access for advocacy of their rights.
- E
PASARR screening for Mental disorders or Intellectual Disabilities
Inspectors wroteBased on interview and record review, the facility failed to ensure Preadmission Screening and Resident Review (PASRR-an assessment used to identify people referred to nursing facilities with Serious Mental Illness [SMI], Intellectual Disabilities [ID]; or related conditions are not inappropriately placed in nursing homes for long-term care) Level I screening form for an exempted hospital discharge (residents who remained in the facility for more than 30 days) was submitted for a Level II evaluation for 3 of 6 residents (Resident 1, 6, and 18) reviewed. This failure placed the residents at risk of not receiving the appropriate care and services for their needs timely and/or lacking access to specialized services for individuals with identified mental health diagnoses or disabilities.
- E
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observation, interview and record review, the facility failed to ensure respiratory equipment and tubing were regularly cleaned and/or changed and dated for 3 of 3 sampled residents (Resident 2, 8, and 9) reviewed for respiratory care. This failure placed the residents at potential risk for respiratory distress, respiratory infection, and a diminished quality of life.
- 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 residents received care and treatment in accordance with professional standards of practice and received the necessary care and services to attain or maintain their highest practicable level of well-being for 1 of 1 residents (Resident 15) reviewed for hospice services and 2 of 3 residents (Resident 1 and 27) reviewed for diabetic care. The facility failed to ensure Resident 15's physician orders from hospice were implemented timely and ensure diabetic monitors were in place for Resident 1 and 27. These failures placed the residents at increased risk of unmet care needs and delay in care and treatment.
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on observation, interview, and record review the facility failed to ensure 1 of 2 residents (Resident 17) reviewed for Pressure Ulcers (PU), were provided recommended and physician ordered interventions they required for the prevention and treatment of a PU. This failure placed residents at risk for PU development, worsening of PU, pain and a diminished quality of life.
- 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, the facility failed to ensure safety assessment and monitoring were conducted and ensure consent and/or physician orders were completed prior to placing resident's bed against the wall for 1 of 2 residents (Resident 38) reviewed for accidents/falls. These failures placed residents at risk for injury and diminished quality of life.
- D
Ensure medication error rates are not 5 percent or greater.
Inspectors wroteBased on observation, interview and record review, the facility failed to ensure staff provided medications at the appropriate time for 2 of 25 medication observations, creating an 8.33 % error rate. Failure to provide medications at the correct time placed residents at risk of decreased effectiveness of medication.
- 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, interview and record review, the facility failed to properly label and/or discard undated, opened Aplisol (solution used to test for persons with possible Tuberculosis - an infectious respiratory disease), to ensure refrigerated drugs were stored at proper temperatures, and to ensure expired medications were properly disposed of in 2 of 2 medication rooms reviewed for medication storage and labeling. The facility failed to ensure treatment carts were locked for 1 of 3 treatment carts (200 hall treatment cart). These failures placed residents at risk of receiving compromised or ineffective medications and at risk for having access to treatment supplies and medications, missing medication, and access to medication by unauthorized individuals.
- D
Provide or obtain dental services for each resident.
Inspectors wroteBased on observation, interview, and record review the facility failed to ensure prompt dental services were provided for 1 of 2 sampled residents (Resident 12) reviewed for dental services. This failure placed residents at increased risk for continued dental problems, difficulty chewing, associated health complications, and diminished quality of life.
- D
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on observations and interviews, the facility failed to ensure resident meals were stored in accordance with professional standards of food safety for 1 of 3 nourishment refrigerators. The failure to ensure nourishment refrigerators were free from potential contaminants left residents at risk for food contamination, food borne illnesses, and consumption of spoiled food. Findings Included .On 01/20/2026 at 1:13 PM observed the refrigerator/freezer unit in the conference room/dining room which contained the following:-the bottom left drawer of the refrigerator contained a plate covered with foil, not dated, with a name and room number. The plate had turkey (dried on the edges), potatoes, stuffing and gravy.-Rice pudding with a name and room number with an expiration date of 01/17/2026.-Plastic bag with [pizza dated 01/18/2026. A printed sign was on the door to freezer that read: [...]
- 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 a system in which resident's records were complete, accurate, accessible and systematically organized for 1 of 1 resident (Resident 17) for dialysis and 1 of 2 residents (Resident 5) reviewed for unnecessary medications. These failures placed residents at risk for not having their medical records accurate and incorrect/incomplete information being considered when making medical decisions.
February 5, 2025Standard inspection, Complaint 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 and interviews, the facility failed to ensure resident meals were prepared and stored in accordance with professional standards of food safety for 1 of 1 facility kitchens, and 1 of 2-nourishment refrigerators. The failure to ensure the kitchen and nourishment refrigerators were free from potential contaminants, maintenance to ensure the kitchen refrigerator and freezer were properly maintained left residents at risk for food contamination, food borne illnesses, and spoiled food. Findings Included . On 01/29/2025 at 9:23 AM observed the following in the facility kitchen refrigerator: - applesauce in a container with a green lid-undated and not labeled - opened cottage cheese container with no open date -opened freezer jam with no open date. [...]
- E
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Inspectors wroteBased on interview and record review, the facility failed to ensure the Resident Assessment Instrument (RAI), an assessment of a resident's needs, strengths, goals, and preferences, and included thorough summaries of the Care Area Assessments (CAA's), an assessment of a specific resident care or medical issue, to holistically analyze the plan of care for 5 of 16 residents (Residents 1, 12, 16, 22, and 32) reviewed for comprehensive assessments. This failure placed the residents at risk of not having appropriate services provided based on the resident's individualized needs and placed all other residents at risk of their needs and preferences not met.
- 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 observations, interviews and record review, the facility failed to review, revise and implement a comprehensive plan of care to included resident specific information for 6 of 18 sampled residents (Residents 12, 22, 34, 40, 16, & 33) reviewed for care plans. The failure to establish and implement care plans that were individualized, accurately reflected assessed care needs and provided direction to staff, placed residents at risk to receive inappropriate and inadequate care to meet their individualized needs and preferences. <RESIDENT 22> Resident 22 admitted to the facility on [DATE] with diagnoses that included dementia. <WANDERING> Review of Resident 22's care plan dated 05/11/2022 showed they were at risk for wandering. [...]
- E
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on observation, interview and record review, the facility failed to ensure 5 of 7 resident's (Resident 13, 19, 20, 40, and 260) received care and treatment in accordance with professional standards of practice and received the necessary care and services to attain or maintain their highest practicable level of well-being. This failure placed all residents at increased risk of unmet care needs, medical complications and decreased quality of life.
- 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 observation, interview and record review, the facility failed to ensure 2 of 5 sampled residents (1 and 22) reviewed for unnecessary medications, were free from unnecessary psychotropic medications (a drug that affects the brain activities associated with mental processes and behavior). The facility failed to ensure there were valid diagnoses for use of psychotropic medications, implement non-medication and behavioral interventions, accurately monitoring target behaviors and updating care plans. The facility failed to ensure Resident 22's use of an as needed psychotropic medications was limited to 14 days. These failures placed residents at risk for receiving unnecessary psychotropic medications, for adverse events, and diminished quality of care.
- E
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that staff were compliant with Infection Prevention and Control Guidelines and standards of practice for 3 of 4 hallways with Enhanced Barrier Precautions (EBP), 1 of 1 observations for wound care (Resident 33), 1 of 3 residents observed during personal care (Resident 13) and 1 of 1 housekeeping staff observed for hand hygiene. The facility failed to ensure that staff used the Personal Protective Equipment ([PPE] - specialized clothing worn to protect from infection or illness) during high contact resident care activities and failed to perform proper hand hygiene. These failures placed all residents and staff at risk for the potential transmission of infections. The facility was currently in a gastrointestinal virus outbreak.
- D
Allow residents to self-administer drugs if determined clinically appropriate.
Inspectors wroteBased on observation, interview, and record review the facility failed to ensure 2 of 2 residents (Resident 5 and 263) were properly assessed for the safety of self-medication administration. This failed practice placed residents at risk for medical complications and medication errors.
- D
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Inspectors wroteBased on interview and record review the facility failed to provide the required beneficiary notice for 2 of 3 residents (Residents 47 and 265) reviewed for liability notices. Failure to provide the appropriate form for the beneficiary notice and failure to give the Notice of Medicare Non-Coverage (NOMNC) 48 hours before the Medicare Part A's last covered day placed the residents at risk for not being fully informed of their rights to appeal the decision to end skilled services and/or the potential costs of continued services if the residents wished to stay longer at the facility.
- D
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Inspectors wroteBased on interview and record review, the facility failed to promptly initiate, resolve and document resident grievances for 2 of 4 sampled residents (Resident's 45 and 25) reviewed for grievance resolution. The failure of staff to initiate resident grievances resulted in delays in grievance resolution and an extended period where a resident went without their missing clothing, broken furnishing and placed residents at risk for frustration and diminished quality of life.
- 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 policies and procedures for timely reporting of alleged financial exploitation of 1 of 2 residents (Resident 16) reviewed for abuse/neglect. The facility failed to report to the state agency and law enforcement when a resident voiced concerns related to their financial affairs. This failure by the facility to identify, report, and investigate an allegation of potential abuse or neglect placed residents at risk of being victims of unidentified and uninvestigated abuse and/or neglect and limited the thoroughness of investigations.
- D
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Inspectors wroteBased on observations, interviews and record reviews the facility failed to review and revise care plans for 2 of 12 residents (Residents 40 and 1) reviewed for care planning. The failure to review and revise care plans by the interdisciplinary team placed residents at risk for unmet care needs, adverse health effects and diminished quality of life.
- 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 the necessary activities of daily living care (ADL) and services for 1 of 4 residents (Resident 263) reviewed for bathing. This failure placed the resident at risk for hygiene issues and for diminished quality of life.
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observation, interview, and record review the facility failed to provide respiratory care consistent with professional standards of practice for 1 of 3 sampled residents (Resident 40) reviewed for respiratory care. Failure to follow provider's orders for oxygen (O2) therapy placed the resident at risk for unmet needs, potential negative outcomes and a diminished quality of life.
- D
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Inspectors wroteBased on observations, interviews, and record review the facility failed to develop a dementia care plan that addressed the physical, mental and psychosocial needs of the resident, established personalized and achievable goals, and identified interventions to promote a person-centered environment for 1 of 4 residents (Resident 22) reviewed for dementia care. These failures placed residents at risk for unmet physical and psychosocial needs, increased behaviors and decreased quality of life.
- 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 interview the facility failed to ensure drugs and biologicals (diverse group of medicines made from natural sources) were refrigerated after opening from 2 of 2 medication carts (Medicare and North Hall) and expired medications and biologicals were disposed of timely in accordance with professional standards from 1 of 2 medication rooms (Medicare Hall). These failures placed residents at risk to receive expired medications, ineffective medication from lack of refrigeration, to experience adverse side effects and other potential negative health outcomes. Findings Included . On 02/03/2025 at 9:49 AM observed the refrigerator of the medication room to contain 3 vials of lorazepam (an antianxiety medication) in a small, clear bag with the expiration date of 10/2024. [...]
- D
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Inspectors wroteBased on observation, interview and record review, the facility failed to ensure foods were served in a timely manner and were palatable for 1 of 1 Halls (South Hall) and 1 of 1 organized resident groups (Resident Council) who were interviewed about the food palatability and temperatures. Failure to meet these requirements could negatively impact the residents' nutritional status, appetite, and meal acceptance. Findings Included . In a review of facility policy titled Long Term Care Policy & Procedure Manual labeled food temperatures, undated, showed the facility recommended ranges of temperatures for the safe holding, storage and serving of foods such as hot cereal and hot beverages (coffee and tea) was at 165 degrees Fahrenheit or above. These are the standards suggested for food acceptance and palatability as well as safety. [...]
- 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 have a system in place that ensured effective consistent communication, collaboration, and coordination of care occurred between the facility and the hospice provider for 1 of 3 residents (Resident 22) reviewed for hospice services. The facility failed to obtain and/or maintain a copy of a resident's current hospice coordinated plan of care and integrate it into the facility care plan. This failure placed the resident at risk for not receiving necessary care and services and/or unmet care needs.
August 23, 2024Complaint inspection · 4 citations
- J
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on interview and record review, the facility failed to provide the needed assessments and timely treatment for 1 of 1 residents (Resident 1) reviewed for an unexpected hospitalization, who experiences ongoing abdominal pain and discomfort for at least two days to the extent that staff moved the roommate out of the room and closed the door because the resident was calling out in pain. The resident experienced harm when treatment was delayed for several hours and there was a lack of effective communication with the physician. The resident was sent to the hospital the next morning and passed away shortly after admission to the hospital. The disregard of the pain the resident experienced and recognizing the need to take timely action constituted an immediate jeopardy. On 08/15/2024 at 3:35 PM, the facility was notified of an IJ in F684. [...]
- G
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Inspectors wroteBased on interview and record review the facility failed to provide necessary care and services to prevent neglect for 1 of 3 residents (Resident 1) reviewed for abuse and neglect. Licensed staff was aware of the change in condition and abdominal pain experienced by Resident 1 yet did not conduct a thorough assessment or consult with the physician timely and left the resident alone in their room and in pain during the night shift with door closed for at least 30 minutes. The lack of addressing the residents needs placed all residents at risk for neglect. Review of the facility policy titled, Abuse and Neglect, undated stated the facility has effective procedures to protect and prevent neglect of residents .licensed nurses, and nurse management staff are responsible for the supervision of facility staff to identify inappropriate behaviors such as . [...]
- E
Respond appropriately to all alleged violations.
Inspectors wroteBased on interview and record review, the facility failed to conduct a thorough investigation for three of three residents (1, 2, and 3) reviewed for complete and thorough investigations. The facility failed to thoroughly investigate an unexpected hospitalization that led to the death of Resident 1 and failed to thoroughly investigate two allegations of abuse towards residents (2 and 3) that involved the same staff member [Staff I, Nursing Assistant Certified (NAC)]. This failure to investigate timely and thoroughly placed residents at risk of being victims of unidentified and uninvestigated abuse and/or neglect.
- 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 policies and procedures for timely reporting of an unexpected death were in place for 1 of 3 residents (Resident 1) reviewed for abuse/neglect. The facility failed to report to the state agency when a resident was sent to the hospital and unexpectedly died hours later. This failure by the facility to identify, report, and investigate an allegation of potential abuse or neglect placed residents at risk of being victims of unidentified and uninvestigated abuse and/or neglect and limited the thoroughness of investigations.
January 12, 2024Standard inspection · 4 citations
- D
Ensure each resident receives an accurate assessment.
Inspectors wroteBased on interview, and record review, the facility failed to accurately assess 1 of 3 sampled residents (Resident 8) reviewed for accuracy of assessments. The failure to ensure a resident had an accurate assessment placed residents at risk for unmet care needs and a diminished quality of life.
- D
Notify the appropriate authorities when residents with MD or ID services has a significant change in condition.
Inspectors wroteBased on interview, and record review the facility failed to ensure Preadmission Screening and Resident Review (PASRR - a federally required screening of all individuals who has both an Intellectual Disability or Related Condition and a serious mental illness prior to admission to a Medicaid-certified nursing facility or a significant change of condition) assessments were completed for all residents with newly evident or possible serious mental disorders for 2 of 5 sampled residents reviewed (Residents 2 and 22). This failure resulted in potential unidentified residents mental health needs, delay in access to Level II PASRR (an in-depth evaluation to determine whether the resident requires specialized rehabilitation services) services and decreased quality of life.
- D
Provide enough food/fluids to maintain a resident's health.
Inspectors wroteBased on interview, and record review, the facility failed to provide nutritional care and services for 1 of 3 residents (Resident 8) reviewed for nutrition and/or hydration. The failure to offer meal replacements and supplements when the resident consumed less than 50% of their meals placed residents at risk for nutrition-related complications and for diminished quality of life.
- D
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 observation, interview and record review, the facility failed to ensure 2 of 5 sampled residents (Resident 15 and 21) reviewed for unnecessary medications, were free of unnecessary psychotropic medications. The facility failed to ensure there were valid diagnoses for use of psychotropic medications, to consistently monitor and care plan target behaviors, to monitor for adverse side effects, and to attempt gradual dose reductions. These failures placed residents at risk for receiving unnecessary psychotropic medications, for adverse events, and diminished quality of care.
Fire safety inspections
14 fire safety citations on file: 5 on January 26, 2026, 1 on February 5, 2025, 8 on January 12, 2024.
Every fire safety citation14 citations
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · January 26, 2026 · Corrected (the home has a date of correction)
- F
Ensure that testing and maintenance of electrical equipment is performed.
K 921 · January 26, 2026 · Corrected (the home has a date of correction)
- E
Keep aisles, corridors, and exits free of obstruction in case of emergency.
K 211 · January 26, 2026 · Corrected (the home has a date of correction)
- D
Properly select, install, inspect, or maintain portable fire extinguishes.
K 355 · January 26, 2026 · Corrected (the home has a date of correction)
- D
Have restrictions on the use of portable space heaters.
K 781 · January 26, 2026 · Corrected (the home has a date of correction)
- E
Ensure proper usage of power strips and extension cords.
K 920 · February 5, 2025 · Corrected (the home has a date of correction)
- F
Establish procedures for tracking staff and patients during an emergency.
E 18 · January 12, 2024 · Corrected (the home has a date of correction)
- F
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
K 521 · January 12, 2024 · 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 · January 12, 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 12, 2024 · Corrected (the home has a date of correction)
- E
Provide emergency officials' contact information.
E 31 · January 12, 2024 · Corrected (the home has a date of correction)
- D
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · January 12, 2024 · Corrected (the home has a date of correction)
- D
Inspect, test, and maintain automatic sprinkler systems.
K 353 · January 12, 2024 · Corrected (the home has a date of correction)
- D
Have properly installed electrical wiring and gas equipment.
K 511 · January 12, 2024 · Corrected (the home has a date of correction)