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 40 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
38D
2E
0F
Potential for minimal harm
0A
0B
0C
January 23, 2026Standard inspection, Complaint inspection · 17 citations
- D
Reasonably accommodate the needs and preferences of each resident.
Inspectors wroteBased on observation and interview, it was determined that the facility failed to ensure residents' call devices were in reach. This was evident for 1 resident (Resident #39) of 24 residents screened during the initial pool portion of the recertification survey.
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on record review and interview, it was determined that the facility 1) failed to report an allegation of abuse timely, and 2) failed to report an allegation of abuse. This was evident for one facility reported incident (#351278) of 8 facility reported incidents (FRIs) reviewed during the recertification survey, and one resident (Resident #22) of three residents reviewed for grievances.
- D
Respond appropriately to all alleged violations.
Inspectors wroteBased on record review and interview, it was determined that the facility failed to thoroughly investigate allegations of abuse. This was evident for 3 (#351276, #351281, and #2623047) of 8 facility reported incidents reviewed during the recertification survey.
- D
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Inspectors wroteBased on record reviews and interviews, it was determined that the facility failed to communicate a resident's comprehensive care plan goals to the receiving healthcare institution to ensure safe and effective transition of care. This was evident for 1 (Resident #64) of 1 resident reviewed for hospitalization.
- D
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Inspectors wroteBased on record reviews and staff interviews, it was determined that the facility failed to complete comprehensive Minimum Data Set (MDS) assessments within the regulatory timeframes to facilitate appropriate care planning and maintain current, accurate assessment records. This was evident for 2 (Resident #43 and #52) of 3 residents reviewed for activities and 1 (Resident #55) of 4 residents reviewed for Resident assessment.
- D
Assure that each resident’s assessment is updated at least once every 3 months.
Inspectors wroteBased on record reviews and interviews, it was determined that the facility failed to complete Quarterly Minimum Data Set (MDS) assessments for residents within the required regulatory timeframes to facilitate appropriate care planning and maintain current assessment records. This was evident for 1 (Resident #7) of 3 residents reviewed for Resident assessments and for 1 (Resident #27) of 3 residents reviewed for Nutrition.
- D
Ensure each resident receives an accurate assessment.
Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to accurately code residents' Minimum Data Set (MDS) assessments correctly. This was evident for one (Resident #43) of one resident reviewed for communication and sensory, one (Resident #52) of 3 residents reviewed for Activities, and one (Resident #8), of 2 residents reviewed for dental care during the recertification survey.
- 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 interviews, record reviews, and observations, it was determined that the facility failed to develop and implement comprehensive, resident-centered care plans. This was evident in 1 (Resident #43) of 1 resident reviewed for communication and sensory, and 1 (Resident #52) of 3 residents reviewed for ActivitiesThe
- 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 record reviews and interviews, it was determined that the facility failed to 1) revise care plans, and 2) conduct care plan meetings after the completion of the comprehensive and/or quarterly assessments. This was evident for two residents (Resident #5, #8) of 2 residents reviewed for dental care, and one resident (Resident #62) of 2 residents reviewed for care planning.
- D
Provide activities to meet all resident's needs.
Inspectors wroteBased on observations, record reviews, and interviews, it was determined that the facility failed to provide an ongoing program of activities that met residents' needs and preferences. This was evident for 2 (Resident #43 and #52) out of 3 residents reviewed for activities.
- D
Provide safe, appropriate pain management for a resident who requires such services.
Inspectors wroteBased on interviews and record review, it was determined that the facility failed to 1) effectively manage residents' pain, and 2) ensure pain management was provided to residents according to professional standards of practice. These was evident for 2 (Resident #43, #2) of 3 residents reviewed for pain management during the recertification survey.
- D
Ensure that nurse aides who have worked more than 4 months, are trained and competent; and nurse aides who have worked less than 4 months are enrolled in appropriate training.
Inspectors wroteBased on record review and interview, it was determined that the facility failed to ensure that residents were cared for by licensed Geriatric Nursing Assistants (GNAs). This was evident for 1 GNA (Staff #10) of 5 GNA licenses reviewed during the staffing investigation portion of the recertification survey.
- D
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Inspectors wroteBased on observation and staff interview, the facility failed to ensure that resident medication storage areas and medical supplies were properly stored, free from expired items, and maintained in a sanitary and organized manner within 2 of 2 medication storage areas observed during the annual recertification survey.
- 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 record review, it was determined that the facility failed to store food in accordance with professional standards. This was evident in 1 of 2 observations of the facility's kitchen during the recertification survey.
- D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on observations, interviews, and record review, it was determined that the facility failed to ensure that staff accurately documented in a resident's medical record. This was evident in one (Resident #69) of three residents reviewed for infection control.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observations, record reviews, and interviews, it was determined that the facility failed to ensure all staff donned appropriate personal protective equipment (PPE) for enhanced barrier precautions. This was evident for 1 (Resident #62) of 3 residents reviewed for pressure ulcers.
- D
Provide bedrooms that don't allow residents to see each other when privacy is needed.
Inspectors wroteBased on observations and interviews, it was determined that the facility failed to ensure full visual privacy was provided to residents residing in semi-private rooms. This was evident for 1 (Resident #12) of 1 resident reviewed for privacy.
August 16, 2024Standard inspection, Complaint inspection · 7 citations
- E
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Inspectors wroteBased on record review, staff interviews, and facility policy review, the facility failed to ensure four of six residents reviewed for abuse (Residents (R) 22, R11, R106 and R35) out of a total sample 29 were free from resident-to-resident abuse. This failure had the potential to cause physical injury or psychosocial distress for the four residents involved.
- E
Provide and implement an infection prevention and control program.
Inspectors wroteBased on policy review, interviews, and review of Centers for Disease Control (CDC) and American Society of Heating, Refrigerating and Air-Conditioning Engineers (ASHRAE) guidelines, the facility's water management program was incomplete in that it was not consistent with current ASHRAE guideline, which specifically called for the design to evaluate the potential exposure of Legionnaire's disease (a serious pneumonia infection) within a healthcare facility. This failure created a potential for the 43 facility residents, who were over the age of 65, to be infected by Legionella
- D
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 record review, interview, and facility policy review, the facility failed to ensure two of two residents (Resident (R) 23 and R55) reviewed for hospital transfers in the sample of 29 was given a written copy of a bed hold notice prior to or within 24-hours of emergency transfer to the hospital. This failure created the potential for the residents and/or responsible parties to not have the information needed to safeguard their return to the facility.
- D
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Inspectors wroteBased on observation, interview, record review, document review, and manufacturer's instruction review, the facility failed to provide education for one of one Licensed Practical Nurse (LPN1) to possess the competencies and skill set necessary to ensure proper technique was used to administer insulin for one of two residents (Resident (R)52) that received insulin during medication administration. This failure had the potential to result in the resident receiving the wrong dose of insulin.
- D
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Inspectors wroteBased on interview, record review, review of the Centers for Disease Control and Prevention (CDC) guidelines, and facility policy review, the facility failed to offer one of six residents (Resident (R) 37) and/or their representatives reviewed for immunizations, the opportunity for the resident to be vaccinated in accordance with nationally recognized standards out of a current facility census of 54. This practice had the potential to increase the risk for the residents to contract pneumonia.
- 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 record review and staff interview it was determined that the facility failed to investigate a grievance regarding care concerns for a resident. This was evident for 1 (#14) of 8 residents reviewed for complaints.
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on record review and staff interview it was determined facility staff failed to ensure that a resident who relied on staff for care needs had the care provided. This was evident for 2 (#14 and 902) of 8 residents reviewed for complaints.
June 27, 2019Standard inspection · 16 citations
- D
Reasonably accommodate the needs and preferences of each resident.
Inspectors wroteBased on observation, it was determined that the facility staff failed to ensure that a call bell was within reach for every resident. This was evident for 2 (Residents #8, #47) residents observed during the initial tour of the facility.
- D
Honor the resident's right to organize and participate in resident/family groups in the facility.
Inspectors wroteBased upon record review, resident interview, and staff interview, it was determined that facility staff failed to put a system in place to ensure that resident's grievances regarding call bell response time and staff interaction with residents were addressed in a timely manner and outcomes communicated back to the resident. This was true for three out of 48 resident council members but had the potential to affect all residents in the facility.
- 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 record review and staff interview, it was determined that the facility staff failed to discuss changes in the resident's medical status related to end stage condition with the Resident Representative (RR). This was evident in 1 (R#45) of 1 resident reviewed regarding advanced directives in the investigative portion of the survey.
- 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 record review, observation, and staff interview, it was determined that the facility staff failed to 1. notify or include a Resident Representative (RR) in changes regarding residents' care and 2. to notify the physician, resident and/or their family and care staff of the unavailability of medications. This was evident for 2 (R#6 and #36) of 20 residents reviewed during the investigative portion of the survey.
- D
Keep residents' personal and medical records private and confidential.
Inspectors wroteBased on review of a facility reported incident and staff interview, it was determined that the facility staff failed to protect a cognitively impaired resident's right to privacy. This was evident for 1 (R #98) of 20 residents reviewed during an annual recertification survey.
- D
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Inspectors wroteBased on review of Facility Reported Incident MD00 1390223, investigation review, and interview with staff, it was determined that the facility failed to follow policy on completing background employee checks of potential new employees. This was evident in 1 of 2 employees records reviewed.
- D
Respond appropriately to all alleged violations.
Inspectors wroteBased on review of the medical record, facility investigations and interviews, it was determined that the facility failed to complete a thorough investigations of abuse allegations related to injury of unknown origins. This was found to be evident for one out of the seven facility reported incidents (FRI) reviewed during the investigative portion of the survey (R#149).
- 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 medical record review and staff interview, it was determined the facility staff failed to provide the resident/resident representative with a copy within 48 hours of admission to the facility. This was evident for 1 (Residents #36) of 20 residents reviewed during an annual recertification survey.
- 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 medical record review, and interview with facility staff, it was determined that the facility failed to develop a person-centered comprehensive care plan to as evidenced by the facility's failure to develop a care plan to address a resident's chronic diagnosis and long-term use of antibiotics. This was found to be evident for 1 out of 20 residents (Resident #23) reviewed during the investigative stage of the survey.
- 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 medical record review and interview, it was determined the facility staff failed to revise Resident #27's oxygen care plan regarding weaning Resident #27 from the use of continuous oxygen. This was evident for 1 of 1 resident reviewed for oxygen use.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on observation, medical record review and interview with staff, it was determined that the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan, as evidenced by failure to ensure a follow up urology consult to determine if the continued use of an antibiotic was necessary. This was evident for 1 of 20 (R#23) residents reviewed during the investigative stage of the long-term care survey process.
- D
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Inspectors wroteBased on review of medical records and interview with staff, it was determined that the facility failed to have an effective system in place to ensure that pharmacist recommendations (resulting from identified irregularities during the monthly pharmacy review were addressed and acted upon by the physician. This was found to be evident for 1 out of the 5 residents (Resident #23) sampled for medication regimen review during the investigative stage of the survey.
- D
Ensure medication error rates are not 5 percent or greater.
Inspectors wroteBased on medication administration observation and staff interview, it was determined that the facility staff failed to ensure a medication administration error rate of less than 5 percent. This was evident for 3 errors involving Residents # 36 and #47 out of 30 opportunities for error observed on the Skyline Unit resulting in a medication administration error rate of 10%.
- 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 wroteDELETE - KS TO IMPORT Based on observation, record review and staff interview, it was determined that the facility staff failed to put a system in place to; ensure all drugs and biologicals in the facility are labeled according to professional standards, keep consistent temperature logs for medication and biological storage, and keep an accurate inventory log for controlled substances. This was true for 2 of 3 medication carts and 2 of 2 storage rooms reviewed during the survey.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation and staff interview, it was determined that the facility staff failed to apply standard infection control practices while administering medications to residents. This was true for 2 (Residents # 10 and #36) of 3 residents reviewed during a medication administration observation on the Skyline unit. However, this deficient practice has the potential to affect all residents, visitors, and staff in the facility.
- D
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Inspectors wroteBased on medical record review and staff interview, it was determined the facility staff failed to take steps to offer a resident the pneumococcal and flu vaccine after admission. This was evident for 1 (Residents #47) of 5 residents reviewed for immunizations during an annual recertification survey.
Fire safety inspections
18 fire safety citations on file: 8 on January 23, 2026, 5 on August 16, 2024, 5 on June 27, 2019.
Every fire safety citation18 citations
- F
Use approved construction type or materials.
K 161 · January 23, 2026 · Corrected (the home has a date of correction)
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · January 23, 2026 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · January 23, 2026 · 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 23, 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 23, 2026 · Corrected (the home has a date of correction)
- E
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
K 223 · January 23, 2026 · Corrected (the home has a date of correction)
- E
Install corridor and hallway doors that block smoke.
K 363 · January 23, 2026 · Corrected (the home has a date of correction)
- E
Ensure proper usage of power strips and extension cords.
K 920 · January 23, 2026 · Corrected (the home has a date of correction)
- F
Develop and maintain an Emergency Preparedness Program (EP).
E 4 · August 16, 2024 · Corrected (the home has a date of correction)
- F
Use approved construction type or materials.
K 161 · August 16, 2024 · Corrected (the home has a date of correction)
- E
Have proper medical gas storage and administration areas.
K 923 · August 16, 2024 · Corrected (the home has a date of correction)
- D
Keep aisles, corridors, and exits free of obstruction in case of emergency.
K 211 · August 16, 2024 · Corrected (the home has a date of correction)
- D
Inspect, test, and maintain automatic sprinkler systems.
K 353 · August 16, 2024 · Corrected (the home has a date of correction)
- D
Have ramps, exits, fire escape ladders, steps, and areas of refuge that meet safety requirements.
K 227 · June 27, 2019 · Corrected (the home has a date of correction)
- D
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
K 321 · June 27, 2019 · Corrected (the home has a date of correction)
- D
Install smoke barrier doors that can resist smoke for at least 20 minutes.
K 374 · June 27, 2019 · Corrected (the home has a date of correction)
- C
Use approved construction type or materials.
K 161 · June 27, 2019 · Not yet corrected
- C
Have proper medical gas storage and administration areas.
K 923 · June 27, 2019 · Corrected (the home has a date of correction)