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 64 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
1J
0K
0L
Actual harm
1G
0H
0I
Potential for more than minimal harm
54D
2E
4F
Potential for minimal harm
0A
1B
1C
July 10, 2026Complaint inspection · 1 citation
- D
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, review of a facility investigation, review of a facility self reported incident (SRI), review of a police report, staff interview and policy review, the facility failed to ensure a resident was free from abuse. The affected one (#58) out of four residents reviewed for abuse. The facility census was 57.
July 1, 2026Complaint inspection · 2 citations
- E
Provide and implement an infection prevention and control program.
Inspectors wroteBased on medical record review, observation, staff interview, and review of online resources from the Centers for Disease Control and Prevention (CDC), policy review, the facility failed to ensure appropriate infection control practices were implemented. This affected four Residents (#47, #46, #16, and #38) of four residents reviewed for infection control. The facility census was 56.
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on medical record review, staff interview, and policy review, the facility failed to ensure falls were documented and investigated in a thorough manner. This affected one (#21) of three residents reviewed for safety. The facility census was 56.
June 22, 2026Complaint inspection · 4 citations
- J
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on record review, observations, staff and resident interviews, and review of the facility's smoking policy, the facility failed to adequately assess and supervise residents identified as being supervised smokers to prevent them from smoking while oxygen was in place. This resulted in Immediate Jeopardy and serious life-threatening harm and/or injuries on 04/14/26 when Resident #43 lit a cigarette while wearing oxygen via nasal cannula and sustained burns to his face. On 05/31/25, Resident #43 again lit a cigarette while wearing oxygen and sustained additional burns to his face. This affected one (Resident #43) of three residents reviewed for accident hazards. The facility identified 28 residents (#04, #06, #08, #11, #12, #16, #22, #24, #26, #27, #28, #31, #32, #33, #36, #40, #41, #42, #43, #50, #53, #54, #57, #58, #59, #60, and #61) who smoked. The facility census was 61. [...]
- 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 , staff interviews, and policy review, the facility failed to ensure the physician was notified when a resident experienced a change in condition. This affected one resident (#43) of three reviewed for change in condition. The facility census was 61.
- D
Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit.
Inspectors wroteBased on review of the medical record, staff interviews, and policy review, the facility failed to ensure the physician progress notes were written, signed and dated at the time of the visit. This affected three Residents (#33, #50, and #62) of three residents reviewed for physician visits. The facility census was 61.
- D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on review of the medical record, staff interviews, and policy review, the facility failed to ensure resident's records were complete and accurately documented. This affected one (#43) of three residents reviewed for documentation. The facility census was 61.
May 21, 2026Complaint inspection · 2 citations
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on medical record review, observation, resident and staff interviews, and review of the facility policy, the facility failed to ensure staff provided the necessary level of supervision for safe smoking and residents smoked in the designated smoking areas. This affected two (Residents #29 and #41) of three residents reviewed for smoking safety. The facility census was 57.
- D
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Inspectors wroteBased on observations, staff interviews, Long-Term Care Ombudsman interview, and policy review, the facility failed to maintain the residents' floors and medical equipment in a clean manner. This affected two residents (Residents #38 and #40). The facility census was 57.
April 2, 2026Complaint inspection · 1 citation
- D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Inspectors wroteBased on medical record review, resident interview, staff interview, physician interview, and policy review, the facility failed to ensure physician orders were transcribed accurately. This affected one (Resident #08) of four residents reviewed for physician orders. The facility census was 60.
January 8, 2026Standard inspection, Complaint inspection · 9 citations
- F
Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
Inspectors wroteBased on record review and staff interview, the facility failed to submit the Payroll Based Journal (PBJ) staffing information to Centers for Medicare and Medicaid Services (CMS) as required. This had the potential to affect all 55 residents residing in the facility. The facility census was 55.
- 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, staff interview, and review of facility policy, the facility failed to ensure resident care plans were accurate to reflect the residents needs. This affected three (#2, #3, and #65) of 21 residents reviewed in the sample. The census is 55.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on medical record review, staff and resident interviews, review of information from Medscape and review of information from the National Library of Medicine, the facility failed to ensure bowel movements were monitored for residents at risk of constipation. This affected one (#2) out of two residents reviewed for constipation. The census was 55.
- 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 medical record review, observations and staff and resident interviews, the facility failed to ensure a resident's indwelling urinary catheter (Foley) was attempted to be removed as ordered. This affected one (#2) of one reviewed for Foley catheter care. The census was 55.
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on medical record review, observations, staff interview, and review of facility policy, the facility failed to ensure staff cared for a resident's tracheostomy appropriately. This affected one (#10) of one residents reviewed for tracheostomy care. The census was 55.
- D
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Inspectors wroteBased on medical record review, staff interview, interview with dialysis staff, review of dialysis treatment logs, and policy review, the facility failed to ensure pre and post dialysis evaluations were completed, failed to ensure communication with dialysis center was consistently done, failed to ensure the medical record contained documentation related to missed dialysis treatments, and failed to ensure the physician was notified of missed dialysis treatments. This affected the one (#03) of one residents reviewed for dialysis services. The facility census was 55.
- 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 medical record review, observation, staff interviews, and review of facility policy, the facility failed to ensure medications were not left at a resident's bedside. This affected one (#50) out of 55 residents observed during the initial pool. The census was 55.
- D
Provide timely, quality laboratory services/tests to meet the needs of residents.
Inspectors wroteBased on medical record reviews, staff interviews, and policy review, the facility failed to ensure laboratory (labs) values were obtained as per physician orders. This affected three (#02, #03, and #09) residents out of five residents reviewed for lab services. The facility census was 55.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on medical record review, observation, staff interview, and review of facility policy, the facility failed to ensure staff implemented enhance barrier precautions (EBP). This affected one (#10) of five reviewed for transmission-based precautions (TBP). The census was 55.
September 3, 2025Complaint inspection · 1 citation
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on observation, resident interview, staff interview and review of facility policy, the facility failed to ensure residents were supervised while smoking and further failed to ensure residents smoked in designated areas per facility policy. Additionally, the facility failed to ensure residents utilized non-combustible containers to extinguish smoking materials. This affected two (#21 and #07) of two residents reviewed for smoking. The facility identified 15 (#07, #08, #13, #15, #16, #20, #21, #24, #26, #32, #34, #43, #48, #49, and #50) residents who smoked. The facility census was 50.
March 12, 2025Complaint inspection · 5 citations
- 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, staff interviews and policy review, the facility failed to provide notification to the physician or family for a newly identified pressure ulcer. This affected one (#10) of three reviewed for pressure ulcers. care. The facility census was 56.
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on record review and staff interviews, the facility failed to provide assistance with personal hygiene and Activities of Daily Living (ADL). This affected one (#10) of three residents reviewed for ADL care. The facility census was 56.
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on record review, observations, interviews with staff and Wound Physician and policy review, the facility failed to provide appropriate care and services to pressure ulcers. This affected two (#10 and #11) of three reviewed for pressure wounds. The facility census was 56.
- D
Provide or get specialized rehabilitative services as required for a resident.
Inspectors wroteBased on record review, review of a hospital referral and interviews with staff, the facility failed to provide timely therapy services. This affected one (#10) of three residents reviewed for therapy services. The facility census was 56.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on record review, observations, staff interviews and policy review, the facility failed to ensure proper infection control procedures were followed during resident care. This affected one (#12) out of three residents reviewed for infection control. The facility census was 56.
January 22, 2025Complaint inspection · 5 citations
- D
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 wroteBased on observation, medical record review, resident and staff interview, and facility policy review, the facility failed to maintain and clean and sanitary environment. This affected two (#13 and #34) of six resident's rooms observed for environmental cleanliness. The facility census was 59. Findings Included: 1. Review of the medical record for Resident #34 revealed an admission date 12/15/24. Diagnoses included chronic diastolic heart failure, cognitive communication deficit, atrial flutter, and hypertension. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #34 was assessed with severely impaired cognition. Observation on 01/22/25 at 11:01 A.M. of Resident #34's room revealed the floor to the left side of the bed had 25 circular brownish-black marks approximately two to three inches in diameter scattered on the floor. [...]
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on observation, resident and staff interview, medical record review, and facility policy review, the facility failed to provide timely care and services when answering call lights. This affected one (#29) of three residents reviewed for call light response. The facility census was 59. Findings Included: Review of the medical record for Resident #29 revealed an admission date of 11/11/24. Diagnoses included bipolar disorder, type two diabetes, morbid obesity, anxiety, and major depression. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #29 was assessed with intact cognition, required partial to moderate assistance with bathing, toileting hygiene, personal hygiene, dressing the lower body, placing shoes on and off the feet, and required a walker to ambulate. [...]
- D
Provide safe, appropriate pain management for a resident who requires such services.
Inspectors wroteBased on observation, resident and staff interview, and medical record review, the facility failed to provide timely pain medication as ordered to effectively treat pain. This affected one (#3) of three residents reviewed for pain management. This facility census was 59. Findings Included: Review of the medical record for Resident #3 revealed a most recent admission date of 01/10/25. Diagnoses included cellulitis of the right lower limb, acute kidney failure, major depressive disorder, and hypertension. Review of the Minimum Data Set (MDS) assessment MDS dated [DATE] revealed Resident #3 was assessed with moderately impaired cognition. Review of a physician order dated 01/10/25 revealed Resident #3 had an order for the narcotic pain medication oxycodone immediate release (IR) five (5) milligrams (mg) to take one tablet by mouth every eight hours as needed for pain. [...]
- D
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Inspectors wroteBased on observation, resident and staff interview, and medical record review, the facility failed to ensure blood glucose levels were adequately monitored as ordered to determine the need for sliding scale insulin. This affected one (#13) of three residents reviewed for insulin usage. The facility census was 59. Findings Included: Review of the medical record revealed Resident #13 had an admission date 11/06/24. Diagnoses included type two diabetes, alcohol dependence, bipolar disorder, major depressive disorder, acute kidney failure, and hypertension. Review of an admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #13 was assessed as cognitively intact. Review of a plan of care dated 11/06/24 revealed Resident #13 had the potential for hypoglycemia or hyperglycemia related to diabetes. [...]
- 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, resident and staff interview, and medical record review, the facility failed to ensure medication administration records were accurately documented to reflect blood glucose monitoring. This affected one (#13) of three residents reviewed for insulin usage. The facility census was 59. Findings Included: Review of the medical record revealed Resident #13 had an admission date 11/06/24. Diagnoses included type two diabetes, alcohol dependence, bipolar disorder, major depressive disorder, acute kidney failure, and hypertension. Review of an admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #13 was assessed as cognitively intact. Review of a plan of care dated 11/06/24 revealed Resident #13 had the potential for hypoglycemia or hyperglycemia related to diabetes. [...]
September 27, 2024Complaint inspection · 1 citation
- D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on medical record review, staff interviews and policy review, the facility failed to ensure the administration of as needed medication was documented in the resident's medical record. Additionally, the facility failed to document care and services related to incontinent care and application of durable medical equipment as ordered. This affected three (#15, #45 and #18) of three residents reviewed for medical record accuracy. The facility census was 42.
August 2, 2024Complaint inspection · 1 citation
- D
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, resident and staff interviews, review of the facility's self-reported incident (SRI) and investigation, and policy review, the facility failed to prevent resident-to-resident physical abuse when a resident struck another resident with a cane, and a third resident came up behind the resident and struck the same resident. This affected one (Resident #19) of three residents reviewed for abuse. The facility census was 51.
July 3, 2024Complaint inspection · 2 citations
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on medical record review, staff interview, and policy review, the facility failed to prevent elopement. This affected one (Resident #24) of three reviewed for elopement. The facility census was 48.
- D
Ensure that residents are free from significant medication errors.
Inspectors wroteBased on observation, medical record review, staff interview, and review of the policy, the facility failed to ensure medications were administered timely. This affected one resident (#12) of four observed for medication administration. The facility census was 48.
November 30, 2023Complaint inspection · 7 citations
- F
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Inspectors wroteBased on review of staffing schedules and staff interviews, the facility failed to provide eight hours of continuous Registered Nurse (RN) care seven days a week as required. This had the potential to affect all 47 residents residing in the facility. The facility census was 47.
- 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, staff interviews, review of dishwasher logs and manufacturers instructions, the facility failed to ensure the dishwasher temperatures and sanitation was being followed as per manufacturer instructions. This had the potential to affect 44 out of 45 residents residing in the facility, two (#39 and #46) residents did not receive their meals from the kitchen. The facility census was 47.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on medical record review and staff interview, the facility failed to complete an admission assessment on a newly admitted residents. This affected one (#33) of three residents reviewed who were newly admitted . The facility census was 47.
- D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Inspectors wroteBased on staff interviews and record review the facility failed to ensure medications were administered as ordered. This affected two (#57 and #33) of four residents reviewed for medication administration. The facility census was 47.
- D
Ensure medication error rates are not 5 percent or greater.
Inspectors wroteBased on medical record review, observations, staff interviews and review of manufacturer instructions, the facility failed to ensure medications were administered as physician orders resulting in three medication errors out of 32 opportunities or a 9.37 percent (%) medication error rate. This affected two (#32, #56) of three residents observed during medication administration. The facility census was 47.
- D
Ensure that residents are free from significant medication errors.
Inspectors wroteBased on medical record review, observation, staff interviews and review of manufacturer instructions, the facility failed to ensure a residents insulin pen was primed according to manufacturer guidelines resulting in a significant medication error. This affected one (#32) of three residents observed for medication administration. Facility census was 47.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on record review, review of hospital medical records, observations, staff interview, review of manufactures instruction policy review and review of guidelines from the Centers for Disease Control and Prevention (CDC), the facility failed to ensure proper infection control procedures were followed. This affected two residents (#33 and #34) of three residents reviewed for infection control. Facility census was 47.
October 18, 2023Complaint inspection · 2 citations
- G
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on record review, observation, staff interview, review of the facility policy, and review of the guidelines from the National Pressure Ulcer Advisory Panel (NPUAP), the facility failed to thoroughly assess the resident's skin and failed to timely identify the resident's pressure ulcers until they reached an advanced stage. This resulted in Actual Harm to Residents #32, #39, and #42 who developed pressure ulcers while in the facility which were not identified until they had reached an advanced stage. Resident #42 was not assessed for the risk of pressure ulcer until after the resident developed four pressure ulcers (a stage III pressure ulcer (Full thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon or muscle is not exposed) to the right thigh, a stage III pressure ulcer to the superior coccyx, an unstageable pressure ulcer (slough and/or eschar: [...]
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on record reviews, observations, staff interviews, and review of the facility policy, the facility failed to ensure the resident's oxygen tubing was clean and changed regularly and failed to ensure Resident #16 had a physician's order for the administration of oxygen. This affected two (Residents #16 and #41) of three residents reviewed for oxygen administration. The facility census was 41 residents.
December 13, 2022Standard inspection · 10 citations
- 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, record review, staff interviews, and review of the facility policy, the facility failed to ensure proper storage of medications including ensuring that expired medications were not being used. This affected two of the four medication carts and one of one medication storage room located in the facility. This had the potential to affect eighteen residents due to expired medications and one other resident (#30) related to medication storage. The facility census was 56.
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on record review, staff interview, review of the facility's Self-Reported Incidents (SRI), and review of the facility policy, the facility failed to report an allegation of misappropriation to the State Survey Agency. This affected one (Resident #31) of one resident reviewed for abuse during the annual survey. The facility census was 56.
- D
Respond appropriately to all alleged violations.
Inspectors wroteBased on record review, staff interview, and review of the facility policy, the facility failed to investigate an allegation of misappropriation. This affected one (Resident #31) of one resident reviewed for abuse during the annual survey. The facility census was 56.
- D
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Inspectors wroteBased on record review, staff interview, and review of the facility policy, the facility failed to complete a comprehensive assessment of the resident's cognition and behavior on the Minimum Data Set (MDS) assessments. This affected three (#37, #38, and #47) of 22 residents reviewed for MDS assessments. The facility census was 56.
- D
Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
Inspectors wroteBased on medical record review and staff interview, the facility failed to have a discharge summary or recapitulation of stay for a resident. This affected one (Resident #307) of four residents reviewed for discharge. The facility census was 56.
- 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 medical record review, staff interview, and review of the facility policy, the facility failed to complete urinary catheter care as physician ordered for a resident. This affected one (Resident #25) one resident reviewed for a urinary catheter. The facility identified two residents with urinary catheters. The facility census was 56.
- D
Provide enough food/fluids to maintain a resident's health.
Inspectors wroteBased on medical record review, staff interview, and review of the facility policy, the facility failed to timely re-assess and address the resident's significant weight gain or weight loss. This affected two residents (#37 and #47) of four residents reviewed for nutrition. The facility census was 56.
- D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on medical record review and staff interview, the facility failed to ensure the resident's medical record was accurate. This affected one (Resident #20) of 22 residents reviewed for accuracy of the medical records. The facility census was 56.
- D
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 medical record review, staff interview, and review of facility policy, the facility failed to provide or offer the COVID-19 vaccines to residents. This affected two (#2 and #48) of five residents reviewed for immunizations. The facility census was 56.
- B
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Inspectors wroteBased medical record review, staff interview, and review of the facility policy, the facility failed to provide notification to the Office of the State Long-Term Care Ombudsman of the residents' transfers to the hospital. This affected two (Residents #26 and #54) of six residents reviewed for hospitalization. The facility census was 56.
December 5, 2019Standard inspection · 11 citations
- F
Provide and implement an infection prevention and control program.
Inspectors wroteBased on review of facility risk assessment, review of water temperature logs, observation, staff interview and review of facility policy and procedures the facility failed to ensure the laundry room maintain proper infection control measures. In addition the facility failed to ensure an effective Legionella monitoring program was in place. This had the potential to affect all 48 residents residing 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 medical record review and staff interview, the facility failed to ensure the electronic medical record contained documentation of physician's orders for advanced directives for two Residents (#23 and #46) of three reviewed during the annual survey. The facility census was 48.
- D
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Inspectors wroteBased on closed medical record review, staff interview, and review of facility policy and procedures the facility failed to ensure a request for a demand bill was carried out appropriately to ensure a resident continued to receive Medicare Part A services as requested. This affected one (Resident #19) of three residents reviewed for beneficiary protection notification. The facility census was 48.
- D
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 medical record review and staff interview, the facility failed to ensure residents and their responsible parties were provided with transfer discharge notices for residents hospitalization. This affected three Residents (#8, #23 and #46) of three reviewed for transfer discharge notices. The facility census was 48.
- D
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Inspectors wroteBased on medical record review and staff interview the facility failed to ensure quarterly Minimum Data Set (MDS) assessments were submitted within 14 days of completion to Center for Medicare & Medicare Services (CMS). This affected one (Resident #2) of one resident reviewed for resident assessments based on information submitted to CMS. The facility census was 48.
- 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 resident interview and staff interview the facility failed to ensure care planning conferences were being held. This affected two Residents (#7 and #21) of four reviewed for care planning conferences. The facility census was 48.
- 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 medical record review, observation, and resident and staff interviews, the facility failed to ensure a physician ordered splint was implemented. This affected one (Resident #21) of one resident reviewed for limited range of motion (ROM). The facility census was 48.
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on medical record review, observation, staff interview and review of facility policy and procedure the facility failed to ensure medical care equipment was plugged into a proper electrical outlet. This affected one (Resident #15) resident during a random observation. In addition the facility failed to ensure smoking material was properly secure for a dependent resident. This affected one (Resident #8) out of two residents reviewed for smoking. The facility further failed to ensure fall interventions were in place to prevent a resident's fall. This affected one (Resident #37) out of three residents reviewed for falls. The facility census was 48.
- D
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Inspectors wroteBased on medical record review and staff interview, the facility failed to ensure residents had proper diagnoses for medications and also failed to ensure blood draw orders had the correct reason. This affected one (Resident #8) of five residents reviewed for unnecessary medication. The facility census was 48.
- 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 medical record review, observation, staff interview and facility policy review, the facility failed to ensure one of five medication carts were locked and secure. This had the potential to affect two Resident's (#44 and #45) the facility identified as independently mobile and cognitively impaired. The facility census was 48.
- C
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
Inspectors wroteBased on record review and staff interview it was determined the facility failed to have all require staff members attendance the quarterly Quality Assessment and Assurance (QAA) meetings as required. This had the potential to effect all 48 residents residing in the facility.
Fire safety inspections
39 fire safety citations on file: 7 on January 8, 2026, 10 on February 20, 2025, 7 on December 13, 2022, 15 on December 5, 2019.
Every fire safety citation39 citations
- F
Conduct testing and exercise requirements.
E 39 · January 8, 2026 · Corrected (the home has a date of correction)
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · January 8, 2026 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · January 8, 2026 · Corrected (the home has a date of correction)
- F
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
K 761 · January 8, 2026 · Corrected (the home has a date of correction)
- E
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
K 222 · January 8, 2026 · Corrected (the home has a date of correction)
- E
Provide properly protected cooking facilities.
K 324 · January 8, 2026 · Corrected (the home has a date of correction)
- E
Have an alternate power supply for its alarm system.
K 344 · January 8, 2026 · Corrected (the home has a date of correction)
- F
Develop and maintain an Emergency Preparedness Program (EP).
E 4 · February 20, 2025 · Corrected (the home has a date of correction)
- F
Conduct risk assessment and an All-Hazards approach.
E 6 · February 20, 2025 · Corrected (the home has a date of correction)
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · February 20, 2025 · Corrected (the home has a date of correction)
- F
Follow proper procedures when the fire alarm was out of service for more than 4 hours.
K 346 · February 20, 2025 · Corrected (the home has a date of correction)
- F
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
K 354 · February 20, 2025 · Corrected (the home has a date of correction)
- F
Provide a written emergency evacuation plan.
K 711 · February 20, 2025 · Corrected (the home has a date of correction)
- F
Have simulated fire drills held at unexpected times.
K 712 · February 20, 2025 · Corrected (the home has a date of correction)
- F
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
K 741 · February 20, 2025 · Corrected (the home has a date of correction)
- E
Keep aisles, corridors, and exits free of obstruction in case of emergency.
K 211 · February 20, 2025 · Corrected (the home has a date of correction)
- E
Inspect, test, and maintain automatic sprinkler systems.
K 353 · February 20, 2025 · Corrected (the home has a date of correction)
- F
Have exits that are accessible at all times.
K 271 · December 13, 2022 · Corrected (the home has a date of correction)
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · December 13, 2022 · Corrected (the home has a date of correction)
- F
Follow proper procedures when the fire alarm was out of service for more than 4 hours.
K 346 · December 13, 2022 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · December 13, 2022 · Corrected (the home has a date of correction)
- F
Provide a written emergency evacuation plan.
K 711 · December 13, 2022 · Corrected (the home has a date of correction)
- F
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · December 13, 2022 · Corrected (the home has a date of correction)
- E
Provide properly protected cooking facilities.
K 324 · December 13, 2022 · Corrected (the home has a date of correction)
- F
Meet other general requirements.
K 100 · December 5, 2019 · Corrected (the home has a date of correction)
- F
Install emergency lighting that can last at least 1 1/2 hours.
K 291 · December 5, 2019 · Corrected (the home has a date of correction)
- F
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
K 321 · December 5, 2019 · Corrected (the home has a date of correction)
- F
Have an alternate power supply for its alarm system.
K 344 · December 5, 2019 · Corrected (the home has a date of correction)
- F
Follow proper procedures when the fire alarm was out of service for more than 4 hours.
K 346 · December 5, 2019 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · December 5, 2019 · Corrected (the home has a date of correction)
- F
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · December 5, 2019 · Corrected (the home has a date of correction)
- F
Have properly installed electrical wiring and gas equipment.
K 511 · December 5, 2019 · Corrected (the home has a date of correction)
- F
Provide a written emergency evacuation plan.
K 711 · December 5, 2019 · Corrected (the home has a date of correction)
- F
Have simulated fire drills held at unexpected times.
K 712 · December 5, 2019 · Corrected (the home has a date of correction)
- F
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
K 761 · December 5, 2019 · Corrected (the home has a date of correction)
- E
Keep aisles, corridors, and exits free of obstruction in case of emergency.
K 211 · December 5, 2019 · Corrected (the home has a date of correction)
- E
Install corridor and hallway doors that block smoke.
K 363 · December 5, 2019 · Corrected (the home has a date of correction)
- E
Ensure proper usage of power strips and extension cords.
K 920 · December 5, 2019 · Corrected (the home has a date of correction)
- C
Conduct testing and exercise requirements.
E 39 · December 5, 2019 · deficient, provider has