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 47 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
1G
0H
0I
Potential for more than minimal harm
39D
3E
4F
Potential for minimal harm
0A
0B
0C
January 30, 2026Complaint inspection · 4 citations
- G
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on observation, record review, hospital record review and interview, the facility failed to ensure Resident #2, with a known history of hypothermia, was comprehensively monitored for a change in condition to ensure timely notification to the resident's medical provider to prevent a delay in treatment. This affected one resident (#2) of three sampled residents reviewed for quality of care. The facility census was 49. Actual Harm occurred on 01/17/26 when Resident #2 was noted to exhibit decreased consciousness and was transported to the hospital for evaluation where she was admitted with hypothermia (body temperature of 91 degrees F) and multiple infections requiring treatment in the intensive care unit and antibiotic therapy. [...]
- F
Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.
Inspectors wroteBased on review of the facility assessment and interview, the facility failed to ensure the facility assessment was completed accurately. This had the potential to affect all residents in the facility. The facility census was 49.
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on record review, observations, interview, and policy review, the facility failed to ensure respiratory care was completed as ordered. This affected two residents (#1 and #2) of two residents reviewed for respiratory care. The facility census was 49.
- 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 medical record review, review of staff schedules, review of the National Library of Medicine literature, and interviews, the facility failed to ensure sufficient registered nurses or respiratory therapists were available at the facility to care for residents with ventilators. This affected two (#1 and #2) of two residents with ventilators. The facility census was 49.
November 24, 2025Complaint inspection · 3 citations
- D
Protect each resident from the wrongful use of the resident's belongings or money.
Inspectors wroteBased on record review, review of facility investigations, observations, interviews, and policy review, the facility failed to ensure residents' controlled narcotic medications were not misappropriated. This affected two (#8 and #50) of three residents reviewed for misappropriation of medications.
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on record review, review of facility investigations, observations, interviews, and policy review, the facility failed to ensure all allegations/ suspicions of misappropriation of resident property was reported to the State Survey Agency as required. This affected two (#8 and #50) of three residents reviewed for misappropriation of medications.
- D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Inspectors wroteBased on review of a facility investigation pertaining to an alleged/ suspected tampering of controlled narcotic medications, review of shift to shift controlled medication reconciliation sheets, staff interviews, and policy review, the facility failed to ensure proper pharmacy procedures were followed in regards to performing an appropriate reconciliation of all controlled medications each time keys to medication administration carts providing access to those controlled medications were exchanged between nurses. This affected two (#8 and #50) of three residents reviewed for the handling of controlled narcotic medications.
January 8, 2025Standard inspection · 14 citations
- F
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
Inspectors wroteBased on record review, policy review and interviews, the facility failed to meet at least quarterly to coordinate and evaluate activities under the Quality Assurance and Performance Improvement (QAPI) program. This had the potential to affect all 52 residents residing in the facility.
- E
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Inspectors wroteBased on record review, resident interview, staff interview, and policy review, the facility failed to ensure a multi-disciplinary approach was taken and resident's and/or their representatives were included in the development of their care plans. This affected four (Resident #6, #19, #148, and #149) of four residents reviewed for care planning. The facility census was 52.
- D
Ensure each resident receives an accurate assessment.
Inspectors wroteBased on medical record review and staff interview, the facility failed accurately reflect Resident #14's significant change, including hospice, in the comprehensive significant change in condition assessment. This affected one resident, (Resident #14) of one resident reviewed for Hospice care. The facility census was 52.
- D
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Inspectors wroteBased on medical record review, staff interview and facility policy review, the facility failed to complete a new Pre-admission Screening and Resident Review (PASARR) assessment for Resident #6 with a new diagnosis. The facility also failed to ensure the admission PASARR for Resident #37 was accurate. This affected two residents (#6 and #37) of three residents reviewed for PASARR completion. The facility census was 52.
- D
Notify the appropriate authorities when residents with MD or ID services has a significant change in condition.
Inspectors wroteBased on medical record review, staff interview and facility policy review, the facility failed to notify the mental health authority by completing a resident Pre-admission Screening and Resident Review (PASARR)Level II assessment for Resident #6 with a new diagnosis. This affected one resident (#6) of three residents reviewed for PASARR. The facility census was 52.
- 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 record review and interviews, the facility failed ensure Residents #4, #19, and #36 or their representatives were provided with a copy of their baseline care plan. This affected three residents (#4, #19, #36) of three residents reviewed for baseline care plans. The facility census was 52.
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wrote3. Record review revealed Resident #19 admitted to the facility on [DATE] with diagnoses including malignant neoplasm of stomach and esophagus, muscle wasting and atrophy, and hypertension. Review of a MDS assessment completed 11/27/24 revealed Resident #19's cognition remained intact, and he had no behaviors. Interview on 12/30/24 at 9:42 A.M. with Resident #19 revealed he asks for showers but never gets them unless a certain aide is working. Review of EMR for showers and shower sheets from 12/02/24 through 12/30/24 revealed three scheduled showers were missed on 12/04/24, 12/20/24, and 12/25/24. Interview on 01/08/25 at 9:59 A.M. with LPN #557 confirmed three showers were missing for Resident #19. [...]
- D
Provide activities to meet all resident's needs.
Inspectors wroteBased record review, observations, and interviews, the facility failed to ensure Residents #4 and #19 were invited to participate in activities. This affected two residents (#4 and #19) of two residents reviewed for activities. The facility census was 52.
- 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 record review, interview and facility policy review, the facility failed to address signs and symptoms of a urinary tract infection (UTI) in a timely manner for Resident #36. This affected one resident (#36) of one resident reviewed for UTIs. The facility census was 52.
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on record review, observations, interview and policy review, the facility failed to ensure Resident #4's oxygen tubing was changed once per week as ordered by the physician. This affected one resident (#4) of two residents reviewed for respiratory services. The facility census was 52.
- D
Provide safe, appropriate pain management for a resident who requires such services.
Inspectors wroteBased on record review, interview and facility policy review, the facility failed to address signs and symptoms of pain Resident #36 in a timely manner. This affected one resident (#36) of one resident reviewed for pain. The facility census was 52.
- 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 record review, staff interview and policy review, the facility failed to ensure Resident #37, who received an antipsychotic medication, had an abnormal involuntary movement scale (AIMS) assessment completed to monitor the resident for any extrapyramidal side effects of the medication. This affected one resident (#37) of five residents reviewed for unnecessary medications. The facility assessment was 52.
- 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, staff interview and policy review, the facility failed to ensure stock medications were stored in its original packaging and in a manner that allowed the staff to identify the expiration date of that medication. This affected three (Resident #2, #6, and #12), who resided on the 200 hall and had orders to receive Tylenol Extra Strength medication and received medication from the 200-hall medication administration cart where the improperly stored stock medication was found. The facility census was 52.
- D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wrote3. Review of Resident #11's medical record revealed an admission date of 04/25/23 and a reentry date of 06/12/24. Diagnoses include end stage renal disease, diabetes, morbid obesity, depression, cerebral infarction, and nontraumatic intracerebral hemorrhage. Review of the MDS assessment dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 15 indicating Resident #11 had intact cognition. Further review revealed Resident #11 had orders for hemodialysis every Monday, Wednesday and Friday since 06/13/24. Review of assessments titled Dialysis Pre and Post Evaluation revealed missing assessments on 06/17/24, 06/19/24, 06/28/24, 07/01/24, 07/03/24, 07/10/24, 07/19/24, 07/24/24, 07/26/24, 07/29/24, 07/31/24, 08/28/24, 08/30/24, 10/04/24, 10/11/24, 10/18/24, 10/23/24, 11/01/24,11/04/24, 11/20/24 and 11/27/24. In an interview with LPN Unit Manager #557 on 01/02/25 at 3:00 P.M. [...]
May 10, 2024Complaint inspection · 5 citations
- F
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, medical record review, policy review and interview, the facility failed to initiate enhanced barrier precautions as required. This affected one (Resident #37) of three sampled residents and the potential to affect all 48 residents. The facility identified 21 residents on enhanced barrier precautions (EBP).
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on medical record review, observation and interview, the facility failed to ensure dependent residents received assistance with activities of daily living (ADL) and grooming as needed. This affected two residents (#7, #53) of three sampled residents. The census was 48.
- 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, medical record review and interview, the facility failed to ensure competent nursing staff administered intravenous medications. This affected one (#47) of five residents observed for medication admininstration. The census was 48.
- D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Inspectors wroteBased on observation, medical record review, policy review and interview, the facility failed to ensure medications were stored appropriately and administered when dispensed. This affected two residents (#1, #3) from one of three medication carts observed during medication administration. The census was 48.
- D
Ensure medication error rates are not 5 percent or greater.
Inspectors wroteBased on observation, medical record review, policy review and interview, the facility failed to ensure medications were administered without error. This affected two (#5, #47) of five residents observed during 25 medication opportunities with four medications errors. The medication administration error rate was 16%. The census was 48.
January 18, 2024Standard inspection · 11 citations
- F
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on observation, staff interview, and facility policy review, the facility failed to maintain sanitary conditions in the kitchen. This had the potential to affect all 44 residents residing in the building.
- E
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Inspectors wroteBased on medical record review, staff interview, and review of Centers for Disease Control and Prevention (CDC) documents, the facility failed to provide education to residents regarding influenza and pneumonia vaccines and failed to ensure residents received the recommended pneumonia vaccines. This affected four (Residents #15, #20, #32 and #97) of four residents reviewed for immunizations. The facility census was 44.
- D
Notify the appropriate authorities when residents with MD or ID services has a significant change in condition.
Inspectors wroteBased on record review and staff interview the facility failed to complete and submit a new Preadmission Screening and Resident Review (PASARR) for residents with a significant change in behaviors. This affected one (Resident #05) of two residents reviewed for PASARR screenings. The facility census was 44.
- 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 staff interview the facility failed to ensure the development of comprehensive resident care plans. This affected two (Residents #15 and #20) of 12 residents reviewed for care plans. The facility census was 44.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on medical record review, observation, staff interview, and review of the facility policy, the facility failed to accurately assess residents' skin and obtain timely treatment for areas of impaired skin integrity. This affected two (Residents #01 and #35) of three residents reviewed for skin integrity. The facility census was 44.
- 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 the facility policy, the facility failed to accurately assess resident risk for falls and failed to ensure fall prevention interventions were implemented to prevent falls. This affected one (Resident #11) of one resident reviewed for accidents. The facility census was 44.
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on medical record review, staff interview, and review of the facility policy the facility failed to ensure residents were provided with oxygen therapy as ordered. This affected one (Resident #11) of one resident reviewed for respiratory care. The facility census was 44.
- D
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
Inspectors wroteBased on medical record review and staff interview, the facility failed to provide necessary behavioral health services to residents. This affected one (Resident #5) of one resident reviewed for behavioral health. The facility census was 44.
- 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 medical record review and staff interview the facility failed to ensure physicians documented a rationale indicating why consultant pharmacist medication regimen recommendations were rejected. This affected one (Resident #32) of five residents reviewed for unnecessary medications. The facility census was 44.
- D
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Inspectors wroteBased on medical record review, observation, staff interview, review of alternate menu and review of the facility policy, the facility failed to ensure alternate menu items included a variety based on resident preferences, likes or dislikes and failed to ensure residents knew what was on the alternate menu and where to find it. This affected two (Residents #15 and #20) of two residents reviewed for food preferences. The facility census was 44.
- 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 and staff interview the facility failed to ensure residents were educated regarding the risk and benefits of Coronavirus (COVID-19) vaccination. This affected three (Residents #20, #32, and #97) of four residents reviewed for vaccines. The facility census was 44.
November 14, 2022Standard inspection · 10 citations
- E
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wrote3. Review of Resident #349's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including pneumonia, diabetes, severe protein calorie malnutrition, pacemaker, epilepsy, dementia, high blood pressure and anemia. Review of the admission MDS 3.0 assessment, dated 11/08/22 revealed the resident required staff assistance for activities of daily living. Review of the physician's orders for 11/2022 revealed an order to change aerosol nebulizer set-up every seven days and as needed (PRN) on night shift every Sunday. The resident also had an order for Ipratropium Bromide Solution 0.02 % 2.5 ml inhalation three times a day for COPD. On 11/07/22 at 12:30 P.M., 3:03 P.M. and 4:02 P.M. observation revealed the resident's nebulizer with tubing and mask were not dated or covered and laying on the resident's bed side stand uncovered. On 11/08/22 at 10:43 A.M. [...]
- 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, facility policy and procedure and interview the facility failed to ensure Resident #43's physician was notified timely regarding the resident's discharge against medical advice. This affected one resident (#43) of four residents reviewed for hospitalization.
- 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, facility policy and procedure review and interview the facility failed to ensure written notification was provided related to bed hold procedures. This affected two residents (#27 and #44) of four residents reviewed for hospitalization.
- 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 review, facility policy and procedure review and interview the facility failed to ensure Resident #95's plan of care was accurate and updated to reflect the resident's advance directives. This affected one resident (#95) of one resident reviewed for advanced directives.
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on observation, record review, facility policy and procedure review and interview the facility failed to ensure Resident #246, who required staff assistance for activities of daily living received adequate and timely assistance with nail care to maintain proper hygiene. This affected one resident (#246) of four residents reviewed for activities of daily living (ADL) care.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on observation, record review and interview the facility failed to ensure physician ordered anti-embolism stockings/(TED) hose were in place for Resident #2. This affected one resident (#2) of one resident reviewed for hemodialysis.
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on observation, record review, facility policy and procedure review and interview the facility failed to ensure wound care was provided using proper and adequate infection control techniques to decrease the risk of infection for Resident #349. This affected one resident (#349) of two residents reviewed for pressure ulcers.
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on observation, record review, facility policy and procedure review and interview the facility failed to ensure fall safety measures were in place for Resident #19 as planned. This affected one resident (#19) of three residents reviewed for accidents.
- D
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
Inspectors wroteBased on observation, record review, facility policy and procedure review and interview the facility failed to ensure pureed food was prepared by the recipe to ensure it was served at the proper consistency. This affected two resident (#39 and #349) two residents who received pureed diets from the kitchen.
- 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, record review and interview the facility failed to ensure Resident #21's medical record was maintained in an accurate manner related to wound care. This affected one resident (#21) of two residents reviewed for pressure ulcers.
Fire safety inspections
11 fire safety citations on file: 7 on January 8, 2025, 2 on January 18, 2024, 2 on November 14, 2022.
Every fire safety citation11 citations
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · January 8, 2025 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · January 8, 2025 · Corrected (the home has a date of correction)
- F
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · January 8, 2025 · Corrected (the home has a date of correction)
- E
Install an approved automatic sprinkler system.
K 351 · January 8, 2025 · Corrected (the home has a date of correction)
- E
Install smoke barrier doors that can resist smoke for at least 20 minutes.
K 374 · January 8, 2025 · Corrected (the home has a date of correction)
- E
Have properly installed electrical wiring and gas equipment.
K 511 · January 8, 2025 · Corrected (the home has a date of correction)
- E
Have proper power supply for life support equipment.
K 915 · January 8, 2025 · Waiver
- F
Provide properly protected cooking facilities.
K 324 · January 18, 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 18, 2024 · Corrected (the home has a date of correction)
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · November 14, 2022 · Corrected (the home has a date of correction)
- E
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
K 321 · November 14, 2022 · Corrected (the home has a date of correction)