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 28 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
1G
0H
0I
Potential for more than minimal harm
23D
2E
2F
Potential for minimal harm
0A
0B
0C
March 3, 2026Standard inspection · 7 citations
- D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteBased on observations, interviews, and record review, the facility failed to assure staff treated five sampled residents (Residents #1, #11, #30, #31, and #39) in a manner that maintained their dignity during mealtimes by standing during meals, assisting multiple residents at a time, and meals being served without assistance available. The facility census was 57. Review of the facility policy titled, Resident Rights, revised December 2016, showed:- Employees shall treat all residents with kindness, respect, and dignity;- Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: a. a dignified existence; b. be treated with respect, kindness, and dignity; c. be free from abuse, neglect, misappropriation of property, and exploitation; d. be supported by the facility in exercising his/her rights. [...]
- D
Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death.
Inspectors wroteBased on interview and record review, the facility failed to refund resident funds within 30 days of when a resident expired for three residents (Residents #69, #71, and #72) out of three sampled residents and failed to complete a final accounting of resident personal funds within 30 days of discharge for one resident (Resident #70) out of one sampled resident. The facility census was 57. [...]
- D
PASARR screening for Mental disorders or Intellectual Disabilities
Inspectors wroteBased on interview and record review, the facility failed to provide a preadmission screening and resident review (PASARR - a federally mandated preliminary assessment to determine whether a resident may have a mental illness or an intellectual disorder and to determine the level of care needed) for one resident (Resident #8) out of two sampled residents and one resident (Resident #52) outside the sample. The facility census was 57. The facility failed to provide a policy regarding the PASRR. 1. [...]
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on observation, interview, and record review, the facility failed to document the type, the stage, the measurements, and the characteristics of the facility acquired pressure ulcer (areas of localized damage to the skin and/or underlying soft tissue usually over a bony prominence, generally the result of pressure, shear, and/or friction) and also failed to notify and obtain a physician order for one resident (Resident #11) out of one sampled resident with a pressure ulcer. This resulted in Resident #11's stage 1 (intact skin with non-blanchable (discoloration of the skin that does not turn white when pressed) redness of a localized area usually over a bony prominence) pressure ulcer progressing to an open wound. The facility census was 57. [...]
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure proper storage of nasal cannulas (plastic tubing placed in the nostrils to provide supplemental oxygen) when not in use for two residents (Residents #4 and #38) and failed to follow oxygen orders for two residents (Residents #38 and #52) out of four sampled residents. The facility census was 57. [...]
- D
Ensure medication error rates are not 5 percent or greater.
Inspectors wrote:Based on observation, interview, and record review, the facility failed to maintain a medication error rate of less than five percent (%). There were 25 opportunities with two errors made, resulting in an error rate of 8% for two residents (Residents #13 and #54) out of seven sampled residents. The facility's census was 57. Review of the facility's policy titled, Administering Medications, revised April 2019, showed:- Only persons licensed or permitted by this state to prepare, administer and document the administration of medications may do so;- Medications are in accordance with prescriber orders, including any required time frame;- Insulin pens containing multiple doses of insulin are for single resident use only;- Insulin pens are clearly labeled with the resident's name or other identifying information. [...]
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview, and record review, the facility failed to implement enhanced barrier precautions (EBP) and follow appropriate infection control practices with hand hygiene and glove changes when staff performed wound care for three residents (Residents #2, #20, and #58) out of four sampled residents, and during incontinent care for three residents (Residents #11, #31, and #58) out of four sampled residents. The facility also failed to correctly screen three residents (Residents #20, #51, and #68) for tuberculosis (TB - an infectious disease characterized by the growth of nodules in the tissues, especially the lungs) out of five sampled residents as required by state regulation 19 CSR 20-20.100. The facility census was 57. [...]
December 6, 2024Standard inspection · 15 citations
- G
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on interview and record review, the facility failed to provide a safe environment per the resident's assessed level of need, when Resident #21 received a second degree (a burn that damages the epidermis and dermis, the two layers of skin) burn from the spilled coffee in his/her lap after a Certified Nursing Assistant (CNA) handed the resident hot coffee in a coffee cup without a lid for one sampled resident. The census was 69. The facility did not provide a policy regarding accidents/incidents. 1. Review of Resident #21's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument required to be completed by the facility staff, dated 11/19/24, showed: [...]
- 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, interview, and record review, the facility failed to store and distribute food under sanitary conditions, increasing the risk of cross-contamination and food-borne illness. This had the potential to affect all residents. The facility census was 69. The facility did not provide a policy regarding the kitchen. 1. Observation on 12/03/24 at 9:34 A.M., and 12/05/24 at 11:38 P.M., of the kitchen showed: - No cleaning logs; - Two unlabeled white plastic food bins with clear unlabeled lids near the gas range with white sugar and brown sugar; - A metal backsplash behind the gas range with a 2 foot (ft.) diameter (dia.) area with dark brown carbon build-up; - The commercial style can opener with an oily film on the base and blade; - One 3 ft. by 4 ft. [...]
- D
Assure the security of all personal funds of residents deposited with the facility.
Inspectors wroteBased on interview and record review, the facility failed to maintain the surety bond (a purchased bond for security of the residents' personal funds) for at least one and one-half times the average monthly balance of the residents' personal funds for the last twelve consecutive months from October 2023 to September 2024. The facility census was 69. The facility did not provide a policy for the surety bond. 1. Review of the residents' personal funds account on 12/05/24, for the last twelve consecutive months from October 2023 to September 2024, showed: - The facility's current approved bond amount equaled $100,000.00; - The average monthly balance for the residents' personal funds equaled $68,621.10; - An average monthly balance of $68,621.10 required a bond of at least $103,500. [...]
- D
Ensure services provided by the nursing facility meet professional standards of quality.
Inspectors wroteBased on observation, interview, and record review, the facility failed to follow physician orders for one resident (Resident #118) out of six sampled residents when the facility failed to administer the correct amount of insulin (a hormone that helps regulate blood sugar levels by moving glucose from the bloodstream into cells for energy). The facility also failed to follow Registered Dietician (RD) recommendations for one resident (Residents #22) out of four sampled residents. The facility census was 69. Review of the facility's policy titled, Administering Medications, dated April 2019, showed: - Medications are administered in a safe and timely manner and as prescribed; - Medications are administered in accordance with prescriber orders, including any required time frame. The facility did not provide a policy regarding RD recommendations. 1. [...]
- D
Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
Inspectors wroteBased on interview and record review, the facility failed to complete a comprehensive discharge summary for two residents (Residents #58 and #66) out of two discharged residents. The facility's census was 69. The facility did not provide a policy regarding a discharge summary or recapitulation. 1. Review of Resident #58's closed medical record showed: - Resident discharged home on [DATE]; - No documentation of a recapitulation or completed discharge summary. 2. Review of Resident #66's closed medical record showed: - Resident discharged home on [DATE]; - No documentation of a recapitulation or completed discharge summary. During an interview on 12/07/24 at 2:00 P.M., the Administrator and Director of Nursing (DON) said the discharging nurse was responsible for completing the discharge summary. [...]
- 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 observation, interview and record review, the facility failed to ensure a urinary catheter (a tube inserted into the bladder to drain urine) drainage bag and tubing was kept off the floor for one resident (Resident #31) out of two sampled residents. The facility census was 69. Review of the facility policy titled, Catheter Care, Urinary, Revised August 2022, showed: - Be sure the catheter tubing and drainage bag are kept off the floor. Review of Resident #31's Physician Order Sheet (POS), dated December 2024, showed: - An order for urinary catheter care every shift for urinary retention (an inability to empty the bladder of urine), dated 11/26/24; - An order for a 16 French (FR - size of catheter) catheter with 10 cubic centimeter (cc) bulb one time a day every one month starting on the 15th for 28 days, dated 11/26/24; [...]
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observation, interview, and record review, the facility failed to follow physician's orders for supplemental oxygen therapy for two residents (Residents #39 and #62) out of two sampled residents, and failed to ensure proper tracheostomy (trach - incision in the windpipe to relieve an obstruction to breathing) care for one resident (Resident #39) out of one sampled resident. The facility census was 69. The facility did not provide an oxygen policy. Review of the facility's policy titled, Tracheostomy Care, revised August 2023, showed: - The purpose of this procedure is to guide tracheostomy care and the cleaning of reusable tracheostomy cannulas; - Aseptic technique must be used: during cleaning and sterilization of reusable tracheostomy tubes; during tracheostomy tube changes, either reusable or disposable; [...]
- D
Provide care or services that was trauma informed and/or culturally competent.
Inspectors wroteBased on observation, interview, and record review, the facility failed to identify, assess and provide supportive interventions for one resident (Resident #31) with a diagnosis of post traumatic stress disorder (PTSD - a mental health condition triggered by a terrifying event - either experiencing it or witnessing it; symptoms may include flashbacks, nightmares and severe anxiety, as well as uncontrollable thoughts to the event) out of one sampled resident. The facility's census was 69. The facility did not provide a PTSD policy. 1. Review of Resident #31's medical record showed: - admission date of 08/12/24; - Diagnoses of PTSD, depression (a serious medical illness that negatively affects how you feel, the way you think and how you act), and anxiety disorder (persistent worry and fear about everyday situations); [...]
- D
Post nurse staffing information every day.
Inspectors wroteBased on observation and interview, the facility staff failed to post the required daily nurse staffing information which included the total number of staff and the actual hours worked by both licensed and unlicensed nursing staff directly responsible for resident care, in a prominent location readily accessible to residents and visitors for three out of four days. The facility census was 69. The facility did not provide a policy regarding posting of nurse staffing. Observation on 12/04/24 at 9:30 A.M., 12/05/24 at 11:00 A.M., and 12/06/24 at 12:00 P.M., of the facility's Staff Posting Sheet, located on a bulletin board beside the nurse's station showed: -The Staff Posting Sheet, dated 12/02/24; -The facility did not post the required daily nurse staffing information for 12/04/24, 12/05/24, and 12/06/24. [...]
- 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, interview, and record review, the facility failed to ensure the narcotic reconciliations (a process that allows one staff to reconcile the exact narcotic inventory on hand with another staff) were accurate when on-coming and off-going staff failed to document narcotic medications as they were administered for two residents (Residents #21 and #46) which resulted in the inaccuracy of the narcotic counts. The facility census was 69. The facility did not provide a policy for the narcotic count. 1. Review of the 100/200 Certified Medication Technician's (CMT's) cart Controlled Drug Receipt-Record Disposition form on 12/05/24 at 9:45 A.M., showed: - A count of 22 tablets for Resident #21's hydrocodone (a narcotic pain medication) 5/325 milligram (mg) by mouth two times a day for pain, dated 06/13/24; [...]
- 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 interview and record review, the facility failed to limit the use of an as needed (PRN) order for psychotropic (medications that affect how the brain works and causes changes in mood, awareness, thoughts, feelings, or behaviors) medication to 14 days for one resident (Resident 29), failed to attempt a gradual dose reduction (GDR) for one resident (Resident #7), and failed to ensure an appropriate diagnosis for the use of a psychotropic medication for two residents (Residents #31 and #43) out of nine sampled residents. The facility census was 69. Review of the facility policy titled, Tapering Medications and GDR, revised April 2007, showed: [...]
- 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 label and store medications in a safe and effective manner when opened insulin was found undated in the medication cart, failed to ensure the medication cart was locked while unattended, and the facility failed to ensure resident safety by leaving medication in one resident's (Resident #31) room, unattended out of one sampled resident. This had the potential to affect all residents. The facility census was 69. Review of the facility policy titled, Storage of Medications, dated April 2007, showed: - The facility shall store all drugs and biologicals in a safe, secure, and orderly manner; - The nursing staff shall be responsible for maintaining medication storage; - The facility shall not use discontinued, outdated, or deteriorated drugs or biologicals; [...]
- D
Dispose of garbage and refuse properly.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the dumpster was maintained to keep pests out and/or to keep the garbage contained in the dumpster. This failure had the potential to affect all residents. The facility census was 69. The facility did not provide a policy regarding the dumpster. 1. Observations on 12/03/24 at 10:17 A.M., 12/05/24 at 11:33 A.M., and 12/06/24 at 8:53 P.M., of the outside trash dumpster located near the kitchen entrance showed one 6-yard (yd.) dumpster partially filled with two plastic lids completely opened. During an interview on 12/05/24 at 2:10 P.M., the Administrator said the dumpster should be closed when it was unattended and not being filled by the facility staff. During an interview on 12/06/24 at 8:56 A.M., the Assistant Maintenance Director said the trash dumpster should remain closed when it was not being filled. [...]
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview, and record review, the facility failed to perform hand hygiene and glove changes during wound care for two residents (Residents #21 and #36) out of three sampled residents, incontinence care for two residents (Residents #9 and #60) out of five sampled residents, and Foley catheter (a flexible tube inserted into the bladder to drain urine through the urethra) care for one resident (Resident #32) out of one sampled resident. Additionally, the facility failed to follow Enhanced Barrier Precautions (EBP), including wearing of a gown, during high contact patient care activities to prevent the spread of multi-resistant organisms for one resident (Resident #32) out of four sampled residents. [...]
- D
Implement a program that monitors antibiotic use.
Inspectors wroteBased on interview and record review, the facility failed to maintain an Infection Prevention and Control Program (IPCP) that included an antibiotic stewardship program to include an infection surveillance program and antibiotic use protocols. This deficient practice had the potential to affect all residents in the facility. The facility census was 69. Review of the facility's policy titled, Antibiotic Stewardship, revised December 2016, showed: - Antibiotic will be prescribed and administered to the residents under the guidance and the facility's Antibiotic Stewardship Program; - The purpose of the Antibiotic Stewardship Program is to monitor the use of antibiotics in the residents. Review on 12/06/24 at 9:45 A.M., of the Antibiotic Stewardship Program showed: - No documentation of the antibiotic stewardship tracking completed. [...]
March 1, 2024Complaint inspection · 1 citation
- 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 follow professional standards of practice for one resident (Resident #1) of three sampled residents. The facility failed to follow physician's orders and did not attain treatment orders for a wound in a timely manner. The facility census was 69. Review of the facility's policy titled admission Assessment and Follow Up: Role of the Nurse, dated September 2012, showed: - The purpose of this procedure is to gather information about the resident's physical, emotional, cognitive and psychosocial condition upon admission for the purpose of managing the resident, initiating the care plan, and completing required assessment instruments, including Minimum Data Set (MDS); - Conduct admission assessment including a summary of the individual's recent hospitalization, acute illnesses and overall status prior to admission; [...]
July 6, 2023Standard inspection · 5 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 keep one of two facility ice machines clean and sanitary. The failure created the potential for contamination of the ice used for ice water and ice chips for 65 of 66 residents in the facility. 1. Observation on 07/03/23, at 3:35 P.M., of the ice machine utilized to provide ice for the facility residents, showed the following: -The inside of the blue ice scoop receptacle was dirty with dark black matter at the bottom where the scoop was placed; -The outside of the white ice scoop was black on one side; -Corrosion around the base of the condenser located on the top of the ice machine. Particles from the corrosion could fall into the ice when the lid was opened. During an interview on 07/03/23, at 3:49 P.M., [NAME] 8, the Director of Nursing (DON), and a Maintenance Staff (MS) all confirmed the above observation. [...]
- E
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Inspectors wroteBased on observation, record review, and staff interviews, the facility failed to provide a safe, clean, comfortable, and homelike environment for for all residents when the facility failed to maintain clean floors and failed to maintain one resident room, without holes in the walls, where two residents (Resident #6 and #10) resided. 1. Review of Resident #6's Clinical Census, found in the electronic medical record (EMR), under the Clinical tab showed the following: -admission date of 09/25/16; -Diagnoses included bilateral (both sides) hearing loss, legal blindness, adult osteochondrosis of spine (pathologic degenerative process involving the intervertebral disc and the respective vertebral body endplates), and major depressive disorder. [...]
- E
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Inspectors wroteBased on interview and record review,the facility failed to follow related Centers for Disease Control and Prevention (CDC) guidelines for pneumococcal vaccinations for four residents (Resident #26, #33, #35, and #49) of five sampled residents reviewed for influenza/pneumococcal vaccinations. Review of document provided by the facility titled Pneumococcal Vaccination Update/CDC/Advisory Committee on Immunization Practices (ACIP) Guidelines for Older Adults in Long-Term Care Facilities showed the following: -For resident of age greater of equal to [AGE] years of age, giving a dose of the Pneumococcal Conjugate Vaccine ( PCV) 13 was based on clinical decision-making; -For Pneumococcal Polysaccharide Vaccine (PPSV23), it would be one dose; -If PCV13 has been given, then give one year after PCV13. [...]
- D
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Inspectors wroteBased on interviews and record review, the facility failed to protect two residents' (Resident #17 and #52) right to be free from physical abuse when staff failed sufficiently monitor one resident (Resident #169) after the resident hit, or was alleged to have hit, a resident. Review of the facility's policy titled, Resident-to-Resident Altercations, revised September 2022 showed the following: -Facility staff monitor residents for aggressive/inappropriate behaviors towards other residents; -Behaviors that may provoke a reaction by residents or others include physically aggressive behavior, such as hitting, kicking, grabbing, scratching, pushing/shoving, biting, spitting, threatening gestures, throwing objects; -If two residents are involved in an altercation, staff separate the residents, and institute measures to calm the situation. 1. [...]
- D
Ensure services provided by the nursing facility meet professional standards of quality.
Inspectors wroteBased on observation, interview, and record review, the facility failed to assess any potential cause and failed to care plan regarding an itchy scalp and possible scalp condition for one out of one resident (Resident # 21). 1. Review of Resident #21's Clinical tab, located in the electronic medical record (EMR), showed the following: -admission date of 06/21/22; -Diagnoses included Alzheimer's disease and anxiety disorder. Review of the resident's annual Minimum Data Set (MDS - a federally mandated assessment tool completed by facility staff), located under the MDS tab, with an Assessment Reference Date (ARD) of 06/16/23, showed a Brief Interview for Mental Status (BIMS) score of five out of 15, indicating the resident was severely cognitively impaired. Review of the resident's Care Plan, located under the Care Plan Detail, tab, with a a revision date of 06/29/23, showed the following: [...]
Fire safety inspections
9 fire safety citations on file: 2 on March 3, 2026, 2 on December 6, 2024, 5 on July 6, 2023.
Every fire safety citation9 citations
- F
Ensure proper usage of power strips and extension cords.
K 920 · March 3, 2026 · Corrected (the home has a date of correction)
- D
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 · March 3, 2026 · Corrected (the home has a date of correction)
- F
Provide properly protected cooking facilities.
K 324 · December 6, 2024 · Corrected (the home has a date of correction)
- F
Meet requirements for the installation and maintenance of electrical systems.
K 911 · December 6, 2024 · Corrected (the home has a date of correction)
- F
Have simulated fire drills held at unexpected times.
K 712 · July 6, 2023 · Corrected (the home has a date of correction)
- F
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · July 6, 2023 · Corrected (the home has a date of correction)
- E
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · July 6, 2023 · Corrected (the home has a date of correction)
- E
Ensure proper usage of power strips and extension cords.
K 920 · July 6, 2023 · Corrected (the home has a date of correction)
- E
Have proper medical gas storage and administration areas.
K 923 · July 6, 2023 · Corrected (the home has a date of correction)