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 33 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
1J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
24D
4E
3F
Potential for minimal harm
0A
0B
1C
August 8, 2025Standard inspection, Complaint inspection · 12 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 a review of policy, observation and staff interview, it was determined that the facility failed to properly maintain kitchen equipment in a sanitary condition creating the potential for cross contamination in the main kitchen of the facility. A review of facility policy Food Safety and Sanitation dated 1/3/25, indicated all local, state and federal standards and regulations are followed in order to assure a safe and sanitary food service department. During an observation on 8/4/25, at 10:55 a.m., of the walk-in cooler in the main kitchen, conducted with Dietary Supervisor (DS) Employee E2, revealed that the cold air condenser unit had a build-up of dust, grime, and dark colored debris around the fan covers and the area of the condenser immediately around the fans. DS Employee E2 confirmed observation by surveyor when viewed. [...]
- E
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Inspectors wroteBased on review of facility policy, clinical record review, and staff interview, it was determined that the facility failed to make certain that the necessary resident information was communicated to the receiving health care provider for four of six residents sampled with facility-initiated transfers (Residents R11, R42, R143, and R201), and failed to notify the resident or resident's representative of the facility bed-hold policy (an agreement for the facility to hold a bed for an agreed upon rate during a hospitalization) for three of six resident hospital transfers (Residents R4, R11, and R143).
- 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 review of facility policies, observations, and staff interviews, it was determined that the facility failed to properly store medications for one of four residents (Resident R171) the pharmacy driver left medications unattended and unsecured during a delivery during one observation.
- D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteBased on review of facility policy, resident and staff interviews it was determined that the facility failed to offer residents the opportunity to vote for the May 2025 election.
- D
Reasonably accommodate the needs and preferences of each resident.
Inspectors wroteBased on review of facility policy, observations, and staff interview, it was determined that the facility failed to accommodate the call bell needs for one of five residents (Resident R80).
- D
Post a list of names, addresses, and telephone numbers of all pertinent State agencies and advocacy groups and a statement that the resident may file a complaint with the State Survey Agency.
Inspectors wroteBased on observations and staff interview it was determined that the facility failed to have complete contact information for the State Long Care Ombudsman program posted at the facility.
- D
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
Inspectors wroteBased on facility policy, clinical record review and staff interviews, it was determined that the facility failed to ensure that residents medication regime was free from unnecessary psychotropic medication for one of four residents (Resident R10). Review of facility policy Use of Psychotropic Medication(s) date 1/3/25, indicated that residents only receive psychotropic medications when other nonpharmacological interventions are clinically ineffective. Additionally, these medications should only be used to treat the resident's medical symptoms and not used to discipline or staff convenience, which would deem it a chemical restraint. A psychotropic drug is any drug that affects brain activities associated with mental processes and behaviors. [...]
- 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 review of policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to develop comprehensive care plans that included specific and individualized interventions to address the care needs of residents for one of two residents reviewed (Resident R84), relating to visual impairment.
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on review of facility policy, clinical records, and staff interview, it was determined that the facility failed to make certain that residents received proper treatment for pressure ulcers for one of five residents (Resident R5).
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on review of facility policy, review of facility documentation, review of clinical records, and staff interview, it was determined that the facility failed to identify and assess a resident for smoking safety in a timely manner for one of two residents (Resident R89).
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on review of facility policies and clinical records, observations, and staff interviews, it was determined that the facility failed to properly monitor resident's personal refrigerators to ensure that food is properly stored and maintained for two of two residents (Residents R5 and R143), and failed to ensure enhanced barrier precautions (EBP) were implemented for two of three residents (Resident R10 and R40).
- D
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Inspectors wroteBased on facility policy, clinical record review and staff interview, it was determined that the facility failed to complete Influenza vaccination consent and administer the Influenza vaccination in a timely manner for one of five residents (Resident R3).
September 12, 2024Complaint inspection · 1 citation
- C
Ensure services provided by the nursing facility meet professional standards of quality.
Inspectors wroteBased on review of clinical records and staff interview it was determined that the facility failed to provide care and services according to accepted standards of clinical practice in the identification of a resident's transfer destination prior to disposition of a body for two of three residents (Resident CRR1 and CRR2).
August 29, 2024Standard inspection · 10 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 policy, observations and staff interview, it was determined that the facility failed to properly label food products in the dry storage area and maintain sanitary conditions in the dish room and kitchen which created the potential for cross contamination in the designated main kitchen.
- E
Allow residents to self-administer drugs if determined clinically appropriate.
Inspectors wroteBased on observations, resident, and staff interviews, it was determined that the facility failed to determine the ability to self-administer medications for three of six residents (Residents R24, R77, and R281).
- E
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 review of facility policy, clinical record review, observations, and staff interview, it was determined that the facility failed to ensure that appropriate treatment and services were provided for five of seven residents with a urinary catheter (a hollow, flexible tube that collects urine from the bladder and leads to a drainage bag) (Resident R38, R63, R78, R93 and R99).
- 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 review of facility policy, clinical records, and staff interview, it was determined that the facility failed to revise/update care plans for two of seven residents to accurately reflect the current status of the resident (Resident R54 and R86).
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on observation, facility procedure review, clinical record review, and staff interview, it was determined that the facility failed to make certain that residents were provided appropriate treatment and care of a medical device for one of four residents (Resident R283).
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on review of facility policy and clinical records, and staff interview, it was determined that the facility failed to ensure that residents received treatment and care in accordance with standards of practice and obtain physician orders regarding the dressing displacement for one of three residents (Resident R100).
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on facility policy review, observations, and staff interviews, it was determined that the facility failed to maintain sanitary conditions of respiratory equipment for two of eight residents reviewed (Residents R38 and R281), and failed to care plan use and management of respiratory equipment for two of three residents (Resident R5 and R6).
- D
Ensure that residents are free from significant medication errors.
Inspectors wroteBased on review of facility policy, clinical records, and staff interview, it was determined that the facility failed to make certain medications were administered as ordered by the physician and failed to notify the physician of missed medications for one of four residents (Residents R335).
- 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 review of facility policy, observation, and staff interviews, it was determined that the facility failed to properly store medical supplies and biologicals in one of four medication rooms (Blankenbuehler medication room).
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on facility policy, Centers for Disease Control (CDC) documents, clinical record review, observation, and staff interview, it was determined that the facility failed to follow enhanced barrier precautions for one of two residents with an enteral feeding (Resident R96), and failed to prevent the potential for cross contamination during a dressing change for one of three residents (Resident R93).
July 12, 2024Complaint inspection · 2 citations
- J
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on review of facility policy, clinical records, facility documents, and staff interviews, it was determined that the facility failed to make certain each resident received adequate supervision that resulted in an elopement (resident exits to an unsupervised or unauthorized area without the facility's knowledge) for one resident. This failure created an immediate jeopardy situation for one of eight residents who were identified as at risk for elopement (Resident R1).
- D
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Inspectors wroteBased on review of job descriptions, clinical records, and staff interviews, it was determined that the Nursing Home Administrator and Director of Nursing did not effectively manage the facility to make certain that necessary care and services were provided to residents requiring adequate supervision to prevent elopement.
October 20, 2023Standard inspection · 8 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 facility policy, observations and staff interviews it was determined that the facility failed to maintain sanitary conditions in the dish room which created the potential for cross contamination. (Main Kitchen)
- D
Ensure each resident receives an accurate assessment.
Inspectors wroteBased on clinical record review and staff interview, it was determined that the facility failed to ensure complete and accurate Minimum Data Set (MDS) assessments for two of two residents reviewed (Residents R134 and R136).
- 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 review of facility policy, resident observations, clinical record review and staff interviews, it was determined that the facility failed to develop a plan of care to include a focus and interventions to for a resident's tube feed in order to maintain a resident's highest practicable physical well-being as required for one of six residents reviewed. (Resident R114)
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on review of facility policy, clinical records and staff interview, it was determined that the facility failed to follow a order as prescribed by the physician for one of four residents (Resident R66).
- 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 review of facility policy and the clinical record and interview with staff, it was determined that the facility failed to provide care and treatment as ordered for two of four residents with foley catheters reviewed (Resident R66, R106).
- D
Ensure that nurse aides who have worked more than 4 months, are trained and competent; and nurse aides who have worked less than 4 months are enrolled in appropriate training.
Inspectors wroteBased on review of personnel files and staff interview, it was determined that the facility failed to ensure nurse aides who failed to become certified within four months were not working in the facility for one of five Employees reviewed (Nurse Aide, Employee E5). Findings Include: Review of Nurse Aide (NA), Employee E5 personnel file indicated he was hired on 5/15/23, as a non-certified nursing assistant. Review of NA, Employee E5's personnel file indicated he completed the Nurse Aide Training program on 6/8/23. A further review indicated NA, Employee E5 failed the Nurse Aide Written exam on 10/5/23. Review of the facility Deployment Sheets dated 10/7/23, indicated NA, Employee E5 worked 2:00 p.m. until 10:30 p.m. Review of the facility Deployment Sheets dated 10/10/23, indicated NA, Employee E5 worked 10:00 p.m. until 6:30 a.m. [...]
- D
Observe each nurse aide's job performance and give regular training.
Inspectors wroteBased on review of facility policy, personnel files and staff interviews it was determined that the facility failed to complete annual performance evaluations for two out of five personnel files (Nurse Aide Employee E2 and E3).
- D
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
Inspectors wroteBased on review of facility policy, personnel files and staff interview it was determined that the facility failed to ensure the minimum 12 hours of nurse aide training per year and annual training on dementia management for one out of five nurse aide personnel files were completed (Nurse aide, Employee E4).
Fire safety inspections
10 fire safety citations on file: 5 on August 8, 2025, 3 on August 29, 2024, 2 on October 20, 2023.
Every fire safety citation10 citations
- F
Have proper medical gas storage and administration areas.
K 923 · August 8, 2025 · Corrected (the home has a date of correction)
- E
Inspect, test, and maintain automatic sprinkler systems.
K 353 · August 8, 2025 · Corrected (the home has a date of correction)
- C
Provide properly protected cooking facilities.
K 324 · August 8, 2025 · Corrected (the home has a date of correction)
- B
Have an enclosure around a vertical opening shaft.
K 311 · August 8, 2025 · Corrected (the home has a date of correction)
- B
Have power receptacles that are properly grounded.
K 912 · August 8, 2025 · Corrected (the home has a date of correction)
- F
Meet other general requirements.
K 100 · August 29, 2024 · Corrected (the home has a date of correction)
- D
Satisfy building requirements after a repair, renovation, modification, or change of user/occupancy.
K 111 · August 29, 2024 · Corrected (the home has a date of correction)
- C
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · August 29, 2024 · Corrected (the home has a date of correction)
- E
Provide properly sized and located linen or trash receptacles.
K 754 · October 20, 2023 · Corrected (the home has a date of correction)
- D
Ensure proper usage of power strips and extension cords.
K 920 · October 20, 2023 · Corrected (the home has a date of correction)