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 75 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
3J
0K
0L
Actual harm
1G
0H
0I
Potential for more than minimal harm
48D
11E
10F
Potential for minimal harm
0A
1B
1C
June 30, 2026Complaint inspection · 7 citations
- E
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Inspectors wroteBased on review of facility policies, employee file review, observations, and staff interviews it was determined that the facility failed to prohibit and prevent retaliation, as defined at section 1150B(d)(1) and (2) of the Social Security Act for five of fifteen staff members (Terminated Employees E1, E2, E3, E4, and E5) (Staff interviews to remain confidential). Findings Include: Review of the United States Social Security Act, Section 1150B indicated that:(d) Additional Penalties for Retaliation.-(1) In general.-A long-term care facility may not-(A) discharge, demote, suspend, threaten, harass, or deny a promotion or other employment-related benefit to an employee, or in any other manner discriminate against an employee in the terms and conditions of employment because of lawful acts done by the employee; [...]
- E
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on review of clinical records, observations, and staff interview, it was determined that the facility failed to provide prescribed treatment and services related to the care of pressure ulcers for four of five residents (Resident R6, R16, R26, and R44).
- E
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Inspectors wroteBased on review of facility policy, resident observations, resident and staff interviews, it was determined that the facility failed to have sufficient nursing staff to provide nursing and related services to attain or maintain the highest practicable physical, mental, and psychosocial well-being for 16 of 20 residents interviewed and/or observed (R3, R4, R5, R6, R10. R16, R17, R26, R30, R32, R39, R46, R47, R48, R49, and R50).
- E
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 clinical records, facility policy, and staff and resident interviews, it was determined that the facility failed to ensure the complete and timely administration of a prescribed medications for 48 of 59 residents (Resident R1 through R48).
- E
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 facility documents, clinical records, and staff interview, it was determined that the facility failed to make certain that medical records on each resident are completely and accurately documented. Findings Include:Review of the Medication Administration Audit Report for 6/11/26, indicated Licensed Practical Nurse (LPN) Employee E2 provided the following medications and treatments between 2:00 p.m. and 4:00 p.m.-83 oral medications-2 topical medications-7 injected medications-1 intravenous medication-6 inhaled medications-4 ophthalmic medications-4 blood sugar assessments-8 nutritional supplements provided-1 tuberculosis test assessed-29 pain assessments-6 skilled nursing assessments-3 whole body skin assessments-2 vital sign assessments-1 weight assessment During an interview on 6/25/26, at 12:50 p.m. [...]
- D
Give the resident's representative the ability to exercise the resident's rights.
Inspectors wroteBased on review of facility provided documents, clinical records and staff interviews, it was determined that the facility failed to ensure that a resident's legal surrogate (power of attorney) was provided access to medical records for one of two residents (Resident R51).
- B
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Inspectors wroteBased on review of the Resident Assessment Instrument User's Manual, clinical records, and staff interview, it was determined that the facility failed to make certain that comprehensive Minimum Data Set assessments were completed in the required time frame for six of 24 residents (Resident R3, R6, R27, R15, R17, R20, and R37).
June 1, 2026Complaint inspection · 5 citations
- J
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Inspectors wroteBased on review of facility policy, facility documentation, clinical records, staff and resident representative interview, it was determined that the facility failed to protect a cognitive impairment resident (Resident R1) from non-consensual sexual contact by Closed Record Resident CR2 (Resident CR2) who had a history of sexually inappropriate behaviors with Resident R1. This failure resulted in an Immediate Jeopardy situation for one of 58 residents, when Resident CR2 was found exposing genitals to Resident R1, and Resident R1's hands were on Resident CR2's genitals. Findings Include: Review of facility policy Abuse, Neglect, and Exploitation dated [DATE], indicated that abuse can be identified as verbal, physical, mental, and sexual. [...]
- D
Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death.
Inspectors wroteBased on review of facility policy, closed resident records, business office documents, and staff interview it was determined that the facility failed to convey funds credited to a resident's family for one of three closed resident records (Closed Resident Record CR3).
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on review of facility policy, resident clinical records, reports submitted to the State, and staff interview, it was determined that the facility failed to report allegations of sexual abuse for two of three sampled resident records (Resident R1 and Closed Resident Record CR2).
- D
Respond appropriately to all alleged violations.
Inspectors wroteBased on review of facility policy, clinical records, facility documents, and staff interview, it was determined that the facility failed to conduct a thorough investigation involving an allegation of resident abuse for two of three sampled resident records (Resident R1 and Closed Resident Record CR2).
- D
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Inspectors wroteBased on a review of a job description, facility and clinical records, and staff interviews, it was determined that the Nursing Home Administrator (NHA), and Director of Nursing (DON) did not effectively manage the facility to make certain that residents were free from abuse and failed to make certain the facility implemented its abuse policies, creating an immediate jeopardy situation.
April 23, 2026Standard inspection, Complaint inspection · 20 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 the facility's job descriptions, observations, and staff interviews, it was determined that the facility failed to ensure the consistent services of a full-time Director of Nursing (40 or more hours a week) in the facility. Findings Include: Review of the facility provided Director of Nursing (DON) job description, signed and dated 12/22/25, indicated that the DON position purpose was, to plan, organize, develop, and direct the overall operation of the Nursing Service Department in accordance with current federal, stated, local standards, guidelines, and regulations that govern the facility, and as may be directed by the Administrator and the Medical Director, to ensure the highest level of quality care is maintained at all times. [...]
- F
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on review of facility policy, observations and staff interview, it was determined that the facility failed to properly store, label and date food items in the Main kitchen which created the potential for food borne illness.
- E
Observe each nurse aide's job performance and give regular training.
Inspectors wroteBased on review of facility policy, personnel records and staff interviews, it was determined that the facility failed to complete annual performance evaluations for four of five nursing staff (Nurse Aide (NA) Employees E10, E11, E12, and E13).
- 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 a resident representative's concern, and staff interview, it was determined that the facility failed to ensure that residents have the right to communication and access to persons and services inside the facility. for one of two residents (Resident R64).
- 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 review of facility policy, clinical records, and staff interview, it was determined that the facility failed to provide documentation that residents or resident representatives were given the opportunity to formulate an advance directive (a written instruction such as a living will or durable power of attorney for health care for when the individual is incapacitated) for two of three residents reviewed (Resident R4 and R5).
- 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 review of facility policy, review of clinical records, and staff interview, it was determined that the facility failed to notify the physician of a change in condition for one of three residents (Resident R1).
- D
Ensure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge.
Inspectors wroteBased on review of facility policy and clinical records, and staff interview, it was determined that the facility failed to ensure that discharge documentation was on record for one of three closed resident records (Closed Resident Record R64).
- D
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 one of three residents sampled with facility-initiated transfers (Residents R1), and failed to provide a transfer notice to a representative of the Office of the Long-Term Care Ombudsman Division for one of three residents (Resident R1).
- D
Ensure services provided by the nursing facility meet professional standards of quality.
Inspectors wroteBased on policy review, and staff interview, it was determined that the facility failed to ensure that the nutrition services provided met professional standards of quality for comprehensive care plan development for two of twelve months (March and April 2026). Findings Include: Review of the facility's policy Nutritional Management dated 3/1/26, and previously dated 1/21/26, indicated that monitoring of the resident's condition and care plan interventions will occur on an ongoing basis. [...]
- D
Provide activities to meet all resident's needs.
Inspectors wroteBased on review of facility policy, clinical records, activity documentation, resident council group interview, and resident and staff interviews, it was determined that the facility failed to provide an ongoing program of activities to meet the interests and support the physical, mental, and psychosocial well-being of each resident for one of three residents (Resident R15) and failed to have sufficient activity staff.
- 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, clinical record review, facility provided documents, and staff interviews, it was determined the facility failed to maintain an environment free of potential accident hazards and provide safe bed mobility for one of two residents (Resident R32), and that the facility failed to ensure leg rests were applied to a resident's wheelchair prior to moving resident for one of two residents (Resident R53).
- D
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Inspectors wroteBased on review of facility policy, clinical record review, and staff interview, it was determined that the facility failed to ensure that a resident with an enteral feeding tube (a tube inserted in the stomach through the abdomen) received appropriate treatment and services to prevent potential complications for one of two residents (Residents R10).
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on review of facility policy, clinical records, staff interview, and observations, it was determined that the facility failed to provide appropriate respiratory care for two of two residents (R14 and R44). Findings Include: Review of facility policy Oxygen Administration dated 3/16/26, indicated oxygen is administered to residents who need it, consistent with professional standards of practice, the comprehensive person-centered care plans, and the residents' goals and preferences. Change oxygen tubing weekly and as needed. Change humidifier bottles when empty. Keep delivery system in plastic bag when not in use. Review of facility policy Comprehensive Care Plans dated 3/16/26, indicated the facility will develop and implement a comprehensive person-centered care plan for each resident. [...]
- D
Provide safe, appropriate pain management for a resident who requires such services.
Inspectors wroteBased on review of facility policy, clinical records, and staff and resident interviews it was determined that the facility failed to meet residents pain needs for one of three residents reviewed (Resident R7). Findings Include: Review of the facility policy Pain Management dated 3/16/26, indicated the facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences. Based upon the evaluation, the facility in collaboration with the attending physician/prescriber, otherhealth care professionals and the resident and/or the resident's representative will develop, implement, monitor and revise as necessary interventions to prevent or manage each individual resident's pain beginning at admission. [...]
- D
Provide care or services that was trauma informed and/or culturally competent.
Inspectors wroteBased on review of facility policy, clinical records, and staff interview it was determined that the facility failed to provide trauma survivors with trauma informed care to eliminate or mitigate triggers that may cause re-traumatization of the resident for one of two residents (Resident R43).
- D
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
Inspectors wroteBased on review of facility policy, resident clinical records, and staff interviews, it was determined that the facility failed to ensure a resident received appropriate behavioral health management to maintain the highest practicable well-being for one of four sampled residents (Resident R50).
- 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 facility policy review, clinical record review, and staff interviews, it was determined that the facility failed to provide evidence that the licensed pharmacist's medication regimen was reviewed and acted upon timely for one of five sampled residents (Resident R8).
- 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, observations, and staff interviews, it was determined that the facility failed to properly store medical supplies in one of one medication storage rooms (Main Storage Room), and failed to store one of six residents' medications securely (Resident R45).
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on facility policy, clinical record review, observation, and staff interviews, it was determined that the facility failed to prevent cross contamination and implement appropriate transmission-based precautions for one of three residents (Residents R3). Findings Include: Review of the facility policy Enhanced Barrier Precautions (EBP) last reviewed 3/16/26, indicated Enhanced Barrier precautions are an infection control intervention designed to reduce transmission of multidrug resistant organisms (MDRO) that employs targeted gown and gloves use during high contact resident care activities. An order for enhanced barrier precautions will be obtained for residents with wounds. Gloves and gowns are made available immediately near or outside the resident's room. [...]
- D
Keep all essential equipment working safely.
Inspectors wroteBased on observations, review of facility documentation, and staff interviews, it was determined that the facility failed to make certain that equipment was in safe operating condition for one of one of the facilities crash cart (a cart that contains supplies in the event of an emergency), (Main Nursing Unit).
March 14, 2026Complaint inspection · 11 citations
- J
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Inspectors wroteBased on review of facility policy, clinical records, staff and resident interviews, it was determined that the facility failed to ensure that residents were free from mental and verbal abuse which caused a resident to experience severe psychosocial harm (embarrassment, humiliation) because of the abuse (Resident R1). This situation created an Immediate Jeopardy situation for one of six residents reviewed (Resident R1). Findings Include: Review of the facility provided policy titled Abuse, Neglect, Exploitation and Misappropriation of Resident Property review date of 1/21/26, indicated This facility will not tolerate Abuse, Neglect, and Exploitation of its residents or the Misappropriation of Resident Property. Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting in physical harm, pain, or mental anguish. [...]
- J
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Inspectors wroteBased on policy, employee files, facility documents, staff interviews, it was determined that the facility failed to ensure all staff had a criminal background check prior to working in the facility for one of seven staff members (Social Worker, Employee E1). The facility failed to identify incidents of abuse/neglect, and timely report and investigate allegations of abuse/neglect for one of six residents (Resident R1). The facility put other residents at risk for abuse/neglect from the Nursing Home Administrator (NHA) and Licensed Practical Nurse LPN), Employee E2, by allowing the staff members to continue to work after abuse/neglect occurred. This failure created an immediate jeopardy situation.
- F
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Inspectors wroteBased on review of facility policy, resident observations, resident and staff interviews, it was determined that the facility failed to have sufficient nursing staff to provide nursing and related services to attain or maintain the highest practicable physical, mental, and psychosocial well-being for six residents (Residents R2, R3, R9, R10, R11, and R12).
- F
Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
Inspectors wroteBased on staff interviews and review of employee files it was determined that the facility failed to employ a qualified Food Service Director to manage the daily operations of the Dietary Department for three out of three months (January 2026 through March 2026).
- F
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Inspectors wroteBased on a review of a job description, facility and clinical records, and staff interviews, it was determined that the Nursing Home Administrator (NHA) did not effectively manage the facility to make certain that residents were free from abuse and failed to make certain the facility implemented its abuse policies, creating an immediate jeopardy situation.
- 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 facility documents and staff interview, it was determined that the facility failed to accurately complete the Facility Assessment.
- F
Have a plan that describes the process for conducting QAPI and QAA activities.
Inspectors wroteBased on review of facility documents and staff interviews it was determined that the facility failed to put forth a good faith effort to correct the deficient practice cited during the survey of 3/14/26, by failing to provide adequate staffing to meet the needs of the resident, providing qualifying coursework for the Dietary Manager, provide on sight oversight of daily dietary operations, training the Human Resources Director (Staff member responsible for hiring of qualified staff) to the qualifications of a Dietary Manager, hiring a qualified Dietary Manager to fill a vacant position, and making certain that the Facility Assessment documents are current and accurate as required. (Staffing, training, employment process, and Facility Assessment)
- E
Ensure that the resident and his/her doctor meet face-to-face at all required visits.
Inspectors wroteBased on the review of facility policy,, clinical records, and staff interviews, it was determined that the facility failed to ensure a physician completed the initial visits for three of four residents (Resident R5, R7, and R8).
- E
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on the review of clinical records and staff interview, it was determined that the facility failed to appropriately and timely document progress note in the clinical record for four of four residents (Residents R5, R6, R7, and R8).
- E
Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members.
Inspectors wroteBased on review of facility education documents, and staff interview, it was determined that the facility failed to provide training on effective communication for five of five staff members (Registered Nurse (RN) Employee E15, and Nurse Aides (NA) Employee E8, NA E16, NA E17 and, NA E18).
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on review of facility policy, clinical records, observation, and interviews with staff, it was determined that the facility failed to make certain residents were provided necessary treatment and services, consistent with professional standards of practice, for a pressure ulcer (PU/PIs- injuries to skin and underlying tissue resulting from prolonged pressure on the skin) for one of four residents (Resident R2).
February 19, 2026Complaint inspection · 3 citations
- F
Have a plan that describes the process for conducting QAPI and QAA activities.
Inspectors wroteBased on a review of the facility's plan of correction, documents and staff interviews it was determined that the facility failed to make a good faith effort to correct and sustain improvement for one of two citations issued for failure to provide the required number of Nurse Aides (NA) per resident per shift as required (Citation P5520).
- E
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Inspectors wroteBased on review of facility policy, resident observations, resident and staff interviews, it was determined that the facility failed to have sufficient nursing staff to provide nursing and related services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of five of six residents (Residents R2, R3, R4, R5, and R6).
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on review of facility policy, clinical record review, and staff interview, it was determined that the facility failed to ensure that a resident received neurological assessments after an incident involving a fall for one of five residents (Resident R1).
November 13, 2025Complaint inspection · 8 citations
- G
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Inspectors wroteBased on review of facility policy, facility provided documents, clinical records, and staff interviews, it was determined the facility failed to ensure a resident was free from mental abuse and intimidation for one of two residents reviewed (Resident R1), which resulted in psychosocial harm and mental anguish related to the reasonable person concept.
- 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, clinical record, and staff interview it was determined that the facility failed to have the responsible party sign financial papers for one of two residents ( Resident R2).
- D
Give the resident's representative the ability to exercise the resident's rights.
Inspectors wroteBased on review of facility provided documents, clinical records and staff interviews, it was determined that the facility failed to ensure that a resident's legal surrogate (power of attorney) was utilized for legal action of non-payment of bills for one of two residents (Resident R1).
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on review of facility policy, facility provided documents, clinical records, and staff interviews, it was determined that the facility failed to report an allegation of abuse for one of two residents (Resident R1).
- D
Respond appropriately to all alleged violations.
Inspectors wroteBased on review of facility policy, facility provided documents, clinical records, and staff interviews , it was determined that the facility failed to identify and investigate an incident of possible abuse for one of two incidents (Resident R1).
- D
Ensure the activities program is directed by a qualified professional.
Inspectors wroteBased on review of facility documentation and staff interview it was determined that the facility failed to employ a qualified actives director from October 6, 2025.
- D
Have a plan that describes the process for conducting QAPI and QAA activities.
Inspectors wroteBased on a review of the facility's plan of correction, documents and staff interviews it was determined that the facility failed to make a good faith effort to correct and sustain improvement for two of two citations issued for failure to provide the required number of Nurse Assistants (NA) and Licensed Practical Nurse (LPN) per resident per shift as required ( Citations P 5520, and P5530).
- C
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 post complete contact information for State Long-Term Care Ombudsman program, and accessible, and complete contact information for State Survey Agency at the facility as required.
August 12, 2025Complaint inspection · 1 citation
- 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 review of facility policy, observations and staff interviews it was determined that the facility failed to provide a clean, safe, comfortable, and homelike environment for two of five rooms (C Hall and Shower Room).
June 4, 2025Standard 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 facility policy, observations and staff interview, it was determined that the facility failed to properly label and date food products, in the Main Kitchen. (Main Kitchen).
- 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 two of three residents sampled with facility-initiated transfers (Residents R28 and R61), 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 three resident hospital transfers (Residents R28, R41, and R61), and failed to notify the Office of the State Long-Term Care Ombudsman upon transfer to the hospital for three of three resident hospital transfers (Resident R28, R41, and R61).
- D
Ensure each resident receives an accurate assessment.
Inspectors wroteBased on a review of facility policy, Resident Assessment Instrument (RAI) User's Manual, clinical records, and staff interviews, it was determined that the facility failed to ensure that Minimum Data Set (MDS - a periodic assessment of care needs) assessments accurately reflected the resident's status for three of three residents (Resident R66).
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on clinical record review and staff interview it was determined that the facility failed to make certain that residents were provided appropriate treatment and care for two of eight sampled residents (Resident R39, and R61).
- D
Provide care or services that was trauma informed and/or culturally competent.
Inspectors wroteBased on review of facility policy, resident record review, and staff interviews, it was determined that the facility failed to provide trauma survivors with trauma informed care to eliminate or mitigate triggers that may cause re-traumatization of the resident for one of three residents (Resident R39).
May 6, 2025Complaint inspection · 1 citation
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on review of clinical records, staff, and resident interviews, it was determined that the facility failed to provide Activity of Daily Living (ADL) assistance for three out of nine residents (Resident R2, R3, and R4).
August 19, 2024Complaint inspection · 2 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 facility policy, clinical record review and staff interviews, it was determined the facility failed to notify a family representative of a change in condition for one of three residents. (Resident R1).
- D
Provide timely, quality laboratory services/tests to meet the needs of residents.
Inspectors wroteBased on clinical record review and staff interview it was determined the facility failed to obtain laboratory services as ordered for one of two residents (Resident R1). Findings Include: A review of the facility Medication and Treatment Orders reviewed 3/27/24, indicated physician orders for medications and treatments will be consistent of safe and effective order writing. Treatment orders and follow up appointments will be documented in Point Click Care (PCC) and on the treatment administered record (TAR). A review of Resident R1's clinical record indicates an admission date of 11/21/2023, with the diagnosis of peripheral vascular disease (PVD-narrowing of blood vessels), hypertension (high blood pressure), and atrial fibrillation (abnormal heart rhythm). [...]
July 2, 2024Standard inspection · 9 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 observations and staff interview, it was determined that the facility failed to properly label and date food products in the reach-in cooler and walk- in freezer and failed to maintain sanitary conditions which created the potential for cross contamination (Main Kitchen).
- D
Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
Inspectors wroteBased on facility policy, observation and staff interview, it was determined that the facility failed to maintain the personal dignity for a resident during the dressing change observation (Resident R42).
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on review of facility policy, clinical records, incident reports, State reportable incidents, and staff interview it was determined that the facility failed to report an incident of resident-to-resident abuse altercation for one out of five sampled residents (Residents R24).
- 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, observations, and staff interviews it was determined that the facility failed to ensure that a resident's care plan was updated and revised to reflect the resident's specific care needs for one of four residents (Resident R56).
- 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 facility policy, observation, clinical record review, and staff interview, it was determined that the facility failed to provide treatment and services to prevent further decrease in range of motion for one of three residents (Resident R41).
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on facility policy, clinical and facility record review, facility provided documents and staff interviews, it was determined that the facility failed to provide adequate supervision for two of six residents, resulting in a fall for one of six residents (Resident R24), and resulting in potential interaction with an unsecured disinfectant for one of six residents (Resident R56).
- D
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
Inspectors wroteBased on review of facility documents, clinical records and staff interviews it was determined that the facility failed to identify and meet residents' highest practicable psych-social needs for one of six residents (Resident R33).
- 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, observations and staff interview it was determined that the facility failed to date opened medications and properly store medications in one of three medication carts observed (Middle medication cart).
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on facility policy, clinical record review, observation, and staff interview, it was determined that the facility failed to prevent cross contamination during a dressing change for one of four residents (Resident 42) and failed to provide a safe and sanitary environment to help prevent the potential for cross contamination in the sole shower room.
March 18, 2024Complaint inspection, Infection control · 2 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 clinical record review and staff interview, it was determined the facility failed to notify the physician of a change in condition for twelve of nineteen residents testing positive for Covid-19 (Resident R1, R2, R5, R7, R8, R10, R11, R12, R16, R17, R18, R19).
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on clinical record review and staff interview, it was determined the facility failed to obtain physician orders for transmission-based precautions for three of nineteen residents (Resident R1, R5, R8).
January 19, 2024Complaint inspection · 1 citation
- 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 the facility failed to update a care plan for one of three residents (Resident R23) to accurately reflect the current status of the resident after an elopement event.
Fire safety inspections
8 fire safety citations on file: 1 on May 27, 2026, 2 on April 23, 2026, 1 on June 4, 2025, 4 on July 2, 2024.
Every fire safety citation8 citations
- D
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 · May 27, 2026 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · April 23, 2026 · Corrected (the home has a date of correction)
- E
Meet requirements for the installation and maintenance of electrical systems.
K 911 · April 23, 2026 · Corrected (the home has a date of correction)
- E
Provide properly sized and located linen or trash receptacles.
K 754 · June 4, 2025 · deficient, provider has
- E
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
K 761 · July 2, 2024 · Corrected (the home has a date of correction)
- D
Meet other general requirements.
K 100 · July 2, 2024 · Corrected (the home has a date of correction)
- D
Inspect, test, and maintain automatic sprinkler systems.
K 353 · July 2, 2024 · Corrected (the home has a date of correction)
- C
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · July 2, 2024 · Corrected (the home has a date of correction)