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 31 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
1G
0H
0I
Potential for more than minimal harm
15D
4E
9F
Potential for minimal harm
0A
2B
0C
June 24, 2026Standard inspection · 6 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 interview, the facility did not store, prepare, distribute, serve food in accordance with professional standards for food service safety. This has the potential to affect all 62 residents. -Surveyor observed clean water pitchers not inverted on open shelf in kitchen. -Surveyor observed in the walk-in cooler an open bag of whipped topping, an open container of butter, and prepared cinnamon rolls in a baking pan without dates indicating when they were opened, prepared, or when they should be used by. -Surveyor observed in the walk-in freezer opened bags of potato wedges, vegetables, and berries all without dates of when they were opened. -Surveyor observed in the dry storage area opened packages of cookies, dried noodles, split peas, powdered pudding and gelatin mixes, all without dates indicating when they were opened or when they should be used by.
- F
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview and record review, the facility did not establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 5 of 62 residents residing in the facility. Improper hand hygiene was observed during personal cares for R4, R6, R13, R40. Staff did not disinfect mechanical lifts after use for R4, R13, and R40 observed transferring with a mechanical lift. Staff did not wear proper personal protective equipment (PPE) when caring for R30 who is on Enhanced Barrier Precautions (EBP). Example1 The facility policy, titled Handwashing/Hand Hygiene, dated 2000, states: This facility considers hand hygiene the primary means to prevent the spread of healthcare-associated infections.1. Hand Hygiene is indicated:a. [...]
- F
Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
Inspectors wroteBased on record review and interviews, the facility failed to ensure the Infection Preventionist (IP) is trained in the required specialized education for infection prevention and control. This has the potential to affect all 62 residents.-The facility failed to ensure Registered Nurse (RN) G, who is acting in the role of the facility's Infection Preventionist (IP), had completed specialized training in infection prevention and control.
- F
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 interview and record review, the facility did not maintain documentation of screening, education, offering, and current Coronavirus 19 (COVID) vaccination status to staff. This has the potential to affect all 62 residents.
- E
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 interview and record review, the facility did not ensure that the Advanced Directives information related to resuscitation status was clearly identified on residents' medical records to ensure their life-sustaining wishes would be honored. This occurred for 9 of 18 sampled residents (R) reviewed for Advanced Directives. (R31, R5, R9, R7, R2, R59, R4, R30, and R32) R31's physician order noted code status of Do Not Resuscitate (DNR)/Do Not Intubate (DNI). R31's advance directive did not include R31's wishes for resuscitation, no DNR/DNI form was signed by R31 or R31's representative, and no documentation in R31's medical record regarding conversation with R31 regarding code status. R5's physician order noted code status of Do Not Resuscitate (DNR)/Do Not Intubate (DNI). [...]
- 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 did not provide pharmaceutical services, including procedures that ensure that accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals to meet the needs of each resident, for 1 of 1 resident (R32) reviewed. R32 did not receive prescribed eye drops per physician order.
March 30, 2026Complaint inspection · 2 citations
- D
Notify the appropriate authorities when residents with MD or ID services has a significant change in condition.
Inspectors wroteBased on interview and record review the facility did not complete a Minimum Data Set (MDS) assessment for significant change in a timely manner.-R1 was admitted to hospice. The MDS assessment for significant change was not completed within 14 days.
- D
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 did not ensure each resident receives adequate supervision and assistance devices to prevent accidents for 1 of 3 residents reviewed (R4). R4 had a fall during a 1-staff transfer with mechanical lift. Per care plan, R4 required 2-assist.
April 10, 2025Standard inspection, Complaint inspection · 15 citations
- 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 interview and record review, the facility did not designate a person to serve as the director of food and nutrition services who had completed the minimum qualification requirements for the position. This practice could potentially affect all 60 residents residing in the facility. This is evidenced by: On 4/7/25 at 9:10 AM, Surveyor conducted initial tour of the kitchen with Dietary Manager (DM) D. Surveyor interviewed DM D and requested verification of DM D's qualifications. DM D directed Surveyor to the two certifications on her office wall. On 4/8/25, Surveyor was provided copies of the certifications. In review of the DM certification, Surveyor noted it is for a Food Protection Manager which is accredited by the American National Standards Institute (ANSI)-Conference for Food Protection (CFP). Completed 2023-8-10 and valid through 2028-8-10 from the Always Food Safe Company. [...]
- 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 did not ensure the safety of food handling in accordance with professional standards for food service safety. The facility practices had the potential to affect all 60 residents. Foods stored in the walk-in-cooler were not labeled and dated and the Head [NAME] did not allow the thermometer probe to air dry after cleaning with isopropyl alcohol prior to inserting into foods items intended to be served to residents for lunch. This is evidenced by: The facility policies titled, Food Receiving and Storage revised December 2008, states in part, 7. All foods stored in the refrigerator or freezer will be covered, labeled and dates (use by date). The Food and Drug Administration (FDA) Food Code states in part, 4-901.11 Equipment and Utensils, Air-Drying Required. After cleaning and SANITIZING, EQUIPMENT and UTENSILS: [...]
- F
Provide and implement an infection prevention and control program.
Inspectors wroteExample 3 Facility policy titled, Enhanced Barrier Precautions, dated 05/01/24, states in part: It is the policy of this facility to implement enhanced barrier precautions for the preventions of transmission of multidrug-resistant organisms . 2. Initiation of Enhanced Barrier Precautions: b. An order for enhanced barrier precautions will be initiated for residents with any of the following: 1. Wounds and/or indwelling medical devices (e.g., central lines, urinary catheters .) even if the resident is not known to be infected or colonized with a MDRO. The facility policy titled, Handwashing/Hand Hygiene revised October 2023 states in part, Indications for Hand Hygiene . c. after contact with blood, body fluids, or contaminated surfaces; d. after touching a resident; e. after touching a resident's environment; f. [...]
- F
Implement a program that monitors antibiotic use.
Inspectors wroteBased on interview and record review, the facility did not establish an Infection Prevention and Control Program (IPCP) that must include, at a minimum, the following elements: An Antibiotic Stewardship Program that includes antibiotic use protocols and a system to monitor antibiotic use. This has the potential to affect all 60 residents in the building who may utilize antibiotics. The facility did not ensure a standard of practice for antibiotic use or surveillance was being utilized in the facility's antibiotic stewardship program. This is evidenced by: The Facility policy titled Antibiotic Stewardship Program, dated 10/23, states in part: The Infection Preventionist is responsible for monitoring; investigating and setting forth a control plan to prevent unnecessary infections. [...]
- E
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Inspectors wroteBased on interview, observation and record review, the facility did not take action through documenting grievances, conducting a thorough investigation of the issues identified or provide resolution of the concerns brought to the attention of facility staff regarding missing laundry items. This affected R27, R42, R47, R44, and R4. This is evidenced by: Procedure for completing complaint reports: 1. All sections in complaint/grievance box must be completed entirely. 2. 2. After the complaint is recorded determine if a complaint is related to misappropriation. If the answer is Yes, the Administrator must be notified immediately. 3. In documentation of investigation box, the person in charge in the building will need to start the initial investigation. This may include interviews with staff or other residents, observations, memos posted to particular staff, etc. [...]
- E
Provide safe, appropriate pain management for a resident who requires such services.
Inspectors wroteBased on observation, interview and record reviews, the facility staff failed to ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, to develop comprehensive person-centered care plans to meet residents' goals for pain for or adequately assess and treat pain for 5 of 5 residents (R) reviewed (R49, R1, R24, R30 and R35). -Facility did not provide adequate pain relief, properly assess for pain, or develop a pain care plan for R49, R35 and R1. -R24 had no non-pharmacological interventions for pain. Care plan did not include resident's desired/tolerable pain level or follow-up pain assessment. -R30 received tramadol (an opioid medication) for pain. The facility did not implement pain assessments or interventions to determine the effectiveness of the medication. This is evidenced by the following: [...]
- D
Keep residents' personal and medical records private and confidential.
Inspectors wroteBased on observation, interview and policy review, the facility did not maintain confidentiality of resident medical record information for 3 of 5 sampled and supplemental residents (R45, R19, R16) reviewed. This is evidenced by: Facility policy titled, Confidentiality, Security, and Access to Protected Health Information, with an effective date of 08/19/03, states in part: Protected health information .written, verbal, or stored in paper, photographic, video, or electronic format .will remain confidential. 2. Protected Health Information (PHI) - Health information (medical record) that is identifiable to a specific individual and that is maintained or transmitted by a covered entity in any form, whether in oral, paper, or electronic form. Confidentiality and Security of PHI: 2. Care needs to be taken .in an area and manner that ensures client privacy. [...]
- 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 observation, interview and record review, the facility did not develop and implement a comprehensive person-centered care plan addressing medical and nursing needs. This occurred for 2 of 15 residents (R), (R1, R3) reviewed. R1 did not have a care plan developed to monitor for adverse reactions when R1 was prescribed a diuretic medication. R3's care plans were not developed for hospice and end of life care. This is evidenced by: [...]
- 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 interview and record review, the facility did not ensure care plans were revised to reflect residents' current needs and to provide the needed direction to staff in providing necessary care and services. The facility practice affected 1 of 15 residents' care plans reviewed (R55). R55 had recent increase in behaviors resulting in resident-to-resident altercations on 3/03/2025 and again on 4/1/2025. R55's care plan was not updated to reflect changes identified and the care the resident received.
- 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 observation, interview and record review, the facility did not ensure a resident with limited mobility receives appropriate restorative services, and assistance to maintain or improve mobility with the maximum practicable independence for 2 out of 6 sampled residents (R3 and R9). R3 and R9's passive range of motion (PROM) exercise programs were not completed as ordered. The programs were not reviewed and assessed for appropriateness. This is evidenced by: Example 1 R3 was admitted to the facility on [DATE]. R3's current diagnoses include Alzheimer's disease, dementia, constipation, hypertension, neuralgia, osteoarthritis of knee, muscle weakness, spinal stenosis, pain, transient ischemic attack, anxiety, dysphagia, hemiplegia and hemiparesis, dysphagia, atrial fibrillation, cognitive communication deficit. [...]
- D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Inspectors wroteBased on observations, interviews and record reviews, the facility failed to provide pharmaceutical services related to the accurate administration of inhaled medication for 1 of 2 residents (R), (R19) reviewed. This is evidenced by: Facility policy titled, Administering Medications, with a revised date of 04/2019, states in part: .22. As required or indicated for a medication, the individual administering the medication records in the resident's medical record: c. the route of administration; d. the injection site (if applicable) R19 was admitted to the facility on [DATE] with a pertinent diagnosis of allergic rhinitis. R19's orders noted calcitonin spr 200/act instill one spray into 1 nostril once daily - alt nostril daily. On 04/09/25 at 7:24 AM, Surveyor observed medication administration performed by Licensed Practical Nurse (LPN) H. [...]
- D
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Inspectors wroteBased on observation, interview and record review, the facility did not ensure that a resident's drug regimen was free from unnecessary medications for 3 of 5 residents (R) reviewed for unnecessary medications (R35, R8, R9). R3 is on medications for sleep, without adequate indication for use for the medications melatonin and trazadone. R8 receives an antibiotic daily for urinary tract infection (UTI) prevention. R8 receives a sleep aid of melatonin and hydroxyzine for sleep without adequate indication for use and no sleep care plan with non-pharmacological interventions to promote sleep. R9 receives melatonin for sleep without adequate indication for use and no sleep care plan with non-pharmacological interventions to promote sleep.
- 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 did not ensure residents (R) who were prescribed psychotropic medication were comprehensively assessed for qualitative and quantitative data for individualized targeted behaviors and non-pharmacological interventions implemented for 2 of 4 residents (R1, R8) reviewed. R1 received trazodone, an antidepressant medication, for insomnia. The facility did not implement monitoring interventions to determine the effectiveness of the medication. R8 uses trazodone, an anti-depressant medication, to promote sleep with no adequate indications for use and no non-pharmacological intervention to promote sleep. R8 uses antipsychotic medication and psychotropic medications. Pharmacist requested a gradual dose reduction (GDR), and physician did not provide rationale to continue medication. This is evidenced by: [...]
- 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 interview and record review, the facility did not maintain documentation of screening, education, and ensure offering of current Coronavirus 19 (COVID) vaccination for 1 of 5 residents (R) reviewed. (R1) This is evidenced by: The facility policy titled Influenza and Pneumococcal Vaccinations, dated March 2022, does not refer to COVID vaccinations. This was the only policy provided when requested. Two requests for a related policy were made. The CDC COVID 19 Staying Up to Date with Covid 19 Vaccines states in part: Everyone ages 6 months and older should get a 2024-2025 COVID 19 vaccine. It is especially important to get your 2024-2025 COVID 19 vaccine if you are ages 65 and older, are at high risk for severe Covid-19, or have never received a COVID 19 vaccine. R1 was admitted to the facility on [DATE] and was admitted with the diagnoses that include: [...]
- B
Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.
Inspectors wroteBased on observation and interview, the facility did not ensure at least 100 square feet in a single resident room for 1 of 63 residents (R)58. R58 resides in a room that is less than the required 100 square feet in a single resident room. This is evidenced by: The state Operations Manual, titled Appendix PP- Guidance to Surveyors for Long Term Care Facilities, dated 8/8,24, states: Unless a variance has been applied for and approved under CFR (Code of Federal Regulation) 483.90 (e)(1)(ii), . (rooms must) Measure at least . 100 square feet in single resident rooms. R58 was admitted to the facility on [DATE] with diagnoses atrial fibrillation, anxiety, depression, malnutrition, unspecified mental disorder due to unknown physiological concern and attention deficit hyperactivity disorder. [...]
September 25, 2024Complaint inspection · 1 citation
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on interview, the facility did not ensure residents (R) received adequate supervision in transferring with a mechanical lift to prevent the risk of falling. This occurred for 3 of 3 residents. (R5, R6 and R7).
March 7, 2024Standard inspection · 7 citations
- G
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on observation, interview and record review, the facility did not ensure that 2 of 4 residents (R) reviewed for pressure injuries (PI) (R27 and R6) received care consistent with professional standards of practice to prevent the development of a new pressure injury and promote healing of existing PIs. R27 developed a stage II PI on 10/28/23. On 12/27/23, the PI reoccurred as a stage 3. The care plan for PI interventions was not updated since 12/4/2023. R27 was not repositioned as instructed on the PI care plan, nor had a support surface for a stage 3 PI. The PI reoccurred on 2/14/24, healed on 2/26/24 and reoccurred on 3/6/24 causing actual harm. R6 has a PI; repositioning was not done as indicated on the PI care plan to promote healing of R6's PI. This is evidenced by: [...]
- 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, prepare and distribute food under sanitary conditions. Touching ready to eat foods with contaminated gloves had potential to affect 48 of 58 residents. Not taking temperatures of pureed and liquidized food. Improper hand hygiene by staff for R54, R27, R264 and R31. Bare hand touching of toast for 3 of 3 (R264, R11, R3) residents observed.
- E
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteBased on observation, interview and record review, the facility did not ensure residents (R) were treated with respect and dignity and cared for in a manner to enhance their quality of life. Facility staff stood over R4, R6, R28 and R20 while assisting them to eat. Facility staff used a clothing protector, the edge of a spoon, and rim of a cup to wipe R28, R32 and R4's face during dining.
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on observation, record review and interviews, the facility did not ensure that 1 of 6 sampled residents (R) who are unable to carry out activities of daily living received the necessary services to maintain personal hygiene (toileting/incontinence care). (R7)
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on observation, interview and record review, the facility did not ensure residents received adequate supervision and assistance with eating to prevent the risk of choking. This occurred for 2 of 2 residents (R) reviewed for eating, (R3 and R7).
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview and record review, the facility did not maintain an infection and control program to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. -Improper hand hygiene/glove use for Foley catheter care and during dressing change for suprapubic catheter for 2 of 2 residents with catheters. (R15, R54) -Improper infection control procedure for resident on contact precautions. (R7)
- B
Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.
Inspectors wroteBased on observation and interview, the facility did not ensure at least 100 square feet in a single resident room for 1 of 58 residents (R)264. R264 resides in a room that is less than the required 100 square feet in a single resident room. This is evidenced by: During the entrance conference, it was noted facility has a room with less than the required square footage and is occupied by a resident. room [ROOM NUMBER] measures 96 1/2 square feet. On 03/04/24 at 9:35 AM, Surveyor interviewed Nursing Home Administrator (NHA) A and asked about R264 living in a room with less than the required square footage. NHA A indicated that room [ROOM NUMBER] is still 96.5 square feet and the reason is that it is not cost-effective to remodel the room to expand. NHA A indicated they do usually explain this to residents and/or family and offer a different room if unhappy with this. [...]
Fire safety inspections
16 fire safety citations on file: 2 on June 24, 2026, 12 on April 10, 2025, 2 on March 7, 2024.
Every fire safety citation16 citations
- E
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
K 222 · June 24, 2026 · Corrected (the home has a date of correction)
- D
Install corridor and hallway doors that block smoke.
K 363 · June 24, 2026 · Corrected (the home has a date of correction)
- F
Develop Emergency Preparedness policies and procedures.
E 13 · April 10, 2025 · Corrected (the home has a date of correction)
- F
Establish methods for sharing information.
E 33 · April 10, 2025 · Corrected (the home has a date of correction)
- F
Have properly located and lighted "Exit" signs.
K 293 · April 10, 2025 · Corrected (the home has a date of correction)
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · April 10, 2025 · Corrected (the home has a date of correction)
- F
Install an approved automatic sprinkler system.
K 351 · April 10, 2025 · Corrected (the home has a date of correction)
- E
Have restrictions on the use of highly flammable decorations.
K 753 · April 10, 2025 · Corrected (the home has a date of correction)
- E
Have restrictions on the use of portable space heaters.
K 781 · April 10, 2025 · Corrected (the home has a date of correction)
- D
Keep aisles, corridors, and exits free of obstruction in case of emergency.
K 211 · April 10, 2025 · Corrected (the home has a date of correction)
- D
Have a complete alarm system manually initiated and initiated by fire sprinkler system connection.
K 342 · April 10, 2025 · Corrected (the home has a date of correction)
- D
Have a fire alarm with audible and visual signals that transmits the alarm automatically to notify emergency forces in event of fire.
K 343 · April 10, 2025 · Corrected (the home has a date of correction)
- D
Inspect, test, and maintain automatic sprinkler systems.
K 353 · April 10, 2025 · Corrected (the home has a date of correction)
- D
Have power receptacles that are properly grounded.
K 912 · April 10, 2025 · Corrected (the home has a date of correction)
- D
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
K 741 · March 7, 2024 · Corrected (the home has a date of correction)
- D
Ensure proper usage of power strips and extension cords.
K 920 · March 7, 2024 · Corrected (the home has a date of correction)