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 16 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
1K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
13D
2E
0F
Potential for minimal harm
0A
0B
0C
September 11, 2025Standard inspection, Complaint inspection · 6 citations
- E
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Inspectors wroteBased on record review, resident interview, staff interview, and policy review the facility failed to ensure care conferences were conducted quarterly. This affected four (#12, #38, #39, and #51) of four residents reviewed for care conferences. The facility census was 67. 1. Review of medical record for Resident #12 revealed an admission date of 04/29/25 with diagnoses including but not limited to type two diabetes, congestive heart failure, chronic atrial fibrillation, and major depressive disorder. Review of Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #12 was cognitively intact. Review of care conference notes revealed the last care conference was held on 11/19/24 and only two members of the interdisciplinary team (IDT) were present. 2. [...]
- D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteBased on record review, observation, interview, and policy review the facility failed to ensure resident dignity when giving insulin injections. This affected one (#39) resident of one resident reviewed for insulin injections. The facility census was 67. Review of medical record for Resident #39 revealed an admission date of 08/26/22 with diagnoses including type two diabetes, dementia, and major depressive disorder. Review of Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #39 had moderate cognitive impairment. Review of current physician orders revealed an order initiated on 09/08/25 following the observation in the dining room indicating may give medications, check blood sugar and give insulin in public spaces and dining room. Observation on 09/08/25 at 11:22 A.M. [...]
- D
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Inspectors wroteBased on record review, interview, and policy review the facility failed to ensure residents were provided written bed hold notices. This affected two (#75 and #78) of three reviewed for hospitalizations. The facility census was 67. 1. Review of Resident #75 medical record revealed an admission date of 6/10/25, diagnoses included acute and chronic respiratory failure with hypoxia, atrial fibrillation, heart failure, hypo-osmolality and hyponatremia, chronic lymphocytic leukemia of B-cell, atherosclerotic heart disease, chronic obstructive pulmonary disease, hypertension, and cerebral infarction. Review of Resident #75's Minimal Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively intact, required partial assistance with activities, and required a wheelchair for ambulation. [...]
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on record review, interview, and policy review the facility failed to ensure wounds were assessed weekly for Resident #67, and the facility further failed to ensure treatments were in place and completed per physician order for Resident #52. This affected two (#67 and #52) residents of three residents reviewed for wounds. The facility census was 67. 1. Review of medical record for Resident #67 revealed an admission date of 01/19/25 with diagnoses including but not limited to acute transverse myelitis in demyelinating disease of central nervous system, paraplegia, pressure ulcer of right buttock stage four (severe form of skin damage involving full-thickness tissue loss exposing muscle, tendon, or bone), and major depressive disorder. Review of Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #67 was cognitively intact. [...]
- D
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Inspectors wroteBased on record review and interview the facility failed to ensure pre and post dialysis communication forms. This affected one (#55) resident of one resident reviewed for dialysis. The facility census was 67. Review of medical record for Resident #55 revealed an admission date of 06/20/25 with diagnoses including but not limited to type two diabetes, end stage renal disease, and dependence on renal dialysis. Review of Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #55 was cognitively intact. Review of current physician orders revealed an order to complete the pre dialysis communication form every night shift on Tuesday, Thursday, and Sunday and to complete the post dialysis form every Monday, Wednesday, and Friday. [...]
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview, and facility policy review the facility failed to ensure gloves and/or hand hygiene was completed prior to administering an insulin injection. This affected one resident #39 of one resident observed for insulin administration. Further more, the facility failed to provide sanitary environment when passing meal trays in resident's rooms. This affected two residents (#41 and #43) out of seven room trays observed. Census was 67. 1. Review of medical record for Resident #39 revealed an admission date of 08/26/22 with diagnoses including type two diabetes, dementia, and major depressive disorder. Review of Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #39 had moderate cognitive impairment. [...]
February 20, 2025Complaint inspection · 1 citation
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on record review, review of the facility policy, staff interview, and resident interview, the facility failed to ensure all care was provided to residents with pressure ulcers per thier physician's orders. This affected one (Resident #2) out of four residents reviewed for pressure ulcer care. The current census is 67.
September 9, 2024Complaint inspection · 4 citations
- D
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Inspectors wroteBased on medical record review, review of the facilities Self-Reported Incident (SRI) including investigation, observations, staff interview, and review of the facilities abuse policy, the facility failed to ensure a resident was free from physical abuse. This affected one (#200) of four residents reviewed for abuse. The facility census was 66.
- 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 medical record review, observations, staff interviews, and review of the facility policy, the facility failed to ensure a resident's plan of care was revised when changes were made for the resident's comfort and positioning. This affected one (#200) of four residents reviewed for plan of care. The facility census was 66.
- D
Ensure medication error rates are not 5 percent or greater.
Inspectors wroteBased on observation, record review, staff interview, and facility policy review the facility failed to ensure medications were administered according to physician orders, resulting in a medication error rate exceeding five percent (%). 32 opportunities were observed with two medication errors, resulting in 6.3% error rate. This affected one (Resident #450) of four residents observed during the medication administration. The facility census was 66.
- D
Ensure that residents are free from significant medication errors.
Inspectors wroteBased on record review, facility policy review and resident and staff interviews, the facility failed to ensure medications were administered to the residents without any significant medication errors. This affected two (#100 and #125) of six residents reviewed for medication administration. The facility census was 66.
May 30, 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 medical record review, staff interview and policy review, the facility failed to ensure a resident representative was notified of a resident elopement timely. This affected one (#46) resident out of the three residents reviewed for notification of changes. The facility census was 73.
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on medical record review, review of a facility self-reported incident (SRI), staff interviews and policy review, the facility failed to provide adequate interventions and/or supervision to ensure a resident who was assessed as being at risk for elopements did not elope from the facility. This affected one (#46) resident out of three residents reviewed for elopement. The facility census was 73.
January 22, 2024Complaint inspection · 1 citation
- K
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on observations, staff interviews, medical record review, review of Joerns Hoyer user instruction manual and Invacare patient slings operator's manual, review of the facility's Self-Reported Incident (SRI) and investigation including witness statements, review of the emergency medical services (EMS) report, review of hospital documentation, review of the facility policies on transfer, mechanical lifts, and the mechanical lift checklist, the facility failed to ensure a resident requiring transfers with a mechanical lift was transferred safely. [...]
July 13, 2023Standard inspection · 1 citation
- 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 record review, staff interview, review of a facility investigation, and review of a self-reported incident, the facility failed to ensure care plans were developed and implemented for residents with wandering and eloping behaviors. This affected two (#53 and #20) of five residents reviewed for behaviors. The current census was 68.
September 12, 2019Standard inspection · 1 citation
- E
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on observation, staff interview, and record review, the facility failed to ensure yogurt was not expired. This had the potential to affect all 70 residents who reside on Mac-o-[NAME] Hall, Buckeye Hall, Myeerah Hall, and Madriver Hall. The facility census was 84.
Fire safety inspections
29 fire safety citations on file: 11 on September 11, 2025, 11 on July 13, 2023, 7 on September 12, 2019.
Every fire safety citation29 citations
- F
Conduct risk assessment and an All-Hazards approach.
E 6 · September 11, 2025 · Corrected (the home has a date of correction)
- F
Establish staff and initial training requirements.
E 37 · September 11, 2025 · Corrected (the home has a date of correction)
- F
Install emergency lighting that can last at least 1 1/2 hours.
K 291 · September 11, 2025 · Corrected (the home has a date of correction)
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · September 11, 2025 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · September 11, 2025 · Corrected (the home has a date of correction)
- F
Have simulated fire drills held at unexpected times.
K 712 · September 11, 2025 · Corrected (the home has a date of correction)
- F
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · September 11, 2025 · Corrected (the home has a date of correction)
- E
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · September 11, 2025 · Corrected (the home has a date of correction)
- E
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
K 741 · September 11, 2025 · Corrected (the home has a date of correction)
- E
Have restrictions on the use of highly flammable decorations.
K 753 · September 11, 2025 · Corrected (the home has a date of correction)
- E
Ensure proper usage of power strips and extension cords.
K 920 · September 11, 2025 · Corrected (the home has a date of correction)
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · July 13, 2023 · Corrected (the home has a date of correction)
- F
Have simulated fire drills held at unexpected times.
K 712 · July 13, 2023 · Corrected (the home has a date of correction)
- F
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
K 914 · July 13, 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 13, 2023 · Corrected (the home has a date of correction)
- E
Install emergency lighting that can last at least 1 1/2 hours.
K 291 · July 13, 2023 · Corrected (the home has a date of correction)
- E
Provide properly protected cooking facilities.
K 324 · July 13, 2023 · Corrected (the home has a date of correction)
- E
Install corridor and hallway doors that block smoke.
K 363 · July 13, 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 13, 2023 · Corrected (the home has a date of correction)
- E
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
K 741 · July 13, 2023 · Corrected (the home has a date of correction)
- E
Ensure proper usage of power strips and extension cords.
K 920 · July 13, 2023 · Corrected (the home has a date of correction)
- E
Have proper medical gas storage and administration areas.
K 923 · July 13, 2023 · Corrected (the home has a date of correction)
- F
Install emergency lighting that can last at least 1 1/2 hours.
K 291 · September 12, 2019 · Corrected (the home has a date of correction)
- F
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · September 12, 2019 · Corrected (the home has a date of correction)
- F
Provide a written emergency evacuation plan.
K 711 · September 12, 2019 · Corrected (the home has a date of correction)
- E
Inspect, test, and maintain automatic sprinkler systems.
K 353 · September 12, 2019 · Corrected (the home has a date of correction)
- E
Install smoke barrier doors that can resist smoke for at least 20 minutes.
K 374 · September 12, 2019 · Corrected (the home has a date of correction)
- E
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
K 761 · September 12, 2019 · Corrected (the home has a date of correction)
- E
Ensure proper usage of power strips and extension cords.
K 920 · September 12, 2019 · Corrected (the home has a date of correction)