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 74 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
2J
2K
0L
Actual harm
2G
0H
0I
Potential for more than minimal harm
23D
45E
0F
Potential for minimal harm
0A
0B
0C
May 14, 2026Complaint inspection · 1 citation
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on record reviews, observations and interviews, the facility failed to ensure residents with pressure injuries received necessary treatment and services consistent with professional standards of practice to promote healing for 2 (#1and #3) residents of 3 sampled residents. The facility failed to ensure:1. Resident #1's right lateral ankle pressure injury remained free of moisture and 2. EBP signage was in place for Resident #1 and Resident #3.
December 4, 2025Complaint inspection · 3 citations
- G
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Inspectors wroteBased on record review, observation and interviews, the facility failed to follow procedures to ensure a resident received pain medication to be administered as ordered for 1 (Resident #2) of 6 sampled residents. The facility failed to provide effective pain management due to the resident's scheduled morphine not being available. The deficient practice resulted in an actual harm for Resident #2 on 11/27/2025 at 8:10 p.m. when Resident #2 received a prn (as needed) dose of Oxycodone-acetaminophen 10-325 mg (milligram) po (by mouth) for a pain level of 10 which had a follow-up status of ineffective. The facility had ran out of Resident #2's Morphine Sulfate (controlled substance) narcotic pain medication ordered for the administration of 30 mg 2 tablets for a total of 60 mg po q (every) eight hours. Resident #2's last documented dose of scheduled Morphine was on 11/26/2025 at 2:00 p.m. [...]
- 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 and interviews, the provider failed to ensure a plan of care had been developed and implemented for 2 (#1 and #5) of 6 (#1, #2,#3,#4 #5 #6) residents whose care plans were reviewed by:1. Failing to develop a plan of care for the use of a PICC (peripheral inserted central catheter) line for Resident #1 and Resident #5.2. Failing to administer Resident #1 intravenous antibiotic medication as ordered and failing to provide restorative care for Resident #5 as ordered.
- 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 record review, observation, and interview, the facility failed ensure a resident's Percutaneous Endoscopic Gastrostomy (PEG) tube (a soft, plastic feeding tube that goes into the stomach used to provide nutrition when oral intake is inadequate) feeding was not administered while a resident was in a flat position for 1 (#4) of 6 (#1, #2, #3, #4, #5 and #6) sampled residents.
July 24, 2025Standard inspection, Complaint inspection · 20 citations
- E
Ensure that residents are fully informed and understand their health status, care and treatments.
Inspectors wroteBased on record reviews and interviews the facility failed to ensure 1 (#165) of 5 (#5, #7, #14, #158, and #165) residents or resident's representatives reviewed for unnecessary medications were informed of risk and benefits, treatment alternatives or other options of psychotropic medications prior to administration.
- E
Honor the resident's right to organize and participate in resident/family groups in the facility.
Inspectors wroteBased on record reviews, observations and interviews the facility failed to act promptly to concerns presented in the resident council meetings. The deficient practice affected 4 (#37, #139, #170, #178) of 7 (#37, #45, #139, #170, #173, #174, #178) residents interviewed for resident care and life in the facility. The deficient practice had the potential to affect the total census of 176 residents in the facility.
- E
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Inspectors wroteBased on observations and interviews the facility failed to provide a safe, clean, comfortable and homelike environment for 4 (#50, #88, #91, #110) of 11 (#35, #50, #56, #68, #88, #91, #110, #128, #158, #179 #189) residents reviewed for environment. The facility failed to: 1. provide a clean room and a closet door for Resident #110.2. provide linens that were in good repair for all residents. (This had the ability to affect 176 residents residing in the facility.)3. provide the required furnishings in each resident room. The facility failed to provided a chair for Resident #88 and #91.4. provide a clean uncluttered room for Resident #50, Resident #50's clothes were stored on the floor.
- E
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Inspectors wroteBased on record review and interview the facility failed to provide the required documents to 1 (#110) of 1 (#110) resident and or resident representative who was transferred out of the facility for treatment. The facility failed to provide Resident #110 a copy of the facility's bed hold policy when transferred out of the facility.
- E
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Inspectors wroteBased on record review and interview, the facitiy failed to ensure resident assessments were encoded, transmitted and completed for 1 (#81) of 3 (#81, #130, #183) residents reviewed for resident assessments.
- E
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Inspectors wroteBased on record reviews and interviews, the facility failed to develop and implement a baseline care plan for 2 (#110, #188) out of 63 total sampled residents reviewed.
- E
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 and interview, the facility failed to provide services according to the written plan of care for 1 (#14) of 5 (#5, #7, #14, #158, and #165) reviewed for unnecessary medications. The facility failed to ensure Resident #14's lab were obtained as ordered by the physician.
- E
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on record reviews, observations and interviews, the facility failed to ensure residents who were unable to complete their activities of daily living received the necessary services to maintain grooming and hygiene for 4 (#50, #68, #74, #187) out of 4 (#50, #68, #74, #187) residents reviewed for activities of daily living. The facility failed to:1. Ensure Resident #50 received baths, washed hair and toenails were trimmed,2. Ensure Resident #68 received baths, oral care and nail care,3. Ensure Resident #74 received proper peri-care for MASD (moisture-associated skin damage)4. Ensure Resident #187 received baths.
- E
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on record review and interview the facility failed to ensure residents received care and services that are resident centered, in accordance with professional standards of practice for 2 (#74, #110) of 63 sampled residents. The facility failed to: 1.provide a splint for Resident #74 as ordered.2.complete all admission lab test ordered Resident #110.3.revise/update Resident #110's plan of care to reflect a diagnosis of hyperkalemia.4.complete Resident #110's admission lab in a timely manner.
- E
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 failed to ensure a resident environment remains as free of accident hazards for 1 (#158) reviewed for accidents. The facility did not maintain resident #158's wheelchair in safe operating condition.
- E
Provide enough food/fluids to maintain a resident's health.
Inspectors wroteBased on record reviews and interviews, the facility failed to provide care and services to maintain acceptable parameters of nutritional status for 1 (#62) resident reviewed for nutrition. The facility failed to consult a Registered Dietician for Resident #62 diagnosed with a pressure ulcer.
- E
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on record review, observations and interview, the facility failed to provide residents necessary respiratory care and services in accordance with accepted professional standards of practice for 5 (#2, #35, #109, #128, #188) out of 6 (#2, #35, #109, #128, #186 and #188) residents reviewed for respiratory. The facility failed to store hand held nebulizer equipment in a covered bag and change and date oxygen tubing and humidification bottles weekly.
- E
Provide or get specialized rehabilitative services as required for a resident.
Inspectors wroteBased on interviews and record review the facility failed to provide specialized rehabilitation services for 1 of 1 (#158) sample resident as required by the resident's plan of care. Resident #158 was not provided restorative services.
- E
Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
Inspectors wroteBased on record reviews and interview, the facility failed to electronically submit accurate direct care staffing information based on payroll to Centers for Medicare and Medicaid Services (CMS) as required.
- E
Provide and implement an infection prevention and control program.
Inspectors wroteBased on record reviews, observations, and interviews the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of communicable diseases and infections. This deficient practice had the potential to effect 176 residents residing at the facility at time of entrance on 07/21/2025 as reported by the Administrator. The facility failed to:1. maintain an up to date monthly tracking and trending for infection prevention and control, 2. ensure resident care equipment, dirty linens and briefs were handled in a sanitary manner.
- E
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Inspectors wroteBased on record review and interview the facility failed to maintain and follow policies and procedures for immunization for 4 (#55, #84, #87, #186) of 5 ( #55, #77, #84, #87 and #186) sampled residents for influenza, pneumococcal disease and COVID-19. The facility failed to educate and offer residents and/or their representative immunizations of pneumonia, influenza and coronavirus disease (COVID-19), and failed to allow them to refuse and/or agree to either of the vaccines.
- D
Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.
Inspectors wroteBased of observations and interview the facility failed to have the most recent annual survey results of the facility posted in a place readily accessible to the residents, family members or anyone to review.
- D
Keep residents' personal and medical records private and confidential.
Inspectors wroteBased on observations and interviews the facility failed to accommodate 1 (#165) out of 1 resident reviewed for personal privacy. The facility failed to ensure Resident #165 had a privacy curtain in a shared room.
- D
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Inspectors wroteBased on record reviews and interview the facility failed to develop an individualized person centered care plan for 1 (#14) of 2 (#5, #14) residents with measurable goals and appropriate interventions to address the care and treatment for a resident with dementia.
- D
Keep all essential equipment working safely.
Inspectors wroteBased on record reviews, observation, and interviews the facility failed to maintain electrical equipment in safe operating condition for 1 (#35) of 11 (#35, #50, #56, #68, #88, #91, #110, #128, #158, #179, #189) residents reviewed for environment. The facility failed to ensure that Resident #35's bed control was properly maintained and in safe working order.
April 23, 2025Complaint inspection · 1 citation
- D
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Inspectors wroteBased on observation and interviews, the facility failed to ensure resident's personal dietary choices were met for 1 (#2) out of 3 (#1, #2, #3) sampled residents. The facility prepared a lunch meal with Resident #2's dislikes.
April 9, 2025Complaint inspection · 2 citations
- E
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on record reviews and interviews the facility failed to ensure 1 (#4) of 6 (#1, #2, #3, #4, #5, and #6) sampled residents received treatment and care in accordance with professional standards of practice. The facility failed to ensure: 1. Resident #4's high blood glucose levels were rechecked as ordered after being administered sliding scale insulin for glucose levels greater than 400. 2. Resident #4's blood glucose levels were checked to determine if sliding scale insulin needed to be administered as ordered. 3. Resident #4's MD (medical doctor) was notified when Resident #4's finger stick glucose was greater than 250. 4. Resident #4's Lantus insulin was administered as ordered.
- E
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on record review and interview the facility failed to ensure residents received necessary treatment and services, consistent with professional standards of practice to promote healing and prevent the development of new pressure ulcers for 1 (#4) of 4 (#3, #4, #5, and #6) residents reviewed for pressure ulcers. The facility failed to perform wound care as recommended by S2 Wound NP (nurse practitioner) for Resident #4.
February 19, 2025Complaint inspection · 1 citation
- 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 observations, interviews and record reviews the facility failed to ensure the facility's Grievance Policy was followed for 1 (#2) of 7 (#1, #2, #3, #4, #5, #6 and #7) sample residents. The facility failed to resolve a grievance of resident #2's call light not being answered and failed to provide a completed review of the grievance in writing and/or verbal to resident #2 or his RP (responsible party).
February 4, 2025Complaint inspection · 6 citations
- K
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Inspectors wroteBased on interviews and record reviews the facility failed to protect the residents' right to be free from sexual abuse and psychosocial harm from another resident for 3 (Resident #1, #6, #7) of 7 (Resident #1, #2, #3, #4, #5, #6, and #7) sampled residents. The deficient practice resulted in an Immediate Jeopardy on 12/27/2024 at approximately 2:38 a.m., when Resident #1 was approached at his bedside by Resident #2 with Resident #2's penis exposed playing with himself. Residents #6 and #7 resided in the shared resident room at the time of the event. Resident #1 was verbal and his cognition was intact. Resident #1 reported Resident #2 grabbed him by his upper arms and shoulders and he had to wrestle with Resident #2 to get away. Resident #1 reported Resident #2 asked him if he was gay and had his penis exposed, in his hand playing with it. [...]
- K
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Inspectors wroteBased on interviews and record reviews, the facility failed to be administered in a manner that enabled its resources to be used effectively and efficiently to attain or maintain the highest practicable physical, mental and psychosocial well-being for 1 (Resident #1) of 7 (#1, #2, #3, #4, #4, #5, #6, and #7) residents. The deficient practice resulted in an Immediate Jeopardy on 12/27/2024 at approximately 2:38 a.m., when Resident #1 was approached at his bedside by Resident #2 with Resident #2's penis exposed playing with himself. Residents #6 and #7 resided in the shared resident room at the time of the event. Resident #1 was verbal and his cognition was intact. Resident #1 reported Resident #2 grabbed him by his upper arms and shoulders and he had to wrestle with Resident #2 to get away. [...]
- G
Provide safe, appropriate pain management for a resident who requires such services.
Inspectors wroteBased on record review and interviews, the facility failed to ensure pain management was provided to a resident who required such services, consistent with professional standards of practice for 1 (#4) of 5 (#1, #2, #3, #4, and #5) sampled residents reviewed for pain. The facility failed to ensure Resident #4, who reported pain after a post-surgery wound, received medication or interventions to alleviate pain. The deficient practice resulted in an actual harm for Resident #4 on 01/10/2025 at approximately 6:00 p.m. when Resident #4 requested pain medication for her post-surgical wound. Resident #4 requested Tylenol on the evening shift from S3 LPN (Licensed Practical Nurse). S3 LPN told Resident #4 she could not give her anything for pain. Resident #4 called 911 as a result of not getting pain medication. [...]
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on record reviews and interview, the facility failed to ensure an alleged violation of sexual abuse was reported immediately to the facility's administrator and to the state agency within 2 hours after the allegations were made for 1 (#1) of 7 (#1, #2, #3, #4, #5, #6 and #7) sample residents.
- D
Respond appropriately to all alleged violations.
Inspectors wroteBased on record review and interviews the facility failed to thoroughly investigate an allegation of sexual abuse for 1 (#1) of 7 (#1, #2, #3, #4, #5, #6 and #7) sample residents.
- D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on record reviews and interviews, the facility failed to ensure medical records were accurately documented for 1 (Resident #2) of 7 (Resident #1, #2, #3, #4, #5, #6, and #7) sampled residents. The facility failed to have documentation of a physician's discharge order.
December 4, 2024Complaint inspection · 1 citation
- E
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteBased on record reviews and interviews the facility failed to ensure residents had access to services outside the facility for 1 resident (#2) out of 3 residents (#2, #3, #4) reviewed for appointments outside the facility.
October 3, 2024Complaint inspection · 2 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 and interviews the facility failed to ensure the plan of care had been revised for 1 (#4) of 9 (#1, #2, #3, #4, #5, #6, #7, #8, #9) sampled residents.
- E
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on record reviews and interviews the facility failed to ensure a resident at risk for wounds received necessary treatment and services, consistent with professional standards of practice, to promote healing, to prevent infection, and to prevent wounds for 1 (#5) of 9 (#1, #2, #3, #4, #5, #6, #7, #8, and #9) sampled residents. The facility failed to ensure an accurate assessment was performed and the Medical Doctor (MD)/Nurse Practitioner (NP) was notifed of a current skin condition.
August 28, 2024Complaint inspection · 4 citations
- E
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 reviews and interviews, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that includes measurable objectives to meet residents' medical, nursing, mental and psychosocial needs for 2 (#2, #4) of 4 (#1, #2, #3, #4) sampled residents. The facility failed to ensure: 1.) Resident #2's physician orders had been followed, and 2.) Resident #4's care plan had been revised with each of Resident #4's falls
- 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 record review and interviews, the facility failed to ensure resident's responsible party was notified when there was a change in condition for 1 (#2) out of 4 (#1, #2, #3, #4) sampled residents. The facility failed to notify Resident #2's responsible party of an infection requiring antibiotic treatment.
- 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 record review, observation, and interview the facility failed to ensure residents with an indwelling catheter received appropriate care and services to prevent urinary tract infections to the extent possible for 1 (#4) of 4 (#1, #2, #3, #4) sampled residents.
- D
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
Inspectors wroteBased on record reviews, observations, and interviews, the facility failed to ensure received a written order from the physician for and an informed consent for bed rails prior to installation for 1 (#2) out of 4 (#1, #2, #3, #4) sampled residents.
August 14, 2024Complaint inspection · 1 citation
- E
Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.
Inspectors wroteBased on record reviews and interview the facility failed to ensure required annual abuse and dementia training was completed for 1 direct care staff [S2 CNA (Certified Nursing Assistant)] out of 6 [S2 CNA, S3 CNA, S4 CNA, S5 CNA, S6 LPN (Licensed Practical Nurse), S7 LPN] direct care staff personnel records reviewed.
June 6, 2024Standard inspection · 16 citations
- E
Reasonably accommodate the needs and preferences of each resident.
Inspectors wroteBased on record reviews, observations and interviews, the facility failed to accommodate the needs of 2 (#39 and #67) of 5 (#21, #39, #51, #67, and #120) residents investigated for environment. The facility failed to ensure residents' call lights remained within reach.
- E
Honor the resident's right to organize and participate in resident/family groups in the facility.
Inspectors wroteBased on record reviews and interviews the facility failed to consider the views of the resident council group and act promptly to concerns related to laundry presented in the resident council meetings. The deficient practice had the potential to affect a total of 189 residents according to Long-Term Care Facility Application for Medicare and Medicaid dated 06/03/2024.
- E
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 and interviews the facility failed to ensure a plan of care was developed and implemented for 2 (#25, 98) of 2 residents reviewed for UTI (urinary tract infection). The facility failed to: 1. Develop a plan of care for 2 (#25, 98) residents diagnosed with urinary tract infection. 2. Administer medication as ordered for resident # 98.
- 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 reviews and interviews the facility failed to ensure the resident's plan of care was revised to meet the resident's needs for 1 resident (#159) out of 4 residents (#159, #7, #121, #161) investigated for weight loss.
- E
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on record review, observations, and interviews the facility failed to ensure a resident who was unable to complete their activities of daily living received the necessary services to maintain grooming and hygiene for 6 (#25, #57, #98, #120, #141, #174) of 10 residents (#16, #25, #33, #57,#65, #98, #120, #141, #174) reviewed for Activities of Daily Living. The facility failed to ensure: 1. residents #25, #57, #98, and #141's fingernails were clean and trimmed. 2. resident #120's toenails were clean and trimmed. 3. resident #174 received scheduled bath/shower.
- E
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on observations, interviews and record reviews, the facility failed to ensure 1 (#139) resident out of 1 reviewed for edema received treatment and care in accordance with professional standards of practice by failing to follow physician orders for applying ted hose, monitoring for edema with use of diuretics (Lasix), and revision to care plan of edema with use of diuretics (Lasix).
- E
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on record reviews and interviews the facility failed to ensure 1 resident (#164) out of 3 residents (#164, #6, #94) investigated with pressure ulcers received necessary treatment and services consistent with professional standards of practice to promote healing and prevent infection. The facility failed to obtain and implement wound care treatment orders on Resident #164 upon readmissionn to the facility.
- E
Provide enough food/fluids to maintain a resident's health.
Inspectors wroteBased on record reviews and interview, the facility failed to ensure: 1. Resident #85 received at least quarterly Registered Dietician assessments according to policy. 2. Monthly weights were documented in EHR (electronic health record) to ensure Resident #135 maintained a desired weight. There were a total of 9 (#7, #21, #34, #52, #79, #85, #135, #159, #161) residents reviewed for nutrition.
- E
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 record reviews, observations and interview the facility failed to provide appropriate treatment and services for 2 (#85 and #161) of 3 (#21, #85, and #161) residents reviewed for tube feeding. The facility failed to ensure the tube feeding container was appropriately labeled.
- E
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on record reviews, observations, and interviews the facility failed to ensure residents who need respiratory care were provided care consistent with professional standards of practice for 4 (#79, #120, #136, #139) out of 5 (#79, #120, #136, #139, #164) residents reviewed for respiratory care. The facility failed to ensure: 1. The oxygen concentrator and filter were clean and the nasal cannula was dated for Resident #79. 2. The respiratory supplies (oxygen mask and tubing for Resident ##139 and nebulizer mask and tubing for Resident #120, #136, and #139 were changed weekly, labeled with date and initials upon opening and stored in plastic bag between uses.
- 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 record reviews and interview the facility failed to ensure there was a sufficient number of skilled licensed nurses, nurse aides, and other nursing personnel to provide care and respond to each resident's basic needs. The facility failed to provide the minimum required staffing hours for 3 of 27 weekend days during FY (Fiscal Year) Quarter 1 2024.
- E
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Inspectors wroteBased on record review and interview, the facility failed to adequately monitor for 2 (# 27, #106) residents reviewed for unnecessary medications out of a total 6 (#27, #67, #72, #78, #106, #175) residents reviewed. The facility failed to adequately monitor residents #27 and #106 for edema while on a diuretic, and resident #27 for bleeding and bruising while on an anticoagulant.
- E
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
Inspectors wroteBased on record review and interview the facility failed to ensure the Quality Assessment and Assurance (QAA) Committee met at least quarterly. The failed practice had the potential to affect the 189 residents residing in the facility as documented by the facility's Long-Term Care Facility Application for Medicare and Medicaid form [CMS (Centers for Medicare and Medicaid Services)-671] dated 06/03/2024.
- E
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observations, interviews, and record review the facility failed to: 1. Ensure staff practices were consistent with current infection control principles and practices to prevent cross contamination by failing to ensure staff used appropriate PPE (Personal Protective Equipment) during resident care for 1 resident (#112) who was on contact isolation. 2. Ensure an infection prevention and control program was maintained by failing to provide written evidence of implemented infection control policies and procedures for surveillance of tracking and trending of infections in the facility. This deificient practice had the potential to effect the total census was 189 according to the Long-Term Care Facility Application for Medicare and Medicaid Form dated 06/03/2024.
- E
Put firmly secured handrails on each side of hallways.
Inspectors wroteBased on observations and interviews the facility failed to ensure hallway hand rails were securely affixed to the walls. The facility failed to ensure hand rails were secure on 1 (Hall W) of 4 hallways in the building. This had to potential to affect 31 residents residing on Hall W.
- D
Ensure each resident receives an accurate assessment.
Inspectors wroteBased on record reviews and interview the facility failed to ensure the MDS (Minimum Data Set) assessment accurately reflected the resident's status for 1 (#178) of 2 (#178, #34) residents investigated for hospitalization.
March 26, 2024Complaint inspection · 1 citation
- 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 record review and interview the facility failed to ensure a medical doctor or representative was notified after a resident had a fall in the facility for 2 (#1, #2) of 2 (#1, #2) residents reviewed for falls.
March 6, 2024Complaint inspection · 2 citations
- E
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on record review and interview, the Facility failed to ensure a resident with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for 1 (Resident #9) of 13 (Residents #1, #2, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13) sampled residents.
- D
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 record review and interview, the facility failed to ensure there were a sufficient number of personnel to provide care and respond to each Resident's basic needs. The facility failed to provide the minimum required staffing hours for 1 of 26 days reviewed during the month of February 2024.
December 28, 2023Complaint inspection · 2 citations
- E
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 reviews and interview, the facility failed to develop a comprehensive care plan for 2 (#1, #2) out of 4 (#1, #2, #3, #4) sampled residents reviewed.
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on record reviews and interviews, the facility failed to ensure resident received care and necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for 1 (#1) out of 4 (#1, #2, #3, #4) sampled residents. The facility failed to follow up on Resident #1 identified skin issue and complete weekly skin checks for Resident #1.
June 8, 2023Standard inspection · 11 citations
- J
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on record reviews and interviews, the provider failed to ensure residents received adequate supervision and to prevent elopement for 1 (#140) out of 1 (#140) residents reviewed for wandering. This failed practice led to an immediate jeopardy situation for Resident #140, which began on 05/06/2023 at 3:25 p.m. when he exited the facility, attempted to walk home and received a ride from a person unknown to him. S20 Agency LPN (licensed practical nurse) failed to notify the appropriate staff after he had not observed Resident #140 after administering four o'clock medications on the evening shift of 05/06/2023. S21 LPN failed to notify the appropriate staff when S20 Agency LPN reported Resident #140 had not been seen after four o'clock. S21 LPN failed to notify appropriate staff during the night shift on 05/06/2023 when Resident #140 was not observed. [...]
- J
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Inspectors wroteBased on record reviews and interviews the facility failed to be administered to in a manner that used its resources efficiently to ensure staff supervised residents to prevent elopement for 1 (#140) of 1 (#140) residents reviewed for wandering. This failed practice led to an immediate jeopardy situation for Resident #140, which began on 05/06/2023 at 3:25 p.m. when he exited the facility, attempted to walk home and received a ride from a person unknown to him. S20 Agency LPN (licensed practical nurse) failed to notify the appropriate staff after he had not observed Resident #140 after administering four o'clock medications on the evening shift of 05/06/2023. S21 LPN failed to notify the appropriate staff when S20 Agency LPN reported Resident #140 had not been seen after four o'clock. [...]
- E
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 observations, interviews and record review the facility failed to ensure the plan of care was developed and/or implemented for 6 (#32, #40, #73, #109, #125 and #130) of 6 residents reviewed. 1. The facility failed to ensure labs were obtained for resident #32 as ordered by the physician 2. The facility failed to ensure splint devices were used according to resident's plan of care for residents #40, #73, #109, #125 and #130.
- E
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on record reviews, observations and interviews the facility failed to ensure residents who were unable to complete their (ADLs) activities of daily living received the necessary services to maintain proper hygiene and grooming for 4 (#91, #5, #43, #79) of 7 (#32, #67, #5, #43, #91, #79, #111) residents reviewed for ADL. The facility failed to ensure Resident #91 received nails care and weekly skin assessments #5, #43, #79 received nail care #79 face was shaved
- E
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 record reviews, interviews and observations, the facility failed to provide appropriate treatment and services to prevent complications of enteral feeding for 4 (Residents #31, #22, #66, #132) of 4 sampled residents (Residents #31, #43, #79, #142) who received nutrition via a PEG (percutaneous endoscopic gastrostomy) tube. There were 25 residents in the facility with orders for feeding via gastrostomy tube. The facility failed to: 1. Assure tolerance to feedings with gastric residual checks prior to restarting resident's daily feedings for residents #22, #66, and #132. 2. Ensure the water flush and feeding bags were labeled properly for residents #22, #66, and #132. 3. Ensure the tubing was covered to prevent contamination for resident #31.
- E
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 that a resident who required dialysis received services consistent with professional standards of practice for 1 (#46) of 1 (#46) resident reviewed for dialysis by failing to communicate and collaborate with the dialysis facility as evidenced by completing dialysis pre/post evaluation form.
- D
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Inspectors wroteBased on record review and interview, the facility failed to ensure resident assessments were transmitted within the required timeframe for 1 (#127) of 1 (#127) residents reviewed for assessments.
- D
Ensure each resident receives an accurate assessment.
Inspectors wroteBased on record review and interviews, the facility failed to ensure MDS (Minimum Data Set) assessments were accurate for 1 (#141) out of 2 (#131, #141) residents reviewed for hospitalization. The facility failed to enter an accurate discharge status for Resident #141.
- 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 record review, observation and interview the facility failed to ensure a resident who was incontinent of the bladder received appropriate treatment to prevent urinary tract infections for 1 (#7) of 1 (#7) residents reviewed. The facility failed to position resident #7's catheter bag above the floor.
- D
Verify that a nurse aide has been trained; and if they haven't worked as a nurse aide for 2 years, receive retraining.
Inspectors wroteBased on record reviews and interview the facility failed to ensure the state Adverse Action Website checks were completed at time of hire and then monthly for 5 [S15 CNA (Certified Nursing Assistant), S16 CNA, S17 CNA, S18 CNA, S19 CNA] of 5 employees whose personnel files were reviewed.
- 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 record reviews and interview the facility failed to ensure nurse aides received required in-service training for 1 [S15 CNA (Certified Nursing Assistant)] of 5 employees whose personnel files were reviewed.
Fire safety inspections
4 fire safety citations on file: 2 on July 24, 2025, 2 on January 16, 2025.
Every fire safety citation4 citations
- F
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
K 223 · July 24, 2025 · Corrected (the home has a date of correction)
- E
Construct fire resistant interior walls.
K 331 · July 24, 2025 · Corrected (the home has a date of correction)
- D
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
K 321 · January 16, 2025 · Corrected (the home has a date of correction)
- D
Meet requirements for the use and maintenance of medical gas equipment.
K 922 · January 16, 2025 · Corrected (the home has a date of correction)