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 49 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
1K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
29D
17E
2F
Potential for minimal harm
0A
0B
0C
November 26, 2025Standard inspection, Complaint inspection · 13 citations
- K
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on observation, record review, and staff and resident interviews, the facility failed to ensure safe water temperatures throughout the building and in areas accessible to residents. This failed practice placed an unlimited number of residents currently residing in the facility at risk for possible harm, including scalds, burns, severe injury, and even death. The state agency determined this was an Immediate Jeopardy (IJ) situation, and Immediate action was required to prevent serious injury, scalding, burns, harm, or even death to residents at the facility. In addition, the facility failed to implement appropriate safety precautions for residents at risk of falls. Locations: room [ROOM NUMBER], South Shower Room, Dining Room sink, and Resident #4's room. Facility Census: 109. [...]
- E
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Inspectors wroteBased on interview, observation, and record review, the facility failed to honor resident choices for baths/showers. This was true for three (3) of four (4) residents. Resident identifiers: #71, #73, and #95. Facility Census: 109. Findings Includea) Resident #71During an interview on 11/19/25 at approximately 11.13 AM, the resident stated that her last tub bath had been on 10/30/25. The resident also said that on 11/02/25, the Nurse Aide had asked her whether she wanted a bed bath or a bath in the tub. Resident #71 stated that she had requested a whirlpool bath. The resident stated that the Nurse Aide (NA) left her room and did not return. Resident #71 stated that she had filed a grievance. Record review revealed a grievance form dated 11/03/25 in which Resident #71 complained about not receiving a bath on 11/02/25. The grievance form noted the following: [...]
- E
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on record review, resident interview, and staff interview, the facility failed to follow physician's orders regarding wound care for Resident #123, administer medications for Resident #90, #106, #107, and accuchecks for Resident #80, #61, #87, #51 and #102. This was true for nine (8) of 42 residents reviewed during the survey process. Resient Identifiers: #90, #106, #107, #80, #61, #87, #51, and #102.b) Resident #90 -During an interview on 11/17/25 at 3:49 PM with Resident #90, reported his evening medications were sometimes late. -Review of facility policy and form titled Liberalized Med Pass times, it was revealed that the facility utilized liberalized medication pass times listed as follows: [...]
- E
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Inspectors wroteBased on observation and interview, the facility failed to ensure that opened medications were discarded within the manufacturer-specified period. In addition, the facility failed to ensure that medications were stored at the manufacturer-specified temperatures. Medication Rooms: 100/200 Hallway, and 200/400 Hallway. Facility Census: 109. Findings Includea) Medication room [ROOM NUMBER]/200 HallwayDuring an inspection of the Medication Room on the 100/200 Hallway, accompanied by Licensed Practical Nurse (LPN) #291 on 11/20/2025 at 12:17 PM, it was noted there were three refrigerators in the medication room, one for medications, another for Insulin, and the third for vaccines. All refrigerators were kept locked. The refrigerator temperature logs were not available for view in the medication room. LPN #291 stated that the logs were in the Narcotic Medication binder on the medication cart. [...]
- E
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Inspectors wroteBased on observation of food temperatures and resident interview the facility failed to provide residents with palatable food at an appetizing temperature. This is true for Resident's #35 and #107. Facility Census 109.
- E
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on record review and staff interview, the facility failed to provide an accurate and complete medical record for Resident #55's capacity and Physician's Order for Scope of Treatment (POST) form, Resident #9's transfer form and a progress note listing an incorrect medical diagnosis, a transfer form for Resident #4, and a psychotropic medication evaluation for Resident #5. This was true for four (4) of 42 residents reviewed during the survey process. Resident Identifiers: #55, #9, #4, and #5. Facility Census: 109. Findings Include:a) Resident #55On 11/24/25 at 11:00 AM, a record review was completed for Resident #55. The review found a physician determination of capacity dated 08/04/25 indicating the resident did have capacity to make medical decisions. [...]
- E
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, record review and staff interview, the facility failed to maintain an infection control program while providing housekeeping services in room [ROOM NUMBER] and providing ADL care in room [ROOM NUMBER]. The staff failed to don PPE. Both rooms were under contact precautions. Additioanl issues were found through observation of inappropriate storage of a bath basin and fracture pan in room [ROOM NUMBER], and storage of a nebulizer mask for Resident #75. These were random opportunities for discovery. Room identifiers: #103, and #115. Resident Identifier: #75. Facility Census: 109. Findings Include:a) On 11/17/25 at 2:15 PM, the Administrator was asked for a copy of the door signage for contract precaution rooms. The contact precaution signage was provided by the Centers for Disease Control and Prevention (CDC) and was yellow with black and red lettering. [...]
- D
Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.
Inspectors wroteBased on observation, Resident Council, and staff interview, the facility failed to post a notification of the availability of survey results and provide the survey results in an accessible location for review by residents and visitors. This was a random opportunity for discovery. Facility Census: 109. On 11/18/25 at 2:00 PM, during the Resident Council meeting, of the 14 residents that were attending the meeting, no one was able to verbalize where the survey results binder was located. On 11/18/25 at 3:00 PM, this Surveyor attempted to find the survey results binder without success. On 11/18/25 at 3:10 PM, an interview was held with Social Services designee (SSD) #36. SSD #36 stated, I do not know where it is, let me ask someone. On 11/18/25 at 3:15 PM, the SSD #36 entered the Administrator's office. [...]
- D
PASARR screening for Mental disorders or Intellectual Disabilities
Inspectors wroteBased on staff interview and documentation review, the facility failed to ensure one (1) residents Pre-admission Screening (PASAR) form contained her current diagnosis at the time of admission. This was true for Resident #5. Facility census: 109. a) Resident #5 On 11/18/25 a review of resident's Pre-admission Screening and Resident Review (PASRR) dated for 09/19/23, question #30 Current Diagnosis Answer (None). On 11/18/25 a review of a Diagnosis Report for Resident #5 revealed a diagnosis of Bipolar Disorder, Unspecified (F41.9) with and onset 8/31/23. On 11/20/25 at 8:45 AM during an interview with Administrator who reported a new PASRR had since been completed and was awaiting the physician's signature so it could be submitted. The facility had started an audit to correct and update all PASRRs.
- 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, record review and staff interview, the facility failed to develop a care plan for assistance with showers and implement a fall intervention for Resident #4, and develop a care plan regarding triggers for Post-Traumatic Stress Disorder (PTSD) for Resident #8. This was true for two (2) of 42 residents reviewed during the survey process. Resident identifiers: #4, and #8. Facility Census: 109. b) Resident #8 On 11/18/25 at 12:06 PM, an interview was conducted with Resident #8 who reported she had a diagnosis of Post Traumatic Stress Disorder (PTSD) and had recently had an incident of some concern in this area when the resident were all evacuated from the facility. This diagnosis was confirmed with her electronic chart. On 11/20/25 review of resident's care plan revealed there were no triggers listed as on resident's care plan under the care area of PTSD. [...]
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on record review and staff interview, the facility failed to ensure ADLs were provided to dependent resident. This is true for one (1) of two (2) residents reviewed under the care area of activities of daily living. Resident Identtifier: #4. Facility Census: 109. Findings Include:a) Resident #4On 11/19/25 at 7:35 PM, a record review was completed for Resident #4. The review found a dependent resident had not been provided assistance for showers. The resident did not receive a shower or bed bath during the following dates:--09/01/25-09/12/25 11 days--09/19/25-09/26/25 7 days--10/10/25-10/21/25 11 days--10/31/25-11/04/25 5 days On 11/20/25 at 10:00 AM, the Adminstrator confirmed the activities of daily living were not provided to a dependent resident.
- 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 interview and record review, the facility failed to ensure that residents were provided with assistance for toileting and appropriate care to prevent potential urinary tract infections. This was true for two (2) of three (3) residents sampled. Resident Identifiers: #45 and #73. Facility Census: 109. Findings Include a) Resident #45During an interview on 11/18/25 at approximately 11:22 AM, the resident stated that she was incontinent and must wait for assistance when she needs to go to the bathroom, frequently ending up sitting in wet briefs for long periods of time. Resident #45 added that she had submitted a complaint to the facility on [DATE]. A review of the complaint revealed the following note: [Typed as Written] Resident reported that she is tired of using the bathroom in her brief. [...]
- 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 record review and staff interview, the facility failed to ensure monthly pharmacy reviews were signed, dated or provided with a response to the pharmacisit recommendationby the facility physician. This was true for two (2) of five (5) residents reviewed under the care area of unnnecessary medications. Resident Identifiers: #5 and #12. Facility Census: 109.b) Resident #12 On 11/24/25 at 9:30 AM, a record review was completed for Resident #12. The review revealed the monthly pharmacy review for 05/25/25 was not signed by the physician and no response was recorded. The issue and recommendation read as follows: Resident was prescribed Divalproex and was due for a Valproic Acid level (ordered for every 6 (six) months). Please consider obtaining this level on the next convenient lab day. This note was completed by the consultant pharmacist. [...]
January 10, 2024Standard inspection · 20 citations
- 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 observation, record review, and staff interview, the facility failed to designate a licensed nurse to serve as a charge nurse on each tour of duty. Additionally, the facility failed to ensure sufficient staffing to allow residents to dine in the communal areas for breakfast and dinner. This deficient practice had the potential to affect all residents residing in the building. Census: 110.
- 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 record review and staff interview, the facility failed to have an RN at least 8 hours a day, 7 days a week. This deficient practice had the potential to affect all residents in the building. Census: 110.
- 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 observation, resident council meeting and staff interviews the facility failed to make grievances forms accessible to all residents and/or residents family/representatives residing in the facility. This had the potential to affect more than a limited number of residents living in the facility. Facility Census: 110 Findings Included: A review of the facility policy titled Grievance/Concern with an effective date of 01/12/17 read as follows. .Policy: .The facility will make available to all residents posting in a prominent location in the facility information of the right to file grievances orally or in writing; the right to file grievances anonymously. [...]
- E
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wrotec) Based on medical record review, resident interview and staff interview the facility failed to provide care required to maintain hygiene to a resident who was dependent for Activities of Daily Living (ADL) care. This is true for three (3) of four (4) reviewed for the ADL care area. Resident Identifiers: Resident #70, Resident #52, and Resident #90. Facility Census: 110. Findings Included: a) Resident #70 During an interview on 01/03/24 at 8:29 AM, Resident # 70 stated they never follow the shower schedule. Resident #70 said, I get mine on Monday and Thursday. I had visitors on Christmas day, so I refused to take a shower at that time and the staff never came back and asked me to get a shower and did not get one on Thursday. I should have been showered on Monday New Year's Day but not enough staff for showers. [...]
- E
Provide activities to meet all resident's needs.
Inspectors wrotec) Resident #49 During an Interview with Resident #49 on 01/02/24 at 11:26 AM, he stated that there are no activities offered in the evening. He continued to say that the only thing to do in the evenings is watch television. Resident #49 stated that there are only two activities a day and he would like to have more or even be offered evening activities. An observation on 01/03/24 at 10:09 AM, Resident #49 sitting outside the activities room asking staff passing by to help him find something to do. A record review of Resident #49's participation sheets revealed he participated in scheduled group activities. A continued record review of Resident #49's Annual 12/06/24 Minimum Data Set (MDS), found the resident's brief interview for mental status was fifteen (15) the highest score obtainable. A review of the current care plan showed: Focus: [...]
- E
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Inspectors wroteBased on resident interview, record review and staff interview, the facility failed to ensure dialysis services were provided in accordance with professional standards of care. This deficient practice had the potential to affect one (1) of (1) residents reviewed for the care area of dialysis. Resident identifier: #24. Facility census: 110.
- E
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 resident interview, record review, and staff interview the facility failed to monitor efficacy of psychotrophic medication via monitoring behavior and symptoms. This deficient practice had the potential to effect 1 of 5 residents reviewed for the care area of Behavioral-Emotional wellbeing. Resident identifier: #48. Census: 110.
- 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, policy review and staff interview the facility failed to store food in accordance with professional standards for food safety. The facility failed to label and date food items that were open and failed to dispose of expired food items. The facility also failed to record accurate food temperatures and failed to ensure hot foods were held at 135.0 degrees Fahrenheit or higher on the steam table. The facility also failed to keep utensils stored appropriately and equipment clean and sanitized. This failed practice had the potential to affect all residents currently receiving nourishment from the facility's kitchen. Facility Census: 110. Findings Included: a) Labeling and Dating During the initial tour of the kitchen on 01/02/23 at 12:58 PM, with the Culinary Director (CD) #95 revealed the following issues: [...]
- E
Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse.
Inspectors wroteBased on facility record review and interview the facility failed to explain Binding Arbitration Agreement accurately and, in a form, and manner residents or Resident Representatives can understand. This has the potential to affect all residents or Residents Representatives that sign a Binding Arbitration Agreement. Facility Censes: 110.
- 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 observation, resident interview, and staff interview, the facility failed to ensure a safe, clean, comfortable, home-like environment. Window curtains were dirty in room [ROOM NUMBER] and privacy curtains were dirty in room [ROOM NUMBER]. These were random opportunities for discovery. Resident identifiers: #90, #58. Facility census: 110.
- D
Ensure each resident receives an accurate assessment.
Inspectors wroteBased on record review and staff interview, the facility failed to complete an accurate Minimum Data Set (MDS) assessment for two (2) of 24 residents reviewed in the long-term care survey sample. Resident identifiers: #69, #115. Facility census: 110.
- D
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Inspectors wroteBased on record review and staff interviews, the facility failed to ensure that the resident's Pre-admission Screening (PAS) reflected pre-admission diagnoses for two (2) of three (3) residents reviewed for the category of PASARR, during the long-term care survey. Resident identifier #43 and #40. Census 110. Findings Included: a) Resident #43 On 01/08/24, a record review of the resident's electronic medical record (EMR), the resident's admission PASARR, dated 04/18/23, indicated no level II was needed. Section lll #30 MI/MR Assessment indicated None. A continued record also revealed the resident received a psych diagnosis of Major Depression and Schizophrenic Disorder on the diagnosis listed on admission [DATE] but did not receive a new PAS to address whether or not specialized services were needed. [...]
- 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 staff interview, the facility failed to ensure two (2) of four (4) residents had a person-centered comprehensive care plan developed and implemented to meet his activities preferences and goals and address the resident's quality of life needs. The failure to ensure the comprehensive care plan was developed for the resident's highest practicable well-being placed the residents at risk of not receiving services that would meet their desires or wants and a decreased quality of life. Resident identifier: #49. Facility census: 110.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on observation, record review, and staff interview, the facility failed to follow the physician's orders to label a tube feeding formula container and administration set with the resident's name, date, time, and nurse's initials. This deficient practice had the potential to affect one (1) of one (1) residents reviewed for the care area of tube feeding. Resident identifier: #97. Facility census: 110.
- 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 staff interview the facility failed to provide appropriate treatment for urinary catheter care, specifically to ensure the resident's catheter had an anchor strap to prevent trauma. This is true for one of one reviewed for catheter care. Facility Census: 110. Findings Included: a) Resident #97 Medical record review found Physician Orders for Resident #97: - Foley Cath #18fr /10ML to Continuous drain. - Indwelling urinary Foley catheter is in privacy bag and leg strap on at all times. - Secure indwelling catheter tubing using anchoring device to prevent movement and urethral traction. A review of the current care plan with the initiated date of 11/ 06/2023 showed the care plan: -Focus: Resident has indwelling 18fr/10ml Foley Catheter, renal failure / hematuria/ nephrology referred. Goal: [...]
- D
Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care.
Inspectors wroteBased on a medical record review, resident interview and staff interview the facility failed to ensure the attending physician supervises the resident medical care. The facility failed to notify the physician of weight loss for one (1) of two (2) residents reviewed for the care area of nutrition. Resident identifier: #40. Facility Census: 110.
- 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 observation and staff interview, the facility failed to ensure storage of point-of-care testing devices within acceptable standards of practice. Two vials of urine reactant strips stored in the medication room had expired. Facility census: 110.
- D
Provide timely, quality laboratory services/tests to meet the needs of residents.
Inspectors wroteBased on record review and staff interview, the facility failed to obtain laboratory services to meet the needs of its residents. This deficient practice had the potential to affect one (1) of six (6) residents reviewed for the care area of behavioral/emotional. Resident identifier: #47. Facility census: 110.
- D
Dispose of garbage and refuse properly.
Inspectors wroteBased on observation and staff interview, the facility failed to ensure trash was disposed of properly and dumpster lids were closed. This was a random observation. Facility census: 110.
- 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 review and staff interview, the facility failed to ensure a complete and accurate medical record. The indication for Resident #47's psychotropic medication, Depakote, was incorrect. This deficient practice had the potential to affect one (1) of six (6) residents reviewed for the care area of behavioral/emotional. Resident identifier: #47. Facility census: 110.
December 7, 2022Standard inspection · 16 citations
- 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 observation and staff interview, the facility failed to ensure each resident had the right to a clean, comfortable homelike environment that was in good repair. Walls were observed to be scarred and/or with missing or torn wallpaper for Resident # 107 and #53. Cove base trim was missing from Resident #59's room. Wallpaper and cove base trim , in the hallway adjacent to the North Nursing Station, was gaped and/or torn not allowing for effective cleaning. This deficient practice was true through a random opportunity for discovery and had the potential to affect more than a limited number of residents. Resident identifiers: Resident #107, #53 and #59, Census: 109.
- E
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Inspectors wroteBased on observation and staff interview, the facility failed to label medications when opened and administered to residents to ensure the safety and effective use of medications. This failed practice was identified through a random opportunity for discovery and was found to be true for two (2) of two (2) medication carts observed. Insulin pens, currently being administered to residents, were not dated when opened to provide staff administering the insulin, a reference date, based on manufacture's guidelines, for safe usage date. Over the Counter medications were not dated when opened. This failed practice had the potential to affect more than a limited number of residents. Resident identifiers: Resident # 168, #57, # 59 and #9. Facility census:
- E
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 interview the facility failed to honor residents' personal dietary choices and preferences. This affected five (5) of (31) resident reviewed, during the Long-Term Care Survey Process (LTCSP). Resident identifier #2, #30, #85, #68 and #95. Facility census: 109.
- E
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on record review and staff interview, the facility failed to maintain an accurate medical record for one three (3) of 32 sampled residents reviewed during the Long-Term Care Survey process. Resident identifiers: #43, #54, and #81. Facility census: 109.
- D
Ensure that residents are fully informed and understand their health status, care and treatments.
Inspectors wroteBased on record review and staff interview, the facility failed to ensure a resident representative was informed of medical treatment and allowed to make treatment decisions for a resident who lacked decision making capacity. There was a delay in appointing a Health Care Surrogate (HCS) decision maker for Resident #115. This was a random opportunity for discovery. Resident identifier: #115. Facility census: 109.
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on record review, family interview, resident interview, facility documentation of reportable occurrences review, and staff interview, the facility failed to ensure that all alleged violations of abuse and neglect, were reported immediately, and failed to ensure the results of the investigation were reported within five (5) working days of the occurrence, to other officials (including to the State Survey Agency and Adult Protective Services (APS) where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures. This deficient practice was identified through a random opportunity for discovery and had the potential to affect more than a limited number of residents. Two (2) residents were found to have reported allegations of abuse to facility staff; [...]
- D
Respond appropriately to all alleged violations.
Inspectors wroteBased on family interview, resident and staff interview, record review and review of facility documentation of reportable incidents, the facility failed to ensure, in the response to allegations of abuse, neglect, exploitation or mistreatment, evidence that all alleged violations were thoroughly investigated for two (2) residents reviewed during the Long Term Care Survey Process. This deficient practice was based on a random opportunity of discovery and had the potential to affect more than a limited number of residents residing in the facility. Resident #53 and Resident #68 were found to have allegations of abuse reported to facility staff and had not been investigated and evidence of the investigation maintained by the facility. Resident identifiers: Resident #53 and #68. Census: 109.
- D
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Inspectors wroteBased on medical record review and staff interview, the facility failed to provide evidence a resident/resident's representative was provided a written Notice of Transfer for an acute hospital transfer. This was true for one (1) of two (2) residents reviewed for hospitalizations/discharges during the long-term care survey process. Resident identifier: #101. Facility census: 109.
- D
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Inspectors wroteBased on medical record review and staff interview, the facility failed to provide evidence a resident/resident's representative was provided a written Bed Hold Notice for an acute hospital transfer. This was true for one (1) of two (2) residents reviewed for hospitalizations/discharges during the long-term care survey process. Resident identifier: #101. Facility census: 109.
- 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 medical record review and staff interview, the facility failed to develop a care plan for a resident with long term antibiotic use. This is true for one (1) of one (1) reviewed for antibiotics. Resident identifier: #113. Facility census: 109.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on record review, resident interview and staff interview, the facility failed to notify the physician of abnormal blood glucose readings for two (2) of two (2) Residents reviewed for insulin. The facility also failed to complete neurological checks for one (1) of four (4) Residents reviewed for accidents. These failed practices had the potential only affect a limited number of residents. Resident identifiers: #36, #54, #53. Facility census: 109.
- 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 observation and staff interview the facility failed to properly anchor Resident #50's indwelling catheter with a leg band. This failed practice was random opportunity for discovery and had the potential to affect only a limited number of Residents. Resident identifier: #50. Facility census: 109.
- 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 resident council minutes, resident interviews, resident representative interviews, grievances, resident council, and review of the Payroll Based Journal staffing report, and the CMS Nursing Home Compare's Report, the facility failed to ensure sufficient qualified nursing staff were available at all times to provide nursing and related services to meet the residents' needs safely and in a manner that promoted resident rights, physical, mental and psychosocial well-being. Facility census: 109.
- D
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Inspectors wroteBased on medical record review and staff interview. The facility failed to develop an individualized, person-centered approaches to address the care and treatment for a resident with dementia. This practice affected one (1) of one (1) residents reviewed for dementia during the Long-Term Care Survey Process (LTCSP). The failure to ensure the comprehensive care plan was developed for the resident's highest practicable well-being placed the residents at risk resulting in the Residents inability to achieve the highest level of functioning. Resident Identifier: #6. Facility census: 109.
- 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 record review, staff interview, and policy the facility failed to have drug regimen reviews available on the resident medical record. This was true for two (2) of five (5) reviewed for unnecessary medications. Resident identifier #2 and #6. Facility census: 109.
- D
Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs.
Inspectors wroteBased on observation, Resident interview, and medical record review the facility failed to provide a nourishing diet to Resident #30. This is true for one (1) of five (5) reviewed for diet preferences. Facility census: 109.
Fire safety inspections
16 fire safety citations on file: 6 on November 26, 2025, 4 on January 10, 2024, 6 on December 7, 2022.
Every fire safety citation16 citations
- F
Install emergency lighting that can last at least 1 1/2 hours.
K 291 · November 26, 2025 · Corrected (the home has a date of correction)
- F
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · November 26, 2025 · Corrected (the home has a date of correction)
- F
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
K 521 · November 26, 2025 · Corrected (the home has a date of correction)
- E
Ensure that testing and maintenance of electrical equipment is performed.
K 921 · November 26, 2025 · Corrected (the home has a date of correction)
- D
Provide properly protected cooking facilities.
K 324 · November 26, 2025 · Corrected (the home has a date of correction)
- C
Develop and maintain an Emergency Preparedness Program (EP).
E 4 · November 26, 2025 · Corrected (the home has a date of correction)
- F
Install a fire alarm system that can be heard throughout the facility.
K 341 · January 10, 2024 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · January 10, 2024 · Corrected (the home has a date of correction)
- F
Ensure that testing and maintenance of electrical equipment is performed.
K 921 · January 10, 2024 · Corrected (the home has a date of correction)
- C
Have simulated fire drills held at unexpected times.
K 712 · January 10, 2024 · Corrected (the home has a date of correction)
- F
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
K 321 · December 7, 2022 · Corrected (the home has a date of correction)
- F
Provide properly protected cooking facilities.
K 324 · December 7, 2022 · Corrected (the home has a date of correction)
- F
Install an approved automatic sprinkler system.
K 351 · December 7, 2022 · 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 · December 7, 2022 · Corrected (the home has a date of correction)
- F
Ensure that testing and maintenance of electrical equipment is performed.
K 921 · December 7, 2022 · Corrected (the home has a date of correction)
- C
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · December 7, 2022 · Corrected (the home has a date of correction)