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 43 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
1J
1K
2L
Actual harm
1G
0H
0I
Potential for more than minimal harm
21D
6E
10F
Potential for minimal harm
0A
0B
1C
October 29, 2025Complaint inspection · 1 citation
- D
Let each resident or the resident's legal representative access or purchase copies of all the resident's records.
Inspectors wroteBased on record review and interview, the facility failed to provide R1's medical record to the Power of Attorney (POA) in a timely manner after a request was made for one (R1) of four residents reviewed for medical records requests in a sample of five.
March 12, 2025Complaint inspection · 2 citations
- K
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 provide adequate supervision for cognitively impaired residents and keep hazardous disinfectant, alcohol gel, and hazardous odor eliminating spray secured and out of the reach of cognitively impaired, self-mobile residents for seven of seven residents (R1, R2, R3, R4, R5, R6, R7) reviewed for accidents in the sample of eight. These failures resulted in, on 2-14-25 R1, a cognitively impaired resident, obtaining a bottle of hazardous disinfectant (BNC-15), R1 ingesting the hazardous disinfectant, and R1 requiring emergency room services for treatment. These failures resulted in an Immediate Jeopardy. [...]
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on record review and interview the facility failed to follow physician's order to follow-up with gastroenterology following a resident who ingested a hazardous chemical for one of seven residents (R1) reviewed for accidents in the sample of eight.
May 16, 2024Standard inspection · 6 citations
- F
Provide and implement an infection prevention and control program.
Inspectors wroteBased on interview and record review, the facility failed to perform infection surveillance regarding logging, tracking and trending of resident and employee illnesses and infections. This failure has the potential to affect all 38 residents residing in the facility.
- F
Implement a program that monitors antibiotic use.
Inspectors wroteBased on interview and record review, the facility failed to ensure their antibiotic stewardship program was implemented. This failure has the potential to affect all 38 residents residing in the facility.
- D
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Inspectors wroteBased on interview and record review, the facility failed to have a Practitioner Order for Life-Sustaining Treatment/ POLST in the Medical Record one resident (R191) reviewed for Advanced Directives in the sample of 24.
- 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 interview and record review, the facility failed to develop a Care Plan for two of 16 residents (R16 and R27) reviewed for care plans in the sample of 24. Findings Include: The Care Plan policy dated 6/1/22, documents It is the policy of this facility to develop and implement a Base Line Care Plan, a Comprehensive Person-Centered Care Plan and conduct Care Plan Meetings as appropriate for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. 1. R16's current computerized medical record, documents R16 was admitted to the facility on [DATE] with a diagnosis of Non-Pressure Chronic Ulcer of Buttock with Unspecified Severity (Primary); Type 2 Diabetes Mellitus with Unspecified Complications; [...]
- D
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Inspectors wroteBased on observation, interview and record review, the facility failed to ensure showers and nail care were provided for two of two residents (R4 and R191) reviewed for activities of daily living in the sample of 24.
- D
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Inspectors wroteBased on observation, interview, and record review the facility failed to complete psychotropic assessments prior to the use of antipsychotic medications, document the resident's response to non-pharmacological interventions to manage behaviors/symptoms, and to ensure the resident has behaviors that warrant the use of antipsychotic medications for two of three residents (R5, R22) reviewed for antipsychotic medication use with the diagnosis of Dementia or Alzheimer's Disease in the sample of 24.
January 6, 2024Complaint inspection · 2 citations
- G
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 interview the facility failed to assess a resident with a history of leaning forward in her wheelchair for safe positioning while in her wheelchair and failed to apply foot pedals to the resident's wheelchair prior to transporting the resident for one of three residents (R1) reviewed for falls with injury in the sample of three. These failures resulted in R1 leaning forward in her wheelchair and abruptly dropping her feet to the floor, which caused R1 to fall face first onto the floor out of her wheelchair, sustaining a three-centimeter laceration to the right forehead that was bleeding and required closure with six sutures in the hospital emergency room.
- 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 record review and interview the facility failed to update fall care plans with newly developed fall interventions for two of three residents (R1 and R3) reviewed for falls in the sample of three.
October 8, 2023Complaint inspection · 3 citations
- E
Reasonably accommodate the needs and preferences of each resident.
Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a call light was within reach for four of four residents (R1, R2, R3, R4) reviewed for accommodation of needs in the sample of ten.
- E
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on observation, interview, and record review the facility failed to provide oral care/personal care to four of four residents (R1, R2, R3, and R4) reviewed for ADL (Activities of Daily Living) Care in the sample of ten.
- D
Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.
Inspectors wroteBased on observation, interview, and record review the facility failed to provide a resident with pureed meat as ordered by the physician for one of four residents (R2) reviewed for meals in the sample of ten.
May 19, 2023Standard inspection · 11 citations
- F
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure monitoring of high temperature sanitization of dishes. This failure has the potential to affect all 38 residents who receive meals from the kitchen.
- F
Implement a program that monitors antibiotic use.
Inspectors wroteBased on interview and record review, the facility failed to follow an Antibiotic Stewardship Program, this failure has the potential to affect all 39 residents who currently reside in the facility. Findings Include: The Facility's Antibiotic Stewardship Policy dated 12/18/19 documents It is the policy of the facility to follow an Antibiotic Stewardship Program, including the core elements as outlined by the CDC (Center for Disease Control). The Facility Antibiotic Stewardship policy documents Antibiotic use will be calculated on a monthly basis for QAPI (Quality Assurance and Performance Improvement). The CDC (Center for Disease Control) website documents As of November 2017 each (long term care) facility must have had an antibiotic stewardship program in place as part of their infection prevention and control program. [...]
- F
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 interview and record review, the facility failed to ensure CNAs/Certified Nursing Assistants received twelve hours of required continuing competency training annually. This failure has the potential to affect all 39 residents residing in the facility.
- 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 observation, interview the facility failed to develop care plans for multiple care areas and services for nine residents (R4, R6, R18, R20, R23, R28, R29, R35, R140) of 16 residents reviewed for care plans in the sample of 40.
- E
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Inspectors wroteBased on record review the facility failed to administer vaccinations per CDC (Center for Disease Control) guidelines for five residents (R16, R18, R23, R24 and R29) of five residents reviewed for immunizations in a total sample of 39. Findings Include: The Facility's Immunizations policy dated 06/2017 documents It is the policy of the facility to provide immunizations in accordance with CDC (Center for Disease Control Control) recommendations, resident consent, and physician orders. Purpose: to reduce the overall incidence of influenza by offering immunizations to all residents and to reduce the overall incidence of pneumococcal pneumonia by providing the pneumonia vaccines to residents 65 years or older and to others at high risk. [...]
- D
Allow residents to self-administer drugs if determined clinically appropriate.
Inspectors wroteBased on observation, interview, and record review the facility failed to assess one resident (R6) for self-administration of medications of 16 residents reviewed for medications in the sample of 40.
- D
Respond appropriately to all alleged violations.
Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a thorough investigation of an allegation of employee to resident abuse for one resident (R23) and failed to ensure thorough investigations were completed for two residents (R29, R140) with injuries of unknown origin of three residents reviewed for abuse in the sample of 40.
- 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 observation, interview, and record review the facility failed to revise a nutrition and wound Care Plan for one (R4) of 16 residents reviewed for Care Planning in the sample of 40.
- D
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Inspectors wroteBased on observation, interview, and record review, the facility failed to continue a restorative mobility program as recommended by Physical Therapy for one resident (R29) of 16 residents reviewed for mobility in the sample of 40.
- D
Provide enough food/fluids to maintain a resident's health.
Inspectors wroteBased on observation, interview, record review, the facility failed to monitor the weight of a new admission for one resident (R18) of four residents reviewed for nutrition in a total sample of 40. This failure caused R18's significant weight loss to be undetected therefore not treated. Findings Include: R18's Medical Record documents she was admitted on [DATE] after a fall at home. R18's Medical Record documents on 3/17/23 R18 weighed 103 pounds. R18's medical record documents the next weight being done on 4/3/23 at 101 pounds. R18's medical record documents on 4/11/23, R18 was 102.4 pounds and on 4/17/23 R18 was 99.6 pounds. On 5/18/23 V4 (LPN/Infection Preventionist) stated R18 should have been weighed on 3/24/23 and 3/31/23. When R18 went from 102.4 pounds to 99.6 pounds in one week, we should have reweighed her. [...]
- D
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Inspectors wroteBased on observation, interview, and record review, the facility failed to provide an appropriate indication for use, failed to monitor behaviors and failed to provide target behaviors on a consent for an antipsychotic medication for two residents (R23 and R140) with a diagnosis of Dementia receiving antipsychotic medications of five residents reviewed for unnecessary medications in the sample of 40.
June 16, 2022Standard inspection · 18 citations
- L
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure all employees were screened upon entrance to the facility for COVID-19 (Coronavirus Disease 2019) every day before their scheduled work shift, failed to remove a symptomatic employee from work immediately and quarantine this employee, and failed to isolate residents who are unvaccinated or not up to date with the COVID-19 vaccination immediately after exposure to COVID-19 positive employees. These failures resulted in V4 and V6 (CNAs/Certified Nursing Assistant) continuing to provide direct care to all of the residents within the facility for three to five days after exhibiting symptoms of COVID-19 and eventually testing positive for COVID-19. [...]
- L
Perform COVID19 testing on residents and staff.
Inspectors wroteBased on record review and interview, the facility failed to test an employee who had symptoms of COVID-19 immediately, failed to follow the COVID-19 rapid tests manufacturer's recommendations for accurate testing, failed to ensure COVID-19 testing supplies were readily available for staff to obtain testing on the designated testing days, and failed to utilize trained licensed staff to obtain the staff's COVID-19 tests. These failures resulted in one positive COVID-19 staff member V6 (Certified Nursing Assistant/CNA) working with residents due lack of testing supplies readily available upon entrance to the facility, and then testing positive for COVID-19. [...]
- J
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 interview the family of a confused resident to accurately assess elopement risk prior to admission, screen for supervision needs and develop an elopement care plan, failed to provide adequate supervision to prevent an elopement, failed to ensure all exit doors were secured and/or alarmed and the exit door alarm system was in working order, and failed to investigate an elopement for one of three residents (R27) reviewed for wandering in the sample of 27. [...]
- F
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on observation, interview, and record review, the facility failed to cover, label, and date pans filled with cooked chicken, cooked pork and cooked rice, and failed to maintain the temperature of milk below 41 degrees Fahrenheit. These failures had the potential to affect all 30 residents within the facility. Findings Include: The CMS (Centers for Medicare & Medicaid Services) Form 672 dated 6-7-22 documents 30 residents reside within the facility. The facility's Food Storage and Labeling Procedure dated 10/2021 documents, Objective: To provide staff with guidelines for food storage and labeling of foods. Food Storage: Keep all food covered in a resealable bag or container or the original container, if applicable. Labeling of Refrigerated Foods: The label should include: 1. Product Name: [...]
- F
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Inspectors wroteBased on observation, interview, and record review, the facility failed to properly screen a resident prior to admission to determine safety needs, failed to administer, operate and implement policies and procedures in a manner that ensured the safety of residents identified as an elopement risk, and failed to have the ability to implement an effective Abatement Plan for Immediate Jeopardies identified during survey. These failures have the potential to affect all 30 residents residing in the facility.
- F
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Inspectors wroteBased on interview and record review, the facility failed to develop and implement a plan of action to correct identified quality of care related deficiencies and follow up on resident care areas identified as a concern, through the Quality Assessment & Assurance Committee. This failure has the potential to affect all 30 residents living in the facility.
- F
Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
Inspectors wroteBased on interview and record review, the facility failed to designate a qualified Infection Preventionist. This failure has the potential to affect all 30 residents residing in the facility.
- F
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 review and interview, the facility failed to ensure the Nursing Aides were provided with annual Dementia management training. This failure has the potential to affect all 30 residents within the facility.
- 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 observation, interview and record review, the facility failed to develop a resident centered comprehensive plan of care related to elopement risk, respiratory care, discharge, psychotropic medication use, impaired/limited range of motion and hospice services, for six of 15 residents (R4, R13, R27, R31, R40, R89) reviewed for care planning, in a sample of 27.
- E
Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.
Inspectors wroteBased on interview and record review, the facility failed to ensure bedtime snacks were given to seven of eight residents (R2, R7, R18, R26, R29, R31, & R90) reviewed for receiving an evening snack, in a sample of 27.
- 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 interview and record review, the facility failed to notify the Physician and resident representative of an elopement for one of three residents (R27) reviewed for wandering in the sample of 27.
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on observation, interview and record review, the facility failed to keep a resident's fingernails trimmed and clean for one of one resident (R2) reviewed for Activities of Daily Living in the sample of 27.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on interview and record review, the facility failed to document a thorough assessment was completed after a resident elopement for one of three residents (R27) reviewed for wandering in the sample of 27.
- D
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Inspectors wroteBased on observation, interview, and record review, the facility failed to provide treatment/services for residents with limitations of range of motion or document rationale for the services to not be provided for two of two residents (R4, R13) reviewed for range of motion in the sample of 27.
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observation, interview and record review, the facility failed to ensure oxygen was delivered according to the Physician's order, for one of one resident (R31) reviewed with oxygen, in a sample of 27.
- D
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Inspectors wroteBased on observation, interview and record review, the facility failed to attempt non-pharmacological interventions and obtain consent prior to initiating an antipsychotic medication, monitor targeted behaviors and complete psychotropic assessments for two of four residents (R10, R27) reviewed for psychotropic medications in the sample of 27.
- D
Make sure that a working call system is available in each resident's bathroom and bathing area.
Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a resident's call light was in working order at all times for one of twelve residents (R24) reviewed for call lights in the sample of 27.
- C
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
Inspectors wroteBased on interview and record review, the facility failed to ensure the Quality Assessment and Assurance (QAA) meetings were held at least quarterly. This failure has the potential to affect all 30 residents residing in the facility.
Fire safety inspections
12 fire safety citations on file: 5 on May 16, 2024, 6 on May 19, 2023, 1 on June 16, 2022.
Every fire safety citation12 citations
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · May 16, 2024 · Corrected (the home has a date of correction)
- F
Have simulated fire drills held at unexpected times.
K 712 · May 16, 2024 · Corrected (the home has a date of correction)
- E
Install a two-hour-resistant firewall separation.
K 133 · May 16, 2024 · Corrected (the home has a date of correction)
- E
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
K 321 · May 16, 2024 · Corrected (the home has a date of correction)
- E
Install an approved automatic sprinkler system.
K 351 · May 16, 2024 · Corrected (the home has a date of correction)
- F
Establish staff and initial training requirements.
E 37 · May 19, 2023 · Corrected (the home has a date of correction)
- F
Conduct testing and exercise requirements.
E 39 · May 19, 2023 · Corrected (the home has a date of correction)
- F
Have simulated fire drills held at unexpected times.
K 712 · May 19, 2023 · Corrected (the home has a date of correction)
- E
Have properly installed electrical wiring and gas equipment.
K 511 · May 19, 2023 · Corrected (the home has a date of correction)
- E
Ensure proper usage of power strips and extension cords.
K 920 · May 19, 2023 · Corrected (the home has a date of correction)
- E
Have proper medical gas storage and administration areas.
K 923 · May 19, 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 · June 16, 2022 · Corrected (the home has a date of correction)