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 41 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
2J
0K
1L
Actual harm
1G
0H
0I
Potential for more than minimal harm
21D
11E
4F
Potential for minimal harm
0A
0B
1C
March 18, 2026Complaint inspection · 2 citations
- D
Respond appropriately to all alleged violations.
Inspectors wroteBased on observation, staff interview, clinical record review and facility documentation review, the facility staff failed to complete a thorough investigation of an alleged violation (resident elopement) for one of six residents in the survey sample (Resident #1).
- D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on staff interview and clinical record review, the facility staff failed to ensure a complete and accurate clinical record for one of six residents in the survey sample (Resident #2).
November 28, 2023Complaint inspection · 1 citation
- D
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Inspectors wroteBased on staff interview and clinical record review, the facility staff failed to develop a baseline care plan for one of 3 residents in the survey sample. Resident #3 (R3) did not have an accurate or timely baseline care plan for immediate care. The Findings Include: Diagnoses for R3 included: Coronary artery disease, end stage renal disease with dialysis (ESRD), hypertension, anxiety, chronic pain, neuropathy, and ischemia. The most current MDS (minimum data set) was a discharge assessment with an ARD (assessment reference date) of 10/15/23. R3 was assessed with a cognitive score of 12 out of 15, indicating cognitively intact. Review of R3's clinical record indicated R3 was admitted to the facility on [DATE]. The admission Evaluation was reviewed and documented R3's full assessment was not completed until 10/14/23 (4 days after admission). [...]
October 26, 2023Complaint inspection · 4 citations
- J
Ensure services provided by the nursing facility meet professional standards of quality.
Inspectors wroteBased on staff interview, facility document review, and clinical record review, the facility staff failed to follow professional standards of care for one of twelve residents in the survey sample (Resident #1). Facility staff failed to clarify with the provider a new order to administer 100 units of short-acting insulin at each meal, when Resident #1 was intended to receive 20 units with meals. Resident #1 received a total of 200 units of short-acting insulin in a 4-hour period leading to life-threatening hypoglycemia, requiring hospitalization in the intensive care unit for treatment of the insulin overdose (serious harm). Immediate jeopardy was identified from 10/14/23 through 10/19/23 related to this deficiency.
- J
Ensure that residents are free from significant medication errors.
Inspectors wroteBased on staff interview, facility document review, and clinical record review, the facility staff failed to ensure one of twelve residents in the survey sample (Resident #1) was free from a significant medication error. Facility staff entered an erroneous order to administer an 100-unit dose of short-acting insulin with meals, when Resident #1 was intended to get 20 units with meals. Resident #1 (R1) was administered a total of 200 units of short-acting insulin in a 4-hour period based upon this order, leading to life-threatening hypoglycemia (low blood sugar) requiring immediate treatment of the insulin overdose and subsequent hospitalization in the intensive care unit (serious harm). Immediate jeopardy was identified from 10/14/23 through 10/19/23 related to this deficiency.
- E
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased upon staff interview and clinical record review, the facility staff failed to follow physician orders for one of twelve residents in the survey sample (Resident #1).
- D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Inspectors wroteBased on staff interview and clinical record review, the facility staff failed to ensure medications were available for administration for one of twelve residents in the survey sample (Resident #1).
July 26, 2023Standard inspection · 7 citations
- F
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on observations, interview, record review, and policy review, the facility failed to ensure the kitchen was maintained in a sanitary manner to prevent potential foodborne illness for 93 out of 94 residents (1 resident was receiving tube feedings). Specifically, the main kitchen freezer was found to have improperly labeled foods in the freezer and three out of four-unit pantry refrigerators were found to be improperly labeled and had expired food items. This failure had the potential to expose residents to expired and/or spoiled food, unknown allergens, and food items that were not in compliance with current dietary orders.
- D
Ensure each resident receives an accurate assessment.
Inspectors wroteBased on observation, resident interview, staff interview, and clinical record review, the facility staff failed to complete an accurate minimum data set (MDS) for one of twenty-two residents in the survey sample (Resident #19).
- 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 resident interview, staff interview, and clinical record review, the facility staff failed to develop a comprehensive care plan for one of twenty-two residents in the survey sample (Resident #19)
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on observation, staff interview, and clinical record review, the facility staff failed to apply a wander prevention device as required in the plan of care for one of twenty-two residents in the survey sample (Resident #25).
- D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Inspectors wroteBased on observation, staff interview, facility document review, and clinical record review, the facility staff failed to ensure medication was available for administration for two of four residents during the medication pass and pour observation (Resident #8 and Resident #89). 1. 2. The Findings Include: 1. Resident #8's (R8) Telmisartan 40 milligrams (given for hypertension) was unavailable for administration as ordered by the physician. During a medication pass and pour observation conducted on 7/25/22 at 8:00 AM, Resident #8 (R8) was scheduled to receive Telmisartan 40 MG at 8AM. Licensed practical nurse (LPN #2) looked into the medication cart and verbalized that the medication was not available to give. LPN #8 then called the pharmacy and relayed that it was stated that the medication would be arriving later in the day. [...]
- D
Ensure medication error rates are not 5 percent or greater.
Inspectors wroteBased on observation, staff interview, facility document review, and clinical record review, the facility staff failed to ensure a medication error rate of less than five percent. Medication pass observations revealed five errors out of forty-one opportunities, resulting in a 12.2% error rate The Findings Include: 1. Resident #2 (R2) was given the wrong dose of Calcium. During a medication pass and pour observation conducted on 7/25/23 at 8:00 AM, license practical nurse (LPN #2) began pulling medications out of the medication cart for R2 and handing the medications to this surveyor to document. One of the medications pulled from the medication cart was Calcium 600 MG (milligrams) with Vitamin D 5 mcg (micrograms). LPN #1 dispensed the medication into the medication cup and administered to R2. R2's physician's orders were then reviewed to verify accuracy of medications given. [...]
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, staff interview, facility document review and clinical record review, the facility staff failed to follow infection control practices regarding hand hygiene during a dressing change for one of twenty-two residents in the survey sample (Resident #25) and on one of two units during the medication pass (unit 2).
May 19, 2022Standard inspection · 24 citations
- L
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 interview, family interview, staff interview, observation, and clinical record review, the facility staff failed to provide sufficient nursing staff to ensure care and services were provided to maintain the highest practicable well-being for 11 of 22 residents in the survey sample, residing on three of three floors, Residents #188, #73, #80, #238, #11, #20, #62, #51, #35, #47, and #9. Resident #188 did not receive pain medication as ordered, which was identified as harm. Call bells were not answered in a timely manner as evidenced by resident and family interviews, and as documented in the resident council meeting minutes. Eight residents did not receive skin and/or wound care evaluations, Residents #73, #80, #238, #11, #20, #62, #51, and #35. Two residents who were identified as wandering were not provided supervision, Resident #9 and #47. [...]
- G
Provide safe, appropriate pain management for a resident who requires such services.
Inspectors wroteBased on resident interview, staff interview, and clinical record review, the facility staff failed to provide effective pain management for one of 22 residents, Resident #188. Resident #188 reported on two separate occasions, her pain medication was delayed and/or not available for administration resulting in extreme pain greater than ten (on a scale of 1-10) and through the roof. This is harm.
- F
Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
Inspectors wroteBased on facility document review and staff interview, the facility staff failed to employ a qualified dietitian. There had been no registered dietitian employed since 4/15/22 in the facility with a census of 73.
- F
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Inspectors wroteBased on staff interviews, family interview, clinical record review, and survey findings, the facility staff failed to provide effective administration in a manner to maintain the highest practicable well-being of each resident. The census in the facility was 73. The facility staff failed to employ sufficient nursing staff which resulted in the identification of Immediate Jeopardy.
- F
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, staff interview, and facility document review, the facility staff failed to implement a Legionella water management program in the facility; failed to follow infection control practices for proper PPE (personal protective equipment) when going in and out of a resident room for one of 22 residents, Resident # 73; and failed to follow infection control practices during a dressing change for one of 22 residents, Resident # 11. 1. The facility failed to implement a Legionella water management program in the facility. 2. Facility staff did not use proper PPE when entering Resident #73's room. There was also no order or care plan in place for droplet precautions for Resident #73. 3. Staff failed to follow infection control practices during a dressing change for Resident # 11.
- 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 staff interview, clinical record review, resident interview, and facility document review, the facility staff failed to develop a baseline care plan for three of 22 residents in the survey sample, Resident # 238, # 188, and # 73. 1. Resident # 238 did not a care plan for NASH (non-alcoholic steatohepatitis). 2. Resident # 188 did not have a baseline care plan for pain related to a fractured ankle, and also did not receive a copy of the baseline care plan. 3. Resident # 73 did not have a baseline care plan for droplet precautions.
- 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 staff interview and clinical record review, the facility staff failed to develop a comprehensive care plan (CCP) for 5 of 22 residents in the survey sample, Residents #62 #51, #6, #70, and #76. Resident #62's CCP did not include a focus areas with goals and interventions for the use of an anticoagulant. Resident #51's CCP did not include a focus area with goals and interventions for hospice care. Resident #6's CCP did not include a focus area with goals and interventions for nutritional/dietary needs. Resident #70's CCP did not include a focus area with goals and interventions for palliative care. Resident #76's CCP did not include a focus area with goals and interventions for mood disorder and behaviors.
- E
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on resident interview, staff interview, and clinical record review, the facility staff failed to follow physician orders for 4 of 22 residents in the survey sample, Residents #6, #62, #188, and #33; and failed to assess and monitor a left hip hematoma for one of 22 in the survey sample, Resident #47. Resident #6 did not have Debrox drops administered as ordered. Resident #62 did not have prophylactic medications administered as ordered. Resident #188 did not have fluid intake monitored for compliance with fluid restriction as ordered. Resident #47 did not have a hematoma monitored. Resident #33 did not have the medication Abilify administered as ordered.
- E
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on observation, staff interview, clinical record review, and facility document review, the facility staff failed to assess and implement interventions for the treatment of pressure ulcers for eight of 22 residents, Resident #73, #80, #238, #20, #62, #51, #11, and #35. Resident #73 was admitted to the facility with a Stage IV pressure ulcer to the sacrum. There was no skin assessment, measurement, or intervention for treatment of the pressure ulcer at the time of admission. Resident #80, #238, #20, #62, and #51, all identified as being at risk for the development of pressure ulcer/skin injury, did not have weekly skin assessments completed. Resident #11 did not have weekly skin assessments completed and the facility staff failed to follow infection control practices during a dressing change. [...]
- E
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on observation, resident interview, family interview, staff interview, and clinical record review, the facility staff failed to ensure supervision and interventions to prevent accidents for two of 22 residents in the survey sample, Resident #47, and #9. The facility failed to provide appropriate footwear and supervision to prevent falls as per the comprehensive care plan for Resident #47. Resident #9, with a non-functioning wander prevention device, eloped from the facility without staff knowledge and/or supervision.
- E
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Inspectors wroteBased on staff interview, facility document review and clinical record review, the facility failed to ensure medications were available for administration for two of twenty-two residents in the survey sample, Resident #33 and #62. Resident #33's prescribed medication Abilify was not available resulting in six missed doses. Resident #62's medications for urinary health were not available for administration.
- E
Ensure medication error rates are not 5 percent or greater.
Inspectors wroteBased on medication pass and pour observation, staff interview, and clinical record review, the facility staff failed to ensure a medication error rate of less than five percent. A medication pass and pour observation conducted on 05/10/2022 with 27 opportunities and 22 errors, yielded an medication error rate of 81.48 percent.
- 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, staff interview, and facility document review, the facility staff failed to ensure expired medications were not available for administration; and also failed to date open vials of insulin and stock medications on the medication carts on three of three units. 1. Unit 3 medication carts included open vials of undated insulin and expired insulin. 2. Unit 1 and Unit 2 medication carts included a total of twenty-one house stock medications that were not dated, four vials of insulin open and not dated, and one bottle of expired insulin still in the medication cart and available for administration.
- 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, facility document review and staff interview, the facility staff failed to store resident food in a sanitary manner on three of three nursing units. Expired and/or undated food items were observed in the nourishment refrigerators on unit 1, unit 2 and unit 3.
- 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 family interview, staff interview and clinical record review, the facility staff failed to notify the physician and resident representative of an elopement for one of twenty-two residents in the survey sample, Resident #9. Resident #9's family and physician were not notified when the resident was found out of the facility unsupervised.
- D
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Inspectors wroteBased on clinical record review, staff interview and facility document review, the facility staff failed to implement their abuse policy for one of 22 residents in the survey sample, Resident #51. Facility staff failed to follow the abuse policy to report and investigate an injury of unknown orgin in a timely manner.
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on clinical record review, staff interview and facility document review, the facility staff failed to implement their abuse policy for one of 22 residents in the survey sample, Resident #51. Facility staff failed to report an injury of unknown origin to the state agency in a timely manner.
- D
Provide doctor's orders for the resident's immediate care at the time the resident was admitted.
Inspectors wroteBased on staff interview and clinical record review, the facility staff failed to obtain order for the immediate care of Stage IV sacral pressure ulcer for one of 22 residents, Resident #73.
- D
Ensure each resident receives an accurate assessment.
Inspectors wroteBased on staff interview and clinical record review, the facility staff failed to ensure a complete and accurate MDS (minimum data set) assessment for two of 22 residents in the survey sample, Resident # 84 and # 76. 1. Resident # 84, was coded in the electronic medical record (EMR) as discharged to an acute hospital, when the resident actually transferred to another facility. 2. Resident # 76 did not have sections C, D, and Q completed of the MDS.
- 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, staff interview and clinical record review, the facility staff failed to review and revise a comprehensive care plan for one of 22 residents, Resident #47. Resident #47 fell at the facility on 04/01/2022 resulting in a large hematoma to her left hip. Her care plan was not revised to include treatment of the area.
- D
Ensure services provided by the nursing facility meet professional standards of quality.
Inspectors wroteBased on family interview, staff interview, facility document review and clinical record review, the facility staff failed to follow professional standards of practice for one of twenty-two residents in the survey sample, Resident #9. Resident #9 eloped from the facility without staff knowledge and/or supervision. Nursing made no record of the incident, documented no assessment of the resident when found, and made no notification to administration, the provider or family about the incident.
- D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on resident interview, clinical record review, and staff interview, the facility staff failed to ensure a complete and accurate record for two of 22 residents in the survey sample, Resident # 80 and # 238. 1. Resident # 80 had weights inaccurately recorded. 2. Resident # 238 did not have a code status documented.
- D
Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
Inspectors wroteBased on staff interview, clinical record review, and facility document review, the facility staff failed to provide records of weekly hospice visits as required in the hospice services agreement, for one of 22 residents in the [NAME] sample, Resident #51.
- C
Keep all essential equipment working safely.
Inspectors wroteBased on observation, facility document review and staff interview, the facility staff failed to ensure proper function of the dishwasher. The rinse temperature gauge on the main kitchen's dishwasher was in disrepair.
February 6, 2020Standard inspection · 3 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 observations, clinical record review, resident interview, and staff interview, the facility staff failed to develop a person centered plan of care to address the residents' use of side rails for four of 21 residents in the survey sample, Residents # 14, 20, 21 and 36. The plan of care for each of the four residents had the same problem, goal, and interventions.
- 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 clinical record review, staff interview, and facility document review, the facility staff failed to ensure an advance directive was signed by the authorized representative for one of 21 residents, Resident #78.
- D
Assure that each resident’s assessment is updated at least once every 3 months.
Inspectors wroteBased on staff interview, and clinical record review, the facility failed to ensure a quarterly MDS (minimum data set) was completed timely for one of 21 Resident's. Resident #2 did not have a quarterly MDS completed within 92 days. The findings Include: Resident #2 was admitted to the facility on [DATE]. Diagnoses for Resident #2 included: Osteoporosis, pain, and anxiety. The most current MDS (minimum data set) was a quarterly assessment with an ARD (assessment reference date) of 1/30/20. Resident #2 was assessed with a cognitive score of 15 indicating cognitively intact. Review of Resident #2's clinical record indicated Resident #2's comprehensive MDS with an ARD of 9/23/19 was completed on 10/1/19. Further review of Resident #2's MDS's indicated there was not an MDS completed within the 92 days following the comprehensive MDS. [...]
Fire safety inspections
11 fire safety citations on file: 5 on July 26, 2023, 5 on May 19, 2022, 1 on February 6, 2020.
Every fire safety citation11 citations
- E
Have properly installed hallway dispensers for alcohol-based hand rub.
K 325 · July 26, 2023 · Corrected (the home has a date of correction)
- E
Provide a written emergency evacuation plan.
K 711 · July 26, 2023 · Corrected (the home has a date of correction)
- E
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
K 761 · July 26, 2023 · Corrected (the home has a date of correction)
- D
Have elevators that firefighters can control in the event of a fire.
K 531 · July 26, 2023 · Corrected (the home has a date of correction)
- D
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · July 26, 2023 · Corrected (the home has a date of correction)
- F
Install corridor and hallway doors that block smoke.
K 363 · May 19, 2022 · Corrected (the home has a date of correction)
- E
Use approved construction type or materials.
K 161 · May 19, 2022 · Corrected (the home has a date of correction)
- E
Have properly located and lighted "Exit" signs.
K 293 · May 19, 2022 · Corrected (the home has a date of correction)
- E
Inspect, test, and maintain automatic sprinkler systems.
K 353 · May 19, 2022 · Corrected (the home has a date of correction)
- D
Provide a written emergency evacuation plan.
K 711 · May 19, 2022 · Corrected (the home has a date of correction)
- F
Install an approved automatic sprinkler system.
K 351 · February 6, 2020 · Corrected (the home has a date of correction)