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 38 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
1G
0H
0I
Potential for more than minimal harm
19D
16E
0F
Potential for minimal harm
0A
0B
2C
April 7, 2026Complaint inspection · 2 citations
- E
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a safe, sanitary, and homelike environment in 3 of 6 unit halls and common resident spaces. The 100 unit hall temperature was 70 degrees Fahrenheit (F), the Garden Ridge unit hall was 64 degrees F, and the Cedar point unit hall was 69 degrees F. (100 unit, Garden Ridge unit, Cedar Pointe unit, Resident B, Resident D).
- 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, interview, and record review, the facility failed to ensure care plan interventions to prevent falls were in place for 1 of 3 residents reviewed for quality of care. A resident with a history of falls did not have specific interventions to prevent further falls in place according to the plan of care. (Resident C)
June 13, 2025Standard inspection · 6 citations
- E
Allow resident to participate in the development and implementation of his or her person-centered plan of care.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure care plan conferences were held for 4 of 5 residents reviewed for unnecessary medications. (Resident 6, Resident 7, Resident 11, Resident 44)
- E
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 ensure notification to family/resident representative with a change in resident condition for 4 of 5 residents reviewed for falls. Family/resident representatives were not notified following falls. (Resident 39, Resident 43, Resident 52, Resident 56)
- 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 adequate supervision and assistive devices were provided to prevent accidents for 4 of 5 residents reviewed for falls. Complete and thorough assessments were lacking after each fall, care plans were not updated with each fall, current interventions were not in place to at times of falls and a comprehensive review of all falls was not completed. (Resident 39, Resident 43, Resident 52, Resident 56)
- D
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Inspectors wroteBased on interview and record review, the facility failed to provide a required notice to a resident being discharged from Medicare services for 1 of 3 residents reviewed. No record of a SNF-ABN (Skilled Nursing Facility-Advanced Beneficiary Notification) notice was available that indicated the resident was notified of a discharge from Medicare services with days remaining prior to the resident's discharge from the facility. (Resident 75)
- D
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure resident's drug regimens were free from unnecessary drugs for 2 of 5 residents reviewed for falls. A resident was given an antipsychotic without a physician's order and a gradual dose reduction (GDR) wasn't done for a resident taking an antipsychotic and antianxiety medication. (Resident 39, Resident 6)
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a sanitary environment to help prevent the development and transmission of communicable diseases and infections for 3 of 3 residents observed for incontinence care. Hand hygiene was not completed between glove changes, staff washed hands with less then 15 second lather, an incontinence pad was held between the bed and the staff's knees (with the inside of the incontinence pad against her scrub pants), staff left a visibly soiled incontinence pad on a resident after toileting him, and residents were not offered to wash their hands after toileting. (Resident 7, Resident 45, Resident 6)
May 22, 2024Standard inspection · 21 citations
- E
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 interview and record review, the facility failed to ensure a notice of transfer or discharge was given to residents or resident representatives for 5 of 5 residents reviewed for hospitalizations. The transfer or discharge notice was not completed and clinical records lacked documentation of residents/representatives receiving a notice of transfer or discharge at the time of the hospitalizations. (Resident 38, Resident 52, Resident 46, Resident 43, Resident 15)
- E
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 interview and record review, the facility failed to ensure a bed hold form and policy was given to residents or resident representatives for 5 of 5 residents reviewed for hospitalizations. The bed hold form was not completed and clinical records lacked documentation of residents/representatives receiving a bed hold form and policy at the time of the hospitalizations. (Resident 38, Resident 52, Resident 46, Resident 43)
- E
Ensure each resident receives an accurate assessment.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure accuracy of assessments for 14 of 26 resident records reviewed during the survey. MDS (Minimum Data Set) Assessments did not accurately reflect resident status. (Resident 52, Resident 38, Resident 12, Resident 35, Resident 36, Resident 41, Resident 19, Resident 17, Resident 19, Resident 43, Resident 48, Resident 5, Resident 53)
- 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 comprehensive person-centered care plan with resident specific needs for 4 of 22 residents reviewed for care plan development and implementation. Resident on hospice did not have a care plan for hospice, resident did not have a care plan for eating meals at a bedside table in the main dining room, residents that were taking an antianxiety, diuretic, and antidepressant did not have care plans for use. (Resident 19, Resident 5, Resident 48, Resident 45)
- 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 observation, interview, and record review, the facility failed to ensure residents had care plan conferences and care plans were revised for 1 of 2 residents reviewed for accidents and 3 of 5 residents reviewed for unnecessary medications. A resident moved out of the locked dementia unit and a resident's sleep medication was changed but the care plans were not revised. Residents did not have care plan conferences timely. (Resident 38, Resident 12, Resident 5, Resident 48)
- 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 interview and record review, the facility failed to ensure residents were free from unnecessary medications for 5 of 6 residents reviewed for unnecessary medications. Resident's as needed anti-anxiety medication was ordered for greater than 14 days. A resident had a Physician's Order for an antipsychotic with an unacceptable diagnosis. (Resident 45, Resident 3, Resident 14, Resident 19, Resident 48)
- 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, interview and record review, the facility failed to maintain safe and secure storage of medications for 3 of 4 medication carts observed and 1 of 3 medication storage rooms observed. Loose pills were observed in the medication carts, and refrigerator temperature logs were not filled out completely in the medication room.
- 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, interview, and record review, the facility failed to ensure distribution and food service was provided in accordance with professional standards for food service safety for 2 of 2 meals observed, and 1 of 1 meal services observed in the kitchen. (Main Kitchen, Locked Unit Dining Room)
- E
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Inspectors wroteBased on interview, and record review, the facility failed to properly document influenza and pneumococcal vaccines being offered to residents for 3 of 5 residents reviewed for influenza and pneumococcal vaccination. Clinical records lacked the vaccine consent/refusal date, the reason why it was refused, and a date education was provided to the resident and/or resident representative. (Resident 19, Resident 4, Resident 36)
- E
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a safe, functional, sanitary, and comfortable environment for residents for 2 of 5 halls observed, and 1 of 1 common area observed. (Locked Unit, room [ROOM NUMBER] )
- D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were treated with respect and dignity for 2 of 2 random observations. A staff member was observed standing while assisting to feed a resident, and a staff member walked away from a resident with visible urine under her chair. (Resident 27, Resident 48)
- D
Reasonably accommodate the needs and preferences of each resident.
Inspectors wroteBased on observation and interview the facility failed to provide services based on resident preferences for 1 of 5 residents reviewed. The facility failed to provide ice water to one resident when requested. (Resident 45)
- 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 observation, interview, and record review, the facility failed to clarify a Resident's code status for 1 of 1 residents reviewed for Advanced Directives. A Resident's current Physician Orders did not match the signed DO NOT RESUSCITATE DECLARATION AND ORDER form. A Resident had a care plan for DNR (Do Not Resuscitate) and CPR (Cardiopulmonary Resuscitation). (Resident 18)
- D
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the resident right to be free of a physical restraint for 1 of 1 residents reviewed for physical restraints. A bed rail was used as a physical restraint. (Resident 12)
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on observation, interview, and record review, the facility failed to report an allegation of abuse for 1 of 1 residents reviewed for abuse. A Certified Nurse Aide (CNA) physically removed the resident's fingers and hand from the stand aide lift. (Resident 4)
- D
Respond appropriately to all alleged violations.
Inspectors wroteBased on observation, interview, and record review, the facility failed to properly investigate an allegation of abuse for 1 of 1 residents reviewed for abuse. A Certified Nurse Aide (CNA) physically removed the resident's fingers and hand from the stand aide lift. (Resident 4)
- D
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 adequate supervision to prevent accidents for 2 of 2 residents reviewed for falls. Neurological checks were not completed after a fall, new interventions were not put into place after falls, and interventions on care plans were not followed for residents at risk for falls resulting in multiple falls. (Resident 38, Resident 52)
- 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, interview, and record review, the facility failed to ensure a resident received services and assistance to prevent and treat urinary tract infections (UTI) for 1 of 1 residents reviewed for UTIs. A resident with recurrent UTIs was not treated appropriately, and incontinence care provided lacked appropriate infection control practices to prevent infection. (Resident 36)
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wrote2. On 5/15/24 at 1:58 P.M., Resident 28's oxygen filter on the side of the oxygen machine was observed to be caked with dust. Resident 28 was sitting in his recliner wearing O2 per nasal cannula at 2 lpm with gauze on the tubing to protect his ears. On 5/16/24 at 9:11 A.M., Resident 28 was observed sitting in his recliner with O2 on at 2 lpm per nasal cannula. The filter on the side of the oxygen machine remains dusty. On 5/15/24 at 2:49 P.M., Resident 28's clinical records were reviewed. Diagnosis included, but were not limited to chronic respiratory failure with hypoxia. The most current Annual MDS (Minimum Data Set) Assessment and State Optional MDS, dated [DATE], indicated Resident 28 was cognitively intact, required, extensive assistance of one for bed mobility and toilet use, limited assistance of one for transfers, and used oxygen. [...]
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure infection control practices were followed for 2 of 4 residents during observation of incontinence care and 1 of 3 observations of obtaining a blood sugar with a glucometer. Gloves were not changed between dirty and clean tasks during peri care and staff cleaned a glucometer for an unmeasurable amount of time. (Resident 7, Resident 11, Resident 43).
- C
Post nurse staffing information every day.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure posted nurse staffing sheets were posted daily during the survey for 2 of 9 days reviewed during the survey process. Post nurse staffing was not updated over the weekend. (May 18, May 19)
December 12, 2023Complaint inspection · 1 citation
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on interview and record review, the facility failed to ensure timely reporting of an abuse allegation to facility administration and to the state agency for 1 of 2 abuse allegations reviewed. Staff filed an abuse allegation as a grievance rather than immediately notifying the DON (Director of Nursing) or facility administrator, and the allegation was not reported to the state agency within the required 2 hour time frame. (Resident D)
February 9, 2023Standard inspection · 8 citations
- G
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 each resident received adequate supervision and assistive devices to prevent accidents for 2 of 2 residents reviewed for accidents. Care plan interventions were not followed or updated after falls, and one random observation of a treatment cart containing prescription medication was observed left unlocked and unattended. This deficient practice resulted in Resident 44 having 9 falls in 11 months resulting in three fractures. (Resident 44, Resident 28, Treatment Cart)
- E
Ensure services provided by the nursing facility meet professional standards of quality.
Inspectors wrote4. During record review on 2/1/23 at 2:48 P.M., Resident 12 was [AGE] years old when admitted to the facility on [DATE]. Resident 12's diagnosis included, but was not limited to, schizoaffective disorder, diagnosed 3/26/21. Resident 12's most recent significant change MDS, dated [DATE], indicated Resident 12 had schizophrenia and received antipsychotics on a routine basis. Resident 12's current physician orders included, but were not limited to, Zyprexa (antipsychotic medication) 5 milligrams (mg) by mouth two times a day for a diagnosis of schizoaffective disorder. Resident 12's assessments, behavior monitoring, and documentation of diagnosis criteria for schizoaffective disorder was requested, but not received. 5. During record review on 2/3/23 at 1:59 P.M., Resident 2 was [AGE] years old when admitted to the facility on [DATE]. [...]
- E
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview, and record review, the facility failed to properly prevent and/or contain COVID-19 during 1 random observation of staff entering a COVID-19 positive resident room, 3 of 5 resident observed for care, and 1 of 4 residents observed for medication administration. Gloves were not changed from dirty to clean tasks, hands were not washed appropriately, staff was not appropriately wearing a face mask, staff did not sanitize hands prior to providing incontinence care, and staff did not sanitize hands prior to handling medications. (Resident B, Resident G, Resident K, Resident M, Resident J)
- 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, interview, and record review, the facility failed to ensure that appropriate treatment and services were provided to for an incontinent resident in 1 of 2 residents reviewed for UTI (urinary tract infections). A resident with a UTI was observed incontinent of urine, and was not cleaned appropriately. (Resident B)
- 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 the residents received the necessary respiratory care and services in accordance with the professional standards of practice for 2 of 2 residents reviewed for respiratory care. The facility failed to follow physician oxygenation orders and have an oxygen use care plan. (Resident 29, Resident 303)
- 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 interview and record review, the facility failed to ensure a communication process with hospice personnel was developed and implemented, including how the communication will be documented between the LTC (long term care) facility and the hospice provider, and to ensure that the needs of the resident were addressed for 1 of 1 residents reviewed for hospice. The clinical record of Resident 41 lacked documentation of ongoing communication between facility staff and hospice staff. (Resident 41)
- D
Ensure staff are vaccinated for COVID-19
Inspectors wroteBased on interview and record review, the facility failed to ensure staff COVID-19 vaccination medical exemptions specified a clinically recognized contraindication for 1 of 1 staff medical exemptions reviewed. (Staff 10)
- C
Post nurse staffing information every day.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure completed staffing sheets were posted daily for 6 of 6 days during the survey.
Fire safety inspections
34 fire safety citations on file: 5 on June 13, 2025, 14 on May 22, 2024, 15 on February 9, 2023.
Every fire safety citation34 citations
- F
Have simulated fire drills held at unexpected times.
K 712 · June 13, 2025 · Corrected (the home has a date of correction)
- F
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · June 13, 2025 · Corrected (the home has a date of correction)
- E
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
K 521 · June 13, 2025 · Corrected (the home has a date of correction)
- E
Ensure proper usage of power strips and extension cords.
K 920 · June 13, 2025 · Corrected (the home has a date of correction)
- E
Have proper medical gas storage and administration areas.
K 923 · June 13, 2025 · Corrected (the home has a date of correction)
- F
Address patient/client population and determine types of services needed.
E 7 · May 22, 2024 · Corrected (the home has a date of correction)
- F
Establish staff and initial training requirements.
E 37 · May 22, 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 · May 22, 2024 · Corrected (the home has a date of correction)
- F
Install a fire alarm system that can be heard throughout the facility.
K 341 · May 22, 2024 · Corrected (the home has a date of correction)
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · May 22, 2024 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · May 22, 2024 · Corrected (the home has a date of correction)
- F
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
K 761 · May 22, 2024 · Corrected (the home has a date of correction)
- F
Have proper medical gas storage and administration areas.
K 923 · May 22, 2024 · Corrected (the home has a date of correction)
- F
Have proper fire barriers, ventilation and signs for the transfilling of oxygen.
K 927 · May 22, 2024 · Corrected (the home has a date of correction)
- E
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
K 222 · May 22, 2024 · Corrected (the home has a date of correction)
- E
Install an approved automatic sprinkler system.
K 351 · May 22, 2024 · Corrected (the home has a date of correction)
- E
Install corridor and hallway doors that block smoke.
K 363 · May 22, 2024 · Corrected (the home has a date of correction)
- E
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · May 22, 2024 · Corrected (the home has a date of correction)
- C
Conduct testing and exercise requirements.
E 39 · May 22, 2024 · Corrected (the home has a date of correction)
- F
Conduct risk assessment and an All-Hazards approach.
E 6 · February 9, 2023 · Corrected (the home has a date of correction)
- F
Include a process for Emergency Preparedness collaboration.
E 9 · February 9, 2023 · Corrected (the home has a date of correction)
- F
Develop a communication plan.
E 29 · February 9, 2023 · Corrected (the home has a date of correction)
- F
Establish emergency prep training and testing.
E 36 · February 9, 2023 · Corrected (the home has a date of correction)
- F
Establish staff and initial training requirements.
E 37 · February 9, 2023 · Corrected (the home has a date of correction)
- F
Conduct testing and exercise requirements.
E 39 · February 9, 2023 · Corrected (the home has a date of correction)
- F
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
K 222 · February 9, 2023 · Corrected (the home has a date of correction)
- F
Provide a written emergency evacuation plan.
K 711 · February 9, 2023 · Corrected (the home has a date of correction)
- E
Provide properly protected cooking facilities.
K 324 · February 9, 2023 · Corrected (the home has a date of correction)
- E
Ensure proper usage of power strips and extension cords.
K 920 · February 9, 2023 · Corrected (the home has a date of correction)
- C
Develop and maintain an Emergency Preparedness Program (EP).
E 4 · February 9, 2023 · Corrected (the home has a date of correction)
- C
Develop Emergency Preparedness policies and procedures.
E 13 · February 9, 2023 · Corrected (the home has a date of correction)
- C
Establish procedures for tracking staff and patients during an emergency.
E 18 · February 9, 2023 · Corrected (the home has a date of correction)
- C
Establish policies and procedures for medical documentation.
E 23 · February 9, 2023 · Corrected (the home has a date of correction)
- C
Create arrangements with other facilities to receive patients.
E 25 · February 9, 2023 · Corrected (the home has a date of correction)