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 27 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
1J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
21D
5E
0F
Potential for minimal harm
0A
0B
0C
April 3, 2026Standard inspection · 5 citations
- 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 store and distribute food under sanitary conditions, increasing the risk of cross-contamination and food-borne illness. These deficient practices had the potential to affect all residents. The facility census was 64. Review of the facility's policy titled, Sanitization, revised November 2022, showed:- The food service area is maintained in a clean and sanitary manner;- All utensils, counters, shelves, and equipment are kept clean, maintained in good repair and are free from breaks, corrosions, open seams, cracked and chipped areas that may affect their use or proper cleaning;- All equipment, food contact surfaces, and utensils are cleaned and sanitized;- The policy did not address refrigerator and/or freezer defrosting. [...]
- 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 issue a Skilled Nursing Facility Advanced Beneficiary Notice (SNF ABN) and/or a Notice of Medicare Non-Coverage (NOMNC) form to the resident and/or the resident's representative in writing at least two calendar days before discharge from skilled services. This notice informs the beneficiary about potential non-coverage and the option to continue services with the beneficiary accepting the financial liability for those services. This practice affected two residents (Residents #100 and #101) out of three sampled residents. The facility census was 64. [...]
- D
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Inspectors wroteBased on interview and record review, the facility failed to electronically transmit Minimum Data Set (MDS - a federally mandated assessment instrument required to be completed by facility staff) in a timely manner and in accordance with guidelines for one resident (Resident #53) out of one sampled resident. The facility census was 64. Review of the facility's policy titled, Resident Assessments, dated [DATE], showed:- A comprehensive assessment of each resident is completed at intervals designated by the Omnibus Budget Reconciliation Act of 1987 (OBRA) regulations and Prospective Payment System (PPS) requirements. Data from the MDS is submitted to the Internet Quality Improvement Evaluation System (iQIES) as required;- OBRA-Required Assessments are federally mandated, and therefore, must be performed for all residents of Medicare/Medicaid certified homes. [...]
- 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 develop and implement care plans with specific interventions to meet individual needs for two residents (Residents #7 and #37) out of 16 sampled residents. The facility census was 64. Review of the facility's policy titled, Care Plans, Comprehensive Person-Centered, revised March 2022, showed:- The interdisciplinary team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident;- The comprehensive, person-centered care plan: includes measurable objectives and timeframes, describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, including: [...]
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview, and record review, the facility failed to follow Enhanced Barrier Precautions (EBP - Precautions for use during high-contact resident care activities for residents infected with a multidrug-resistant organism (MDRO - microorganism that are resistant to one or more classes of antimicrobial agents) or any resident who has a chronic wound and or indwelling medical device) and proper infection control practices when staff administered medications through a peripherally inserted central catheter (PICC - a tube/catheter inserted into a vein for medication administration) for one resident (Resident #30) out of one sampled resident. [...]
June 5, 2025Complaint inspection · 3 citations
- 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 follow their policy to notify the designated resident representative/emergency contact for one resident (Resident #1) out of three sampled residents who had a significant change in condition. The facility census was 72. Review of the facility's policy titled, Change in a Resident's Condition or Status, showed: - The facility promptly notifies the resident, his/her attending physician, and the resident representative of changes in the resident's medical/mental condition and or status; - A nurse will notify the resident's representative when there is a significant change in the resident's physical, mental, or psychosocial status. 1. Review of Resident #1's medical record showed: - admission date of 01/09/24; [...]
- 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 two residents (Residents #4 and #5) out of two sampled residents who were incontinent of bladder, received appropriate treatment and services after an incontinent episode which left the residents in urine saturated briefs and with a strong urine odor. The census was 72. Review of the facility's policy titled, Activities of Daily Living (ADLs), Supporting, revised April 2025, showed: - Appropriate care and services are provided for residents who are unable to carry out ADLs independently, with the consent of the resident, and in accordance with the plan of care, including appropriate support and assistance with: [...]
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview, and record review, the facility failed to perform hand hygiene, change gloves and provide appropriate incontinent care for two residents (Resident #4 and #5) out of two sampled residents who were incontinent of bladder. The census was 72. The facility did not provide a policy addressing infection control practices during incontinent care. 1. Review of Resident #4's medical record showed: - Diagnoses of cerebral infarction (stroke), hemiplegia (paralysis of one side of the body) and hemiparesis (weakness of one side of the body) of the left side, and vascular dementia (dementia caused by impaired blood supply to the brain). Review of the resident's quarterly MDS, dated [DATE], showed: - Moderate cognitive impairment; - Impairment on one side of the upper and lower extremities; - Substantial/Moderate assist for sit to stand and transfers; [...]
January 13, 2025Standard inspection · 9 citations
- E
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Inspectors wroteBased on interview and record review, the facility failed to ensure staff reconciled narcotics (a process that allows one staff to reconcile the exact narcotic inventory on hand with another staff) at each shift change for five out of five medication carts. This practice had the potential to affect all residents. The facility census was 66. The facility did not provide a policy on narcotic reconciliation documentation. 1. Review of the A Hall Certified Medical Technician (CMT) Narcotic Count Log for Controlled Substances on 01/09/25 at 10:17 A.M., showed: - For 7 A.M. - 7 P.M. shift on 11/27/24 - 12/18/24, the staff missed 11 out of 44 opportunities to reconcile the narcotics; - For 7 P.M. - 7 A.M. shift on 12/18/24 - 01/08/25, the staff missed 13 out of 44 opportunities to reconcile the narcotics. 2. [...]
- 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 store and distribute food under sanitary conditions, increasing the risk of cross-contamination and food-borne illness. These deficient practices had the potential to affect all residents. The facility census was 66. Review of the facility's policy titled, Sanitization, revised November 2022, showed: - The food service area is maintained in a clean and sanitary manner; - All utensils, counters, shelves, and equipment are kept clean, maintained in good repair and are free from breaks, corrosions, open seams, cracked and chipped areas that may affect their use or proper cleaning; - All equipment, food contact surfaces, and utensils are cleaned and sanitized; - The policy did not address refrigerator and/or freezer defrosting. [...]
- 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 document a code status for one resident (Resident #9) outside the sample of 17 sampled residents. The facility census was 66. Review of the facility's policy titled, Cardiopulmonary Resuscitation (CPR - lifesaving technique used in emergencies in which someone's breathing or heartbeat has stopped), revised [DATE], showed: - CPR will be provided to a resident who suddenly ceases to have a spontaneous pulse and respirations unless there is a physician's order for no CPR, Do Not Attempt Resuscitation (DNAR), or a do not resuscitate (DNR) order, Out of Hospital Do Not Resuscitate (OHDNR), or allow a natural death; - A minimum of one CPR certified staff will be available on each shift; - The policy did not address code status documentation throughout the resident's medical record. 1. Review of Resident #9's medical record showed: [...]
- 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, interview and record review, the facility failed to monitor and keep one resident's (Resident #4) equipment in good, working order. The facility also failed to provide a safe, clean and comfortable homelike environment. This deficient practice had the potential to affect all residents in the facility. The facility census was 66. Review of the facility's policy titled, Homelike Environment, revised February 2021, showed: - Residents are provided with a safe, clean, comfortable, homelike environment and encouraged to use their personal belongings to the extent possible; - The facility staff and management maximizes, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting such as a clean, sanitary and orderly environment. 1. [...]
- 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 interview and record review, the facility failed to develop and implement a baseline care plan (initial plan for delivering of care and services) within 48 hours of admission for one resident (Resident #9) outside the sample of two sampled residents that included the instructions needed to provide effective and person-centered care to meet professional standards of quality care. The facility census was 66. Review of the facility's policy titled, Care Plans - Baseline, revised March 2022, showed: - A baseline plan of care to meet the resident's immediate health and safety needs is developed for each resident within 48 hours of admission; [...]
- 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 ensure an appropriate diagnosis for the use of a psychotropic (any drug that affects brain activities associated with mental processes and behavior) medication for one resident (Resident #45) out of five sampled residents. The facility census was 66. Review of the facility's policy titled, Antipsychotic (medications that treat psychosis-related conditions and symptoms) Medication Use, dated July 2022, showed: - Residents will not receive medications that are not clinically indicated to treat a specific condition; - Residents will only receive antipsychotic medications when necessary to treat specific conditions for which they are indicated and effective; [...]
- D
Ensure medication error rates are not 5 percent or greater.
Inspectors wroteBased on observation, interview and record review, the facility failed to maintain a medication error rate of less than five percent (%). There were 27 opportunities with two errors made, resulting in an error rate of 7.41% for two residents (Residents #7 and #16) out of nine sampled residents. The facility's census was 66. Review of the facility's policy titled, Insulin Administration, last reviewed September 2014, showed: - Depress the plunger and remove the needle after approximately five seconds; - This policy did not address the priming of the insulin pen prior to each use. Review of the Humalog/lispro (a rapid insulin injected just below the skin that helps lower mealtime blood sugar spikes) Kwik Pen (insulin in a pen-type device) instructions, revised, July 2023, showed: - Prime the pen by turning the dose knob to two units; - Hold the pen with the needle pointing up; [...]
- D
Dispose of garbage and refuse properly.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the dumpsters were closed at all times and maintained to keep pest out and/or to keep the garbage contained in the dumpster. The facility census was 66. Review of the facility's policy titled, Food Related Garbage and Refuse Disposal, revised October 2017, showed: - Food-related garbage and refuse (trash) are disposed of in accordance with current state laws; - Garbage and refuse containing food wastes will be stored in a manner that is inaccessible to pests; - Outside dumpsters provided by garbage pickup services will be kept closed and free of surrounding litter. Observations made on 01/07/25 at 8:58 A.M. and 3:47 P.M., 01/08/25 at 8:36 A.M. and 3:10 P.M., 01/09/25 at 9:11 A.M. and 2:40 P.M., of the outside dumpster area showed: - A bed mattress lay on the ground behind the right side of the dumpster; [...]
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview, and record review, the facility failed to implement Enhance Barrier Precautions (EBP) during wound care for five residents (Residents #24, #32, #45, #46, and #60) out of five sampled residents and one resident (Resident #3) outside the sample. The facility census was 66. Review of the facility's policy titled, Enhanced Barrier Precautions, not dated, showed: - It is the policy of this facility to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms; - EBP refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and gloves use during high contact resident care activities; - High-contact resident care activities include: [...]
August 14, 2024Complaint inspection · 2 citations
- J
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on interview, and record review the facility failed to provide a safe transfer per facility policy and the resident's assessed level of assistance needed when one Nurse Aide attempted to transfer the resident, who was a two person transfer, alone by bear hugging the resident and attempting to pivot him/her, twisting the resident's left leg and resulting in a left femur fracture and loss of the ability to bear weight on the left leg for one resident (Resident #1) out of six sampled residents. The census was 66. On 08/14/24 at 4:00 P.M., the Administrator was notified of the past non-compliance immediate jeopardy (IJ) which began on 08/02/24. The facility immediately conducted an investigation and inserviced staff on the Resident Transfer Safety policy. The IJ was corrected on 08/08/24. Review of the facility's policy titled, Resident Handling Policy, revised 2000 showed: [...]
- 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 a resident's family in a timely manor, after a transfer where the resident's left leg became entangled in the wheelchair resulting in pain and subsequent injury, for one resident (Resident #1) out of six sampled residents. The facility also failed to notify the resident's family/responsible party when the resident was transferred to the hospital related to increased pain in the affected leg which was determined to be a fractured femur. The facility census was 66. The facility did not provide a policy regarding the guidelines to notify the resident's family/representative. 1. Review of Resident #1's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument required to be completed by the facility staff, dated, 06/11/2024, showed: [...]
December 15, 2023Standard inspection · 8 citations
- E
Assure the security of all personal funds of residents deposited with the facility.
Inspectors wroteBased on interview and record review, the facility failed to maintain the surety bond (a purchased bond for security of residents' personal funds) for at least one and one-half times the average monthly balance of the residents' personal funds for the last 12 consecutive months from November 2022 through October 2023. The facility census was 74. Review of the facility's policy titled, Surety Bond, revised March 2021, showed: - A surety bond is an agreement between the facility, the insurance company, and the resident of the State acting on behalf of the resident, wherein in the facility and insurance company agree to compensate the resident for any loss of residents' funds that the facility holds, accounts for, safeguards, and manages; - The facility holds a surety bond to guarantee the protection of residents' funds managed by the facility on behalf of its residents; [...]
- 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, interview, and record review, the facility failed to provide a safe, clean and comfortable homelike environment. This deficient practice had the potential to affect all residents in the facility. The facility census was 74. Review of the facility's policy titled, Homelike Environment, revised February 2021, showed: - Residents are provided with a safe, comfortable and homelike environment and encouraged to use their personal belongings to the extent possible; - Staff provides person-centered care that emphasizes the residents' comfort, independence, and personal needs and preferences; - The facility staff and management maximizes, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting which includes a clean, sanitary and orderly environment. [...]
- D
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Inspectors wroteBased on interview and record review, the facility failed to ensure a comprehensive Minimum Data Set (MDS), a federally mandated assessment to be completed by the facility staff, had been completed in a timely manner, for one resident (Resident #12) out of 18 sampled residents and one resident (Resident #14) outside the sample. The facility's census was 74. Review of the facility's policy titled, MDS Completion and Submission Timeframes, dated July 2017, showed: - The Assessment Coordinator or designee is responsible for ensuring that resident assessments are submitted to Centers for Medicare and Medicaid Services (CMS) Quality Improvement and Evaluation System (QIES) Assessment Submission and Processing (ASAP) system in accordance with current federal and state guidelines; [...]
- D
Assess the resident when there is a significant change in condition
Inspectors wroteBased on interview and record review, the facility failed to complete a significant change Minimum Data Set (MDS) (a federally mandated assessment tool completed by the facility) assessment within 14 days of a resident admitted to hospice (health care focused on the quality of life of a terminally ill person). This affected one resident (Resident #46) out of four sampled residents. The facility's census was 74. Review of the facility's policy titled, MDS Completion and Submission Timeframes, dated July 2017, showed: - The Assessment Coordinator or designee is responsible for ensuring that resident assessments are submitted to Centers for Medicare and Medicaid Services (CMS) Quality Improvement and Evaluation System (QIES) Assessment Submission and Processing (ASAP) system in accordance with current federal and state guidelines; [...]
- D
Assure that each resident’s assessment is updated at least once every 3 months.
Inspectors wroteBased on interview and record review, the facility failed to ensure a quarterly Minimum Data Set (MDS), a federally mandated assessment to be completed by the facility staff, had been completed in a timely manner for 15 residents (Resident #2, #4, #7, #8, #22, #27, #30, #31, #33, #39, #42, #45, #46, #48, and #51) outside the sample. The facility's census was 74. Review of the facility's policy titled, MDS Completion and Submission Timeframes, dated July 2017, showed: - The Assessment Coordinator or designee is responsible for ensuring that resident assessments are submitted to Centers for Medicare and Medicaid Services (CMS) Quality Improvement and Evaluation System (QIES) Assessment Submission and Processing (ASAP) system in accordance with current federal and state guidelines; [...]
- D
Ensure services provided by the nursing facility meet professional standards of quality.
Inspectors wroteBased on interview and record review, the facility failed to obtain a physician's order for medication, oxygen, bilevel positive airway pressure (BiPAP) (a device that helps with breathing) machine, and an indwelling urinary catheter (tube left in the bladder that allows urine to drain into a drainage bag) prior to administration for one resident (Resident #13) out of 18 sampled residents. The facility census was 74. Review of the facility's policy titled, Medication and Treatment Orders, dated July 2016, showed drugs and biological orders must be recorded on the Physician's Order Sheet (POS) in the resident's chart. 1. Review of Resident #13's medical record showed: - admitted to the facility on [DATE]; [...]
- D
Plan the resident's discharge to meet the resident's goals and needs.
Inspectors wroteBased on interview and closed record review, the facility failed to ensure a discharge planning process was in place which addressed goals and needs and involved the resident and/or the resident's legal guardian and the interdisciplinary team (IDT) (a group of health care professionals from diverse fields who work in a coordinated effort toward a common goal for a resident) in developing a discharge plan for one resident (Resident #60) out of one sampled discharged resident. The facility census was 74. Review of the facility's policy titled, Discharge Summary and Plan, revised October 2022, showed the discharge plan is developed by the care planning/interdisciplinary team with the assistance of the resident and his or her family. Review of Resident #60's closed medical record showed: - admission date of 10/16/23; [...]
- D
Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
Inspectors wroteBased on interview and closed record review, the facility failed to complete a comprehensive discharge summary for one resident (Resident #60) out of one sampled discharged resident. The facility census was 74. Review of the facility's policy titled, Discharge Summary and Plan, revised October 2022, showed the discharge summary includes a recapitulation of the resident's stay at the facility and a final summary of the resident's status at the time of the discharge in accordance with established regulations governing release of the resident information and as permitted by the resident. Review of Resident #60's closed medical record showed: - The resident discharged to home on [DATE]; - No documentation of a comprehensive discharge summary. [...]
Fire safety inspections
9 fire safety citations on file: 4 on April 3, 2026, 3 on January 13, 2025, 2 on December 15, 2023.
Every fire safety citation9 citations
- 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 · April 3, 2026 · Corrected (the home has a date of correction)
- F
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
K 223 · April 3, 2026 · Corrected (the home has a date of correction)
- F
Provide properly protected cooking facilities.
K 324 · April 3, 2026 · Corrected (the home has a date of correction)
- F
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · April 3, 2026 · Corrected (the home has a date of correction)
- F
Provide properly protected cooking facilities.
K 324 · January 13, 2025 · Corrected (the home has a date of correction)
- F
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
K 741 · January 13, 2025 · Corrected (the home has a date of correction)
- F
Ensure proper usage of power strips and extension cords.
K 920 · January 13, 2025 · Corrected (the home has a date of correction)
- F
Install proper backup exit lighting.
K 281 · December 15, 2023 · Corrected (the home has a date of correction)
- F
Have simulated fire drills held at unexpected times.
K 712 · December 15, 2023 · Corrected (the home has a date of correction)