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 12 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
11D
0E
1F
Potential for minimal harm
0A
0B
0C
December 3, 2025Standard inspection, Complaint inspection · 6 citations
- D
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Inspectors wroteBased on staff interview and record review, the facility did not ensure reconciliation of discharge medications for 1 resident (R) (R51) of 2 sampled residents. R51 was private pay status and discharged to an Assisted Living (AL) facility on 8/25/25. Medications were not sent with R51 at the time of discharge. The pharmacy was not able to fill all of R51's medications because some were filled by the nursing facility less than 30 days prior. The facility delivered some medications to R51's AL facility on 8/26/25 but did not have a record of which medications were delivered. R51 missed three doses of a Parkinson's medication.
- D
Ensure services provided by the nursing facility meet professional standards of quality.
Inspectors wroteBased on staff and resident representative interview and record review, the facility did not ensure a new diagnosis of schizophrenia met clinical criteria for 1 resident (R) (R1) of 1 sampled resident. R1 was admitted to the facility on [DATE]. On 6/6/25, R1 received a new diagnosis of schizophrenia. The facility did not have evidence that R1's diagnosis met the diagnostic criteria in The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5).
- 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 staff and resident representative interview and record review, the facility did not provide restorative therapy to increase and/or prevent decrease in range of motion (ROM) or activities of daily living (ADLs) for 1 resident (R) (R51) of 1 sampled resident. Power of Attorney for Healthcare (POAHC)-K received notice on 8/19/25 that R51's Medicare benefits were ending. Therapy was not provided while POAHC-K pursued an appeal.
- 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 record review, the facility did not ensure the resident environment remained as free of accident hazards as possible for 2 residents (R) (R23 and R12) of 3 sampled residents. R23 had a history of falls. R23's care plan contained an intervention for a call light within reach with prompt response to requests. During multiple observations, R23 did not have a call light within reach. R12 had a history of falls. R12's care plan contained an intervention to have a walker in front of R12 when in bed and in R12's recliner. During multiple observations, R12 did not have a walker in front of R12 when in bed or the recliner.
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observation, staff and resident interview, and record review, the facility did not provide necessary respiratory care and services for 2 residents (R) (R1 and R5) of 2 sampled residents. R1 had diagnoses of obstructive sleep apnea (OSA) and chronic obstructive pulmonary disease (COPD). R1 had an order for a bilevel positive airway pressure (BiPAP) machine with oxygen provided by a concentrator and connected to the machine via tubing. Staff did not clean R1's BiPAP machine per manufacturer's instructions. In addition, two open one-gallon jugs of distilled water for use with R1's BiPAP machine were expired. R5 had a diagnosis of OSA and an order for a continuous positive airway pressure (CPAP) machine. Staff did not clean R5's CPAP machine per manufacturer's instructions.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, staff interview, and record review, the facility did not maintain an infection prevention and control program designed to prevent the development and transmission of communicable disease and infection for 3 residents (R) (R42, R11, and R1) of 16 sampled residents. R42 was on droplet precautions. Staff provided care for R42 without wearing personal protective equipment (PPE). R11 was on contact precautions. Staff provided care for R11 without wearing PPE. R1 had a diagnosis of pneumonia. R1 was not listed on the facility's infection control resident line list for surveillance.
April 30, 2025Complaint inspection · 1 citation
- D
Assess the resident when there is a significant change in condition
Inspectors wroteBased on staff interview and record review, the facility did not ensure a Significant Change in Status (SCIS) Minimum Data Set (MDS) assessment was completed timely for 1 resident (R) (R1) of 3 sampled residents. R1 met the criteria for a Significant Change in Status MDS assessment on 3/15/25. A SCIS assessment was not completed.
August 14, 2024Standard inspection · 1 citation
- D
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Inspectors wroteBased on staff interview and record review, the facility did not ensure vaccinations were reviewed, offered, or administered for 1 Resident (R) (R13) of 5 sampled residents. The facility did not offer R13 the PCV20® vaccine.
June 22, 2023Standard inspection · 4 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, staff interview, and record review, the facility did not ensure food was stored and prepared in a safe and sanitary manner. This practice had the potential to affect all 30 residents residing in the facility. Cold food items were served outside the temperature safe zone and dessert was not covered appropriately during meal service. Hand hygiene was not completed appropriately during lunch service on 6/20/22.
- 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 staff interview and record review, the facility did not ensure comprehensive care plans were developed for 3 Residents (R) (R6, R12, and R22) of 13 sampled residents. The facility did not develop a hospice care plans for R6 and R12 when R6 and R12 started hospice services. The facility did not develop a care plan which included the intervention of a splint to R22's left arm.
- 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 and resident interview, and record review, the facility did not ensure the accurate administration of medication for 1 Resident (R) (R4) of 13 sampled residents. R4 did not receive scheduled pain medication timely when the facility ran out of the medication and did not have a current prescription.
- D
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Inspectors wroteBased on staff interview and record review, the facility did not ensure monitoring of a high-risk medication for 1 Resident (R) (R15) of 5 residents reviewed. R15's medical record did not contain monitoring for the side effects of Lasix (a diuretic medication).
Fire safety inspections
13 fire safety citations on file: 4 on December 3, 2025, 8 on August 14, 2024, 1 on June 22, 2023.
Every fire safety citation13 citations
- F
Have exits that are accessible at all times.
K 271 · December 3, 2025 · Corrected (the home has a date of correction)
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · December 3, 2025 · Corrected (the home has a date of correction)
- E
Inspect, test, and maintain automatic sprinkler systems.
K 353 · December 3, 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 · December 3, 2025 · Corrected (the home has a date of correction)
- F
Provide emergency officials' contact information.
E 31 · August 14, 2024 · Corrected (the home has a date of correction)
- F
Provide primary/alternate means for communication.
E 32 · August 14, 2024 · Corrected (the home has a date of correction)
- F
Provide properly protected cooking facilities.
K 324 · August 14, 2024 · Corrected (the home has a date of correction)
- F
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · August 14, 2024 · Corrected (the home has a date of correction)
- E
Have properly located and lighted "Exit" signs.
K 293 · August 14, 2024 · Corrected (the home has a date of correction)
- E
Install smoke barrier doors that can resist smoke for at least 20 minutes.
K 374 · August 14, 2024 · Corrected (the home has a date of correction)
- E
Have restrictions on the use of highly flammable decorations.
K 753 · August 14, 2024 · Corrected (the home has a date of correction)
- D
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
K 321 · August 14, 2024 · Corrected (the home has a date of correction)
- D
Have properly located and lighted "Exit" signs.
K 293 · June 22, 2023 · Corrected (the home has a date of correction)