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 36 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
1G
0H
0I
Potential for more than minimal harm
24D
11E
0F
Potential for minimal harm
0A
0B
0C
June 17, 2026Standard inspection · 9 citations
- D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteBased upon clinical record review, staff interviews, and observations, it was determined that the facility failed to ensure residents are provided with dignity while receiving care for one of 33 residents reviewed (Resident 156).
- D
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Inspectors wroteBased upon clinical record review and facility documentation, it was determined that the facility failed to ensure notification to the State ombudsman's office occurred for hospital transfers for two of thirty-three residents reviewed. (Resident 18 and Resident 25).
- D
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Inspectors wroteBased on clinical record review and staff interview it was determined the facility failed to accurately assess residents for two of two residents reviewed. (Residents 24 and 149)Findings Include: Review of Resident 24's clinical record reviewed Resident 24 was admitted to the facility on [DATE] with diagnosis of chronic respiratory failure. Further review of Resident 24's clinical record revealed resident was discharged to an acute care facility on January 28, 2026. Further review of Resident 24's clinical record failed to reveal evidence that a discharge MDS (periodic assessment of resident needs) was completed upon discharged .Review of Resident 149's clinical record revealed resident was admitted [DATE], and discharged [DATE]. Further review of Resident 149's clinical revealed that a Discharge MDS (Minimum Data Set - periodic assessment of resident needs) was not completed. [...]
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on resident interview, review of clinical records, and interviews with staff, it was determined that the facility failed to provide timely care and services for two of 33 residents reviewed (Residents 2 and 11).
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on staff interviews, clinical record review, and facility documentation review it was determined the facility failed to ensure that one of five residents reviewed was free from accidents and provided adequate supervision for Resident 12. Review of Resident 12's diagnosis sheet revealed diagnoses type 2 diabetes (insufficient production of insulin, causing high blood sugar), and Alzheimer's Dementia (a progressive disease that destroys memory and other important mental functions). Review of Resident 12's June 2026 Medication Administration Record revealed an order for Metformin HCl Tablet 500 MG Give 1 tablet by mouth two times a day. Review of facility documentation revealed that on June 12, 2026, Resident 12 was administered crushed Metformin HCL tablet 500mg in coffee by Licensed Nursing Employee E6. [...]
- D
Provide enough food/fluids to maintain a resident's health.
Inspectors wroteBased on facility policy, clinical record review, and staff interview, it was determined that the facility failed to obtain and monitor weights for one of eight residents reviewed for nutrition (Resident 45). Findings Include:Review of facility policy Weight Assessment and intervention revised September 2008 revealed that .Negative trends will be evaluated by the treatment team whether or not the criteria for significant weight change has been met. Interventions for undesirable weight loss shall be based on careful consideration. Review of Resident 45's clinical record revealed recorded weights of 151.4 pounds January 7, 2026; 140.2 pounds February 2, 2026, with a reweight on February 18, 2026, of 162 pounds; 140.4 pounds March 4, 2026. Further review of Resident 45's clinical record revealed a dietary note dated March 4, 2026, indicating the resident's weight. [...]
- D
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 upon medication insert review, observation, and staff interview it was determined that the facility failed to ensure medications were labeled with open and expiration dates for three of six medication carts observed (A South Medication Cart, A South Back Medication Cart and B South Back Medication Cart).
- D
Provide or obtain dental services for each resident.
Inspectors wroteBased on review of clinical records, and staff and resident interviews, it was determined that the facility failed to ensure that a resident was assessed by a dentist for one of one resident. (Resident 164)
- D
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Inspectors wroteBased on interviews with residents, review of facility policy, observations, and interviews with staff, it was determined that the facility failed to serve food that was at an appetizing temperature on one of four units (B wing - Countryside).
March 31, 2026Complaint inspection · 1 citation
- G
Ensure that residents are free from significant medication errors.
Inspectors wroteBased on review of clinical record, hospital record, and facility documentation, and staff interviews, it was determined the facility failed to ensure that one of three residents (Resident R1) were free from significant medication errors which resulted in actual harm to Resident R1 requiring transfer to hospital and in patient monitoring due to medication administration. This was identified as a past non-compliance.
July 25, 2025Standard inspection · 7 citations
- E
Observe each nurse aide's job performance and give regular training.
Inspectors wroteBased on review of facility documentation and staff interviews it was determined that the facility failed to complete a performance review at least once every 12 months for five of five nurse aides (Employees E4, E5, E6, E7, and E8).
- E
Provide and implement an infection prevention and control program.
Inspectors wroteBased upon review of facility policy and procedure, observation and clinical record review, it was determined that the facility failed to ensure proper infection control procedures were followed during medication administration observation and pressure ulcer wound treatments for three of three residents observed (Resident 6, Resident 22 and Resident 136.)
- 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 observations, clinical record review and staff interview it was determined that the facility failed to develop a comprehensive care plan for one of 32 residents reviewed (Resident 1).
- D
Provide enough food/fluids to maintain a resident's health.
Inspectors wroteBased on review of facility policy, review of clinical records and staff interviews, it was determined that the facility failed to maintain acceptable parameters of nutritional status for two of three residents reviewed (Residents 4 and 22).
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observations, clinical record review and staff interview it was determined that the facility failed to ensure respiratory care was provided consistent with professional standards of practice for one of one resident reviewed (Resident 1).
- D
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 upon observation, it was determined that the facility failed to ensure adequate and competent staffing levels were maintained to promptly respond to resident call bells on one day of three days of the survey.
- D
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 review of facility policies and procedures and observation, it was determined that the facility failed to ensure medications were properly labeled with open and expiration dates and failed to ensure expired medications were not administered for one of three medication carts reviewed (B Wing Medication Cart).
March 5, 2025Complaint inspection · 1 citation
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observation, clinical record review, hospital record review, and resident and staff interviews, it was determined that the facility failed to provide appropriate respiratory care and follow the physician's orders for two of the two residents reviewed (Resident CL1 and Resident 1).
August 22, 2024Standard inspection, Complaint inspection · 18 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 clinical record reviews and staff interviews, it was determined that the facility failed to notify the resident and resident's representative, in writing, regarding the reason for hospitalization for five of 56 residents reviewed (Residents 18, 36, 38, 77, 85).
- E
Ensure each resident receives an accurate assessment.
Inspectors wroteBased on review of the Resident Assessment Instrument User's Manual and clinical records, as well as staff interviews, it was determined that the facility failed to complete accurate Minimum Data Set assessments for seven of 56 residents reviewed (Residents 28, 52, 53, 91, 94, 139, 162).
- 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 review of facility policies, clinical records, and staff interviews, it was determined that the facility failed to develop a comprehensive care plan that included specific and individualized interventions to address the care needs of residents for six of 56 residents reviewed (Residents 8, 25, 27, 38, 53, 120).
- E
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on review of clinical records, as well as staff interviews, it was determined that the facility failed to ensure that physicians orders were followed for three of 56 residents reviewed (Residents 104, 112, 139).
- E
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on clinical record reviews, observations, and staff interviews, it was determined that the facility failed to ensure that each resident received assistance devices to prevent accidents for two of 56 residents reviewed (Residents 109, 125) and failed to protect the safety of other residents from violence from two of 56 residents reviewed (Residents 52, 85).
- E
Ensure that residents are free from significant medication errors.
Inspectors wroteBased on review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that it was free from significant medication errors for two of 56 residents reviewed (Residents 8, 56).
- E
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Inspectors wroteBased on observations and interviews with residents and staff, it was determined that the facility failed to serve food that was palatable to residents.
- E
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on review of policies, as well as observations and staff interviews, it was determined that the facility failed to ensure that food was stored and served in accordance with professional standards for food service safety and failed to effectively sanitize dishes during mechanical dishwashing.
- E
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that residents' clinical records were complete and accurately documented for three of 56 residents reviewed (Residents 94, 98, 112).
- D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteBased on clinical record reviews, observations, and staff interviews, it was determined that the facility failed to provide care in a manner that maintained dignity for one of 56 residents reviewed (Resident 48).
- D
Reasonably accommodate the needs and preferences of each resident.
Inspectors wroteBased on a review of clinical records, as well as staff interviews, it was determined that the facility failed to determine a resident's preference for bathing for one of 56 residents reviewed (Resident 48).
- D
Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made.
Inspectors wroteBased on clinical record reviews and observations, as well as resident and staff interviews, it was determined that the facility failed to ensure that in preparation for room changes each resident received written notice, including the reason for the change, before the resident's room or roommate was changed for one of 56 residents reviewed (Resident 139).
- D
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Inspectors wroteBased on review of the Resident Assessment Instrument User's Manual and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that comprehensive admission Minimum Data Set assessments were completed in the required time frame for nine of 56 residents reviewed (Residents 22, 82, 112, 120, 131, 136, 153, 155, 157).
- D
Assure that each resident’s assessment is updated at least once every 3 months.
Inspectors wroteBased on review of the Resident Assessment Instrument User's Manual and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that Quarterly Minimum Data Set assessments were completed within the required timeframe for seven of 56 residents reviewed (Residents 21, 26, 64, 70, 98, 139, 148).
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on clinical record reviews, observations, and staff interviews, it was determined that the facility failed to obtain physician's orders for the administration of oxygen for one of 56 residents reviewed (Resident 139).
- D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Inspectors wroteBased on facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to maintain accountability for controlled medications (drugs with the potential to be abused) for three of 56 residents reviewed (Residents 36, 94, 116).
- D
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 review of policies, as well as observations and staff interviews, it was determined that the facility failed to label medications with the date they were opened in one of two medication rooms reviewed (A unit) and in two of four medication carts reviewed (A and B unit).
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on review of established infection control guidelines, facility policy, and residents' clinical records, as well as observations and staff interviews, it was determined that the facility failed to follow infection control guidelines from the Centers for Medicare/Medicaid Services (CMS) and the Centers for Disease Control (CDC) to reduce the spread of infections and prevent cross-contamination for three of 56 residents reviewed (Residents 25, 77, 94).
Fire safety inspections
3 fire safety citations on file: 2 on July 25, 2025, 1 on December 17, 2024.
Every fire safety citation3 citations
- F
Conduct risk assessment and an All-Hazards approach.
E 6 · July 25, 2025 · Corrected (the home has a date of correction)
- C
Develop and maintain an Emergency Preparedness Program (EP).
E 4 · July 25, 2025 · Corrected (the home has a date of correction)
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · December 17, 2024 · Corrected (the home has a date of correction)