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 64 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
1J
0K
0L
Actual harm
2G
0H
0I
Potential for more than minimal harm
35D
21E
2F
Potential for minimal harm
0A
0B
3C
June 2, 2026Complaint inspection · 2 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 ensure food was stored in accordance with food safety standards to maintain a sanitary environment and prevent foodborne illness during 2 of 2 kitchen observations. Food preparation areas contained a buildup of dust, the walk-in freezer contained a build-up of ice, milk cartons were stored in crates resting on the floor, and the dry food storage room contained canned goods on the floor and a buildup of dust and debris under storage shelving.
- 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 the plan of care was implemented for 1 of 3 residents reviewed for wandering and/or elopement. A care plan intervention to indicate which residents were at risk for elopement was not in place for a resident who had demonstrated increased exit seeking behaviors. (Resident F)
March 13, 2026Standard inspection · 5 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, interview, and record review, the facility failed to ensure proper sanitation to prevent foodborne illness during during 2 of 2 observations of the kitchen. The high temperature dishwasher did not reach a rinse temperature of 180 degrees Fahrenheit, hands were washed with seven and ten second lather, and a suction cup was placed on the cart and then on clean plates used to serve food to the residents. (Kitchen)
- 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 ensure safe and secure storage of medications for 8 residents during a random observation of the medication carts. Medications, including narcotics, had been pre-prepared and held in medication cups in the medication cart prior to administration. Loose pills were observed in the medication cart. (Resident 40, Resident 43, Resident 2, Resident 3, Resident 10, Resident 30, Resident 54, Resident 47)
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure care and services were provided to a resident at risk to prevent pressure ulcers and promote the healing of existing pressure ulcers for 1 of 3 residents reviewed for pressure ulcers. Skin assessments were not completed as ordered, specific care plans were not developed for pressure ulcers, and pressure ulcer healing interventions were not in place. (Resident 4)
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff used proper hand hygiene and wound care to help prevent the development and transmission of communicable diseases and infections for 1 of 2 observations of wound care and 1 of 1 observations of incontinence care. While packing a wound, the packing touched the incontinence pad under the resident. During hand washing, the lather time was 5-12 seconds. (Resident 30, Resident 5, CNA 2, LPN 3)
- C
Post nurse staffing information every day.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure posted nurse staffing forms were posted daily with the actual working hours of nursing staff during the survey for 5 of 5 days reviewed during the survey. The posted nurse staffing form was not updated over the weekend and the actual working hours of staff was not included on the form. (3/9/26, 3/10/26, 3/11/26, 3/12/26, 3/13/26)
December 11, 2025Complaint inspection · 1 citation
- 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 2 of 3 resident halls observed. Resident areas contained uneven floors, the main dining room contained an odor of cigarette smoke, resident rooms and restrooms were unkept, hall closet doorknobs were missing or were in disrepair, and duct tape was used to repair coved base and door trim. (East Hall, [NAME] Hall, room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], Resident B, Resident C, Resident D, Resident F, and Resident G)
October 7, 2025Complaint inspection · 2 citations
- 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 the interview and record review, the facility failed to update or revise the care plan for 1 of 3 residents reviewed for advance directives. A resident's code status was not updated in the plan of care. (Resident B)
- 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 and ensure residents were free from accident hazards for 1 of 3 resident reviewed for smoking. Resident areas contained a cigarette smoke odor and a resident indicated smoking in his room without supervision and against facility policy. (West Hall, Resident C)
August 14, 2025Complaint inspection · 1 citation
- G
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on interview and record review, the facility failed to implement ordered treatment for a rectal fissure for 1 of 3 residents reviewed for skincare. This deficient practice resulted in the resident being hospitalized with severe sepsis and a necrotizing soft tissue infection. (Resident C)
May 21, 2025Complaint inspection · 3 citations
- D
Protect each resident from the wrongful use of the resident's belongings or money.
Inspectors wroteBased on interview and record review, the facility failed to ensure residents were free from misappropriation for 1 of 1 residents reviewed for misappropriation. A resident's debit card was taken without consent and used by staff to make multiple unauthorized purchases. (Resident D)
- D
Ensure services provided by the nursing facility meet professional standards of quality.
Inspectors wroteBased on interview, and record review, the facility failed to ensure the physicans orders were thoroughly followed and documented when completed for 2 of 3 residents reviewed for nursing services related to wound care. Routine dressing changes and skin assessments were not completed per the physician's orders. (Resident F, Resident G)
- D
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 adequate pharmaceutical services were available to provide physician prescribed routine treatments for 1 of 3 residents reviewed for pharmaceutical services. A facility did not have a treatment on hand and could not provide proof that the treatment (ointment) had been delivered by the pharmacy. (Resident C)
March 27, 2025Complaint inspection · 2 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 adequate supervision, and a secure environment was provided to prevent a resident with dementia from exiting the facility and leaving the property for 1 of 3 residents reviewed for elopement risk. This deficient practice resulted in an elopement that occurred during the early morning hours on 3/15/25 after being last seen by facility staff at approximately 2:00 A.M. A resident exited the facility through an unsecured window and was not realized to be missing until approximately 5:00 A.M. The resident was located by local law enforcement at approximately 6:00 A.M. in a field near the facility wet and shivering and required hospitalization. (Resident C)
- D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on interview and record review, the facility failed to ensure resident records were complete and accurate for 1 of 3 residents reviewed for elopement risks. Resident records contained no documentation of an elopement event, and the Medication Administration Records (MAR) was documented inaccurately. (Resident C)
January 30, 2025Standard inspection · 15 citations
- E
Allow resident to participate in the development and implementation of his or her person-centered plan of care.
Inspectors wroteBased on interview and record review, the facility failed to facilitate care plan meetings with the resident and/or resident representatives for 5 of 6 random clinical records reviewed for care plan conferences and 1 of 5 residents reviewed for unnecessary medications. A newly admitted resident did not have an initial care plan conference and other residents care plan conferences were not held quarterly. (Resident 260, Resident 11, Resident 35, Resident 26, Resident 3, Resident 30)
- 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 6 of 17 resident records reviewed during the survey. Minimum Data Set (MDS) assessments did not accurately reflect resident status. (Resident 31, Resident 20, Resident 6, Resident 23, Resident 30, Resident 40)
- 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 ensure development and implementation of a comprehensive person-centered care plan for each resident for 4 of 17 residents reviewed for care plans. A resident lacked a care plan for antidepressant use, and current care plan interventions were not followed. (Resident 4, Resident 54, Resident 23)
- 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 provide adequate supervision and an environment free of accident hazards for 1 of 3 residents reviewed for accidents and 2 random observations. Residents were keeping smoking supplies on their person, smoking unsupervised, and in undesignated areas. A dementia resident that was at high risk for falls had an extension cord in his room that was not secured down. (Resident 32, Resident 22, Resident 54)
- 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 and interview, the facility failed to ensure a sanitary and home-like environment for 2 of 2 halls, 1 of 1 shower rooms reviewed for environment, and 3 of 3 resident personal refrigerator temperature logs reviewed. Temperature logs were not completed for resident personal refrigerators, a call light was out of the wall, brown spots on the wall of resident's room, and cracked tiles along shower front and side wall, paint peeling on ceiling, and vent caked with dust in [NAME] Shower Room. (room [ROOM NUMBER], room [ROOM NUMBER]-A, room [ROOM NUMBER]-A, room [ROOM NUMBER]-B, room [ROOM NUMBER]-B, [NAME] Shower Room)
- D
Ensure residents have reasonable access to and privacy in their use of communication methods.
Inspectors wroteBased on interview and record review, the facility failed to deliver mail to the residents on Saturdays. Eleven of eleven anonymous residents interviewed indicated they failed to get mail every Saturday.
- 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, interview and record review, the facility failed to revise resident care plans for 1 of 2 residents reviewed for a decline in activities of daily living (ADLs) and 1 of 3 residents reviewed for nutrition. A resident's ADL care plan was not revised with an ADL decline and a resident was receiving a diuretic but the care plan indicated she was not. (Resident 11, Resident 35)
- D
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a resident was given the appropriate treatment and services to maintain or improve his ability to carry out the activities of daily living for 1 of 2 residents reviewed for a decline in activities of daily living (ADLs). A resident's functional ability declined, the ADL Care Plan was not revised, and restorative therapy was not provided as recommended. (Resident 35)
- D
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident with dementia, received the appropriate treatment and services to attain or maintain his or her highest practicable physical, mental, and psychosocial well-being for 1 of 2 residents reviewed for dementia care. A resident didn't have a plan of care for dementia, safety risks were not identified, wandering behavior and interventions were not being documented and evaluated, and a daily routine was not established. (Resident 54)
- D
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Inspectors wroteBased on interview and record review, the facility failed to ensure medications were administered appropriately for 1 of 5 residents reviewed for unnecessary medication use. A blood pressure medication was administered without adequate monitoring as well as given outside of ordered parameters, and an opioid pain medication was administered with excessive use. (Resident 6)
- 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 interview and record review, the facility failed to ensure unnecessary use of psychotropic medications for 2 of 5 residents reviewed for unnecessary medications. An antianxiety medication lacked a required gradual dose reduction (GDR) and an antipsychotic medication was given without an appropriate indication. (Resident 31, Resident 54)
- 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 observation, interview and record review, the facility failed to maintain safe and secure storage of medications for 1 of 1 medication carts observed. A medication cup with loose pills and a narcotic was observed in a medication cart. (Resident 17)
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation and interview, the facility failed to provide a safe and sanitary environment to help prevent the development and transmission of communicable diseases and infections for 1 of 1 residents observed for wound care and 1 of 2 residents with catheters. Staff did not change gloves after touching multiple items before starting wound care. One resident with a catheter did not have Enhanced Barrier Precautions in place. (Resident 26, Resident 3)
- D
Have policies on smoking.
Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the smoking policy was followed for 2 of 2 residents reviewed for smoking. Residents had their smoking supplies on their person, smoking assessments were not completed quarterly, smoking care plans were not revised, residents were smoking without staff supervision, and residents were smoking in undesignated area. (Resident 32, Resident 22)
- C
Post nurse staffing information every day.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure thoroughly completed staffing sheets were posted daily for 7 of 7 days during the survey.
December 16, 2024Complaint 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 2 of 2 resident halls observed. Resident areas had holes in walls, floors were in disrepair, specimen collection hats were stored uncovered, resident trash receptacles were full, and odors were present during 2 of 2 days of the survey. (East Hall, [NAME] Hall, room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER])
- 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 observation, interview, and record review, the facility failed to ensure medications and syringes were stored safely and securely during a random observation during the survey. Discontinued medications along with an unsecured sharps container with unused syringes were stored in an unlocked conference room. (Resident J)
June 3, 2024Complaint inspection · 1 citation
- J
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 was provided to prevent a resident with dementia and a history of elopement from exiting the facility and leaving the property for 1 of 4 residents reviewed for elopement and risk for wandering. This deficient practice resulted in an elopement that occurred during the night of 5/14/24 and early morning hours of 5/15/24, after being last seen by facility staff around 10:00 P.M. on 5/14/24, a resident exited the facility and was not realized to be missing until approximately 1:00 A.M. on 5/15/24. The resident was located by local law enforcement at a previous residence approximately 22 miles from the facility. (Resident C) This Immediate Jeopardy began on 5/15/24 when the facility failed to ensure Resident C did not exit the facility through a window in the resident's room. [...]
March 14, 2024Standard inspection, Complaint inspection · 26 citations
- F
Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
Inspectors wroteBased on record review and interview, the facility failed to electronically submit to CMS (Center for Medicare and Medicaid Services) required information regarding direct care staffing for Fiscal Quarter 4 from 7/1/23 thru 9/30/23. Findings Include: During an interview on 3/7/24 at 9:37 A.M., the Administrator indicated PBJ (Payroll-Based Journal) information was submitted by staff outside of the facility. On 3/8/24 at 2:13 P.M., the Administrator provided a copy of the [NAME] Report 1702S, Staffing Summary Report from 7/1/23 thru 9/30/23, which indicated No data returned for selected criteria. On 3/11/24 at 10:53 A.M., the Administrator provided an undated Reporting Direct Care Staffing Information (Payroll-Based Journal) policy which indicated .9. Direct care staffing is submitted on the schedule specified by CMS, but no less frequently than quarterly. 10. [...]
- E
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 each resident was treated with dignity for 3 of 3 residents reviewed for dignity and 2 random observations. Two residents had catheter bags that were not covered. A resident was walking down the hall with wet pants and another with debris on her face and shirt. A resident asked for breakfast tray to be removed but it was not. (Resident 203, Resident 27, Resident 29, Resident 101, Anonymous Resident)
- 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 7 of 9 residents reviewed for hospitalizations. The transfer discharge form was not completed. There was no documentation of a resident, representative, and the ombudsman receiving a notice of transfer or discharge at the time of hospitalization. (Resident B, Resident C, Resident E, Resident F, Resident G, Resident H, Resident J)
- 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 policy was given to residents or resident representatives for 5 of 9 residents reviewed for hospitalizations. The bed hold form was not completed. There was no documentation of a resident or representative receiving a bed hold at the time of hospitalization. (Resident C, Resident E, Resident F, Resident G, Resident H, Resident J)
- E
Ensure each resident receives an accurate assessment.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure MDS (Minimum Data Set) Assessments were accurate for 6 of 23 residents reviewed for MDS Assessments. Medications were not accurately documented. (Resident E, Resident J, Resident 13, Resident 30, Resident 34, Resident 203)
- 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 and implement person-centered care plans and interventions specific to resident needs for 4 of 18 residents reviewed for care plan development. An intervention for monthly weights was not followed, a care plan was developed with inaccurate diagnosis, care plans were not developed for residents on antiplatelets and antianxiety medication. (Resident J, Resident G, Resident 41, Resident 34)
- 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 wrote2. On 3/4/24 at 8:32 A.M., Resident 13's clinical record was reviewed. Diagnoses included, but were not limited to, hypertension and diabetes mellitus. The most recent quarterly MDS, dated [DATE], indicated Resident 13 was cognitively intact. Discontinued Physician's Orders included, but were not limited to, .Droplet Precautions x 7 days for positive influenza test start date 1/20/2024 .end date 1/26/2024. Current care plans included, but were not limited to, I am in contact/droplet isolation as I am positive for Influenza . dated 1/25/24. During an interview on 3/8/24 at 9:09 A.M., the DON (Director of Nursing) indicated the MDS Coordinator revised care plans. During an interview on 3/11/24 at 1:53 P.M., the MDS Coordinator indicated the isolation care plan should have been removed 7 days after Resident 13 was diagnosed with influenza. 3. [...]
- E
Provide activities to meet all resident's needs.
Inspectors wroteBased on observation and interview, the facility failed to ensure an ongoing activity program was in place for residents in 2 of 2 halls during the survey period. (West Hall and East Hall)
- 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 each resident received adequate supervision and assistance to prevent accidents for 4 of 7 residents reviewed for accidents. Interventions were not implemented following falls, thorough assessments were not performed following unwitnessed falls, and assessments were not completed for a residents with an electronic cigarette. (Resident 7, Resident 31, Resident G, [NAME] Hall Treatment Cart)
- E
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Inspectors wroteBased on interview and record review, the facility failed to provide an RN (registered nurse) for 8 consecutive hours, seven days a week, for 2 of 7 days reviewed.
- 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 storage of food in a safe and sanitary manner for 2 of 2 kitchen observations. Open food items were observed unlabeled and open to air, debris was observed on the floor, and the window screen was observed damaged in the dishwasher area.
- E
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an infection prevention program for 1 of 2 residents reviewed for infections, 1 random observation, and 2 of 2 halls reviewed for water system management. Proper PPE (personal protective equipment) was not used to care for a resident with MRSA (Methicillin Resistant Staph Aureus-a skin infection), an uncovered catheter bag was dragging on the floor, and there was no program for monitoring the water system for the growth of Legionella (bacteria). (Resident 16, Resident 29, East Hall, [NAME] Hall)
- 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, staff, and the public for 2 of 2 resident halls, 2 of 2 shower rooms, and 1 of 2 nurses stations. (East Hall, East Hall nurses station, [NAME] Hall)
- D
Allow residents to self-administer drugs if determined clinically appropriate.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents that were self administering medications were assessed for capability to self administer medications for 1 of 1 residents observed with medications in their rooms. (Resident F)
- 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 observation, interview, and record review, the facility failed to ensure appropriate parties were notified following a change in resident condition for 1 of 3 residents reviewed for nutrition and 1 random observation. The physician, Registered Dietician (RD), nor a representative were notified following a significant weight loss, and the physician was not notified of a resident's use of an electronic cigarette. (Resident 7, Resident J)
- 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 report an allegation of misappropriation of medications for 1 of 1 residents reviewed for missing medications. A finding of missing controlled substances was not reported to the State Survey Agency. (Resident J)
- D
Respond appropriately to all alleged violations.
Inspectors wroteBased on interview and record review, the facility failed to perform a thorough and complete investigation of an alleged incident for 1 of 1 residents reviewed for missing medications. A finding of missing medications was not thoroughly investigated after being reported to the facility. (Resident J)
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on observation, interview, and record review, the facility failed to do a comprehensive assessment of residents and that residents received appropriate treatment and care in accordance with professional standards of practice for 3 of 9 residents reviewed for hospitalizations. A resident's weight and height were not accurately assessed, a resident's skin assessments were not completed, and a resident was not given Lasix (diuretic) as ordered and was hospitalized for weight gain. (Resident E, Resident 3, Resident G)
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident with a pressure ulcer received necessary treatment and services to promote healing in 1 of 2 residents reviewed for pressure ulcers. A resident's wound culture was not collected timely, the wound vac (wound therapy using vacuum assisted closure) was not documented as physician ordered, and the wound was left open to air. (Resident E)
- D
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
Inspectors wroteBased on observation, interview, and record review, the facility failed to provide the necessary behavioral health monitoring to attain or maintain the highest practicable physical, mental, and psychosocial well-being in accordance with the comprehensive assessment and plan of care for 2 of 3 residents reviewed for behavior. Behavior monitoring was not accurately completed, and a care plan was not developed after behaviors observed. (Resident G, Resident H)
- D
Provide medically-related social services to help each resident achieve the highest possible quality of life.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medically-related social services were provided to residents for 1 of 2 residents reviewed for dental services and 1 of 1 resident leaving the building. Staff was unsure if a resident had dentures or not for Resident 14 and Resident 41 was assisted to leave the building without first verifying there was a physician order to leave, to leave with medication. (Resident 14, Resident 41)
- D
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 accurate dispensing and administration of medications for 1 of residents reviewed for hospitalizations. A resident's controlled medications were documented as given during a hospitalization, and after a change to the order resulting in missing doses. (Resident J)
- D
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Inspectors wroteBased on observation, interview, and record review, the facility failed to serve food at an appetizing temperature for 1 of 1 lunch trays tested. (East Hall)
- D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on observation, interview, and record review the facility failed to maintain accurate medical records on 3 of 27 residents reviewed. (Resident 41, Resident G, Resident J)
- D
Make sure that a working call system is available in each resident's bathroom and bathing area.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure resident's call lights were properly functioning and in reach for 3 of 21 residents reviewed in the sample. Call lights were on the floor, out of reach for the resident and not functioning. (Resident 46, Resident 203, Resident E, room [ROOM NUMBER])
- 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 and contained the correct information daily for 3 of 9 days reviewed during the survey. (March 4, March 6, March 7)
December 7, 2023Complaint inspection · 3 citations
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on observation, interview, and record review, the facility failed to provide ADL (activities of daily living) care to 1 of 1 residents observed for ADL care. (Resident B)
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on observation, interview, and record review, the facility failed to provide treatment or notify the physician of suspected deep tissue injury for 1 of 3 residents reviewed for pressure wounds. (Resident C)
- 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 done for 1 of 3 resident's observed for care. Hand hygiene was not done and gloves were not changed. (Resident B)
September 20, 2023Complaint inspection · 1 citation
- 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 residents were free from physical restraints for 1 of 1 residents reviewed for restraints. A resident was placed in a new wheel chair that restricted mobilization and was strapped into the wheelchair without documented clinical rational for the need of the wheelchair with straps, assessments, or a plan of care for the use of restraints. (Resident C)
Fire safety inspections
22 fire safety citations on file: 2 on March 13, 2026, 7 on January 30, 2025, 13 on March 14, 2024.
Every fire safety citation22 citations
- F
Install corridor and hallway doors that block smoke.
K 363 · March 13, 2026 · Corrected (the home has a date of correction)
- F
Have simulated fire drills held at unexpected times.
K 712 · March 13, 2026 · Corrected (the home has a date of correction)
- F
Install emergency lighting that can last at least 1 1/2 hours.
K 291 · January 30, 2025 · Corrected (the home has a date of correction)
- F
Ensure that testing and maintenance of electrical equipment is performed.
K 921 · January 30, 2025 · 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 · January 30, 2025 · Corrected (the home has a date of correction)
- E
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
K 321 · January 30, 2025 · Corrected (the home has a date of correction)
- E
Construct fire resistant interior walls.
K 331 · January 30, 2025 · Corrected (the home has a date of correction)
- E
Install smoke barrier doors that can resist smoke for at least 20 minutes.
K 374 · January 30, 2025 · Corrected (the home has a date of correction)
- E
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
K 741 · January 30, 2025 · Corrected (the home has a date of correction)
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · March 14, 2024 · Corrected (the home has a date of correction)
- F
Follow proper procedures when the fire alarm was out of service for more than 4 hours.
K 346 · March 14, 2024 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · March 14, 2024 · Corrected (the home has a date of correction)
- F
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
K 354 · March 14, 2024 · Corrected (the home has a date of correction)
- F
Provide a written emergency evacuation plan.
K 711 · March 14, 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 · March 14, 2024 · Corrected (the home has a date of correction)
- E
Install proper backup exit lighting.
K 281 · March 14, 2024 · Corrected (the home has a date of correction)
- E
Have properly located and lighted "Exit" signs.
K 293 · March 14, 2024 · Corrected (the home has a date of correction)
- E
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
K 321 · March 14, 2024 · Corrected (the home has a date of correction)
- E
Construct fire resistant interior walls.
K 331 · March 14, 2024 · Corrected (the home has a date of correction)
- E
Install an approved automatic sprinkler system.
K 351 · March 14, 2024 · Corrected (the home has a date of correction)
- E
Have properly installed electrical wiring and gas equipment.
K 511 · March 14, 2024 · Corrected (the home has a date of correction)
- E
Have an externally vented heating system.
K 522 · March 14, 2024 · Corrected (the home has a date of correction)