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 53 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
1G
0H
0I
Potential for more than minimal harm
35D
13E
1F
Potential for minimal harm
0A
0B
3C
April 22, 2025Complaint inspection · 2 citations
- G
Provide appropriate foot care.
Inspectors wroteBased on clinical record review, staff, and family interviews, the facility failed to provide the necessary foot care and treatment to avoid complications from conditions such as diabetes, including referral and treatment by a qualified professional, for one (1) (Resident #5) of five (5) residents in the survey sample, which resulted in harm.
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteF600 AFTER F689 Based on clinical record review, staff, and resident interviews, the facility staff failed to ensure adequate assistance was implemented for bed mobility, which the facility had control over to prevent accidents for one (1) of five (5) residents in the survey sample, Resident #1.
June 8, 2023Standard inspection · 14 citations
- F
Provide and implement an infection prevention and control program.
Inspectors wroteBased on staff interview and facility documentation review, the facility staff failed to maintain an infection control and prevention program to help prevent the development and transmission of infections, which has the ability to affect all Residents residing at the facility.
- E
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on observation, interview, clinical record review and facility documentation the facility staff failed to 1) mitigate hazards for Residents that use slings, for 1 Resident (#33) in a survey sample of 26 Residents and 2) the facility staff failed to maintain water temperatures in a range to mitigate burns, scalding and other injuries.
- 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 facility documentation the facility staff failed to maintain Registered Nurse coverage 7 days a week. This has the potential to affect Residents who need the services of a Registered Nurse (RN).
- E
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Inspectors wroteBased on observation, interview, clinical record review, and facility documentation the facility staff failed to 1) ensure controlled substances were disposed of correctly and 2) failed to provide routine medications for 2 Residents (#28 and 16).
- E
Implement a program that monitors antibiotic use.
Inspectors wroteBased on staff interview and facility documentation review, the facility staff failed to maintain an ongoing antibiotic stewardship program to monitor the use of antibiotics which had the ability to impact numerous Residents throughout the facility on all nursing units/resident care units.
- D
Reasonably accommodate the needs and preferences of each resident.
Inspectors wroteBased on observations, staff interview, resident interview and clinical record review, the facility staff failed to ensure reasonable accommodation of needs for one Resident (Resident #35) in a survey sample of 26 residents.
- 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 observation, resident interview, staff interview, and clinical record review, the facility staff failed to develop and implement a baseline care plan that included instructions to provide person-centered care for one resident (Resident #255) in a sample of 26 residents.
- D
Ensure services provided by the nursing facility meet professional standards of quality.
Inspectors wroteBased on observation, interview, clinical record review and facility documentation the facility staff failed to provide care that meets professional standards of care for 1 Residents (#5) in a survey sample of 26 Residents.
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observation, staff interview, facility documentation review and clinical record review, the facility staff failed to ensure 1 resident (Resident # 1) in a survey sample of 26 residents received oxygen care in a manner to prevent the spread of infection.
- D
Ensure medication error rates are not 5 percent or greater.
Inspectors wroteBased on observation, staff interview, clinical record review, and facility documentation, the facility staff failed to ensure the medication error rate was less than 5%. There were 3 medication errors in 35 opportunities, resulting in an 8.57% error rate.
- 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, staff interview, clinical record review and facility documentation the facility staff failed to properly store medications for 1 of 2 medication carts inspected.
- D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on observations, interview, clinical record review and facility documentation the facility staff failed to ensure the medical record was accurate for 1 Resident (#32) in a survey sample of 26 Residents.
- D
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Inspectors wroteBased on staff interview, clinical record review, and facility documentation review, the facility staff failed to determine the Resident's immunization status and offer influenza and pneumonia vaccines for 2 Residents (Resident #255 & #48) in a survey sample of 5 residents reviewed for immunizations.
- D
Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
Inspectors wroteBased on staff interview, clinical record review and facility documentation review, the facility staff failed to offer COVID-19 immunizations for 2 Residents (Resident #255 and 48) in a survey sample of 5 Residents reviewed for COVID-19 immunizations.
February 17, 2022Standard inspection · 18 citations
- E
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Inspectors wroteBased on staff interview, employee record review and facility documentation review, the facility staff failed to operationalize policies and procedures on screening for 12 of 25 new employees in the Employee Records Check Sample.
- E
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Inspectors wroteBased on observation, Resident interview, staff interview, and facility documentation review, the facility staff failed to prepare the meal in accordance with the menu, which affected 52 of the 57 Residents, residing at the facility during survey.
- E
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Inspectors wroteBased on observation, Resident interview, staff interview, and in the course of a complaint investigation, the facility staff failed to provide Residents with food at an appetizing temperature for 3 Residents (Resident #21, #33, and #41) in a survey sample of 28 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 observation, staff interview, and facility documentation review, the facility staff failed to store, prepare and distribute food in accordance with professional standards for food service safety in 4 of 4 food storage and food preparation areas.
- E
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, staff interview, facility documentation review, and clinical record review, the facility staff failed to maintain an infection control program in accordance with the Centers for Disease Control and Prevention (CDC) to prevent the spread of COVID-19 within the facility on 3 of 3 Resident halls within the facility.
- D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteBased on observation, interview, facility documentation and clinical record review the facility staff failed to ensure Residents rights to a dignified existence for 1 Resident (#46) in a survey sample of 28 Residents.
- D
Reasonably accommodate the needs and preferences of each resident.
Inspectors wroteBased on observations, Resident interview, staff interviews, clinical record review, and facility documentation review, the facility staff failed to provide reasonable accommodation to Residents who had paralysis for two (2) Residents (Resident #33 and #44) in a survey sample of 28 Residents. The facility staff failed to take into consideration the Residents' paralysis and inability to use one side, when placing the call bell so that they could call for assistance if needed.
- 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 interview, clinical record review and facility documentation the facility and in the course of a complaint investigation, staff failed to revise a care plan for 2 Residents ( #46 and #208) in a survey sample of 28 Residents.
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on observation, interview, clinical record review, and facility documentation, the facility staff failed to provide proper ADL care for dependant Residents, for 2 Residents (#46 and #41) in a survey sample of 28 Residents.
- 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 observations, staff interview, facility documentation, and clinical record review, the facility staff failed to apply a hand splint to prevent the progression of contractures for one (1) Resident (Resident #27) in a survey sample of 28 Residents.
- D
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Inspectors wroteBased on staff interview and facility documentation review, the facility staff failed to ensure that competencies were completed for 1 of 5 sampled staff (LPN C).
- D
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
Inspectors wroteBased on interview, clinical record review and facility documentation the facility staff failed to provide behavioral heath services for 1 Resident (#46) in a survey sample of 28 Residents.
- 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 facility staff failed to store drugs appropriately in locked compartments for one of the two med carts at the facility.
- D
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Inspectors wroteBased on observation, Resident interview, staff interview, and clinical record review, the facility staff failed to accommodate meal preferences for two Residents (Resident #33 and #10) in a survey sample of 28 Residents.
- D
Make sure that a working call system is available in each resident's bathroom and bathing area.
Inspectors wroteBased on observation, Resident interview, facility staff interview, and facility documentation review, the facility staff failed to ensure there was a functional system for Residents to call staff for assistance, for one Resident (Resident #33) in a survey sample of 28 Residents.
- C
Ensure residents have reasonable access to and privacy in their use of communication methods.
Inspectors wroteBased on Resident interview, staff interview and local Post Master interview, the facility staff failed to uphold Residents rights to receive mail for all Residents at the facility.
- C
Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.
Inspectors wroteBased on observation, interview and facility record review the facility staff failed to ensure the Residents right to examine the most recent survey results.
- C
Post nurse staffing information every day.
Inspectors wroteBased on observation, staff interview, and facility documentation review, the facility staff failed to post daily staffing information for Residents, staff, and visitors to see on one of three dates of survey. This has the potential to affect all residents.
February 7, 2019Standard inspection · 19 citations
- E
Keep residents' personal and medical records private and confidential.
Inspectors wroteBased on observation, staff interview, and facility record review, the facility staff failed to provide personal privacy, and a dignified living experience for 9 of 13 Residents in the Resident council meeting. Residents complained of no privacy due to staff refusal to close personal bedroom doors, no private areas to meet with family and friends, staff refuse residents requests to make their own telephone calls, wandering residents enter rooms freely without supervision, and staff will talk about Residents medical needs out in the open around visitors and other residents.
- E
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Inspectors wrote4. For Resident #39 the facility failed to develop and implement a person centered care plan to address behaviors related to refusing (Activities of Daily Living) ADL care. Resident #39 an [AGE] year old woman admitted to the facility on [DATE] with diagnoses of but not limited to Fracture of Femur, Dementia without behavioral disturbance, Arthritis and long term use of anticoagulants. Resident #39's last (Minimum Data Set) MDS coded as having a (Brief Interview of Mental Status) BIMS score of 99 indicating severe cognitive impairment. On 2/5/2019 in the course of a complaint investigation, a clinical record review was conducted and it was found that Resident # 39 had a history of refusing ADL care. Nurse's notes dated 3/26/18 at 2:26 PM stating Bruise found on top of the right hand. Red blue in color. [...]
- E
Ensure services provided by the nursing facility meet professional standards of quality.
Inspectors wroteBased on observation, resident interview, staff interview, clinical record review, and facility documentation review, the facility staff failed to follow the professional standards for the administration and documentation of medication administration in a timely manner for 3 Residents (Residents # 41, 53, and 27) in a survey sample of 27 residents. 1. For Resident #41, the facility staff failed to administer insulin in a timely manner on many days during the months of December, 2018 and January, 2019. 2. For Resident # 53, the facility staff failed to document the administration of multiple medications as ordered by the physician. 3. For Resident # 27, the facility staff failed to document the administration of multiple medications as ordered by the physician.
- E
Ensure that residents are free from significant medication errors.
Inspectors wrote3. For Resident #52, the facility staff failed to ensure that a significant medication error did not occur due to unavailable insulin for a period of 14 days. Resident #52 was an [AGE] year old who was admitted to the facility on [DATE]. Resident #52's diagnoses included: Diabetes Mellitus Type Two, Hyperlipidemia, Dementia, Seizure Disorder, Traumatic Brain Injury, Anxiety Disorder, and Post Traumatic Stress Disorder. The Minimum Data Set, which was a Quarterly Assessment with an Assessment Reference Date of 1/15/19, was reviewed. It coded Resident #52 as having a Brief Interview of Mental Status Score of 2, indicating severe cognitive impairment. On 2/6/19 a review was conducted of Resident #52's clinical record, revealing the following signed physician order, Bydureon Injection 2 MG subcutaneously one time a day every week on Monday. [...]
- 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, staff interview, clinical record review, and facility documentation review, the facility staff failed to notify the physician of an unavailable diabetic management medication. For Resident #52, the facility staff failed to notify the physician of an unavailable diabetic management medication (Bydureon BCise auto-injector/insulin), resulting in the resident receiving the medication in 14 days, instead of 7 days, as per the signed physician order.
- D
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Inspectors wroteBased on staff interview, facility documentation and clinical record review the facility failed to provide a Medicaid/ Medicare Coverage Liability Notice for 1 Resident (Resident # 40) in a survey sample of 27 Residents. For Resident #4 the facility failed to provide Resident with a Medicaid/ Medicare Coverage Liability Notice prior to discharge.
- D
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Inspectors wrote2. For Resident #39 the facility failed to ensure freedom from verbal abuse by a staff member and being undressed and held down and made to shower after having refused on several occasions. Resident #39 an [AGE] year old woman admitted to the facility on [DATE] with diagnoses of but not limited to Fracture of Femur, Dementia without behavioral disturbance, Arthritis and long term use of anticoagulants. Resident #39's last (Minimum Data Set) MDS coded as having a (Brief Interview of Mental Status) BIMS score of 99 indicating severe cognitive impairment. On [DATE] the facility provided their investigation of a complaint involving Resident #39. The complaint alleged the resident was physically abused by staff, forced to undress against her will and forced to shower against her will. The documents included witness statements made at the time of the incident. [...]
- D
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Inspectors wroteBased on staff interview, facility documentation review, and clinical record review, and in the course of a complaint investigation, the facility staff failed to operationalize the abuse policy to include documentation of training after investigation of injuries of unknown origin for 1 residents (Resident # 55) in a survey sample of 27 residents. 1. For Resident # 55, the facility staff failed to report train the staff regarding proper transfers after investigation of an injury of unknown origin revealed a staff member used improper transfer resulting in fracture of her right ankle.
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on observation, staff interview, facility documentation review, clinical record review, and in the course of a complaint investigation the facility staff failed to report an allegation of abuse timely for Resident #13 in a survey sample of 27 residents. Resident #3 (male) willfully assaulted Resident #13 (female) on 9-4-18 and no report was sent to the state agency until 6 days later. All abuse reporting must be completed within 24 hours of the incident, or sooner.
- D
Respond appropriately to all alleged violations.
Inspectors wrote2. For Resident #39 the facility failed to submit an accurate complete investigation to the OLC and failed to provide additional training to all involved staff. Resident #39 an [AGE] year old woman admitted to the facility on [DATE] with diagnoses of but not limited to Fracture of Femur, Dementia without behavioral disturbance, Arthritis and long term use of anticoagulants. Resident #39's last (Minimum Data Set) MDS coded as having a (Brief Interview of Mental Status) BIMS score of 99 indicating severe cognitive impairment. On [DATE] the facility provided their investigation of the complaint involving Resident #39. The complaint alleged the resident was physically abused by staff, forced to undress against her will and forced to shower against her will. Their documents included witness statements written at the time of the incident. [...]
- D
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 staff interview, closed record review, and facility documentation, the facility staff failed to notify the ombudsman of transfer to hospital for one Resident (Resident #56) in a sample size of 27 residents. Because the resident was no longer at the facility, a closed record review was conducted.
- D
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 staff interview, closed record review, and facility documentation, the facility staff failed to give notice of a bed hold when transferred to hospital for one Resident (Resident #56) in a sample size of 27 residents. Because the resident was no longer at the facility, a closed record review was conducted.
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on staff interview, clinical record review and in the course of a complaint investigation, the facility staff failed to provide supervision to mitigate accident hazards for two resident in a survey sample of 27 residents. 1. For Resident # 55, the facility staff failed to transfer properly using two person assistance and gait belt as written in the care plan. 2. The facility staff failed to provide supervision, to include cueing and oversight for Resident #10 while she drank scalding hot chocolate.
- 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 interview and clinical record review the facility staff failed to ensure medication was available for use for 2 of 27 residents. 1. For Resident # 53, the facility staff failed to ensure medication was available for use. 2. For Resident #52, the facility staff failed to ensure that diabetic management medication was available for administration. The Findings Include: 1. For Resident # 53, the facility staff failed to ensure medication was available for use. Resident # 53 was an [AGE] year old male admitted to the facility on [DATE] and readmitted on [DATE] with the diagnoses of, but not limited to Gastrointestinal hemorrhage, Muscle Weakness, Multiple fractures of ribs, left side, Malignant neoplasm of bronchus or lung, Malignant neoplasm of Kidney, long term use of anticoagulants, chest pain, fracture of sternum and Dementia without behavioral disturbance. [...]
- D
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Inspectors wroteBased on staff interview, facility documentation review and clinical record review, the facility staff failed to perform Medication Regimen Reviews for two Residents (# 53 and # 27) in a survey sample of 27 residents. 1. For Resident # 53, the facility staff failed to conduct a Monthly Medication Regimen Review in December 2018. 2. For Resident # 27, the facility staff failed to conduct a Monthly Medication Regimen Review in December 2018.
- 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 staff interview, clinical record review and facility documentation the facility failed to ensure that Residents were free from unnecessary psychotropic medication for 1 Residents (Resident #6) in a survey sample of 27 Residents. 1. For Resident #6 the facility failed to ensure the Resident had the appropriate diagnosis for receiving Anti-psychotic medications.
- 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 staff interview and facility documentation, the facility staff failed to date a multi-dose vial that had been accessed.
- D
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Inspectors wroteBased on observation, resident interview, staff interview, clinical record review, and facility documentation review, the facility staff failed to serve hot chocolate at a safe temperature. The facility staff failed to ensure that Resident #10 was not served scalding hot chocolate.
- D
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 facility documentation review, the facility staff failed to obtain holding temperatures of breakfast and lunch food items on 2/5/19. In addition, facility staff failed to obtain hot water and coffee temperatures since January 2019.
Fire safety inspections
16 fire safety citations on file: 1 on February 5, 2026, 1 on June 8, 2023, 10 on February 17, 2022, 4 on February 7, 2019.
Every fire safety citation16 citations
- E
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
K 521 · February 5, 2026 · deficient, provider has
- D
Inspect, test, and maintain automatic sprinkler systems.
K 353 · June 8, 2023 · Corrected (the home has a date of correction)
- D
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
K 222 · February 17, 2022 · Corrected (the home has a date of correction)
- D
Properly select, install, inspect, or maintain portable fire extinguishes.
K 355 · February 17, 2022 · Corrected (the home has a date of correction)
- D
Install corridor and hallway doors that block smoke.
K 363 · February 17, 2022 · Corrected (the home has a date of correction)
- D
Have enough space near smoke barriers to protect residents.
K 373 · February 17, 2022 · Corrected (the home has a date of correction)
- D
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
K 761 · February 17, 2022 · Corrected (the home has a date of correction)
- D
Meet requirements for the installation and maintenance of electrical systems.
K 911 · February 17, 2022 · Corrected (the home has a date of correction)
- D
Ensure electrical receptacles or cover plates have distinctive color or marking.
K 917 · February 17, 2022 · Corrected (the home has a date of correction)
- C
Address subsistence needs for staff and patients.
E 15 · February 17, 2022 · Corrected (the home has a date of correction)
- C
Establish policies and procedures for medical documentation.
E 23 · February 17, 2022 · Corrected (the home has a date of correction)
- C
Establish policies and procedures for volunteers.
E 24 · February 17, 2022 · Corrected (the home has a date of correction)
- E
Have properly located and lighted "Exit" signs.
K 293 · February 7, 2019 · Corrected (the home has a date of correction)
- E
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
K 914 · February 7, 2019 · Corrected (the home has a date of correction)
- D
Install corridor and hallway doors that block smoke.
K 363 · February 7, 2019 · Corrected (the home has a date of correction)
- D
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · February 7, 2019 · Corrected (the home has a date of correction)