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 19 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
14D
0E
2F
Potential for minimal harm
0A
0B
3C
December 5, 2025Standard inspection · 4 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 observation, interview, and record review, the facility failed to update and revise care plans with specific interventions tailored to meet individual needs for two residents (Residents #67 and #87) out of 18 sampled residents. The facility census was 74. Review of the facility's policy titled, Care Plan Review, undated, showed:- To ensure each resident will have an updated person-centered comprehensive care plan developed and implemented to meet and address the resident's medical, physical, mental and psychological needs;- Care plans are reviewed quarterly and as resident's condition changes;- Individualized to provide person-centered care;- Areas of review to provide but not limited to: activities of daily living (ADLs), nutrition, skin, behaviors, and individualized preferences. 1. [...]
- D
Provide safe, appropriate pain management for a resident who requires such services.
Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one resident (Resident #48) out of 18 sampled residents received treatment and care in accordance with professional standards of practice, the comprehensive care plan, and the resident's choices related to pain management. The facility's census was 74. [...]
- 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 two residents (Residents #3 and #36) had medications and biologicals labeled in accordance with currently accepted practices for two medication carts out of two sampled medication carts. This had the potential to affect all residents. The facility's census was 74. Review of the facility's policy titled, Medication Storage, dated October 2017, showed:- All medications must be clearly labeled with the resident name, drug name, strength, dosage, directions, and expiration date;- Any multi-dose vials or solutions, once opened, must be dated and initialed and discarded within 28 days unless manufacturer specifies otherwise.1. Observation of the A Hall medication cart on 12/05/25 at 7:40 A.M., for Resident #3 showed: - One opened bottle of Rybelus (diabetes medication) not labeled; [...]
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview and record review, the facility failed to follow infection control protocols during wound care for one resident (Resident #81) out of five sampled residents. The facility census was 74. Review of the facility's policy titled, Dressings, Dry/Clean, dated January 2018, showed:- Put on clean gloves;- Assess the wound and surrounding skin for edema, redness, drainage, tissue healing progress and wound stage;- Cleanse the wound. If using gauze, use a clean gauze for each cleansing stroke. Clean from the least contaminated area to the most contaminated area (usually from the center outward);- Use dry gauze to pat the wound dry;- Apply the ordered dressing and secure with tape;- Discard disposable items into the designated container;- Remove disposable gloves and discard into designated container. Wash and dry your hands thoroughly.1. [...]
August 22, 2024Standard inspection · 10 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 store and distribute food under sanitary conditions, increasing the risk of cross-contamination and food-borne illness. This had the potential to affect all residents. The facility census was 73. Review of the facility's policy titled, Cleaning and Sanitation - General, revised January 2012, showed: - The kitchen will be maintained in a clean and sanitary condition; the state and/or federal food code will be maintained on file within the food service department and will be the basis of all sanitation and food safety practices; - Hairnets or hair coverings will be worn at all times; - Utensils and dishes will be handled so that food and customer contact surfaces are not touched; Disposables will be opened from the bottom of the package; [...]
- 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 interview and record review, the facility failed to provide a written copy of the notice of transfer or discharge to the resident and/or the the resident's responsible party for three residents (Resident #32, #37 and #60) out of four sampled residents. The facility census was 73. Review of the facility's policy titled, Notice of a Transfer and/or Discharge, revised on October 2017, showed: - The facility shall provide a resident and/or the resident's representative with a 30-day written notice of an impending transfer or discharge; - Except as specified below, a resident, and/or his/her representative will be given notice as soon as practicable before transfer or discharge when: the transfer is necessary for the resident's welfare and the resident's needs cannot be met in the facility; the health of the individuals in the facility would otherwise be endangered; [...]
- 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 interview and record review, the facility failed to provide written notification of the bed-hold policy to the resident and/or their representatives at the time of transfer for three residents (Resident #32, #37 and #60) out of four sampled residents. The facility census was 73. Review of the facility's policy titled, Bed-Hold Policy, undated, did not address the facility providing the resident or resident's representative a written copy. 1. Review of Resident #32's medical record showed: - admitted on [DATE]; - The resident transferred to the hospital on [DATE], and returned on 05/03/24; - The resident transferred to the hospital on [DATE], and returned on 07/28/24; - No documentation of the written notification for the bed-hold policy provided to the resident and/or the responsible party on 04/30/24, and 07/28/24. 2. Review of Resident 37's medical record showed: [...]
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on interview and record review, the facility failed to provide needed care and services in accordance with professional standards of practice for one resident (Resident #12) out two sampled residents who required treatment due to a skin condition. The facility census was 73. The facility did not provide a policy related to treatment of skin conditions. 1. Review of Resident #12's Physician Order Sheet (POS), dated August 2024, showed: - admitted on [DATE]; - Diagnoses of psoriasis (a condition in which the skin cells build up and form scales and itchy dry patches), stroke, and aphasia (a language disorder that affects a person's ability to communicate); - An order for skin observations once a week every Saturday, dated 04/23/24; - No order for a psoriasis treatment. Review of the resident's care plan, last reviewed on 06/13/24, showed: [...]
- 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 provide a safe environment when the facility failed to monitor the elopement prevention wander guard system for one resident (Resident #70) out of one sampled resident and one resident (Resident #62) outside the sample. The facility census was 73. Review of the facility's policy titled, Elopement Prevention Policy, undated, showed: - The policy is to provide a safe and secure environment for all residents. To ensure this process, the staff will assess all residents for the potential for elopement. Determination of risk will be assigned for each individual resident and interventions for prevention be established in the plan of care to minimize the risk for elopement; [...]
- D
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a physician's order for a catheter (a tube inserted into the bladder to drain urine) which included catheter care for two residents (Resident #10 and #28), failed to ensure a urinary catheter drainage bag was kept off the floor, and failed to ensure proper positioning of the catheter for one resident (Resident #10) out of two sampled residents. The facility census was 73. Review of the facility policy titled, Urinary Catheter Care, revised July 2017, showed; - The urinary drainage bag must be held or positioned lower than the bladder at all times to prevent the urine in the tubing and drainage bag from flowing back into the urinary bladder; - Be sure the catheter tubing and drainage bag are kept off the floor. Review of the facility's policy titled, Physician's Orders, dated February 2020, showed: [...]
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a physician's order for oxygen was obtained for two resident (Resident #10 and #43) out of two sampled residents. The facility census was 73. Review of the facility's policy titled, Oxygen Administration, revised October 2010, showed staff to verify there is a physician's order and to review the order. 1. Review of Resident #10's medical record showed a diagnosis of heart failure (a condition that develops when your heart doesn't pump enough blood for your body's needs). Review of the resident's significant change Minimum Data Set (MDS - a federally mandated assessment to be completed by facility staff), dated 03/25/24, showed the resident didn't receive oxygen. Review of the resident's August 2024 Physician Order Sheet (POS) showed no order for oxygen therapy or to change tubing. [...]
- D
Ensure medication error rates are not 5 percent or greater.
Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an error rate of less than five percent (%) when medications were administered. There were 48 opportunities with 24 errors made, for an error rate of 50% for three residents (Resident #43, #48 and #179) outside the seven sampled residents. The facility census was 73. Review of the facility's policy titled, Preparation and Administration, Oral Medication, undated, showed staff to remain with the resident until the medication is swallowed. Review of the facility's policy titled, Preparation and Administration, Nasal Medication, undated, showed administer the dosage, insert spray nozzle gently into the nose and spray. 1. [...]
- 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 store medications in a safe and effective manner when staff left the medication cart unlocked and unattended, leaving the narcotics behind only one lock. This had the potential to affect all residents The facility census was 73. The facility did not provide a policy regarding storage of medication. 1. Observation on 08/19/24 at 9:37 A.M., of the 60 Hall medication cart showed: - At 9:37 A.M., the medication cart was unlocked and faced the hall between the mechanical and the soiled utility rooms. Certified Medication Technician (CMT) F walked past the unlocked medication cart and placed a nystatin (an antifungal medication) bottle on top of the medication cart and walked down the hall; [...]
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview and record review, the facility failed to maintain proper infection control practices during incontinent care for four residents (Residents #4, #10, #38, and #50) out of four sampled residents and one resident (Resident #34) outside the sample, during wound care for two residents (Residents #50, and #57) out of three sampled residents, and during the medication pass for two residents (Residents #48 and #69) out of four sampled residents. The facility failed to disinfect the glucometer (a machine used to test how much sugar is in a blood sample) for three residents (Residents #24, #45, and #46) out of three sampled residents. The facility also failed to follow enhanced barrier precautions (EBP) for two residents (Residents #10 and #50) out of three sampled residents during care. The facility census was 73. [...]
March 10, 2023Standard 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 store and distribute food under sanitary conditions, increasing the risk of cross-contamination and food-borne illness. These deficient practices had the potential to affect all residents. The facility census was 56. Record review of the facility's Cleaning and Sanitizing policy, not dated, showed: - Cleaning a surface, equipment or utensils involves the use of hot water and detergent. It removes soil, grease, food, and odors. It is a very important procedure for food handling; - All surfaces must be cleaned on a routine basis as well as whenever necessary even if not scheduled. [...]
- D
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe, clean and comfortable homelike environment. This deficient practice had the potential to affect all residents in the facility. The facility census was 56. Observations on 3/7/23 at 11:11 A.M., 3/8/23 at 8:31 A.M., and 3/9/23 at 11:21 A.M., of the B hall showed: - room [ROOM NUMBER] with two - one inch (in.) x 18 in. areas, a two in. x eight in. area, and a two in. x two in. area with exposed sheetrock located behind the headboard of the bed by the window; - room [ROOM NUMBER] with several scratched up areas on the left lower side of the wall beside the nightstand by the window; - room [ROOM NUMBER] with a one in. x 12 in. area, a one in. x 8 in. area, and a 1 in. x 5 in. area with exposed sheetrock located behind the headboard of the bed by the window; - room [ROOM NUMBER] with a 21 in. x 40 in. [...]
- C
The resident has the right to receive notices in a format and a language he or she understands.
Inspectors wroteBased on observation, interview, and record review, the facility failed to provide information on the location of the Resident Rights, State Long-Term Care Ombudsman program (a statewide network of individuals who help residents in long-term care facilities maintain and improve their quality of life by helping ensure their rights were preserved and respected). This practice could potentially affect all residents. The census was 56. Record review of the facility's Resident Rights policy, revised October 2017, showed: - The facility must post in a form and manner accessible and understandable to residents and resident representatives; [...]
- C
Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.
Inspectors wroteBased on observation, interview, and record review, the facility failed to notify residents of the availability and location of the most recent survey results in an accessible location to the residents. This practice had the potential to affect all residents and visitors. The facility's census was 56. Record review of the facility's Resident Rights policy, dated October 2017, showed: - The resident has the right to examine the results of the most recent survey of the facility conducted by Federal or State surveyors and any plan of correction in effect with respect to the facility; -The facility must post in a place readily accessible to the residents, and the family members and the legal representatives of the residents, the results of the most recent survey of the facility; [...]
- C
Post nurse staffing information every day.
Inspectors wroteBased on observation and interview, the facility staff failed to post the required daily nurse staffing information which included the total number of staff and the actual hours worked by both licensed and unlicensed nursing staff directly responsible for resident care, in a prominent location readily accessible to residents and visitors. The facility census was 56. Observations from 3/7/23 through 3/9/23, showed the required daily nurse staffing information not found near any of the nurse's stations or the main lobby where it would be easily visible to residents and visitors. Observation on 3/10/23 at 8:51 A.M., showed the daily nurse staffing information posted in a dark purple colored notebook sleeve located in a frame on the wall in a recessed cove near a water fountain not in use. [...]
Fire safety inspections
9 fire safety citations on file: 2 on December 5, 2025, 3 on August 22, 2024, 4 on March 10, 2023.
Every fire safety citation9 citations
- F
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
K 222 · December 5, 2025 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · December 5, 2025 · Corrected (the home has a date of correction)
- F
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
K 222 · August 22, 2024 · Corrected (the home has a date of correction)
- F
Provide properly protected cooking facilities.
K 324 · August 22, 2024 · Corrected (the home has a date of correction)
- F
Have proper medical gas storage and administration areas.
K 923 · August 22, 2024 · Corrected (the home has a date of correction)
- F
Meet other general requirements that are deficient.
K 300 · March 10, 2023 · Corrected (the home has a date of correction)
- F
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 10, 2023 · Waiver
- F
Properly select, install, inspect, or maintain portable fire extinguishes.
K 355 · March 10, 2023 · Corrected (the home has a date of correction)
- F
Have restrictions on the use of highly flammable decorations.
K 753 · March 10, 2023 · Corrected (the home has a date of correction)