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 18 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
15D
1E
2F
Potential for minimal harm
0A
0B
0C
January 6, 2026Complaint inspection · 1 citation
- D
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 interviews and record review, the facility failed to follow the planned menu and failed to provide and document nutritionally equivalent substitutions when a menu item was unavailable. This failure affected one (R1) of four residents reviewed for dining.
July 18, 2024Standard inspection · 2 citations
- F
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Inspectors wroteBased on interview and record review, the facility failed to follow its policy on conducting background checks for one (V11) of 10 employees reviewed for background checks. This failure has the potential to affect 61 residents currently residing in the facility.
- 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: 1) follow their policy and procedures for ensuring food is prepared and served under sanitary conditions by not using PPE (personal protective equipment) properly when serving food, 2) Ensure food items were labeled and dated per facility policy, 3) Ensure no expired foods, and 4) Ensure Staff wear hair restraint in kitchen area. This applies to 61 residents that receive oral nutrition and food prepared in the facility kitchen.
September 8, 2023Standard inspection · 6 citations
- D
Keep residents' personal and medical records private and confidential.
Inspectors wroteBased on observation, interview and record review the facility failed to provide privacy when administering an injection to a resident. This deficiency affects one (R28) of 13 residents in the sample of 19 reviewed for privacy during medication administration.
- D
Provide appropriate foot care.
Inspectors wroteBased on observation, interview and record review the facility failed to provide foot care and treatment to resident who is totally dependent. The facility also failed to carry out and implement a podiatrist recommendation order. This deficiency affects one (R43) of three residents in the sample of 19 reviewed for foot care.
- D
Provide enough food/fluids to maintain a resident's health.
Inspectors wroteBased on observation, interview and record review the facility failed to monitor and record fluid intake of resident who is on push fluids as ordered due to dehydration. This deficiency affects one (R63) of three residents in the sample of 19 reviewed for ensuring proper Hydration.
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observation, interview and record review the facility failed to obtain physician's order for oxygen and tracheotomy care management for a resident who has tracheostomy capped and using oxygen via nasal cannula. The facility failed to ensure that there is water in the humidifier bottle. This deficiency affects one (R43) of one resident in the sample of 19 reviewed for Respiratory care.
- 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 safe and secure storage including proper temperature control of medications. The facility also failed to remove the opened and expired medication in the medication cabinet. These failures have the potential to affect all residents taking medication who reside in the facility.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview and record review the facility failed to remove gloves and perform hand hygiene before exiting the isolation room. This deficiency affects one (R43) of one resident in the sample of 19 reviewed for Infection control on isolation precaution.
December 9, 2022Standard inspection · 9 citations
- E
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 observation, interview and record review the facility failed to implement its policy in monitoring resident receiving psychotropic medications for medication side effects (Abnormal Involuntary Movement Scale/AIMS) . This deficiency affects all 4 (R21, R30, R35 and R39) residents in a sample of 18 reviewed for psychotropic medication usage.
- D
Reasonably accommodate the needs and preferences of each resident.
Inspectors wroteBased on observation, interview and record review the facility failed to ensure that call lights were in reach and easily accessible for 3 of 6 residents reviewed for accommodation of needs in a sample of 18.
- D
Keep residents' personal and medical records private and confidential.
Inspectors wroteBased on observation, interview and record review the facility failed to provide privacy to residents when providing care/procedure/medication. This deficiency affects two (R11 and R30) of three residents in the sample of 18 reviewed for privacy.
- 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 maintain personal hygiene for one of six residents (R262) observed for activities of daily living (ADLs) in the sample of 18 residents. Finding Include: On 12/6/2022 at 10:45 AM, surveyor observed R262 sitting in 2nd floor dining room with V19 - CNA (Certified Nurse's Aide) assigned to R262. R262's shirt, mouth and chin were stained with food particles from breakfast food that morning. V19 stated R262's shirt should have been changed and his mouth/chin cleaned after breakfast. On 12/6/2022 at 11:00 AM, surveyor observed R262 with V7 RN (Registered Nurse) assigned to R262. R262 was still wearing the shirt with stained food particles and his mouth and chin not cleaned. V7 stated that V19 should have taken R262 to his room, cleaned him up and put a clean shirt on him. [...]
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on observation, interview and record review the facility failed to follow manufacturer's recommendations when using low air loss mattress (LAL) for a resident who has a Stage 3 pressure ulcer. This failure affects one (R35) of three residents in the sample of 18 reviewed for Pressure Ulcer management.
- 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 follow its policy on fall prevention management by failure to provide adequate supervision to prevent falls to residents who have history of multiple falls, failure to complete fall assessments after each fall incident, and failure to update fall safety care plan with new interventions after each fall incident to prevent future falls. This failure affects two (R162 and R262) of three residents in the sample of 18 reviewed for fall prevention management.
- D
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 and record review the facility failed to properly administer medication to a resident. This deficiency affects one (R11) of 12 residents in a sample of 18 observed for medication administration.
- 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 in the medication refrigerator are routinely stored under proper temperature control and routinely monitored to ensure drug safety. This deficiency affects one of two medication rooms reviewed for medication storage.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview, and record review, the facility failed to minimize the risk of infection transmission by not properly storing Continuous Positive Airway Pressure (CPAP) and Nebulizer supplies after use. The facility also failed to implement a policy on Nebulizer treatment during COVID. These failures affected 3 residents (R11, R19, R29) in a total sample of 18 reviewed for infection control.
Fire safety inspections
10 fire safety citations on file: 2 on July 18, 2024, 1 on September 8, 2023, 7 on December 9, 2022.
Every fire safety citation10 citations
- F
Establish staff and initial training requirements.
E 37 · July 18, 2024 · Corrected (the home has a date of correction)
- F
Conduct testing and exercise requirements.
E 39 · July 18, 2024 · Corrected (the home has a date of correction)
- F
Establish staff and initial training requirements.
E 37 · September 8, 2023 · Corrected (the home has a date of correction)
- F
Address patient/client population and determine types of services needed.
E 7 · December 9, 2022 · Corrected (the home has a date of correction)
- F
Address subsistence needs for staff and patients.
E 15 · December 9, 2022 · Corrected (the home has a date of correction)
- F
Establish policies and procedures for sheltering.
E 22 · December 9, 2022 · Corrected (the home has a date of correction)
- F
Create arrangements with other facilities to receive patients.
E 25 · December 9, 2022 · Corrected (the home has a date of correction)
- F
Establish staff and initial training requirements.
E 37 · December 9, 2022 · Corrected (the home has a date of correction)
- F
Conduct testing and exercise requirements.
E 39 · December 9, 2022 · Corrected (the home has a date of correction)
- F
Implement emergency and standby power systems.
E 41 · December 9, 2022 · Corrected (the home has a date of correction)