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 46 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
2J
0K
0L
Actual harm
2G
0H
0I
Potential for more than minimal harm
30D
9E
3F
Potential for minimal harm
0A
0B
0C
May 1, 2025Standard inspection · 2 citations
- E
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, medical record review and interview and policy review the facility failed to ensure personal protective equipment (PPE) was worn in Resident #6's room during meal delivery. This had the potential to affect the remaining 26 residents who resided on the 300-hall. (Resident #2, #5, #9, #12, #20, #21, #29, #31, #35, #39, #43, #44, #45, #47, #48, #49, #54, #59, #62, #63, #65, #67, #70, #76, #184 and #185). The facility census was 82. Findings Include: Review of Resident #6's medical record revealed an admission date of 03/04/25 with diagnoses including infection following a procedure, acquired absence of right leg above knee, muscle weakness, and Methicillin Resistant Staphylococcus Aureus infection (MRSA) (a bacterial infection resistant to many antibiotics that is spread by skin to skin contact or contact with contaminated surfaces). [...]
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on observation, medical record review and interview, the facility failed to follow insulin administration and blood glucose monitoring per physician orders. This affected one resident (Resident #79) of three residents reviewed for insulin use. The facility census was 82. Findings Include: Review of the medical record for Resident #79 revealed an admission date of 03/03/25. Diagnosis included type 2 diabetes, atherosclerotic heart disease of native coronary artery without angina pectoris and presence of aortocoronary bypass graft. Review of orders for March 2025 revealed Lantus (long acting insulin) insulin 42 units subcutaneous once a day started on 03/03/25, Insulin Lispro seven units three times a day before meals and per sliding scale dated 03/03/25. Review of the Minimum data Set (MDS) dated [DATE] revealed intact cognition. [...]
March 20, 2025Complaint inspection · 2 citations
- J
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 closed medical record review, review of a resident communication log, review of visiting healthcare service orders, review of a customer alert form, hospital notes, policy review, medication instructions, and death certificate, and interview with family and facility staff the facility failed to ensure comprehensive monitoring and timely identification of a change in condition for Resident #94, who was incontinent of bladder with a diagnosis of Stage 3 chronic kidney disease. In addition, the facility failed to ensure Resident #94 received timely, necessary and appropriate treatment and services of a urinary tract infection (UTI). This resulted in Immediate Jeopardy, actual harm, and subsequent death beginning on [DATE] when Resident #94's daughter requested a urinalysis to be performed due to changes in the resident's cognition that was not completed by the facility. [...]
- D
Provide timely, quality laboratory services/tests to meet the needs of residents.
Inspectors wroteBased on medical record review and interview the facility failed to ensure a resident received laboratory services per physician orders. This affected one resident (#65) of four residents reviewed.
February 18, 2025Complaint inspection · 1 citation
- J
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, medical record review, policy review, national library glove use review guidance and interview, the facility failed to ensure a resident with an indwelling urinary catheter was provided appropriate care and services. This affected one resident (#2) of three residents reviewed for indwelling catheter use. The facility identified six residents with indwelling urinary catheters. The census was 93.
January 21, 2025Complaint inspection · 2 citations
- G
Provide safe, appropriate pain management for a resident who requires such services.
Inspectors wroteBased on observation, medical record review, policy review and interview, the facility failed to ensure Resident #74 and #87 were provided an individualized and comprehensive pain management program to adequately control pain. This affected two residents (#74 and #87) of three residents reviewed for pain management. The census was 94. Actual Harm occurred on [DATE] when Resident #87, who had an order for scheduled narcotic pain medication twice a day, was observed lying in bed, turning his head side to side, moaning and he verbalized his pain was a 10 out of 10 (a 0-10 pain scale is a way to measure pain intensity, where 0 represents no pain and 10 represents the worst possible pain imagined). The resident reported he had not received his scheduled pain medication and due to not receiving the medication timely, his pain level rating was severe.
- 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, medical record review, controlled drug receipt review, policy review, and interview, the facility failed to ensure controlled medications were documented accurately to account for all controlled drugs. This affected two residents (#74, #87) of three residents reviewed for pain management. The census was 94.
December 10, 2024Complaint inspection · 2 citations
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on observation, medical record review, policy review and interview, the facility failed to maintain care and services for pressure ulcers. This affected one (#38) resident observed for a pressure ulcer dressing change. The facility identified five residents with pressure ulcers. The census was 92.
- D
Ensure medication error rates are not 5 percent or greater.
Inspectors wroteBased on observation, medical record review, policy review, manufacturer guideline review and interview, the facility failed to administer medications as ordered. This affected three (#30, #64 and #270) of three residents observed for medication administration with five errors out of 33 opportunities resulting in an error rate of 15.15%. The census was 92.
November 14, 2024Complaint inspection · 1 citation
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on observations, review of the medical record and interview with staff the facility failed to ensure the air mattress for Resident #26 was set at the proper setting for her weight and the treatment for Resident #55 was completed as ordered. This affected two residents ( #26 and #55) of four residents reviewed for wounds. The facility census was 99.
October 22, 2024Complaint inspection · 2 citations
- D
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Inspectors wroteBased on record review, family interview, and staff interview, the facility failed to ensure a resident, who was known to have multiple dislodgements of his Percutaneous Endoscopic Gastrostomy (Peg) tube, had an abdominal binder in place as ordered to prevent any accidental dislodgements. This affected one resident (#4) of three residents reviewed for feeding tubes.
- D
Provide special eating equipment and utensils for residents who need them and appropriate assistance.
Inspectors wroteBased on record review, observation, and staff interview, the facility failed to ensure a resident received the appropriate eating equipment and utensils as ordered during a meal to aid the resident in being able to feed himself. This affected one resident (#4) of three residents observed for eating/ feeding assistance.
September 20, 2024Complaint inspection · 2 citations
- E
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on self-reported incident review, fire drill review, policy review and interview, the facility failed to submit a self-reported incident (SRI) for possible neglect after staff were observed sleeping on the night shift. This affected 27 residents (#65, #66, #67, #68, #69, #70, #71, #72, #73, #74, #75, #76, #77, #78, #79, #80, #81, #82, #83, #84, #85, #86, #87, #88, #89, #90, #230) residing on Unit 3. The census was 91.
- E
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, medical record review, policy review and interview, the facility failed to maintain infection control practices during incontinence care and failed to ensure staff wore face masks during a COVID-19 outbreak. This affected one resident (#70) of two residents observed for incontinence care and had the potential to affect 31 residents (#1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, #20, #21, #22, #23, #24, #25, #26, #27, #28, #29, #30 and #31) residing on Unit 1 during the COVID-19 outbreak. The census was 91.
September 13, 2024Complaint inspection · 2 citations
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on review of the medical record, review of hospital discharge orders, policy review, and interview, the facility failed to ensure special respiratory equipment was available for resident use. This affected one resident (#94) of four residents reviewed for admission rights. The facility census was 93.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on medical record review, observation, staff interview, and facility policy and procedure review, the facility failed to ensure proper infection control techniques were followed during pressure ulcer wound care. This affected one resident (#23) of three residents reviewed for pressure ulcers. The census was 93.
August 7, 2024Complaint inspection · 3 citations
- E
Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs.
Inspectors wroteBased on observations, review of the facility meal spreadsheet, interview with staff and review of the facility policy the facility failed to ensure the residents were served the proper portion size of meat. This had potential to affect all residents receiving meals from the kitchen except for nine residents (Resident #1, #5, #14, #51, #61, #80, #81, #86 and #88) the facility had identified as nothing by mouth, mechanical soft or pureed diets. The facility census was 96.
- D
Protect each resident from the wrongful use of the resident's belongings or money.
Inspectors wroteBased on review of the medical record, review of the Self-Reported Incident (SRI), interview with staff, and review of the facility policy the facility failed to prevent the misappropriation of medication for Resident #66 by facility staff. This affected one resident ( Resident #66) of three reviewed for medications. The facility census was 96.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on review of the medical record and interview with the staff the facility failed to ensure a wound vacuum (vac) for Resident #58 was changed as ordered, and medications were administered in a timely manner for Resident #96. This affected one resident ( Resident #58) of three reviewed for wounds and one resident ( Resident #96) of three reviewed for medications. The facility census was 96.
February 5, 2024Standard inspection, Complaint inspection · 7 citations
- G
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on closed record review, review of a fall investigation, review of hospital records, facility policy review and interview, the facility failed to ensure timely identification of changes in resident condition status post fall. Actual Harm occurred on 01/25/24 at 12:15 A.M. when Resident #288, who had confusion/ dementia and was admitted status-post left hip replacement sustained an unwitnessed fall in her bathroom/shower room with complaints of pain and signs of injury to the right hip that were not timely addressed. Following the fall, facility staff failed to complete a timely and appropriate assessment of the resident and failed to implement effective interventions. The resident was transported to the emergency room (per family request) on 01/24/25 at 2:58 P.M. due to leg pain and deformity. [...]
- F
Provide and implement an infection prevention and control program.
Inspectors wroteBased on interview, record review, and review of the infection control logs the facility failed to maintain a comprehensive infection control log to include antibiotic use. This had the potential to affect all residents in the facility. The facility census was 84.
- D
Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made.
Inspectors wroteBased on observation, interview, and record review the facility failed to obtain written notice before relocating Resident #27 to a different room. This affected one resident (Resident #27) of one residents reviewed for room transfers. The facility census was 84.
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on interview, record review and policy review the facility failed to investigate a fall with injury and failed to complete neurological assessments after a fall with head injuries. This affected two residents (Resident #39 and #278) of four residents reviewed for falls. The census was 84.
- D
Provide safe, appropriate pain management for a resident who requires such services.
Inspectors wroteBased on record review, interview and policy review the facility failed to ensure pain was addressed post-fall and pain assessments were completed post-fall per policy. This affected one resident (Resident #19) of four residents reviewed for falls.
- 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, record review and policy review the facility failed to maintain accurate medical records. This affected one resident (Resident #13) of one residents reviewed for fluid restrictions. The census was 84.
- 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 interview, record review, policy review and Centers for Disease Control and Prevention (CDC) immunization guidance the facility failed to offer timely Covid-19 vaccine information and the option to get updated Covid-19 vaccines. This affected three (Resident #27, Resident #32, and Resident #77) of five residents reviewed for Covid-19 Vaccinations. The facility census was 84.
December 11, 2023Complaint inspection · 8 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 payroll based journal review, email correspondence review, and interview, the facility failed to timely submit federally required staffing information to the Centers of Medicare and Medicaid Services (CMS). This had the potential to affect all 93 residents residing in 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, medical record review, and interview, the facility failed to maintain resident dignity with use of an indwelling urinary catheter. This affected one resident (#54) of three residents reviewed for activities of daily living. The facility identified four residents with indwelling catheters. The facility census was 93.
- D
Reasonably accommodate the needs and preferences of each resident.
Inspectors wroteBased on observation and interview, the facility failed to ensure residents had access to their call lights. This affected two residents (#23, #81) of three residents reviewed for activities of daily living. The facility census was 93.
- D
Keep residents' personal and medical records private and confidential.
Inspectors wroteBased on observation, medical record review, policy review and interview, the facility failed to ensure resident information remained confidential. This affected one resident (#90) of 93 residents residing in the facility.
- D
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Inspectors wroteBased on observation, medical record review and interview, the facility failed to provide assistance as needed with dining. This affected two residents (#68, #81) of three residents reviewed for activities of daily living (ADL). The facility census was 93.
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on observation, medical record review, policy review, and interview, the facility failed to ensure fall interventions were in place and interventions were immediately implemented to maintain resident safety after a fall. This affected one resident (#81) of three residents reviewed for accidents/incidents. The facility census was 93.
- 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, medical record review, policy review and interview, the facility failed to provide adequate incontinence care to dependent residents. This affected one resident (#8) of three residents reviewed for urinary incontinence. The facility census was 93.
- D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on medical record review and interview, the facility failed to ensure medical records were accurate. This affected one resident (#81) of three residents reviewed for incidents and one resident(#67) of three residents reviewed for pressure ulcers. The facility census was 93.
January 20, 2022Standard inspection · 12 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 and staff interview the facility failed to ensure food preparation and serving areas were clean and sanitary. This had the potential to affect 79 of 79 residents who received meal trays from the kitchen. The facility identified one resident (#10) who received nothing by mouth. The facility census was 80.
- E
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Inspectors wroteBased on record review, facility policy and procedure review and interview the facility failed to ensure a summary of the initial (baseline) care plan was provided to each resident and/or their representative at the time of admission. This affected five residents (#10, #11, #50, #75 and #226) of 18 sampled residents reviewed for baseline care planning.
- 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 wroteBased on record review, facility policy and procedure review and interview the facility failed to ensure admission/quarterly care planning conferences were held on behalf of the residents with all required disciplines in attendance. This affected four residents (#18, #64, #70 and #226) of four sampled residents reviewed for care plans conferences
- E
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Inspectors wroteBased on observation, record review, facility policy and procedure review and interview the facility failed to ensure Resident #15, Resident #52 and Resident #56 were provided the necessary care and services to maintain/promote optimal nutrition and the ability to eat and failed to ensure Resident #18 received the necessary care and services to maintain optimal oral hygiene. This affected four residents (#15, #18, #52 and #56) of seven residents review for activities of daily living (ADL) care.
- 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, record review and interview the facility failed to ensure residents ordered a low concentrated sweets diet were provided the diet/dessert as ordered during the lunch meal on 01/12/22. This affected 26 residents (22, #40, #8, #400, #11, #14, #26, #38, #7, #36, #18, #228, #23, #20, #42, #9, #29, #1, #48, #41, #71, #229, #53, #47, #25, and #376) of 26 residents who had an order for a low concentrated sweets diet. The facility census was 80.
- E
Provide and implement an infection prevention and control program.
Inspectors wrote3. On 01/11/22 at 9:00 A.M. STNA #47 was observed in Resident #64's room. Resident #64 was in contact/ droplet isolation precautions as evidenced by signs on the resident's door indicating such and a personal protective equipment (PPE) cart outside of his room. STNA #47 was observed to be standing next to the bed where Resident #64 was lying in. STNA #47 was within a few feet of the resident and was observed to be taking the resident's meal order. STNA #47 placed the select menu on the resident's bedside table as he recorded the resident's responses for what he wanted to eat for an upcoming meal. STNA #47 was not noted to be wearing a gown or gloves when in the resident's room. The STNA was observed wearing goggles and an N95 mask as the facility staff were wearing throughout the building as they had a Covid-19 outbreak occurring. [...]
- D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteBased on observation, record review, facility policy and procedure review and interview the facility failed to ensure Resident #45's urinary catheter drainage bag was covered to promote the resident's dignity. This affected one resident (#45) of five residents identified to have indwelling urinary (Foley) catheters.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on observation, record review, facility policy and procedure review and interview the facility failed to ensure Resident #55, who was receiving anticoagulant medication was monitored for bruising and also failed to monitor/ record Resident #70's gastric residual amounts emptied from a gastrostomy tube as ordered by the physician. This affected one resident (#55) of one resident reviewed for anticoagulant medication side effects and one resident (#70) of one resident reviewed for tube feedings.
- 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, record review, facility policy and procedure review, review of a Nursing Assistant Candidate handbook and interview the facility failed to provide adequate and complete perineal care for Resident #67 to prevent the risk of infection. The facility also failed to ensure Resident #52 was assessed timely for the removal of an indwelling urinary catheter and failed to ensure proper placement of the resident's catheter to prevent contamination/infection. This affected one resident (#67) of one resident observed for perineal care and one resident (#52) of one resident reviewed for indwelling urinary catheter use.
- D
Provide enough food/fluids to maintain a resident's health.
Inspectors wroteBased on observation, record review and interview the facility failed to ensure Resident #56, who had a history of weight loss received the appropriate diet as ordered and assistance with meals to meet her nutritional needs and failed to ensure dietary recommendations to address Resident #45's significant weight loss were followed up timely. This affected two residents (#45 and #56) of six residents reviewed for nutrition.
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observation, record review, facility policy and procedure review and interview the facility failed to ensure Resident #18's oxygen tubing was changed weekly as per facility policy. This affected one resident (#18) of two residents reviewed for respiratory care.
- 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 record review and interview the facility failed to ensure an accurate diagnosis and monitoring of a psychoactive (benzodiazepine) medication for Resident #73. This affected one resident (#73) of five residents reviewed for unnecessary medication use.
Fire safety inspections
5 fire safety citations on file: 2 on May 1, 2025, 1 on February 5, 2024, 2 on January 20, 2022.
Every fire safety citation5 citations
- F
Install a fire alarm system that can be heard throughout the facility.
K 341 · May 1, 2025 · Corrected (the home has a date of correction)
- F
Have simulated fire drills held at unexpected times.
K 712 · May 1, 2025 · Corrected (the home has a date of correction)
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · February 5, 2024 · Waiver
- E
Meet other general requirements.
K 100 · January 20, 2022 · Corrected (the home has a date of correction)
- E
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
K 223 · January 20, 2022 · Corrected (the home has a date of correction)