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 30 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
1J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
16D
11E
0F
Potential for minimal harm
0A
1B
1C
July 17, 2026Standard inspection, Complaint inspection · 10 citations
- E
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Inspectors wroteBased on record review, and staff, Physician Assistant (PA) and Physician interviews, the facility failed to have a system in place to inform and provide written information to the residents/representatives pertaining to their right to accept or refuse medical/surgical treatment and to formulate an advanced directive (a form that indicates a resident's wish and what action to take for their health if the residents were no longer able to make their own decision) for 15 of 22 sampled residents (Resident #1, #21, #71, #80, #105, #126, #5, #11 #20, #55, #14, #17, #7, #10, and #43.)
- E
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on record review and staff and Responsible Party (RP) interviews and Physician and Physician Assistant interviews, the facility failed to accurately document the administration of insulin when two Medication Aides (Medication Aide #1 and Medication Aide #2) signed the medication administration record which indicated they administered physician ordered insulin instead of the assigned Nurses (Nurse #11 and Nurse #1) for 1 of 5 residents (Resident #5) reviewed for unnecessary medications; failed to accurately document the completion of weekly skin assessments (Nurse #5); and when Medication Aide #3 documented in the electronic medical record that she had completed the weekly skin assessment instead of the assigned Nurse (Unit Manager #2) for 1 of 1 resident (Resident #43) reviewed for bilateral leg wounds; [...]
- D
Ensure that residents are fully informed and understand their health status, care and treatments.
Inspectors wroteBased on record review, staff, resident and Physician Assistant (PA) interviews, the facility failed to obtain consent and inform the resident or resident representative in advance of the risks and benefits of taking psychotropic medications prior to the administration and/or dosage change of the medications for 3 of 5 residents reviewed for unnecessary medications (Resident #5, #1, #14).
- 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 record review, staff interviews, physician and physician assistant interviews, the facility failed to notify the physician of a change in status related to bilateral lower leg wounds that were open and weeping for 1 of 2 residents (Resident #43) reviewed for wound care; and failed to provide notification to the Responsible Party (RP) of the resident's death. This was for 1 of 1 resident (Resident #126) reviewed for death in facility.
- D
Keep residents' personal and medical records private and confidential.
Inspectors wroteBased on observations and Responsible Party and staff interviews, the facility failed to obtain informed consent for a contactless monitoring system installed in resident rooms above the bed to monitor resident information for 2 of 9 residents reviewed for privacy (Resident #21 and Resident #1).
- D
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
Inspectors wroteBased on record review, and staff and Physician Assistant (PA) interviews, the facility failed to ensure a resident's (Resident #14) medication regime was free from unnecessary medications for administering an as needed antianxiety medication without a discontinue date. This deficient practice occurred for 1 of 5 residents reviewed for unnecessary medications.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on record review, observation, staff interviews, Physician Assistant interview and Physician interview, the facility failed to provide wound care to a resident with bilateral lower extremity leg wounds that were open and weeping, for 1 of 1 resident reviewed for vascular wound care, Resident #43.
- D
Ensure that residents are free from significant medication errors.
Inspectors wroteBased on observations, record review, staff and Physician Assistant (PA) interviews, the facility failed to follow the physician order for the administration of insulin. Nurse #1 was observed obtaining a blood sugar (a blood sample indicating the concentration of sugar in the blood) for a resident after the resident's meal and then administered scheduled insulin and sliding scale (a scale used to measure amount of insulin to be given based on residents' blood sugar results) insulin based on the blood sugar result for 1 of 5 residents (Resident #5) observed for Unnecessary Medications.
- D
Provide timely, quality laboratory services/tests to meet the needs of residents.
Inspectors wroteBased on record review, staff and Physician Assistant (PA) interviews, the facility failed to follow up on a urine analysis (U/A) that was ordered for 1 of 1 resident (Resident #124) reviewed for laboratory services.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observations, record review, and staff interviews, the facility failed to implement their infection control policy and procedures when 1) a nurse (the Staff Development Coordinator) was observed not wearing a gown while administering medications through Resident #17's feeding tube; and 2) the Treatment Nurse was observed cleaning and dressing wounds at two different wound sites without washing her hands and wearing the same gloves during Resident #43's bilateral leg dressing changes. This deficient practice occurred for 2 of 5 staff members observed for infection control practices.
May 15, 2025Standard inspection, Complaint inspection · 5 citations
- D
Ensure each resident receives an accurate assessment.
Inspectors wroteBased on observations, record review and staff and resident interviews, the facility failed to accurately code the Minimum Data Set (MDS) assessment in the area of vision for a resident with visual impairment. This was for 1 of 32 residents reviewed for MDS accuracy (Resident #61).
- 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 observations, record review, and staff interviews the facility failed to implement care planned interventions by not placing a fall mat at the bedside of residents with a history of a fall with major injury. This occurred for 2 of 6 residents reviewed for accidents and care plan interventions (Residents #24 and #81).
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on record review, and staff, family and physician interviews, the facility failed to obtain orders from a Pulmonologist for the appropriate setting for a resident's (Resident #189) Continuous Positive Airway Pressure (CPAP) machine (used as a type of ventilator with diagnoses of obstructive sleep apnea; a health condition that causes brief pauses in breathing during sleep) upon resident's admission and during the resident's stay at the facility for 8 days. This was for 1 of 1 resident reviewed that utilized a CPAP machine.
- 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 record review, observations and staff interviews, the facility failed to have a system in place to train nurses and nursing assistants (NAs) and verify their competency with infection control procedures necessary for providing care to meet residents' needs. Nurse #4 failed to follow infection control protocol by not wearing a gown and not changing gloves after touching items in the resident's environment while providing care to a peripherally inserted central catheter (PICC) line, a thin flexible tube inserted into a vein in the arm and threaded up to a larger vein in the chest close to the heart used for long term intravenous therapy. [...]
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observations, record review, and staff interviews the facility failed to implement the infection control policy and procedures for Enhanced Barrier Precautions (EBP) when providing direct care activities to residents. 1. Nurse # 4 provided care to a resident with a peripherally inserted central catheter (PICC) line, a thin flexible tube inserted into a vein in the arm and threaded up to a larger vein in the chest close to the heart used for long term intravenous therapy. The nurse donned gloves but no gown during the procedure and did not change gloves after obtaining items from the bedside table. 2. Nursing Assistant #2 and Nursing Assistant # 4 provided turning and repositioning for a resident on EBP due to a gastrostomy tube and a wound to the right upper chest that was positive for MRSA (methicillin resistant staphylococcus aureus) without donning gowns or gloves. [...]
May 2, 2024Standard inspection, Complaint inspection · 12 citations
- E
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 observations, resident and staff interviews the facility 1a) failed to repair torn floor linoleum in resident rooms (513 and 515), 1b) failed to remove the black greenish substance from the commode base caulking in resident rooms (511, 513, 515, 606, and 608), 1c) failed to repair a broken free standing clothes cabinet doors in resident rooms (510, 513, and 608), 1d) failed to repair leaking commode bases in resident rooms (506, 511, 513, 515, 608, 612, and 615), 1e) failed to replace broken or missing bathroom door threshold strip in resident rooms (500, 510, 612, 613, and 615), 1f) failed to replace broken or missing toilet paper dispensers in resident rooms (612), 1g) failed to repair resident's overhead lights that were either non-functioning, missing a light cover, or had broken light covers in rooms (515 and 601), 1h) failed to replace broken window blinds in resident [...]
- E
Ensure each resident receives an accurate assessment.
Inspectors wroteBased on record review and staff interviews, the facility failed to code the Minimum Data Set (MDS) assessments accurately in the areas of Hospice services, respiratory care, nutrition and weight loss, unnecessary medications, and communication and sensory for 5 of 35 residents whose MDS assessments were reviewed (Residents #19, #47, #35, #17 and # 1).
- E
Provide enough food/fluids to maintain a resident's health.
Inspectors wroteBased on record review and staff, Registered Dietician (RD) and Physician Assistant (PA) interviews, the facility failed to 1.) obtain and record accurate weights per physician order and verify the accuracy of a resident with a significant change in weight (Resident #47), and 2.) obtain weekly weights according to the physicians order and provide nutritional supplements for a resident with weight loss (Resident #81). This occurred for 2 of 2 residents reviewed for nutrition (Resident # 47 and Resident # 81).
- E
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Inspectors wroteBased on observations, record review, staff and Physician Assistant interviews the facility failed to discontinue an order for the antibiotic Clindamycin and an opioid medication Oxycodone. This resulted in the resident receiving 16 additional doses of the Clindamycin and 15 additional doses of the Oxycodone. This occurred for 1 of 5 residents reviewed for unnecessary medications (Resident #401).
- E
Ensure that residents are free from significant medication errors.
Inspectors wroteBased on record review, staff, Pharmacy Consultant, and the Physician Assistant interviews the facility failed to: 1a) administer an as needed antihypertensive medication as prescribed by the physician for blood pressure greater than 160 millimeters of mercury (mm Hg) resulting in 2 missed doses (Resident #3), and 1b) failed to check a blood pressure prior to administering an antihypertensive medication with parameters to hold the medication if systolic (the top number of a blood pressure reading that measures the pressure in the arteries when the heart beats) blood pressure was less than 100 (Resident #3), and 2) failed to check a resident's blood pressure prior to administering a scheduled nitrate medication used to treat angina (chest pain) with parameters to hold the medication if systolic blood pressure was less than 100 (Resident #10), and 3.) administer the full course of the [...]
- E
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on observations and staff interviews, the facility failed to air dry kitchenware before stacking them in storage and failed to ensure refrigerated meat items stored for use in the reach-in refrigerator for resident sandwiches were dated and sealed. These practices had the potential to affect food quality.
- E
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Inspectors wroteBased on observations, record review and resident, Physician, Physician Assistant, and staff interviews, the facility's Quality Assurance and Performance Improvement Program (QAPI) failed to maintain implemented procedures and monitor interventions that the committee put into place following the recertification and complaint investigation surveys of 11/19/21 and 1/20/23 and the complaint investigation surveys of 4/21/22, 11/8/22, and 11/20/23. This was for 6 recited deficiencies on the current recertification and complaint investigation survey of 5/2/24 in the areas of: safe, clean, comfortable, and homelike environment (584), resident assessments (F641), bowel/bladder incontinence, catheter care, urinary tract infections (F690), posting of accurate nurse staffing information (F732), medication error rate of 5% or more (759), and significant medication errors (760). [...]
- 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 observations, record review and staff interviews, the facility failed to use a clean washcloth and clean water to provide catheter care for 1 of 1 resident reviewed for an indwelling urinary catheter (Resident #61).
- 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, observation, and staff interviews, the facility failed to store the plastic plunger and plastic syringe used for the administration of water and medications separated resulting in the potential for bacterial growth for 1 of 2 residents (Resident #47) reviewed for feeding tube.
- D
Ensure medication error rates are not 5 percent or greater.
Inspectors wroteBased on observations, record review, and staff interviews the facility failed to maintain a medication error rate of less than 5%. There were 3 medication errors observed out of 25 opportunities which resulted in a medication error rate of 12%. This occurred for 2 of 3 residents reviewed during a medication pass observation. (Resident #401, #84).
- C
Post nurse staffing information every day.
Inspectors wroteBased on record review and staff interviews, the facility failed to post accurate nurse staffing information for 18 of 106 days reviewed (October 1, 2023 through April 30, 2024) and failed to complete a Daily Staffing Form on one day (12/25/23) for staffing.
- B
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 record review and staff interviews, the facility failed to provide written notification of discharge or transfer to the resident and their Responsible Party (RP) of the reason for discharge to the hospital for 1 of 1 sampled resident (Resident #102) reviewed for hospitalization.
November 20, 2023Complaint inspection · 3 citations
- J
Ensure that residents are free from significant medication errors.
Inspectors wroteBased on observations, record review, staff, Physician Assistant, Physician, Emergency Medical Service Responder, Adult Day Care staff nurse, and Pharmacist Consultant interviews, the facility failed to prevent a significant medication error when Medication Aide #1 administered Resident #1 medications prescribed to Resident #3 to include Clonazepam (a medication to treat anxiety classified as benzodiazepine) 1 milligram (mg) and Buprenorphine HCI-Naloxone (a medication to treat opioid addiction) 8mg/2 mg causing Resident #1 to become unresponsive. [...]
- 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 observations and staff interviews the facility failed to record an open date on insulin pens, failed to discard an expired insulin pen and inhalers and to refrigerate an unopened insulin, and failed to store medications safely when a medication cup filled with an over the counter stock medication was stored on the top shelf of the medication cart and multiple loose pills were noted in 4 of 4 medications cart observed for medication storage for the 400, 500, 300, and 100/200 hall medications carts.
- E
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Inspectors wroteBased on observations, record review and staff interviews, the facility's Quality Assurance and Performance Improvement Program (QAPI) failed to maintain implemented procedures and monitor interventions that the committee put into place following a complaint investigation on [DATE] and a recertification, follow up, and complaint investigation on [DATE]. This was for 2 deficiencies that were originally cited in the areas of significant medication errors and medication storage and were subsequently recited on the current complaint investigation on [DATE]. The continued failure during 3 surveys of record shows a pattern of the facility's inability to sustain an effective Quality Assurance Program.
Fire safety inspections
8 fire safety citations on file: 3 on May 15, 2025, 3 on May 2, 2024, 2 on January 20, 2023.
Every fire safety citation8 citations
- D
Inspect, test, and maintain automatic sprinkler systems.
K 353 · May 15, 2025 · Corrected (the home has a date of correction)
- D
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · May 15, 2025 · Corrected (the home has a date of correction)
- D
Have proper medical gas storage and administration areas.
K 923 · May 15, 2025 · Corrected (the home has a date of correction)
- F
Have an alternate power supply for its alarm system.
K 344 · May 2, 2024 · Corrected (the home has a date of correction)
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · May 2, 2024 · Corrected (the home has a date of correction)
- F
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
K 521 · May 2, 2024 · Corrected (the home has a date of correction)
- D
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 20, 2023 · Corrected (the home has a date of correction)
- D
Have properly installed electrical wiring and gas equipment.
K 511 · January 20, 2023 · Corrected (the home has a date of correction)