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 14 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
4J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
6D
4E
0F
Potential for minimal harm
0A
0B
0C
January 7, 2026Standard inspection · 2 citations
- D
Provide timely, quality laboratory services/tests to meet the needs of residents.
Inspectors wroteBased on record reviews and interview, the facility failed follow the physician orders for lab services for 1 of 5 residents sampled for medication review. (Resident #6)
- 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, policy review, and interviews, the facility failed to discard spoiled foods and failed to store food in a sanitary manner that is in accordance with professional standards to prevent foodborne illness.
August 29, 2024Standard inspection · 3 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 and staff interview, the facility failed to provide housekeeping and maintenance services to maintain a clean and orderly environment for 7 of 26 sampled resident rooms. (Rooms 701, 703, 705, 706, 707, 708, and 710)
- D
Provide activities to meet all resident's needs.
Inspectors wroteBased on observations, staff interviews, review of the electronic medical record (EMR), and review of the facilities policies and procedures for individual activities, the facility failed to provide recreational activities designed to meet the interests of and support the physical, mental, and psychosocial well-being for one of one resident sampled for activities. (Resident #4)
- 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 record review, staff interview, and policy review, the facility failed to ensure the provider documented a resident specific rationale for declination of a pharmacist's request for a gradual dose reduction for a psychotropic medication for 1 of 5 sampled residents reviewed for unnecessary medications. (Resident #25)
May 19, 2023Standard inspection · 9 citations
- J
Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.
Inspectors wroteBased on observations, interviews, record review, diet manual review and facility policy review, the facility failed to ensure sufficient food and nutrition services support staff that had the appropriate competencies and skill sets to accurately prepare, plate and serve modified consistency diets for 2 of 5 residents sampled for mechanically altered diets (Resident #46 and Resident #278). This failure resulted on a choking incident on 05/06/2023 for Resident #46 when she was served an intact meat patty instead of the ground or pureed meat that she was ordered to receive. On Sunday 05/14/2023, the facility contracted Dietary Manager (Dining Services Director) was removed from the position and the rest of the food and nutrition services staff resigned at the same time. [...]
- J
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 observations, staff interviews, clinical record review, menu review, diet manual review, and policy review, the facility food and nutrition services staff failed to follow the Dysphagia (difficulty swallowing) Advanced Texture and Dysphagia Mechanically Altered diets for 2 of 5 residents sampled for mechanically altered diets (Resident #46 and Resident #278). On 05/06/2023 Resident #46 was served the incorrect diet texture during the lunch meal which resulted in the resident choking on a meat patty necessitating the immediate medical intervention of abdominal thrusts by a Registered Nurse (RN) to clear the meat from the resident's airway. On 05/17/2023, Resident #278, who was ordered a Dysphagia Mechanically Altered diet, did not receive the correct diet texture during the dinner meal. Resident #278 was ordered to receive pureed bread, but instead received a whole hamburger bun. [...]
- J
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
Inspectors wroteBased on meal observation, staff interview, resident interview, clinical record review, review of the diet manual, and policy review, the facility failed to prepare and serve food designed to meet individual needs for 2 of 2 residents sampled who required mechanically altered diets (Residents #46 and #278). Resident #46 had diet orders for ground meat due to dysphagia (difficulty swallowing). On 05/06/2023, Resident #46 was served a whole hamburger patty and had a subsequent choking event requiring abdominal thrusts to remove airway blockage. Resident #46 had diet orders for a Dysphagia Advanced diet which required all meats to be mechanically altered by chopping or grinding methods. On the evening of 05/17/2023, Resident #278 was served a sandwich with whole slices of bread for dinner. [...]
- J
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Inspectors wroteBased on observations, staff interviews, clinical record review, review of the quality assurance performance plan, and policy review, the facility failed to implement their corrective action plan for educating staff on ensuring the residents were served the correct diets as ordered for 2 of 5 residents selected for modified texture diets. (Resident #46 and #278). On 05/6/2023, Resident #46 was served the incorrect diet texture during the lunch meal that resulted in the resident choking on a meat patty, necessitating the Heimlich Maneuver (abdominal thrusts) by Registered Nurse (RN) D in order to clear the meat from the resident's airway. [...]
- E
PASARR screening for Mental disorders or Intellectual Disabilities
Inspectors wroteResident #2 On 5/15/23, a record review was conducted for Resident #2. The resident, admitted on [DATE], had diagnoses of major depressive disorder, general anxiety disorder and vascular dementia. The PASARR dated 9/18/20, did not list these diagnosis. The facility did not correct the PASARR upon admission and had not updated the form at the time of this survey. On 5/17/23 at approximately 3:49 PM, an interview was conducted with the DON who stated she does the PASARR if the resident comes from home or a hospice. If they come from the hospitals, they usually come in with a PASARR already completed. The DON stated that they always review to make sure the PASARRs are appropriate and completed and signed. [...]
- 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, resident and staff interviews, record review, and policy review, the facility failed to provide 6 of 7 residents sampled with palatable meals and snacks that took resident preferences into consideration (Residents #49, #8, #63, #278, #26, and #34).
- 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, interviews, record reviews of temperature logs, maintenance logs, and policy review, the facility failed to maintain 1 of 2 ice machines and 2 of 2 nourishment room refrigerators located on A and B wing, in a sanitary and safe operating condition. The unsanitary condition of the ice machine represented a potential source of pathogen exposure to all residents served ice. Inadequate temperature control of residents' food during refrigeration indicates an unsafe food storage practice that can promote bacterial growth thereby increasing the nursing home residents' risk of food borne illness.
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on staff interviews, clinical record reviews, and review of facility investigations, the facility failed to submit federal immediate reports for 2 of 2 residents sampled for abuse reporting (Residents #46 and #76). The facility failed to report an allegation of neglect for Resident #46 in May 2023, and an allegation of resident to resident abuse for Resident #76 in January 2023.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on observations, resident interviews, staff interviews, and record reviews, the facility failed to provide appropriate wound care and treatment for 1 of 1 residents sampled for non-pressure related skin conditions. (Resident #34)
Fire safety inspections
4 fire safety citations on file: 3 on January 7, 2026, 1 on May 19, 2023.
Every fire safety citation4 citations
- D
Inspect, test, and maintain automatic sprinkler systems.
K 353 · January 7, 2026 · Corrected (the home has a date of correction)
- D
Properly select, install, inspect, or maintain portable fire extinguishes.
K 355 · January 7, 2026 · Corrected (the home has a date of correction)
- D
Install corridor and hallway doors that block smoke.
K 363 · January 7, 2026 · Corrected (the home has a date of correction)
- D
Install corridor and hallway doors that block smoke.
K 363 · May 19, 2023 · Corrected (the home has a date of correction)