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 24 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
19D
4E
1F
Potential for minimal harm
0A
0B
0C
July 18, 2025Standard inspection · 3 citations
- 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 observation, interview, and review of facility policies and medication guidelines, the facility failed to store, label and dispose of medications in accordance with accepted professional standards for 1 of 2 medication rooms and 2 of 2 medication carts. Observation of the East Medication Room refrigerator on 07/14/2025, revealed an opened ampule of Tubersol without an expiration date or opened date. Observation of the Medication Cart 2 Narcotics bin on 07/16/2025, revealed an unidentified tablet secured with tape into a blister pack containing one milligram Lorazepam tablets. Observation of Medication Cart 1, on 07/17/2025, revealed 14 unidentified loose pills, tablets and capsules in the cart drawer with the medication blister packs.
- 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 interview, record review, and review of facility policy, it was determined the facility failed to revise the Comprehensive Care Plan for 1 of 15 sampled residents, Resident (R)42. Specifically, the facility failed to revise R42's Care Plan with interventions to address weight loss after the resident sustained a 32.6 pound (18.09%) severe weight loss in less than one month. The finding Include: Review of the facility's Care Planning-Interdisciplinary Team policy, undated, revealed .2. The care plan is based on the resident's comprehensive assessment and is developed by a Care Planning/Interdisciplinary Team which may include, but is not necessarily limited to the following personnel: a. the resident's Attending Physician; b. The Registered Nurse who has responsibility for the resident; c. The Dietary Manager/Dietician; d. The Social Services Worker responsible for the resident; [...]
- D
Provide enough food/fluids to maintain a resident's health.
Inspectors wroteBased on interview, record review, and review of facility policy, the facility failed to ensure that a resident receives and maintains acceptable parameters of nutritional status, such as body weight, unless the resident's clinical condition demonstrates that this is not possible for 1 of 2 sampled residents reviewed for nutrition, Resident (R)42. Specifically, the facility failed to identify and respond to R42's 32.6 pound (18.09%) severe weight loss in less than one month.
May 1, 2021Standard inspection · 14 citations
- E
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Inspectors wroteBased on observation, interview, record review, and facility policy review, it was determined the facility failed to protect four (4) of thirty-one (31) residents from resident to resident abuse. The facility failed to protect Resident #10 from abuse resulting in a skin tear to the hand. The facility failed to protect Resident #35, #366 and #313 from verbal abuse.
- E
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, record review and review of facility policy, the facility failed to ensure the temperature of each cooked food item was checked before served per facility policy for 57 meals between 04/01/2021 and 04/25/2021.
- 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 interview, record review and review of facility policy, it was determined the facility failed to ensure the physician was notified of a resident change in condition for one (1) of thirty-one (31) sampled residents (Resident #313). On [DATE], a change in skin condition was noted on Resident #313's nose; however, the physician was not notified until [DATE].
- D
Keep residents' personal and medical records private and confidential.
Inspectors wroteBased on record review, interview and review of facility policy, the facility failed to protect the right to privacy and confidentiality for two (2) of thirty-one (31) sampled residents (Resident #363 and Resident #364). The facility failed to ensure the privacy and confidentiality of Resident #363 and Resident #364 when Resident #365 took photographs in the facility common area of both residents and posted them on his/her public social media page without the knowledge or consent of Resident #363 or Resident #364 or their resident representatives.
- D
Protect each resident from the wrongful use of the resident's belongings or money.
Inspectors wroteBased on observation, interview, record review and review of facility policy, it was determined the facility failed to protect two (2) of thirty-one (31) sampled residents (Residents #11 and #47) from misappropriation of resident property (controlled medications). The Controlled medication count was not correct for Resident #11 and #47 on 04/28/2021.
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on interview, record review and facility policy review, it was determined the facility failed to report an allegation of verbal abuse timely for one (1) of thirty one (31) sampled residents (Resident #9). State Registered Nurse Aide (SRNA) #18 failed to immediately report an allegation of verbal abuse toward Resident #9 by SRNA #19.
- D
Respond appropriately to all alleged violations.
Inspectors wroteBased on interview, record review and policy review, the facility failed to ensure an abuse allegation was thoroughly investigated for one (1) of thirty-one (31) sampled residents (Resident #163). The facility investigated an abuse allegation related to a nurse making an inappropriate statement to Resident #163 when the resident requested pain medication on [DATE]. Although, the facility investigated the statement made by the nurse to the resident, the facility failed to investigate the if the resident received the pain medication as requested.
- 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 interview, record review and facility policy review, the facility failed to revise/update the comprehensive plan of care for two (2) of thirty one (31) sampled residents (Resident #25 and Resident #313) related to safety concern and a change in skin condition.
- D
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Inspectors wroteBased on observation, interview, record review, and review of facility policy, the facility failed to provide care and services to ensure one (1) of thirty-one (31) sampled residents (Resident #14) received assistance with bathes and showers. The facility assessed Resident #14 to require extensive assistance of staff for bathing/showers. However, from 01/12/2021 through 01/20/2021, the facility staff failed to assist the resident with bathes or showers.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on observation, interview, record review and facility policy review, it was determined the facility failed to ensure care was provided to a surgical wound in accordance with professional standards of practice for one (1) of thirty-one (31) sampled residents (Resident #54). Observations during wound care revealed the nurse did not wash her hands between glove changes while performing the wound care.
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on observation, interview, record review and facility policy review, it was determined the facility failed to ensure a resident with a pressure ulcer received the necessary treatment to promote healing and prevent infection for (1) of thirty-one (31) sampled residents (Resident #24). Observations during wound care revealed the nurse did not wash her hands between glove changes while performing the wound care.
- 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, record review and a review of the facility policy, it was determined the facility failed to provide appropriate treatment/services (incontinent care) to prevent urinary tract infections for one (1) of thirty-one (31) sampled residents (Resident #58) who was incontinent of urine.
- D
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Inspectors wroteBased on observation, interview, record review and facility policy review, it was determined the facility failed to coordinate care with outside dialysis center that provided services to one (1) of thirty-one (31) sampled residents (Resident #20). Resident #20 required outpatient hemodialysis treatments three (3) times a week due to end stage renal failure. Per transportation records, Resident #20 had seventeen (17) treatments from 03/15/2021 to 04/26/2021. However, there was no communication forms/documented evidence that the facility coordinated care with the dialysis center between 03/15/2021 and 04/26/2021.
- D
Ensure that residents are free from significant medication errors.
Inspectors wroteBased on observation, interview, record review and a review of the facility policy for medication administration, it was determined the facility failed to ensure one (1) of thirty-one (31) sampled residents (Resident #53) was free of significant medication errors. Resident #53 was ordered to have Dilantin (a medication to control seizures) 150 milligrams (mg) every day. However, the resident received the incorrect dose of Dilantin (100 mg instead of 150 mg) for three (3) days in April (on 04/26/2021, 04/27/2021 and 04/28/2021).
June 21, 2019Standard inspection · 7 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 review of facility policy, it was determined the facility failed to follow the dishwasher manufacturer recommendations for the high temperature wash cycle in the facility kitchen. Observation during survey revealed the dishwasher temperature reached one hundred forty (140) degrees Fahrenheit for several wash cycles. In addition, other observations during survey revealed the Dietary [NAME] #2 was unsure of the correct calibration process for the thermometer.
- 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 observation, interview, record review and facility policy it was determined the facility failed to ensure medications were properly labeled and dated for two (2) of three (3) medication rooms in the [NAME] and Rehab Nursing Stations. Observations revealed opened bottles of Tubersol (a purified protein derivative of the Mycobacterium tubercula used with the detection of tuberculosis (TB)) were not labeled with a date and time the agent was opened. In addition the facility failed to ensure one (1) of three (3) refrigerated medication lock boxes were properly secured to the refrigerator. Other observations revealed one (1) of four (4) medication room doors were unsecured for four (4) of four (4) days and one (1) of four (4) medication carts unlocked and unsupervised.
- 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 observation, interview, record review, and review of the facility's policy, it was determined the facility failed to implement care plan interventions for one (1) of thirty-eight (38) sampled residents, Residents #63. Observations revealed the facility failed to provide dining assistance as care planned.
- D
Provide enough food/fluids to maintain a resident's health.
Inspectors wroteBased on observation, interview, record review, and review of facility program Skin, and Weight Assessment Team (SWAT), it was determined the facility failed to provide care and services to maintain or address a resident's nutritional status for one (1) of thirty-eight (38) sampled residents, Resident #63. Observations revealed Staff did not provide or assist Resident #63 with meals after the facility identified the resident with potential for alteration in nutritional status.
- 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 observation, interview, record review, and facility policy review, it was determined the facility failed to ensure one (1) of thirty-eight (38) residents, Resident #63, was free from unnecessary psychotropic medication and as needed (PRN) psychotropic medication (Ativan). In addition, the facility did not monitor behaviors or for side effects of a psychoactive medication. (Ativan/Lorazepam).
- 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 observation, interview, record review, and facility policy review it was determined the facility failed to ensure dining choices were honored for one (1) of eleven (11) sampled residents, Resident #42.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview, and facility policy review it was determined the facility failed to implement an effective infection control program as evidenced by clean personal care items stored in one (1) of three (3) soiled utility rooms located on the Rehab unit.
Fire safety inspections
10 fire safety citations on file: 2 on July 18, 2025, 3 on March 12, 2025, 5 on May 1, 2021.
Every fire safety citation10 citations
- E
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · July 18, 2025 · Corrected (the home has a date of correction)
- D
Have proper medical gas storage and administration areas.
K 923 · July 18, 2025 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · March 12, 2025 · Corrected (the home has a date of correction)
- E
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · March 12, 2025 · Corrected (the home has a date of correction)
- D
Install smoke barrier doors that can resist smoke for at least 20 minutes.
K 374 · March 12, 2025 · Corrected (the home has a date of correction)
- E
Install corridor and hallway doors that block smoke.
K 363 · May 1, 2021 · Corrected (the home has a date of correction)
- E
Have properly installed electrical wiring and gas equipment.
K 511 · May 1, 2021 · Corrected (the home has a date of correction)
- D
Have corridors or aisles that are unobstructed and are at least 8 feet in width.
K 232 · May 1, 2021 · Corrected (the home has a date of correction)
- D
Properly select, install, inspect, or maintain portable fire extinguishes.
K 355 · May 1, 2021 · Corrected (the home has a date of correction)
- D
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
K 741 · May 1, 2021 · Corrected (the home has a date of correction)