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 34 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
4G
0H
0I
Potential for more than minimal harm
19D
8E
3F
Potential for minimal harm
0A
0B
0C
March 29, 2026Standard inspection · 1 citation
- 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, staff interview, and review of the facility policy titled Use of Psychotropic Medication(s), the facility failed to ensure a stop date was implemented, not to exceed 14 days, for psychotropic medications administered to one resident (R) (R84) from a sample of 33 residents. The deficient practice increased the risk of adverse clinical outcomes.
August 28, 2024Standard inspection, Complaint inspection · 17 citations
- G
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, record review, interview, and review of the facility policy, the facility failed to implement a person-centered comprehensive plan of care with measurable goals and plans related to fall prevention for three of 22 sampled residents (R31, R47, and R10). Harm was identified to have occurred on 07/18/24 when the facility failed to develop and implement a care plan for R31 that addressed his desire for more independence with ambulation and his desire for bilateral prostheses. (Cross reference F657, F689 and F688)
- G
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on record review, staff interviews, and facility policy review, the facility failed to provide appropriate adaptive equipment as directed by Physical Therapy recommendation for one of 22 sampled residents (R) (R31) related to a bi-lateral prosthesis to prevent further potential decline in muscle strength, joint mobility, and an ability to ambulate independently. Psychosocial harm was determined to exist on 7/18/24 due to R31's emotional state when he repeatedly expressed his need for the prosthesis to promote his independence. (Cross Reference F656)
- G
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on observations, interviews, record review, and facility policy review, the facility failed to prevent a fall for two of three residents (R) (R10 and R47) reviewed for falls. This failure resulted in harm to R10 when the nursing assistant failed to provide incontinence care with the assistance of another staff member per the care plan; R10 fell off the bed and suffered a closed head injury, laceration to the forehead, and fracture of the fifth finger on the right hand.
- F
Have a plan that describes the process for conducting QAPI and QAA activities.
Inspectors wroteBased on interviews and review of facility documentation, the facility failed to ensure a Quality Assurance Performance Improvement (QAPI) plan was developed to drive quality assurance (QA) measures that addressed resident care and safety, quality of life, and resident choice. This failure had the potential to affect all 91 residents who currently lived in the facility.
- E
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to provide Form CMS-10055 (Centers for Medicaid and Medicare Services) Skilled Nursing Facility Advance Beneficiary Notice (SNFABN) to two of three residents (R) (R145 and R146) reviewed for liability notices. This failure prevented the resident or responsible party the ability to make an informed decision related to the cost of continued therapy services.
- E
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 facility policy, record review, and staff interviews, the facility failed to ensure notice regarding the reason for the transfer was provided, in writing for three of three residents (R) (R64, R70, and R94) reviewed for hospitalization. This failure created the potential for the residents to be uninformed about their rights related to hospital transfer and subsequent return to the facility.
- E
PASARR screening for Mental disorders or Intellectual Disabilities
Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to complete Pre-admission Screening and Resident Reviews (PASARR) as required for two of three sampled residents (R) (R31 and R64) reviewed for PASARR status.
- E
Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse.
Inspectors wroteBased on interviews and record review, the facility failed to contain specific language in the facility's arbitration agreement for two of three sampled residents (R) (R86 and R84) reviewed for an arbitration agreement.
- D
Honor the resident's right to manage his or her financial affairs.
Inspectors wroteBased on record review and staff and resident interviews, the facility failed to ensure the timely availability of personal resident funds for three of eight residents (R) (R3, R31, and R37) reviewed for access to their funds. The facility's banking hours were limited to Monday through Friday from 9:00 AM to 3:00 PM and residents did not have access to their money outside of these hours.
- D
Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home.
Inspectors wroteBased on facility policy, interviews, and record review, the facility failed to ensure accurate financial accounting and record retention for two of eight residents (R) (R31 and R37) reviewed for resident funds.
- D
Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death.
Inspectors wroteBased on staff interviews and record review, the facility failed to ensure resident funds managed by the facility in a Personal Needs (PN) Account were released to the resident or resident's Responsible Party (RP) within 30 days of discharge for three of eight residents (R) (R195, R197, and R199) reviewed for personal funds.
- D
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Inspectors wroteBased on record review, staff interviews, and facility policy, the facility failed to ensure the facility's Bed Hold Policy was provided in writing to three of three residents (R) (R64, R70, and R94) reviewed for hospitalization. This failure created the potential for the residents to be uninformed about their rights related to the facility's bedhold procedures.
- D
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Inspectors wroteBased on interview, record review, and policy review, the facility failed to make a referral for a Level II Preadmission admission Screening and Resident Review (PASARR) evaluation for one of three sampled residents (R) (R31) reviewed for PASARR Level II evaluations.
- D
Ensure services provided by the nursing facility meet professional standards of quality.
Inspectors wroteBased on observation, interview, record review, and policy review, the facility failed to label the enteral feeding bag in accordance with professional standards of practice for enteral feeding tube administration for one of 22 sampled residents (R) (R69). This failure had the potential to result in the incorrect amount of feeding administered to the resident.
- D
Ensure medication error rates are not 5 percent or greater.
Inspectors wroteBased on record review, observations, staff interviews, and policy review, the facility failed to ensure a medication error rate of less than 5% for two of six residents (R) (R54 and R79) reviewed for medication administration. Two errors were made with a total of 33 opportunities for error, resulting in a 6.06% error rate. The nurse observed administering medication to R54 failed to ensure the resident's insulin pen was primed appropriately before the administration of insulin and the nurse observed administering R79's medication did not leave the resident's insulin pen needle inserted in the resident's skin for the proper amount of time to ensure full absorption of the medication. These failures created the potential for R54 and R79 to experience negative effects related to not receiving the full dose of their insulin.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview, record review, and review of the facility's policies, the facility failed to maintain an effective infection control program for two of 22 sampled residents (R) (R10 and R89) related to R89's indwelling catheter tubing observed on the floor and R10 was COVID-19 positive, however, staff failed to don personal protective equipment (PPE) prior to entering the resident's room. This failure had the potential to spread the COVID-19 virus to other residents in the facility.
- D
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Inspectors wroteBased on interviews, record review, review of the Centers for Disease Prevention and Control (CDC) guidelines, and facility policy review, the facility failed to offer the pneumococcal vaccination in accordance with the nationally recognized standards for two of six residents (R) (R48 and R55) reviewed for immunizations. This failure had the potential to increase the risk for the residents to contract pneumonia.
March 16, 2023Standard inspection · 16 citations
- G
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Inspectors wroteBased on interview, record review, and policy review, the facility failed to ensure one (Resident (R) 87) of two residents reviewed for abuse was free from physical abuse. Actual harm occurred on 2/4/2023 when R87 sustained a contusion to the scalp, left shoulder, and left knee after R300 attacked him in the common area.
- 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 facility policy review, the facility failed to store and prepare food in a manner designed to assure food sanitation. The facility failed to assure the kitchen's metal exhaust hood cover was free of chipping paint. Food preparation sheet pans were not cleaned and sanitized prior to storing them for use, bread products and nutritional shakes that were stored in the kitchen were not dated. Undated and expired foods that were stored in the two resident hallway refrigerators were not discarded. This had the potential to affect 88 of 92 residents who consumed food from the kitchen or food stored in the two resident hall refrigerators.
- F
Have a plan that describes the process for conducting QAPI and QAA activities.
Inspectors wroteBased on interview and review of facility documentation, the facility failed to ensure a Quality Assurance Performance Improvement (QAPI) plan was developed to drive quality assurance (QA) measures which addressed resident care and safety, quality of life, and resident choice. This failure had the potential to affect all 92 residents who currently live in the facility.
- E
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to implement their abuse policy related to the screening component. The facility failed to ensure references were checked prior to employment for five of 10 employees whose employee files were reviewed.
- E
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Inspectors wroteBased on observation (including tasting of food served on a requested test tray), interview, record review, recipe review and facility policy review, the facility failed to serve food that was hot and/or well-seasoned to six of six sampled residents reviewed for food palatability (Resident (R) 21, 73, R39, R13, R89, and R9).
- E
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interviews, record review, and review of information from ASHRAE (American Society of Heating, Refrigerating and Air-Conditioning Engineers) and the Centers for Disease Control and Prevention (CDC), the facility failed to have an adequate water management program designed to prevent the spread of infection. The facility's water management program was incomplete and was not consistent with current ASHRAE Guidelines, which call for specific design and maintenance procedures related to the potential exposure of Legionnaire's disease (a serious pneumonia infection) within a healthcare facility. This failure created a potential to affect 24 facility residents, who were over the age of 65, of a total census of 92.
- E
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Inspectors wroteBased on observation, interview, and review of facility policy, the facility failed to ensure the bathrooms on the 300-unit were clean and in good repair. This failure affected 23 residents' rooms (room [ROOM NUMBER]B, 303A, 301B, 301A, 302B, 302A, 304B, 304A, 306B, 306A, 308A, 308B, 307A, 307B, 305B, 305A, 310A, 310B, 312A, 312B, 311B, 311A and 309A). Additionally, shower rooms on two units (200 Hall and 500 Hall) were in disrepair with black substance on the tile and walls. The facility census was 92.
- 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 policy review, the facility failed to report an injury of unknown origin for one (Resident (R) 201) of 64 sampled residents. R201 was identified with bruising to the breast with no witnessed/verified etiology; however, the facility failed to immediately report the injury to the State Survey Agency (SSA).
- D
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 interview, record review, and facility policy review, the facility failed to provide written notice of transfer to the resident and/or the resident's representative for two (Resident (R)198 and R68) of two sampled residents reviewed for facility-initiated transfers. The facility failed to provide the required written transfer notice, which includes information about the reason, date, and location of the transfer, as well as information on how to appeal the transfer, when the facility initiated a transfer to the hospital for R198 and R68.
- D
Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy.
Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to permit a resident to return to the facility after a facility-initiated transfer to a hospital for behavior assessment for one (Resident (R) 198) of two sampled residents reviewed for facility-initiated transfers.
- D
Ensure each resident receives an accurate assessment.
Inspectors wroteBased on interview, record review, and review of the Resident Assessment Instrument (RAI) Manual, the facility failed to ensure one resident (Resident (R) 28) of six residents reviewed for nutrition had an accurate Minimum Data Set (MDS) assessment. The facility failed to code that the resident experienced a significant weight loss, based on a 10% weight loss in six months.
- D
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Inspectors wroteBased on interview and record review, the facility failed to make a referral for a Level II Preadmission admission Screening and Resident Review (PASARR) evaluation after a resident experienced a change in mental health status and was newly diagnosed with paranoid schizophrenia. The failure to ensure the required PASARR screening and review was completed affected one (Resident (R) 80) of two sampled residents reviewed for PASARR Level II evaluations.
- 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 ensure resident care plans were revised for one (Resident (R) 59) of 64 sampled residents so that the care plan accurately reflected the resident's health status. In addition, the facility failed to invite R21 to her quarterly care conference. This failure created an increased risk for the resident to receive care and services not appropriate for their current clinical condition and/or in accordance with their preferences.
- D
Ensure services provided by the nursing facility meet professional standards of quality.
Inspectors wroteBased on interview, record review, and job description review, the facility failed to provide care that met professional standards of practice for one (Resident (R) 200) of 64 sampled residents. Licensed Practical Nurse (LPN) 5 acted outside the LPN's scope of practice and removed a peripherally inserted central catheter (PICC) without competency. This failure placed Resident (R) 200) a risk for poor quality care and complications related to the removal of the PICC line.
- 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 review of facility policy, the facility failed to ensure the proper storage for vials of insulin for three residents (Resident (R) 36, R65, and R90) on two medication carts observed. The use of expired insulin, which was available in the medication carts, creates the potential for decreased medication efficacy.
- D
Make sure that a working call system is available in each resident's bathroom and bathing area.
Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure that the room for one (Resident (R) 87) of 64 sampled residents was equipped with a functioning call light that was accessible to the resident. This failure had the potential to result in a delayed response to the needs of the resident.
Fire safety inspections
15 fire safety citations on file: 4 on March 29, 2026, 4 on August 28, 2024, 7 on March 16, 2023.
Every fire safety citation15 citations
- E
Inspect, test, and maintain automatic sprinkler systems.
K 353 · March 29, 2026 · Corrected (the home has a date of correction)
- D
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · March 29, 2026 · Corrected (the home has a date of correction)
- D
Install corridor and hallway doors that block smoke.
K 363 · March 29, 2026 · Corrected (the home has a date of correction)
- D
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · March 29, 2026 · Corrected (the home has a date of correction)
- F
Establish an Emergency Preparedness Program (EP).
E 1 · August 28, 2024 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · August 28, 2024 · Corrected (the home has a date of correction)
- D
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
K 761 · August 28, 2024 · Corrected (the home has a date of correction)
- D
Have proper medical gas storage and administration areas.
K 923 · August 28, 2024 · Corrected (the home has a date of correction)
- F
Install an approved automatic sprinkler system.
K 351 · March 16, 2023 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · March 16, 2023 · Corrected (the home has a date of correction)
- F
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · March 16, 2023 · Corrected (the home has a date of correction)
- D
Have an enclosure around a vertical opening shaft.
K 311 · March 16, 2023 · Corrected (the home has a date of correction)
- D
Install a fire alarm system that can be heard throughout the facility.
K 341 · March 16, 2023 · Corrected (the home has a date of correction)
- D
Properly select, install, inspect, or maintain portable fire extinguishes.
K 355 · March 16, 2023 · Corrected (the home has a date of correction)
- D
Have proper medical gas storage and administration areas.
K 923 · March 16, 2023 · Corrected (the home has a date of correction)