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 29 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
1G
0H
0I
Potential for more than minimal harm
12D
11E
5F
Potential for minimal harm
0A
0B
0C
November 5, 2025Complaint inspection · 1 citation
- G
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure residents received adequate supervision to prevent accidents for one (#1) of five residents reviewed for accidents out of five sample residents. Resident #1 was admitted on [DATE] for postoperative left knee replacement rehabilitation services and physical therapy. Resident #1 was determined to be a high fall risk related to her postoperative status and history of falls. On 10/17/25 Resident #1 sustained an unwitnessed fall when she was left unattended in the bathroom. On 10/24/25 Resident #1 sustained an additional fall when she was left unattended in the shower. She sustained a left femur fracture that was deemed inoperable for repair. Specifically, the facility failed to ensure fall interventions were consistently implemented for Resident #1, which resulted in a fall with major injury.
November 21, 2024Standard inspection · 12 citations
- F
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Inspectors wroteBased on observations, record review and interviews, the facility failed to consistently serve food that was palatable and attractive. Specifically, the facility failed to consistently ensure foods were appealing and palatable in temperature and seasoning.
- F
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure food was prepared, distributed and served under sanitary conditions in the main kitchen and two of two nourishment refrigerators. Specifically, the facility failed to: -Ensure ready-to-eat foods were handled in a sanitary manner to prevent cross contamination in the main kitchen; and, -Ensure safe and appropriate storage of food items in the kitchen and nourishment room refrigerators.
- 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 interviews and record review, the facility failed to develop an acute/baseline care plan for four (#380, #376, #382 and #225) of four residents reviewed for baseline care plans out of 60 sample residents. Specifically, the facility failed to ensure Resident #380, #376, #382 and #225 were provided a copy of their baseline care plan with 48 hours of admission to the facility.
- E
Plan the resident's discharge to meet the resident's goals and needs.
Inspectors wroteBased on observations, record review and interviews, the facility failed to develop and implement an effective discharge plan for nine (#376, #378, #380, #371, #388, #382, #10, #185 and #225) of 10 residents reviewed for discharge planning out of 60 sample residents. Specifically, for Residents #376, #378, #380, #371, #388, #382, #10, #185 and #225, the facility failed to: -Ensure residents and their representatives were involved in the development of the discharge plan; -Ensure the discharge plan of care was updated with the residents' discharge goals; and, -Ensure the discharge planning process was documented in the residents' electronic medical records (EMR).
- E
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observations and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of diseases and infection on one of three units. Specifically, the facility failed to: -Ensure staff wore the appropriate personal protective equipment (PPE) in COVID-19 positive resident rooms; -Ensure proper infection control practices were followed for wound care; -Identify an effective process to ensure staff were aware of which residents required enhanced barrier precautions (EBP); and, -Ensure staff wore the appropriate PPE for residents on EBP.
- D
Ensure that residents are fully informed and understand their health status, care and treatments.
Inspectors wroteBased on record review and interviews, the facility failed to ensure consent was obtained for the use of psychotropic medications for one (#226) of five residents reviewed for unnecessary medications out of 60 sample residents. Specifically, the facility failed to ensure informed consent, which included the risks associated with taking a psychotropic medication, were obtained for Resident #226 prior to the administration of a psychotropic medication.
- D
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Inspectors wroteBased on record review and interviews, the facility failed to honor resident choices for one (#53) of one resident out of 60 sample residents. Specifically, the facility failed to ensure Resident #53's preference to have her bed bath completed during the day shift was honored.
- D
Protect each resident from the wrongful use of the resident's belongings or money.
Inspectors wroteBased on record review and interviews, the facility failed to prevent misappropriation of property for three (#228, #46 and #229) of three residents reviewed for personal property out of 60 sample residents. Specifically, the facility failed to prevent the loss of property for Resident #228, Resident #46 and Resident #229 during their time in the facility.
- D
Provide activities to meet all resident's needs.
Inspectors wroteBased on observations, record review and interviews the facility failed to ensure activities were designed to support residents physical, mental and psychosocial well-being were provided for two (#373 and #36) of two residents out of 60 sample residents. Specifically, the facility failed to identify and meet the socialization needs for Resident #373 and #36.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on record review, observations, and interviews, the facility failed to provide treatment and care in accordance with professional standards of practice for one (#53) one resident out of 60 sample residents. Resident #53 was admitted to the facility for rehabilitation services on 10/4/24 with a diagnosis of fracture of the left femur, end stage renal disease, type two diabetes and morbid obesity. The 10/5/24 admission skin assessment indicated the resident had a surgical incision on her left hip, multiple scattered bruises to both upper extremities and a chest port for dialysis. The assessment did not indicate that the resident had any abdominal wounds. On 10/24/24 the resident was noted to have two facility acquired moisture associated skin disorder (MASD) wounds to her abdominal folds. The facility failed to provide the resident with showers per her preferences. [...]
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure one (#174) of one resident reviewed for pressure ulcers out of 60 sample residents received the necessary treatment and services according to professional standards of practice. Specifically, the facility failed to ensure Resident #174's physician ordered heel protection boots were consistently implemented as an intervention to prevent potential pressure wounds.
- D
Provide safe, appropriate pain management for a resident who requires such services.
Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure one (#382) of one resident reviewed for pain out of 60 sample residents had an effective pain management regimen in a manner consistent with professional standards of practice, resident-centered care plans and resident preferences. Specifically, the facility failed to ensure Resident #382, who experienced an acute episode of pain, was provided pain relief and had an effective pain management program to address her continuous pain.
October 8, 2024Complaint inspection · 1 citation
- D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Inspectors wroteBased on record review and interviews, the facility failed to provide pharmaceutical services to meet the needs of one (#1) of three residents out of three sample residents. Specifically, the facility failed to ensure two inhaler medications for Resident #1 were ordered and delivered to the facility as ordered by the physician.
June 6, 2023Standard inspection · 8 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 observations, record review, and staff interviews, the facility failed to ensure food was prepared, stored, and served under safe and sanitary conditions to prevent the potential contamination of food and the spread of food-borne illness in one of one kitchens. Specifically, the facility failed to: -Ensure a clean and sanitary kitchen within the dry storage room; around the grill and fryer; within smaller refrigerator units; and surfaces of the kitchen; and, -Ensure open food items were properly labeled with open dates and sealed for storage to prevent contamination.
- F
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observations and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of diseases and infection for six out of six rooms. Specifically, the facility failed to: -Ensure housekeeping staff were following the proper cleaning techniques for cleaning resident rooms and disinfecting high frequency touched areas (call lights, door handles, phone and hand rails); -Ensure surface disinfectant times were followed; and, -Ensure staff followed personal protective equipment (PPE) precautions for a resident diagnosed with COVID-19 when providing care and when cleaning the resident room.
- E
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Inspectors wroteBased on record review observations and interviews, the facility failed to maintain a system of documenting grievances and demonstrating prompt action for residents. Specifically, the facility failed to: -Follow up and document Resident #33's grievance reported to a staff member; and, -Ensure residents were aware how to file a grievance and place grievance forms in prominent locations throughout the facility.
- E
Ensure medication error rates are not 5 percent or greater.
Inspectors wroteBased on observations, record review and interviews the facility failed to ensure the medication error rate was less than five percent for three residents (#226, #232 and #236). Specifically, the facility had a medication error rate of 7.89 percent, which was three errors out of 38 opportunities for error.
- E
Ensure that residents are free from significant medication errors.
Inspectors wroteBased on observations, record review and interviews the facility failed to ensure residents were kept free of significant medication errors for three residents (#226 #232 and #236) of four reviewed for medication administration out of 44 sample residents. Specifically, the facility failed to ensure insulin pens were primed prior to medication administration for Residents #226, #232 and #236. Cross-reference F759 failure to ensure the medication error rate was less than five percent.
- 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 interviews the facility failed to ensure drugs and biologicals were labeled and stored in accordance with accepted professional standards on two of two units reviewed of four units. Specifically the facility failed to: -Ensure prescribed medications were labeled correctly; -Remove expired medications from the cart; and, -Ensure topical medications were not stored with oral medications. I. Professional standards According to [NAME], P.A., [NAME], A.G., et.al., Fundamentals of Nursing, 10 ed. (2020), E.[NAME], St. Louis Missouri, pp. 608, Medication error often occurs because a patient gets a medication intended for another patient. Therefore, an important step in safe medication administration is being sure that you give the right medication to the right patient. II. [...]
- E
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Inspectors wroteBased on interviews, observations and record review, the facility failed to consistently serve food that was palatable and attractive at the appropriate temperatures for all residents. Specifically, the facility failed to ensure resident food was palatable in taste and temperature.
- E
Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.
Inspectors wroteBased on record review and interview, the facility failed to implement an effective training program for staff. Specifically, the facility failed to: -Ensure two certified nurse aides (CNA) out of five CNAs reviewed completed the required annual abuse identification, prevention and reporting training; and, -Ensure three CNAs out of five CNAs reviewed completed the required annual dementia care training.
September 12, 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 observations, record review and staff interviews, the facility failed to ensure food items were stored and served under sanitary conditions for one of one serving areas. Specifically, the facility failed to ensure: --Food temperatures of cold food items were held at the proper temperature to reduce the risk of food borne illness; and --Disinfecting chemicals were maintained at appropriate parts per million (PPM). --Chemical constituents were not making contact with food
- E
Ensure medication error rates are not 5 percent or greater.
Inspectors wroteBased on observation, interview and record review the facility failed to ensure it was free of a medication error rate of five percent (%) or greater. Specifically, the medication pass observation error rate was 10%, or three errors out of 30 opportunities for error.
- E
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview and record review the facility failed to ensure infection control practices were followed to prevent the spread of infection. Specifically the facility failed to: -Follow proper handwashing; -Follow proper glove use when working between dirty and clean processes; -Clean equipment between residents; and -Use personal protective equipment (PPE) correctly.
- D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteBased on observations, and interviews, the facility failed to ensure three residents (#173, #182, and #63) out of five were treated with respect and dignity. Specifically, the facility failed to: -Ensure staff addressed concerns about food and medication for Resident #182; -Ensure outside agency staff interacted with Resident #173 who had severe cognitive impairments, in a manner appropriate to his health care needs; and -Provide meaningful interaction with Resident #63 to ensure needs were met.
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on observations and record review, the facility failed to provide necessary assistance with activities of daily living (ADLs) for two (#276 and #63) of two residents reviewed. Specifically, the facility failed: - to provide timely incontinent care for Resident #276 - to provide meal assistance to Resident #63
- D
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Inspectors wroteBased on observations, record review and interview, the facility failed to establish nurses were able to demonstrate the skills and competencies needed to provide peripheral intravenous central catheter (PICC) line care to residents. Specifically the facility failed to: -provide an order to obtain blood from a PICC line -discard blood according to standard during PICC lab draw -ensure LPN #4 had an intravenous (IV) certificate to work on the PICC line
- D
Provide safe, appropriate pain management for a resident who requires such services.
Inspectors wroteII.Failed to follow physician prescribed pain level parameters when administering pain medications to Resident #63. A.Facility policy The Pain Management for Cognitively Impaired Residents policy, dated 5/9/17, was provided by the nursing home administrator (NHA) on 9/12/19 at 4:02 p.m. It read in pertinent part; Purpose is to help staff identify pain in the resident, and to develop interventions to manage resident's pain when resident is cognitively impaired. It is the responsibility of the nursing staff member to evaluate the resident's pain every shift. If the resident has a cognitive impairment, the [name brand] Pain Scale should be utilized. B.Resident #63's status Resident #63, age [AGE], was admitted on [DATE]. [...]
Fire safety inspections
14 fire safety citations on file: 3 on November 21, 2024, 10 on June 6, 2023, 1 on September 12, 2019.
Every fire safety citation14 citations
- F
Install emergency lighting that can last at least 1 1/2 hours.
K 291 · November 21, 2024 · Corrected (the home has a date of correction)
- F
Have a battery powered remote alarm panel in a location accessible by operating personnel.
K 916 · November 21, 2024 · Corrected (the home has a date of correction)
- F
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · November 21, 2024 · Corrected (the home has a date of correction)
- F
Conduct testing and exercise requirements.
E 39 · June 6, 2023 · Corrected (the home has a date of correction)
- F
Install emergency lighting that can last at least 1 1/2 hours.
K 291 · June 6, 2023 · Corrected (the home has a date of correction)
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · June 6, 2023 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · June 6, 2023 · 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 · June 6, 2023 · Waiver
- F
Have simulated fire drills held at unexpected times.
K 712 · June 6, 2023 · Corrected (the home has a date of correction)
- F
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
K 914 · June 6, 2023 · Corrected (the home has a date of correction)
- F
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · June 6, 2023 · Waiver
- E
Provide properly protected cooking facilities.
K 324 · June 6, 2023 · Corrected (the home has a date of correction)
- E
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · June 6, 2023 · Corrected (the home has a date of correction)
- D
Provide properly protected cooking facilities.
K 324 · September 12, 2019 · Corrected (the home has a date of correction)