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 32 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
30D
1E
1F
Potential for minimal harm
0A
0B
0C
November 21, 2025Standard inspection · 13 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 and interview, the facility failed to: 1. Ensure a clear container which contained turkey sandwich meat was dated and labeled in the delivery freezer. This deficient practice had the potential to result in foodborne illness and contamination for 34 out of 54 residents.
- D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain dignity for one of 15 sampled residents (Resident 49) when Resident 49 was observed with eyeglasses that had the left lens taped into the frames. This deficient practice did not respect Resident 49's right to a dignified existence and placed Resident 49 at risk for injury related to broken eyeglasses.
- D
Reasonably accommodate the needs and preferences of each resident.
Inspectors wroteBased on observation and interviews the facility failed to:1. Ensure call light device was placed within reach for one of 15 sampled residents (Resident 2). This deficient practice had the potential to result in a delay in or an inability for the residents to obtain necessary care and services.
- D
Ensure each resident receives an accurate assessment.
Inspectors wroteBased on interview and record review, the facility failed to ensure the Minimum Data Set (MDS, a resident assessment tool) was accurately completed for one of 15 sampled residents (Resident 48). This deficient practice resulted in the transmission of inaccurate data to the Centers for Medicare and Medicaid Services (CMS, a federal agency that administers the Medicare and Medicaid programs) regarding Resident 1's health status.
- 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, and record review, the facility failed to ensure care plans were developed for two of 15 sampled residents (Residents 32 and 49). This deficient practice placed Residents 32 and 49 at risk for not receiving the necessary interventions for their diagnoses and/or health problems.
- 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 and record review, the facility failed to: 1. Review, update, and/or revise the care plan to address supervision while smoking for two of five sampled residents (Residents 10 and 54). This deficient practice had the potential to result in injury to Residents 10 and 54 due to conflicting documentation and inadequate supervision while smoking.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Failed to ensure blood glucose monitoring and insulin orders were clarified and continued after being readmitted from the hospital for one of five sampled residents (Resident 8). This deficient practice had the potential to result in Resident 8 having a hypoglycemic (low blood glucose) or hyperglycemic (high blood glucose) episode.
- D
Assist a resident in gaining access to vision and hearing services.
Inspectors wroteBased on interview and record review, the facility failed to ensure an optometry (the practice or profession of examining the eyes for visual defects and prescribing corrective lenses) referral was made for one of one sampled residents (Resident 49). This deficient practice placed Resident 49 at risk of not receiving the necessary care and interventions needed to maintain his vision and quality of life.
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Failed to ensure oxygen was administered as ordered for one of five sampled residents (Resident 24). This deficient practice had the potential to result in oxygen toxicity for Resident 24.
- D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Provide pharmaceutical services that met the needs one of five sampled residents (Resident 24). Resident 24's lidocaine patch was not removed at the scheduled time as ordered by the physician. This deficient practice had the potential for avoidable physical harm related to lidocaine patch not being removed on time or experiencing potential adverse drug reactions from medications being administered differently from how they were ordered.
- 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 and interviews the facility failed to: 1. Ensure an unopened prefilled pen of Lantus (a long-lasting insulin [a hormone that removes excess sugar from the blood, can be produced by the body or given artificially via medication]) was stored inside the refrigerator per manufacturer's guidelines instead of storing inside Medication Cart Westback. This deficient practice had the potential to result in the deterioration and loss of effectiveness for insulin Lantus' improper storage and potential for ineffective management of the residents' diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing).
- D
Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse.
Inspectors wroteBased on interview and record review, the facility failed to ensure the correct information was provided to one of three sampled residents (Resident 7) prior to asking him to enter into a binding arbitration agreement (the resolution of a dispute where both parties waive their right to a trial). This deficient practice resulted in Resident 7 unknowingly forfeiting his right to resolve any disputes with the facility in court, alongside a judge and/or jury.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain infection control for all facility residents when: 1. Resident 48 was not tested for Covid-19 (an infectious disease caused by the SARS-CoV-2 virus) after first exhibiting symptoms on 11/12/2025. 2. The facility failed to ensure there was warm running water in the handwashing sink located in the soiled laundry sorting area. These deficient practices created the potential for the transmission and spread of infection to all facility residents.
October 13, 2024Standard inspection · 11 citations
- D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two out of six sampled residents (Resident 27 and 24) were dressed appropriately. This deficient practice of the Residents 24 and 27 not wearing their own clothes had the potential to make the residents feel left out from socialization (activities that contributes to the integrity of an individual's health and wellness).
- D
Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one out six sampled residents (Resident 24) was offered his dentures before eating. This deficient practice of not offering Resident 24 his dentures while eating had the potential to not be able to chew food effectively.
- D
Reasonably accommodate the needs and preferences of each resident.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one out of six sampled residents (Resident 27) had the appropriate call light device to call for assistance. This deficient practice of not having the appropriate call light device had the potential for Resident 27 to not get assistance in a timely manner.
- D
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Inspectors wroteBased on interview and record review, the facility failed to inform and provide the Notice of Medicare Non-Coverage (NOMNC) form 48 hours prior to the end of skilled nursing services for one of three sampled residents (Resident 205). This deficient practice had the potential to result in the resident not being able to exercise his right to file an appeal and unknowingly paying for non-covered care expenses.
- D
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 observation, interview, and record review, the facility failed to ensure one out of six sampled residents (Resident 34) was provided a homelike environment and did not have chipped paint on the wall next to the resident's bed. This deficient practice of not providing a homelike environment for Resident 34 had the potential to negatively impact the resident quality of life.
- 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 interview and record review, the facility failed to ensure one out of six sampled residents (Resident 2) had a care plan (a communication tool for patient care between nurses) for the refusal of dental services. This deficient practice of not having a care plan for refusal of dental services had the potential to place Resident 2 at risk for not receiving the appropriate interventions to prevent discomfort when eating.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on interview and record review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice, by failing to measure the abdominal girth (the measurement of the distance around the abdomen at a specific point, usually at the level of the belly button) weekly per the physician's order for one of one sampled resident (Resident 45) who had a diagnosis of ascites (a condition where fluid builds up in the abdomen). This deficient practice would put Resident 45 at risk for abdominal pain and shortness of breath possibly leading to medical complications requiring hospitalization.
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the low air loss mattress ([LALM] a mattress designed to prevent and treat pressure ulcer (injuries to skin and underlying tissue resulting from prolonged pressure on the skin) was set and maintained at the correct setting for one of three sampled residents (Resident 6). This deficient practice placed Resident 6 at risk for worsening of pressure ulcer/injury ([PU] localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence) and further skin breakdown.
- D
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Inspectors wroteBased on interview and record review, the facility failed to ensure a resident who received hemodialysis ([HD]) a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney[s] have failed) treatment received care in accordance with standards of practice for one of two sampled residents (Resident 204) by failing to monitor and record the resident's daily fluid restriction (medical treatment that limits the amount of fluids a person can consume each day). This deficient practice placed Resident 204 at risk for swelling, discomfort, and shortness of breath.
- 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 interview and record review, the facility failed to: 1. Ensure a resident with a diagnosis of dementia was free from the use of antipsychotic medication (class of drug to treat mental illness) for one out of five sampled residents (Resident 49). This deficient practice had the potential to result in use of unnecessary psychotropic drugs (drug or other substance that affects how the brain works and causes changes in mood, awareness, thoughts, feelings, or behavior) for Resident 49.
- D
Provide routine and 24-hour emergency dental care for each resident.
Inspectors wroteBased on interview and record review, the facility failed to: 1. Ensure a dental services follow-up was completed for one of five sampled residents (Resident 17). This deficient practice had the potential to result in a decreased appetite and weight loss for Resident 17.
August 6, 2024Complaint inspection · 1 citation
- 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 interview and record review, the facility failed to develop and implement a comprehensive (complete; including all or nearly all elements or aspects of something) and patient-centered care plan for one out of four sampled residents (Resident 1) following allegations of financial abuse and Resident 1 missing $ 11,000. This failure had the potential to result in Resident 1 repeatedly being placed at risk for financial abuse.
April 24, 2024Complaint inspection · 1 citation
- D
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Inspectors wroteBased on interview and record review the facility failed to: 1). Implement its policy and procedure (P&P) titled Theft and Loss, which indicated residents ' personal property will be safeguarded and when a resident ' s property was missing, the facility will investigate and document the incident on a theft and loss log. 2. Implement its P&P titled Abuse Prevention, Screening, and Training Program, which indicated misappropriation of resident property and financial abuse were the deliberate misplacement, exploitation, or wrongful use of a resident ' s belongings or money without the resident ' s consent. As a result, Resident 1 and other residents in the facility were placed at risk.
October 13, 2023Standard inspection · 6 citations
- 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 and record review, the facility failed to ensure safe and sanitary food storage and food preparation practices in the kitchen were followed when: 1. Three bags of breaded potato hash browns were stored in the reach-in freezer with no date label. One large container of apple sauce was store in the reach-in refrigerator with no date. 2. Personal water bottles were stored in the facility two door reach-in refrigerator. 3. Nutritional supplement labeled store frozen, with manufactures instruction to use within 14 days of thawing, were not monitored for the date they were thawed to ensure expired shakes were discarded after this time frame. 30 strawberry flavored nutrition supplements were stored in the reach in refrigerator with no thaw date. [...]
- D
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Inspectors wroteBased on interview and record review, the facility failed to ensure the Skilled Nursing Facility (SNF) Advance Beneficiary Notice of Non-coverage form (SNFABN, a document issued by medical providers to Medicare recipients, warning that services might not be covered; formally and legally transfers liability for payment of services to the Medicare recipient instead of Medicare) was completely filled out, by having one of three residents (Residents 256), chose one of the options for billing the anticipated non-covered inpatient skilled nursing facility (an in-patient rehabilitation and medical treatment center staffed with trained medical professionals) stay. This deficient practice had the potential to affect the skilled nursing services needed to progress and achieve the highest practicable physical, mental, and psychosocial wellbeing of the affected resident (Resident 256).
- D
Ensure each resident receives an accurate assessment.
Inspectors wroteBased on interview and record review, the facility failed to ensure an accurate Minimum Data Set (MDS) assessment, a comprehensive assessment and care planning tool, regarding the pneumococcal vaccination (vaccine to prevent pneumococcal disease), was conducted for one of two sampled residents (Resident 3). This deficient practice had the potential for a poor care planning which can affect the health and safety of the affected resident (Resident 3).
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observation, interview and record review, the facility failed to follow its policy and procedure by ensuring one of one sampled resident (Resident 42), had a titration order (order to adjust flow of oxygen to achieve target oxygen level range in the system) for oxygen use, and ensuring the oxygen tubing was changed and labeled every seven days per policy. The deficient practice had the potential to cause respiratory complications and had the potential for facility acquired respiratory infections associated with oxygen therapy.
- 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 record review, the facility failed to ensure two insulin pens (a type of medication used to treat high blood sugar) requiring refrigeration were stored according to the manufacturer's requirements affecting Residents 10 and 21, in one of two inspected medication carts (West Back Medication Cart 1.) The deficient practices of failing to store medications per the manufacturers' requirements increased the risk that Residents 10 and 21 could have received medication that had become ineffective or toxic due to improper storage possibly leading to health complications resulting in hospitalization.
- D
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Inspectors wroteBased on observation, interview and record review, the facility failed to prepare food by methods that conserved flavor, texture, and appearance for one of one puree food test-tray. The texture of the pureed diet was sticky and gummy with glossy and shiny appearance. When tasted the food was sticky to palate and gums and difficult to swallow and the flavor was bland. This deficient practice had the potential to result in meal dissatisfaction, decreased intake and placed Four resident on the puree diet at risk for unplanned weight loss.
Fire safety inspections
17 fire safety citations on file: 5 on November 21, 2025, 5 on October 13, 2024, 7 on October 13, 2023.
Every fire safety citation17 citations
- E
Inspect, test, and maintain automatic sprinkler systems.
K 353 · November 21, 2025 · Corrected (the home has a date of correction)
- E
Ensure proper usage of power strips and extension cords.
K 920 · November 21, 2025 · Corrected (the home has a date of correction)
- D
Install emergency lighting that can last at least 1 1/2 hours.
K 291 · November 21, 2025 · Corrected (the home has a date of correction)
- D
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
K 521 · November 21, 2025 · Corrected (the home has a date of correction)
- D
Have proper medical gas storage and administration areas.
K 923 · November 21, 2025 · Corrected (the home has a date of correction)
- F
Have a fire alarm with audible and visual signals that transmits the alarm automatically to notify emergency forces in event of fire.
K 343 · October 13, 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 · October 13, 2024 · Corrected (the home has a date of correction)
- E
Ensure proper usage of power strips and extension cords.
K 920 · October 13, 2024 · Corrected (the home has a date of correction)
- D
Have a complete alarm system manually initiated and initiated by fire sprinkler system connection.
K 342 · October 13, 2024 · Corrected (the home has a date of correction)
- D
Have proper medical gas storage and administration areas.
K 923 · October 13, 2024 · Corrected (the home has a date of correction)
- F
Provide emergency officials' contact information.
E 31 · October 13, 2023 · Corrected (the home has a date of correction)
- F
Conduct testing and exercise requirements.
E 39 · October 13, 2023 · Corrected (the home has a date of correction)
- F
Implement emergency and standby power systems.
E 41 · October 13, 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 · October 13, 2023 · Corrected (the home has a date of correction)
- E
Keep aisles, corridors, and exits free of obstruction in case of emergency.
K 211 · October 13, 2023 · Corrected (the home has a date of correction)
- E
Construct fire resistant interior walls.
K 331 · October 13, 2023 · Corrected (the home has a date of correction)
- E
Ensure proper usage of power strips and extension cords.
K 920 · October 13, 2023 · Corrected (the home has a date of correction)