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 27 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
17D
7E
3F
Potential for minimal harm
0A
0B
0C
March 5, 2026Standard inspection, Complaint inspection · 12 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, interviews, record review, and facility policy titled Housekeeping Operations Manual, the facility failed to ensure the dining room, and 2 of 2 communal shower rooms were maintained in a safe, clean, comfortable and homelike environment. The deficient practice had the potential to affect patient comfort and safety.
- E
Ensure medication error rates are not 5 percent or greater.
Inspectors wroteBased on observations, record review, staff interviews, review of the facility's policies titled Administering Medications, the facility failed to ensure accurate administration of medications for six of 25 medication opportunities observed, resulting in a medication error rate of 24% (percent.) The deficient practice increased the risk of adverse clinical outcomes. Findings Include:Review of the facility's policy titled, Administering Medications, dated 2/2020 documented that Medications shall be administered in a safe and timely manner, and as prescribed. [...]
- E
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observations, staff and resident interviews, record review, and review of the facility policies titled Handwashing/Hand Hygiene, Insulin Administration, Housekeeping-Infection Control Procedures, and Cleaning and Disinfection of Resident-Care Items and Equipment, the facility failed to follow proper infection control practices for one of four nursing units and two of two shower rooms. Specifically, top of an insulin vial not disinfected, blood pressure cuff not disinfected between residents, Housekeeping Aide pouring liquid from resident cup into mop water, and nursing staff exiting resident rooms without removing gloves and performing hand hygiene. In addition, multiple personal items in the communal shower rooms were unlabeled. The deficient practice increased the risk of cross contamination and spread of infection. Facility census was 127. Findings Include: [...]
- D
Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
Inspectors wroteBased on record reviews, observations, staff and resident interviews, and a review of the facility's policy titled Personal Property, the facility failed to promote dignity by not exercising reasonable care and protection to prevent damage to the glasses for one resident (R) (R109) from a sample of 47 residents. The deficient practice had the potential to affect R109 from reaching the highest practicable level of function.
- D
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Inspectors wroteBased on record review, staff interviews, and review of the facility policy titled, Abuse Prevention Program, the facility failed to ensure safety and freedom from an act of physical abuse for one resident (R) (R84) from a sample of three residents reviewed for abuse. The deficient practice had the potential to affect the quality of life and safety for other residents.
- D
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Inspectors wroteBased on resident and staff interviews, record reviews, and review of the facility's policy titled Transfer of Discharge Notice, the facility failed to ensure two of two sampled residents (R) (R131 and R133) were provided with a written bed hold notice or reason for transfer at the time of transfer. This failure had the potential to place the resident or resident's representative at risk of being uninformed about their rights related to hospital transfer and subsequent return to the facility.
- D
Ensure each resident receives an accurate assessment.
Inspectors wroteBased on record review, policy review, and staff interviews, the facility failed to ensure that Minimum Data Set (MDS) assessments were accurate for two of four residents (R) (R112 and R113) reviewed for elopement risk. This deficient practice had the potential to place R112 and R113 at increased risk of not receiving care and services according to their assessed needs.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on observations, staff and resident interviews, record review, and review of the facility's policies titled Administering Medications, Provision of Care, and Change in a Resident's Condition or Status, the facility failed to ensure that residents received care in accordance with physician orders and facility policy for five residents (R) (R47, R72, R106, R137, and R128) of 47 sampled residents. Specifically, the facility failed to: ensure a wound vac was applied and connected; ensure medications were administered by the nurse who pulled the medication; notify the physician of deviations from orders; accurately document medication administration; obtain resident weights as ordered; and provide timely pain medication. These deficient practices increased the risk of adverse clinical outcomes. Findings Include: [...]
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on observations, record review, staff interviews, and review of the policy titled, Accidents and Incidents-Investigation and Reporting, the facility failed to ensure the environment remained as free of accident hazards as possible and failed to provide adequate supervision for two residents (R) (R49 and R145) from a sample of 47 residents. The deficient practice increased the risk of avoidable accidents and injury.
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observations, staff and resident interviews, record review, and review of the facility policy titled Oxygen Administration, the facility failed to ensure oxygen (O2) was administered according to physician's order for two of 13 residents (R) (R140 and R75) who use O2. This deficient practice had the potential to result in inappropriate respiratory treatment and adverse clinical outcomes.
- D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Inspectors wroteBased on observations, staff interviews, and review of facility policies titled Administering Medications, the facility failed to maintain accurate records on controlled substances for resident (R) (R43) on one of three medication carts. The deficient practice increased the risk of medication error for R43 and the potential for drug diversion.
- D
Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.
Inspectors wroteBased on observation, interview and record review the facility failed to assure that two residents (R) (R34 and R90) from a sample of 47 residents, received and consumed foods in the appropriate form as prescribed by a physician, and/or assessed by the interdisciplinary team to support the resident's treatment, plan of care, in accordance with goals and preferences. The deficient practice increased the risk of adverse clinical outcomes.
February 2, 2025Standard inspection, Complaint inspection · 7 citations
- F
Observe each nurse aide's job performance and give regular training.
Inspectors wroteBased on staff interviews, record review, and review of the facility's policy titled Competency of Nursing Staff, the facility failed to conduct annual performance reviews to ensure competency for the Certified Nursing Assistants (CNAs) employed by the facility. The census was 135.
- 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, staff interviews, and review of the facility's policy titled Food and Nutrition Services, and review of the facility document titled [Name of supply company] TELS (The Equipment Lifecycle System) Ice Machines Preventative Maintenance, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety. Specifically, the facility failed to ensure foods were not left open to air, label and date opened and unopened foods in addition to, serving cold fruit at 68 degrees Fahrenheit (F). Also, the facility failed to ensure that one of two ice machines was clean and sanitary as evidenced by one ice machine had discoloration on the inside middle part of the machine. This deficient practice had the potential to cause a diminished quality of life for 132 out of 135 residents receiving an oral diet.
- F
Dispose of garbage and refuse properly.
Inspectors wroteBased on observations, staff interviews, and review of the facility's policy titled Food-Related Garbage and Refuse Disposal, the facility failed to ensure that the area around the dumpster was free from garbage and refuse. This deficient practice had the potential to attract pest. The facility census was 135.
- 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, staff interviews, record review, review of the facility's policy titled Maintenance Service, and review of documents titled [Name of supply company] TELS (The Equipment Lifecycle System), the facility failed to provide a safe, clean, comfortable, homelike environment related to dirty filters in the Packaged Terminal Air Conditioner (PTAC) units, walls in disrepair and missing paint, missing chair rail, and missing/falling ceiling tiles for nine resident rooms (room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], and room [ROOM NUMBER]) on three of four halls (B,C, and D halls) and falling ceiling tiles the kitchen. The deficient practice had the potential to place the residents at risk for accidents and hazards and diminished quality of life. [...]
- D
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Inspectors wroteBased on staff interviews, record review, and review of the facility's policy titled Resident Assessment-Coordination with PASARR (Preadmission Screening and Resident Review) Program, the facility failed to ensure one of one resident (R) (R99) reviewed with a serious mental disorder was referred for a Level II PASARR assessment on admission or within 30 days of a new diagnosis. This deficient practice had the potential to affect the appropriate level of care and services provided for R99.
- 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 observations, resident and staff interviews, record review, and review of the facility policy titled, Care Plan, Comprehensive Person Centered, the facility failed to develop and implement care plans for four of 42 (R) (R84, R50, R20, and R90) sampled residents. The deficient practices had the potential to place the residents at risk for medical complications, unmet needs, and a diminished quality of life.
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on observations, resident and staff interviews, record review, and review of the facility policy titled Activities of Daily Living (ADLs), the facility failed to ensure ADL care was provided for three of 42 sampled residents (R) (R20, R90, and R50) related to showers, nail care, and shaving of facial hair. This failure placed R20, R90, and R50 at risk for unmet needs and a diminished quality of life.
November 7, 2024Complaint inspection, Infection control · 1 citation
- E
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observations, staff interviews and review of the facility's policy titled Laundry Operations Manual, the facility failed to ensure the soiled linen hampers located in the hallways of the facility, were emptied immediately when full. This failure has the potential to impact 71of 128 residents residing on the A and C Halls.
August 24, 2023Standard inspection · 7 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, interviews, and review of facility documentation, the facility failed to maintain a functional and sanitary environment in two of 20 sampled resident rooms on the A Hall. Specifically, the facility failed to maintain its packaged terminal air conditioners (PTAC) in a sanitary condition in rooms [ROOM NUMBERS]. In addition, the facility failed to maintain one of 35 resident wardrobes on the B Hall, room [ROOM NUMBER], in a functional condition.
- 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, staff interviews, and review of the Contracted Dietary Company's policies titled, General HACCP Guidelines, Uniform Policy and Personal Hygiene Policy, the facility failed to allow dishes to air dry prior to use, ensure kitchen staff perform hand hygiene and wear gloves when preparing food for residents, to ensure staff entering the kitchen wear hair net and perform hand hygiene upon entering the kitchen. This deficient practice had the potential to affect 128 of 133 residents receiving an oral diet. Review of policy titled General HACCP Guidelines dated January 2022, under subtitle, Policy revealed, Staff must be educated and supervised on all HACCP information and procedures. A good training program and the proper systems and tools will help to assure a successful HACCP /Food Safety program. [...]
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on staff interviews, record review, and review of the facility's policy titled, Bladder and Bowel Evaluation, the facility failed to obtain a physician's order for a urinary catheter for one of five Residents (R) #69. The deficient practice had the potential to affect the needed care and services to meet the resident's needs.
- D
Provide appropriate foot care.
Inspectors wroteBased on observations, interviews, review of facility documentation, and review of the facility's policy titled, Foot Care, the facility failed to identify and treat four of five wounds on the toes of the left foot for one of seven Residents (R) (R#32). The deficient practice had the potential to affect proper treatment and care to maintain mobility and good foot health.
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observations, staff interview, review of records, and review of the facility's policy titled, Oxygen Administration, the facility failed to change disposable respiratory supplies and failed to maintain the cleanliness of respiratory supplies for eight of 22 Residents (R) (R#17, R#25, R#35, R#57, R#64, R#97, R#106, and R#108) with physician orders for continuous Oxygen (O2) and/or bilevel positive airway pressure (BiPAP) therapy. The deficient practice had the potential to affect the necessary respiratory care and services that are in accordance with professional standards of practice.
- D
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Inspectors wroteBased on staff interviews, record review, and review of the facility's document titled, Internal Agreement Request Prep Form; Nursing Home Dialysis Transfer Agreement, the facility failed to secure a contract with the dialysis center. The facilities census was 133.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observations and interviews, the facility failed to maintain personal use equipment in a sanitary manner for two of six shared bathrooms on the B Hall. Specifically, unlabeled/unbagged wash basins were observed in the bathrooms serving rooms [ROOM NUMBERS].
Fire safety inspections
24 fire safety citations on file: 5 on March 5, 2026, 8 on February 2, 2025, 11 on August 24, 2023.
Every fire safety citation24 citations
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · March 5, 2026 · Corrected (the home has a date of correction)
- D
Properly select, install, inspect, or maintain portable fire extinguishes.
K 355 · March 5, 2026 · Corrected (the home has a date of correction)
- D
Install corridor and hallway doors that block smoke.
K 363 · March 5, 2026 · Corrected (the home has a date of correction)
- D
Ensure proper usage of power strips and extension cords.
K 920 · March 5, 2026 · Corrected (the home has a date of correction)
- D
Have proper medical gas storage and administration areas.
K 923 · March 5, 2026 · Corrected (the home has a date of correction)
- F
Conduct testing and exercise requirements.
E 39 · February 2, 2025 · Corrected (the home has a date of correction)
- D
Establish staff and initial training requirements.
E 37 · February 2, 2025 · Corrected (the home has a date of correction)
- D
Have properly located and lighted "Exit" signs.
K 293 · February 2, 2025 · Corrected (the home has a date of correction)
- D
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
K 321 · February 2, 2025 · Corrected (the home has a date of correction)
- D
Provide properly protected cooking facilities.
K 324 · February 2, 2025 · Corrected (the home has a date of correction)
- D
Install a fire alarm system that can be heard throughout the facility.
K 341 · February 2, 2025 · Corrected (the home has a date of correction)
- D
Install corridor and hallway doors that block smoke.
K 363 · February 2, 2025 · Corrected (the home has a date of correction)
- D
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
K 761 · February 2, 2025 · Corrected (the home has a date of correction)
- D
Establish an Emergency Preparedness Program (EP).
E 1 · August 24, 2023 · Corrected (the home has a date of correction)
- D
Meet other general requirements.
K 100 · August 24, 2023 · Corrected (the home has a date of correction)
- D
Install a fire alarm system that can be heard throughout the facility.
K 341 · August 24, 2023 · Corrected (the home has a date of correction)
- D
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · August 24, 2023 · Corrected (the home has a date of correction)
- D
Install an approved automatic sprinkler system.
K 351 · August 24, 2023 · Corrected (the home has a date of correction)
- D
Properly install and monitor supervisory attachments on automatic sprinkler systems.
K 352 · August 24, 2023 · Corrected (the home has a date of correction)
- D
Inspect, test, and maintain automatic sprinkler systems.
K 353 · August 24, 2023 · Corrected (the home has a date of correction)
- D
Provide properly sized and located linen or trash receptacles.
K 754 · August 24, 2023 · Corrected (the home has a date of correction)
- D
Meet requirements for the use of electrical equipment.
K 919 · August 24, 2023 · Corrected (the home has a date of correction)
- D
Ensure proper usage of power strips and extension cords.
K 920 · August 24, 2023 · Corrected (the home has a date of correction)
- D
Have proper medical gas storage and administration areas.
K 923 · August 24, 2023 · Corrected (the home has a date of correction)