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 52 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
1J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
34D
15E
0F
Potential for minimal harm
0A
0B
2C
July 29, 2025Complaint inspection · 5 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 resident interview, staff interview, facility document review and clinical record review, it was determined the facility staff failed to ensure three of five residents were free from verbal abuse, Residents #3, #4 and #5.
- E
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 staff interview, facility document review, and clinical record review, it was determined the facility staff failed to review and revise the comprehensive care plan for three of five residents in the survey sample, Residents #3, #4, and #5.
- E
Provide medically-related social services to help each resident achieve the highest possible quality of life.
Inspectors wroteBased on resident interview, facility document review and clinical record review, it was determined the facility staff failed to provided medical related social services for three of five residents in the survey sample, Residents #3, #4 and #5.
- E
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on staff interview, facility document review and clinical record review, the facility staff failed to maintain a complete and accurate clinical record for three of five residents, Resident #3, #4, and #5.
- D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteBased on resident interview, staff interview, and facility document review, it was determined that the facility staff failed to treat one of five residents in the survey sample, in a dignified manner, Resident #3.
March 13, 2025Complaint inspection · 2 citations
- 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 staff interview and facility document review, it was determined the facility staff failed to completely document grievances and failed to document the resolution of the grievances.
- D
Let each resident or the resident's legal representative access or purchase copies of all the resident's records.
Inspectors wroteBased on family interview, staff interview, and clinical record review, it was determined the facility staff failed to release the medical records for one of three residents in the survey sample, in a timely manner, Resident #1.
July 10, 2024Standard inspection, Complaint inspection · 23 citations
- J
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wrote3. For Resident #97 (R97), the facility staff failed to provide supervision for safe LOA (leave of absence). On 7/9/24 at 10:08 a.m., R97 was interviewed. He stated that he leaves the premises and walks across the street to the store about once a week by himself. He also stated that he lets the front desk, and the nurses know before leaving, but staff do not supervise his trips. He stated that he should be using his cane to walk, but he does not. On 7/9/24 at 5:50 PM, R97 was observed walking over to Walgreens without a cane. He looked both ways on his way to Walgreens while crossing Sunset Lane. He was observed crossing 4 lanes of traffic across the street with no staff supervision. He walked with a shuffling gait. Upon his return to the facility, he was observed crossing the same 4 lanes of traffic with no staff supervision and did not look for oncoming traffic. [...]
- E
Honor the resident's right to organize and participate in resident/family groups in the facility.
Inspectors wroteBased on staff interview and facility document review, the facility staff failed to respond to resident council concerns for two of three resident council meetings reviewed, the May 2024 and June 2024 meetings.
- E
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 staff interview, facility document review, and clinical record review, the facility staff failed to notify the physician of a change in condition and possible need to alter treatment for one of 50 residents in the survey sample, Resident #106.
- 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 wrote4. For Resident #32 (R32), Resident #34 (R34), and Resident #104 (R104), the facility staff failed to serve lunch in a homelike manner on 7/8/24. Staff left meal trays and plate lids sitting on the tables during the meal. On R32's most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 6/27/24, the resident scored 14 out of 15 on the BIMS (brief interview for mental status), indicating the resident was cognitively intact for making daily decisions. On R34's most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 5/29/24, the resident scored 15 out of 15 on the BIMS (brief interview for mental status), indicating the resident was cognitively intact for making daily decisions. [...]
- E
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Inspectors wrote4. For Resident #86, the facility staff failed to implement the care plan for pressure injury (1) care. The comprehensive care plan dated, 3/1/24, documented in part, Focus: Skin Impairment: The resident has a skin impairment: R/L (right/left) groin necrotizing fasciitis post-surgical, R/L ABD (abdominal) rash, L axilla hidradenitis, L/R scrotum hidradenitis, R lateral groin post-surgical necrotizing fasciitis, L groin post-surgical necrotizing fasciitis, sacrum pressure. The Interventions documented in part, Notify MD (medical doctor) as indicated. Observe area for signs of improvement or decline. Treatment as ordered. The wound care nurse practitioner note dated 5/20/24 documented in part, Sacrum scar tissue. The wound care physician notes dated, 5/31/24, documented in part, Sacrum - stage 2 (2) measuring approximately 1x1x 0.1 cm (centimeters) in size. [...]
- E
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on staff interview, clinical record review and facility document review, it was determined that the facility staff failed to provide care and services to promote or maintain the highest level of well being for two of 50 residents in the survey sample; Residents #269 and #151.
- E
Ensure that residents are free from significant medication errors.
Inspectors wroteBased on staff interview, clinical record review and facility document review, it was determined that the facility staff failed to prevent one of 50 residents in the survey sample, Resident #269, from a significant medication error.
- 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 interview, and facility document review, it was determined that the facility staff failed to maintain one of one kitchen in a safe and sanitary manner.
- E
Provide and implement an infection prevention and control program.
Inspectors wroteBased on staff interview, resident interview, clinical record review and facility document review, it was determined the facility staff failed to implement infection control practices for four of four residents in medication administration and one of one infection control program, Residents #45, #25, #132, #118 and the facility.
- D
Reasonably accommodate the needs and preferences of each resident.
Inspectors wroteBased on observation, resident interview, staff interview, clinical record review and facility document review, it was determined that the facility staff failed to maintain the call bell in a position accessible to the resident for two of 50 residents in the survey sample, Resident #89 and Resident #13.
- D
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Inspectors wroteBased on staff interview, clinical record review and facility document review, it was determined the facility staff failed to implement the baseline care plan for one of 50 residents in the survey sample, Residents #470.
- 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 observation, resident interview, staff interview, clinical record review, and facility document review, it was determined that the facility staff failed to review and revise the comprehensive care plan to reflect the residents current status for two of 50 residents in the survey sample; Resident #148 and #120.
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on observation, resident interview, staff interview, clinical record review and facility document review, it was determined that the facility staff failed to provide ADL (activities of daily living) care for dependent residents for three of 50 residents in the survey sample, Residents #90, #89 and #151.
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on observation, staff interview, facility document review and clinical record review, it was determined the facility staff failed to assess and monitor a pressure injury for one of 50 residents in the survey sample, Resident #86.
- D
Provide appropriate foot care.
Inspectors wroteBased on observation, staff interview and clinical record review, facility staff failed to provide toenail care for one of 50 residents, Resident #56 (R56).
- D
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Inspectors wroteBased on observation, staff interview and facility document review, the facility staff failed to apply splints for one of 50 residents, Resident #56.
- 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, resident interview, staff interview, clinical record review and facility document review, it was determined that the facility staff failed to maintain a urinary catheter bag in a sanitary manner for one of 50 residents in the survey sample, Resident #89.
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observation, staff interivew, facility document review and clinical record review, it was determined the facility staff failed to provide respiratory services for two of 50 residents in the survey sample, Residents #56 and #13.
- D
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Inspectors wroteBased on staff interview, facility document review, and clinical record review, the facility staff failed to act on a pharmacy recommendation for one of 50 residents in the survey sample, Resident #79.
- 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 staff interview and clinical record review, the facility staff failed to ensure a resident was free from an unnecessary psychotropic medication for one of 50 residents in the survey sample, Resident #79.
- 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, staff interview and facility document review it was determined facility staff failed to secure Medications in a safe and secure manner according to professional standards for two of 50 residents, Resident #32 and Resident #159.
- D
Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame.
Inspectors wroteBased on observation, staff interview, facility document review, and clinical record review, it was determined the facility staff failed to perform a bed inspection for two of 50 residents in the survey sample, Residents #86 and #124.
- D
Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.
Inspectors wroteBased on staff interview and facility document review, it was determined that the facility staff failed to ensure QAPI (quality assurance and performance improvement) program training was completed for one of five employees reviewed, OSM (other staff member) #5.
September 15, 2022Standard inspection · 14 citations
- E
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Inspectors wroteBased on staff interview, clinical record review, and facility document review, it was determined that the facility staff failed to provide care and service for a complete dialysis program for one of 55 residents in the survey sample, Residents #87 (R87).
- 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, staff interview, and facility document review it was determined facility staff failed to store food in a sanitary manner in one of one facility kitchens. 1. The facility staff failed to seal one 13.9 ounce package of dry gravy mix in one of one dry food storage rooms. 2. The facility staff failed to close a box containing one frozen pie and seal a package of frozen cookie dough in one of one walk-in freezers.
- D
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Inspectors wroteBased on staff interview, facility document review and clinical record review, it was determined the facility staff failed to determine if a resident had an Advance Directive for one of 55 residents in the survey sample, Resident #110 (R110).
- D
Keep residents' personal and medical records private and confidential.
Inspectors wroteBased on staff interview, facility document review and clinical record review, it was determined that the facility staff failed to respect the resident's right to privacy for one of 55 residents, Resident #467.
- 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, staff interview, facility document review, and clinical record review, it was determined that the facility staff failed to implement the comprehensive care plan for 2 of 55 residents in the survey sample; Residents #146 and #82.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on staff interview, clinical record review and in the course of a complaint investigation, the facility staff failed to provide care and services to maintain a resident's highest level of well-being for one of 55 residents in the survey sample, Resident #367. The facility staff failed to ensure Resident #367's (R367) high white blood cell count (1) result was addressed by the nurse practitioner on 7/8/22.
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on observation, staff interview, facility document review, and clinical record review, it was determined that the facility staff failed to provide treatment to a pressure ulcer in a sanitary manner for one of 55 residents in the survey sample, Resident #107 (R107). For R107, the nurse providing wound care failed to wash/sanitize hands between glove changes (between dirty and clean parts of the procedure).
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on observation, staff interview, facility document review and clinical record review, it was determined that the facility staff failed to implement interventions to prevent accidents and hazards for one of 55 residents in the survey sample; Resident #146.
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observation, staff interview, facility document review and clinical record review, the facility staff failed to provide respiratory care and services per the plan of care for one of 55 residents in the survey sample, Resident #82. For Resident #82 (R82), the facility staff failed to administer to oxygen at the physician prescribed rate of 3 liters per minute.
- D
Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care.
Inspectors wroteBased on staff interview, clinical record review and in the course of a complaint investigation, the facility staff failed to ensure the nurse practitioner and/or physician supervised the residents care for one of 55 residents in the survey sample, Resident #367. The covering nurse practitioner failed to address Resident #367's (R367) reported high white blood cell count (1) on 7/8/22 when reported by the laboratory.
- D
Provide and implement an infection prevention and control program.
Inspectors wrote2. For R107, the nurse providing wound care failed to follow infection control procedures related to washing/sanitizing hands between glove changes (between dirty and clean parts of the procedure). On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 8/5/22, R107 was coded as being in a persistent vegetative state. R107 was coded as having no pressure ulcers during the look back period. On 9/14/22 at 10:59 a.m., RN (registered nurse) #3 was observed as she provided wound care to R107. RN #3 removed the old dressing from the top of R107's right foot wound. RN#3 cleansed the wound with wound cleanser, and wiped the wound with dry gauze. RN #3 threw the soiled gauze in the trash can, removed her dirty gloves and put on a clean pair of gloves. [...]
- D
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Inspectors wroteBased on staff interview, facility document review and clinical record review, it was determined the facility staff failed to determine and document the pneumococcal vaccination status for two of five residents in the infection control review, Residents #128 and #218.
- D
Make sure that a working call system is available in each resident's bathroom and bathing area.
Inspectors wrote2. The facility staff failed to maintain a functioning call bell system for Resident #217 (R217). There was no MDS (minimum data set) assessment completed at the time of survey. The Admission/readmission Nursing Collection Tool dated 9/6/2022, documented in part, R217 was cognitively intact. During the resident interview on 9/13/2022 at approximately 11:30 a.m. R217 stated it takes a long time for the staff to answer the call bell. Observation was made of the call bell on 9/13/2022 at approximately 1:30 p.m. The call bell was turned on by one surveyor. The other surveyor observed that the call light outside the room did not turn on. An interview was conducted with LPN (licensed practical nurse) #8 on 9/13/2022 at 1:49 p.m. When asked if a resident's call bell is not working, how does the staff know when the need assistance, LPN #8 stated they make constant rounds. [...]
- C
Post nurse staffing information every day.
Inspectors wroteBased on observation and staff interview, it was determined that the facility staff failed to post daily nurse staffing information before the shift. On 09/13/2022 and 09/14/2022 the facility staff failed to post the nurse staffing prior to the beginning of the shift.
May 19, 2021Standard inspection · 8 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, staff interview and clinical record review, it was determined that facility staff failed to promote resident's dignity for three of 33 current residents in the survey sample, Resident's # 26, #141 and #108. The facility staff were observed standing while feeding Resident #26 and Resident #141. The facility staff failed to provide privacy for Resident # 108's catheter collection bag [1].
- 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, resident interview, staff interview, clinical record review and facility document review it was determined that the facility staff failed to implement the comprehensive care plan for the use of TED hose for one of 33 residents in the survey sample, Resident #42.
- D
Ensure services provided by the nursing facility meet professional standards of quality.
Inspectors wroteBased on observation, staff interview and clinical record review it was determined that the facility staff failed to follow professional standards of practice for one of nine residents in the medication administration observation, Resident #30. The facility staff failed to follow medication administration standards of practice during the administration of a Dulera Aerosol inhaler to Resident #30 on 5/17/2021.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on observation, resident interview, staff interview, clinical record review and facility document review it was determined that the facility staff failed to follow the physician's order for the use of TED hose for one of 33 residents in the survey sample, Resident #42.
- 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, staff interview, facility document review and clinical record review, it was determined that the facility staff failed to provide care and services for a catheter bag for one of 33 residents in the survey sample, Resident #142. Multiple observations of Resident #142 revealed the attached leg bag above the level of the nephrostomy (1) site it was connected to.
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observation, staff interview, clinical record review, and facility document review, it was determined that the facility staff failed to consistent with professional standards of practice, the comprehensive person-centered care plan for two of 33 residents in the survey sample, Residents #38 and #42. 1. The facility staff failed to maintain an Ambu bag [1] at Resident # 38's bed side according to physician's orders. 2. The facility staff failed to store a nebulizer (1) in a sanitary manner for Resident #42.
- D
Make sure that a working call system is available in each resident's bathroom and bathing area.
Inspectors wroteBased on observation, resident interview, staff interview and facility document review, it was determined that the facility staff failed to maintain a functional call system for two of 33 residents in the survey sample, Resident #46 and Resident #66. Resident #46 and Resident #66 shared a room with a broken call bell and had no alternate means to call staff when the call bell was not working.
- C
Dispose of garbage and refuse properly.
Inspectors wroteBased on observation, staff interview, and facility document review, it was determined that the facility staff failed to dispose of trash in a sanitary manner in one of three rolling linen carts positioned outside the kitchen door. The rolling linen cart was open to air, and contained standing water and several bags of trash. One of the bags contained soiled linens which were covered in green mold like appearing substance.
Fire safety inspections
11 fire safety citations on file: 5 on July 10, 2024, 4 on September 15, 2022, 2 on May 19, 2021.
Every fire safety citation11 citations
- D
Install emergency lighting that can last at least 1 1/2 hours.
K 291 · July 10, 2024 · Corrected (the home has a date of correction)
- D
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · July 10, 2024 · Corrected (the home has a date of correction)
- D
Inspect, test, and maintain automatic sprinkler systems.
K 353 · July 10, 2024 · Corrected (the home has a date of correction)
- D
Ensure that any exit in an area undergoing construction, repair, or improvements shall be inspected daily to ensure its ability to be used instantly in case of emergency.
K 791 · July 10, 2024 · Corrected (the home has a date of correction)
- D
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
K 914 · July 10, 2024 · Corrected (the home has a date of correction)
- E
Keep aisles, corridors, and exits free of obstruction in case of emergency.
K 211 · September 15, 2022 · Corrected (the home has a date of correction)
- E
Provide properly protected cooking facilities.
K 324 · September 15, 2022 · Corrected (the home has a date of correction)
- D
Inspect, test, and maintain automatic sprinkler systems.
K 353 · September 15, 2022 · Corrected (the home has a date of correction)
- D
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · September 15, 2022 · Corrected (the home has a date of correction)
- D
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
K 761 · May 19, 2021 · Corrected (the home has a date of correction)
- D
Have proper power supply for life support equipment.
K 915 · May 19, 2021 · Corrected (the home has a date of correction)