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
29D
1E
2F
Potential for minimal harm
0A
0B
0C
June 11, 2025Standard inspection · 13 citations
- F
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure sufficient qualified nursing staff were always available to provide nursing and related services to meet the residents' needs safely and in a manner that promotes each resident's rights, physical, mental, and psychosocial well-being.
- F
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wrote). During an observation of the mechanical ware washing machine, as part of the initial kitchen tour, it was noted that the water temperature of the rinse cycle did not reach the 160 degrees necessary for hot water sanitizing, and that there was an accumulation of residue on the spray arms and nozzles inside of the ware washing machine. At the time of the observation, the Food Service Director acknowledged the concerns and stated that the machine will default automatically to chemical sanitizer when hot water sanitizing was not working appropriately. 4). During an observation of lunch being served to the residents in the Dining Room, on 06/08/25 at 1:04 PM, the following were noted a. Saff K, Restorative Aide, was observed pouring coffee into the basin of the only hand washing sink in the Dining Room. [...]
- 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 review of policy and procedure, observation and interview, the facility failed to provide liners for sharps containers for 2 out of 4 wings in the facility.
- D
Reasonably accommodate the needs and preferences of each resident.
Inspectors wroteBased on policy review, observation, interview and record review, the facility failed to ensure the call light was in reach for 1 of 33 sampled residents (Resident #463).
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on policy review, interviews, observation and record review, the facility failed to follow treatment and services for heel pressure ulcers for 1 of 2 sampled residents (Resident #463) reviewed for not offloading heels as a preventative pressure ulcer measure.
- 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 review of policy and procedure, observation, interview and record review, the facility failed to properly secure catheter for 1 of 1 sampled resident observed during Foley Catheter care, Resident #82.
- D
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Inspectors wroteBased on interviews, and record review, the facility failed to monitor the dialysis (Central Venous Catheter) CVC access site for 1 of 1 sampled resident reviewed for dialysis (Resident #35).
- 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, interviews and record review, the facility failed to ensure controlled substance medication reconciliation was accurate for 4 of 9 sampled residents (Resident #70, #115, #147 and #47) and failed to obtain a physician order for a controlled medication for 1 of 9 sampled residents (Resident #70) reviewed during the controlled drugs record review.
- D
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Inspectors wroteBased on observations, interviews, and record review, the facility failed to monitor the behaviors of residents on psychotropic medication for 2 of 5 sampled residents reviewed for unnecessary medications (Resident #134 and Resident #173).
- D
Ensure that residents are free from significant medication errors.
Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure it was free of significant medication errors for 1 of 5 sampled residents reviewed for medications (Resident #69).
- 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 review of policy the facility's and procedures, observation and interview, the facility failed to 1) ensure that it secured the Wound Care treatment cart for 1 of 5 sampled Wound Care carts observed, East wing Wound Care cart; 2) ensure that it secured the Medication Administration Cart for 1 of 9 sampled Medication Administration carts observed, Medication cart A East wing; 3) secure medication in 1 of 8 medication carts observed, medication cart A, on the Center wing; and 4) failed to properly label medication for general population use for 1 of 9 medication carts, during a Medication Storage Observation (medication cart 2 of the East wing.
- D
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
Inspectors wrote2). Resident #13 was admitted to the facility on [DATE]. According to the resident's most recent complete assessment, a Quarterly MDS, with a reference date of 05/08/25, Resident #13 had a BIMS score of 06, indicating a severe cognitive impairment. The assessment documented that the resident required partial/moderate assistance for eating. Resident #13's diagnoses at the time of the assessment included: Anemia, Hypertension, Renal insufficiency, Alzheimer's disease, Non-Alzheimer's dementia, Malnutrition, Depression, Chronic lung disease, Respiratory failure, Muscle wasting and atrophy, Immunodeficiency, Osteoarthritis, SOB, (Shortness of Breath), Dysphagia, Cognitive communication deficit. Resident #13's care plan for nutrition documented: Care plan for nutrition: [...]
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observations, interviews and record reviews, the facility failed to follow the Center for Disease Control and Prevention (CDC) guidelines for infection control standards on residents for Enhanced Barrier Precautions (EBP) for 1 of 37 residents for EBP (Resident #37) and failed to properly clean the nebulizing equipment after a resident's treatment (Resident #132). The facility also failed to properly dispose of glucose strip containers used on an EBP resident and failed to follow their own policy for blood glucose monitoring for 1 of 37 sampled residents (Resident #37).
October 1, 2024Complaint inspection · 1 citation
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on review of policy and procedure, observation, interview and record review, the facility failed to follow physician's orders to administer Insulin medications to a Diabetic resident; and failed to check and document a Diabetic resident's Blood Sugar Level (BSL). This affected 1 of 2 sampled residents reviewed, Resident #1.
March 7, 2024Standard inspection · 7 citations
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on record review, observation and interview, the facility failed to provide ADL (activities of daily living) care and services for showers for 1 of 2 sampled residents reviewed for ADL's (Resident #47), and fingernail grooming for 1 of 2 sampled residents reviewed for ADL's (Resident #116) .
- D
Provide activities to meet all resident's needs.
Inspectors wroteBased on observation, interview, and record review, the facility failed to provide an ongoing activities program for 1 of 2 sampled residents reviewed for activities (Resident #140).
- 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, interview and record review, the facility failed to obtain urine specimen as ordered for 1 of 12 sampled residents with indwelling urinary catheters (Resident #321).
- D
Ensure that the resident and his/her doctor meet face-to-face at all required visits.
Inspectors wroteBased on interview and record review the facility failed to ensure physician visits were performed as required for 2 of 2 sampled residents reviewed for physician visits (Resident #29 and #81).
- D
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Inspectors wroteBased on observations, interviews, and record review, the facility failed to follow their own menu planning national guidelines, which has the potential to affect 41 residents on a regular diet, and failed to provide food that accommodates resident allergies, intolerances, and preferences: for 3 of 48 residents on East Unit during in-room dining observations (Resident #115, Resident #95, and Resident #370).
- D
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on observations, interviews, and record review, the facility failed to maintain the appropriate food temperatures in the reach-in refrigerators and walk-in freezer and ensure kitchen equipment was in proper working order during 1 of 3 observations/visits in the main kitchen.
- D
Provide or get specialized rehabilitative services as required for a resident.
Inspectors wroteBased on observation, interview and record review, the facility failed to provide rehabilitative (rehab) services to prevent decline in activities of daily living for 1 of 2 sampled residents reviewed for rehab services (Residents #140).
September 22, 2022Standard 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 observations, interviews, and record review, the facility failed to treat residents in a dignified manner for 3 out of 34 sampled residents (Resident #34, #72, #456).
- D
Reasonably accommodate the needs and preferences of each resident.
Inspectors wroteBased on observations, interviews, and record review, the facility failed to provide showers as preferred by resident for 4 out of 34 sampled residents (Resident #29, #456, #62, and #58).
- 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 observations and interviews, the facility failed to maintain a safe, clean, and comfortable homelike environment throughout the facility, which also specifically included Resident #34 and #456.
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on observations, interviews, and record reviews the facility failed to ensure proper nail care for 7 of 34 sampled residents (Resident # 131, 143, 420, 411, 29, 15, 108).
- D
Provide appropriate foot care.
Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to ensure that Resident #146 and Resident #115 received proper follow-up treatment and care to maintain good foot health for 2 of 2 sampled residents observed for Activities of Daily Living (ADLs), Resident #106 and #115.
- D
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Inspectors wroteBased on observation, interview, and record review, the facility failed to adjust the tube feeding regimen to meet a resident's caloric and protein needs, failed to follow the tube feeding order, and failed to prevent the development of a new pressure ulcer for 1 of 1 sampled resident (Resident #30) reviewed for tube feedings.
- D
Post nurse staffing information every day.
Inspectors wroteBased on observation, interview, record review and review of policy and procedure, it was determined that the facility failed to ensure that it visibly posted and correctly dated the Nurse Staffing Information form, for 2 of 4 days during the current Recertification survey.
- 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, record review and review of policy and procedure, it was determined that the facility failed to 1) ensure that it kept its Wound Care Treatment Cart locked and secured during wound care for 3 of 3 sampled residents observed, Resident #102, Resident #73 and Resident #154, and for 1 of 4 Treatment Carts observed, East wing Treatment cart; and 2) facility failed to ensure that it secured medications at the bedside for 1 of 34 sampled residents during an observational tour, Resident #109.
- D
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Inspectors wroteBased on observations, interviews, and record reviews the facility failed to ensure resident's received proper meal preferences for 2 of 2 sampled residents (Resident #417, and #408). Both residents had complaints that their meal choices were not being followed; one of the two residents was routinely served meals she could not eat due to celiac disease and lactose intolerance.
- D
Ensure each resident receives and the facility provides drinks consistent with resident needs and preferences and sufficient to maintain resident hydration.
Inspectors wroteBased on observation, staff interview and record review, the facility failed to provide appropriate beverages to a resident who was prescribed by the Physician to have nectar-thickened consistency liquids for 1 out of 1 sampled residents (Resident #140).
- D
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 interviews, and record review, the facility failed to keep food safety requirements with storage, preparation, and distribution that is by professional standards for food service safety, including holding cold foods at regulatory temperature, failure to adequately cover facial hair, foods not dated and labeled, and failure wear a hairnet in the food production area.
Fire safety inspections
9 fire safety citations on file: 4 on June 11, 2025, 3 on March 7, 2024, 2 on September 22, 2022.
Every fire safety citation9 citations
- D
Provide properly protected cooking facilities.
K 324 · June 11, 2025 · Corrected (the home has a date of correction)
- D
Ensure electrical receptacles or cover plates have distinctive color or marking.
K 917 · June 11, 2025 · Corrected (the home has a date of correction)
- D
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · June 11, 2025 · Corrected (the home has a date of correction)
- D
Ensure proper usage of power strips and extension cords.
K 920 · June 11, 2025 · Corrected (the home has a date of correction)
- D
Provide properly protected cooking facilities.
K 324 · March 7, 2024 · Corrected (the home has a date of correction)
- D
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · March 7, 2024 · 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 · March 7, 2024 · Corrected (the home has a date of correction)
- D
Inspect, test, and maintain automatic sprinkler systems.
K 353 · September 22, 2022 · 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 · September 22, 2022 · Corrected (the home has a date of correction)