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 26 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
2G
0H
0I
Potential for more than minimal harm
15D
3E
6F
Potential for minimal harm
0A
0B
0C
June 23, 2025Standard inspection · 5 citations
- G
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteTHIS IS AN INCIDENCE OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on medical record review, review of facility incident report and investigative documents, resident and staff interview, and facility policy review, the facility failed to ensure a resident was safely transferred by a mechanical lift. This resulted in Actual Harm on 01/30/25 when staff attempted to transfer Resident #16 from the bed to his wheelchair with the mechanical lift and due to poor staff transferring techniques, Resident #16 was dropped to the floor. Resident #16 was sent to the hospital and returned to the facility with the following injuries: [...]
- D
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
Inspectors wroteBased on interview, record review, and review of facility policy, the facility failed to provide proper behavior monitoring and documented discussion of the need for psychotropic's and causes of anxiety. This affected two residents (#10 and #11) of five residents reviewed for unnecessary medications. The facility census was 31.
- D
Ensure each resident receives an accurate assessment.
Inspectors wrote3. Review of the medical record for Resident #54 revealed an admission date of 04/16/25 with no cognitive deficits. Diagnoses included aftercare following surgery on the digestive system, malignant neoplasm colon, and intestinal obstruction, unspecified as to partial versus complete obstruction. Resident #54 discharged from the facility to home on on 04/25/25. Review of Resident #54's Minimum Data Set, dated [DATE] indicated Resident #54 was transferred to the hospital. After surveyor intervention it was modified on 06/17/25 to indicate Resident #54 was discharged home. Interview on 6/17/25 at 10:14 A.M. with the Director of Nursing (DON) confirmed a corrected MDS for Resident #54 was submitted after surveyor intervention on 06/17/25 indicating Resident #54 was not discharged to the hospital as previously recorded, but was discharged home. [...]
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on record review and interview the facility failed to ensure dressing changes were completed as ordered by the physician. This affected one (Resident #22) out of two residents reviewed for pressure ulcers. The facility census was 31.
- D
Provide safe, appropriate pain management for a resident who requires such services.
Inspectors wroteBased on medical record review and staff interview, the facility failed to provide parameters for as needed pain medication. This affected one (Resident #16) of five residents reviewed for unnecessary medications. The census was 31. Findings Include: Resident #16 was admitted to the facility on [DATE]. His diagnoses included but were not limited to osteoporosis, spastic hemiplegia, morbid obesity, Type II diabetes, pneumonia, spinal stenosis, coronary atherosclerosis, chronic embolism and thrombosis, chronic kidney disease, cerebral infarction, mood disorder, peripheral vascular disease, anemia, nicotine dependence, acute kidney failure, epilepsy, insomnia, hyperlipidemia, and anxiety disorder. Review of his Minimum Data Set (MDS) assessment, dated 02/06/25, revealed he was cognitively intact and dependent on staff for transfers. [...]
April 9, 2024Complaint inspection · 1 citation
- D
Provide safe, appropriate pain management for a resident who requires such services.
Inspectors wroteBased on record review, review of the facility policy, and physician and staff interview, the facility failed to monitor the effectiveness of the pain interventions for a resident per the resident's plan of care and professional standards of practice. This affected one (Resident #35) of three residents reviewed for pain management. The facility census was 33.
July 24, 2023Standard inspection · 18 citations
- G
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteThe following deficiency represents an incident of past non-compliance that was subsequently corrected prior to this survey. Based on medical record review, staff interview, review of the fall investigation and witness statements, review of the hospital records, and review of the manufacturer recommendations for use, the facility failed to ensure a resident was safely transferred by a mechanical lift. This resulted in Actual Harm on 03/28/23 when Resident #07 was transferred from the bed to the wheelchair with the mechanical lift when the straps to the lift pad tore and Resident #07 dropped to the floor approximately two to three feet. Resident #07 complained of coccyx and buttock pain. Subsequently, Resident #07 was sent to the local hospital where he was diagnosed with a sacral fracture. This affected one resident (#07) of one resident reviewed for accident hazards. [...]
- F
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Inspectors wroteBased on observation, interview, review of the tray line temperature log, and policy review, the facility failed to serve foods at the appropriate temperature. This had the potential to affect all residents who ate food in the facility. The census was 34.
- F
Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.
Inspectors wroteBased on observation, resident and staff interviews, review of the meal times, and policy review, the facility failed to ensure meals were provided timely. This affected all 34 residents who ate meals in the facility. The facility census was 34.
- 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, interview, and policy review, the facility failed to store and serve food in a sanitary manner to prevent potential contamination. This had the potential to affect all 34 residents who eat in the facility.
- F
Provide and implement an infection prevention and control program.
Inspectors wroteBased on resident record review, observation, staff interviews, review of the infection control logs, and policy review, the facility failed to ensure infection control logs were completed for tracking trends and patterns. This had the potential to affect all 34 residents who reside in the facility. In addition, the facility failed to follow proper infection control policies and procedures during catheter care. This affected one resident (#24) of one resident reviewed for catheter care. The facility census was 34.
- F
Implement a program that monitors antibiotic use.
Inspectors wroteBased on record reviews, staff interview, and policy review, the facility failed to monitor antibiotic use appropriately as part of an antibiotic stewardship plan. This had the potential to affect all 34 residents. The facility census was 34. Findings Include: Review of documents dated April, May, and June 2023, provided by the Director of Nursing (DON), revealed there was no documentation and analysis of appropriate indications for the use of antibiotics. Interview on 07/20/23 at 2:45 P.M. with the DON confirmed the facility used McGreer's criteria for the antibiotic stewardship program. The DON had no evidence how the facility was monitoring antibiotic medications using the McGreer criteria. The DON verified there was no documentation of an antibiotic stewardship program. [...]
- E
Respond appropriately to all alleged violations.
Inspectors wroteBased on medical record review, staff interview, review of the self reported incidents, and policy review, the facility failed to ensure resident abuse, neglect and misappropriation allegations were thoroughly investigated. This affected four residents (#138, #142, #141, and #143) of six residents reviewed for abuse. The facility census was 34.
- E
Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs.
Inspectors wroteBased on observation, staff interview and menu review, the facility failed to ensure diets met the needs of residents. This had the potential to affect four residents (#07, #10, #13, and #22) who received a mechanically altered diet in the facility. The facility census was 34.
- E
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 observation, staff interview and menu review, the facility failed to follow the menu. This affected four residents (#07, #10, #13, and #22) out of four residents on a mechanical altered diet. The facility census was 34.
- D
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Inspectors wroteBased on medical record review, review of the beneficiary notices, staff interview, review of the State Operations Manual, and policy review, the facility failed to ensure residents were provided appropriate beneficiary notices when Medicare part A services were reduced or discontinued and the residents remained in the facility. This affected two residents (#24 and #30) out of three residents reviewed for beneficiary notices. The facility census was 34. Findings Include: 1. Review of the medical record for Resident #24 revealed an admission date on 01/10/23. Diagnoses included type II diabetes, Parkinson's, dementia, muscle weakness, and a history of falling. Review of Resident #24's census revealed the resident had a Medicare part A payer source from 01/10/23 until 03/13/23. Effective 03/13/23, Resident #24 changed to a private pay payer source and remained in the facility. [...]
- D
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Inspectors wroteBased on record review, staff interview and facility document review, the facility failed to notify the ombudsmen of a resident's discharge from the facility. This affected two residents (#05 and #27) out of two residents reviewed for hospitalization. The facility census was 34.
- D
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Inspectors wroteBased on medical record review, staff interview, and facility document review, the facility failed to provide a bed hold notice to resident or resident representative. This affected one resident (#27) of three residents reviewed for hospitalizations. The facility census was 34.
- 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 medical record review, staff interview, and policy review, the facility failed to develop comprehensive care plans for resident specific care needs. This affected three residents (#13, #08, and #20) out of thirteen residents reviewed for comprehensive care plans. The facility census was 34.
- D
Provide enough food/fluids to maintain a resident's health.
Inspectors wroteBased on medical record review, staff interview, and policy review, the facility failed to ensure residents fluid intake was adequate to meet their nutritional needs. This affected one resident (#13) out of two residents reviewed for nutritional support. The facility census was 34.
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on medical record review, observation, staff interview, and policy review, the facility failed to ensure residents oxygen tubing and humidifiers were labeled and dated. This affected three residents (#08, #20 and #148) out of three residents reviewed for respiratory services. The facility identified eight residents (#04, #06, #08, #11, #14, #20, #21, and #148) who were receiving oxygen. The facility census was 34.
- D
Provide safe, appropriate pain management for a resident who requires such services.
Inspectors wroteBased on medical record review, resident and staff interview, and policy review, the facility failed to ensure the physician was updated on residents uncontrolled pain. This affected one resident (#13) out of three residents reviewed for pain management. The facility census was 34.
- D
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Inspectors wroteBased on medical record review, review of the hospital continuity of care form, review of a pharmacy faxed correspondence, and interview, the facility failed to properly monitor a resident on antibiotics and prescribe medications as ordered. This affected one resident (#20) of two residents reviewed for antibiotic use. This had the potential to affect five residents (#09, #10, #13, #20, and #244) who were receiving antibiotics in the facility. The facility census was 34.
- D
Ensure medication error rates are not 5 percent or greater.
Inspectors wroteBased on medical record review, staff interview, observation, and policy review, the facility failed to ensure resident medications were administered with less than five percent error rate. There were two medication errors out of 25 opportunities for error with a calculated error rate of eight percent. This affected two residents (#11 and #17) out of four residents observed during medication administration. The facility census was 34.
March 5, 2020Standard inspection · 2 citations
- F
Provide and implement an infection prevention and control program.
Inspectors wroteBased on staff interview, review of facility policy and procedures, the facility failed to implement their Water Management Plan to reduce the risk, growth and spread of the Legionella Disease. This had the potential to affect all 45 residents of the facility.
- D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wrote2. Medical record review revealed Resident #43 was admitted to the facility 09/07/16 with diagnoses including dementia without behavioral disturbance. Review of the MDS assessment dated [DATE] revealed the resident had severe cognitive impairment. Observations on 03/02/20 at 10:16 A.M., on 03/03/20 at 8:37 A.M., and on 03/04/20 at 8:38 A.M. revealed Resident #43 in her wheelchair in the dining room. Her wheelchair had two strips of pink tape and one strip of blue tape with her first initial of her first name, and full last name taped to the back of her chair. Interview on 03/04/20 at 11:35 A.M. with State Tested Nursing Assistant (STNA) #211 confirmed Resident #43 had two strips of pink duct tape and one strip of blue painter's tape with her first initial of her first name, and full last name on her wheelchair. [...]
Fire safety inspections
15 fire safety citations on file: 2 on June 23, 2025, 6 on July 24, 2023, 7 on March 5, 2020.
Every fire safety citation15 citations
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · June 23, 2025 · 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 23, 2025 · Corrected (the home has a date of correction)
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · July 24, 2023 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · July 24, 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 · July 24, 2023 · Corrected (the home has a date of correction)
- F
Have simulated fire drills held at unexpected times.
K 712 · July 24, 2023 · Corrected (the home has a date of correction)
- F
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
K 761 · July 24, 2023 · Corrected (the home has a date of correction)
- E
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · July 24, 2023 · Corrected (the home has a date of correction)
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · March 5, 2020 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · March 5, 2020 · Corrected (the home has a date of correction)
- F
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
K 761 · March 5, 2020 · Corrected (the home has a date of correction)
- F
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · March 5, 2020 · Corrected (the home has a date of correction)
- E
Have exits that are accessible at all times.
K 271 · March 5, 2020 · Corrected (the home has a date of correction)
- E
Install a fire alarm system that can be heard throughout the facility.
K 341 · March 5, 2020 · Corrected (the home has a date of correction)
- E
Have proper medical gas storage and administration areas.
K 923 · March 5, 2020 · Corrected (the home has a date of correction)