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 14 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
10D
4E
0F
Potential for minimal harm
0A
0B
0C
June 20, 2025Standard inspection · 5 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 food safety and practices were maintained in the kitchen according to standards of practice and policy when food items were not labeled and dated. These failures had the potential to expose the residents to contaminated food and unsanitary practices and place them at risk of developing foodborne illness.
- D
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Inspectors wroteBased on interview and record review, the facility failed to offer a bedhold (the practice of reserving a resident's bed when they are hospitalized ) for one of three sampled residents (Resident 17). This failure had the potential for Resident 17 to not receive continuity of care. According to the admission Record, Resident 17 was admitted to the facility on [DATE] with diagnoses which included severe asthma (a condition in which the airways become narrow, making it difficult to breathe), and immune deficiency disorder (a disorder which affects the body's ability to fight infections). The admission Record indicated Resident 17 was transferred to acute care (short-term care for severe injuries, illnesses or other urgent medical conditions) on 3/22/25. [...]
- 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 implement its policy on specimen collection for one of two sampled residents (Resident 69) when Resident 69 was instructed to provide a sputum specimen. As a result, staff did not follow-up on what to do with the specimen. This failure resulted in the resident feeling bothered and not cared for when the sputum specimen was left at his bedside and not picked up by staff who instructed him to provide the sputum specimen.
- 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 interview and record review, the facility failed to provide appropriate care and services for one of two sampled residents (Resident 72) when Resident 72 had a delay in straight urinary catheterization (SUC -tube to drain the bladder). This failure had the potential to result in discomfort and/or health complications for Resident 72.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview and record review the facility failed to implement infection control procedures when visitors were not educated regarding the need to wear Personal Protective Equipment (PPE-gown, gloves, masks) or hand hygiene. This failure had the potential for the spread of infection to other residents in the facility.
May 24, 2024Standard inspection · 5 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 food was stored and served in accordance with professional standards for food safety when: 1. Spoiled food was stored amongst non-spoiled food inside the walk-in refrigerators; Food was stored without being covered in the refrigeration units; Food was not consistently labeled and dated; The cool-down process (a time sensitive procedure to chill cooked food to a safe temperature range) was not initiated for two trays of cooked chicken. 2. Three dietary aids (DA 1, DA 2, and DA 3) with long facial hair were not wearing beard guards in the kitchen and during food service; One DA (DA 1) used contaminated gloves to touch ready-to-eat food. These failures had the potential for residents consume contaminated and/or hazardous food which put them at risk for foodborne illnesses.
- E
Implement a program that monitors antibiotic use.
Inspectors wroteBased on interview and record review, the facility failed to implement an Antibiotic Stewardship Program to monitor antibiotic use. This failure had the potential to increase the risk of adverse events from unnecessary or inappropriate antibiotic use.
- D
Provide safe, appropriate pain management for a resident who requires such services.
Inspectors wroteBased on interview and record review the facility failed to ensure 1 of 8 residents (74) was reassessed after pain medications were administered. As a result, the resident's pain may not have been relieved.
- D
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Inspectors wroteBased on interview and record review, the facility failed to ensure two of five residents (5, 124) were appropriately offered the pneumococcal vaccine and had the education regarding benefits and potential side effects of pneumococcal vaccine explained to them and documented in the medical record. In addition, the facility's infection prevention nurse (IPN) 1 did not have a process to readily identify the residents' vaccination status. As a result of this deficient practice, the facility missed opportunities to ensure pneumococcal vaccines had been offered to all residents which put residents at potential risk of contracting pneumonia.
- D
Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
Inspectors wroteBased on interview and record review, the facility failed to ensure two of five residents (122, 11) were offered/re-offered the COVID-19 vaccination and had documentation that education regarding the vaccine had been provided. In addition, the facility's infection prevention nurse (IPN) 1 did not have a process to readily identify the residents' vaccination status. As a result of this deficient practice, the facility did not provide all residents the opportunity to accept or change their decision to accept a COVID-19 vaccine which put residents at potential risk of contracting COVID-19.
May 18, 2023Standard inspection · 4 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 the kitchen staff consistently documented accurate final rinse temperature of the dishwashing machine. As a result, there was a potential the final rinse temperatures were not in the required range.
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a physician's order for oxygen therapy was in place before administration for one of three sampled residents (Resident 113) with respiratory issues. As a result, there was a potential Resident 113 did not receive the correct amount of oxygen.
- 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 consistently monitor specific target behaviors and adverse side effects for the use psychotropic medications for two of three residents (3, 8) selected for unnecessary medication review. As a result, the residents were at increased risk for receiving unnecessary medication. 1. Resident 3 was admitted to the facility on [DATE] with diagnoses that included left humerus (arm) fracture, per the resident's demographic sheet. On 5/17/23, Resident 3's clinical record reviewed. A physician's progress note, dated 4/28/23, indicated Resident 3 also had diagnoses that included bipolar disorder and adjustment disorder. According to the physician's orders, on 2/1/23 Resident 3 was prescribed quetiapine (antipsychotic) 150 mg at bedtime for bipolar disorder. [...]
- D
Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.
Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the kitchen staff were knowledgeable of the proper chemical sanitation range values. As a result, there was a potential for spread of food-borne illness.
Fire safety inspections
4 fire safety citations on file: 1 on June 20, 2025, 2 on May 24, 2024, 1 on May 18, 2023.
Every fire safety citation4 citations
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · June 20, 2025 · Corrected (the home has a date of correction)
- D
Inspect, test, and maintain automatic sprinkler systems.
K 353 · May 24, 2024 · Corrected (the home has a date of correction)
- D
Ensure proper usage of power strips and extension cords.
K 920 · May 24, 2024 · Corrected (the home has a date of correction)
- D
Provide a written emergency evacuation plan.
K 711 · May 18, 2023 · Corrected (the home has a date of correction)