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 54 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
1G
0H
0I
Potential for more than minimal harm
33D
19E
0F
Potential for minimal harm
0A
0B
1C
January 7, 2026Complaint inspection · 3 citations
- E
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Inspectors wroteBased on resident interview, staff interview and facility document review, the facility staff failed to provide effective pest control on two of three nursing units (unit 2 and unit 3).
- D
Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made.
Inspectors wroteBased on staff interview, facility document review and clinical record review, the facility staff failed to provide written notice of a room change for one of eleven residents in the survey sample (Resident #3).
- 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, interviews, clinical record review and review of the facility's policy titled, Personal Property the facility staff failed to provide tracking of the resident's personal property for one of eleven residents in the survey sample (Resident #4). This failure contributed to the loss or theft of several articles of clothing belonging to the resident.
December 10, 2024Complaint inspection · 13 citations
- E
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wrote2a. For Resident #111 (R111), the facility staff failed to follow a physician's order regarding notification of the medical provider when the resident's blood sugar was below 70 and above 400. On 12/9/24, in the afternoon, a clinical record review was conducted of R111's chart. This review revealed that R111 had a physician order with the Humalog sliding scale insulin order that indicated to notify the MD [medical doctor] if the blood sugar was 70 or below, or greater than 400. According to the medication administration record, R111 had multiple instances of her blood sugar exceeding 400 and there was no indication that the doctor was made aware. On 12/1/24, at 4:30 p.m., the blood glucose level was 445. On 12/3/24, the resident's blood sugar readings were 459, 525, 408. On 12/6/24, the blood sugar was recorded as having been 500 and 435. On 12/7/24, the resident's blood sugar at 7:30 a. [...]
- E
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, the facility staff failed to properly store insulin on three out of five medication carts inspected.
- D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteBased on observation and staff interview, the facility staff failed to knock on the door of resident rooms prior to entering on one unit of three units.
- 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, staff interview, clinical record review, and facility documentation, the facility staff failed to review and revise the care plan for two resident's, Resident #103 (R103) and Resident #107 (R107), in a survey sample of 21 residents.
- D
Ensure services provided by the nursing facility meet professional standards of quality.
Inspectors wroteBased on observation, staff interview, resident interview, clinical record review, and facility documentation review, the facility staff failed to follow professional standards of care regarding medication administration for one resident, Resident #115 (R115) out of a survey of 21 residents.
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on resident interview, staff interview, clinical record review and facility documentation review, the facility staff failed to provide ADL (activities of daily living) care to one resident (Resident #102- R102) in a survey sample of 21 residents.
- D
Provide enough food/fluids to maintain a resident's health.
Inspectors wroteBased on observation, staff interview, clinical record review, and facility documentation review, the facility staff failed to provide a physician ordered therapeutic diet for one resident (Resident #108-R108) in a survey sample of 21 residents.
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observation, staff interview, resident interview, clinical record review, and facility documentation review, the facility staff failed to provide oxygen at the physician ordered rate for two residents, Resident #115 (R115) and Resident #117 (R117) out of a survey of 21 residents and failed to store the respiratory equipment to prevent contamination for one resident, R115 out of a survey of 21 residents.
- D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Inspectors wrote2. For resident #111 (R111), the hydrocortisone tablet was not available for administration as ordered by the doctor. On 12/9/24, a clinical record review was conducted. According to the physician order dated 8/21/24, that remained an active order. The order read, Hydrocortisone Tablet 10 MG, Give 1 tablet by mouth one time a day for adrenal insufficiency. According to the nursing progress notes, R111 was not given a dose on 12/3/24 and 12/4/24, because the medication was not available. On 12/3/24 at 10:09 p.m., the administration note read, on order, not in Omnicell, pharm notified pervious shift per nurse [sic]. The nursing note dated 12/4/24 at 12:12 p.m., read, Medication not given, contacted pharmacy and medication will be delivered this evening. NP notified, no new orders. Resident is aware. [...]
- D
Help the resident make transportation arrangements to and from radiology services.
Inspectors wroteBased on staff interview, clinical record review, and facility documentation review, the facility staff failed to assist one resident, Resident #121 (R121) out of a survey of 21 residents, with transportation arrangements to an appointment with radiology services.
- 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, resident interviews, staff interviews, and facility documentation review, the facility staff failed to follow the resident food preference for two residents, Resident #103 (R103) and Resident #106 (R106), in a survey sample of 21 residents.
- D
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, clinical record review and facility documentation review, the facility staff failed to maintain a complete and accurate clinical record for one resident (Resident #111- R111) in a survey sample of 21 residents.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on staff observation, staff interviews, and facility documentation the facility staff failed to follow infection control standards on one of three units.
October 2, 2024Standard inspection · 28 citations
- G
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on observation, resident interview, staff interview, clinical record review, and facility documentation review, the facility staff failed to provide interventions for the prevention and/or treatment of pressure ulcers for two residents (Resident #15- R15 and Resident #24-R24) in a survey sample of 29 residents. The facility staff also failed to identify a pressure ulcer until at an advanced stage (stage III) for one resident- R15, which was harm.
- 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 observation, resident interview, staff interview, clinical record review, and facility documentation review, the facility staff failed to review and revise the care plan for five residents (Resident #78, Resident #70, Resident #83, Resident #15, and Resident #106), in a survey sample of 29 residents.
- E
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on observation, staff interviews, resident interviews, clinical record review and facility documentation review the facility staff failed to provide activity of daily living (ADL) care for three residents (Resident #13 (R13), Resident #43 (R43) and Resident #56 (R56)) of 29 residents in the survey sample.
- E
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on observation, staff interview and clinical record review, the facility staff failed to follow physician orders for seven of twenty-nine residents in the survey sample (Residents #20, #24, #56, #70, #27, #76 and #78).
- E
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Inspectors wroteBased on resident interview, staff interview, clinical record review, and facility documentation review, the facility staff failed to ensure medications were available for administration for three residents (Resident #27-R27, resident #83-R83, and resident #76-R76), in a survey sample of 29 residents.
- E
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, the facility staff failed to properly store insulins on four out of five medication carts inspected.
- 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 documentation review, the facility staff failed to store food in accordance with professional standards for food safety in the main kitchen.
- E
Provide and implement an infection prevention and control program.
Inspectors wroteBased on resident interview, staff interviews, clinical record review, and facility documentation review, the facility staff failed to follow infection control practices for one resident (Resident #106- R106). The facility also failed to develop and implement an infection control program and failed to respond to a COVID outbreak in accordance with the guidance from the Centers for Disease Prevention and Control (CDC), which involved two staff (registered nurse #6 (RN #6) and certified nursing assistant #2 (CNA #2) but had the potential to affect numerous residents on 2 of 2 nursing units.
- E
Implement a program that monitors antibiotic use.
Inspectors wroteBased on staff interview, clinical record review, and facility documentation review, the facility staff failed to provide credible evidence of an antibiotic stewardship program, having the potential to affect residents on 3 of 3 units.
- E
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Inspectors wroteBased on resident interview, staff interview, clinical record review and facility documentation review, the facility staff failed to provide education and offer pneumonia immunizations, to 4 of 5 residents (resident #2-R2, Resident #24-R24, Resident #13-R13, and resident #70-R70) sampled for immunizations.
- E
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 resident interview, staff interview, clinical record review, and facility documentation review, the facility staff failed to provide education and offer COVID immunizations, to 3 of 5 residents (Resident #2-R2, Resident #24-R24, and Resident #13-R13) sampled for immunizations.
- E
Make sure that a working call system is available in each resident's bathroom and bathing area.
Inspectors wroteBased on observation, resident interviews, staff interviews and facility documentation review, the facility staff failed to have an alternate means for residents to communicate with staff after an extended call bell outage affecting residents on two of three nursing units.
- E
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Inspectors wroteBased on observation, resident interviews, staff interviews, and facility documentation review, the facility staff failed to maintain an effective pest control program ensure the facility is free of pests affecting 2 of 3 resident care units.
- D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteBased on observation, resident interview, and clinical record review, the facility staff failed to provide respect for privacy for one of twenty-nine residents in the survey sample (Resident #44).
- D
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Inspectors wroteBased on staff interview, facility documentation review and clinical record review, the facility staff failed to complete a SNF ABN (Skilled Nursing Facility Advance Beneficiary Notice) for 2 residents in a survey sample of 3 residents (Resident #316, Resident #317, Resident # 318) reviewed for Beneficiary Notifications.
- D
Keep residents' personal and medical records private and confidential.
Inspectors wroteBased on observations, staff interviews and resident interviews, the facility staff failed to uphold the resident's right to privacy with regards to mail and failed to provide timely mail delivery for residents on 3 of 3 units.
- 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 observation, resident interview, staff interview, and facility documentation review, the facility staff failed to maintain a homelike environment for two residents (resident #70-R70 and resident #78-R78) in a survey sample of 29 residents.
- D
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Inspectors wroteBased on staff interview, clinical record review, and facility documentation review, the facility staff failed to accurately complete a pre-admission screening and resident review (PASARR) to identify if a level II evaluation was warranted for one resident (resident #90-R90) in a survey sample of 29 residents.
- 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, and facility documentation review, the facility staff failed to develop a comprehensive care plan for one resident (resident #5- R5) in a survey sample of 29 residents.
- D
Ensure services provided by the nursing facility meet professional standards of quality.
Inspectors wroteBased on observation, resident interview, staff interview, facility document review and clinical record review, the facility staff failed to follow professional standards of care for three of twenty-nine residents in the survey sample (Residents #53, #68 and #166).
- D
Assist a resident in gaining access to vision and hearing services.
Inspectors wroteBased on observation, resident interview, staff interview, clinical record review and facility document review the facility staff failed to ensure that residents receive proper treatment and assistive devices to maintain vision abilities for one resident (Resident#43, R43) in a survey sample of 29 residents.
- D
Provide enough food/fluids to maintain a resident's health.
Inspectors wroteBased on observation, staff interview, resident interview, clinical record review and facility document review, the facility staff failed to offer a therapeutic diet for one resident (Resident #56, R56) out of a survey sample of 29 residents.
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wrote3. For resident #90- R90, the facility staff failed to maintain the nebulizer mask in a manner to prevent contamination to prevent infection. On [DATE] at 11:26 a.m., R90 was observed in his room having a nebulizer treatment being administered via a mask. The mask nor tubing were dated as to when they were last changed. On [DATE] at approximately 4:02 p.m., R90 was visited in his room. The nebulizer mask was observed open to air and not in a bag. On [DATE] at 3:03 p.m., R90 was again visited in the room. It was noted that the nebulizer mask was laying in the floor at the bedside. On [DATE] at 3:16 p.m., an interview was conducted with licensed practical nurse #4 (LPN #4). LPN #4 was asked about nebulizers and the storage of them. LPN #4 stated they are to be stored in a bag and are changed nightly and dated. [...]
- D
Help the resident make transportation arrangements to and from radiology services.
Inspectors wroteBased on staff interview, clinical record review, and facility documentation review, the facility staff failed to assist one resident, Resident #121 (R121) out of a survey of 21 residents, with transportation arrangements to an appointment with radiology services.
- D
Provide routine and 24-hour emergency dental care for each resident.
Inspectors wroteBased on observation, resident interview, staff interview, and clinical record review, the facility staff failed to arrange for routine dental services for one resident (resident #5-R5) in a survey sample of 29 residents.
- 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, resident interviews, staff interviews, and facility documentation review, the facility staff failed to follow the resident food preference for two residents, Resident #103 (R103) and Resident #106 (R106), in a survey sample of 21 residents.
- D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on observation, resident interviews, staff interviews, clinical record review and facility documentation review, the staff failed to maintain a complete and accurate clinical record for 3 residents (Resident #13, R13, Resident #78, R78, and Resident #53, R53) in a survey sample of 29 residents.
- D
Keep all essential equipment working safely.
Inspectors wroteBased on observation, resident interview, staff interview and facility documentation review, the facility staff failed to maintain resident beds in operating condition for one resident (Resident #78-R78) in a survey sample of 29 residents.
October 11, 2023Complaint inspection · 3 citations
- E
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on staff interview and clinical record review, the facility staff failed to follow physician orders for one of 6 residents in the survey sample: Resident # 4. Resident # 4 was ordered to have 3 showers a week, but received bed baths.
- 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 one of six residents in the survey sample (Resident #1).
- 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, clinical record review, and facility document review, the facility failed to ensure medications were stored correctly for one of 6 residents in the survey sample. Resident #5's (R5) inhaler medication was at the bedside. The Findings Include: Diagnoses for R5 included: Respiratory failure, dysphagia, and kidney disease. The most current MDS (minimum data set) was an admission assessment with an ARD (assessment reference date) of 10/5/23, in which Resident #5 was assessed with moderately cognitive impairment. On 10/10/23 at 10:30 AM, during an initial tour of the facility, R5 was observed laying in bed. During a conversation with R5, it was noted that an inhaler labeled Trelegy 100/62.5 mcg [micrograms] was sitting on the bed side table. When asked about the medication, R5 verbalized uncertainty why the medication was in the room. [...]
October 13, 2021Standard inspection · 3 citations
- E
Provide and implement an infection prevention and control program.
Inspectors wrote2. Resident #384 was admitted to the facility on [DATE] with the following diagnoses, including but not limited to: Acute chronic anemia, chronic kidney disease, heart failure and hypercalcemia. Due to her recent admission an MDS (minimum data set) had not been completed. A Nursing admission Assessment Comprehensive dated 10/11/2021 contained the following information under the cognitive section: .Short Term Memory of-seems/appears to recall after 5 minutes .Usually Understood-difficulty finding words or finishing thoughts .Unclear Speech-slurred mumbled words .Usually Understands-may miss some part/intent of message . Her admission nursing not dated 10/12/2021 at 2:56 a.m., described Resident #384 as alert with confusion. Initial tour of the third floor of the facility was conducted on 10/12/2021 beginning at approximately 10:30 a.m. At approximately 11:05 a.m. [...]
- 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, the facility failed to dispose of expired IV (intravenous) antibiotic medication which was available for administration, in one of four medication rooms, Unit 1.
- 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, staff interview, and facility policy review, facility staff failed to store and prepare food properly in the main kitchen.
January 16, 2019Standard 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, staff interview, and facility policy review, facility staff failed to prepare, store and serve food in a sanitary manner in the main kitchen. Facility staff failed to obtain initial food temperatures before plating food for resident consumption on the first floor and the cook failed to wear a cover over his beard while preparing and serving food. Two quart-size containers of V8 juice and two pint-size containers of cranberry juice were noted open and not dated in the refrigerator.
- 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 resident interview, staff interview and clinical record review, the facility staff failed to give advance notice of a care plan meeting for two of 22 residents in the survey sample. Residents #39 and #60 were not given advance notice of their most recent care plan meeting and stated they had not been invited to the meeting.
- 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 clinical record review and staff interviews, the facility failed to discontinue an order for PRN (as needed) psychotropic medication for one of 22 residents in the survey sample. Resident #43 had a physician's order for PRN (as needed) Lorazepam for more than 14 days without a stop date reflected.
- C
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 staff interview and clinical record review the facility staff failed to provide written notification of a hospital transfer for two of 22 residents in the survey sample: Residents # 80 and # 23. 1. The facility staff failed to provide written documentation to Resident # 80 of a transfer to the hospital. 2. The facility staff failed to provide written documentation to Resident # 23 of a transfer to the hospital.
Fire safety inspections
24 fire safety citations on file: 8 on October 2, 2024, 13 on October 13, 2021, 3 on January 16, 2019.
Every fire safety citation24 citations
- F
Provide large enough exits.
K 231 · October 2, 2024 · Corrected (the home has a date of correction)
- E
Meet fire sprinkler requirement for tall buildings.
K 400 · October 2, 2024 · Corrected (the home has a date of correction)
- E
Have a battery powered remote alarm panel in a location accessible by operating personnel.
K 916 · October 2, 2024 · Corrected (the home has a date of correction)
- D
Install emergency lighting that can last at least 1 1/2 hours.
K 291 · October 2, 2024 · Corrected (the home has a date of correction)
- D
Provide properly protected cooking facilities.
K 324 · October 2, 2024 · Corrected (the home has a date of correction)
- D
Inspect, test, and maintain automatic sprinkler systems.
K 353 · October 2, 2024 · Corrected (the home has a date of correction)
- D
Have simulated fire drills held at unexpected times.
K 712 · October 2, 2024 · Corrected (the home has a date of correction)
- D
Ensure electrical receptacles or cover plates have distinctive color or marking.
K 917 · October 2, 2024 · Corrected (the home has a date of correction)
- F
Install proper backup exit lighting.
K 281 · October 13, 2021 · Corrected (the home has a date of correction)
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · October 13, 2021 · Corrected (the home has a date of correction)
- F
Properly install and monitor supervisory attachments on automatic sprinkler systems.
K 352 · October 13, 2021 · Waiver
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · October 13, 2021 · Corrected (the home has a date of correction)
- F
Have properly installed electrical wiring and gas equipment.
K 511 · October 13, 2021 · Waiver
- F
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
K 521 · October 13, 2021 · Waiver
- F
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
K 914 · October 13, 2021 · Corrected (the home has a date of correction)
- E
Provide properly protected cooking facilities.
K 324 · October 13, 2021 · Waiver
- E
Install corridor and hallway doors that block smoke.
K 363 · October 13, 2021 · Corrected (the home has a date of correction)
- E
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
K 761 · October 13, 2021 · Corrected (the home has a date of correction)
- D
Have properly installed hallway dispensers for alcohol-based hand rub.
K 325 · October 13, 2021 · Corrected (the home has a date of correction)
- D
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · October 13, 2021 · Corrected (the home has a date of correction)
- D
Provide a written emergency evacuation plan.
K 711 · October 13, 2021 · Corrected (the home has a date of correction)
- F
Have corridors or aisles that are unobstructed and are at least 8 feet in width.
K 232 · January 16, 2019 · Corrected (the home has a date of correction)
- F
Have properly located and lighted "Exit" signs.
K 293 · January 16, 2019 · Corrected (the home has a date of correction)
- F
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
K 321 · January 16, 2019 · Corrected (the home has a date of correction)