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 29 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
3J
0K
0L
Actual harm
1G
0H
0I
Potential for more than minimal harm
4D
19E
2F
Potential for minimal harm
0A
0B
0C
May 22, 2025Standard inspection · 1 citation
- D
Ensure that residents are free from significant medication errors.
Inspectors wroteBased on observation of medication administration, interview, record review, facility document review, policy review, and the manufacturer's instructions, the facility failed to follow manufacturer's instructions during the administration of insulin for 1 (Resident #69) of 4 residents sampled for medication administration.
December 11, 2024Complaint inspection · 8 citations
- J
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Inspectors wroteBased on interviews and record review, the facility failed to ensure physical and psychosocial care interventions were implemented and modified to meet a resident ' s activities of daily living needs and failed to exhaust all available remedies as evidenced by the deterioration of a resident ' s physical status resulting in death for 1 (Resident #1) of 8 sampled residents. It was determined the facility's non-compliance with one or more requirements of participation had caused, or was likely to cause, serious injury, harm, impairment, or death to residents. The Immediate Jeopardy (IJ) was related to State Operations Manual, Appendix PP, 483.12 (Freedom from Abuse, Neglect, and Exploitation) at a scope and severity of J. [...]
- J
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteF686 J Based on interviews, record review, facility document review, facility policy review, it was determined that the facility failed to ensure care and services were provided to prevent new pressure ulcer development and promote healing of existing pressure ulcers including admission and ongoing wound care assessments, appropriate and alternative interventions, and resident understanding of consequences of refusal; specifically no surgical interventions under anesthesia were offered, no intravenous pain medication was offered, no anti-anxiety medication was offered, the Medical Director was not made aware of or involved in care, interventions, or resident education; [...]
- J
Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder.
Inspectors wroteBased on interview and record review, the facility failed to ensure a newly admitted resident, who continued to refuse activity of daily living (ADL) care and assistance, and assessment and treatment for pressure wounds, and all available remedies were provided to ensure the resident's mental and psychosocial health did not continue to deteriorate for 1 (Resident #1) of 8 residents reviewed for mental and psychosocial health, as evidenced by the failure to ensure a newly admitted resident's wounds were assessed, monitored, and treated to prevent death. It was determined the facility's non-compliance with one or more requirements of participation had caused, or was likely to cause, serious injury, harm, impairment, or death to residents. The Immediate Jeopardy (IJ) was related to State Operations Manual, Appendix PP, 483.40 (Behavioral Health) at a scope and severity of J. [...]
- G
Ensure each resident receives an accurate assessment.
Inspectors wroteBased on observations, interviews, and facility document review, it was determined that the facility failed to accurately identify resident verbal, physical, or other self-directed behavior symptoms as potential indicators of mental instability for 1 (Resident #1) of 1 resident reviewed for significant change assessment.
- 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, record review, facility document review, and facility policy review, it was determined that the facility failed to ensure sufficient staffing to meet residents' needs as evidenced by not following the facility assessment staffing guidelines for 74 of 87 shifts reviewed from 11/10/2024 day shift through 12/07/2024 night shift.
- E
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Inspectors wroteBased on observations, interviews, record review, facility document review, facility policy review, it was determined that the facility failed to maintain an account of all controlled substances for 1 (Medication Cart 300-Hall) of 5 medication carts reviewed for accounting of controlled substances; and maintain a record of controlled substances for 4 Residents on 2 medication carts (Resident #20, Resident #21, Resident #22, and Resident #23) of 5 medication carts reviewed for accurate records; and it was determined that the facility failed to ensure resident medications were administered within the specified time to ensure continued therapeutic status was maintained for 3 (Resident #26, # 27 and #28) of 3 residents who stated medications were not received.
- 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 observations, interviews and record reviews it was determined that the facility failed to keep medications safely secured for 1 medication cart of 1 medication cart reviewed for medication storage. A review of a facility policy titled, Medication Storage in the Facility, revised January 2018, indicated, Medications are stored safely and securely accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. Medication room, carts, and medication supplies are locked when not attended by persons with authorized access. During a concurrent observation and interview on 11/28/2024 at 6:13 AM, Registered Nurse (RN) #12 was seen passing medication at the end of 600-Hall. The medication cart was parked in the hallway outside suite 610. RN #12 took medication into room [ROOM NUMBER]-B. [...]
- E
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observations, interviews, and facility policy review, it was determined that the facility failed to ensure hand hygiene was performed during meal service for 1 dining room of 4 dining rooms observed during meal service. This failed practice had the potential to affect all residents receiving meals in the 100-hall dining room.
June 13, 2024Standard inspection, Complaint inspection · 11 citations
- 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 and interview, the facility failed to ensure expired food items were promptly removed from stock to prevent potential food borne illness for residents who received meal trays from 1 of 1 kitchen. These failed practices had the potential to affect 92 residents who received meals from the kitchen.
- E
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteBased on record review, observations, and interviews, the facility failed to ensure staff did not stand over residents while assisting with meal service to maintain and promote dignity for 1 (Resident #26) of 1 sampled resident.
- E
Keep residents' personal and medical records private and confidential.
Inspectors wroteBased on observation, record review, and interview the facility failed to ensure privacy was maintained for 2 (Resident #46, and #392) sampled residents due to personal health information left unattended in public areas.
- E
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on observation, record review, and interview the facility failed to ensure necessary services were provided in a timely manner to maintain good hygiene for 1 (Resident #21) sampled resident that was unable to carry out personal care without assistance.
- E
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on record review, observations, and interviews, the facility failed to ensure the residents environment was free from accidents and hazards to prevent possible ingestion and or injury for 2 (Resident #49 and #56) of 2 sampled residents; and failed to ensure chemicals and handheld razor blades were stored and contained properly; and failed to ensure a smoking assessment was obtained for 1 (Resident #295) of 1 sampled resident.
- E
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure controlled narcotics were properly documented when acquired from the pharmacy to prevent the risk of misappropriation, and to ensure a record of receipt and disposition was in place for Ativan oral concentrate in 1 of 2 medication rooms. This failed practice had the potential to affect 5 sampled Residents (Residents #12, #56, #73, #79, and #342) of 21 residents with a physician's order for Ativan.
- 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 record review, observations, and interviews, the facility failed to ensure medications were stored in accordance with state laws and accepted standards of pharmacy practice for 3 (Resident #49, #72, and #342) of 3 sampled residents; and the facility failed to ensure a narcotic box was double locked to prevent the possible misappropriation, ingestion and or injury.
- E
Provide and implement an infection prevention and control program.
Inspectors wroteBased on record review, observations, and interviews the facility failed to ensure hand hygiene/change gloves was performed to prevent the spread of disease and or infections during meal service for 1 (Resident #26) of 1 sampled residents; and failed to ensure hand hygiene was performed during medication administration for 2 (Resident #69 and #392) of 2 sampled residents; and failed to ensure hand hygiene / change gloves was performed and clean items were not contaminated during incontinent care for 2 (Resident #82 and #28) of 2 sampled residents.
- E
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Inspectors wroteBased on record review, observations, and interviews, the facility failed to maintain a safe and functional environment to prevent possible injury, as evidenced by failure to ensure a night light cover was provided for 2 (Resident #33 and #92) of 2 sampled residents; and failed to ensure the vinyl flooring was maintained on the 300 hall secure unit.
- D
PASARR screening for Mental disorders or Intellectual Disabilities
Inspectors wroteBased on interviews, record review, and facility document review, it was determined the facility failed to coordinate with the state designated office to get evaluation of resident to ensure resident received designated services for 1 (Resident #44) of 2 resident reviewed for Preadmission Screening and Resident Review (PASARR).
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observation, record review, and record review the facility failed to ensure that oxygen order included parameters for 1 of 1 Resident #12 receiving oxygen to prevent respiratory complications.
May 18, 2023Standard inspection · 9 citations
- E
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents sitting at the same table were assisted with meals to promote dignity and respect for 4 (Residents #12, #20, #62, and #80) residents. This failed practice had the potential to affect 6 residents who need assistance with meals as documented on a list provided by the Administrator on 5/18/2023 at 9:13 a.m.
- E
Allow residents to self-administer drugs if determined clinically appropriate.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were assessed to safely self-administer medications for 1 (Resident #58) of 32 sampled residents.
- 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, interview, and record review, the facility failed to ensure residents' individualized care plans were updated to ensure appropriate care was received for 3 (Residents #53, #54, and #58) of 32 sampled residents who had a new service or level of care ordered or provided.
- E
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure smokeless tobacco was contained and out of reach of cognitively impaired residents to prevent the potential accidental ingestion of hazards. This failed practice had the potential to affect 2 (Resident #53 and #54) cognitively impaired residents who ambulated by any means according to a list provided by the Director of Nursing (DON) on 5/18/2023 at 11:08 a.m.
- E
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents had an order for oxygen administration for 1 (Resident #58) resident; and failed to ensure residents received oxygen was administered at the physician prescribed rate for 1 (Resident #54) resident; and failed to ensure residents oxygen tubing was changed based on the physicians order for 1 (Resident #75) of 8 sampled residents: and the facility failed to ensure nebulizer masks were contained when not in use for 1 (Resident #54) of 7 sampled residents who had orders for updraft/nebulizer treatments according to a list provided by the Administrator on 5/18/2023 at 9:13 a.m. 1. Resident #54 had a diagnosis of Heart Failure, Alzheimer's Disease, and Respiratory Failure. [...]
- 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, interview, and record review, the facility failed to ensure 1 (Hall 100) of 5 medication carts was locked and failed to ensure medication was locked in a secure location for 1 (Resident #54). This practice had the potential to affect 1 (Resident #47) of 1 cognitively impaired residents who ambulate by any means as documented on a list provided by Director of Nursing (DON) on 5/18/2023 at 11:08 a.m.
- 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, record review and interview, the facility failed to ensure food items stored in the refrigerator, freezer and dry storage areas were sealed or covered and were stored in accordance with the manufacturer's instructions; staff washed their hands between dirty and clean tasks and before handling clean dishes or food items; ice machines were maintained in clean and sanitary condition; and cold food items were maintained at or below 41 degrees Fahrenheit (F). while awaiting service to prevent potential food borne illness for residents who received meals from 1 of1 kitchen. These failed practices had the potential to affect 105 residents who received meals from the 1 of 1 affected kitchen (total census:105), as documented on a list provided by the Administrator on 5/18/2023
- E
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff performed hand hygiene before, during, and after assisting residents with meals/meal trays for 4 of 4 (Resident #20, #40, #62, and #80) sampled residents observed during meal service and this failed practice had the potential to affect 104 residents as documented on the Resident Census and Conditions provided by the Director of Nursing (DON) on 5/14/2023 at 11:08 a.m.; and the facility failed to ensure staff performed hand hygiene before performing flushing an intravenous (IV) line for 2 of 2 (Resident #62 and #94) sampled residents with IV therapy; and the facility failed to ensure staff perform hand hygiene prior to performing/emptying a suprapubic foley catheter to prevent the spread of infection for 1 of 1(Resident #84) sampled residents with a catheter. [...]
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on observation, interviews and record review, the facility failed to provide Resident #78, who is unable to carry out Activities of Daily Living (ADL's) the necessary services to promote and maintain good grooming and personal hygiene. This had the potential to affect 8 sampled residents (R#84, R#25, R#20, R#7, R#47, R#53, R#80, and R#62) out of 19 Residents who were dependent on staff for ADL care. 1. Resident #78 had diagnoses of neurocognitive disorder with Lewy Bodies and Type 2 Diabetes Mellitus. A Minimum Data Set (MDS) with an annual review date (ARD) of February 14, 2023, had a Staff Assessment for Mental Status with extensive assistance with dressing and personal hygiene with 2-person support and assistance. a. On 05/14/23 at 12:14 PM, The Surveyor observed Resident #78 sitting in a recliner in the resident room. [...]
Fire safety inspections
7 fire safety citations on file: 2 on May 22, 2025, 4 on June 13, 2024, 1 on May 18, 2023.
Every fire safety citation7 citations
- F
Provide properly protected cooking facilities.
K 324 · May 22, 2025 · Corrected (the home has a date of correction)
- F
Install an approved automatic sprinkler system.
K 351 · May 22, 2025 · Corrected (the home has a date of correction)
- F
Conduct testing and exercise requirements.
E 39 · June 13, 2024 · Corrected (the home has a date of correction)
- F
Properly provide smoke detection systems in areas open to corridors.
K 347 · June 13, 2024 · Corrected (the home has a date of correction)
- F
Have properly sized and located compartments to protect residents from smoke.
K 371 · June 13, 2024 · Corrected (the home has a date of correction)
- F
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
K 761 · June 13, 2024 · Corrected (the home has a date of correction)
- E
Properly provide smoke detection systems in areas open to corridors.
K 347 · May 18, 2023 · Corrected (the home has a date of correction)