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 38 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
27D
10E
1F
Potential for minimal harm
0A
0B
0C
July 10, 2025Standard inspection · 14 citations
- F
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wrote*Based on observations, interviews and record reviews, the facility failed to provide food that was prepared, stored and served in a sanitary manner in accordance with standards for food safety professionals.
- 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 observations and interviews, the facility failed to provide maintenance and housekeeping services and linens in a manner to provide a clean, sanitary and homelike environment.
- D
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Inspectors wroteBased on facility policy review, observation and interviews, the facility failed to file a grievance in a timely manner, for 1 of 1 sampled resident reviewed for grievances. As evidenced by failure of staff to respond to Resident #46's grievance regarding her missing blankets for almost 2 weeks.
- D
Ensure each resident receives an accurate assessment.
Inspectors wroteBased on record review and interview, the facility failed to ensure accurate Minimum Data Set (MDS) assessments for 1 of 5 sampled residents, Resident #39, related to antipsychotic use, and for 1 of 10 sampled residents, Resident #37, related to weights.
- 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 observations, interviews and record reviews, the facility failed to develop and implement a care plan to address Post Traumatic Stress Disorder (PTSD) for 1 of 1 sampled resident reviewed for Behavior, Resident #61; The facility failed to develop and implement a care plan for 1 of 5 sampled residents reviewed for unnecessary medications, Resident #63.
- 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 record review, the facility failed to update the care plan for 2 of 28 sampled residents, as evidenced by failure to ensure that the diet orders were care planned for Resident #50 and failure to ensure the antianxiety medication care plan for Resident #63 was updated.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on observations, record review, and interviews, the facility failed to ensure that 1 of 1 sampled resident reviewed for skin rash received further treatment as evidenced by Resident #35 remained symptomatic after the initial treatment for a skin rash.
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on observation, record review and interview, the facility failed to follow physician orders for treatment of a facility acquired pressure ulcer for 1 of 3 sampled residents reviewed for pressure ulcers, as evidenced by not changing the dressing, as ordered for Resident #13 pressure ulcer.
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on policy review, observation, record review, and interview, the facility failed to ensure care and services, and supervision to prevent falls, for 1 of 4 sampled residents, as evidenced by Resident #39 having had eight falls since 05/01/25, with six being from her chair. The three most recent falls occurred while Resident #39 was in her Broda chair, the newest of intervention as of 06/19/25. The facility also failed to ensure the provision of two neurology consults for increased involuntary movements related to Huntington's Disease, which was care planned as part of the resident's risk for falls.
- D
Provide enough food/fluids to maintain a resident's health.
Inspectors wroteBased on policy review, observation, interview, and record review, the facility failed to ensure the provision of foods to address nutritional concerns for 2 of 10 sampled residents, as evidenced by the failure to include fortified foods as ordered for Resident #37 and Resident #50 , and failure to provide ordered meals for Resident #63. All three sampled residents had weight loss concerns or were underweight.
- D
Ensure medication error rates are not 5 percent or greater.
Inspectors wroteBased on facility policy, observations, record review and interviews, the facility failed to ensure that it was free of medication errors for 3 of 7 sampled residents, as evidenced by a medication error rate of 15.6% with 32 opportunities due to failure to ensure that Resident #7 received medications ordered and was available for him, failure to ensure Resident #5 received medications that are prescribed to him, failure to notify the physician prior to holding blood pressure medications for Resident #27. The finding Included:The facility policy titled Medication Administration documented in part Policy Explanation and Compliance Guidelines 8. Obtain and record vital signs, when applicable or per physician orders. When applicable, hold medications for those vital signs outside the physician's prescribed parameters. 12. [...]
- D
Provide timely, quality laboratory services/tests to meet the needs of residents.
Inspectors wroteBased on record review and interview, the facility failed to obtain a laboratory test for 1 of 5 sampled residents reviewed for laboratory testing. (Resident #8).
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on policy review, observation, record review, and interview, the facility failed to ensure infection control practices for 3 of 30 sampled residents, as evidenced by the failure to abide by Transmission Based Precaution (TBP) guidelines, Enhanced Barrier Precaution (EBP guidelines, and failure to use Personal Protective Equipment (PPE) during direct care, for Resident #75, #288 and #71.
- D
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Inspectors wroteBased on observations and interview, the facility failed to have an effective pest control program.
January 28, 2025Complaint inspection · 1 citation
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on record review and interview, the nursing staff failed to follow prescribed parameters including blood sugar and blood pressure results for 2 of 4 sampled residents (Resident #1 and Resident #5).
July 8, 2024Complaint inspection · 2 citations
- D
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Inspectors wroteBased on record review and interview, the facility failed to coordinate medication administration times with dialysis services for 2 of 3 sampled residents reviewed (Residents #1 and #6). In addition, the facility failed to ensure the completion of dialysis communication records to validate continuity of care for Resident #1.
- D
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Inspectors wroteBased on policy review, record review and interview, the facility failed to ensure licensed nurses were able to demonstrate competency related to following physician's orders for medication administration and documentation for 1 of 3 sampled residents (Resident #1).
March 28, 2024Standard inspection, Complaint inspection · 13 citations
- E
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wrote4) A medication pass observation with a random resident, who asked to remain confidential, was made on 03/27/24. Upon entering the room, the surveyor introduced herself and explained she was observing the nurse. The resident stated, The nurses are great, but you need to check up on the CNAs (Certified Nursing Assistants). On 03/27/24 in the afternoon, when asked what was meant by check up on the CNAs, the random resident stated, Some are great, but some have such attitudes. They don't care. I treat them with respect and expect the same from them, but don't always get it. The resident stated, Some act as if they don't want to be here. I know it's a tough job, but it is their job. And they don't let us know they are the CNA for the shift. The resident explained that the nurses come around at the beginning of each shift and let them know they will be the nurse for the shift. [...]
- E
Honor the resident's right to organize and participate in resident/family groups in the facility.
Inspectors wroteBased on record review and interviews, the facility failed to consider the views of the resident council group and act promptly upon the grievances and recommendations of the group concerning issues of resident care and life in the facility for 9 of 9 sampled residents interviewed during the Resident Council meeting (Resident #47, #45, #8, #10, #58, #63, #33, #70, and #7). This failure has the potential to affect all residents in the facility, as the resident council represents all residents.
- 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 observations, interviews and record reviews, the facility failed to provide maintenance and housekeeping services to maintain a clean, comfortable and homelike environment on 3 of 4 units (100 Unit, 300 Unit and 400 Unit).
- E
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Inspectors wroteBased on observation, interview and record review, the facility failed to: 1) Ensure that all voiced grievances made by residents to staff are put in writing on a grievance form and submitted to the appropriate person for resolution for 9 of 9 resident council members interviewed; 2) Ensure all written grievances include the date the grievance was received, a summary statement of the resident's grievance, the steps taken to investigate the grievance, a summary of the pertinent findings or conclusions regarding the resident's concerns(s), a statement as to whether the grievance was confirmed or not confirmed, any corrective action taken or to be taken by the facility as a result of the grievance, and the date the written decision was issued for 9 of 9 resident council members interviewed; [...]
- E
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 reviews, the facility failed to store, prepare and serve foods in a sanitary manner, in accordance with professional standards for food safety.
- D
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Inspectors wroteBased on observation, interview, and record review, the facility failed to honor preferences for 3 of 8 sampled residents (Resident #159, #161 and #74). The facility failed to respond to a verbal request for side rails to assist with bed mobility for Resident #159. Shower preferences and schedules were not followed for Resident #161 and #74.
- 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 observations, interviews and record reviews, the facility failed to update care plans related to nutrition interventions for 1 of 29 sampled residents (Resident #60), and Hospice status for 1 of 29 sampled residents (Resident #43).
- D
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 thoroughly investigate a fall for 1 of 2 sampled residents (Resident #13) reviewed for falls.
- 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, record review, interview, and policy review, the facility failed to ensure indwelling catheter bags remained off the floor for 3 of 4 sampled residents (Resident #61, #83, and #50); and failed to ensure staff documented the monitoring of input and output of fluids, as per physician orders, for 1 of 4 sampled residents (Resident #50).
- D
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure proper care and services for a peripheral intravenous (IV) line for 1 of 1 sampled resident (Resident #61).
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on policy review, observation, interview and record review, the facility failed to conduct respiratory assessment with nebulizer treatment per facility policy for 1 of 1 sampled resident reviewed for respiratory concerns (Resident #29)
- D
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Inspectors wroteBased on record review and interview, the facility failed to ensure proper monitoring of blood sugars as evidenced by the failure to notify the physician of blood sugar levels greater than 250, as per physician order, for 1 of 5 sampled residents (Resident #13).
- 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 record review and interviews, the facility failed to honor resident's food preference for 1 of 10 sampled residents reviewed for food concerns (Resident #25).
December 15, 2022Standard inspection · 8 citations
- E
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wrote4) Review of the record revealed Resident #32 was admitted to the facility on [DATE]. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #32 had a Brief Interview for Mental Status (BIMS) score of 15, on a 0 to 15 scale, indicating he was cognitively intact. This MDS also revealed Resident #32 needed extensive to total assistance of one to two persons for all Activities of Daily Living (ADLs). During an interview on 12/13/22 at 11:33 AM, Resident #32 was asked about the food at the facility and explained he had been asking for cold cereal for breakfast and the nurses said it's too far away (for them to get it). During this continued interview at 11:38 AM, when asked if he was treated with respect and dignity, Resident #32 stated, The CNAs (Certified Nursing Assistants) are lazy. [...]
- 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 facility policy, interview, and observation, the facility failed to provide hot water for showers for 3 Residents (#82, #84 and #52); failed to maintain resident room doors for 3 Residents (#71, #19, and #52); and failed to ensure a clean and comfortable environment on 3 of 4 resident units (unit 200, unit 300 and unit 400).
- E
Ensure each resident receives an accurate assessment.
Inspectors wroteBased on record review and interview, the facility failed to ensure accuracy of the MDS assessment for 3 of 5 sampled residents. This concern involved Resident #98, #21, and #52.
- E
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on facility policy, observation, interview, and record review, the facility failed to provide quality of care for 6 of 29 sampled residents reviewed. The facility failed to investigate conflicting medication orders on admission for Resident #92, failed to obtain stool for occult blood for Resident #82, failed to obtain consults in a timely manner for Resident #84 and #20, failed to maintain and utilize an indwelling blood sugar monitoring device as ordered for Resident #71, and failed to ensure diabetic ulcer wound care for Resident #93.
- D
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Inspectors wroteBased on record review and interview the facility failed to notify the family of a significant change of 1 of 1 sampled residents, Resident #75.
- D
Provide activities to meet all resident's needs.
Inspectors wroteBased on observation, record review and interview, the facility failed to ensure activities were provided, failed to ensure an accurate activity care plan was completed, which the resident's may have benefited from one-on-one activities for 2 of 2 sampled residents reviewed for activities (Resident #55 and Resident #75).
- D
Provide appropriate foot care.
Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure the provision of podiatry services for 1 of 2 sampled residents (Resident #52).
- D
Provide enough food/fluids to maintain a resident's health.
Inspectors wroteBased on interview and record review, the facility failed to ensure nutritional service (supplements and weight monitoring), as ordered by the physician and as recommended by the Registered Dietitian for 2 of 5 sampled residents reviewed. This involved Resident #97 and #16.
Fire safety inspections
4 fire safety citations on file: 1 on July 10, 2025, 1 on June 11, 2025, 2 on March 28, 2024.
Every fire safety citation4 citations
- D
Ensure proper usage of power strips and extension cords.
K 920 · July 10, 2025 · 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 · June 11, 2025 · Corrected (the home has a date of correction)
- D
Provide properly protected cooking facilities.
K 324 · March 28, 2024 · Corrected (the home has a date of correction)
- D
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
K 354 · March 28, 2024 · Corrected (the home has a date of correction)