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 25 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
14D
8E
1F
Potential for minimal harm
0A
2B
0C
June 5, 2025Standard inspection, Complaint inspection · 9 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, interview, and record review the facility failed to ensure one of one ice machines was clean. This failure practice could be result in illnesses and infections.
- D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteBased on observations and interviews, the facility failed to ensure one of two sample selected residents (Resident 52) was treated with dignity, when Resident 52's urine bag was not covered by a privacy bag. This deficient practice had the potential to result in Resident 52 feeling embarrassed, humiliated, or disrespected, which can negatively impact Resident 52's mental and emotional well-being.
- 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 interviews and record reviews, the facility did not revise the care plan for two of two sample selected residents (Resident 19 and 52) with new diagnoses, when Residents 19, and 52 were diagnosed with depression and staff did not develop a care plan for depression. This failure in practice had the potential to result in inadequate care and support, potentially worsening their mental health condition, experiencing emotional distress, social withdrawal, and other negative health outcomes, and compromise to their overall well-being and quality of life.
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on observation, interview, and record review, the facility failed to provide necessary services to maintain good grooming to one of three sampled residents (Resident 50) when she did not receive nail care. This failure had the potential for development of skin injuries and infection for Resident 50. During a review of Resident 50's admission Record, undated, the admission Record indicated Resident 50 was admitted to the facility in March 2025 with diagnoses that included diabetes, dementia, and heart failure. [...]
- 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 ensure one of five sampled residents (Resident 181) was monitored for side effects of divalproex sodium (Depakote -a mood stabilizing medication) which was given to Resident 181 in error. This failure exposed Resident 181 to potentially serious adverse effects.
- D
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Inspectors wroteBased on interview and record review, the facility failed to ensure that one of five sampled residents (Resident 181) was not given unnecessary psychoactive (controls mood and behavior) medication when Resident 181 was given divalproex sodium (Depakote, a mood stabilizer) without appropriate indications for use. This failure resulted in Resident 181 receiving psychoactive medication without actual psychiatric diagnoses and unnecessarily exposed her to serious adverse side effects.
- D
Ensure that residents are free from significant medication errors.
Inspectors wroteBased on interview and record review, the facility failed to ensure one of five sampled residents (Resident 181) was free from significant medication error when Resident 181 was administered divalproex sodium (Depakote, a psychoactive medication that controls mood and behavior) in error 30 times. This failure resulted in Resident 181 to receive psychoactive medication in error. This failure also exposed Resident 181 to serious health complications and/or jeopardized her safety.
- 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, interview and record review, the facility failed to ensure proper labeling and storage of medication when the following was noted: 1. Two multi-dose insulin pens for Residents 228 and 40 had no open and beyond use date (BUD-the date after which a medication should not be used) label. 2. Thirteen expired nasal swabs were kept with ready to use medications in medication storage area. This failure had the potential to result in the Residents 228 and 40 receiving ineffective medication doses and Residents receiving abnormal nasal swab test results which could lead to more health issues.
- D
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Inspectors wroteBased on observation, interview, and record review, facility did not ensure sanitary and comfortable rooms for two of two sample selected residents (Resident 61 and 52), when Resident 61 and 52's rooms (Room numbers 36 and 38) were not clean with brown spots on various surfaces, and the floors were sticky and had food particles scattered around. This failure in practice could have potentially resulted an environment conducive to the growth of bacteria, mold, and other harmful microorganisms resulting in infections and other health issues for residents, and emotional distress and discomfort, leading to a decline in mental health and overall satisfaction with the facility.
April 9, 2024Complaint inspection · 2 citations
- D
Prepare residents for a safe transfer or discharge from the nursing home.
Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sample selected residents (Resident 1) had a safe and orderly discharge from the facility, when the facility discharged Resident 1 to home without preparation and orientation to the discharge and did not provide complete discharge medication for Resident 1. This failure resulted in Resident 1 suffering from pain and did not have pain medication as ordered by the physician (MD).
- D
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Inspectors wroteBased on interview and record review, the facility failed to provide care and services for hygiene and bathing for one of three sample selected residents (Resident 1) when Resident 1 did not receive a shower as scheduled by the facility. This failure resulted in Resident 1 being uncomfortable and complained about not receiving the services that she was supposed to receive from the facility.
November 30, 2023Standard inspection · 8 citations
- E
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observation, interview, and record review, the facility failed to provide respiratory care consistent with professional standards of practice for two of 31 sample selected residents (Residents 10 and 11), when: 1. Resident 11 did not receive the oxygen rate based on physician order. 2. Resident 10's oxygen tube was not replaced weekly and the oxygen's humidifier was not replaced when it was empty. These deficient practices had the potential to result in oxygen toxicity for Resident 11 and for Resident 10 to potentially develop respiratory complications.
- 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, interview, and record review, the facility failed to follow posted menu when: 1. On 11/28/23, during lunch meal: - Pot stickers were not served as a garnish according to the menu. - Salad plates were provided which was not on the menu. 2. Resident 47 and Resident 140 stated menu was not routinely followed as listed. These failures had the potential for served meals to not meet the nutritional needs of the residents who received food from the kitchen.
- E
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
Inspectors wroteBased on observation, interview, and record review, the facility failed to prepare pureed (cooked food that has been ground, pressed, and blended to a consistency of creamy paste) food designed to meet the needs of residents with a specialized diet. This failure had the potential to result in aspiration and choking (inhaling of food and drinks) of medically compromised residents who received pureed food from the kitchen.
- 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 store, prepare, and serve food under sanitary conditions when: 1. In the kitchen pantry, multiple opened gallon containers of liquid condiments did not have opened dates. 2. Freezer 1 contained three sealed boxes of meat stored without labels. 3. A dietary staff entered the kitchen without a hairnet. 4. Ice machine interior was unclean. 5. Ice Machine Room door was left open and accessible to unauthorized persons. 6. Resident Food Refrigerator inside Station 1 Medication Room was not cleaned routinely and freezer compartment at Station 1, had ice build-up. These failures had the potential to result in food contamination and resident foodborne illnesses.
- E
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for one (Resident 234) of 31 sample selected residents when Registered Nurse (RN) 1 did not follow infection control standards during wound care for Resident 234. This failure had the potential to result in wound complications and infection for Resident 234.
- 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 observation, interview and record review, the facility failed to ensure one of four sampled resident (Resident 70) on an antipsychotic (medication that treats several kinds of mental health conditions) was free from unnecessary drugs when the interdisciplinary team did not evaluate Resident 20's use of a PRN (as needed) for Seroquel's (antipsychotic) appropriateness, adequate clinical rational and indication for continued usage. This failure had the potential for Resident 70 to receive unnecessary drugs and suffer adverse medication side effects.
- B
Assure that each resident’s assessment is updated at least once every 3 months.
Inspectors wroteBased on interview and record review, the facility failed to ensure for one (Resident 14) of eight sampled residents, the quarterly minimum data set (MDS, a resident assessment instrument used to identify resident care problems to be addressed in an individualized care plan.) assessment was completed within the deadline determined by the assessment reference date (ARD, an endpoint for observation periods for MDS assessment data entry). This failure had the potential to delay Resident 14's individualized care.
- B
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Inspectors wroteBased on interview and record review, the facility failed to ensure for three (Residents 14, 67, 36) of eight sampled residents, the minimum data set (MDS, a resident assessment instrument used to identify resident care problems to be addressed in an individualized care plan.) assessments were submitted to the Centers for Medicare and Medicaid Services (CMS) within the deadlines determined by the assessment reference date (ARD, an endpoint for observation periods for MDS assessment data entry) when, 1. Resident 14's quarterly MDS assessment was not completed and transmitted, 2. Resident 67's discharge assessment was not completed and transmitted, and 3. Resident 36's discharge assessment was completed 26 calendar days past the ARD and not transmitted. [...]
November 4, 2021Standard inspection · 6 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 protect the right of privacy of confidential information for three of 28 sampled residents (Residents 73B, 50, 19) when personal care instructions were posted on the walls of the residents' shared rooms. These failures had the potential to result in emotional distress for Residents 19, 50, and 73B from public disclosure of personal information.
- 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 that food was stored, prepared, and served under sanitary conditions when: 1. Refrigerator 1 had multiple undated food items and repackaged food in plastic bags labeled with use-by dates more than three days in the future. 2. Refrigerator 2 had a cracked pasteurized egg left inside the refrigerator and an open carton of liquid whole eggs without an opened-on date. 3. Refrigerator 3 had a sealed bag of mixed green lettuce that had no label or use-by date. 4. Undated and unlabeled food items were stored in a large clear container. 5. The holder for the can opener in the kitchen work area was covered with brownish-yellow-colored sticky material around the can opener rest. These failures had the potential for residents to develop food-borne illness.
- E
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Clean the area around the enteral feeding pump (a pump used to deliver liquid nutrition directly into the stomach or intestines through a tube inserted into the nose, mouth, or a surgical opening directly into the gastrointestinal tract) for one (Resident 62) of 18 sampled residents. 2. Clean a resident walker stored in a common hallway. 3. Clean a bedside commode stored in a common hallway. These failures had the potential to result in infection and/or the spread of infection for Resident 62, and other residents and visitors in the facility.
- 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, interview, and record review, the facility failed to provide maintenance services to maintain a clean, orderly, and comfortable environment for two of 28 sampled residents (Resident 50 and Resident 19) when: 1. Resident 50's dresser had no top drawer. 2. Resident 19's floor had multiple scattered black scratches and dimples on the surface of the floor and next to the resident's bed were sticky, brown-colored spots on the floor. This failure had the potential to decrease the comfort and well-being of Resident 50 and Resident 19.
- D
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Inspectors wroteBased on interview and record review, the facility failed to act upon an irregularity identified by the Consultant Pharmacist (CP) during the monthly medication regimen review (MRR) for one of 28 sampled residents (Residents 50) when the facility delayed scheduling Resident 50's Abnormal Involuntary Movement Scale test (AIMS, a 12-item clinician rated scale of involuntary movements of various areas of the patient's body) for one month. This failure had the potential to result in Resident 50 having undiagnosed and untreated adverse side effects from prescribed medication use.
- D
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Inspectors wroteBased on observation, interview, and record review, the facility failed to offer and/or provide pneumococcal vaccine (a vaccination to prevent pneumonia, a lung infection which can cause difficulty breathing and death) to one (Resident 3) of five sampled residents. This failure had the potential for Resident 3 to develop and spread pneumonia.
Fire safety inspections
30 fire safety citations on file: 5 on June 5, 2025, 9 on November 30, 2023, 16 on November 4, 2021.
Every fire safety citation30 citations
- E
Ensure proper usage of power strips and extension cords.
K 920 · June 5, 2025 · Corrected (the home has a date of correction)
- D
Keep aisles, corridors, and exits free of obstruction in case of emergency.
K 211 · June 5, 2025 · Corrected (the home has a date of correction)
- D
Install corridor and hallway doors that block smoke.
K 363 · June 5, 2025 · Corrected (the home has a date of correction)
- D
Have proper medical gas storage and administration areas.
K 923 · June 5, 2025 · Corrected (the home has a date of correction)
- C
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · June 5, 2025 · Corrected (the home has a date of correction)
- E
Establish roles under a Waiver declared by secretary.
E 26 · November 30, 2023 · Corrected (the home has a date of correction)
- E
Provide family notifications of emergency plan.
E 35 · November 30, 2023 · Corrected (the home has a date of correction)
- E
Have properly located and lighted "Exit" signs.
K 293 · November 30, 2023 · Corrected (the home has a date of correction)
- E
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · November 30, 2023 · Corrected (the home has a date of correction)
- E
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · November 30, 2023 · Corrected (the home has a date of correction)
- E
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
K 521 · November 30, 2023 · Corrected (the home has a date of correction)
- E
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · November 30, 2023 · Corrected (the home has a date of correction)
- D
Inspect, test, and maintain automatic sprinkler systems.
K 353 · November 30, 2023 · Corrected (the home has a date of correction)
- C
List the names and contact information of those in the facility.
E 30 · November 30, 2023 · Corrected (the home has a date of correction)
- E
Develop and maintain an Emergency Preparedness Program (EP).
E 4 · November 4, 2021 · Corrected (the home has a date of correction)
- E
Implement emergency and standby power systems.
E 41 · November 4, 2021 · Corrected (the home has a date of correction)
- E
Keep aisles, corridors, and exits free of obstruction in case of emergency.
K 211 · November 4, 2021 · Corrected (the home has a date of correction)
- E
Have simulated fire drills held at unexpected times.
K 712 · November 4, 2021 · Corrected (the home has a date of correction)
- E
Ensure proper usage of power strips and extension cords.
K 920 · November 4, 2021 · Corrected (the home has a date of correction)
- D
Establish policies and procedures including evacuation.
E 20 · November 4, 2021 · Corrected (the home has a date of correction)
- D
Establish roles under a Waiver declared by secretary.
E 26 · November 4, 2021 · Corrected (the home has a date of correction)
- D
Provide emergency officials' contact information.
E 31 · November 4, 2021 · Corrected (the home has a date of correction)
- D
Provide family notifications of emergency plan.
E 35 · November 4, 2021 · Corrected (the home has a date of correction)
- D
Use approved construction type or materials.
K 161 · November 4, 2021 · Corrected (the home has a date of correction)
- D
Have properly located and lighted "Exit" signs.
K 293 · November 4, 2021 · Corrected (the home has a date of correction)
- D
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
K 321 · November 4, 2021 · Corrected (the home has a date of correction)
- D
Inspect, test, and maintain automatic sprinkler systems.
K 353 · November 4, 2021 · Corrected (the home has a date of correction)
- D
Install corridor and hallway doors that block smoke.
K 363 · November 4, 2021 · Corrected (the home has a date of correction)
- D
Have properly installed electrical wiring and gas equipment.
K 511 · November 4, 2021 · Corrected (the home has a date of correction)
- D
Have proper medical gas storage and administration areas.
K 923 · November 4, 2021 · Corrected (the home has a date of correction)