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 17 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
7D
5E
2F
Potential for minimal harm
0A
3B
0C
November 19, 2025Standard inspection, Complaint inspection · 5 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 observations and staff interviews, the facility failed to: label and date leftover food stored for use in 1 of 1 walk-in cooler and 1 of 1 walk-in freezer and discard food showing signs of spoilage or past its use-by date in the walk-in cooler; monitor dish machine temperatures; and maintain a clean kitchen ice machine. These practices had the potential to affect food served to residents.
- D
Reasonably accommodate the needs and preferences of each resident.
Inspectors wroteBased on record reviews, observations, staff and resident interviews, the facility failed to provide access to the call bell, telephone, and water cup to accommodate a visually impaired resident. This resulted in Resident #6 yelling for assistance or asking his roommate to turn on the call bell, missing phone calls, and prevented access to the water cup as he wanted. This was for 1 of 1 resident reviewed for accommodation of needs (Resident #6).
- 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 and staff interviews, the facility failed to provide a clean homelike environment when they failed to maintain a sink drain that leaked in 1 of 4 shared bathrooms used only by Resident #50.
- D
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
Inspectors wroteBased on observations, record review, and staff interviews, the facility failed to provide a pureed diet (a smooth, creamy consistency/ texture) to a resident on an ordered therapeutic diet. Resident #24 was observed eating a moist to minced (food that can be easily mashed with little pressure from metal dinner fork, not sticky, no larger than 4 millimeters) breakfast meal. This deficient practice affected 1 of 8 residents reviewed for food form (Resident #24).
- D
Provide special eating equipment and utensils for residents who need them and appropriate assistance.
Inspectors wroteBased on record reviews, resident and staff interviews, and observations, the facility failed to provide resident meals in bowls along with preferred foods as ordered, for 1 of 1 resident with visual impairment (Resident #6), which resulted in Resident #6 having difficulty feeding himself and missing preferred foods.
September 11, 2024Standard inspection · 3 citations
- 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, record reviews, staff, and resident interviews the facility failed to maintain resident areas and equipment in a safe and sanitary manner for 2 of 3 shower (Shower room [ROOM NUMBER] on the 200 hall, Shower room [ROOM NUMBER] on the 300 hall), clean wheelchairs for 4 of 7 Resident's wheelchairs (Resident #24, Resident #132, Resident # 64, and Resident #3), and repair a wall behind the bed (room [ROOM NUMBER] bed A) for 1 of 10 rooms reviewed for environmental concerns.
- D
Assess the resident when there is a significant change in condition
Inspectors wroteBased on staff interviews and record review the facility failed to complete a comprehensive significant change in status Minimum Data Set (MDS) assessment for 1 of 7 residents (Resident #11) reviewed for significant change in condition.
- D
Ensure services provided by the nursing facility meet professional standards of quality.
Inspectors wroteBased on observations, record review, and staff interviews, the facility failed to provide care according to professional standards when Unit Manager #1 failed to ensure Resident #50 swallowed her medications prior to leaving her room and was observed with a pill lying on her chest, and Resident #13 was observed to have a medicine cup with pills left unattended on her bedside table. The deficient practice occurred for 2 of 2 residents reviewed for professional standards (Resident #50 and Resident #13).
December 15, 2023Standard inspection, Complaint inspection · 9 citations
- F
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Inspectors wroteBased on record reviews and staff interviews, the facility failed to use the services of a Registered Nurse (RN) for 8 consecutive hours per day for 10 of 10 dates reviewed (7/8/23, 7/15/23, 7/22/23, 7/23/23, 8/20/23, 8/26/23, 8/27/23, 9/2/23, 9/3/23, and 9/9/23).
- E
Honor the resident's right to organize and participate in resident/family groups in the facility.
Inspectors wroteBased on record reviews, observations, resident and staff interviews, the facility failed to resolve repeat grievances related to dietary issues that were reported during the Resident Council meetings for 8 of 11 months reviewed (January 2023, February 2023, March 2023, April 2023, May 2023, September 2023, October 2023, and November 2023).
- E
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Inspectors wroteBased on a test tray observation, record review, and resident and staff interviews the facility failed to serve food warm that should be served warm to 1 of 4 halls (300 hall). This practice had the potential to impact other residents.
- 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 and staff interviews the facility failed to date and label opened food in 1 of 1 walk in cooler.
- E
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Inspectors wroteBased on observation, record review and staff interviews the facility's Quality Assessment and Assurance Committee failed to maintain implemented procedures and monitor interventions the committee had previously put into place following the 5/12/2022 recertification and complaint investigation survey. The deficiencies were in the areas of (F636) Comprehensive Assessments; (F638) Quarterly Assessments at least every three months; (F641) Accuracy of Assessments; and (F812) Food Procurement and Store, Prepare, and Serve Food in a Sanitary Manner. These deficiencies were subsequently recited on the current recertification and complaint survey on 12/15/23. The continued failure during two federal surveys showed a pattern of the facility's inability to sustain an effective Quality Assurance Program.
- 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, family and staff interviews the facility failed to notify the resident's responsible party (RP) of a change in roommate for 1 of 3 residents reviewed for notification of change (Resident #13).
- B
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Inspectors wroteBased on record reviews and staff interviews, the facility failed to complete 1 of 4 admission comprehensive Minimum Data Set (MDS) assessments within 14 days of an admission (Resident #233) and failed to complete comprehensive MDS assessments within 14 days of the Assessment Reference Date (ARD) [the last day of the assessment period] for 5 of 26 sampled residents (Resident #7, Resident #19, Resident #30, Resident #239, Resident #27).
- B
Assure that each resident’s assessment is updated at least once every 3 months.
Inspectors wroteBased on record reviews and staff interviews, the facility failed to complete quarterly Minimum Data Set (MDS) assessments within 14 days of the Assessment Reference Date (ARD) [the last day of the assessment period] for 6 of 21 sampled residents (Resident #30, Resident #6, Resident #7, Resident #19, Resident # 236, and Resident #50).
- B
Ensure each resident receives an accurate assessment.
Inspectors wroteBased on record reviews and staff interviews, the facility failed to accurately code Minimum Data Set (MDS) assessments for 3 of 26 sampled residents (Resident #30, Resident #6, and Resident #19).
Fire safety inspections
5 fire safety citations on file: 2 on September 11, 2024, 2 on December 15, 2023, 1 on May 12, 2022.
Every fire safety citation5 citations
- D
Install corridor and hallway doors that block smoke.
K 363 · September 11, 2024 · Corrected (the home has a date of correction)
- D
Have proper medical gas storage and administration areas.
K 923 · September 11, 2024 · 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 · December 15, 2023 · Corrected (the home has a date of correction)
- D
Meet requirements for the installation and maintenance of electrical systems.
K 911 · December 15, 2023 · Corrected (the home has a date of correction)
- D
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · May 12, 2022 · Corrected (the home has a date of correction)