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 31 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
16D
7E
4F
Potential for minimal harm
0A
4B
0C
November 19, 2025Complaint inspection · 1 citation
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on record review, and staff interviews the facility failed to conduct a comprehensive nursing assessment and neurological assessments after a Nurse Aide (Nurse Aide #3) reported a newly identified injury on a residents (Resident #1) face to the nurse on duty (Nurse #5) following an unwitnessed injury that resulted in facial bruising around the right eye and above the right eye on the forehead. A nurse did not complete a comprehensive assessment of the resident until a few hours after the initial discovery of the facial bruising and the resident was observed to have bruising to the right shoulder, right lateral knee (outer side), left knee and left toe. A reddened area was also observed to the left neck area. This occurred for 1 of 1 resident reviewed for accidents (Resident #1).
May 1, 2025Standard inspection, Complaint inspection · 5 citations
- 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, staff interviews, Medical Director (MD), and Physician Assistant (PA) interviews, the facility failed to notify the provider of significant weight gain greater than 5-pound discrepancy from the last weight for a resident with Congestive Heart Failure (CHF) and on diuretic medication (a medication that helps the body remove excess fluid) when the resident's weight indicated a 27 pound weight gain in one week. This deficient practice occurred for 1 of 1 sampled resident reviewed for notification of change. (Resident #108)
- D
Ensure services provided by the nursing facility meet professional standards of quality.
Inspectors wroteBased on record review, staff interviews, Medical Director (MD), and Physician Assistant (PA) interviews, the facility failed to determine the accuracy of a weekly weight for a resident with Congestive Heart Failure (CHF) and on diuretic medication (a medication that helps the body remove excess fluid) when the resident's weight indicated a 27 pound weight gain in one week for 1 of 4 residents reviewed for nutrition. (Resident #108)
- D
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 review and staff interviews, the facility failed to provide 8 hours of Registered Nurse (RN) coverage for 1 of 419 days reviewed for staffing (08/11/24).
- D
Provide timely, quality laboratory services/tests to meet the needs of residents.
Inspectors wroteBased on record review, staff, the Nurse Practitioner, and Physician interviews the facility failed to obtain an ordered Pro BNP (pro-B-type natriuretic peptide) a blood test that measures the levels of Pro BNP, a protein produced by the heart and used to help diagnose and monitor heart failure. This occurred for 1 of 1 resident (Resident #23) reviewed for laboratory services.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, record review, and staff interviews, the facility failed to implement infection control policies and procedures when Nurse Aide #1 failed to apply all the required Personal Protective Equipment (PPE) before entering a room with a resident on special contact-droplet precautions. This occurred for 1 of 1 staff observed for infection control practices (Nurse Aide #1).
March 7, 2024Standard inspection · 7 citations
- E
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Inspectors wroteBased on observations, record review, and resident and staff interviews the facility failed to administer medications on time as prescribed by the physician for 1 of 1 residents reviewed. (Resident #7)
- E
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Inspectors wroteBased on observations, record review, staff, and Physician interviews the facility failed to clarify a medication order prescribed for hypotension (low blood pressure) to include hold parameters if the systolic blood pressure was greater than 120 mm/hg ( millimeters of mercury). This resulted in a resident (Resident #61) receiving 59 additional doses of the medication. There was no significant outcome from receiving the medication. This occurred for 1 of 3 residents reviewed for medication administration.
- E
Ensure that residents are free from significant medication errors.
Inspectors wroteBased on observation, record review, staff, Nurse Practitioner, and Physician interviews the facility failed to follow the physicians order and provide sliding scale insulin at bedtime to a resident (Resident #18) when the blood glucose reading was greater than 200 mg/dl (milligrams per deciliter). This resulted in the resident not receiving a total of 74 units of insulin from 01/12/24 through 03/04/24. There was no significant outcome. This occurred for 1 of 3 residents reviewed for medication administration.
- E
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Inspectors wroteBased on observations, record review and staff interviews the facility's Quality Assurance and Performance Improvement (QAPI) committee failed to maintain implemented procedures and monitor the interventions that the committee put into place following the recertification and complaint survey of [DATE] and the recertification and complaint survey of [DATE]. This was for one deficiency that was originally cited in [DATE] in the area of significant medication errors and for two deficiencies originally cited in [DATE] for medication storage and unnecessary medications. These deficiencies were subsequently recited on the current recertification survey of [DATE]. The continued failure during three federal surveys of record shows a pattern of the facility's inability to sustain an effective Quality Assurance Program.
- D
Assist a resident in gaining access to vision and hearing services.
Inspectors wroteBased on record review, observation, and resident, staff and physician interviews, the facility failed to obtain an appointment with a retinol specialist for treatment of visual impairment for 1 of 1 residents (Resident #9) reviewed for vision.
- 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 observations, record review, and staff interviews the facility failed to record an opened date on two insulin pens and on two opened bottles of eye drops that had shortened expiration dates. This was observed on 1 of 3 medication carts (300 hall medication cart) reviewed for medication storage.
- B
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Inspectors wroteBased on record review and staff interview the facility failed to complete comprehensive assessments within the 14-day required timeframe for 2 of 2 residents reviewed for comprehensive Minimum Data Set (MDS) assessments (Resident #290 and Resident #291).
November 21, 2022Standard inspection · 18 citations
- F
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 observations, record review, resident interview and staff interviews, the facility failed to follow the prepared menu for 3 out of 4 meals observed when food items were substituted or omitted, but not noted or updated on the menu in advance time.
- 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 discard leftover food stored ready for use past the use dates and failed to label, date, and seal a leftover food item stored in 1 of 1 walk-in refrigerator. These practices had the potential to affect food served to residents.
- F
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Inspectors wroteBased on observations, record review and staff interviews the facility's Quality Assurance and Performance Improvement (QAPI) committee failed to maintain implemented procedures and monitor the interventions that the committee put into place following the recertification and complaint investigation survey on 07/30/21 and the recertification survey on 01/09/20. This was for two deficiencies that were originally cited in July 2021 in the areas of infection control and competent nursing staff and for one deficiency originally cited in January 2020 for food procurement, storage, and sanitation and were subsequently recited on the current recertification survey of 11/21/22. The continued failure during three federal surveys of record shows a pattern of the facility's inability to sustain an effective Quality Assurance Program.
- F
Keep all essential equipment working safely.
Inspectors wroteBased on observations, record review and staff interviews, the facility failed to make repairs to the flat griddle for greater than 2 months which caused residents to not receive a planned meal since it was inoperable for 1 of 1 flat griddles. This affected all residents who expected grilled items according to the planned menu.
- E
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 observations, record review, staff interviews, and physician interview the facility failed to identify that a resident (Resident #66) was prescribed and administered an antibiotic that was resistant to the organism based on laboratory test results for 1 of 4 residents reviewed for urinary tract infections; failed to initiate physician orders for a continuous indwelling urinary catheter to include the size of the catheter and orders to maintain and care for the catheter; and failed to cleanse the perineal area and catheter site in a manner to prevent contamination for 1 of 3 residents (Resident #9) observed for urinary catheters.
- 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, record review and staff and resident interviews, the facility failed to: accurately label and record an opened date for a bottle of tuberculin solution in the Station #1 medication room refrigerator and a bottle of Influenza vaccine in the 400 hall medication room. The facility failed to accurately record an opened dated for a bottle of eye drops, dispose of 2 expired bottles of nitroglycerin and an expired insulin pen on the 300 hall medication cart. The facility failed to dispose of an expired bottle of nasal spray, discard an expired Insulin pen, and accurately record an opened date for 2 Insulin pens on the 100/200 hall medication cart. The facility failed to lock and secure a medication cart (100/200 hall medication cart) in an unattended resident care area for 1 of 5 medication carts observed. [...]
- E
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observations, record review and staff interviews, the facility failed to: 1a) demonstrate how to clean and disinfect a glucometer device per manufacturer's instructions after use for 2 of 2 nurses (Nurse #4 and Nurse #5) observed during medication pass; 1b) perform hand hygiene prior to donning and after removal of gloves when performing a blood glucose check for 1 of 1 nurse (Nurse #4) observed; 2) perform hand hygiene after removing soiled gloves and prior to donning clean gloves during a wound care observation for 1 of 3 residents (Resident #34) reviewed for infection control practices; and 3) dispose soiled linens in a bag during catheter care for 1 of 3 residents (Resident #9) observed for catheters.
- 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, physician interview, pharmacist interview, and staff interviews, the facility failed to notify the physician that a resident who had a urinary tract infection (UTI) was prescribed a medication that was reported by the laboratory as resistant for 1 of 4 residents reviewed for UTIs (Resident #66).
- D
Ensure each resident receives an accurate assessment.
Inspectors wroteBased on observation, record review, and esident and staff interviews, the facility failed to code the Minimum Data Set (MDS) assessment accurately in the areas of vision and hearing (Resident #32), nutrition (Resident #67), falls (Resident #75), and medications (Resident #84) for 4 of 29 residents reviewed for MDS assessments.
- D
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Inspectors wroteBased on observation, record review, resident and staff interviews the facility failed to apply a left-hand splint for contracture management according to occupational therapy recommendations for 1 of 1 resident (Resident #24) reviewed for limited range of motion.
- D
Provide enough food/fluids to maintain a resident's health.
Inspectors wroteBased on observations, record review and staff interviews the facility failed to obtain a weight upon admission and physician ordered weekly weights on 1 of 2 residents (Resident #82) reviewed for nutrition.
- 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 record review, observation, resident interview, and staff interviews, the facility failed to provide an agency Nurse Aide (NA #1) with education and to verify their competency to deliver catheter care for 1 of 3 residents (Resident #9) observed for catheter care.
- 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 record review, physician interview and Consultant Pharmacist #1 interview, the Consultant Pharmacist failed to identify that a resident (Resident #66) was prescribed and administered an antibiotic that was resistant to the organism based on laboratory test results for 1 of 4 residents reviewed for urinary tract infections.
- D
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Inspectors wroteBased on record review, physician interview, staff interviews, and pharmacist interview, the facility administered a medication to a resident that was not medically justified for 1 of 5 residents reviewed for unnecessary medications, Resident #66.
- 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 observation, record review, resident and staff interviews the facility failed to honor food preferences for 2 of 29 residents (Resident #24, and #7) reviewed for meal preferences.
- B
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Inspectors wroteBased on record review and staff interviews, the facility failed to implement baseline care plans for admitted diagnoses of : 1)Gastrointestinal Bleed (GI Bleed) and anemia (low red blood cell count); and 2) dementia, mood disorder, and atrial fibrilliation (irregular heart rhythm)within 48 hours of admission for 2 of 29 residents (Resident #82 and Resident #75).
- B
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 record review and staff interviews the facility failed to develop and implement a comprehensive person-centered care plan that addressed measurable goals and interventions to reflect the needs of the residents which were identified in the Minimum Data Set (MDS) assessment within 21 days of admission for 2 of 29 residents (Resident #82 and Resident #46) reviewed for care planning.
- B
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 and staff interviews the facility failed to revise a care plan to address: 1a) a facility acquired pressure ulcer (Resident #9), 1b) the insertion of an indwelling urinary catheter (Resident #9), and 2) incontinence care and toileting (Resident #67) for 2 of 29 residents reviewed for care plans.
Fire safety inspections
8 fire safety citations on file: 3 on May 1, 2025, 3 on March 7, 2024, 2 on November 21, 2022.
Every fire safety citation8 citations
- D
Inspect, test, and maintain automatic sprinkler systems.
K 353 · May 1, 2025 · Corrected (the home has a date of correction)
- D
Properly select, install, inspect, or maintain portable fire extinguishes.
K 355 · May 1, 2025 · Corrected (the home has a date of correction)
- D
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
K 914 · May 1, 2025 · Corrected (the home has a date of correction)
- F
Have a battery powered remote alarm panel in a location accessible by operating personnel.
K 916 · March 7, 2024 · Corrected (the home has a date of correction)
- D
Meet other general requirements.
K 200 · March 7, 2024 · Corrected (the home has a date of correction)
- D
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · March 7, 2024 · Corrected (the home has a date of correction)
- D
Use approved construction type or materials.
K 161 · November 21, 2022 · Corrected (the home has a date of correction)
- D
Have simulated fire drills held at unexpected times.
K 712 · November 21, 2022 · Corrected (the home has a date of correction)