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 51 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
1J
0K
0L
Actual harm
3G
0H
0I
Potential for more than minimal harm
35D
8E
0F
Potential for minimal harm
0A
3B
1C
November 24, 2025Complaint inspection · 2 citations
- D
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 maintain dignity for 1 of 3 sampled residents, as evidenced by sending Resident #2, who was severely cognitively impaired, to a physician's appointment wearing two hospital gowns. He was left unattended for 45 minutes in the main waiting area of the physician's office, where 42 people entered during that time.
- 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 coordinate care to ensure 2 of 3 sampled cognitively impaired residents, were appropriately accompanied and or able to be seen at scheduled appointments. Resident #2 had a scheduled new patient cardiology appointment and the facility failed to inform the resident representative of the appointment, failed to ensure needed pre-authorization as per his insurance, failed to send the resident appropriately clothed to ensure comfort, and failed to accompany the resident to the appointment. Resident #4, who was also cognitively impaired, was sent unaccompanied to a medical appointment at the Veteran Affairs (VA) Medical Center.
April 4, 2025Standard inspection, Complaint inspection · 14 citations
- E
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteBased on interview and record review, the facility failed to ensure residents were treated with dignity during activities of daily living (ADLs) care and failed to provide care upon request for 7 of 33 residents reviewed for dignity (Residents #254, 251, 256, 55, 83, 250, and # 23).
- 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 and interviews the facility failed to follow their policy for loss of hot water and ensure sufficient hot water was available to the residents in their rooms and showers for 8 of 34 sampled residents (Residents #29, #27, #13, #301, #302, #303, #68, #23).
- E
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 observation, interview and record review, the facility failed to ensure sufficient staffing to provide timely and appropriate care and services as evidenced by verbal complaints from residents, family, and staff, which resulted in dignity concerns, the lack of call light response, wound care and activity of daily living (ADLs) care concerns. This concerned multiple residents, including Residents #256, #250, #72, #10, #23, #254, #11, #46, #62, #29, #27, #55, #73, #68, #45, #75, #83, #23, #251, #10, #50, and #85.
- E
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to provide food that was palatable and at acceptable food temperatures for 9 residents (Residents #75, #83, #23, #251, #10, #29, #50, #27, and #85) out of 10 residents investigated for food concerns. This had the potential to affect 111 out of 112 residents on PO (by mouth) diets.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on record review and interview, the facility failed to ensure care and services for 5 of 34 sampled residents, as evidenced by the failure to implement the bowel program for Resident #44, failure to follow blood pressure parameters for Resident #10 and #23, failure to ensure the provision of a urology appointment for Resident #62, and failure to notify the physician of blood sugar levels as per physician order for Resident #303.
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on interviews, record review, and policy review, the facility failed to ensure supervision and staff training for 1 of 4 sampled residents (Resident #19), reviewed for falls.
- D
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to follow the physician's order for the administration of enteral feeding for 1 of 2 sampled residents (Resident #31), reviewed for enteral feeding.
- D
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Inspectors wroteBased on policy review, observation, record review, and interview, the facility failed to ensure timely IV (intravenous) dressing changes for 1 of 1 sampled resident, Resident #29.
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observation, interview, and record review, the facility failed to properly administer oxygen therapy for 2 of 2 sampled residents, as evidenced by failure to ensure proper physician orders for oxygen use for Resident #302, and that the prescribed physician order for oxygen was followed for Resident #54.
- D
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
Inspectors wroteBased on observation, record review and interview the facility failed to ensure an assessment and an order for side rails for 1 of 1 sampled resident reviewed for side rails (Resident #302).
- D
Provide timely, quality laboratory services/tests to meet the needs of residents.
Inspectors wroteBased on record review, policy review and interview the facility failed to obtain an ordered laboratory result for a medication (Depakote) for 1 of 1 sampled Resident (Resident #61).
- 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 observation, interview, and record review, the facility failed to honor food preferences for 5 of 10 sampled residents, Residents #27, #29, #44, #50, and #85, who had food complaints, as evidenced by the failure to follow the meal ticket and menu.
- D
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 policy review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety, sanitary conditions, and the prevention of foodborne illnesses. This had the potential to affect 111 of 112 residents on PO (by mouth) diets.
- C
Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse.
Inspectors wroteBased on interview and review of the client's Arbitration agreements, the facility failed to ensure the arbitration agreement is explained to the resident or representative in a manner they understand (Resident #306), and had a signature from the resident or representative if they agree to the arbitration agreement (Residents #87, #306, and #307). This is for 3 of 3 residents reviewed for arbitration.
March 6, 2025Complaint inspection · 1 citation
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on observation, interviews and clinical record review, the facility failed to ensure that residents who are unable to carry out their activities of daily living to maintain personal hygiene, grooming, mobility are provided the necessary care and services in a timely manner. The facility also failed to maintain accurate documentation of the care and services that are provided. This failure affected 3 of 6 sampled residents (Resident #1, #5 and a confidential random resident).
January 23, 2025Complaint inspection · 3 citations
- G
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on observation, record review and interview, the facility staff failed to provide necessary treatment and services to promote healing and prevent infection of existing pressure wounds. The failure affected 2 of 6 sampled residents, Resident #2, who arrived at the hospital with maggots in the wound and Resident #6 who did not receive the prescribed treatment for tissue granulation and autolytic debridement.
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on record review, policy review and interview, the facility staff failed to report an allegation of neglect for 1 of 2 sampled residents reviewed for neglect (Resident #2).
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observation, record review, policy review and interview, the nursing staff failed to implement the facility policy for the storage of nebulizer equipment. The failure affected 1 of 6 sampled residents (Resident #1).
November 22, 2024Complaint inspection · 1 citation
- J
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on interview, observation, and record review, the facility failed to provide appropriate supervision to prevent an elopement, which resulted in two vulnerable residents who were able to leave the facility and travel along a busy roadway with a likelihood of being hurt, killed or lost, for 2 of 3 sampled residents reviewed for an elopement risk (Resident #1 and Resident #2). Due to the likelihood that serious injury, harm and death could've occurred with Resident #1 and #2, a finding of Immediate Jeopardy was identified. The Immediate Jeopardy noncompliance started on 11/07/24 and is determined to be ongoing. The facility's Administrator was notified of Immediate Jeopardy and given the Immediate Jeopardy Template on 11/21/24 at 11:20 AM.
October 3, 2024Complaint inspection · 8 citations
- G
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on record review and interview the facility failed to ensure daily wound care for 1 of 4 sampled residents with surgical incisions (Resident #2). The lack of daily wound care for Resident #2 resulted in maceration of the surgical skin flap resulting in exposure to the bone with need for additional surgery; and the facility failed to ensure appropriate care and services for 1 of 2 sampled residents with an IV (intravenous) line (Resident #1). The lack of timely response to needed care for a Peripherally Inserted Central Catheter (PICC) line dislodgement for Resident #1 on 09/04/24 resulted in psychological harm as evidenced by staff and family report that the resident was irate and hysterical.
- G
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Inspectors wroteBased on record review and interview, the facility failed to ensure appropriate care and services for 1 of 2 sampled residents with an IV (intravenous) line (Resident #1). The lack of timely response to needed care for a Peripherally Inserted Central Catheter (PICC) line dislodgement for Resident #1 on 09/04/24 resulted in psychological harm as evidenced by staff and family report that the resident was irate and hysterical.
- 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 1 of 8 sampled resident representatives of a change in condition and treatment (Resident #5).
- 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 policy review, observation, and interview, the facility failed to ensure a safe and functional environment as evidenced by the failure to maintain 4 of 6 Soiled Utility/Holding (biohazard) rooms secured (1E, 1W, 3E and 3W); failure to maintain 1 of 6 housekeeping areas secured (1W); failure to ensure 1 of 6 (2W) emergency exits of the residential areas secured; failure to ensure 2 of 2 observed oxygen tanks were secured; and failure to provide documented evidence of timely repairs for 4 of 4 resident toilets.
- D
Respond appropriately to all alleged violations.
Inspectors wroteBased on record review, incident review, and interview, the facility failed to ensure a complete and thorough investigation for 1 of 2 sampled residents with an allegation of neglect, as evidenced by a lack of written statements from all staff involved in the incident and contradictions during staff interviews regarding the incident with Resident #1 on 09/04/24.
- D
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 record review, incident review, and interview, the facility failed to ensure sufficient staffing, as evidenced by the lack of timely response to needed PICC (Peripherally Inserted Central Catheter) line dislodgment care for 1 of 2 sampled residents with an IV (intravenous) line (Resident #1); and as evidenced by numerous verbal and written complaints.
- 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 record review and interview the facility failed to ensure food preferences for 2 of 3 sampled residents (Residents #7 and #8).
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on policy review, observation, and interview, the facility failed to maintain an infection control program as evidenced by the failure to initiate and maintain Enhanced Barrier Precautions (EBP) for 4 of 4 sampled residents (Resident #1, #6, #7 and #8)
April 30, 2024Complaint inspection · 2 citations
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on record review, policy review and interview, the facility staff failed to immediately report an allegation of abuse involving 1 of 2 sampled residents (Resident #1).
- 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 and interview, the facility failed to ensure a urinary catheter was secured to prevent excessive tension of the tubing; failed to provide catheter care following infection control practices to minimize complications; and failed to provide a privacy bag to promote the resident's privacy. The failure affected 1 of 2 sampled residents reviewed for urinary catheter care. (Resident #4)
April 2, 2024Complaint inspection · 1 citation
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on record review and interview, it was determined, the clinical staff failed to complete an assessment after a resident sustained an injury; failed to obtain and report all pertinent information to the provider to ascertain the best course of treatment; failed to complete an incident report after the injury was reported by the resident; and failed to complete an investigation to determine if the resulting injury, a fractured wrist, met the criteria for an adverse event. These failures affected 1 of 3 sampled residents (Resident #1).
December 7, 2023Standard inspection · 7 citations
- 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 observations, interviews, and record review, the facility failed to follow their grievance policy related to: 1) Medication concerns for 1 of 29 sampled residents (Resident #28); and 2) Food concerns for 17 out of 29 sampled residents (Resident #21, #289, #287, #31, #4, #67, #285, #59, #292, #186, #290, #69, #291, #294, #44, #15, and #11).
- 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 Power of Attorney (POA) for 1 of 1 sampled resident reviewed for notification of change. The notification of change was related to Resident #28's change in medications.
- 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 reviews and interviews, the Facility failed to ensure the Power of Attorney for 1 of 11 sampled residents' was notified of and included in the Resident's Care Plan Meetings (Resident #28).
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on record review and interview, the facility failed to provide wound care dressing changes for 1 of 2 sampled residents reviewed for wound care, Resident #33.
- D
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Inspectors wroteBased on observation, record review, interview, and policy review, it was determined, the facility staff failed to provide care and services to minimize complications for a resident with a gastronomy tube during medication administration. The failure affected 1 of 1 sampled resident (Resident #141).
- 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 the acquisition and provision of medication administration. The failure affected 1 of 6 sampled residents (Resident #27).
- D
Implement a program that monitors antibiotic use.
Inspectors wroteBased on record review, policy review and interview, the facility staff failed to ensure antibiotic prescribing criteria includes clinical signs and symptoms, laboratory reports and appropriate monitoring to protect residents from harm caused by unnecessary antibiotic use, and to combat antibiotic resistance. The failure affected 1 of 6 sampled residents (Resident #27).
August 11, 2022Standard inspection · 12 citations
- E
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Inspectors wroteBased on record review and interview, the facility failed to ensure accurate documentation of medication removal and administration between the medication administration records (MARs) and the medication monitoring control record for 3 of 4 residents Residents #196, #200 & #147.
- E
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview, record review, and policy review, the facility failed to maintain an infection prevention and control program to help prevent the development and transmission of communicable diseases and infections. Staff J, a Certified Nursing Assistant (CNA) failed to ensure hand hygiene between residents, during the lunch meal tray delivery on 08/08/22 for 1 of 4 units (second floor west), affecting Residents #22, #198, #199, #91, #150, #92, #151, and #152. Staff K, a CNA, failed to don a gown and or ensure hand hygiene during COVID-19 testing for 2 of 5 residents (Resident #196 and Resident #149, also affecting Resident #22). [...]
- E
Perform COVID19 testing on residents and staff.
Inspectors wroteBased on observation, interview, and manufacturer's instructions, Staff K, a Certified Nursing Assistant (CNA) failed to follow instructions for the COVID-19 antigen tests for 4 of 4 sampled residents (Resident #196, #149, #22, and #199).
- 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, record review and policy review, the facility failed to ensure resident choices are honored for 2 of 4 sampled residents. Resident #93 was not transferred back into bed in a timely manner, per her request, on two different occasions (08/06/22 and 08/10/22). Resident #93 was not offered and did not receive showers as per the facility schedule or as per her choice. Resident #94 was placed on contact precautions unnecessarily.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on observation, record review and interview the facility failed to ensure dressing changes for non-pressure ulcers were done as per physician order for 1 of 3 residents reviewed for skin condition (Resident #142).
- 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 proper Foley catheter (indwelling urinary drainage device) care and services for 2 of 3 sampled residents. Staff failed to ensure proper catheter care for Resident #93. The tubing for the urinary catheters for both Residents #93 and #98 lacked anchoring, used to prevent urinary infections.
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observation, interview, record review, and policy review, the facility failed to ensure proper respiratory care and services for 2 of 2 sampled residents (Residents #91 and #96). The nurse failed to stay with and monitor Resident #91 during a respiratory treatment via nebulizer, then failed to properly clean the nebulizer equipment after use. The oxygen tubing for the concentrator and nebulizer for Resident #96 was not changed for two weeks as per physician order.
- D
Dispose of garbage and refuse properly.
Inspectors wroteBased on observations, the facility failed to ensure garbage and refuse were disposed of properly.
- D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on record review and interview, the facility failed to ensure accurate documentation related to self/family administration of medications for Resident #31, 1 of 6 sampled residents reviewed for medications.
- 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 observation, record review, and interview, the facility failed to ensure a completed baseline care plan within 48 hours of admission for 4 of 20 sampled residents. A baseline care plan is used by facility staff to guide the basic care needs of a resident until the comprehensive care plans are developed. The baseline care plans are to be kept up to date until the initiation of the comprehensive care plans. A baseline care plan was not developed for Resident #93. The baseline care plans for Residents #92, #96, and #98 lacked care and services and or essential equipment.
- B
Post nurse staffing information every day.
Inspectors wroteBased on observation, interview, and record review the facility failed to post nurse staffing hours information timely for 4 of 4 days.
- B
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 policy review, the facility failed to safely store medications on 1 of 4 treatment carts (first floor east), and on 1 of 4 medication carts (first floor east).
Fire safety inspections
5 fire safety citations on file: 1 on April 4, 2025, 3 on December 7, 2023, 1 on August 11, 2022.
Every fire safety citation5 citations
- D
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
K 741 · April 4, 2025 · 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 7, 2023 · Corrected (the home has a date of correction)
- D
Meet other general requirements that are deficient.
K 500 · December 7, 2023 · Corrected (the home has a date of correction)
- D
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
K 761 · December 7, 2023 · Corrected (the home has a date of correction)
- D
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
K 223 · August 11, 2022 · Corrected (the home has a date of correction)