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 40 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
1G
0H
0I
Potential for more than minimal harm
28D
8E
1F
Potential for minimal harm
0A
0B
2C
July 31, 2025Complaint inspection · 1 citation
- D
Ensure services provided by the nursing facility meet professional standards of quality.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure physicians' orders were followed for 2 of 3 residents reviewed for medications. Medications were observed at a resident's bedside table; the medication was held without a physician's order. ( Resident B, Resident D)
July 3, 2025Standard 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 the dishwasher was sanitizing dishes properly and staff knew how to properly test for sanitization for 1 of 1 kitchens in the facility. (Kitchen)
- E
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 ensure residents dependent on staff for assistance with activities of daily living (ADL) tasks were provided showers or baths for 4 of 5 residents reviewed for ADL care. (Resident 27, Resident 97, Resident 11, and Resident 36)
- 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, interview, and record review, the facility failed to ensure medications were properly stored and labeled for 4 of 5 medication carts reviewed and 1 treatment cart reviewed. (100 Hall Cart 1, 100 Hall Cart 2, 200 Hall Cart 1, 200 Hall Cart 2, 100 Hall Treatment Cart)
- E
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure infection prevention practices were implemented during laundry services during 1 of 1 observations of laundry services. (Laundry Room)
- D
Provide care by qualified persons according to each resident's written plan of care.
Inspectors wroteBased on interview and record review, the facility failed to ensure as needed (PRN) medications administered by a Qualified Medication Aide (QMA) were preauthorized by a licensed nurse for 2 of 5 resident reviewed for unnecessary medications. (Resident 66 and Resident 87)
- 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, and interview, the facility failed to ensure care according to professional standards of a gastro/jejunal feeding tube (G-Tube) in 1 of 1 residents reviewed for tube feeding. The resident was not checked for residual as ordered prior to feedings. (Resident 44)
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure proper airway management for 1 of 1 residents reviewed with a laryngectomy. A self-assessment for care was not performed, documentation was not accurate, and the facility did not have the correct parts for the laryngectomy tube ([NAME] Tube). (Resident 44)
- D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wrote2. On 6/30/25 at 8:11 A.M., Resident 98's clinical record was reviewed. Resident 98 was admitted to the facility on [DATE]. Diagnoses included, but were not limited to, congestive heart failure. The most recent Quarterly Minimum Data Set (MDS) Assessment, dated 3/22/25, indicated Resident 98 was cognitively intact and was dependent on staff (staff does all of the effort) for toileting, bathing, and transfers. Physician orders included, but were not limited to: Metoprolol 50 milligrams (mg) Extended Release (ER) - Give one tablet by mouth one time a day; Start Date 9/1/21. Care plans included, but were not limited to: (Resident) is at risk for impaired cardiac output; Observe for signs/symptoms of cardiac dysfunction such as .increased or decreased heart rate or blood pressure. Document abnormal findings and notify physician. Date Initiated: [...]
- C
Post nurse staffing information every day.
Inspectors wroteBased on observation, interview, and record review, the facility failed to post a current Posted Nurse Staffing sheet for 1 of 5 days during the survey period.
July 19, 2024Complaint inspection · 2 citations
- D
Provide care by qualified persons according to each resident's written plan of care.
Inspectors wroteBased on interview and record review, the facility failed to ensure physician orders were followed for 1 of 3 residents reviewed. A resident was given a straw to drink with, and hand splints were not applied. (Resident B)
- D
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 food was stored, and served in a sanitary manner for 2 of 2 kitchen observations. The kitchen floors had debris build up, and equipment was soiled. ( Kitchen)
May 9, 2024Standard inspection · 17 citations
- G
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 interview and record review, the failed to ensure a resident who entered the facility with an indwelling urinary catheter was effectively assessed for adverse outcomes of an indwelling urinary catheter, received treatment and services to prevent infection in accordance with the physician orders and the plan of care, or was effectively monitored for complications of bloody urine after the catheter was suspected to be pulled for 1 of 4 residents reviewed for urinary catheters. This deficient practice resulted in Resident 35 being hospitalized for the treatment of urethral obstruction and sepsis. (Resident 35)
- E
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that food was served at an appetizing temperature for 1 of 1 trays tested for temperature. (Resident 21, Resident 246, Resident 74, Resident 73, Resident 87, Resident 4, Resident 24, Resident 55, Resident 25)
- 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 and prepare food under sanitary conditions during 4 of 4 kitchen observations and 1 of 1 nutrition pantry observation. Food was not labeled, left open to air, and expired food was not disposed of from the refrigerator, hair nets were not worn, and hand hygiene was not completed. (Kitchen, 100 hall nutrition pantry, Dietary Aide 3, Dietary Aide 21, Dietary Manager)
- 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 interview and record review, the facility failed to immediately notify the resident's family of a resident to resident altercation for 1 of 1 residents reviewed for notification of changes. (Resident 35)
- D
Ensure each resident receives an accurate assessment.
Inspectors wroteBased on record and interview the facility failed to ensure the MDS (Minimum Data Set) Assessment was completed accurately for 3 of 19 residents reviewed. Antipsychotic medications, dental status, and significant weight loss were coded inaccurately. (Resident 25, Resident 246, Resident 55)
- 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 observation, record review, and interview the facility, failed to ensure care plan interventions were implemented for 1 of 2 residents reviewed for falls. The call light was not within reach. (Resident 26)
- 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 observation, record review, and interview the facility, failed to ensure that documentation of interventions were not revised for 1 of 2 residents reviewed for falls. (Resident 56)
- D
Ensure services provided by the nursing facility meet professional standards of quality.
Inspectors wroteBased on interview and record review, the facility failed to ensure medication was given according to physician orders for 1 of 5 residents reviewed for unnecessary medications. A blood pressure medication was given outside of parameters and glucagon was administered without an order. (Resident 246)
- D
Provide enough food/fluids to maintain a resident's health.
Inspectors wroteBased on observation, interview, and record review, the facility failed to provide nutritional care and services including the failure to obtain weekly weights, failure to provide assistance with meals and alternative food/supplement choices, and failure to notify the physician and address the resident's refusal of nutritional supplements and poor intakes resulting in a significant weight loss of 18.37% in less than 30 days 1 of 3 residents reviewed for significant weight loss and ensure a resident was receiving adequate fluids resulting in dehydration and a urinary tract infection 1 of 1 residents reviewed for dehydration. (Resident 55 and Resident 75)
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure oxygen equipment was labeled and oxygen administration signs were in place for 3 of 3 residents reviewed for oxygen administration. (Resident 24, Resident 73, Resident 88)
- D
Provide safe, appropriate pain management for a resident who requires such services.
Inspectors wroteBased on observation, interview, and record review, the facility failed to provide pain assessments and provide pain management in accordance with the resident's comprehensive care plan for 1 of 1 residents reviewed pain. (Resident 55)
- D
Verify that a nurse aide has been trained; and if they haven't worked as a nurse aide for 2 years, receive retraining.
Inspectors wroteBased on record review and interview, the facility failed to ensure CNA's had a current and valid certificate to work in the facility for 1 of 27 CNA's reviewed. (CNA 2)
- D
Ensure medication error rates are not 5 percent or greater.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure it was free from a medication error rate greater than 5% for 2 of 26 opportunities observed to administer medications, resulting in an error rate of 7.7%. (Residents 7, Resident 15)
- 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 and interview, the facility failed to ensure deteriorated medications were discarded for 1 of 3 medication carts observed. (100 Hall Cart 1)
- 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, interview, and record review, the facility failed to provide food to accommodate a resident's food allergy for 1 of 7 residents reviewed for nutrition. Milk was given with a meal to a resident who had a lactose allergy. (Resident 246)
- D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased observation, interview, and record review, the facility failed to ensure resident records were complete and accurate for 1 of 5 residents reviewed for unnecessary medications, 1 of 3 residents observed for medication administration, and 1 of 2 residents reviewed falls. (Resident 246, Resident 15, Resident 26)
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure infection control practices were implemented for 2 of 2 residents observed for wound care. Hand hygiene and glove changes were not completed. (Resident 12, Resident 11, LPN 8, CNA 7, RN 7, Nurse Practitioner 19)
February 2, 2024Complaint inspection · 2 citations
- 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 ensure residents fall interventions were in place to prevent a fall for 1 of 3 resident reviewed for falls. ( Resident E)
- D
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 food was stored, and served in a sanitary manner for 2 of 2 kitchen observations. The kitchen floors had debris build up, equipment was soiled, and food was open to air and undated. ( Kitchen)
January 18, 2024Complaint inspection · 1 citation
- D
Provide care by qualified persons according to each resident's written plan of care.
Inspectors wroteBased on interview and record review, the facility failed to ensure physician orders were followed for 1 of 3 residents reviewed. The correct dose of a resident's pain medication was not given. (Resident B)
December 4, 2023Complaint inspection · 1 citation
- E
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Inspectors wroteBased on observation, interview, and record review, the facility failed to provide appetizing and palatable meals for 1 of 1 lunch trays sampled on 1 of 2 halls. Residents complained of cold food temperatures at meals and distasteful food during meals. (100 Hall, Resident B, Resident J)
August 12, 2022Standard inspection · 7 citations
- E
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Inspectors wroteBased on observation, record review, and interview, the facility failed to provide food that was palatable, attractive, and at a safe and appetizing temperature for 1 of 1 breakfast trays sampled.
- E
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure infection control practices were followed for 4 of 6 residents during observation of perineal care, medication administration, placement for Foley catheter bag and 1 of 1 resident receiving a Covid 19 test. Gloves were not changed between dirty and clean tasks during peri care, staff was observed not wearing a mask with a resident present, a medication was picked up from the top of a medication cart with bare hands and given to a resident, and Foley catheter bag and tubing was touching the floor. (Resident 156, Resident 221, Resident 226, Resident 122, Resident 229, Resident 2)
- 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 observation, interview, and record review, the facility failed to implement a comprehensive person-centered care plan for each resident in order to meet medical needs that are identified in the comprehensive assessment. Staff did not implement care plan interventions, or follow MD orders for 3 of 5 residents reviewed for implementation of the care plan intervention for respiratory care, urinary care, and weight management while on enteral feedings. (Resident G, Resident 10, Resident 44)
- 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 provide adequate supervision and prevent falls for 2 of 4 residents reviewed for accidents. Fall interventions were not in place for residents with multiple falls. (Resident 25, Resident 9)
- D
Provide enough food/fluids to maintain a resident's health.
Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a resident who experienced weight loss had new interventions instituted and that the registered dietitian and the physician were notified of a significant weight loss for 1 of 3 reviewed for nutrition. (Resident G)
- 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 interview and record review, the facility failed to ensure residents were free from unnecessary medications for 2 of 5 residents reviewed for unnecessary medications. A GDR (gradual dose reduction) was not completed to reduce a psychotropic medication. A resident's as needed anti-anxiety medication was ordered for greater than 14 days. (Resident 32, Resident 55)
- C
Post nurse staffing information every day.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure completed staffing sheets were posted daily for 7 of 7 days during the survey.
Fire safety inspections
25 fire safety citations on file: 1 on July 3, 2025, 20 on May 9, 2024, 4 on August 12, 2022.
Every fire safety citation25 citations
- F
Ensure that testing and maintenance of electrical equipment is performed.
K 921 · July 3, 2025 · Corrected (the home has a date of correction)
- F
Address subsistence needs for staff and patients.
E 15 · May 9, 2024 · Corrected (the home has a date of correction)
- F
Establish procedures for tracking staff and patients during an emergency.
E 18 · May 9, 2024 · Corrected (the home has a date of correction)
- F
Establish policies and procedures including evacuation.
E 20 · May 9, 2024 · Corrected (the home has a date of correction)
- F
Establish policies and procedures for medical documentation.
E 23 · May 9, 2024 · Corrected (the home has a date of correction)
- F
Establish policies and procedures for volunteers.
E 24 · May 9, 2024 · Corrected (the home has a date of correction)
- F
Develop a communication plan.
E 29 · May 9, 2024 · Corrected (the home has a date of correction)
- F
Provide primary/alternate means for communication.
E 32 · May 9, 2024 · Corrected (the home has a date of correction)
- F
Establish methods for sharing information.
E 33 · May 9, 2024 · Corrected (the home has a date of correction)
- F
Provide a means of sharing information on occupancy/needs.
E 34 · May 9, 2024 · Corrected (the home has a date of correction)
- F
Provide family notifications of emergency plan.
E 35 · May 9, 2024 · Corrected (the home has a date of correction)
- F
Establish emergency prep training and testing.
E 36 · May 9, 2024 · Corrected (the home has a date of correction)
- F
Implement emergency and standby power systems.
E 41 · May 9, 2024 · Corrected (the home has a date of correction)
- F
Provide properly protected cooking facilities.
K 324 · May 9, 2024 · Corrected (the home has a date of correction)
- F
Follow proper procedures when the fire alarm was out of service for more than 4 hours.
K 346 · May 9, 2024 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · May 9, 2024 · Corrected (the home has a date of correction)
- F
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
K 354 · May 9, 2024 · Corrected (the home has a date of correction)
- F
Provide a written emergency evacuation plan.
K 711 · May 9, 2024 · Corrected (the home has a date of correction)
- F
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · May 9, 2024 · Corrected (the home has a date of correction)
- E
Have proper medical gas storage and administration areas.
K 923 · May 9, 2024 · Corrected (the home has a date of correction)
- C
Have simulated fire drills held at unexpected times.
K 712 · May 9, 2024 · Corrected (the home has a date of correction)
- C
Develop and maintain an Emergency Preparedness Program (EP).
E 4 · August 12, 2022 · deficient, provider has
- C
Develop Emergency Preparedness policies and procedures.
E 13 · August 12, 2022 · deficient, provider has
- C
Develop a communication plan.
E 29 · August 12, 2022 · deficient, provider has
- C
Establish emergency prep training and testing.
E 36 · August 12, 2022 · deficient, provider has