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 26 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
26D
0E
0F
Potential for minimal harm
0A
0B
0C
June 27, 2025Standard inspection · 5 citations
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on interview, record review and document review, the facility failed to ensure a physician's order was clarified and the accurate amount of medication and water was documented per the physician's order for 1 of 21 sampled residents (Resident 10). The deficient practice had the potential for the resident not receiving the maximum therapeutic effect of the medication and inaccurate documentation of the resident's fluid intake.
- 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, interview, record review and document review, the facility failed to ensure restorative nursing services were provided per therapy recommendations for 1 of 21 sampled residents (Resident 40). The deficient practice had the potential for the resident's further decline in range of motion (extent of movement a joint could perform).
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observation, interview, record review and document review, the facility failed to ensure Oxygen (O2) was administered according to physician's orders for 1 of 21 sampled residents (Resident 31). The deficient practice had the potential to lead to O2 toxicity and exacerbation of the residents' underlying health conditions.
- D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Inspectors wroteBased on observation, interview, record review and document review, the facility failed to ensure a resident received the medication as ordered for 1 of 21 sampled residents (Resident 243). The deficient practice had the potential for the resident having adverse events for not receiving physician prescribed medication.
- 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 document review, the facility failed to discard expired milk stored in a refrigerator located in the kitchen, an ice pack in the first floor nourishment room freezer, and employee food from the freezer located in second floor nourishment room. The deficient practice has the potential to lead to bacterial growth and foodborne illnesses.
February 20, 2025Complaint inspection · 3 citations
- D
Plan the resident's discharge to meet the resident's goals and needs.
Inspectors wroteBased on interview, record review and document review, the facility failed to update discharge instructions and failed to notify the physician of the changes in the discharge plan for 1 of 4 sampled residents (Resident 1). The deficient practice had the potential for a resident not to receive the necessary provisions for continuation of care.
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on interview, record review and document review, the facility failed to provide documented evidence wound care treatments were provided per the physician's order for 1 of 4 sampled residents (Resident 1). The deficient practice had the potential to place the resident at risk for delayed healing of a wound.
- D
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Inspectors wroteBased on interview, record review and document review, the facility failed to provide documented evidence a resident's midline (a long, thin, flexible tube inserted into a large vein of the upper arm used to administer medication into the bloodstream) was removed, and a site assessment was performed upon discharge for 1 of 4 sampled residents (Resident 1). This deficient practice had the potential for an increased risk of infection and to compromise the residents' health.
July 26, 2024Standard inspection · 9 citations
- D
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Inspectors wroteBased on observation, interview, record review, and document review, the facility failed to ensure an assessment for the use of bilateral mitten restraints for a resident was completed accurately and consent for the mitten restraints was obtained from the resident or the appropriate representative for 1 of 20 sampled residents (Resident #44). The deficient practice had the potential to cause physical and psychosocial harm to the resident.
- D
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Inspectors wroteBased on observation, interview, record review, and document review the facility failed to ensure a Preadmission Screening and Resident Review (PASARR) level two referral was completed for 1 of 20 sampled residents (Resident #36). The deficient practice had the potential to deprive the resident of concern and other residents of necessary behavioral health services. Resident #36 (R36) R36 was re-admitted on [DATE], with diagnoses including pulmonary edema, acute respiratory failure with hypoxia, anxiety disorder, mood disorder, generalized anxiety disorder, post-traumatic stress disorder, and major depressive disorder. On 07/23/2024 in the afternoon, R36 was sitting on the bed. R36 stated had been at the facility for about 8 years and the care and services at the facility were good. [...]
- D
Ensure services provided by the nursing facility meet professional standards of quality.
Inspectors wroteBased on observations, interviews, record reviews, and document reviews, the facility failed to ensure documentation accurately reflected medications and treatment services were provided. Specifically, this pertained to 1) wound care treatment; 2) ACE wrap (elastic bandage); 3) Oxygen (O2) therapy; and 4) diuretic medication . This deficient practice could potentially have led to severe harm, including ineffective wound management, an increased risk of respiratory complications, inadequate compression therapy, and compromised medication management.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on observation, interview, record review, and document review, the facility failed to ensure: 1) the wound care treatment was provided as ordered to treat impaired skin; 2) the ACE wrap (elastic bandage) was applied as ordered to treat edema; and 3) the Oxygen flow meter rate was administered as ordered to treat chronic obstructive pulmonary disease (COPD) for 1 of 20 sampled residents (Resident 48). These deficient practices had the potential to cause delayed wound healing, increased risk of complications related to poor circulation and compromised respiratory function.
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on observation, interview, record review, and document review, the facility failed to implement floating heels to prevent pressure ulcers for 1 of 20 sample residents (Resident #11). The deficient practice had the potential to expose the resident to an avoidable skin injury.
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on observation, interview, record review, and document review, the facility failed to complete a post fall assessment and neurological checks after an unwitnessed fall for 1 of 20 residents (Resident 38). The failed practice could have contributed to increased pain and a delay of necessary medical interventions.
- D
Provide enough food/fluids to maintain a resident's health.
Inspectors wrote2) Resident 39 (R39) R39 was admitted to the facility on [DATE], with diagnoses including infection of tracheostomy stoma, chronic pain, nontraumatic intracerebral hemorrhage, unspecified intestinal obstruction, acute embolism and thrombosis, and bed confinement. R39's Weight Summary report, documented a January weight of 218.7 pounds (lbs.) on 01/12/2024. No weights were tracked or monitored for April 2024. According to the weight task history, R39 was on monthly weights from 01/10/2024 until 05/15/2024 when the resident was switched to weekly weights due to weight loss. R39's Weight Report documented weights from January 2024 through July 2024 as follows: -07/22/2024: 198.4 lbs. -07/15/2024: 197.0 lbs. -07/08/2024: 196.8 lbs. -07/01/2024: 196.2 lbs. -06/17/2024: 198.4 lbs. -06/10/2024: 196.4 lbs. -06/03/2024: 196.0 lbs. -05/27/2024: 196.4 lbs. -05/13/2024: 195.8 lbs. -05/12/2024: [...]
- 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, interview, record review, and document review, the facility failed to ensure adequate tube feeding (TF) formula was provided as ordered to a resident who was TF-dependent or to notify the physician when it could not be carried out in a timely manner for 1 of 20 sampled residents (Resident 188). This deficient practice had the potential to compromise the resident's nutritional status and overall health, leading to malnutrition, dehydration, and an increased risk of infection.
- 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 document review, the facility failed to ensure food products were labeled with the date when they were opened, and failed to dispose of fruits showing signs of spoilage. The deficient practice could have exposed the residents to potential health risk associated with contaminated food.
January 3, 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 interview and record review, the facility failed to ensure a resident who required a one-person physical assist in toilet use and had history of falls was not left alone while using the toilet resulting in a fall for 1 of 5 sampled residents (Resident 1). The deficient practice had the potential to place the resident at risk for severe injury due to lack of assistance provided.
- D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Inspectors wroteBased on interview, record review and document review, the facility failed to account for narcotic medications signed out on the controlled drug record (narcotic log) for 1 of 5 sampled residents (Resident 1). The deficient practice had the potential to delay a resident's pain management and increase risk for physical and psychosocial harm.
July 27, 2023Standard inspection · 7 citations
- D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteBased on interview, record review, and document review the facility failed to ensure the resident right of dignity was honored for 1 of 23 sampled residents (Resident 19). The deficient practice had the potential to cause a negative psychosocial outcome. Findings Include: Resident 19 (R19) R19 was admitted on [DATE] with diagnosis of Parkinson's disease. A facility report indicated on 04/10/2023, R19 was placed near the nurse's station on a shower chair with bucket under the chair for the resident to defecate. On 07/25/2023 at 1:15 PM, a Certified Nursing Assistant (CNA) was familiar with incident and confirmed the incident did occur. The CNA explained while making rounds, the CNA noticed the resident close to the nurse's station and immediately advised nurse and CNA responsible for placing the resident at the nurse's station, so the resident could be returned to room. On 07/27/23 at 11: [...]
- D
Allow residents to self-administer drugs if determined clinically appropriate.
Inspectors wroteBased on observation, interview, record review, and document review the facility failed to ensure a physician order for self-administration was obtained and an assessment was completed before allowing a resident to self-administer medications. The deficient practice had the potential to lead to medication errors impacting the well-being of the resident.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on observation, interview, record review and document review, the facility failed to ensure medications were administered per physician's order for 2 of 23 sampled residents (Resident 144 and Resident 20). Specifically, 1) two intravenous (IV) antibiotic medications were not given as scheduled for a resident with pneumonia (Resident 144) and 2) a phosphate binder was not administered with meals for a resident with end stage renal disease (Resident 20). The deficient practice placed Resident 144 at risk for unresolved infection and potentially contributed to Resident 20's hyperphosphatemia (elevated Phosphorus in the blood).
- 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, interview, record review and document review, the facility failed to evaluate and provide appropriate interventions for hand contractures for 1 of 23 sampled residents (Resident 52). The deficient practice had the potential for the resident to develop further decline or decrease in physical functioning.
- D
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Inspectors wroteBased on observation, interview, record review and document review the facility failed to 1) ensure a peripherally inserted central catheter (PICC) dressing was changed per the physician's order or facility's policy for 1 of 4 residents (Resident 83) and 2) ensure a midline complication was reported to the charge nurse and physician for 1 of 4 sampled residents (Resident 144). The deficient practice had the potential for the resident to develop an infection and interrupted another resident's intravenous (IV) antibiotic therapy.
- 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 interview, record review, and document review the facility failed to ensure a Certified Nursing Assistant (CNA) had documented evidence of competency skill sets for 1 of 6 sampled nursing staff members. The deficient practice had the potential to impact the safety of the residents.
- 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 document review, the facility failed to ensure (1) food items in the refrigerator were labeled and dated, personal food items were not placed in resident only refrigerators in the nourishment room and family dining room, and (2) resident food was covered prior to transport to individual units, and meal trays were covered to prevent cross contamination. The deficient practices had to the potential to place all residents at risk for a food-borne illness. 1) On 07/25/2023 at 7:58 AM, the refrigerator in main kitchen contained three food items on shelf in clear plastic bags which were not labeled or dated. On 07/25/2023 at 8:03 AM the Director of Food and Nutrition Services (DNS) indicated all items outside of the manufacturer's box should be labeled and dated and indicated the three bags did not contain a label or date and should be discarded. [...]
Fire safety inspections
37 fire safety citations on file: 9 on June 27, 2025, 12 on July 26, 2024, 16 on July 27, 2023.
Every fire safety citation37 citations
- F
Address subsistence needs for staff and patients.
E 15 · June 27, 2025 · no revisit needed
- E
Conduct risk assessment and an All-Hazards approach.
E 6 · June 27, 2025 · no revisit needed
- E
Include a process for Emergency Preparedness collaboration.
E 9 · June 27, 2025 · no revisit needed
- E
Inspect, test, and maintain automatic sprinkler systems.
K 353 · June 27, 2025 · no revisit needed
- 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 · June 27, 2025 · no revisit needed
- D
Properly select, install, inspect, or maintain portable fire extinguishes.
K 355 · June 27, 2025 · no revisit needed
- D
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · June 27, 2025 · no revisit needed
- D
Have properly installed electrical wiring and gas equipment.
K 511 · June 27, 2025 · no revisit needed
- C
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · June 27, 2025 · no revisit needed
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · July 26, 2024 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · July 26, 2024 · Corrected (the home has a date of correction)
- F
Have simulated fire drills held at unexpected times.
K 712 · July 26, 2024 · Corrected (the home has a date of correction)
- F
Ensure that any exit in an area undergoing construction, repair, or improvements shall be inspected daily to ensure its ability to be used instantly in case of emergency.
K 791 · July 26, 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 · July 26, 2024 · Corrected (the home has a date of correction)
- F
Ensure that testing and maintenance of electrical equipment is performed.
K 921 · July 26, 2024 · Corrected (the home has a date of correction)
- E
Develop and maintain an Emergency Preparedness Program (EP).
E 4 · July 26, 2024 · Corrected (the home has a date of correction)
- E
Conduct risk assessment and an All-Hazards approach.
E 6 · July 26, 2024 · Corrected (the home has a date of correction)
- E
Address subsistence needs for staff and patients.
E 15 · July 26, 2024 · Corrected (the home has a date of correction)
- E
Implement emergency and standby power systems.
E 41 · July 26, 2024 · Corrected (the home has a date of correction)
- E
Have properly installed electrical wiring and gas equipment.
K 511 · July 26, 2024 · Corrected (the home has a date of correction)
- E
Provide a written emergency evacuation plan.
K 711 · July 26, 2024 · Corrected (the home has a date of correction)
- E
Develop and maintain an Emergency Preparedness Program (EP).
E 4 · July 27, 2023 · Corrected (the home has a date of correction)
- E
Conduct risk assessment and an All-Hazards approach.
E 6 · July 27, 2023 · Corrected (the home has a date of correction)
- E
Address subsistence needs for staff and patients.
E 15 · July 27, 2023 · Corrected (the home has a date of correction)
- E
Establish policies and procedures for volunteers.
E 24 · July 27, 2023 · Corrected (the home has a date of correction)
- E
Provide primary/alternate means for communication.
E 32 · July 27, 2023 · Corrected (the home has a date of correction)
- E
Establish staff and initial training requirements.
E 37 · July 27, 2023 · Corrected (the home has a date of correction)
- E
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · July 27, 2023 · Corrected (the home has a date of correction)
- E
Have a properly installed medical gas master alarm panel.
K 904 · July 27, 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 · July 27, 2023 · Corrected (the home has a date of correction)
- D
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
K 225 · July 27, 2023 · Corrected (the home has a date of correction)
- D
Install emergency lighting that can last at least 1 1/2 hours.
K 291 · July 27, 2023 · Corrected (the home has a date of correction)
- D
Construct fire resistant interior walls.
K 331 · July 27, 2023 · Corrected (the home has a date of correction)
- D
Inspect, test, and maintain automatic sprinkler systems.
K 353 · July 27, 2023 · Corrected (the home has a date of correction)
- D
Have simulated fire drills held at unexpected times.
K 712 · July 27, 2023 · Corrected (the home has a date of correction)
- D
Have restrictions on the use of highly flammable decorations.
K 753 · July 27, 2023 · Corrected (the home has a date of correction)
- D
Ensure that testing and maintenance of electrical equipment is performed.
K 921 · July 27, 2023 · Corrected (the home has a date of correction)