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
3D
21E
2F
Potential for minimal harm
0A
0B
0C
January 15, 2026Standard inspection · 1 citation
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, record review, interview, and facility policy review the facility failed to ensure Enhanced Barrier Precautions (EBP) were followed during medication administration through a Percutaneous Endoscopic Gastrostomy (PEG) tube for one (Resident #3) sampled resident based on one of one observation. Specifically, nursing staff did not wear a gown for Personal Protection Equipment (PPE) during medication pass.
October 4, 2024Standard inspection, Complaint inspection · 9 citations
- F
Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.
Inspectors wroteBased on record review and interview, the facility failed to ensure the facility assessment included pertinent information to assure the necessary care and resources were allocated to meet the needs of the residents in 1 of 1 facility. This deficient practice had the potential to affect all residents of the facility. The total census was 100 residents.
- E
Reasonably accommodate the needs and preferences of each resident.
Inspectors wroteBased on observation, interview, and in-service review, it was determined that the facility failed to ensure resident's call lights were in reach for 5 (Residents #13, #24, #51, #80, and #96) of 25 sampled residents.
- 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, interviews, and facility document review, it was determined that the facility failed to clean and sanitize the shower room on 500 Hall which was reviewed for environmental concerns.
- E
Ensure each resident receives an accurate assessment.
Inspectors wroteBased on observation, interviews, record review, and facility policy review, the facility failed to ensure the Minimum Data Set (MDS) assessment was accurately completed for 2 (Resident #88, and Resident #30) of 25 residents reviewed for MDS accuracy. Specifically, the facility failed to ensure information regarding the resident's medication regimen was accurately completed for Resident #30 and failed to ensure information regarding a fall with major injury was accurately completed for Resident #88.
- E
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 observations, interviews, record review, facility document review, it was determined the facility failed to update and/or revise the resident's care plan for 5 (Residents #7, #36, #91, #30, and #72) of 25 residents reviewed for comprehensive care planning. Specifically, the facility failed to include unnecessary medications for Resident #30, change in wound care status for Resident #72, and falls for Resident #7, #36, and #91.
- E
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, record review, and interview, the facility failed to ensure meals were prepared and served according to the planned written menu to ensure nutritionally balanced meals were provided for the residents for 2 of 2 meals observed.
- 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 and interview, the facility failed to ensure foods stored in the refrigerator and freezer were dated to ensure first in and first out; expired dairy products were promptly removed/discarded on or before the expiration or use by date, to prevent the potential for foodborne illnesses; manufacturer's instructions were followed to prevent potential for food spoilage and or bacteria growth; dietary staff washed their hands before handling clean equipment or food items to prevent potential food borne illness for residents who received meals from 1 of 1 kitchen, and hot food items were maintained at 135 degrees Fahrenheit or above on the steam table while awaiting service to prevent potential food borne illness for 1 of 1 meals observed.
- D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteBased on observations, interviews, record review, facility document review, and facility policy review, it was determined the facility failed to provide dignity regarding cleaning the resident after meals for one (Resident #72) of one resident reviewed for resident rights regarding dignity.
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observations, interviews, record review, facility document review, and facility policy review, it was determined the facility failed to ensure an oxygen concentrator was clean, set at the correct rate for delivery, and the tubing was dated appropriately for 1 (Resident #25) of 1 sampled resident reviewed for oxygen therapy.
November 17, 2023Standard inspection · 16 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 and interview, the facility failed to ensure dairy product stored in the refrigerator was sealed to prevent potential for cross contamination; kitchen vents were cleaned to provide a sanitary environment for food preparation, floors, dish washer door frames, kitchen walls, door frames and baseboards were free of rotten wood, chipped floor tiles, debris, dirt, grease, grime, rust, stains, and spills; wall tiles were replaced, kitchen sink was free of utility tape on it; 2 of 2 ice machines were maintained in clean and sanitary condition to prevent potential for bacteria growth for residents who received meals from 1 of 1 kitchen. [...]
- E
Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a suprapubic urinary catheter drainage bag was concealed in a privacy bag when visible to promote dignity and privacy. This failed practice had the potential to affect Resident #81 sample mixed resident with a urinary catheter according to a list of residents with catheters provided by the Administrator on 11/17/23 at 9:10 AM.
- E
Reasonably accommodate the needs and preferences of each resident.
Inspectors wroteBased on observation, interview, and record review the facility failed to ensure call lights were in reach to ensure a safe environment for 2 Residents [Resident #30 and #59] out of 23 Residents [Residents #4, #9, #15, #17, #26, #30, #36, #39, #40, #59, #60, #68, #71, #74, #77, #84, #98, #100, #103, #106, #108, #110, and #221] sample mixed residents from a list of Residents able to use call lights provided by the Administrator on 11/17/23 at 9:10 AM.
- E
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Inspectors wroteBased on interview, and record review the facility failed to ensure 2 Residents (Resident #108, and Resident #4) of 4 Residents (Resident #4, Resident #100, Resident #108, and Resident #221) sampled residents who were reviewed for advance directive had an advance directive readily available in their clinical record.
- 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 observation, interview, and record review the facility failed to maintain resident rooms in good repair [rooms [ROOM NUMBERS]] of 12 rooms on 400 hall, failed to maintain resident rooms in good repair for 1 (room [ROOM NUMBER]) of 8 rooms on 500 Hall.
- E
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Inspectors wroteBased on interview and record review, the facility failed to ensure either a Death or Discharge Minimum Data Set (MDS) was performed for 2 (Residents #2 and #87) sampled residents identified as having MDS records over 120 days old.
- E
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure fingernails were regularly trimmed and cleaned to promote good personal hygiene and grooming. for 2 [Resident #4 and #77] Residents of 23 [Residents #4, #9, #15, #17, #26, #30, #36, ##9, #40, #59, #60, #68, #71, #74, #77, #84, #98, #100, #103, #106, #108, #110, and #221] sample mixed residents from a list of residents provided by the Administrator on 11/17/23 at 9:10 am who require assistance with nail care.
- E
Provide activities to meet all resident's needs.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure an ongoing schedule of activities was provided to meet the needs of 16 Residents (Residents #15, #26, #30, #36, #40, #53, #68, #71, #77, #98, #100, #103, #108, #110, #116, and #221) of 24 sampled residents.
- E
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 obtain a physician's order to administer oxygen for 1 [Resident #15] resident out of 11 [Resident's #15, #36, #53, #59, #60, #74, #77, #98, #100, #110, and #221] sample mix residents on oxygen. The facility failed to complete a Neurological Assessment after an unwitnessed fall, for 1 [Resident #30] resident of 6 [Residents #30, #74, #77, #84, #98, #103] sample mixed residents who had an unwitnessed fall in the past 3 month The facility failed to follow a physician's order, for 1 [Resident #74] resident out of 11 [Resident's #15, #36, #53, #59, #60, #74, #77, #98, #100, #110, #221] sample mix residents who receive oxygen.
- E
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on observation, record review and interview, the facility failed to ensure resident medication was not left at the beside. for 1 Resident #110 out of 24 sampled residents, and the facility failed to provide the proper trash can for the disposal of cigarette butts in the smoking area. This had the potential to affect 115 residents provided by the Administrator from the census list on 11/13/23. The facility failed to post alerts that oxygen was being administered for 4 (Residents #15, #60, #100, #221) of 12 (Residents #15, #36, #53, #59, #60, #74, #77, #98, #100, #104, #110, and #221) sampled residents that had orders for supplemental oxygen. The facility failed to secure a maintenance access hatch in 1 room [ROOM NUMBER] of 8 rooms on 500 Hall. [...]
- E
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observation, interview, and record review the facility failed to follow physician orders for 5 (Resident #74, Resident #98, Resident #100, Resident #110, and Resident #221) of 12 (Resident #15, Resident #36, Resident #53, Resident #59, Resident #60, Resident #68, Resident #74, Resident #77 Resident #98, Resident #100, Resident #110, and Resident #221) sampled residents who had an order for oxygen, and failed to ensure a Continuous Positive Airway Pressure [CPAP] mask was contained. This failed practice had the ability to affect 1 Resident #74 of 3 Residents (Residents #26, #60, #74) sample mixed residents that use a CPAP from a list provided by the Administrator on 11/16/23 at 11:24 AM.
- E
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, record review and interview, the facility failed to ensure meals were prepared and served in accordance with the planned written menu to meet the nutritional needs of the residents for 1 of 1 meal observed. On11/14/23 at 07:38 AM, the following observations were made during breakfast meal service. a. The residents on pureed diets were served pureed sausage, pureed bread, pureed eggs, pureed oatmeal, juice, and milk. There was no pureed pear or pureed french toast served to them. b. The residents on regular and mechanical soft diets were not served fruits. c. On11/14/23 at 8:05 AM Dietary Employee (DE) #1 used a #16 scoop (1/4) cup inside a pan of pureed oatmeal on the steam table to serve a single portion of pureed oatmeal to the residents on pureed diets. [...]
- 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 ensure meals were served in a method that maintained the appearance of cold and hot foods at temperatures that were acceptable to residents to improve palatability and encourage good nutritional intake during 2 of 2 meal observed. This failed practice had the potential to affect 20 residents who receive meal trays in their rooms on the 100 and 200 Hall, 6 residents who receive meal trays on the 300 hall, 15 residents who receive meal trays in their room on the 400 hall, 10 residents who receive meal trays in their room on 500 Hall, 20 residents who receive meal trays in their room on the 700 hall, as documented on a list 1 provided by the Dietary Supervisor on 11/15/23 at 10:47 AM.
- E
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
Inspectors wroteBased on observation and interview, the facility failed to ensure pureed food items were blended to a smooth, lump-free consistency to minimize the risk of choking or other complications for residents who required pureed diets for 3 of 3 meals observed. This failed practice had the potential to affect 11 residents who received pureed diets.
- E
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
Inspectors wroteBased on interview and record review, the facility failed to ensure all required members of the QAA committee attended required quarterly Quality Assessment and Assurance/Quality Assurance & Performance Improvement (QAA/QAPI) meetings.
- E
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview, and record review the facility failed to ensure staff had on appropriate Personal Protective Equipment (PPE) for 1 (Resident #84) of 2 (Resident #40, and Resident #84) sampled residents that were on contact isolation, and failed to ensure a nasal cannula [NC] found on the floor was discarded for1 [Resident #59] resident of 11 [Resident's #15, #36, #53, #59, #60, #74, #77, #98, #100, #110, #221] sample mixed residents that receive oxygen.
Fire safety inspections
9 fire safety citations on file: 3 on January 15, 2026, 1 on October 4, 2024, 5 on November 17, 2023.
Every fire safety citation9 citations
- F
Use approved construction type or materials.
K 161 · January 15, 2026 · Corrected (the home has a date of correction)
- F
Provide properly protected cooking facilities.
K 324 · January 15, 2026 · Corrected (the home has a date of correction)
- F
Ensure proper usage of power strips and extension cords.
K 920 · January 15, 2026 · Corrected (the home has a date of correction)
- F
Provide properly protected cooking facilities.
K 324 · October 4, 2024 · Corrected (the home has a date of correction)
- F
Conduct risk assessment and an All-Hazards approach.
E 6 · November 17, 2023 · Corrected (the home has a date of correction)
- F
Provide emergency officials' contact information.
E 31 · November 17, 2023 · Corrected (the home has a date of correction)
- F
Conduct testing and exercise requirements.
E 39 · November 17, 2023 · Corrected (the home has a date of correction)
- F
Implement emergency and standby power systems.
E 41 · November 17, 2023 · Corrected (the home has a date of correction)
- F
Install a fire alarm system that can be heard throughout the facility.
K 341 · November 17, 2023 · Corrected (the home has a date of correction)