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 24 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
1K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
20D
2E
1F
Potential for minimal harm
0A
0B
0C
June 24, 2025Standard inspection, Complaint inspection · 8 citations
- K
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 each resident received adequate supervision and assistance devices to prevent accidents for 2 out of 32 residents (Resident #93 and Resident #13) reviewed for adequate supervision. - The facility failed to ensure Resident #93 who was on continuous oxygen did not smoke while oxygen was being administered from 03/20/25 through 06/03/25. The facility documented they found cigarettes and a lighter in Resident #93's room on 03/22/25 and was observed smoking while on oxygen in front of the facility on 4/18/25 and 06/03/25. -The facility failed to ensure Resident #13 bed rail/assistance bar was attached to the bed securely. when the rail/assistance bar was observed on the floor on 06/03/25. [...]
- 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 ensure residents have a right to personal privacy for 1 of 4 residents (Resident #355) reviewed for privacy, in that: - The facility failed to place Resident #355's foley catheter bag inside of a privacy bag on 06/03/2025. These failures placed residents at risk for embarrassment, at risk of loss of dignity and decrease in quality of life.
- D
Reasonably accommodate the needs and preferences of each resident.
Inspectors wroteBased on observations, interviews and record review, the facility failed to ensure residents receive services in the facility with reasonable accommodation of resident needs for 1 of 8 residents (Resident #11) reviewed for call lights. The facility failed to ensure Resident #11 call light within reach while resident was in bed on 06/03/25. This failure could place residents at risk for a delay in care and services, increased falls, and a decreased quality of life.
- 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 interview and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs and describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 2 of 4 residents (Resident #20 and Resident #78) reviewed for comprehensive care plans. -The facility failed to ensure that Resident #20's requirement for anticoagulants was a focus area in the resident's comprehensive care plan no date provided and no intervention was documented in place. [...]
- 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, interview, and record review, the facility failed to ensure residents who were incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 2 of 3 residents (Resident #155 and Resident #88) reviewed for incontinent care. 1. The facility failed to ensure CNA M cleaned Resident #155's indwelling Foley catheter properly and followed proper hand hygiene during incontinent care on 6/5/25. 2. The facility failed to ensure C.NA P cleaned Resident #88 properly during incontinent care on 6/5/25 These failures could place residents at risk for pain, infection, injury, and hospitalization.
- 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, and record review, the facility failed to provide pharmaceutical services including procedures that assure the accurate acquiring, receiving, dispensing, and sdministering of all drugs and biologicals to meet the needs of each resident for 1 of 1 medicationstorage room observed for expired medications in that: The facility failed- On 06/03/35 when there were 15 hydrocortisone acetate 25mg (a topical steroid used to treat pain, itching, and swelling in the rectum {the end of the large intestine where stool is stored until it exits the body through the anus} and anus,) suppositories (medication used to insert into the rectum) with an expiration date that read 05/2025. This medication belonged to CR #100 who discharged on 04/12/2025. This failure placed resident at risk for an unwanted adverse drug reaction had the resident not discharged from the facility.
- 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, interview, and record review, the facility failed to ensure that drugs and biologicals used in the facility were labeled in accordance with currently accepted professional standards for 1 medication storage room. in that: The facility failed- On 06/03/35 when there were 15 hydrocortisone acetate 25mg (a topical steroid used to treat pain, itching, and swelling in the rectum {the end of the large intestine where stool is stored until it exits the body through the anus} and anus,) suppositories (medication used to insert into the rectum) with an expiration date that read 05/2025. This medication belonged to CR #100 who discharged on 04/12/2025. This failure placed resident at risk for an unwanted adverse drug reaction had the resident not discharged from the facility.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview and record review, the facility failed to maintain an infection and prevention control program that included, at a minimum, a system for preventing and controlling infections for 1 of 2 residents (Resident #155) and 1 of 2 staff (CNA M) reviewed for incontinent care and to help prevent the development and transmission of communicable diseases and infections for 1 (Resident #71) of 28 residents reviewed for infection control. The facility failed to ensure CNA M washed or sanitized her hands and performed glove changes appropriately while providing incontinence care to Resident #155 on 06/05/25. The facility failed to ensure Resident #71's foley catheter drainage bag was not resting on the resident's floor mat on 06/03/25. This deficient practice placed residents at risk for cross contamination and the spread of infection.
May 22, 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 interview and record review, the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality for 1 of 2 closed records (CR #1) reviewed for resident rights. 1. The facility failed to ensure the Certified Occupational Therapist Assistant (COTA) did not use CR#1's debit card resulting in CR #1 losing $45.00. 2. The facility failed to ensure the COTA did not use CR #1's cellphone to access CR #1's banking information resulting in CR #1 losing $250.00. These failures placed residents at risk of decreased feelings of self-worth and decreased quality of life.
- D
Protect each resident from the wrongful use of the resident's belongings or money.
Inspectors wroteBased on interview and record review, the facility failed to ensure residents had the right to be free of misappropriation of property and exploitation for 1 of 2 residents Closed Record (CR) #1 reviewed for misappropriation and exploitation, in that: 1. The facility failed to ensure the Certified Occupational Therapist Assistant (COTA) did not take CR#1's debit card without permission resulting in CR #1 losing $45.00. 2. The facility failed to ensure the COTA did not use CR #1's cellphone to access CR #1's banking information resulting $250.00 being taken from CR #1's account. These failures could affect residents and their responsible party by preventing them from having access to their funds.
May 2, 2024Standard inspection, Complaint inspection · 8 citations
- D
Keep residents' personal and medical records private and confidential.
Inspectors wroteBased on observation, interview and record review, the facility failed to ensure personal privacy by securing signed consents for the use of security cameras for 1 of 2 (Resident #28) residents reviewed for privacy. The facility failed to ensure CNA A closed Resident #52's door or pulled the curtain when repositioning Resident #52 This failure could place residents at risk of embarrassment, and reduction of the self-esteem and self-worth by not being provided desired privacy during personal care or meetings with family or physicians.
- D
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Inspectors wroteBased on interview and record review, the facility failed to ensure a resident's assessment was completed within 7 and 14 days, and electronically transmit encoded, accurate, and complete MDS data to the CMS System for a subset of items upon a resident's transfer, reentry, discharge, and death for 2 of 2 discharged residents (CR #73 and CR #76) reviewed for encoding and transmitting resident assessments, in that: - The Facility failed to complete and transmit a discharge MDS for CR #73. - The Facility failed to complete and transmit a discharge MDS for CR #76. This failure could place discharged residents at risk of not having a proper discharge and not receiving services post discharge.
- D
Ensure each resident receives an accurate assessment.
Inspectors wroteBased on interview and record review, the facility failed to ensure assessments accurately reflected the status for 1 of 4 residents (CR#93) reviewed for MDS assessments. The facility failed to accurately code CR#93's discharge MDS assessment. This failure could place residents at risk of not receiving adequate care and services to meet their needs.
- 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 interviews, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that includes measurable objective and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 1 (Resident #52) of 8 residents reviewed for care plans. The facility failed to ensure Resident #52's care plan reflected he had a foley catheter. This failure could place residents at risk of not receiving appropriate care to meet their current needs.
- 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, interview, and record review, the facility failed to ensure residents who were incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 1 of 3 residents (Resident #52) reviewed for incontinent care. 1. The facility failed to ensure CNA A cleaned Resident #52's indwelling Foley catheter properly and followed proper hand hygiene during incontinent care. These failures could place residents at risk for pain, infection, injury, and hospitalization.
- 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 and record review, the facility failed to ensure that drugs and biologicals used in the facility were accurately acquired, received, dispensed, and administered in accordance with currently accepted professional standards for 1 of 1 resident (#447), 2 of 4 medication carts (400 hall nurse cart and 100 hall medication aide cart) and 1 of 1 medication room reviewed for medication storage. - At bedside of Resident #447 were Equate (brand name) lubricant eye drops 0.5 oz. - The 400-hall nurse's medication cart contained discontinued ipratropium bromide inhalation solution, sore throat spray, and genteel tears and there was no expiration date on medication: zinc oxide ointment skin protectant. [...]
- 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, interview, and record review, the facility failed to ensure all drugs and biological were stored in locked storage area and to limit access to authorized personnel for 1 of 1 resident (#447) room reviewed for medication storage. -The facility failed to ensure all drugs and biologicals were stored in locked storage area and limited access to authorized personnel. These deficient practices could place residents at risk of medication misuse and drug diversion.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview and record review, the facility failed to maintain an infection and prevention control program that included, at a minimum, a system for preventing and controlling infections for 1 of 2 residents (Resident #52) and 1 of 2 staff (CNA A) reviewed for incontinent care as indicated by: The facility failed to ensure CNA A washed or sanitized her hands after doffing (taking off) dirty gloves and went to clean linen cart parked on the hallway for linen. This deficient practice placed residents at risk for cross contamination and the spread of infection.
February 2, 2024Complaint inspection · 4 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 interview and record review, the facility failed to provide pharmaceutical services including procedures that assure the accurate acquiring and administering of all medications to meet the needs of each resident for one (Closed Record #1) reviewed for pharmacy services. 1. Unit Manager A failed to transcribe physician orders to administer Atorvastatin Calcium Oral Tablet 40 MG at bedtime for CR #1. These failures placed CR #1 at risk of not receiving full dosage and treatment of medication as ordered. Findings Include: Record review of CR #1's facility face sheet dated 12/1/2023 revealed a [AGE] year-old female with an initial admission date of 5/10/2023 and re-admission date of 11/8/2023. [...]
- E
Ensure that residents are free from significant medication errors.
Inspectors wroteBased on observation, interview and record review the facility failed to ensure residents were free of significant medication errors for 1 resident CR #1) reviewed for medication errors in that: 1. The facility failed to ensure Unit Manager transcribed physician orders to administer Atorvastatin Calcium Oral Tablet 40 MG at bedtime for CR # These failures placed residents at risk of not receiving treatment of medication as ordered to treat medical diagnoses. Record review of the Medication Error Report dated 7/7/2023 read in part .Oral Tablet 40 MG (Atorvastatin Calcium) Give 1 tablet by mouth one time a day related to other Hyperlipidemia was d/c'd in error for CR #1;orders to run lab. Lipid panel lab results were returned and within normal ranges. NP notified . [...]
- D
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Inspectors wroteBased on interview and record review, the facility failed to ensure residents were free from abuse for 1 of 4 residents (Resident #2) reviewed for resident abuse. The facility failed to prevent Resident #2 from being verbally abused by RA O. This failure could place residents at risk of physical harm, mental anguish, and/or emotional distress.
- D
Protect each resident from the wrongful use of the resident's belongings or money.
Inspectors wroteBased on interview and record review, the facility failed to ensure residents had the right to be free from abuse, neglect, misappropriation of resident property, and exploitation for 2 of 7 residents (Resident #2 and Resident #3) reviewed for misappropriation. The facility failed to prevent misappropriation of property when RA O and CNA M used Resident #2 and Resident #3's phone chargers and charged their phones. This deficient practice could affect any resident and could contribute to continued misappropriation of resident's property.
February 16, 2023Standard inspection · 2 citations
- F
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 each resident receives and the facility provides food that is palatable and at an appetizing temperature for 7 of 21 residents reviewed for food and nutrition dietary services (Resident #32, #50, #52, #53, #55, #79, #88), in that: ---(11) residents in a confidential group interview said the food was cold and not palatable when it was served ---residents said food was cold and not palatable when it was served and had no flavor This failure placed residents who ate meals in the dining room and in their rooms at risk of diminished quality of life and weight loss due to decreased food quality and temperature.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an infection prevention and control process designed to provide safe and sanitary environment and to help prevent the development and transmission of diseases and infections for handling of residents clothes and linen in the laundry. Facility failed to ensure residents dirty and soiled clothes/linen were contained in a bag. This failure could place residents who had their clothes or linen laundered by the facility at risk of cross contamination and infection.
Fire safety inspections
7 fire safety citations on file: 2 on June 24, 2025, 5 on May 2, 2024.
Every fire safety citation7 citations
- E
Provide properly protected cooking facilities.
K 324 · June 24, 2025 · Corrected (the home has a date of correction)
- E
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
K 741 · June 24, 2025 · Corrected (the home has a date of correction)
- E
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
K 222 · May 2, 2024 · Corrected (the home has a date of correction)
- E
Provide properly protected cooking facilities.
K 324 · May 2, 2024 · Corrected (the home has a date of correction)
- E
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · May 2, 2024 · Corrected (the home has a date of correction)
- E
Ensure precautions for handling oxygen cylinders and equipment are correctly followed.
K 929 · May 2, 2024 · Corrected (the home has a date of correction)
- D
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · May 2, 2024 · Corrected (the home has a date of correction)