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 47 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
2J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
32D
11E
0F
Potential for minimal harm
0A
1B
1C
September 17, 2025Standard inspection, Complaint inspection · 15 citations
- 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, residents and staff interviews, the facility failed to fill the gaps around the packaged terminal air conditioners (PTACs) to separate the exterior environment from the interior of the residents' rooms and failed to secure the seal around the PTACs (rooms #108, #110, #135, #151) for 4 of 8 rooms on 3 of 4 halls reviewed for homelike environment.
- E
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Inspectors wroteBased on observations, record review and resident, staff and Pest Control Technician interviews, the facility failed to maintain an effective pest control program to prevent the presence of roaches and/or flies that were observed in 1 of 1 conference room, 1 of 1 lobby, 2 of 2 resident hallways (East and [NAME] hallways), and 4 of 4 resident rooms (Rooms 108, 109, 113, and 134).
- D
Reasonably accommodate the needs and preferences of each resident.
Inspectors wroteBased on observations, resident and staff interviews, the facility failed to ensure a dependent resident could access the call light device for 1 of 2 residents reviewed for accommodation of needs (Resident #5).
- D
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Inspectors wroteBased on observation, record review, resident, responsible party, and staff interviews, the facility failed to protect a resident's right to be free from resident to resident sexual abuse when Nurse Aide #7 and Floor Technician #1 observed Resident #22, a male resident, fondle a severely cognitively impaired female resident (Resident #27) when he placed his hand under her shirt near/on her bare breast. Resident #27 did not have the cognitive capacity to consent to this intimate sexual contact. This deficient practice affected 1 of 3 residents reviewed for resident-to-resident abuse (Resident #27).
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on record review and staff interviews, the facility failed to report an allegation of resident to resident sexual abuse to Adult Protective Services (APS) for 1 of 3 residents reviewed for resident to resident abuse (Resident #27).
- D
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Inspectors wroteBased on record review and staff and Ombudsman interviews, the facility failed to notify the Ombudsman in writing of the resident's discharge home for 1 of 3 residents reviewed for discharge (Resident #88).
- D
Ensure services provided by the nursing facility meet professional standards of quality.
Inspectors wroteBased on observations, record review, and family and staff interviews, the facility failed to provide treatment to a resident's bilateral legs for arterial and venous ulcers (an ulcer due to inadequate blood supply) as specified in the physician orders for 1 of 2 residents reviewed for arterial and venous wounds (Resident #2). In addition, the facility failed to ensure transportation was arranged for a resident to attend a scheduled appointment with a Gastroenterologist (doctor who specializes in gastrointestinal issues). This occurred for 1 of 3 residents reviewed for medical appointments (Resident #97).
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on record review, family member, staff, Nurse Practitioner, wound care physician, and Assisted Living Facility Executive Director interviews, the facility failed to identify, assess, and obtain wound care orders for a wound on the left ankle for 1 of 5 residents reviewed for wound care (Resident #89).
- D
Provide appropriate foot care.
Inspectors wroteBased on observations, staff, resident, and Nurse Practitioner (NP) interviews and record review, the facility failed to assess resident's feet to determine if nail care was needed, ensure resident's toenails were trimmed and podiatry services were arranged for 2 of 2 residents reviewed for foot care (Resident #3 and Resident #2).
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on observation, record review, resident and staff interviews, the facility failed to provide safe mechanical lift transfers when the lift swung and hit the resident on the forehead resulting in a hematoma (collection of blood outside of a blood vessel) (Resident #56). In addition, staff failed to follow manufacturer guidelines for the use of a mechanical lift (Resident #5). This affected 2 of 3 residents reviewed for free of accident hazards, supervision and devices (Resident #56 and Resident #5).
- 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 observations, record review, and staff interviews, the facility failed to empty urinary drainage bag and secure urinary catheter tubing with anchoring device to prevent trauma to urinary opening or dislodgment of the catheter. The deficient practice occurred for 1 of 2 residents reviewed for urinary catheter care (Resident #5).
- 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, record review, and staff interviews, the facility failed to follow procedure for labeling a continuous gastrostomy tube (a tube surgically placed in the stomach to provide nutrition, hydration, and medications) feeding. This deficient practice was for 1 of 2 residents reviewed for enteral (the administration of nutrients directly into the gastrointestinal tract through a tube) feeding management (Resident #3).
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observations, record reviews, and staff and Nurse Practitioner (NP) interviews, the facility failed to ensure oxygen was delivered at the prescribed rate for 1 of 4 residents reviewed for respiratory care and services (Resident #3).
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observations, record reviews and staff interviews, the facility failed to follow their Enhanced Barrier precaution policy when Nurse #2 did not don (put on) a gown to administer medications via gastrostomy (tube in the stomach) tube and Nurse Aide (NA) #1 did not don a gown to provide care to a urinary catheter for Resident #5. Additionally, the facility did not follow their hand hygiene policy or their clean dressing policy when the Wound Nurse failed to clean and sanitize her hands while preparing for a wound dressing after coming in contact with unclean surfaces. The deficient practice occurred for 3 of 10 staff (Nurse #2, NA #1, and Wound Nurse) observed for infection control.
- D
Make sure that a working call system is available in each resident's bathroom and bathing area.
Inspectors wroteBased on observations, resident, and staff interviews, the facility failed to ensure the call light system was functioning properly for 1 of 2 residents who required assistance for activities of daily living (Resident #66).
June 27, 2024Standard inspection · 5 citations
- E
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 record reviews, and interviews with staff, Hospice Nurse, Medical Director and Consultant Pharmacist, the facility failed to limit the duration of an antipsychotic medication (a drug that affects brain activities associated with mental processes and behaviors) ordered on an as needed (PRN) basis to 14 days and failed to monitor for abnormal involuntary movements on a resident receiving an antipsychotic medication (Resident #63) for 1 of 5 residents reviewed for unnecessary medications.
- E
Ensure that residents are free from significant medication errors.
Inspectors wroteBased on record review and staff, Medical Director, Vascular Physician Assistant (PA), Nurse Practitioner (NP) interviews, the facility failed to prevent a significant medication error when a resident did not receive an antiplatelet medication as ordered. This deficient practice occurred for 1 of 1 resident (Resident #68) reviewed for significant medication errors.
- D
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 record review and staff interviews, the facility failed to have advanced directives accurate throughout the medial record for 2 of 3 residents (Resident #47 and Resident #45) reviewed for advanced directives.
- D
Ensure medication error rates are not 5 percent or greater.
Inspectors wroteBased on observations, record review, staff, Nurse Practitioner (NP), and Pharmacist interviews the facility failed to maintain a medication error rate of less than 5% by having 2 errors out of 27 opportunities which resulted in an 7.41% medication error rate. This affected 1 of 3 residents observed for medication administration (Resident # 14).
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observations, record review, staff, and Nurse Practitioner (NP) interview the facility failed to wear personal protective equipment (PPE) while providing wound care for a resident requiring Enhanced Barrier Precautions (EBP). This deficit practice occurred for 1 of 3 residents reviewed for EBP (Resident #68).
May 3, 2024Complaint inspection · 3 citations
- 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 observations, record review, resident and staff interviews, the facility failed to keep a urinary catheter drainage bag off the floor to reduce the risk of infection for 1 of 2 residents reviewed with urinary catheters (Resident 2).
- C
Post nurse staffing information every day.
Inspectors wroteBased on observations, staff interviews and record review, the facility failed to post nurse staffing data at the beginning of each shift for 2 of 2 days of the survey.
- B
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, staff interviews and record review, the facility failed to update the comprehensive person-centered individualized care plan to reflect an assessment to self-administer medications. This failure occurred for 1 of 1 sampled resident reviewed for self-administration of medications (Resident #3).
April 24, 2024Complaint inspection · 3 citations
- J
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on record review, observations, and resident and staff interviews, Transporter #1 failed to call emergency medical services (EMS) or have a resident assessed by a medical professional before moving Resident #1 after his wheelchair tipped over and he fell to the floor of a transportation van. On 1/19/24 Transporter #1 pulled out of the dialysis center parking lot and Resident #1's wheelchair tipped backwards, and he hit the left occipital region of his head. Transporter #1 pulled the transportation van over to a parking lot and pulled the resident back up into a sitting position and transported Resident #1 8.4 miles back to the facility. The transporter was not qualified to provide a competent physical assessment to determine if there was an adverse outcome for this resident who was on Plavix (anti-platelet medication that can have a side effect of bleeding). [...]
- J
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on record review, observation, resident, and staff interviews, the facility failed to provide safe transportation for Resident #1 when he was being transported from dialysis back to the facility on 1/19/2024. Transporter #1 pulled out of the parking lot of the dialysis center and Resident #1's wheelchair tipped over, and he hit the left side of his head. Transporter #1 pulled the transportation van over to a parking lot, where Resident #1 insisted upon Transporter #1 sitting him back upright, and Transporter #1 pulled the resident back up into a sitting and upright position. Transporter #1 then transported Resident #1 8.4 miles back to the facility where he was assessed by the Assistant Director of Nursing (ADON) to have a bump on his head behind his left ear and he reported head pain and nausea after the fall. [...]
- D
Allow residents to self-administer drugs if determined clinically appropriate.
Inspectors wroteBased on record review, observations, resident and staff interviews, the facility failed to assess whether the self-administration of medications was clinically appropriate for 1 of 1 resident (Resident #1) who was observed to have a medication at bedside.
February 28, 2023Standard inspection · 21 citations
- E
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Inspectors wroteBased on record review, observations, resident and staff interviews, the facility failed to provide residents with their preferred method of bathing (Residents #135, #1, #12, #58, and #284) and failed to accommodate a resident's request to be assisted out of bed (Resident #70) for 6 of 8 residents reviewed for choices and dignity.
- 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 and staff interviews the facility failed to repair jagged and splintered edges on the middle and lower portion of a bathroom door in the residents shared bathroom (room [ROOM NUMBER]); failed to clean the air vents and filters of the air condition and heating units in resident rooms (rooms 102, 106, 108, and 109); failed to maintain walls in good repair in a resident's room (room [ROOM NUMBER]-B) on 1 of 2 wings (West Wing). The facility failed to maintain a clean and sanitary side rail for a resident's bed (room [ROOM NUMBER]-A); failed to appropriately label and store personal care equipment in residents shared bathrooms (rooms [ROOM NUMBER]); failed to maintain functioning overhead lights in residents bathrooms (rooms [ROOM NUMBERS]); failed to provide functioning soap dispensers in residents bathrooms (rooms [ROOM NUMBERS]); [...]
- E
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on observations, record review, and resident and staff interviews the facility failed to provide incontinence care (Resident #48), nail care (Resident #487, Resident #61, Resident #54, and Resident #185), and a shave (Resident #487) for 5 of 14 dependent residents reviewed for activities of daily living (ADL).
- E
Ensure that the resident and his/her doctor meet face-to-face at all required visits.
Inspectors wroteBased on record review and staff interviews, the facility failed to ensure physician visits were alternated with the Family Nurse Practitioner's visits every 60 days for 3 of 3 sampled residents reviewed for physician visits (Residents #3, #39 and #16).
- 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 observations, record review, resident, family and staff interviews, the facility failed to provide sufficient nursing staff resulting in residents not having their choices honored for bathing and not receiving transfer assistance when requested for 6 of 8 sampled residents (Residents #135, #1, #12, #58, #284, and #70).
- E
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on observations and staff interviews the facility failed to date and label opened food and remove expired food from 1 of 3 reach-in refrigerators. This practice had the potential to affect food served to residents.
- E
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Inspectors wroteBased on observations, record review, and staff interviews, the facility's Quality Assessment and Assurance (QAA) Committee failed to maintain implemented procedures and monitor the interventions that the committee put into place following a recertification and complaint investigation survey completed on 11/22/21 and a complaint investigation survey completed on 02/17/22. This was for one repeat deficiency in the area of activities of daily living provided for dependent residents originally cited on 11/22/21 during a recertification and complaint investigation survey and on 02/17/22 during a complaint investigation survey. [...]
- D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteBased on observations and staff interviews, the facility failed to maintain a resident's dignity by not providing incontinence care and oral hygiene when needed, ensuring bed linen and fall mat were clean and free of food debris, and ensuring the room was free of odor for 1 of 12 residents reviewed for dignity (Resident #48). The reasonable person concept was applied to this deficiency. Individuals would expect to receive care needed and would be upset if observed with dried food debris on their mouth, bed, and floor; lying on bed linen that was not clean; and if their room smelled of urine.
- D
Allow residents to self-administer drugs if determined clinically appropriate.
Inspectors wroteBased on observations, record review, resident and staff interviews, the facility failed to assess the ability of a resident to self-administer medications for 1 of 2 residents reviewed for self-administration of medications (Resident # 186). Resident #186 was admitted to the facility on [DATE]. Review of the admission Minimum Data Set, dated [DATE] revealed Resident #186 was assessed as being cognitively intact. Review of Resident #186's medical records revealed no assessment for self-administering medications was included. Review of physician orders revealed on 02/15/23 an order was written for triamcinolone acetonide external lotion 0.1 % to apply to affected area topically two times a day for 14 days for atopic dermatitis. [...]
- D
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 record review and staff interviews, the facility failed to maintain accurate advanced directives throughout the medical record for 2 of 32 residents reviewed (Residents #18 and #29).
- D
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Inspectors wroteBased on record review and staff interviews, the facility failed to provide a Centers for Medicare and Medicaid Services (CMS) Notice of Medicare Non-coverage (NOMNC) and Skilled Nursing Facility Advanced Beneficiary Notice (SNF ABN) prior to discharge from Medicare Part A skilled services to 1 of 3 residents reviewed for beneficiary notification review (Resident #27). The Findings Included: Resident #27 was admitted to the facility on [DATE]. A review of Resident #27's medical record revealed no evidence a NOMNC and SNF ABN were provided to her or her Responsible Party (RP) which explained Medicare Part A coverage for skilled services would end on 10/31/22. Resident #27 remained in the facility. A joint interview was conducted with the Social Worker (SW) and Minimum Data Set (MDS) Nurse #1 on 02/22/23 at 9:36 AM. [...]
- D
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Inspectors wroteBased on observations and staff interviews the facility failed to ensure that a resident was free from neglect when it failed to provide incontinence care for 1 of 3 residents reviewed for incontinence care (Resident #48). The reasonable person concept was applied to this deficiency. Individuals would expect to receive the care needed and would be upset if left in a wet bed.
- D
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Inspectors wroteBased on record review and staff interviews, the facility failed to complete comprehensive Minimum Data Set (MDS) assessments within 14 days of the Assessment Reference Date (abbreviated as ARD and referring to the last day of the assessment period) for 2 of 32 sampled residents (Residents #75 and #135).
- D
Ensure each resident receives an accurate assessment.
Inspectors wroteBased on record review and staff interviews, the facility failed to accurately code Minimum Data Set (MDS) assessments in the areas of Preadmission Screening and Resident Review (PASRR) and hospice for 2 of 32 sampled residents reviewed for MDS accuracy (Resident #45 and #34).
- D
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Inspectors wroteBased on record review and staff interviews, the facility failed to request a Preadmission Screening and Resident Review (PASRR) before the expiration date for 1 of 3 residents reviewed with a Level II PASRR (Resident #45).
- D
Notify the appropriate authorities when residents with MD or ID services has a significant change in condition.
Inspectors wroteBased on record review and staff interviews, the facility failed to request a Preadmission Screening and Resident Review (PASRR) re-evaluation after a significant change in physical status for 1 of 3 residents diagnosed with a mental health disorder (Resident #29).
- 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 record review and staff interviews, the facility failed to develop a comprehensive, individualized care plan that addressed Preadmission Screening and Resident Review (PASRR) Level II status for 1 of 3 sampled residents reviewed for PASRR (Resident #45).
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on observations, record review, resident and staff interview the facility failed to supervise 1 of 4 residents reviewed for smoking (Resident #22).
- 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 record review and Pharmacy Consultant, Nurse Practitioner (NP), and staff interviews the facility failed to attempt a gradual dose reduction (GDR) of antipsychotic ordered 07/27/22 and antidepressant medication ordered 03/12/22 for 1 of 5 residents reviewed for unnecessary medication (Resident #34).
- 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 observations and staff interviews the facility failed to keep unattended medications stored in a locked medication cart for of 1 of 4 medication carts (East A medication storage cart) and they failed to ensure medications were under direct observation by the administering nurse who left medications unattended at the bedside for 1 of 2 residents (Resident #1) reviewed for medication storage.
- D
Make sure that a working call system is available in each resident's bathroom and bathing area.
Inspectors wroteBased on observations, resident, and staff interviews, the facility failed to ensure the call light annunciator panel located at the nurses' station functioned to identify the room number and sound an alarm and failed to ensure the light above the room entry door worked when the call light at the bedside and bathroom were engaged for 1 of 17 residents (Resident #16) reviewed for call lights on 1 of 2 wings (West Wing).
Fire safety inspections
14 fire safety citations on file: 3 on June 27, 2024, 10 on February 28, 2023, 1 on November 22, 2021.
Every fire safety citation14 citations
- 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 · June 27, 2024 · Corrected (the home has a date of correction)
- D
Inspect, test, and maintain automatic sprinkler systems.
K 353 · June 27, 2024 · Corrected (the home has a date of correction)
- D
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · June 27, 2024 · Corrected (the home has a date of correction)
- D
Have exits that are accessible at all times.
K 271 · February 28, 2023 · 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 · February 28, 2023 · Corrected (the home has a date of correction)
- D
Provide properly protected cooking facilities.
K 324 · February 28, 2023 · Corrected (the home has a date of correction)
- D
Have an alternate power supply for its alarm system.
K 344 · February 28, 2023 · Corrected (the home has a date of correction)
- D
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · February 28, 2023 · Corrected (the home has a date of correction)
- D
Install an approved automatic sprinkler system.
K 351 · February 28, 2023 · Corrected (the home has a date of correction)
- D
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
K 521 · February 28, 2023 · Corrected (the home has a date of correction)
- D
Meet requirements for the use of electrical equipment.
K 919 · February 28, 2023 · Corrected (the home has a date of correction)
- D
Ensure that testing and maintenance of electrical equipment is performed.
K 921 · February 28, 2023 · Corrected (the home has a date of correction)
- D
Have proper medical gas storage and administration areas.
K 923 · February 28, 2023 · Corrected (the home has a date of correction)
- D
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · November 22, 2021 · Corrected (the home has a date of correction)