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 36 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
1G
0H
0I
Potential for more than minimal harm
20D
12E
0F
Potential for minimal harm
0A
3B
0C
June 6, 2025Standard inspection, Complaint inspection · 6 citations
- D
Allow resident to participate in the development and implementation of his or her person-centered plan of care.
Inspectors wroteBased on record review, staff and resident representative interviews, the facility failed to conduct a care plan conference and offer the resident and resident representative the right to participate in the person-centered care planning process for 1 of 5 residents reviewed for care plans (Resident #346).
- D
Ensure each resident receives an accurate assessment.
Inspectors wrote2. A hospital referral form dated 10/25/24 revealed Resident #147 required continuous supplemental oxygen. Resident #147 was admitted to the facility on [DATE] with a diagnosis of chronic obstructive pulmonary disease (COPD). A nursing progress note dated 11/01/24 revealed Resident #147 required 3 liters of supplemental oxygen. A review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #147 was coded for no oxygen therapy. An interview on 6/5/2025 at 9:38 AM with the MDS Coordinator indicated she reviewed the residents progress notes and referral forms prior to completing the initial admission MDS. The interview revealed based on the referral form and the nursing progress notes Resident #147 had received supplemental oxygen from the time of his admission and should have been coded on his admission MDS. [...]
- D
Ensure services provided by the nursing facility meet professional standards of quality.
Inspectors wroteBased on observations, record review, and resident and staff interviews, the facility failed to ensure Resident #9 swallowed all of her prescribed medications before leaving Resident #9's room for 1 of 1 resident reviewed for medication storage (Resident #9).
- 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,and resident and staff interview, the facility failed to provide supervision for storage of smoking supplies (cigarettes/lighter) for 1 of 3 residents sampled for supervision to prevent accidents (Resident #31).
- 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 label an open vial of Tuberculin Purified Protein Derivative (PPD) medication observed in 1of 2 medication storage rooms ([NAME] Hall Medication Storage Room) reviewed for medication storage.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, record review, and staff interviews, the facility failed to follow their Handwashing/Hand Hygiene policy when Nurse #2 did not doff her gloves, perform hand hygiene and don clean gloves prior to applying wound treatment and a clean dressing and before moving to a second wound on Resident #14. The deficient practice occurred for 1 of 4 staff members observed for infection control practices (Nurse #2).
November 26, 2024Complaint inspection · 1 citation
- G
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Inspectors wroteBased on record review, and responsible party (RP), staff, nurse practitioner (NP), and physician assistant (PA) interviews, the facility failed to protect a resident's right to be free of physical restraints for 1 of 3 residents (Resident #1) reviewed for restraints. Resident #1 was found to have his wrists restrained using a pillowcase wrapped in a figure eight [NAME] and then covered with a top sheet. The reasonable person concept was applied as no reasonable person would expect to have their wrists restrained with a pillowcase, restricting their movement, unable to use their call bell for assistance, and making the person feel restricted and/or belittled.
January 25, 2024Standard inspection, Complaint inspection · 10 citations
- E
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Inspectors wrote2. Resident #298 was admitted to the facility on [DATE] with diagnoses that included dysphagia (difficulty swallowing foods or liquids). Resident #298's care plan dated 11/20/23 did not include a care plan to address his tube feed and nutrition. The quarterly Minimum Data Set (MDS) dated [DATE] indicated Resident #298 was cognitively intact and used a feeding tube for nutritional intake. An interview with MDS Coordinator #1 on 1/24/24 at 10:30 AM revealed that the feeding tube should be a part of the care plan and the Dietician usually did the dietary and nutritional care plans. An interview with the Dietician on 1/24/24 at 12:05 PM disclosed that she initiated most dietary care plans. If it was a resident who required nutrition through a feeding tube, she would always initiate a care plan. [...]
- E
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on observations, record review, resident interviews and staff interviews, the facility failed to provide nail care for 2 of 9 residents dependent on staff for activities of daily living (Resident #44 and #1).
- E
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
Inspectors wroteBased on record review and interviews with resident, staff, the Nurse Practitioner and the Mental Health Services Representative, the facility failed to obtain mental health services for 1 of 1 resident reviewed for behavioral and emotional status (Resident #64).
- 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 remove expired food stored for use from 1 of 3 refrigerators (the walk-in refrigerator) in the kitchen. This 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 interview, the facility's Quality Assessment and Assurance (QAA) Committee failed to maintain implemented procedures and monitor interventions the committee put into place following the recertification surveys conducted on 10/8/21 and 7/29/22, and the complaint investigation survey conducted on 4/3/23. This was for repeat deficiencies in the areas of baseline care plan, activities of daily living care provided for dependent residents, and nutrition/hydration status maintenance that were originally cited on 7/29/22 during the recertification survey, and subsequently recited during the current recertification survey completed on 1/25/24. Develop/implement comprehensive care plan was originally cited on the complaint survey on 4/3/23 and was also subsequently recited during the recertification survey on 1/25/24. [...]
- D
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Inspectors wroteBased on record review and staff interviews the facility failed to provide a written discharge notification to the Resident's Responsible Party (RP) for 1 of 1 resident (#335) reviewed for discharge.
- D
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Inspectors wroteBased on record review and staff interviews, the facility failed to complete a baseline care plan within the required timeframe for a new admission for 1 of 3 residents (Resident # 288).
- D
Provide enough food/fluids to maintain a resident's health.
Inspectors wroteBased on record review and staff interviews, the facility failed to assess and address weight loss for 1 of 3 residents reviewed for nutrition (Resident #1).
- B
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 admission and annual Minimum Data Set (MDS) assessments within the regulated time frames for 5 of 6 residents reviewed for completion of comprehensive MDS assessments (Residents #71, #78, #44, #186, and #39).
- B
Assure that each resident’s assessment is updated at least once every 3 months.
Inspectors wroteBased on record review and staff interviews, the facility failed to complete quarterly assessments within the regulated time frames for 5 of 6 residents reviewed for completion of quarterly MDS assessments (Residents #52, #10, #44, #34, and #57).
July 29, 2022Standard inspection · 19 citations
- E
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on observations, record reviews, resident and staff interviews, the facility failed to provide shaving assistance (Resident #71, Resident #2), nail care (Residents #2, #14, and #30), and skin care (Resident #2) for 4 of 10 residents reviewed for activities of daily living for dependent residents.
- E
Provide appropriate foot care.
Inspectors wroteBased on observations, record reviews, resident and staff interviews, the facility failed to provide nailcare for toenails for 4 of 10 residents reviewed for foot care (Residents #14, #71, #2 and #64).
- E
Ensure medication error rates are not 5 percent or greater.
Inspectors wroteBased on observations, record review, staff, and Nurse Practitioner interview the facility to have a medication error rate of less than 5% as evidenced by 4 medication administration errors out of 26 opportunities which gave the facility a medication error rate of 15.38%. This affected 1 of 5 residents observed during medication administration (Resident #83).
- 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 observations, record review and staff interview the facility failed to store controlled substances in a permanently affixed compartment of the refrigerator for 2 of 2 medication rooms (East and [NAME] wing) and failed to remove expired medication from 1 of 1 central supply room.
- E
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Inspectors wroteBased on observations, record reviews, resident and staff interviews, and a test tray, the facility failed to serve food that was appetizing in appearance and temperature for 3 of 4 residents (Resident #64, Resident #71, and Resident #12) reviewed with food concerns.
- E
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observations, record review, and staff interview the facility failed to implement the Center for Disease Control and Prevention (CDC) guidelines for use of personal protective equipment (PPE) when 1 of 2 nurses (Nurse #5) failed to discard her mask and eye protection after entering and exiting a Covid positive patients room (Resident #16) and then entering a non-COVID positive patients room, Nurse #5 also failed to disinfect a glucometer (used to check a resident's blood glucose level) after use per the manufacture's recommendations which resulted in the potential for cross contamination for 1 of 6 residents observed during medication administration (Resident #83). [...]
- E
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Inspectors wroteBased on observations, record review, resident and staff interviews, the facility failed to implement an effective pest control program to control the presence of flies and gnats in the hallway and resident rooms. This was evident in 1 of 1 resident care hall and 5 of 46 resident rooms (Rooms 16, 29, 30, 51 and 52).
- D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteBased on observations, record reviews, resident and staff interviews, the facility failed to treat a resident in a dignified and respectful manner when 1 of 1 staff member (Nurse #3) spoke to the resident in a perceived disrespectful manner and failed to promote the resident's dignity and privacy by not providing a cover for his urinary catheter for 1 of 1 resident (Resident # 64) reviewed for dignity and respect.
- D
Reasonably accommodate the needs and preferences of each resident.
Inspectors wroteBased on record review, staff interviews, and observations the facility failed to implement a care plan intervention for 1 of 3 residents (Resident #34) reviewed for call lights.
- D
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Inspectors wrote2. Resident #19 was admitted to the facility on [DATE]. The quarterly Minimum Data Set assessment dated [DATE] indicated Resident #19 was cognitively intact and had no behaviors of rejection of care. A review of the shower schedule for room [ROOM NUMBER]-A revealed the shower days were scheduled for Tuesday and Friday first shift. A review of the shower notebook revealed there were no shower sheets for Resident #19 in the notebook. A review of Resident #19's medical record revealed there was no documentation of refusing his showers. A review of Resident #19's Activities of Daily Living documentation for 07/2022 revealed there were no showers documented in the Resident's medical record. An observation and interview were conducted with Resident #19 on 07/25/22 at 12:52 PM. [...]
- 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 record review and staff and Nurse Practitioner interviews the facility failed to report an abnormally high white blood cell count to the provider when it was available and two days later the resident was admitted to the hospital with systemic inflammatory response syndrome (SIRS) and altered mental status for 1 of 1 resident reviewed for hospitalizations.
- D
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Inspectors wroteBased on record review, resident and staff interviews the facility failed to record and investigate a grievance for 1 of 7 residents (Resident #468) and failed to provide a written grievance summary for 1 of 7 residents (Resident #67) reviewed for grievances.
- D
Ensure each resident receives an accurate assessment.
Inspectors wroteBased on record review, observation and staff interviews, the facility failed to accurately code the Minimum Data Set (MDS) assessment in the area of cognition for 1 of 1 resident reviewed for MDS accuracy (Resident #13).
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on observations, record review, staff, and Nurse Practitioner interview the facility failed to check a blood glucose level before breakfast as ordered by the provider for 1 of 5 residents observed during medication administration (Resident #83).
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on observations, record review and resident, staff, and Wound Nurse Practitioner interviews the facility failed to implement interventions to promote healing of unstageable pressure ulcers for 1 of 6 residents reviewed with pressure ulcers (Resident #83).
- D
Provide enough food/fluids to maintain a resident's health.
Inspectors wroteBased on record review and staff, Registered Dietitian and Nurse Practitioner interviews the facility failed to assess interventions for significant weight loss and have systems in place to identify further weight loss for 1 of 1 resident reviewed for weight loss (Resident #41).
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observations, record review and resident, staff and Nurse Practitioner interviews the facility failed to have a physician order for the use of oxygen for 1 of 1 resident reviewed with oxygen (Resident #12).
- D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on record review and staff interview the facility failed to maintain a complete and accurate medical record by failing to document the completion of wound care (Resident #42) for 1 of 6 residents reviewed for pressure ulcers.
- B
Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.
Inspectors wroteBased on record review and staff interview the facility failed to document a resident's discharge in the medical record (Resident #52) for 1 of 1 resident reviewed for hospitalizations.
Fire safety inspections
11 fire safety citations on file: 6 on January 25, 2024, 4 on July 29, 2022, 1 on October 8, 2021.
Every fire safety citation11 citations
- D
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 · January 25, 2024 · Corrected (the home has a date of correction)
- 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 · January 25, 2024 · 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 · January 25, 2024 · Corrected (the home has a date of correction)
- D
Provide properly protected cooking facilities.
K 324 · January 25, 2024 · Corrected (the home has a date of correction)
- D
Install corridor and hallway doors that block smoke.
K 363 · January 25, 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 · January 25, 2024 · Corrected (the home has a date of correction)
- F
Establish staff and initial training requirements.
E 37 · July 29, 2022 · Corrected (the home has a date of correction)
- E
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
K 521 · July 29, 2022 · Corrected (the home has a date of correction)
- D
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · July 29, 2022 · Corrected (the home has a date of correction)
- D
Have proper medical gas storage and administration areas.
K 923 · July 29, 2022 · Corrected (the home has a date of correction)
- D
Inspect, test, and maintain automatic sprinkler systems.
K 353 · October 8, 2021 · Corrected (the home has a date of correction)