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 42 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
21D
18E
3F
Potential for minimal harm
0A
0B
0C
December 12, 2025Standard inspection · 0 citations
October 29, 2024Complaint inspection · 2 citations
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on observations, interviews, and record reviews, it was determined the facility failed to administer medications within the recommended time frame for 1 (Resident #3) of 3 (Resident # 1, Resident #3, and Resident #4) sampled residents.
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on observations, interviews, and record reviews it was determined that the facility failed to not administer medications that were pulled by another nurse for 1 (Resident #3) of 3 (Resident # 1, Resident #3, and Resident #4) sampled resident.
August 2, 2024Standard inspection, Complaint inspection · 20 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, interview, and facility policy review, the facility failed to ensure dietary staff practiced good hand washing to prevent potential cross contamination for the residents who received meal trays from 1 of 1 kitchen. These failed practices had the potential to affect 103 residents who received meals from the kitchen (Total Census: 105), as documented on a list provided by the Dietary Manager on 7/31/2024.
- E
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteBased on observation, interviews, and record review, it was determined that the facility failed to ensure dignity was maintained while performing Activities of Daily Living (ADL) care for 2 (Resident # 22 and # 66) of two residents receiving personal care. Specifically, the facility failed to ensure curtains were pulled to provide privacy, and that soiled items were not passed over a resident's face during incontinence care.
- E
Ensure each resident receives an accurate assessment.
Inspectors wroteBased on observation, record review and interview, it was determined that the facility failed to complete an accurate Minimum Data Set (MDS) for two (Resident #36 and #103) sample mix residents.
- E
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Inspectors wroteBased on observation, record review, and interview the facility failed to ensure that base line care planning completed with interventions upon admission for pressure ulcers, enhanced barrier precautions, and Peripherally Inserted Central Catheter (PICC) lines for 4 residents out of the sample residents (Resident #363, #366, #367, and #371). A review of the Order Summary reveals that Resident #363 had diagnosis of malnutrition, and pressure ulcer at an unspecified site and an unspecified stage. A review of the Order Summary reveals that Resident #363 had an order for Treatment to unstageable pressure injury to coccyx: cleanse with wound cleanser or sterile water. Apply thin layer of [named brand of burn gel] cover with calcium alginate. Cover with 6 X 6 border foam daily and PRN until resolved. Every day shift for wound treatment may substitute as necessary. Reassess in 14 days. [...]
- 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 residents who required assistance with activities of daily living were regularly provided with the necessary assistance to maintain good hygiene and grooming, as evidenced by failure to ensure fingernails were kept clean and trimmed for one out of one sampled resident. (Resident #71); to ensure proper Activities of Daily Living (ADLs) was provided for 1 (Resident #22) of 1 sampled resident who were dependent on staff for ADLs.
- E
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on record review, and interview, the facility failed to set up wound assessment upon admission to ensure healing and improvement of wounds for 4 out of the sample residents (Resident #363, #366, #367, and #371); failed to follow physician orders for a scheduled wound care treatment for 1 (Resident #367) of 1 resident reviewed for wound care treatment.
- E
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 observation, record review, interview and facility document review, it is determined that the facility failed to ensure that nursing staff had the competencies and skills to provide care and respond to individualized needs as identified in baseline care plan, comprehensive care plan and care plan revision, setting up enhance barrier precautions for wound care, Percutaneous Endoscopic Gastrostomy (PEG) tubes, Peripherally Inserted Central Catheter (PICC) lines, contact isolation, wound care assessments, Continuous Positive Airway Pressure (CPAP) and medication administration specifically the facility: 1. [...]
- E
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Inspectors wroteBased on observation, record review and interview, the facility failed to ensure all pharmaceuticals were available for the residents during medication administration.
- E
Ensure medication error rates are not 5 percent or greater.
Inspectors wrotebBased on observation, record review and facility policy, review of medication pass on 7/30/2024, and 7/31/2024 it was determined the facility failed to ensure physician orders were followed to maintain a medication rate of less than 5% to prevent complications for 2 (Residents # 31, and #28) of 3 residents observed during medication pass resulting in medication errors.
- 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 quantified recipe and menu to meet the nutritional needs of the residents for 1 of 1 meal observed. This failed practice had the potential to affect 2 residents who received pureed diets and 10 residents who received enhanced food diets from 1 of 1 kitchen.
- 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 food was prepared by methods that maintained flavor, appearance; hot foods were served hot and cold foods were served cold to maintain palatability and encourage adequate nutritional intake for 1 of 1 meal observed on the 400 Hall, 600 Hall, and 700 Hall. The failed practice had the potential to affect 9 residents who received meal trays in their room on 100 Hall 9 residents who received meal trays in their rooms on 200 Hall, 8 residents who received meal trays in their rooms on 300 Hall, 26 residents who received meal trays in their rooms on 400 Hall, 13 residents who received meal trays in their rooms on 500 [NAME]. 29 residents who received meal trays in their rooms on 600 Hall and 9 residents who received meal trays in their rooms on 700 Hall. [...]
- E
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, record review, interview, and facility policy, the facility failed to ensure a resident who is on contact isolation does not have a roommate and that staff wear appropriate personal protective equipment (PPE) while entering the room for 1 (Resident #31) of 1 sample mix resident reviewed for contact isolation; ensure staff while providing care to a resident in an enhanced barrier precautions room wore appropriate personal protective equipment (PPE) for 4 (Resident #363, #366, #367, #371) of 4 residents reviewed for enhanced barrier precautions; ensure staff while providing percutaneous endoscopic gastrostomy (PEG) medication administration and tube feeding wore appropriate personal protective equipment (PPE) and sanitized hands for 1 (Resident #28) of 1 sample mix residents reviewed for medication pass; [...]
- D
Reasonably accommodate the needs and preferences of each resident.
Inspectors wroteBased on observation and interview the facility failed to ensure accommodation needs were met by not ensuring the call light was within reach for one (Resident #366) of one sampled resident.
- 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 interview, the facility failed to ensure an admission Minimum Data Set (MDS) was completed in a timely manner for one (Resident #371) of one sampled resident. On 07/29/2024, an admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 7/11/2024 was reviewed. The admission MDS was started on 07/08/2024 and was currently 18 days overdue for completion. A review of the policy Resident Assessment Instrument revealed l. The Assessment Coordinator is responsible for ensuring that the Interdisciplinary Assessment Team conduct(s) timely resident assessments and reviews according to the following schedule: a. Within fourteen (14) days of the resident's admission to the facility; [...]
- 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 observation, record review, interview, and facility policy review, the facility failed to ensure the comprehensive care plan addressed and individualized appropriate care and services for 1 (Resident #103) of 1 sample mix residents.
- D
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 interviews, record review, and facility policy review, the facility failed to update person-centered care plans to reflect the residents needs for three Residents (Residents #45, #23, and #462) of four residents reviewed for care plans. The facility failed to accurately document code status on the care plan which could result in a negative outcome as staff could provide lifesaving measures contradictory to the residents' choice. The facility failed to develop and implement any interventions for the moderate hearing loss for Resident #45. The facility failed to update the care plan to include elopement interventions for one (Residents #462) who had attempted to elope from the facility as documented in the progress notes.
- D
Provide appropriate foot care.
Inspectors wroteBased on observations, record review and interview, the facility failed to ensure necessary foot/toenail treatment and care was provided to keep toenails trimmed and dry and to prevent flaky skin to decrease the potential for foot complications for 1 (Resident #22) of 1 sampled resident who were dependent on staff for foot/toenail care.
- D
Provide enough food/fluids to maintain a resident's health.
Inspectors wroteBased on observation, record review, and interview the facility failed to ensure that Registered Dietitian recommendations were following in a timely manner for an enteral bolus feeding for one (Resident #28) of one sampled resident.
- 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 facility policy review, it was determined the facility failed to ensure enteral water flush was administered per physicians' orders for a resident with a Percutaneous Endoscopic Gastrostomy (PEG) tube during medication administration based on professional standards of care for 1 (Resident #28) of 1 sample mix resident.
- D
Have a plan that describes the process for conducting QAPI and QAA activities.
Inspectors wroteBased on interview, record review, and facility policy review, it was determined the facility's Quality Assurance Performance Improvement Program (QAPI) failed to maintain records of their program that developed and implemented effective improvement plans to correct identified areas of concern. The facility failed to ensure the facility was able to provide its QAPI plan to the State surveyors during recertification survey or upon request. On 8/2/24 10:30 AM, Administrator states he is unable to provide records of the QA (Quality Assurance) committee meetings when requested. The administrator states, We can't find them, I've been here a week, and I don't have them.
July 3, 2024Complaint inspection · 4 citations
- E
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteBased on observations, interviews and facility policy review, it was determined the facility failed to knock on doors prior to entering resident rooms for 4 resident rooms (Rooms 609, 610, 612, and 613) viewed for protecting and valuing the resident's private space.
- E
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 observations, interviews, record review, and facility document review, the facility failed to ensure licensed nurses have the knowledge, competencies, and skill sets to provide care and respond to each resident's individualized needs as identified in resident assessment, care plans, and physician orders for 2 (Resident #6 and Resident #7) of 2 residents reviewed for assessments, care plans, and competent staff. Specifically, the facility: 1. Failed to ensure Minimum Data Set (MDS)was completed in accordance with guidelines set forth in the Resident Assessment Instrument for Resident #6. 2. Failed to ensure that care plans were revised and updated according to the resident's current physician orders, assessments, and resident's current individualized needs for Resident #6 and Resident #7. 3. [...]
- E
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation interview and record review, the facility failed to ensure infection prevention and control practices were implemented to prevent the development of communicable diseases and infections as evidenced by failure to perform hand hygiene between residents, during perineal care and wound care to prevent cross contamination.
- D
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, record review, and interview the facility failed to ensure a comfortable, sanitary, clean, and homelike environment was provided in facility hallways and in room [ROOM NUMBER].
December 29, 2023Complaint inspection · 1 citation
- D
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 ensure incontinent care was provided is a safe manner to prevent a resident from sliding out of the bed resulting in the resident receiving a fracture of the femur for 1 (Resident #2) of 1 sampled resident.
October 27, 2023Complaint inspection · 1 citation
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on observation, interview and record review the facility failed to provide appropriate care to include, completing admission assessment, completing initial body audit and failed to ensure treatment and services were in place to prevent pressure ulcers for 1 resident. R#1.
October 4, 2023Complaint inspection · 1 citation
- E
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on observations, interview, and record review, the facility failed to ensure the call light was answered in a timely manner for 1 (Resident #5) and fingers were clean and trimmed for 4 (Residents #6, #7, #8 and #9) of 16 (Residents #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15 and #16) sampled residents who required assistance with activities of daily living.
September 15, 2023Standard inspection, Complaint inspection · 13 citations
- F
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 interview and record review, the facility failed to ensure sufficient nursing staff were available to meet the needs of residents who required assistance with activities of daily living. This failed practice had the potential to affect all 111 residents who resided in the facility.
- 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 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. The failed practice had the potential to affect 109 residents who received meals from the kitchen, (total census: 111), as documented on a list provided by Dietary Supervisor #1 on 09/13/23 at 11:55 PM.
- 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 ensure resident rooms were maintained in a clean and homelike manner for 6 (Rooms 401, 408, 413, 508, 601 and 610) of 41 (Rooms 401, 402, 403, 404, 405, 406, 407, 408, 409, 410, 411, 412, 413, 414, 415, 416, 501, 502, 503, 504, 505, 506, 507, 508, 509, 601, 602, 603, 604, 605, 606, 607, 608, 609, 610, 611, 612, 613, 614, 615 and 616) resident rooms on the 400 Hall, 500 Hall and 600 Hall.
- E
Assure that each resident’s assessment is updated at least once every 3 months.
Inspectors wroteBased on record review and interview, the facility failed to ensure quarterly resident assessments were completed no later than the Assessment Reference Date (ARD) plus 14 calendar days and were submitted within 14 days after completion to meet the requirements for the Centers for Medicare & Medicaid Services for 4 (Residents #66, #84, #67 and #90) of 4 sampled residents whose Quarterly Assessments were reviewed.
- 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 and at temperatures that were acceptable to the residents during 1 of 1 meal observed. This failed practice had the potential to affect 10 residents who received meal trays in their rooms on the 100 Hall, 10 residents who received meal trays on the 200 Hall, 14 residents who received meal trays in their room on the 300 Hall, 24 residents who received meal trays in their room on 400 Hall, 13 residents who received meal trays in their room on the 500 hall, 24 residents who received meal trays in their room on the 600 Hall, and 11 residents who received meal trays in their room on the 700 hall as documented on a list provided by Dietary Supervisor #1 on 09/13/23 at 9:36 AM.
- D
Honor the resident's right to manage his or her financial affairs.
Inspectors wroteBased on interview and record review, the facility failed to ensure residents with a trust account had access to their personal funds after business hours and on weekends for 2 (Residents #32 and #73) of 2 (Residents #32, #73,) sampled residents.
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure Activities of daily living (ADL) care was provided for 4 (Residents #26, #59, #75 and #81) of 13 (Residents #4, #14, #26, #37, #48, #49, #59, #73, #75, #81, #83, #94 and #307) sampled residents who were dependent or required assistance with ADL care.
- D
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 ensure a medication administered by a family member was ordered by the attending physician for 1 (Resident #357) of 1 sampled resident.
- 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, and interview, the facility failed to ensure medications were not left unattended in resident rooms for 2 (Resident #14, #48) of 2 sampled residents.
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observation, interview, and record review, the facility failed to administer Oxygen at the Physician ordered flow rate for 1 (Residents #57) and failed to ensure the nebulizer mouthpiece was stored in a bag for 1 (Resident #48) of 14 (Residents #4, #32, #33, #41, #42, #48, #49, #52, #57, #59, #75, #81, #90 and #357) sampled residents who received respiratory therapy.
- 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 and interview, the facility failed to ensure opened vials of insulin were dated, medication carts were locked, and medications were not left on top of the medication carts when out of the line of the nurse's sight.
- D
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Inspectors wroteBased on record review and interview, the facility failed to ensure the Quality Assurance and Performance Improvement (QAPI) Committee developed and implemented appropriate plans of action to prevent repeated deficiencies with maintaining a clean, comfortable homelike environment, with distributing and serving food in a sanitary manner, preventing accidents and hazards, and providing respiratory care. These failed practices had the potential to affect all 111 residents who resided in the facility.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observations, interview and record review, the facility failed to ensure staff changed gloves and washed hands during wound care for 1 (Resident #307), failed to maintain a bath table free of cracks, staff failed to perfume hand hygiene during medication administration, and laundry staff used Personal Protective Equipment (PPE) and clean technique when providing laundry services. These failed practices have the potential to affect 31 residents who received wound care, 24 residents who used the bath table, and all 111 residents who resided in the facility.
Fire safety inspections
6 fire safety citations on file: 3 on December 12, 2025, 3 on August 2, 2024.
Every fire safety citation6 citations
- F
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
K 321 · December 12, 2025 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · December 12, 2025 · Corrected (the home has a date of correction)
- F
Have simulated fire drills held at unexpected times.
K 712 · December 12, 2025 · Corrected (the home has a date of correction)
- F
Properly provide smoke detection systems in areas open to corridors.
K 347 · August 2, 2024 · Corrected (the home has a date of correction)
- F
Install an approved automatic sprinkler system.
K 351 · August 2, 2024 · Corrected (the home has a date of correction)
- F
Install corridor and hallway doors that block smoke.
K 363 · August 2, 2024 · Corrected (the home has a date of correction)