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 16 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
15D
1E
0F
Potential for minimal harm
0A
0B
0C
July 2, 2025Standard inspection · 7 citations
- E
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on observation and interview, the facility failed to maintain resident snack refrigerators appropriately related to proper labeling for 2 of 2 snack refrigerators observed. (Resident snack refrigerator in the Main Building and the Resident snack refrigerator in the Legacy Building)
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on interview, observation, and record review, the facility failed to provided Activities of Daily Living (ADL) care related to toileting a dependent resident in a timely manner for 4 of 24 residents reviewed. (Residents 8, 30, 25, and 23)
- 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 proper positioning of a resident's indwelling urinary catheter drainage bag related to a resident who had a history of Urinary Tract Infections (UTIs) for 1 of 4 residents reviewed for urinary catheters / UTIs. (Resident 48)
- D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Inspectors wroteBased on record review and interview, the facility failed to ensure a resident's medications were accurately administered for 1 of 5 residents reviewed for pharmacy services. (Resident 20)
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview, and record review, the facility failed to follow infection control guidelines related to urinary catheter care for 1 of 18 residents reviewed for infection control. (Resident 3)
- D
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Inspectors wroteBased on observation and interview, the facility failed to provide a sanitary homelike environment related to odors for 1 of 3 resident room hallways observed. (200 Hall)
- D
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
Inspectors wroteBased on record review and interview, the facility failed to ensure the staff had the required six hours of dementia training within six months of hire and three hours annually thereafter for 2 of 10 employee records reviewed. (Qualified Medication Aid [QMA]8 Certified Nurse Aide [CNA] 9)
July 29, 2024Standard inspection · 2 citations
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on interview and record review, the facility failed to provide the scheduled Activities of Daily Living care related to bathing for 1 of 3 residents reviewed. (Resident 64)
- 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 wroteBasedonobservation recordreview andinterview thefacilityfailedtofollowappropriateinfectioncontrolguidelineswhileprovidingindwellingurinarycathetercareforresidentswithahistoryofUTIs (UrinaryTractInfections for2 of3 residentsreviewedforUTIs (Residents62 and26)
June 21, 2023Standard inspection · 7 citations
- D
Ensure each resident receives an accurate assessment.
Inspectors wroteBased on interview and record review, the facility failed to accurately complete comprehensive MDS (Minimum Data Set) assessments for 3 of 18 resident records reviewed for accuracy of assessments. (Residents 70, 37, and 31)
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on interview, observation, and record review, the facility failed to prevent the development of an unstageable (obscured full-thickness skin and tissue loss, full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because the wound bed is obscured by slough, moist dead tissue, or eschar, dry dead tissue) pressure ulcer (Resident 57), and failed to implement Care Plan interventions to prevent the development of pressure ulcers (Resident 2) for 2 of 3 residents reviewed for pressure ulcers.
- D
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 care planned interventions were in place for 1 of 3 residents reviewed for accident hazards. (Resident 3)
- D
Post nurse staffing information every day.
Inspectors wroteBased on observation and interview, the facility failed to post nurse staffing daily for 2 of 7 days during the survey period.
- D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Inspectors wroteBased on record review and interview, that facility failed to provide medications for 1 of 18 residents reviewed for pharmacy services. (Resident 46)
- D
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Inspectors wrote2. The clinical record for Resident 49 was reviewed on 06/19/23 at 10:30 A.M. A Quarterly MDS assessment, dated 05/30/23, indicated the resident was severely cognitively impaired. The diagnoses included, but were not limited to, dementia, anemia, hypertension, and renal insufficiency. An open-ended physician's order, with a start date of 05/10/23, indicated the staff were to administer metoprolol succinate, 25 mg once a day. The staff were to hold the medication if the resident's systolic blood pressure was less than 120 or the heart rate was less than 60. The May 2023 EMAR indicated the resident had received the medication when the systolic blood pressure was less than 120 on the following date and times: [...]
- 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 store medications appropriately for 2 of 3 medication carts reviewed. (200 Hall front medication cart and 200 Hall back medication cart)
Fire safety inspections
10 fire safety citations on file: 3 on July 2, 2025, 4 on July 29, 2024, 3 on June 21, 2023.
Every fire safety citation10 citations
- E
Keep aisles, corridors, and exits free of obstruction in case of emergency.
K 211 · July 2, 2025 · Corrected (the home has a date of correction)
- E
Have horizontal exits used in accordance with safety requirements.
K 226 · July 2, 2025 · Corrected (the home has a date of correction)
- E
Install an approved automatic sprinkler system.
K 351 · July 2, 2025 · Corrected (the home has a date of correction)
- F
Have simulated fire drills held at unexpected times.
K 712 · July 29, 2024 · 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 · July 29, 2024 · Corrected (the home has a date of correction)
- E
Have properly located and lighted "Exit" signs.
K 293 · July 29, 2024 · Corrected (the home has a date of correction)
- E
Inspect, test, and maintain automatic sprinkler systems.
K 353 · July 29, 2024 · Corrected (the home has a date of correction)
- E
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
K 761 · June 21, 2023 · Corrected (the home has a date of correction)
- C
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 21, 2023 · Corrected (the home has a date of correction)
- B
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · June 21, 2023 · Corrected (the home has a date of correction)