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
3J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
23D
6E
4F
Potential for minimal harm
0A
0B
0C
April 16, 2026Standard inspection · 8 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 observations, staff interviews, and policy review, the facility failed to ensure the kitchen was clean, staff washed hands and wore gloves appropriately between task changes, staff wore a beard cover when wearing a beard, and temperatures were recorded for the refrigerator and freezer. These failures had the potential to affect 144 residents who consumed food prepared by the kitchen.
- F
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observations, staff interviews, and facility policy review, the facility failed to ensure appropriate infection control practices were implemented with the onset of a COVID outbreak. The facility failed to ensure the dental hygienist used infection control interventions to ensure the dental cart moving from room to room was cleaned and a Certified Nursing Assistant (CNA) using the same box of wipes room to room, not following infection control practice. As a result of this deficient practice, all facility residents had the potential for illness from a COVID exposure since the facility was already in outbreak on the [NAME] unit. The facility census was 144 residents.
- D
Ensure that residents are fully informed and understand their health status, care and treatments.
Inspectors wroteBased on resident family and staff interviews, record review, and facility policy review, the facility failed to ensure the risks, benefits and alternatives involved in the use of psychotropic medications were communicated to the resident/resident representative for one of five residents (Resident (R)1) reviewed for unnecessary medications. This deficient practice had the potential for the resident/resident representative not being informed of treatments being administered by the facility.
- 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 staff interviews, record review, and facility policy review, the facility failed to ensure written information regarding the right to formulate and advanced directive, change an advanced directive, or the right to accept and/or refuse medical and surgical treatment was provided to one of two residents (Resident (R) 10) or their resident representative (RR) for advanced directives out of a total sample of 33 residents. This failure had the potential for resident wishes regarding care not to be honored.
- D
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Inspectors wroteBased on observations, record review, resident and staff interviews, and facility policy review, the facility failed to provide written documentation of a hospital transfer to four of five residents (Resident (R) 27, R5, R12 and R4), and to their representative reviewed out of a total sample of 33 residents. The facility also failed to create a recapitulation (summary) of the resident's stay at the facility, a final summary of the resident's status, and reconciliation of all pre- and post-discharge medications and notification of the Ombudsman of the resident's discharge for one of five residents reviewed (R)158. This failure placed the resident and/or the resident's representative at risk for lack of awareness of rights, including the right to appeal the transfer.
- 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 resident and staff interviews, record review, and facility policy review, the facility failed to ensure a baseline care plan was completed/ shared with the resident for one of one resident (Resident (R) 95) reviewed for baseline care plan. As a result of this deficient practice the residents may not have received care and services needed.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on staff interviews, record review, and review of facility policy, the facility failed to ensure the physician's orders were followed by failing to do a urinary analysis with culture and sensitivity (UA, C&S), a two part test to diagnose a urinary tract infection, for one of one (Resident (R)26) resident reviewed for laboratory orders. This deficient practice had the potential to allow residents to go with undiagnosed ailments when tests were not completed as ordered.
- D
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Inspectors wroteBased on staff interviews, record review, and facility policy review, the facility failed to ensure the March 2026 recommendations from the pharmacist were communicated to the resident's physician and results of the communication documented in the resident's medical record for one of five residents (Resident (R)1) reviewed for unnecessary medications. This deficient practice had the potential for the recommendations needing action by the physician were not addressed affecting needed resident care.
December 19, 2025Complaint inspection · 3 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, staff and resident representative interviews, record reviews and review of the facility's policy titled, Housekeeping Guidelines, the facility failed to provide housekeeping and maintenance services necessary to maintain a sanitary, clean, comfortable and homelike environment for residents.
- E
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observations, staff interviews, and record review, the facility failed to ensure one of two facility ice machines located in the service hallway of the East Wing Unit was free from visible dirt and debris. This deficient practice had the potential to affect all residents who received ice from this ice machine.
- 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, interviews, and record review, the facility failed to ensure medications were secured, one of three medication carts on the East wing was left unlocked and unattended. The deficient practice had the potential to cause harm to residents located on the East Wing Unit by allowing unauthorized access to medications.
April 10, 2025Standard inspection, Complaint inspection · 8 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 observations, policy reviews and staff interviews, the facility failed to ensure that the kitchen was maintained in a sanitary manner. Specifically, the facility failed to maintain hot food items on the steam table above 135 degrees to prevent food borne illness, failed to ensure staff entering the kitchen wore a hairnet properly, and failed to ensure the dish machine had a final rinse temperature at or above 180 degrees for proper sanitization. The deficient practices had the potential to adversely affect 146 of 146 residents receiving an oral diet.
- E
Provide and implement an infection prevention and control program.
Inspectors wrote5. R4 was admitted into the facility on 6/14/2022 with diagnoses of, but not limited to immunodeficiency conditions, end stage renal disease, dementia, and unilateral primary osteoarthritis of right knee. Review of R4's care plan revealed R4 was incontinent of bowel and bladder and required extensive to total assistance with Activities of Daily Living (ADLs). The care plan also stated R4 would receive peri-care with each incontinent episode. R4's Quarterly Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 11, moderate cognitive impairment. The MDS also revealed R4 required extensive to total assistance with ADLs. Observation of incontinent care on 4/8/2025 at 11:45 am for R4 performed by Certified Nursing Assistants (CNAs) JJ and assisted by CNA BB revealed the infection control protocol for incontinent care had not been followed. [...]
- 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 complete Preadmission Screening/Resident Review Assessment I and II (PASARR) for two of three sampled residents; Resident (R) 74 and R31 for serious mental disorders or intellectual disabilities and related conditions.
- 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 staff interview, record review, a review of the facility policy titled Comprehensive Care Plans, the facility identifies weight loss for two residents (R) (R20 and R59) of four residents reviewed for nutrition out of 36 sampled residents.
- D
Ensure services provided by the nursing facility meet professional standards of quality.
Inspectors wroteBased on interviews, record review, and review of the facility's policy titled Medication Administration, the facility failed to administer scheduled medications within 60 minutes before or after the scheduled medication time for one Resident (R) 151 of nine sampled residents reviewed for medication administration.
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on record review and interviews, the facility failed to provide Activities of Daily Living (ADL) care for two of 17 sampled residents (R) (R4 and R A).
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on record review and staff interviews, the facility failed to ensure Vancomycin (antibiotic medication) was administered as ordered for one of six sampled residents. Resident (R) 399 missed three daily doses of intervenous (IV) Vancomycin prescribed for surgically closed wound infection of front left trochanter (left hip).
- D
Provide enough food/fluids to maintain a resident's health.
Inspectors wroteBased on staff interviews, record review, and a review of the facility policy titled Weight Monitoring, the facility failed to perform weekly weights after significant weight loss and failed to implement a dietician recommendation for one resident (R) 20 of four residents reviewed for nutrition.
May 7, 2023Standard inspection · 17 citations
- J
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 observations, interviews, record review, document review, and facility policy review, the facility failed to develop a comprehensive care plan for two of 57 sampled residents (R#12 and R#120). A review of the care plan for R#12 revealed a care plan was not developed to address the resident's needs related to transferring and the use of a mechanical lift to include the sling size that was needed. During observations of a transfer of R#12 utilizing a mechanical lift on 5/3/24, the resident voiced discomfort and concern that the resident was going to fall during the transfer using the lift. Further observations revealed the resident was not properly placed in the sling and the resident was not properly supported by the sling during the transfer. [...]
- J
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on observations, interviews, record review, document review, and facility policy review, the facility failed to ensure two of four sampled residents (R) (R#12 and R#69) for accidents received adequate supervision to prevent accidents. Observations of a mechanical lift transfer of R#12 on 5/3/23 revealed the resident voiced discomfort and concern that they were falling during the transfer and the observation revealed the mechanical lift sling was not positioned properly to support the resident during the transfer. The Certified Nursing Assistants (CNAs), CNA RR and CNA TT, who were performing the transfer failed to appropriately supervise the transfer and intervene to properly position the resident in the sling when the resident verbalized discomfort. [...]
- J
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, document review, and facility policy review, the facility failed to ensure certified nursing assistants (CNAs) demonstrated competency in skills and techniques necessary to care for residents' needs related to transfers using a mechanical lift for two of 15 CNA competency documents that were provided. During observations of a transfer of R#12 by way of a mechanical lift, the resident voiced discomfort and concern of falling during the transfer. Observations revealed the resident was not appropriately positioned in the mechanical lift sling and as a result, after the resident was transferred to the wheelchair, R#12 slid from the wheelchair into the floor because the resident could not be appropriately positioned in the chair. [...]
- F
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on observations, interviews, document review, and facility policy review, it was determined the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. Specifically, kitchen staff failed to: - perform hand hygiene between handling soiled and clean dishes, - maintain adequate sanitizer concentration in the low temperature dish machine, - discard expired food items, and - wear sufficient hair restraints while in the food preparation areas. In addition, the facility failed to ensure the microwave in the central supply room, used for residents' food, was clean. These deficient practices had the potential to affect all residents who receive food from the kitchen.
- 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, document review, and interviews, it was determined that the facility failed to ensure residents had a comfortable and homelike environment by consistently providing linens, towels, and washcloths on three of three halls (West Hall, East Hall, and Terrace Hall) reviewed for environmental concerns. This deficient practice affected all residents.
- 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 review, staff interviews, and facility policy review, it was determined that the facility failed to ensure three of five sampled residents (R) (R#51, R#103, and R#113) reviewed for unnecessary medications were not prescribed psychotropic medications unless necessary to treat a diagnosed, specific condition. Specifically, the facility failed to monitor and document targeted behaviors for R#51, R#103, and R#113 while prescribed psychotropic medications.
- 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, interviews, and facility policy review, it was determined that the facility failed to ensure the proper labeling of drugs and biologicals and expired medications were removed from three of three medication rooms (West Unit Medication Room, East Unit Medication Room, and the Terrace Unit Medication Room); one of four medication carts (East Unit Medication Cart #1); and one of three central supply rooms (East Hall Supply Room).
- D
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Inspectors wroteBased on record review, interviews, observations, and facility documents and policy review, it was determined the facility failed ensure that one of 57 sampled residents (R) (R#379) was free from physical abuse by another resident.
- 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 interviews and record review, it was determined the facility failed to notify the ombudsman in writing when a resident was transferred or discharged from the facility for two of 57 sampled residents (R) (R#94 and R#85). Specifically, the ombudsman was not notified regarding emergency transfers to acute care facilities which were considered facility-initiated discharges.
- D
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Inspectors wroteBased on interviews, record review, and facility policy review, it was determined that the facility failed to notify each resident of the facility's bed-hold and reserve bed payment policy before a hospital transfer for two of 57 sampled residents (R) (R#85 and R#94).
- D
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Inspectors wroteBased on record review, staff interviews, and facility policy review, it was determined that the facility failed to refer a resident with newly evident or possible serious mental disorder for a Level II preadmission screening and resident review (PASARR) for one of 57 sampled residents (R) (R#103).
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on observations, interviews, and record review, it was determined that the facility failed to provide activity of daily living (ADL) task for two of 57 sampled residents (R) (R#104 and R#279) related to showers.
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on record review and interviews, it was determined that the facility failed to assess and monitor a pressure ulcer for one of three residents (R)(R#279) reviewed for pressure ulcers. Specifically, the facility failed to appropriately assess and monitor R#279's left heel wound, and document wound type, characteristics, measurements, healing, and response to treatment.
- 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 interviews, it was determined that the facility failed to ensure medications were available from the pharmacy for one of three sampled residents (R#279) reviewed for medication administration.
- D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on interview, record review, and policy review, the facility failed to ensure an accurate medical record was maintained for one of 57 sampled residents (R) (R#106) related to pre-admission screening and resident review (PASARR) Level II. Specifically, the facility failed to ensure the diagnosis for Depakote (medication used for bipolar disorder, seizures, and migraine headaches) use was correct.
- D
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Inspectors wroteBased on interviews, document review, and policy review, the facility failed to maintain an effective Quality Assurance Program. Specifically, the facility failed to act on available competency validation data to make improvements in staff competency related utilizing a mechanical lift. This deficient practice affected one of three sampled residents (R) (R#12) reviewed for accidents, with the potential to affect the remaining 36 residents who required the use of a mechanical lift for transfer.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteThe facility failed to clean and store continuous positive airway pressure (CPAP) equipment after use for one of two residents (R) (R#14) reviewed for respiratory care; and (2) failed to ensure three of five sampled residents (R) (R#51, R#103, and R#113) reviewed for unnecessary medications were not prescribed psychotropic medications unless necessary to treat a diagnosed, specific condition related to monitoring and documenting targeted behaviors for R#51, R#103, and R#113 while prescribed psychotropic medications.
Fire safety inspections
5 fire safety citations on file: 2 on April 10, 2025, 3 on May 7, 2023.
Every fire safety citation5 citations
- E
Construct fire resistant interior walls.
K 331 · April 10, 2025 · Corrected (the home has a date of correction)
- D
Install corridor and hallway doors that block smoke.
K 363 · April 10, 2025 · Corrected (the home has a date of correction)
- D
Inspect, test, and maintain automatic sprinkler systems.
K 353 · May 7, 2023 · Corrected (the home has a date of correction)
- D
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · May 7, 2023 · Corrected (the home has a date of correction)
- D
Have properly installed electrical wiring and gas equipment.
K 511 · May 7, 2023 · Corrected (the home has a date of correction)