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
12D
2E
2F
Potential for minimal harm
0A
0B
0C
December 18, 2025Standard inspection · 4 citations
- D
Ensure each resident receives an accurate assessment.
Inspectors wroteBased on record review and staff interviews, the facility failed to accurately code the Minimum Data Set (MDS) assessment for 1 of 19 residents reviewed for accuracy of assessments (Resident #4).
- 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 submit a request for a Level II Preadmission Screening Resident Review (PASRR) evaluation for a resident with a new diagnosis of a serious mental illness for 1 of 3 residents reviewed for PASRR (Resident #45).
- 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, record review and staff interviews, the facility failed to separate the tube feeding syringe components prior to storing it for use, which created the potential for bacterial growth, for 1 of 3 residents reviewed for tube feeding (Resident #79).
- D
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Inspectors wroteBased on observation, record review, and staff interviews, the facility failed to clean normal saline solution bag connection port with alcohol prior to connecting antibiotic vial to the normal saline bag for mixing, which could introduce bacteria in the mixture. This was for 1 of 1 staff member observed for intravenous medication administration (Nurse #1).
September 27, 2024Standard inspection, Complaint inspection · 7 citations
- E
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observations, record review, and staff interviews the facility failed to post cautionary and safety signage outside of resident rooms that indicated the use of oxygen for 4 of 4 residents (Residents #73, #52, #15, and #37) reviewed for respiratory care.
- 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, record review and interviews with the Corporate Support Dietary Manager, and staff, the facility failed to perform hand hygiene prior to plating food, wear a hair and beard restraint, maintain a working thermometer in the reach-in refrigerator, remove expired foods from frozen storage, and store potentially hazardous foods in sealed containers with a label that recorded the date of storage and the use by date in four of six cold storage units. This failure had the potential to affect food served to 85 of 92 residents.
- 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 interviews with a resident and staff, the facility failed to replace a nonfunctioning air conditioner unit in room [ROOM NUMBER]. This failure occurred for on 1 of 4 halls reviewed for a safe, clean, comfortable and home like environment (200 hall).
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on observations, record review, and staff interviews the facility failed to provide nail care for a dependent resident for 1 of 6 residents reviewed for activities of daily living (ADL) (Resident #12).
- 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 staff interviews, the facility failed to provide an environment free from a potential hazard when an insulin syringe was observed lying on Resident #74's beside table with the safety cap off and the needle exposed. This deficient practice occurred for 1 of 4 residents reviewed for accidents (Resident #74).
- 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 ensure an opened bottle of tube feeding formula was labeled with the date and time the formula was hung for 1 of 2 residents reviewed for tube feeding (Resident #74).
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observations, record reviews, and staff interviews, the facility failed to don required Personal Protective Equipment (PPE) before entering residents' room under transmission-based precautions for 1 of 3 residents reviewed for infection control (Resident #19).
April 14, 2023Standard inspection · 5 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, record review and vendor and staff interviews, the facility failed to sanitize dishware for meal service by failing to ensure the wash and final rinse cycles of the low temperature dish machine operated at accurate temperatures for 2 of 2 observations. This practice had the potential to affect food served to all residents.
- F
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Inspectors wroteBased on observations, staff interviews and record review, the facility's Quality Assessment and Assurance Committee (QAA) failed to maintain implemented procedures and monitor interventions the committee put into place following the annual recertification survey completed on 7/09/2021 and the complaint survey conducted on 4/22/22. The failure was for two deficiencies that were originally cited in the areas of Dietary Services (F812) and Resident Rights/Exercise of Rights (F550) and were subsequently cited again during the current annual recertification survey on 4/14/2023. The continued failure of the facility during three federal surveys of record showed a pattern of the facility's inability to sustain an effective QAPI program.
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on observations, resident and staff interviews, and record review, the facility failed to provide hand hygiene for a resident who required extensive to total assistance for 1 of 1 resident reviewed for activities of daily living care (Resident #2).
- 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 resident, staff, Nurse Practitioner and Hospice Nurse interviews, the facility failed to obtain orders for suprapubic catheter care for 1 of 1 resident reviewed for catheter use. (Resident #39)
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observations, record review and resident and staff, interviews, the facility failed to obtain a physician order for the use of supplemental oxygen for 1 of 1 resident reviewed for oxygen use (Resident #39).
Fire safety inspections
8 fire safety citations on file: 3 on December 18, 2025, 4 on September 27, 2024, 1 on April 14, 2023.
Every fire safety citation8 citations
- D
Use approved construction type or materials.
K 161 · December 18, 2025 · 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 · December 18, 2025 · Corrected (the home has a date of correction)
- D
Have properly installed electrical wiring and gas equipment.
K 511 · December 18, 2025 · Corrected (the home has a date of correction)
- D
Keep aisles, corridors, and exits free of obstruction in case of emergency.
K 211 · September 27, 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 · September 27, 2024 · Corrected (the home has a date of correction)
- D
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · September 27, 2024 · 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 · September 27, 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 · April 14, 2023 · Corrected (the home has a date of correction)