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 24 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
14D
2E
8F
Potential for minimal harm
0A
0B
0C
August 20, 2025Complaint inspection · 1 citation
- F
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Inspectors wroteBased on observation, interviews and record review the facility failed to provide food at appetizing temperatures. This had the potential to affect 189 of 196 facility residents. The facility identified seven residents (Residents #119, #120, #126, #149, #155, #166, #186) as receiving nothing by mouth (NPO). The facility census was 196.
May 23, 2025Complaint inspection · 1 citation
- D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteTHE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on record review and interview, the facility failed to ensure medical records were accurate and complete. This finding affected one (Resident #42) of nine resident records reviewed for accuracy. The facility census was 74.
September 26, 2024Standard inspection · 6 citations
- F
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Inspectors wroteBased on observation and interviews, and facility policy, the facility failed to serve hot and palatable foods. This had the potential to affect all residents, except resident #54 and #56 who received no food by mouth (NPO). The facility census was 83.
- 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, and facility policies, the facility failed to ensure food was prepared and served under sanitary conditions. This had the potential to affect all residents, except resident #54 and #56 who received no food by mouth (NPO). The facility census was 83.
- E
Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.
Inspectors wroteBased on record review, observation and interview, the facility failed to ensure meals were served in a timely manner. This had the potential to affect all residents residing on the Westpark Unit (#1, #2, #5, #6, #7, #8, #9, #10, #12, #14, #15, #17, #18, #19, #20, #21, #22, #23, #24, #27, #28, #31, #32, #33, #34, #35, #36, #39, #40, #41, #42, #47, #48, #50, #51, #52, #55, #56, #58, #60, #61, #67, #68, #71, #73, #74, #179, #180, #181, #182, #229), except resident #54 and #56 who received no food by mouth (NPO). The facility census was 83.
- D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteBased on observation, record review, staff interview, and facility policy review, the facility failed to ensure urinary drainage bags were covered with privacy bags. This affected one resident (#68) of three reviewed for urinary catheters. The facility census was 83.
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on observation, interview, record review, and policy review, the facility failed to ensure all fall interventions were in place for one resident (Resident #51) of five residents reviewed for accidents. The facility census was 83. Findings Include: Resident #51 was admitted to the facility on [DATE] with diagnoses including multiple fractures of the left sided ribs, diabetes, high blood pressure, hyperlipidemia, gastric reflux, insomnia, over active bladder, major depressive disorder, Alzheimer's, dementia without behavioral disturbance, osteoarthritis, urge incontinence and cataracts. Review of the quarterly comprehensive Minimum Data Set Assessment (MDS) 3.0 dated 06/30/24 revealed the resident was severely cognitively impaired, needed assistance for all personal care, and had fallen once since the previous assessment dated [DATE]. [...]
- D
Provide enough food/fluids to maintain a resident's health.
Inspectors wroteBased on observation, record review, staff interview, and facility policy review, the facility failed to ensure weekly weights were taken and documented per physician orders for a resident that was at risk for weight loss. This affected one resident (#68) of eight residents reviewed for nutrition. The facility census was 83.
May 19, 2022Standard inspection · 10 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 and staff interview, the facility failed to ensure the kitchen area was maintained in a clean and sanitary condition. This had the potential to affect 70 of 71 residents receiving food from the kitchen (the facility identified Resident #53 as receiving no food from the facility kitchen). The facility census was 71.
- F
Dispose of garbage and refuse properly.
Inspectors wroteBased on observation and staff interview the facility failed to ensure the dumpster area was maintained in a clean and sanitary condition. This had the potential to affect all residents. The facility census was 71.
- F
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, record review, and interview the facility failed to properly dispose of red biohazard bags. This had the potential to affect all residents. The facility census was 71.
- 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 the menu was followed and appropriate food substitutions were provided. This affected five residents (#18, #42, #37, #55, and #67) of five residents observed during a breakfast meal and had the potential to affect all residents except Resident #53 who received nothing by mouth. The facility also failed to ensure therapeutic diets were followed as prescribed. This affected one resident (#42) of four residents (#37, #42, #50, and #67) reviewed for food concerns. The facility census was 71.
- 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 interview the facility failed to ensure the Long-Term Care (LTC) Ombudsman was notified of residents discharged to hospital. This affected two residents (#27 and #73) of two residents reviewed for hospitalization. The facility census was 71.
- 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 record review and interview the facility failed to ensure written bed hold notices were provided to residents or the resident representative when transferred to the hospital. This affected two residents (#27 and #73) of two residents reviewed for hospitalization. The facility census was 71.
- 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 the proper use of incontinence briefs and liners to prevent potential skin breakdown and infection. This affected three (#6, #31 and #68) of three residents observed for incontinence care.
- D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Inspectors wroteBased on observation and interview the facility failed to ensure expired medications were discarded timely. This affected two (Residents #35 and #65) of 32 residents whose medications were stored in the first floor medication cart. The facility census was 71.
- D
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Inspectors wroteBased on observation, interview, and record review, the facility failed to serve food at a palatable temperature. This affected one (#55) of five residents reviewed for food concerns and had the potential to affect 70 of 71 residents (the facility identified Resident #53 as receiving no food from the kitchen). The facility census was 71.
- D
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Inspectors wroteBased on observation, record review, and interview the facility failed to ensure resident food preferences were honored. This affected one resident (#67) of four residents (#37, #42, #50, and #67) reviewed for food concerns. The facility census was 71.
April 25, 2019Standard inspection · 6 citations
- F
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 staff interview the facility failed to provide the appropriate portion of the planned menu items during the lunch meal on 04/22/19 according to the dietary spreadsheet. This had the potential to affect all 125 residents who received meal trays from the kitchen. The facility identified two residents (Resident #31 and #73) who received nothing by mouth. The facility census was 127.
- 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, record review and interview the facility failed to ensure the kitchen was maintained in a clean and sanitary manner, food transportation carts were cleaned, food products were dated when opened and food/beverages were served in a manner to prevent contamination and/or food borne illness. This had the potential to affect all 125 residents who received meal trays from the kitchen. The facility identified two residents (Resident #31 and #73) who received nothing by mouth. The facility census was 127.
- D
Ensure each resident receives an accurate assessment.
Inspectors wroteBased on record review and staff interview the facility failed to ensure Minimum Data Set (MDS) 3.0 assessments were accurately completed. This affected two residents (Resident #69 and #114) of 30 residents whose MDS assessments were reviewed. Findings Include: 1. Review of medical record for Resident #114 the resident was admitted to the facility on [DATE] with diagnoses including unspecified dementia with behavioral disturbances, retention of urine and benign prostatic hyperplasia with lower urinary tract symptoms. Record review revealed the resident had an indwelling urinary (Foley) catheter due to diagnoses of retention of urine. Resident #114 also had a care plan in place for the indwelling catheter related to a mass of bladder. A review of MDS 3.0 assessment, dated 03/17/19 revealed no indication of an indwelling catheter in Section H of the MDS 3.0 assessment. [...]
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on observation, record review and interview the facility failed to ensure indwelling urinary catheter tubing was secured per Resident #19 and Resident #114's plan of care to prevent the catheter from pulling and/or causing irritation or pain. This affected two residents (Resident #19 and #114) of three residents reviewed for urinary catheters. Findings Include: 1. Review of the medical record for Resident #114 revealed the resident was admitted to the facility on [DATE] with diagnoses including unspecified dementia with behavioral disturbances, retention of urine and benign prostatic hyperplasia with lower urinary tract symptoms. Record review revealed the resident had an indwelling catheter due to the diagnosis of retention of urine. Resident #114 had a care plan in place to have the catheter tubing secured to her leg every morning. [...]
- D
Ensure each resident receives and the facility provides drinks consistent with resident needs and preferences and sufficient to maintain resident hydration.
Inspectors wroteBased on observation, record review and interview the facility failed to ensure Resident #324's liquids were properly thickened as ordered by the physician. This affected one resident (Resident #324) of four residents reviewed for thickened liquids. Findings Include: Review of Resident #324's medical record revealed an admission date of 04/07/19 with diagnoses including Parkinson's disease, dementia with behavioral disturbance, heart failure, chronic pulmonary disease and major depressive disorder. Review of a physician's orders revealed Resident #324 was ordered a dysphagia II carbohydrate controlled no added salt diet with nectar thick liquids. Review of Resident #324's baseline care plan dated 04/07/19 revealed the resident was on dysphagia II no added salt diet with nectar thick liquids with a goal to maintain adequate nutrition. [...]
- D
Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.
Inspectors wroteBased on observation, record review and staff interview the facility failed to ensure a therapeutic diet was provided to Resident #324 as ordered by the physician. This affected one resident (Resident #324) of five residents who received therapeutic a dysphagia II diet.
Fire safety inspections
18 fire safety citations on file: 6 on September 26, 2024, 6 on May 19, 2022, 6 on April 25, 2019.
Every fire safety citation18 citations
- F
Address subsistence needs for staff and patients.
E 15 · September 26, 2024 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · September 26, 2024 · Corrected (the home has a date of correction)
- F
Have properly installed electrical wiring and gas equipment.
K 511 · September 26, 2024 · Corrected (the home has a date of correction)
- F
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · September 26, 2024 · Corrected (the home has a date of correction)
- E
Provide properly protected cooking facilities.
K 324 · September 26, 2024 · Corrected (the home has a date of correction)
- E
Install corridor and hallway doors that block smoke.
K 363 · September 26, 2024 · Corrected (the home has a date of correction)
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · May 19, 2022 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · May 19, 2022 · Corrected (the home has a date of correction)
- F
Have simulated fire drills held at unexpected times.
K 712 · May 19, 2022 · Corrected (the home has a date of correction)
- E
Provide properly protected cooking facilities.
K 324 · May 19, 2022 · Corrected (the home has a date of correction)
- E
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · May 19, 2022 · Corrected (the home has a date of correction)
- E
Have properly installed electrical wiring and gas equipment.
K 511 · May 19, 2022 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · April 25, 2019 · Corrected (the home has a date of correction)
- E
Keep aisles, corridors, and exits free of obstruction in case of emergency.
K 211 · April 25, 2019 · Corrected (the home has a date of correction)
- E
Have corridors or aisles that are unobstructed and are at least 8 feet in width.
K 232 · April 25, 2019 · Corrected (the home has a date of correction)
- E
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
K 362 · April 25, 2019 · Corrected (the home has a date of correction)
- E
Provide properly sized and located linen or trash receptacles.
K 754 · April 25, 2019 · Corrected (the home has a date of correction)
- E
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
K 761 · April 25, 2019 · Corrected (the home has a date of correction)