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 27 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
1J
0K
0L
Actual harm
3G
0H
0I
Potential for more than minimal harm
16D
1E
6F
Potential for minimal harm
0A
0B
0C
June 11, 2026Complaint inspection · 1 citation
- 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 interviews and observation the facility failed to ensure preventive maintenance measures were in place to ensure Heating, Ventilation, and Air Conditioning (HVAC) system functioned properly to keep the air temperature in proper range. This had the potential to affect all twenty-two (22) Residents residing on the Care Hall. Facility census was 95.
March 13, 2025Standard inspection, Complaint inspection · 10 citations
- G
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on record review, hospital record review, and interview, the facility failed to ensure Resident #16 was safely assisted with activities of daily living to prevent a fall with major injury. Actual harm occurred on 02/06/25 when Resident #16, who was comprehensively assessed and ordered to need two staff members to assist when giving personal care, received incontinence care by only one staff member, resulting in a fall, hospitalization, and fractured hip. This affected one resident (#16) of five residents reviewed for falls. The total census was 110.
- F
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Inspectors wroteBased on observation and interview the facility did not ensure food was served at a palatable temperature. This had the potential to affect 107 residents who received food from nutrition services. The facility census was 110.
- 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, staff interview and facility policy review the facility failed to ensure the kitchen was clean and sanitary. This had the potential to affect all 107 residents receiving food from the kitchen as three residents (Resident #30, #102, and #167) received no food by mouth. The facility census was 110.
- F
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
Inspectors wroteBased on record review and interview the facility failed to have quarterly Quality Assurance meetings. This had the potential to affect all residents. The census was 110. Findings Include: Review of the Quality Assurance (QA) meeting minutes revealed minutes starting in October 2024 to current date. Interview on 03/13/25 at 2:22 P.M. with the Administrator revealed he developed the QA program when he started at the facility in October 2024. He stated there were no prior meeting minutes for review.
- E
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Inspectors wroteBased on record review and interview, the facility failed to ensure residents and/or representatives were provided education regarding the benefits and potential side affects of the influenza and pneumococcal immunizations and the resident's records reflected the consent or refusal of the vaccines and the education provided. This finding affected four (Residents #80, #166, #215 and #217) of five residents reviewed for immunizations.
- D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteBased on record review, observation, interviews and review of facility policy, the facility failed to ensure staff treated residents with respect and dignity. This affected one resident (Resident #81) of four residents reviewed for dignity. The facility census was 110.
- 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, the facility failed to ensure residents received adequate timely assistance with eating and oral hygiene. This affected two residents (Resident #16 and Resident #223) of three residents investigated for activities of daily living (ADL) care. The facility census was 110.
- D
Provide enough food/fluids to maintain a resident's health.
Inspectors wroteBased on record review, and interview the facility failed to monitor and implement nutrition oral supplements as recommended by the registered dietitian and implement weekly weights as ordered by the physician. This affected one resident ( Resident # 166) of three residents reviewed for nutrition. The facility census was 110.
- D
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Inspectors wroteBased on record review and interview, the facility failed to ensure Resident #216's antibiotic medication was discontinued timely following notification of a negative urine culture. This finding affected one (Resident #216) of six residents reviewed for medication administration.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, record review and interview, the facility failed to ensure the glucometer blood glucose testing (BGT) machine was appropriately sanitized and disinfected to prevent the potential of cross contamination of blood borne pathogens. This finding affected two residents (Residents #80 and #166) of three residents (Residents #80, #166 and #209) who receive medications from the Hall One medication administration cart.
December 16, 2024Complaint inspection · 4 citations
- D
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Inspectors wroteTHE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NONCOMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on medical record review, review of facility Self-Reported Incidents (SRIs), review of facility investigation documents, resident interview, staff interview, and review of the facility policy, the facility failed to ensure residents were free from abuse. This affected one (Resident #10) of three residents reviewed for abuse. The facility census was 88 residents.
- D
Ensure medication error rates are not 5 percent or greater.
Inspectors wroteBased on medical record review, observation, staff interview, and review of the facility policy the facility failed to ensure a medication administration error rate of less than five percent (%.) This affected two (Resident #12 and Resident #85) of four residents observed during medication administration. The medication error rate was eight % with 37 medication opportunities and three errors. The facility census was 88 residents.
- 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 medical record review, observation, staff interview, and review of the facility policy, the facility failed to ensure medications were not left unattended at the resident bedside. This affected two (Residents #56 and #85 ) of four residents observed for medication administration. The facility census was 88 residents.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on medical record review, observation, staff interview, and review of the facility policy, the facility failed to ensure staff performed proper hand hygiene during medication administration. This affected three (Residents #12, #17, and #37) of four residents observed for medication administration. The facility census was 88 residents.
February 20, 2024Complaint inspection · 3 citations
- G
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on closed medical record review, policy review and interview, the facility failed to provide preventive care consistent with professional standards of practice to promote healing of a pressure ulcer wound for Resident #98. This affected one (Resident #98) of three residents reviewed for pressure ulcers. The census was 97. [...]
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on observation, medical record review, policy review and interview, the facility failed to ensure Resident #92, who was care-planned as one-staff assistance with meals, was assisted with a meal. This affected one (Resident #92) of three residents reviewed for meal assistance. The census was 97.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on closed medical record review, policy review and interview, the facility failed to consistently implement physician wound care orders for a skin tear and vascular wounds for Resident #98. This affected one (Resident #98) of three residents reviewed for non-pressure wounds. The census was 97.
November 30, 2023Standard inspection, Complaint inspection · 4 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, staff interview, and policy review, the facility failed to ensure proper sanitation was maintained during food preparation, failed to ensure dishes were adequately cleaned, and failed to ensure the dishwasher was maintained in optimal condition to properly clean dishes, eating utensils, and food preparation utensils. This had the potential to affect all 98 residents who the facility identified as receiving food from the kitchen. The facility identified two (#55 and #207) residents who do not eat food prepared in the kitchen. The facility census was 100.
- F
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, review of email correspondence, review of infection control tracking documents, staff interview, and review of facility policies, the facility failed to maintain an infection surveillance program which adequately tracked location, organisms, antibiotic use, and other metrics to determine infection trends. Additionally, the facility failed to ensure staff had means to sanitize their hands in the laundry room. This had the potential to affect all 100 residents in the facility. The census was 100.
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observation and resident and staff interview, the facility failed to ensure oxygen tubing was changed as ordered. This affected one (#29) of one resident reviewed for oxygen. The facility census was 100.
- 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 medical record review, resident and staff interview interview, and review of a facility policy, the facility failed to ensure residents with indwelling urinary catheters were provided routine catheter care and urinary output was monitored. This affected one (#206) of three residents reviewed for urinary catheters. The census was 100.
November 8, 2023Complaint inspection · 3 citations
- J
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on medical record review, staff interview, power of attorney (POA) interview, resident interview, review of a Self -Reported Incident (SRI) and investigation, review of facility sign out sheets, and review of the facility policy for signing residents out, the facility failed to provide supervision and follow the facility policy for a resident signing out for a leave of absence (LOA) to ensure the whereabouts for one resident (Resident #87) who had left the facility after reporting she was leaving on a LOA. This resulted in Immediate Jeopardy and the potential for serious harm, injury or death, on 10/24/23 at approximately 4:30 P.M. when Resident #87, who had mild dementia and required supervision and assistance for activities of daily living, informed staff she was leaving with a friend for an LOA. [...]
- G
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on observation, record review, facility policy review, staff interview, and resident interview, the facility failed to develop and implement a comprehensive and individualized pressure ulcer prevention program to prevent the development of a pressure ulcer for Resident #33. Actual Harm occurred on 10/09/23 when Resident #33, who required extensive assistance from staff for bed mobility and activity of daily living care including turning and repositioning, developed an unstageable pressure ulcer to the left buttocks without being provided adequate pressure relief. Additionally, the resident was left soiled with stool that was in contact with the pressure ulcer wound. This affected one resident (#33) of three residents reviewed for pressure ulcers.
- 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, record review, staff interview, resident interview, and review of facility policy, the facility failed to ensure incontinence care was provided in a timely manner to one (#33) out of three residents reviewed for bowel and bladder incontinence. The facility census was 104.
June 4, 2021Standard inspection · 2 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 interview the facility failed to maintain a clean and sanitary kitchen to prepare food. This had the potential to affect 92 out of 93 residents residing in the facility. One resident (Resident #32) did not receive food from the kitchen. Facility census was 93. Finding Include: 1. On 06/01/21 the initial tour of the kitchen from 8:43 A.M. through 9: 21 A.M. revealed the oven, shelf over the oven, stovetop, fryer, and steamer all had dried food spatters down the sides, and accumulated grease, dust, and/or grime on them. The handles and knobs of the equipment had accumulated grease and grime. The vents over the equipment were greasy. The small [NAME] mixer stand had dried spatters on the side of the mixer and on the stand. 2. On 06/01/21 at 12:47 P.M. [...]
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on interview and record review, revealed the facility failed to ensure Resident #301 who had an order to test her stool for occult blood (a test to check for hidden blood in the stool) was completed as ordered and/ or the physician or nurse practitioner was notified the ordered test was not completed. This affected one resident (Resident #301) out of one resident (Resident #301) reviewed for change in condition. The facility census was 93.
Fire safety inspections
38 fire safety citations on file: 9 on March 13, 2025, 10 on November 30, 2023, 19 on June 4, 2021.
Every fire safety citation38 citations
- E
Use approved construction type or materials.
K 161 · March 13, 2025 · Corrected (the home has a date of correction)
- E
Keep aisles, corridors, and exits free of obstruction in case of emergency.
K 211 · March 13, 2025 · Corrected (the home has a date of correction)
- E
Have an enclosure around a vertical opening shaft.
K 311 · March 13, 2025 · Corrected (the home has a date of correction)
- E
Install an approved automatic sprinkler system.
K 351 · March 13, 2025 · Waiver
- E
Have simulated fire drills held at unexpected times.
K 712 · March 13, 2025 · Corrected (the home has a date of correction)
- E
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
K 761 · March 13, 2025 · Corrected (the home has a date of correction)
- E
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
K 914 · March 13, 2025 · Corrected (the home has a date of correction)
- E
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · March 13, 2025 · Corrected (the home has a date of correction)
- E
Ensure proper usage of power strips and extension cords.
K 920 · March 13, 2025 · Corrected (the home has a date of correction)
- F
Keep aisles, corridors, and exits free of obstruction in case of emergency.
K 211 · November 30, 2023 · Corrected (the home has a date of correction)
- F
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 · November 30, 2023 · Corrected (the home has a date of correction)
- F
Install emergency lighting that can last at least 1 1/2 hours.
K 291 · November 30, 2023 · Corrected (the home has a date of correction)
- F
Have an enclosure around a vertical opening shaft.
K 311 · November 30, 2023 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · November 30, 2023 · Corrected (the home has a date of correction)
- F
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · November 30, 2023 · Corrected (the home has a date of correction)
- F
Provide properly sized and located linen or trash receptacles.
K 754 · November 30, 2023 · Corrected (the home has a date of correction)
- F
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · November 30, 2023 · Corrected (the home has a date of correction)
- E
Install smoke barrier doors that can resist smoke for at least 20 minutes.
K 374 · November 30, 2023 · Corrected (the home has a date of correction)
- E
Have properly installed electrical wiring and gas equipment.
K 511 · November 30, 2023 · Corrected (the home has a date of correction)
- F
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
K 225 · June 4, 2021 · Corrected (the home has a date of correction)
- F
Install a fire alarm system that can be heard throughout the facility.
K 341 · June 4, 2021 · Corrected (the home has a date of correction)
- F
Have a fire alarm with audible and visual signals that transmits the alarm automatically to notify emergency forces in event of fire.
K 343 · June 4, 2021 · Corrected (the home has a date of correction)
- F
Meet requirements for the installation and maintenance of electrical systems.
K 911 · June 4, 2021 · Corrected (the home has a date of correction)
- F
Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk.
K 926 · June 4, 2021 · Corrected (the home has a date of correction)
- E
Meet requirements for outpatient facilities located next to inpatient facilities separated by fire resistive construction.
K 132 · June 4, 2021 · Corrected (the home has a date of correction)
- E
Use approved construction type or materials.
K 161 · June 4, 2021 · Corrected (the home has a date of correction)
- E
Install noncombustible or limited-combustible interior walls.
K 163 · June 4, 2021 · Waiver
- 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 · June 4, 2021 · Corrected (the home has a date of correction)
- E
Have exits that are accessible at all times.
K 271 · June 4, 2021 · Corrected (the home has a date of correction)
- E
Have an enclosure around a vertical opening shaft.
K 311 · June 4, 2021 · Waiver
- E
Install an approved automatic sprinkler system.
K 351 · June 4, 2021 · Corrected (the home has a date of correction)
- E
Properly select, install, inspect, or maintain portable fire extinguishes.
K 355 · June 4, 2021 · Corrected (the home has a date of correction)
- E
Install corridor and hallway doors that block smoke.
K 363 · June 4, 2021 · Corrected (the home has a date of correction)
- E
Have enough space near smoke barriers to protect residents.
K 373 · June 4, 2021 · Corrected (the home has a date of correction)
- E
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
K 521 · June 4, 2021 · Corrected (the home has a date of correction)
- E
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
K 761 · June 4, 2021 · Corrected (the home has a date of correction)
- E
Ensure proper usage of power strips and extension cords.
K 920 · June 4, 2021 · Corrected (the home has a date of correction)
- D
Have restrictions on the use of portable space heaters.
K 781 · June 4, 2021 · Corrected (the home has a date of correction)