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 35 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
1J
0K
0L
Actual harm
3G
0H
0I
Potential for more than minimal harm
20D
10E
1F
Potential for minimal harm
0A
0B
0C
August 21, 2025Standard inspection · 6 citations
- 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 interview and record review it was determined, for 1 of 43 sampled residents, the facility did not allow each resident the right to formulate an advance directive. Specifically, a resident did not have a Physician Order for Life Sustaining Treatment (POLST) form. Resident identifier: 76. Resident 76 was admitted to the facility on [DATE] with diagnoses which included moderate protein-calorie malnutrition, adult failure to thrive, and Alzheimer's disease. Resident 76's medical record was reviewed on 8/18/25 through 8/21/25. No orders related to a code status or a POLST form could be located in resident 76's medical records. On 8/19/25 at 10:46 AM, an interview was conducted with Registered Nurse (RN) 1, who stated that she was unable to locate any orders related to resident 76's code status. [...]
- 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 interview and record review, it was determined the facility did not ensure residents who were continent of bladder received appropriate treatment and services to prevent urinary tract infections (UTI). Specifically, for 1 out of 43 sampled residents, a resident was not started on antibiotics for 11 days after complaining of continued dysuria. Resident identifier: 85.
- D
Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.
Inspectors wroteBased on interview and record review, the facility did not obtain laboratory (lab) services only when ordered by a physician; physician assistant; nurse practitioner, or clinical nurse specialist. Specifically, for 1 out of 43 sampled residents, a resident had a Complete Blood Count (CBC), Comprehensive Metabolic Panel (CMP), erythrocyte sedimentation rate (ESR), and C-Reactive Protein (CRP) collected prior to the date the physician's order stated. Resident identifier: 7.
- D
Keep complete, dated laboratory records in the resident's record.
Inspectors wroteBased on interview and record review it was determined for 2 out of 43 sampled residents, that the facility did not file in the resident's clinical record laboratory reports that were dated and contained the name and address of the testing laboratory. Specifically, two residents laboratory results were not located in the electronic medical record. Resident identifiers: 5 and 85.
- D
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, it was determined that the facility did not store, prepare, distribute, and serve food in accordance with professionals standards for food safety. Specifically, there were observations of numerous flies making contact with food preparation surfaces and utensils in the kitchen, observations of kitchen staff not properly wearing hairnets, observations of staff not washing their hands after leaving the kitchen and returning, and observations of dirty ceiling tiles above food preparation areas of the kitchen. Findings Included:On 8/20/25 at 11:37 AM, an observation was made of the facility kitchen while lunch was being plated and served. There were multiple flies in the kitchen. The flies were landing on hotel pans and food preparation tables. The ceiling above the tray line area of the kitchen was dirty. [...]
- 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 and record review, it was determined for 1 of 43 sampled residents, the facility failed to maintain medical records on each resident that was complete, accurately documented, readily accessible, and systematically organized. Specifically, a resident had no documentation regarding an incident. Resident identifier: 36.
March 20, 2025Standard inspection, Complaint inspection · 9 citations
- E
Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.
Inspectors wroteBased on observation and interview, the facility did not provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. Specifically, surveyors observed two meals that were served late, multiple residents complained of late meals during the initial pool, and there were grievances filed by residents about late meals. Resident identifier: 2 and 44. Findings Included: The posted facility meal times posted outside of the main dining room were as follows: Breakfast: 7:30 to 8:30 AM Lunch: 11:30 AM to 12:30 PM Dinner: 4:30 to 5:30 PM The facility serves residents who eat in their rooms first and then serves residents who choose to eat in the dining room after. On 3/17/25, an observation was made of the breakfast meal service at the facility. The facility did not finish serving residents in the dining room until 8:52 AM. [...]
- E
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 that each resident received and the facility provided food and drink that was palatable, attractive, and at a safe and appetizing temperature. Specifically, surveyors sampled a test tray and found it to not be palatable, there were concerns about the palatability of the food served at the facility identified during the initial pool interviews, and there were grievances filed by residents about the food served at the facility. Resident identifiers: 2, 26, 40, 63, and 72. Findings Included: On 3/17/25 at 10:41 AM, an interview was conducted with resident 2. Resident 2 stated that most of the time the food served at the facility tasted bad. On 3/17/25 at 11:01 AM, an interview was conducted with resident 40. Resident 40 stated that sometimes the food was not so bad, but other times it was so bad he would rather not eat. [...]
- E
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview, and record review, the facility did not maintain an infection prevention and control program to prevent the development and transmission of communicable diseases. Specifically, for 1 out of 38 sampled residents, a resident's feeding tube was observed to be on the floor and not capped while not in use. Additionally, facility staff did not wear Personal Protective Equipment (PPE) while providing high contact care on Enhanced Barrier Precautions (EBP). Resident identifier: 238.
- D
Ensure each resident receives an accurate assessment.
Inspectors wroteBased on interview and record review, the facility did not ensure that the resident assessment accurately reflected the residents' status. Specifically, for 2 out of 38 sampled residents, the facility indicated on the resident assessment that the residents did not have a serious mental illness despite the residents' Preadmission Screening and Resident Review (PASRR) level II assessments that documented the residents had a serious mental illness. Resident identifiers: 45 and 68. Findings Included: 1. Resident 45 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including, but not limited to, paranoid schizophrenia, generalized anxiety disorder, post-traumatic stress disorder, and major depressive disorder recurrent moderate. Resident 45's medical record was reviewed on 3/17/25 through 3/20/25. [...]
- D
Assist a resident in gaining access to vision and hearing services.
Inspectors wroteBased on interview and record review, the facility did not ensure residents received the appropriate treatment and assistive devices to maintain vision and hearing abilities. Specifically, for 2 out of 38 sampled residents, a resident with impaired vision had a referral sent to the eye doctor in January and the resident had not see the eye doctor. In addition, a resident with vision and hearing concerns . Resident identifiers: 2 and 63.
- 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 that the resident environment remained as free of accident hazards as was possible and each resident received adequate supervision and assistance devices to prevent accidents. Specifically, for 1 out of 38 sampled residents, a resident that was a high fall risk did not have interventions implemented to prevent future falls. Resident identifier: 81.
- D
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Inspectors wroteBased on interview and record review, the facility did not ensure that the resident's drug regimen was free of unnecessary drugs without adequate monitoring. Specifically, for 1 out of 38 sampled residents, nursing staff administered blood pressure lowering medications to the resident when the resident's blood pressure was outside of the parameters specified by a physician's order. Resident identifier: 40. Findings Included: Resident 40 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included, but not limited to, essential primary hypertension, type 2 diabetes mellitus with hyperglycemia, mixed hyperlipidemia, and severe morbid obesity due to excess calories. Resident 40's medical record was reviewed on 3/17/25 through 3/20/25. [...]
- D
Ensure that residents are free from significant medication errors.
Inspectors wroteBased on interview and record review, the facility did not ensure the residents were free of any significant medication errors. Specifically, for 1 out of 38 sampled residents, a resident's physician order for oxycodone was transcribed to the wrong resident's Medication Administration Record (MAR) and that resident received five doses of the medication. Resident identifier: 60.
- D
Provide routine and 24-hour emergency dental care for each resident.
Inspectors wroteBased on observation, interview, and record review, the facility did not provide or obtain outside resources for routine or emergency dental services to meet the needs of the resident. Specifically, for 1 out of 38 sampled residents, a resident was not provided dental services for missing teeth. Resident identifier: 2.
September 16, 2024Standard inspection, Complaint inspection · 11 citations
- G
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Inspectors wroteBased on interview and record review it was determined, for 1 of 45 sampled residents, that the facility did not ensure that each resident received the food and drink that accommodated the resident allergies, intolerances, and preferences. Specifically, a resident with food allergies to fish and shellfish was served a Krabbycake and needed Benadryl administered. Resident identifier: 66.
- 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 did not store, prepare, distribute and serve food in accordance with professional standards for food service safety. Specifically, the dish machine was not meeting the required temperature to sanitize the dishes and there were no chemical strips in the kitchen to monitor the sanitizer in the dish machine or the sanitation buckets. Additionally, food items in the freezer and dry storage room were open to air.
- E
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observation, interview and record review, for 4 of 45 residents, the facility did not ensure that residents who needed respiratory care were provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences. Specifically, a resident did not have a physician order for the use of oxygen, and residents did not have properly labeled oxygen tubing. Resident identifiers: 6, 39, 51, and 69.
- 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 observation and interview, it was determined the facility did not ensure that all drugs and biologicals were stored and secured in locked compartments. Specifically, medication was left unattended in a medication cup on top of an unlocked medication cart within reach of other residents and a blue pill was observed to be on the floor during medication pass.
- E
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Inspectors wroteBased on observation, interview, and record review, the facility did not provide food that was palatable, attractive, and at a safe and appetizing temperature. Specifically, for 9 out of 45 sampled resident, residents complained of food quality and a test tray not attractive or palatable. Resident identifiers: 8, 15, 28, 31, 34, 39, 47, 55 and 66.
- E
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview and record review it was determined, for 14 out of 45 sampled residents, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Specifically, hand hygiene was not performed between residents who were being assisted with eating or performed after delivering lunch trays between multiple resident rooms. In addition, after a staff member tested positive for COVID-19 and source control was not implemented. Resident identifiers: 3, 7, 9, 17, 22, 33, 35, 47, 51, 58, 62, 67, 68 and 124.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on observation, interview and record review it was determined, for 1 of 45 sampled residents, the facility did not ensure that residents received treatment and care in accordance with professional standards of practice. Specifically, a resident was complaining that food was getting caught in a tooth that had been extracted. There was no monitoring documented after the resident had the tooth extraction. Resident identifier: 50.
- 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 it was determined, for 1 of 45 sampled residents, that the facility did not ensure that each resident received adequate supervision and assistive devices to prevent accidents. Specifically, a resident that was assessed as requiring supervision while smoking was observed to be smoking unsupervised. Resident identifier: 50.
- 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, interview, and record review it was determined, for 1 of 45 sampled resident, the facility did not ensure that a resident who was fed by enteral means received the appropriate treatment. Specifically, a resident's tube feeding was not infusing at the prescribed infusion rate. Resident identifier: 51.
- D
Ensure that residents are free from significant medication errors.
Inspectors wroteBased on observation, interview and record review, for 1 of 45 sampled residents, the facility did not ensure that residents were free from significant medication errors. Specifically, an order for Furosemide 40 mg (milligrams) was not discontinued when the physician reduced the dose to 20 mg, resulting the resident receiving 60 mg on two separate days. Resident identifier: 39.
- D
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
Inspectors wroteBased on observation, interview, and record review it was determined, for 1 of 45 sampled resident, that the facility did not ensure each resident received and the facility provided food prepared in a form designed to meet individual needs. Specifically, a resident was observed to be coughing after drinking liquids during two different meal times. Resident identifier:
March 21, 2024Complaint inspection · 6 citations
- J
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Inspectors wroteBased on interview and record review, the facility failed to prevent an instance of sexual abuse between resident 269 and resident 270, and neglected to provide the supervision necessary to prevent the elopement of resident 17. The facility's failure to prevent the sexual abuse of resident 270 was determined to be noncompliant and constituted immediate jeopardy. Additionally, due to resident 17's assessed impaired cognitive status and known wandering behavior, the facility's lack of a coordinated plan to supervise the resident's whereabouts was also determined to be noncompliant and constituted immediate jeopardy. However, based on the facility's corrective actions and a review of the facility's current compliance in this regulatory area, the deficiency was determined to be past noncompliance. Resident identifiers: 17, 269, and 270. Corrective Action: Elopement: [DATE]: [...]
- G
Provide safe, appropriate pain management for a resident who requires such services.
Inspectors wroteBased on observation, interview, and record review, the facility did not ensure that pain management was provided to residents who required such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences. Specifically, for 1 out of 45 sampled residents, a resident who sustained a right humerus fracture was not offered a shoulder immobilizer daily as ordered to help mitigate pain. Resident identifier: 58. Findings Included: [...]
- E
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Inspectors wrote3. Resident 21 was admitted to the facility initially on 8/2/19, and re-admitted on [DATE] with diagnoses that included type 2 diabetes with neuropathy, morbid obesity, dementia with behavioral disturbance, and depressive disorder. Resident 21's medical record was reviewed between 3/11/24 and 3/21/24. A quarterly MDS assessment dated [DATE], revealed resident 21 had a BIMS score of 8, indicating moderate cognitive impairment. Resident 21's care plan focus area, initiated on 2/16/24, revealed, [resident's name redacted] has expressed a need for physical intimacy, such as kissing other residents. He has a dx [diagnosis] of dementia and does not have the capacity to consent to physical intimacy. The goal was, Residents psychosocial need for physical touch/intimacy will be met safely through review date. [...]
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on observation, interview, and record review, the facility did not provide necessary services to maintain good nutrition for a resident who was unable to carry out activities of daily living. Specifically, for 1 out of 45 sampled residents, a resident that required assistance with eating waited 35 minutes to get assistance by staff after the meal was served to the resident. Resident identifier: 29.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on interview and record review, the facility did not ensure that residents received treatment and care in accordance with professional standards of practice. Specifically, for 1 out of 45 sampled residents, a resident was admitted to the facility on hospice and was not assessed upon admission, provided the appropriate medications, and was not transferred until the following day to the memory care unit after family requested. Resident identifier: 119.
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observation, interview, and record review, the facility did not ensure that a resident who needs respiratory care was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents goals, and preferences. Specifically, for 1 out of 45 sampled residents, a resident that required continuous oxygen therapy was observed without their oxygen nasal cannula on and out of reach. Staff were observed to not apply the oxygen nasal cannula for the resident. Resident identifier: 59.
September 18, 2023Complaint inspection · 3 citations
- G
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Inspectors wroteBased on observation, interview and record review, it was determined, for 2 out of 33 sampled residents, that the facility did not ensure that each resident was free from abuse, neglect, and misappropriation of resident property. Specifically, a female resident reported that a male resident had grabbed her breast without her consent. The deficiency identified was determined to be at a HARM level. Resident identifiers: 43 and 50.
- E
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on observation, interview, and record review, it was identified that the facility failed to ensure that all alleged violations involving abuse were reported immediately, but not later than 2 hours after the allegation was made, to the State Survey Agency. Specifically, an entity report for 3 separate allegations of abuse were not submitted to the State Survey Agency within 2 hours after the allegations were identified. Resident identifiers: 11, 43, and 52.
- E
Respond appropriately to all alleged violations.
Inspectors wrote2. Resident 43 was admitted to the facility on [DATE] with diagnoses which consisted of intracranial injury with loss of consciousness, hemiplegia, Alzheimer's disease, osteoarthritis, major depressive disorder, insomnia, benign prostatic hypertrophy, and history of malignant neoplasm of the skin. Resident 43's medical record was reviewed 9/11/23 through 9/18/23. On 8/23/23, the Quarterly Minimum Data Set (MDS) Assessment documented a BIMS score of 00, which would indicate a severe cognitive impairment. The assessment documented that resident 43 was an extensive 1 person assist for bed mobility, transfer, locomotion on and off the unit, dressing, toilet use, and personal hygiene. Review of the resident 43's progress notes revealed the following: a. [...]
Fire safety inspections
10 fire safety citations on file: 4 on August 21, 2025, 3 on March 20, 2025, 3 on September 16, 2024.
Every fire safety citation10 citations
- F
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
K 321 · August 21, 2025 · Corrected (the home has a date of correction)
- F
Have properly installed electrical wiring and gas equipment.
K 511 · August 21, 2025 · Corrected (the home has a date of correction)
- F
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · August 21, 2025 · Corrected (the home has a date of correction)
- E
Conduct testing and exercise requirements.
E 39 · August 21, 2025 · Corrected (the home has a date of correction)
- F
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
K 321 · March 20, 2025 · Corrected (the home has a date of correction)
- E
Install smoke barrier doors that can resist smoke for at least 20 minutes.
K 374 · March 20, 2025 · Corrected (the home has a date of correction)
- D
Ensure proper usage of power strips and extension cords.
K 920 · March 20, 2025 · 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 · September 16, 2024 · Corrected (the home has a date of correction)
- D
Inspect, test, and maintain automatic sprinkler systems.
K 353 · September 16, 2024 · Corrected (the home has a date of correction)
- D
Have simulated fire drills held at unexpected times.
K 712 · September 16, 2024 · Corrected (the home has a date of correction)