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 41 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
32D
7E
1F
Potential for minimal harm
0A
0B
1C
August 25, 2025Standard inspection, Complaint inspection · 12 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 it was determined the facility failed to ensure sanitary practices were followed in accordance with professional standards for food service safety, and ensure the dishwasher reached adequate temperature according to the manufacturer's guideline. This was evident during the surveyor's tour of the facility's kitchen and 1 out of 1 nutrition room observed by the surveyor on the first floor of the facility during the survey.
- D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteBased on interviews, medical record reviews, and observations it was determined that the facility failed to provide dignity and respect to residents dependent for activities of daily living assistance. This was evident for two residents (#7 and #43) out of 8 residents observed at mealtimes during the recertification survey.
- 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 observations and interview it was determined the facility failed to ensure a homelike environment and maintain the resident environment in a safe, clean, and homelike manner. This was evident for 1 out of 1 outdoor resident patio spaces and 5 of 15 resident rooms observed during the facility's recertification survey.
- D
Ensure each resident receives an accurate assessment.
Inspectors wroteBased on observation, interview, and record review, it was determined the facility failed to ensure Minimum Data Set (MDS) assessments were accurately coded. This was evident for 1 (Resident #10) out of 5 residents reviewed for pressure ulcers during the facility's recertification survey.
- D
Ensure services provided by the nursing facility meet professional standards of quality.
Inspectors wroteBased on interview and record review it was determined the facility failed to ensure medications were timely administered to a resident (#68). This was evident during the surveyor's review of a complaint during the facility's recertification survey.
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on observation and staff interviews, it was determined that the facility failed to ensure that all residents were free from accident hazards and supervision. This was evident for 4 (Resident #2, 4, 73, and 22) out of 4 residents observed in the dining room area after breakfast time during the survey.
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observation, interview and record review it was determined the facility failed to: 1.) follow an active medical order in place for continuous oxygen for a resident, 2.) ensure the resident's care reviewed by the physician reflected the medical order in place, and 3.) ensure the respiratory care plan accurately reflected the medical order for oxygen. This was evident for 1 out of 1 resident (Resident #68) reviewed for respiratory care during the surveyor's review of a complaint and during the facility's recertification survey.
- D
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Inspectors wroteBased on record review and staff interview, it was determined that the facility failed to ensure the services of a registered nurse were provided for at least 8 consecutive hours a day, 7 days a week. This deficient practice was evident on 1 of 8 days reviewed (08/10/2025) during the recertification survey. On 08/15/2025 at 1:07 PM, record review of staffing schedules and assignments revealed that no registered nurse was scheduled or present to provide coverage for the facility on 08/10/2025 for an 8-hour consecutive period. At 1:26 PM, during an interview with the Director of Nursing (DON), she confirmed there was no nurse coverage for the entire building during the overnight shift on August 9 and all day on August 10. She stated she lives close by and could come in if needed but was not in the facility.
- D
Post nurse staffing information every day.
Inspectors wroteBased on observation and interview, it was determined that the facility failed to post nurse staffing information in a clear and visible manner as required. This deficient practice was evident for 1 of 2 floors during the recertification survey.
- 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 and staff interviews, it was determined that the facility failed to ensure that all items in the medication storage rooms were free from expired expiration dates. This was evident for 1 out of 2 medication storage rooms.
- D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on observations, record review, and staff interview, it was determined that the facility failed to ensure accurate information was placed in residents' records. This was evident for 2 (Resident #2 and #132) residents reviewed during the survey. 1) On 8/21/2025 at 2:13 PM, the surveyor spoke with the DON #2 and asked the question, Who is responsible for reviewing and implementing orders from the doctor after a doctor's appointment? DON #2 explained that the nurse should review the visit summary and update the orders when the resident returns, and the unit manager should also follow up to make sure that the orders are completed. DON #2 was notified that during the surveyor's record review, for Resident #2, there was no documentation of when the Foley was ever changed. DON #2 stated that she is not sure how they document it and that she would get back to the surveyor. [...]
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation and interviews the facility failed to: 1.) maintain optimal infection control and prevention precautions in one area of the laundry room and maintain a clean environment around the eye wash station and the laundry hopper, and ensure water pipes were not left exposed in the area next to and above the laundry hopper. This was evident for 1 out of 1 laundry area observed; 2.) ensure proper infection control/sanitization for any medical equipment that was shared among residents. This was evident for 1 out of 2 medication administration observations; and 3.) ensure oxygen equipment was properly dated to prevent potential infection control risks. This was evident for 1 (Resident #101) of 2 residents reviewed for oxygen use during the facility's recertification survey.
April 6, 2023Standard inspection · 17 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 a tour of the facility it was determined that the facility staff failed to ensure resident rooms were maintained in a homelike manner. This was evident as a result of random observations.
- E
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on observation, interview, and medical record review it was determined that the facility failed to 1.) provide a resident with prompt assistance for positioning and failed to ensure the resident had access to their call bell device (Resident #504) and 2.) failed to document complete assessments of residents when there was a noted change in condition (#305 and #506). This was evident for 1.) 1 of 2 residents reviewed for positioning, and 2.) 2 of 4 residents reviewed for change of condition during an annual survey.
- E
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on medical record review, observation and interview, it was determined the facility staff failed to maintain the medical record in the most complete and accurate form for Residents (#5, #16, #24, #48, #61, #154, #156 and #508). This was evident for 8 of 63 residents selected for medical record review during the annual survey process.
- E
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observations, interviews and medical record review it was determined the facility failed to maintain the safest practicable level of precautions to prevent and control the spread of infectious disease. This was evident during multiple random observations throughout the facility. Review of the CDC website for Interim Infection Prevention and Control Recommendations to Prevent SARS-CoV-2 Spread in Nursing Homes, updated 9/27/22, revealed the following guidance; Post visual alerts (e.g., signs, posters) at the entrance and in strategic places (e.g., waiting areas, elevators, cafeterias) These alerts should include instructions about current IPC recommendations (e.g., when to use source control and perform hand hygiene). Dating these alerts can help ensure people know that they reflect current recommendations. Implement source control measures by; [...]
- E
Implement a program that monitors antibiotic use.
Inspectors wroteBased on the review of medical records, interview with facility staff and review of pertinent documentation including facility policy, it was determined that the facility failed to implement and monitor the usage of antibiotics for the residents. This was identified during the review of the facility line listing during the annual Medicaid/Medicare survey and the infection control task. Random residents selected for review from the facility line listing included (R #80, #106 and #504)
- E
Perform COVID19 testing on residents and staff.
Inspectors wroteBased on medical record review and interview with facility staff, it was determined that the facility staff failed to consistently acquire resident vital signs timely for the Daily COVID-19 tool assessments. This was evident for 3 of 3 residents reviewed during the infection control part of the annual survey.
- 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 clinical record review and staff interview it was determined that the facility staff failed to ensure residents were offered the opportunity to either provide a copy of already written Advanced Directives and/or create a set of Advanced Directives (#28 and #506). This was evident for 2 out of the 63 residents in the survey sample.
- D
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Inspectors wroteBased on medical record review and interview with facility staff, it was determined that the facility failed to notify family and the physician timely when notified of a residents change in condition. This was evident during a random observation.
- D
Keep residents' personal and medical records private and confidential.
Inspectors wroteBased on observation while touring the facility it was determined that the facility staff failed to protect the privacy of its residents (#9). This was evident as a result of three random observations.
- D
Ensure each resident receives an accurate assessment.
Inspectors wroteBased on medical record review, observation and staff interview, it was determined that the facility staff failed to accurately code a resident's status on the Minimum Data Set (MDS) assessment (Resident #50, #73 and #80). This was evident for 3 out of 63 residents selected for review during an annual survey. The MDS is a federally-mandated assessment tool that helps nursing home staff gathers information on each resident's strengths and needs. Information collected drives resident care planning decisions. MDS assessments need to be accurate to ensure each resident receives the care they need.
- D
PASARR screening for Mental disorders or Intellectual Disabilities
Inspectors wroteBased on clinical record review and staff interview it was determined that the facility staff failed to ensure its residents had a complete and accurate Preadmission Screening and Record Review (PASRR). This was evident for 1 out of 63 residents in the survey sample.
- 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 observation and medical record review it was determined the facility failed to address presence and care of a resident's foley catheter (tube that drains urine from the bladder) in the resident's baseline careplan. This was evident for one out of three residents reviewed for catheters.
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on resident medical records, the facility failed to take a resident to the bathroom (Resident #458), change a resident in a timely manner (Resident # 27) and provide showers (Resident #508). This was evident for 3 out of 7 residents reviewed for ADL care during an annual survey.
- D
Provide enough food/fluids to maintain a resident's health.
Inspectors wroteBased on medical record review, observation and interview, it was determined the facility staff failed to provide supplements as recommended by the dietitian for a resident (#64). This was evident for 1 of 4 residents selected for review for nutrition during the annual survey.
- D
Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit.
Inspectors wroteBased on medical record review and interview, it was determined the facility staff failed to include provider notes in the medical record in a timely manner with accurate date of visit (Resident #508). This was evident for 1 of 63 residents reviewed during an annual survey.
- D
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Inspectors wroteBased on record review and interview with facility staff it was determined the facility failed to address and identify the use of a medication in a resident's plan of care (Resident #508). This was evident for one out of three residents reviewed for unnecessary medications.
- D
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on observations of the facility's kitchen and interviews of the dietary staff it was determined that 1) the facility failed to ensure sanitary practices were followed in accordance with professional standards for food service safety and 2) ensure the food maintained an acceptable serving temperature. These deficient practices have the potential to affect all residents.
December 21, 2018Standard inspection · 12 citations
- E
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on observation it was determined the facility staff failed to properly label and date food stored in the walk-in refrigerator. This was evident during the initial tour of the kitchen during the investigative portion of the survey.
- D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteBased on observation, it was determined that the facility staff failed to treat each resident in a dignified manner for. This was evident for 8 of 40 residents (#13, #55, #39, #87, #12, #73, #100, and #63) reviewed during the annual survey.
- D
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Inspectors wroteBased on observation, review of a medical record, and staff interview, it was determined the facility staff failed to 1) obtain a physician's order to use a restraint on a resident, 2) evaluate the use of a restraint on a resident, and 3) initiate a care plan for the use of the restraint on a resident. This was evident for 1 (Resident #55) of 1 resident reviewed for physical restraints during an annual recertification survey.
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on observation and staff interview, it was determined the facility staff failed to ensure that dependent resident's personal hygiene needs were adequately met by trimming the resident's finger nails. This was evident for 2 (#13, #96) of 6 residents reviewed for ADL care during an annual recertification survey.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on observation and interview, the facility staff failed to apply ace bandage wraps for Resident #89 and Ted stockings for Resident #351. This was evident for 2 of 40 residents during the investigative portion of the survey.
- D
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Inspectors wroteBased on observation, medical record review and staff interview it was determined the facility failed to ensure that residents with a limited range of motion received the appropriate treatment and services to prevent further decline in range of motion. This was evident for 1 (Resident #13) of 4 residents reviewed for mobility during an annual recertification survey.
- D
Observe each nurse aide's job performance and give regular training.
Inspectors wroteBased on review of employee files and staff interview, it was determined that the facility failed to perform an annual performance review for a geriatric nursing assistant (GNA, Staff #5).
- 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, staff interviews and review of facility daily narcotic and amphetamine count per shift records, it was determined that the facility failed to accurately complete the narcotic and amphetamine count per shift records. This was evident for 2 of 4 medication storage carts reviewed.
- D
Provide routine and 24-hour emergency dental care for each resident.
Inspectors wroteBased on observation, medical record review, and staff interview, it was determined that the facility failed to obtain dental services for a resident. This was evident for 1 (Resident #36) of 5 residents reviewed for dental services during an annual recertification survey.
- D
Provide or obtain dental services for each resident.
Inspectors wroteBased on interview, medical record review, and staff interview, it was determined that the facility failed to obtain dental services for a resident. This was evident for 1 (Resident #55) of 5 residents reviewed for dental services during an annual recertification survey.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation it was determined that the facility staff failed to provide safe and sanitary conditions to prevent the development and transmission of disease and infection. This was evident during observation of an Indwelling Foley Cather for Resident #99. This was evident for 1 of 2 resident's selected for review of Indwelling Foley Cather.
- C
Post nurse staffing information every day.
Inspectors wroteBased on daily observation during the annual recertification survey it was determined the facility failed to post the required nursing staffing data on the nursing assignment board. This was evident on 2 out of 2 nursing assignment boards
Fire safety inspections
29 fire safety citations on file: 11 on August 25, 2025, 16 on April 6, 2023, 2 on December 21, 2018.
Every fire safety citation29 citations
- F
Provide properly protected cooking facilities.
K 324 · August 25, 2025 · Corrected (the home has a date of correction)
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · August 25, 2025 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · August 25, 2025 · Corrected (the home has a date of correction)
- F
Have simulated fire drills held at unexpected times.
K 712 · August 25, 2025 · Corrected (the home has a date of correction)
- F
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
K 914 · August 25, 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 25, 2025 · Corrected (the home has a date of correction)
- E
Keep aisles, corridors, and exits free of obstruction in case of emergency.
K 211 · August 25, 2025 · Corrected (the home has a date of correction)
- E
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
K 223 · August 25, 2025 · 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 · August 25, 2025 · Corrected (the home has a date of correction)
- E
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
K 761 · August 25, 2025 · Corrected (the home has a date of correction)
- D
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
K 741 · August 25, 2025 · Corrected (the home has a date of correction)
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · April 6, 2023 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · April 6, 2023 · Corrected (the home has a date of correction)
- F
Have simulated fire drills held at unexpected times.
K 712 · April 6, 2023 · Corrected (the home has a date of correction)
- F
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
K 761 · April 6, 2023 · Corrected (the home has a date of correction)
- F
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
K 914 · April 6, 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 · April 6, 2023 · Corrected (the home has a date of correction)
- E
Keep aisles, corridors, and exits free of obstruction in case of emergency.
K 211 · April 6, 2023 · Corrected (the home has a date of correction)
- E
Have properly installed electrical wiring and gas equipment.
K 511 · April 6, 2023 · Corrected (the home has a date of correction)
- E
Have restrictions on the use of portable space heaters.
K 781 · April 6, 2023 · Corrected (the home has a date of correction)
- E
Have proper medical gas storage and administration areas.
K 923 · April 6, 2023 · Corrected (the home has a date of correction)
- D
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
K 223 · April 6, 2023 · 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 6, 2023 · Corrected (the home has a date of correction)
- D
Properly select, install, inspect, or maintain portable fire extinguishes.
K 355 · April 6, 2023 · Corrected (the home has a date of correction)
- D
Meet other general requirements that are deficient.
K 500 · April 6, 2023 · Corrected (the home has a date of correction)
- D
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
K 741 · April 6, 2023 · Corrected (the home has a date of correction)
- D
Ensure gas and vacuum piping is labeled.
K 909 · April 6, 2023 · Corrected (the home has a date of correction)
- F
Meet other general requirements.
K 200 · December 21, 2018 · Corrected (the home has a date of correction)
- F
Have a battery powered remote alarm panel in a location accessible by operating personnel.
K 916 · December 21, 2018 · Corrected (the home has a date of correction)