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 31 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
1J
0K
0L
Actual harm
2G
0H
0I
Potential for more than minimal harm
20D
4E
3F
Potential for minimal harm
0A
1B
0C
March 10, 2026Standard inspection · 9 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, interview, and facility policy review, the facility failed to ensure food was stored off the floor, failed to label, date, and cover stored food, and failed to discard food with expired use by or best by dates in two of two facility kitchens. These failures had the potential to create an environment for food-borne illnesses which could affect 165 residents who consumed food prepared from the facility's two kitchens.
- F
Provide and implement an infection prevention and control program.
Inspectors wroteBased on interviews, record review, and facility policy review, the facility failed to complete an assessment of the building to determine where Legionella and other opportunistic waterborne pathogens can grow and spread. Additionally, there was no diagram of the water maintenance as it flows through the facility. This had the potential to affect 168 of 168 residents who resided at the facility. These failures had the potential to allow for the growth of waterborne pathogens to be unnoticed and placed residents at risk for the spread of infections.
- D
Allow residents to self-administer drugs if determined clinically appropriate.
Inspectors wroteBased on observation, interview, record review, and policy review, the facility failed to ensure one of 20 supplemental residents was assessed for self-administration of medications Resident (R) 177. R177 had seizure medications at her bedside; however, she had not been assessed for or ordered by her physician to be able to self-administer her medications. This failure placed the resident at an increased risk of seizure activity if the medications were not administered as ordered by the physician.
- D
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
Inspectors wroteBased on record review, interview, and facility policy review, the facility failed to ensure one of five residents Resident (R)18 reviewed for unnecessary medications out of a total sample of 35 had adequate indication for the use of an antipsychotic medication. R18 was ordered Seroquel (Quetiapine), an antipsychotic medication for schizophrenia, without documented evidence of the diagnosis. This failure placed the resident at risk of receiving unnecessary medications.
- D
Ensure each resident receives an accurate assessment.
Inspectors wroteBased on review of the facility policy, interviews and record review, the facility failed to ensure the Minimum Data Set (MDS) assessment accurately reflected a facility fall for one of three residents reviewed for falls Resident (R)150 out of a total sample of 35. This failure had the potential to lead to lack of care plan interventions to prevent falls.
- D
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Inspectors wroteBased on interview, record review, and review of the facility's policy, the facility failed to ensure the comprehensive care plan was developed to accurately reflect the indication of the resident's use of an antipsychotic medication for one of five sampled residents Resident (R)18 reviewed for unnecessary medications out of a total sample of 35. This failure placed the resident at risk of staff not meeting the resident's care needs.
- D
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Inspectors wroteBased on record review, interview, and policy review, the facility failed to ensure one of 35 sampled residents Resident (R)6 care plan was revised to reflect the resident's end of life wishes. R6's wishes was to be a Do Not Resuscitate (DNR); however the resident's care plan documented the resident wanted to receive life saving measures of cardio-pulmonary resuscitation (CPR) in the event her heart stopped or she stopped breathing. This failure placed R6 at risk to receive CPR against her wishes for a natural death, potentially causing serious injury from compressions or psychosocial harm related to her preference not being honored.
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on observation, interview, record review, and policy review, the facility failed to implement care to prevent pressure ulcer development for one of four residents reviewed for pressure ulcers Resident (R)6 out of 35 sampled residents. R6's interventions for the prevention of pressure ulcers were not being implemented. This failure placed R6 at risk for development of pressure ulcers.
- 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 observations, record reviews, interviews, and policy review, the facility failed to honor known food preferences for one resident Resident (R)155 of four residents reviewed for food out of 35 sampled residents. This failure had the potential to cause R155's nutritional needs to go unmet.
March 20, 2025Complaint inspection · 1 citation
- G
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Inspectors wroteBased on review of facility policy, record review and interview, the facility failed to protect Resident (R)1 from being physically restrained by Certified Nursing Assistant (CNA)1. Specifically, CNA1 grabbed both of R1's hands, held them crossed against R1's upper chest during incontinence care, for 1 of 3 residents reviewed. On 03/20/25 at 2:00 PM the Administrator and the Director of Nursing were notified that the failure to protect a resident from being physically restrained constituted IJ at F604. On 03/20/25 at 2:00 PM, the survey team provided the Administrator with a copy of the CMS Immediate Jeopardy (IJ) Template and informed the facility IJ existed as of 03/02/25. The IJ was related to 483.12 Freedom from Abuse, Neglect, and Exploitation. On 03/20/25 at 7:20 PM, the facility provided an acceptable IJ Removal Plan. [...]
October 11, 2024Standard inspection, Complaint inspection · 7 citations
- J
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on review of facility policy, interview, and record review, the facility failed to provide appropriate supervision for Resident (R)78, resulting in R78 successfully eloping from the facility. On 10/09/24 at 11:28 AM, the survey team provided the Administrator with a copy of the CMS Immediate Jeopardy (IJ) Template, informing the facility IJ existed as of 09/26/24. The IJ was related to 42 CFR 483.25 - Free of Accidents Hazards/Supervision/Devices. On 10/10/24 at approximately 1:40 PM, the facility provided an acceptable IJ Removal Plan. The survey team validated the facility's corrective actions and determined the facility put forth good faith attempts to address the non-compliance. The IJ is considered at Past Non-Compliance with a correction date of 09/30/24. [...]
- F
Keep all essential equipment working safely.
Inspectors wroteBased on review of facility policy, observation and interview, the facility failed to ensure 3 of 3 clothes dryers in the East Building did not contain an excessive amount of lint. The lint was located above the lint baskets and onto the wiring.
- E
Provide enough food/fluids to maintain a resident's health.
Inspectors wroteBased on review of facility policy, record review, and interview, the facility failed to provide services and interventions to prevent significant weight loss for 3 of 4 resident's reviewed for nutrition, Resident (R)3, R 17, and R78. Findings Include: Review of an undated facility policy titled, Weight Monitoring, revealed, . The facility will ensure that all residents maintain acceptable parameters of nutritional status . Further review of the Compliance Guidelines section, revealed, 1. The facility will utilize a systemic approach to optimize a resident's nutritional status 2. A comprehensive nutritional assessment will be completed upon admission on residents ., 3. Information gathered from the nutritional assessment and current dietary standards of practice are used to develop an individualized care plan ., 4. [...]
- D
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Inspectors wroteBased on the facility policy, record review and interview, the facility failed to provide the required documents to notify Resident (R)63 and R125 regarding medicare eligibility and coverage for 2 of 3 residents reviewed for advance beneficiary notices.
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on review of facility policy, observation, interview, and record review, the facility failed to ensure that Resident (R)18 who needed respiratory care was provided with such care that was consistent with professional standards of practice for 1 of 2 residents reviewed for oxygen therapy.
- 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 review of facility policy, observations, and interviews, the facility failed to ensure that all drugs and biologicals used in the facility were labeled in accordance to professional standards including expiration dates for 3 of 3 Medication Storage Rooms, 1 out of 4 Medication Carts , and 1 out of 3 Treatment Carts.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on review of facility policy, observations, interviews, and record review, the facility failed to properly clean a glucometer machine.
September 29, 2023Complaint inspection · 2 citations
- G
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 facility policy review, the facility failed to properly supervise 1 of 2 residents to prevent a fall, resulting in injury. Specifically, Resident (R)3 wandered into a staff break room and tripped and fell over a hole in the floor, resulting in R3 suffering a closed head injury and pain. This failure constituted actual harm.
- E
Protect each resident from the wrongful use of the resident's belongings or money.
Inspectors wroteBased on review of facility policy, interview, observation, and record review, the facility failed to protect 7 of 19 residents from misappropriation of medications. Specifically, Licensed Practical Nurse (LPN)2 diverted medications from Residents (R)5, R6, R13, R14, R15, R16, and R17 during the months of August and September 2023.
October 20, 2022Standard 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 observations, record review, policy review, and staff interview, the facility failed to maintain one (main building kitchen) of two kitchens in sanitary condition to prevent potential contamination of food that could result in food borne illness for residents who received meals from the dietary department. Specifically, the facility: - failed to ensure stainless-steel service carts, food preparation (prep) tables, the inside of the microwave, the kitchen heating, ventilation, and air conditioning (HVAC) vents, the ice machine, and other kitchen equipment/surfaces were free of rust, dust, and/or debris. - failed to ensure the kitchen floor was maintained in good repair. Additionally, the facility failed to ensure staff wore gloves while handing a resident's food during meal tray delivery and set-up on 1 (300 Hall) of 8 halls. [...]
- E
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Inspectors wroteBased on observation, interviews, and policy review, the facility failed to maintain an effective pest control program for 3 of 3 residents (R)89, R28, and R108) interviewed and 1 of 2 kitchens observed to eradicate roaches and maintain the facility free of pests. This failure had the potential to cause a diminished quality of life for the residents.
- D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteBased on observations, interviews, record review, and facility policy review, the facility failed to maintain the dignity for 2 (Resident (R)11 and R68) of 3 residents reviewed for dignity. Specifically, staff allowed R11 to dine on soiled linens while wearing a soiled brief and dine with dirty hands and fingernails. The facility also failed to provide a privacy cover for R68's indwelling urinary catheter collection bag.
- D
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Inspectors wroteBased on record review, observations, and staff interviews, the facility failed to assess for the use of a lap belt restraint for 1 Resident (R)91 of 1 resident reviewed for restraints.
- D
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Inspectors wroteBased on facility policy review, record review, observation, and interviews, the facility failed to revise a care plan to include a behavioral problem for 1 Resident (R)11, of 28 reviewed.
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on interview, record review, and document review, the facility failed to investigate and identify the root cause of a fall for 1 (Resident #91) of 1 resident reviewed for accidents. Additionally, the facility failed to ensure an assessment of Resident #91 was completed and documented after the fall.
- 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, interviews, record review, and facility policy review, the facility failed to determine the medical justification for the use of an indwelling urinary catheter and failed to secure an indwelling urinary catheter with a leg strap for 1 (Resident #68) of 1 resident reviewed with a urinary catheter.
- D
Ensure medication error rates are not 5 percent or greater.
Inspectors wroteBased on observations, interviews, and record review, the facility failed to maintain a medication error rate of 5% or less. During medication administration observation, four nurses were observed administering medications to six residents for a total of 26 opportunities with two errors, which yielded a medication error rate of 7.69%.
- 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 review of the facility policy titled, Medication Reordering, observation, and interviews, the facility failed to ensure Resident (R)1 received an ordered dose of a Prenatal Vitamin Plus Low Iron on 12/21/22 as ordered by the physician for 1 of 5 residents observed during Medication Administration. Findings Include: Review of the facility policy titled, Medication Reordering, states, It is the policy of this facility to accurately and safely provide or obtain pharmaceutical services including the provision of routine and emergency medications and biological's in a timely manner to meet the needs of each resident. The Policy Explanation and Compliance Guidelines: #1 states, The facility will utilize a systemic approach to provide or obtain routine and emergency medications and biological's in order to meet the needs of each resident. #2. [...]
- D
Provide or obtain dental services for each resident.
Inspectors wroteBased on record review and interviews, the facility failed to follow-up on Resident #106's request to be evaluated for dentures. This affected 1 (Resident #106) of 3 residents reviewed for dental services.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, record review, policy review, and staff interview, the facility failed to ensure staff followed infection control practices related to hand hygiene and wound care supplies during wound treatment for 1 Resident(R)106, of 1 resident observed receiving wound care. Specifically, observations of wound care for R106 revealed staff failed to follow hand washing protocols between glove changes when changing a wound dressing, failed to set up wound care supplies on a clean surface, and failed to ensure contaminated supplies were not returned to a treatment cart after use.
- B
Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home.
Inspectors wroteBased on interviews, document review, and policy review, the facility failed to ensure a resident received a quarterly statement related to a personal funds account for 1 Resident (R)106 of 2 residents reviewed for personal funds.
Fire safety inspections
6 fire safety citations on file: 1 on March 10, 2026, 2 on October 11, 2024, 3 on October 20, 2022.
Every fire safety citation6 citations
- D
Have properly located and lighted "Exit" signs.
K 293 · March 10, 2026 · Corrected (the home has a date of correction)
- D
Address subsistence needs for staff and patients.
E 15 · October 11, 2024 · Corrected (the home has a date of correction)
- D
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · October 11, 2024 · Corrected (the home has a date of correction)
- D
Address subsistence needs for staff and patients.
E 15 · October 20, 2022 · Corrected (the home has a date of correction)
- D
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 · October 20, 2022 · Corrected (the home has a date of correction)
- D
Have restrictions on the use of portable space heaters.
K 781 · October 20, 2022 · Corrected (the home has a date of correction)