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 26 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
7D
16E
3F
Potential for minimal harm
0A
0B
0C
August 28, 2025Standard inspection · 5 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 observations and interviews, it was determined that the facility failed to ensure a comfortable homelike environment for Rooms #430, #428, and #433 occupied by residents reviewed for a homelike environment.
- E
Ensure each resident receives an accurate assessment.
Inspectors wroteBased on observation, interview and record review the facility failed to accurately assess and complete the Minimum Data Set (MDS) for two (Resident #71 and Resident #48) of two residents reviewed.
- E
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on observations, record review, and interviews the facility failed to ensure chemicals were properly stored away from residents to prevent accidents and injuries. Specifically, the storage room door, directly across the hall from the elevator door on 300 hall was left unlocked and unsecured. The room had chemicals, biohazard waste, a housekeeper's cart, and equipment stored inside. The Administrator provided a list of 55 ambulatory residents who could have been potentially affected. The facility failed to ensure razors were properly stored to prevent accidents and injury for one (Resident #57) of one resident reviewed for accidents.
- 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, interview and facility policy review, the facility failed to ensure that the ice scoop holder was maintained in a sanitary manner; food items stored in the refrigerator, freezer, and dry storage area were covered or sealed; expired food items were promptly discarded on or before the expiration or use by-date; that dietary staff washed their hands between handling dirty and clean equipment; and hot food items were maintained at required temperature for one of one meal observed.
- E
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview and record review the facility failed to ensure isolation practices were being followed by housekeeping staff to prevent the possible spread of infectious disease on one (Fourth) floor of the nursing facility.
February 11, 2025Complaint inspection · 1 citation
- E
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on interviews, record review, and facility policy review, it was determined the facility failed to ensure medications were administered as ordered by the physician for 2 (Residents #2 and #4) of 3 residents reviewed for correct medication administration as ordered by the physician.
October 28, 2024Complaint inspection · 2 citations
- E
Protect each resident from the wrongful use of the resident's belongings or money.
Inspectors wroteBased on observations, interviews, record review, facility document review, and facility policy review, it was determined the facility failed to ensure residents were free from misappropriation of property for 4 (Resident #3, #4, #5, #7) of 15 residents reviewed for misappropriation of property.
- E
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on observations, interviews, record review, facility document review, and facility policy review, it was determined the facility failed to ensure allegations of misappropriation of property were reported to the State Agency for 15 Resident, with 3 residents remaining on medications, (Resident #4, Resident #5, Resident #7) of 15 residents reviewed for abuse. Specifically, the facility failed to ensure alleged misappropriations of Resident #4, #5, #7 medications were reported.
May 8, 2024Standard inspection, Complaint 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, record review and interview, the facility to ensure foods stored in the refrigerator, freezer and storage room were covered, and sealed to maintain freshness and decrease the potential for cross contamination; the ice machine and ice scoop holder were maintained in clean condition to prevent potential contamination of residents' food and beverages; dietary employees washed their hands or changed gloves before handling clean equipment or food items to minimize the potential for food borne illness for residents who received meals from 1 of 1 main kitchen. The failed practices had the potential to affect 20 residents who received meals from the kitchen on the 200 Hall; 30 residents who received meals from the kitchen on the 300 Hall; [...]
- E
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observation, record review and interview, the facility failed to ensure oxygen was administered at the flow rate ordered by the physician to prevent respiratory complications for 2 (Residents #71 and #248) sampled residents. This failed practice had the potential to affect 57 residents that had physician orders for oxygen therapy.
- E
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure meals were prepared and served according to the planned written menu to meet the nutritional needs of the residents for 2 of 2 meals observed. This failed practice had the potential to affect 74 residents who received regular diets and 13 residents who received mechanical soft diets from 1 of 1 kitchen.
- E
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Inspectors wroteBased on observation, record review and interview, the facility failed to ensure vegetables were not overcooked and were served in a method that maintained the appearance of food product and hot food items were served at temperatures that were acceptable to the residents to improve palatability and encouraged good nutritional intake during 1 of 2 meals observed. This failed practice had the potential to affect 20 residents who receive meal trays on the 200 Hall, 30 residents who receive meal trays on the 300 Hall, 39 residents who receive meal trays in their room on the 400 Hall.
- E
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interviews and policy review, the facility failed to ensure staff followed Enhanced Barrier Precautions (EBP) between resident rooms to prevent cross contamination. This failed practice had the potential to affect all 99 residents in the facility. Findings Include: On 05/05/2024 at 9:22 AM, the Surveyor observed CNA #4 come out of room [ROOM NUMBER] with gloves on and go straight into room [ROOM NUMBER]. Both rooms #423 and #427 had a sign showing Enhanced Barrier Precautions (EBP). On 05/05/2024 at 9:40 AM, the Surveyor spoke with CNA #4. The Surveyor asked CNA #4 what proper hand hygiene is when you are entering and exiting a room with EBP. CNA #4 indicated you are supposed to leave your gloves on when you carry trash out of a room. The Surveyor asked if it was proper hand hygiene to go from one room to another room with gloves on. CNA #4 stated, No. [...]
- D
Ensure each resident receives an accurate assessment.
Inspectors wroteBased on record review and interview, the facility failed to complete a discharge Minimum Data Set (MDS) assessment to accurately reflect the residents discharge status for 1 (Resident #95) sampled residents. This failed practice had the potential to affect 76 residents that were discharged in the last 90 days.
- 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 observation, interview, and record review the facility failed to review and revise the care plan to include oxygen therapy was in use to ensure appropriate coordination of care for 1 (Resident #71) sampled resident that had physician's orders for oxygen therapy. This failed practice had the potential to affect 55 residents that had physician's orders for oxygen therapy.
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on record review and interview, the facility failed to ensure 1 (Resident #199) received wound care as ordered by the physician to prevent wound infection and healing. This failed practice had the potential to affect 8 residents with pressure ulcer orders.
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on observation and interview, the facility failed to ensure potentially hazardous items were stored in a secured manner for 1 (Resident #38) of 1 sampled resident.
November 22, 2023Complaint inspection · 1 citation
- F
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Inspectors wroteBased on observations, interviews, and policy review, the facility failed to ensure resident rooms were maintained in good repair for 4 (Rooms 202, 301, 304 and 406) resident rooms, and resident rooms and hallways Heating, Ventilation, and Air Conditioning (HVAC) units were maintained in a clean and sanitary manner.
May 11, 2023Standard inspection · 8 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, record review, and interview, the facility failed to ensure the dietary staff washed their hands and changed their gloves before handling food items to prevent the potential for cross contamination for the residents who received meals from 1 of 1 kitchen; Hot food items were not maintained at or above 135 degrees Fahrenheit on the steam table while awaiting service to prevent potential food borne illness for the residents who received meals from 1 of 1 kitchen. These failed practices had the potential to affect 81 residents who received meals from the Kitchen (Total Census: 81), according to the list provided by the Dietary Supervisor on 05/07/23 at 2:55 PM.
- E
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Inspectors wroteBased on record review and interview, the facility failed to ensure that a resident's drug regimen was free from unnecessary drugs for 1 (Resident #82) sample mix resident who was prescribed and received Antipsychotic Medication and Anti-Epileptic medication without adequate indications for its use.
- 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, interview, and record review, the facility failed to ensure medication was secured by leaving it on a bedside table in a resident's room, for 1 (Resident #22) sampled resident. The failed practice had the potential to affect all 35 residents who reside on the 300 hall.
- E
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
Inspectors wroteBased on observation and interview, the facility failed to ensure that pureed food items were blended to a smooth, lump free consistency to minimize the risk of choking or other complications for those residents who required pureed diets for 2 of 2 meals observed. The failed practice had the potential to affect 5 residents who received pureed diets as documented on the list Dietary Supervisor provided by the Food Service Supervisor on 09/08/22.
- E
Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.
Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure the residents' meals were consistently being served at regularly scheduled times, and failed to provide the residents with a dependable eating schedule for 1 of 1 meal service observed. The failed practice had the potential to affect all 81 residents who received meals from the kitchen (total census: 81), according to the list provided by the.
- 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, the facility failed to clean the tube feeding pumps, poles, fall mat and floors for rooms #322, #326, #307, #312, which failed to provide a safe and homelike environment.
- 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, record review, and interview, the facility failed to ensure that devices were put in place in the hands to prevent further contracture and/or decline in Range of Motion (ROM), for 1 (Resident #33) of 4 (#24, #25, #33, and #72) sampled residents with contractures.
- D
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure that meals were prepared and served according to the planned written menu to meet the nutritional needs of the residents for 2 of 2 meals observed. This failed practice had the potential to affect 5 residents who received pureed diets and 10 residents who received mechanical soft diets from 1 of 1 kitchen, according to a list provided by the Dietary Supervisor on 05/09/23
Fire safety inspections
10 fire safety citations on file: 5 on August 28, 2025, 2 on May 8, 2024, 3 on May 11, 2023.
Every fire safety citation10 citations
- F
Have exits that are accessible at all times.
K 271 · August 28, 2025 · Corrected (the home has a date of correction)
- F
Have an alternate power supply for its alarm system.
K 344 · August 28, 2025 · Corrected (the home has a date of correction)
- F
Properly select, install, inspect, or maintain portable fire extinguishes.
K 355 · August 28, 2025 · Corrected (the home has a date of correction)
- F
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · August 28, 2025 · Corrected (the home has a date of correction)
- F
Have proper medical gas storage and administration areas.
K 923 · August 28, 2025 · Corrected (the home has a date of correction)
- F
Have simulated fire drills held at unexpected times.
K 712 · May 8, 2024 · Corrected (the home has a date of correction)
- F
Ensure proper usage of power strips and extension cords.
K 920 · May 8, 2024 · Corrected (the home has a date of correction)
- F
Develop and maintain an Emergency Preparedness Program (EP).
E 4 · May 11, 2023 · Corrected (the home has a date of correction)
- E
Inspect, test, and maintain automatic sprinkler systems.
K 353 · May 11, 2023 · Corrected (the home has a date of correction)
- E
Install corridor and hallway doors that block smoke.
K 363 · May 11, 2023 · Corrected (the home has a date of correction)