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
0J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
16D
17E
2F
Potential for minimal harm
0A
0B
0C
April 17, 2025Standard inspection, Complaint inspection · 4 citations
- D
Reasonably accommodate the needs and preferences of each resident.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a call light was kept in reach to ensure a resident had a means to call for assistance for 1 (Resident #296) of 1 resident sampled for accommodation of needs.
- D
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure incontinent care was provided in a timely fashion and in accordance with the resident ' s needs for one (Resident #247) of one sampled resident dependent on facility staff for incontinent care.
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on record review and interview, the facility failed to ensure a resident was re-assessed for safe smoking behaviors before being allowed to smoke after the admission smoking evaluation indicated the resident did not smoke for 1 (Resident #91) of 1 sampled resident reviewed for smoking.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, record review, and interview, it was determined the facility failed to ensure staff changed gloves and performed proper hand hygiene during incontinent care for 1 (Resident #247) of 1 sampled resident reviewed for incontinent care.
February 8, 2024Standard inspection · 15 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 observations and interview, the facility failed to ensure deep fryer was free of debris to prevent potential cross contamination, food items stored in the freezer or refrigerator were sealed, covered and dated, expired food items were promptly removed /discarded by the expiration or use by dates, and foods were dated as when received to ensure first in and first out usage to prevent the potential for food borne illness, Dish washing air vent was cleaned, wall tiles were free of paint peelings, baseboard were free of missing and replaced, deep fryer and ice machine were free of dirt, rust, and grease and 1 of 2 ice machines was maintained in clean and sanitary condition to prevent food and beverage contamination, staff washed their hands between dirty and clean tasks and before handling clean equipment to minimize the potential for contaminating food items for residents who [...]
- E
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on record review and interview the facility failed to ensure that a self-inflicted incident was reported to the Office of Long-Term Care. This failed practice affected 1 of 1 Residents (R#31).
- E
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 and interview, the facility failed to ensure care plans were reviewed and revised as least quarterly and / or when residents' care needs changed, as evidenced by failure to revise the plan of care to address limited range of motion in the left hand and the use of Oxygen to ensure staff were aware of the necessary care, assessments and services required for 1 (Resident #59) of 1 (Resident #59) sampled resident who had limited range of motion in the left hand and for 1 (Resident #63) of 1 (Resident #63) sampled resident who used Oxygen.
- E
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on observation, record review and interview, the facility failed to ensure personal hygiene and nail care were routinely maintained and all areas of the skin were cleansed during incontinent care to promote good grooming and personal hygiene for 1 (Resident #53) of x (Residents #53 .) sampled residents who required staff assistance for shaving, 2 (Residents #53 and #59) of x (Residents #53, #59 ) sampled residents who required staff assistance with nail care and 1 (Residents #59) of x (Residents #53 #59 ) sampled residents who were dependent on staff for incontinent care as documented on lists provided by the Administrator on 2/8/24.
- 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 a humidifier bottle was changed per the Physician's orders and that Oxygen was administered at the prescribed flow rate to decrease the potential for Respiratory complications for 1 (Resident #63) of 3 (Residents #2, #19 and #63) sampled residents who had a Physician's order for Oxygen (O2) as documented on a listed provided by the Administrator on 2/7/24 at 11:13 AM.
- E
Ensure medication error rates are not 5 percent or greater.
Inspectors wroteBased on observation, record review and interview, the facility failed to ensure the medication error rate was less than 5 percent (%)for 1 (Resident #14) of 3 (Residents #14, #16 and #183) residents observed during the medication pass. The medication error rate was 14.81% based on observation of 27 medications administered and 4 errors detected.
- 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 meals were served at temperatures that were acceptable to the residents to improve palatability and encourage good nutritional intake during 2 of 2 meals observed. The failed practices had the potential to affect 22 residents who received their meal trays in the their rooms on the 100 Hall, 10 residents who received their meal trays in the room on the 200 Hall, 11 residents who received their meal trays on the 300 Hall, 13 residents who received their meal trays in their room on the 400 Hall, 21 residents who received their meat trays in the room on 500 Hall and 4 residents who received their meal trays in their room on 600 Hall, as documented on a list provided by the Dietary Supervisor on 02/06/2024 10:10 AM.
- 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 1 of 1 meal observed. The failed practice had the potential to affect 4 residents who received pureed diets, as documented on the list Dietary Supervisor provided by the Food Service Supervisor on 02/06/2024
- E
Dispose of garbage and refuse properly.
Inspectors wroteBased on observation and interview the facility failed to ensure trash was properly contained within 1 of 1 dumpster, to minimize the presence of foul odors and decrease the potential for pest infestation. The failed practice had the potential to affect all the residents who resided in the facility, as documented on the list provided by the Dietary Supervisor on 2/6/2024 at 010:10 AM.
- D
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Inspectors wroteBased on record review and interview the facility failed to notify the Ombudsman required for 1 (Resident #31) of 6 (Residents #11, #14, #31, #59, #64, and #53) sampled residents who were transferred to the hospital in the last month.
- D
Ensure each resident receives an accurate assessment.
Inspectors wroteBased on observation, interview and record review the facility failed to ensure the Minimum Data Set (MDS) was coded accurately to reflect the resident's nutritional status for 1 sampled resident (R#37).
- 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 services were provided to minimize the potential for further decline in range of motion (ROM) for 1 (Resident #59) of 3 (Residents #16, #31 and #59) sampled residents who had limited range of motion as documented on a list provided by the Administrator on 2/7/24 at 11:13 AM.
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on observation, record review and interview, the facility failed to ensure that interventions that were care planed were utilized to prevent potential accident hazards as possible by continuing to fall for 1 of 1 Resident (#11) 1 sampled resident.
- 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, record review and interview, the facility failed to ensure medications were allowed to flow by gravity through a Percutaneous Endoscopic Gastrostomy (PEG) Tube to decrease the potential for gastric complications for 1 (Resident #16) of 1 (Resident 16) sampled resident whose medications were administered through a PEG Tube.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, record review and interview, the facility failed to ensure proper hand hygiene was performed while providing incontinent care to decrease the potential for the spread of bacteria and promote good hygiene for 1 (Resident #59) of 1 sampled resident who received incontinent care.
December 28, 2023Complaint inspection · 3 citations
- 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 medications were stored and administered appropriately at the bedside, and failed to ensure medication was not sent to the kitchen on food trays.
- D
Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
Inspectors wroteBased on observation, record review, and interview the facility failed to ensure dignity was maintained by providing privacy during incontinent care for 1 (Resident #4) of 1 sampled resident.
- D
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Inspectors wroteBased on observation and interview, the facility failed to ensure food was warm when served to residents to prevent germs and bacteria growth, and appealing taste to the residents. This failed practice had the potential to affect 76 residents that eat from the kitchen.
November 7, 2023Complaint inspection · 1 citation
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on observation, interview and record review, the facility failed to ensure wound care was performed as ordered for one (R#5) of six (R#1, #2, #3, #4, #5 and #6) sampled residents.
November 10, 2022Standard 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, record review, and interview, the facility failed to ensure dietary staff washed their hands and changed gloves before handling food items to prevent the potential for cross contamination for residents who received meals from 1 of 1 kitchen and 1 of 2 ice machines were maintained in a clean and sanitary condition to prevent potential contamination of resident fluids for residents who received ice in their rooms. These failed practices had the potential to affect 19 residents on the 100 Hall, 12 residents on the 200 Hall, 10 residents on the 300 Hall, 12 residents on the 400 Hall, 17 residents on the 500 Hall, 3 residents the 600 Hall and 3 residents on the 700 Hall who received ice in their rooms, (Total Census: 76 ) according to the list provided by the Dietary Supervisor on 11/10/2022 at 8:39 AM.
- E
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 record review and interview, the facility failed to ensure residents' decisions as to whether they desired to have, or did have, an advanced directive, were documented in a prominent part of the clinical record and correct to ensure their wishes were known regarding acceptance or rejection of any life-sustaining treatments in the event of their incapacitation for 2 (Residents #51 and #55) of 2 sampled residents whose advance directives were reviewed. This failed practice had the potential to affect all 76 residents in the facility as documented on the Resident Census and Conditions of Residents provided by the Administrator on [DATE] at 9:10 AM.
- 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 observation, record review, and interview, the facility failed to ensure a resident's room did not have a strong urine odor from the catheter bag dripping for 1 (Resident #29) of 1 sampled resident who had a urinary catheter. This failed practice had the potential to affect 3 residents in the facility who had urinary catheters according to the Resident Census and Conditions of Residents provided by the Administrator on 11/8/22 at 9:10 AM.
- E
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Inspectors wroteBased on record review and interview, the facility failed to ensure a Minimum Data Set (MDS) assessment was completed in a timely manner for 1 (Resident #55) of 9 (Residents #15, #27, #34, #42, #55, #70, #74, #377 and #379) sampled residents who were admitted within the last 90 days and 1 (Resident #70) of 5 (Residents #5, #34, #15, #377 and #70) sampled residents who were discharged within the last 90 days.
- E
Ensure each resident receives an accurate assessment.
Inspectors wroteBased on record review and interview, the facility failed to ensure the Minimum Data Set (MDS) assessment accurately reflected the use of a restraint for 1 (Resident #19) of 1 sampled resident.
- E
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure resident clothing was regularly changed and wasn't worn for 2 to 5 consecutive days to promote cleanliness and good personal hygiene for 2 (Residents #34 and #51), failed to ensure residents were regularly shaved for 1 (Resident #51) and nail care was regularly provided to promote good personal hygiene for 2 (Residents #56 and #377) of 21 (Residents #2, #5, #7, #8, #13, #15, #16, #17, #19, #20, #27, #29, #34, #42, #47, #48, #51, #56, #377, #379, and #380) sampled residents who were dependent for nail care and/or personal hygiene according to the lists provided by the Regional Consultant on 11/09/22 at 4:07 pm.
- E
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure the environment was as free from accidents and hazards as possible, as evidenced by failure to store potentially hazard chemicals in a secure location to prevent potential access by cognitively impaired and or mobile residents on the 400 Hall. This failed practice had the potential to affect 13 residents who resided on the 400 Hall and were ambulatory or wheelchair mobile as documented on a list provided by the Administrator on 11/10/22 at 12:05 PM.
- 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 a physician's order was obtained for the administration and use of oxygen and a Trilogy machine to prevent potential complications for 1 (Resident #51) of 8 (Residents #5, #7, #16, #19, #27, #34, #51 and #380) sampled residents who received oxygen and 1 (Resident #51) of 1 sampled resident who used a Trilogy machine. This failed practice had the potential to affect 16 residents residing in the facility who used oxygen and 1 resident in the facility who used a Trilogy machine according to the list provided by the Administrator on 11/09/22 at 3:50 PM.
- E
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Inspectors wroteBased on record review and interview, the facility failed to ensure a resident's drug regimen review was followed up on according to facility policy and Resident Assessment Instructions guidelines for 1 (Resident #377) of 1 sampled resident who received Lithium.
- 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 observation, interview, and record review the facility failed to develop a comprehensive person-centered care plan that includes measurable objectives and timeframes to meet the needs of a resident who smoked tobacco for 1 (Resident #377) of 5 (Residents #8, #19, #42, #74 and #377) sampled residents who smoked.
- D
Provide appropriate foot care.
Inspectors wroteBased on observation, record review and interview, the facility failed to ensure toenail care was regularly provided to promote good foot care for 1 (Resident #47) of 21 (Residents #2, #5, #7, #8, #13, #15, #16, #17, #19, #20, #27, #29, #34, #42, #47, #48, #51, #56, #377, #379, and #380) sampled residents who were dependent for nail care/personal hygiene according to the lists provided by the Regional Consultant on 11/09/22 at 4:07 PM.
- 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 meals were prepared and served in accordance with the planned, written menu to meet the nutritional needs of the residents for 1 of 2 meals observed. These failed practices had the potential to affect 52 residents who received regular diets and 17 residents who received mechanical soft diets, (Total census: 76) according to a list provided by the Dietary Supervisor on 11/10/2022.
Fire safety inspections
8 fire safety citations on file: 3 on April 17, 2025, 3 on February 8, 2024, 2 on November 10, 2022.
Every fire safety citation8 citations
- F
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 17, 2025 · Corrected (the home has a date of correction)
- F
Install corridor and hallway doors that block smoke.
K 363 · April 17, 2025 · Corrected (the home has a date of correction)
- F
Ensure proper usage of power strips and extension cords.
K 920 · April 17, 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 · February 8, 2024 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · February 8, 2024 · Corrected (the home has a date of correction)
- F
Ensure proper usage of power strips and extension cords.
K 920 · February 8, 2024 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · November 10, 2022 · Corrected (the home has a date of correction)
- F
Properly select, install, inspect, or maintain portable fire extinguishes.
K 355 · November 10, 2022 · Corrected (the home has a date of correction)