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 40 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
36D
3E
1F
Potential for minimal harm
0A
0B
0C
March 27, 2026Standard inspection, Complaint inspection · 15 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, interview, and document review the facility failed to ensure 1) the kitchen was maintained in a sanitary manner, 2) there was no backed up water on the kitchen floor due to a broken drain line in the dishwasher area and a broken sewer line in the beverage area, 3) a nourishment refrigerator did not contain opened food items which were undated, and snacks were stored in proper temperature. The deficient practice placed residents at risk for foodborne illness.
- 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 interview, record review and document review, the facility failed to ensure, a baseline care plan was developed for a resident admitted with an indwelling catheter for 1 of 38 sampled residents (Resident 199). The deficient practice placed residents at risk for inadequate Foley catheter care and potential for infection.
- 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, record review, and document review, the facility failed to ensure care plan interventions for an indwelling catheter were implemented for 1 of 38 sampled residents (Resident 199). The deficient practice placed Resident 199 at risk for inadequate Foley catheter care and potential for infection.
- 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, record review and document review, the facility failed to ensure a comprehensive care plan for skin integrity was reviewed and updated when a resident with existing pressure ulcers and assessed to be at high risk for developing and worsening pressure ulcers returned from hospitalization to treat an infected wound for 1 of 38 sampled residents (Resident 15). The deficient practice placed the resident at risk for recurrent wound infection.
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on observation, interview, record review, and document review, the facility failed to ensure a scheduled shower was provided for a resident who required assistance with bathing for 1 of 38 sampled residents (Resident 231). The deficient practice placed the residents at risk for infection and worsening of skin breakdown.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on observation, interview, record review, and document review, the facility failed to ensure 1) appropriate care and services were provided to prevent recurrent gastrostomy tube dislodgement for 1 of 38 sampled residents (Resident 239) and, care and management orders were obtained for a compression device for 1 of 38 sampled residents (Resident 231). The deficient practice placed Resident 239 at risk for repeat G-tube dislodgement and Resident 231 at risk for recurrent cellulitis.
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on observation, interview, record review and document review, the facility failed to ensure a comprehensive skin assessment was performed by the wound care team upon readmission of a resident who had existing pressure ulcers and the resident was assessed as a high risk for developing and worsening pressure ulcers for 1 of 38 sampled residents (Resident 15). The deficient practice placed the residents at risk for recurrent wound infection.
- D
Provide appropriate foot care.
Inspectors wroteBased on observations, interviews, record review and document review, the facility failed to ensure proper foot hygiene and podiatry care for 1 of 38 sampled residents (Resident R86). This deficient practice placed the resident at risk for pain and foot infection.
- 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 a resident with non weight bearing status was safely transferred from bed to wheelchair using a mechanical lift harness in good repair for 1 of 38 sampled residents (Resident #132). This deficient practice placed the resident at risk for an accident, fall, and injury during transfer.
- 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 observation, interview, record review and document review the facility failed to ensure care and management orders for indwelling Foley catheter were obtained and implemented for 2 of 38 sampled residents (Resident 226 and Resident 199). The deficient practice had the potential to place residents at risk for infection.
- D
Ensure medication error rates are not 5 percent or greater.
Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a medication error rate of less than 5%, as required. This deficient practice placed residents at risk for adverse drug outcomes, decreased therapeutic effectiveness, and compromised safety.
- 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 observation, interview, record review and document review the facility failed to ensure medications were secured for 1 of 38 sampled residents (Resident 175) expired medication was disposed of. The deficient practice had the potential for the facility staff to administer expired and contaminated medications.
- D
Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.
Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure there was sufficient number of kitchen personnel to provide the residents with meals delivered timely, and at proper temperature. The deficient practice placed residents at risk for negatively impacting quality of life.
- D
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Inspectors wroteBased on observation, interview and document review, the facility failed to ensure food was not served late and at appropriate temperatures per facility policy. The deficient practice had the potential to negatively impact residents' quality of life.
- D
Have a policy regarding use and storage of foods brought to residents by family and other visitors.
Inspectors wroteBased on observation, interview and document review, the facility failed to ensure expired food items were discarded from 2 of 38 sampled resident refrigerators (Resident 151 and Resident 175). The deficient practice had the potential for expired foods to be consumed, which could lead to foodborne illness.
March 18, 2025Standard inspection · 7 citations
- E
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 document review, the facility failed to appropriately assess residents who smoked upon admission/readmission, secure smoking materials, including lighters, and establish a policy outlining guidelines on how to address smoking among residents in a non-smoking facility, and ensure safety measures were implemented for 3 of 13 sampled residents (Residents 66, 104, and 65). This deficient practice had the potential to place residents at risk of self-inflicted burns, fire hazards, or other safety concerns.
- 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, interview, and document review, the facility failed to ensure snacks were available to residents outside of scheduled mealtimes. The failed practice had the potential to cause residents to remain hungry in between meals and the resident's nutritional needs not met.
- D
Ensure each resident receives an accurate assessment.
Inspectors wroteBased on observation, interview, record review, and document review, the facility failed to ensure the accuracy of assessment reflected the resident's status regarding the harness and straps being used for safety rather than as a restraint for 1 of 31 sampled residents. This deficient practice had the potential to result in the improper use of restraints, restricted mobility, and diminished quality of care.
- 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, record review, and document review, the facility failed to develop comprehensive care plans to reflect new interventions, specifically a smoking care plan for 1 of 13 sampled residents (Resident 65). The deficient practice had the potential to deprive residents of necessary interventions to maintain overall well-being.
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on observation, interview, record review and document review, the facility failed to ensure showers or a bath, were provided as scheduled for 1 of 4 unsampled residents (Resident 471). The deficient practice had the potential to increase skin breakdown, infections, odor and bacteria buildup.
- 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 observation, interview, record review, and document review, the facility failed to ensure the resident's prescribed Foley size order was followed or clarified and monitored for signs and symptoms of infection, and the physician was notified promptly for the presence of sediments and odorous urine for 1 of 31 sampled residents (Resident 16). This deficient practice had the potential to result in complications such as urinary tract infections (UTIs), discomfort, catheter-associated infections, and other related health risks.
- D
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Inspectors wroteBased on observation, interview, record review, and document review, the facility failed to ensure: 1) The PT-INR (prothrombin time-international normalized ratio, a blood test measuring how long it took for blood to clot) was completed as ordered, and the level was monitored, documented in the Medication Administration Record and reported to the physician for 1 of 31 sampled residents (Resident 12). This deficient practice had the potential to result in adverse health outcomes, including an increased risk of bleeding or clotting complications and potential harm due to inadequate monitoring of anticoagulation therapy, and 2) A pain medication was administered despite a documented reported pain level of zero for one of 13 sampled residents (Resident 13). [...]
January 17, 2025Complaint inspection · 1 citation
- 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 observation and interview, and record review, the facility failed to ensure medicated wound care barrier cream were secured for 1 of 16 sampled residents (Resident 2). The deficient practice had the potential risk of unauthorized access to medication, or misuse of medication within the facility.
March 1, 2024Standard inspection, Complaint inspection · 13 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 document review, the facility failed to ensure food items stored inside the walk-in cooler and walk-in freezer were labeled, dated, and not expired; the janitor closet located inside the kitchen was maintained in a sanitary condition; bottles of hand soap were not stored over the disposable ware and food item on a shelving unit in the Dry Storage Room; a meal tray was served to the correct resident for 1 of 34 sampled residents (Resident 113); and temperature logs were monitored and maintained for 3 of 4 nourishment refrigerators (First floor East Wing, 300 Hall, and 200 Hall). The deficient practices had the potential to place the residents at risk for a foodborne illness and had a resident served with incorrect diet.
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on interview, record review and document review, the facility failed to ensure a final report which included documentation of investigation findings and any corrective actions taken by the facility regarding an allegation of verbal abuse was submitted to the state agency for 1 of 34 sampled residents (Resident 54). The deficient practice which included failure to notify the resident of concern of the outcome of the investigation, had the potential to discourage residents from reporting incidences of potential abuse.
- D
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Inspectors wroteBased on observation, interview, record review and document review, the facility failed to ensure there was a process in place to identify and refer residents with newly identified psychiatric diagnoses for pre-admission screening and resident review (PASARR) level two for 2 of 34 sampled residents (Residents 91 and 69). The deficient practice had the potential to deprive residents of necessary behavioral health services.
- 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, record and document review, the facility failed to ensure comprehensive care plans were developed for: 1) monitoring and managing edema for a resident (Resident 74) and 2) a dialysis access catheter currently in use was care planned (Resident 128). The deficient practice had a potential for staff not to provide personalized care for residents.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on observation, interview, record review and document review, the facility failed to ensure 1) prescribed orders to monitor and manage edema (swelling caused by too much fluid trapped in the body's tissues) were completed as prescribed for 1 of 34 sampled residents (Resident 74), 2) physician's order for fluid restriction was followed and discussed with the resident for 1 of 34 sampled residents (Resident 12). The deficient practices placed the residents at risk for fluid overload, missed edema management and non-compliance with physician orders.
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on interview and record review, the facility failed to ensure wound care treatments were provided per the physician's orders for one unsampled resident (Resident 177). The deficient practice had the potential for the worsening of the resident's skin condition.
- 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 interview, record review and document review, the facility failed to ensure the restorative nursing services were provided per the therapy recommendation for 1 of 34 sampled residents (Resident 104). The deficient practice had the potential for the resident's further decline in physical functioning/mobility.
- 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, record review and document review, the facility failed to ensure the gastrostomy tube (G-tube) feeding and water flush bag were labeled with the name of the resident, room number, infusion rate, and date and time the feeding and water flushes started for one unsampled resident (Resident 129). The deficient practice had the potential for the resident receiving expired or incorrect G-tube feeding, and inaccurate rate of feeding and water flushes.
- D
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Inspectors wroteBased on observation, interview, record review and document review, the facility failed to ensure a peripheral intravenous (IV) line dressing was dated for 1 of 34 residents (Resident 21), and a midline (an 8 - 12 centimeter length IV catheter inserted in the upper arm with the tip located just below the axilla) catheter dressing was changed for 1 of 34 residents (Resident 133). The deficient practice poses an IV access site infection risk for the resident.
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observation, interview, record review and document review, the facility failed to ensure staff received training and obtained a physician's order for a continuous positive airway pressure (CPAP - a machine that uses mild air pressure to keep the airway open during sleep) device utilized within the facility for 1 of 34 sampled residents (Resident 288), The deficient practice had a potential for staff not to be aware and properly care for a resident with a specialized medical device.
- D
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Inspectors wroteBased on observation, interview, record review and document review, the facility failed to ensure 1) dialysis access catheter was assessed and monitored and, 2) refusal of dialysis treatment interventions were documented for 1 of 34 residents (Resident 128). The deficient practice had a potential for the dialysis access not to be monitored for adverse reactions and education regarding dialysis complications were discussed. Resident 128 (R128) R128 was admitted on [DATE], with diagnoses including chronic kidney disease and rheumatoid arthritis. 1) On 02/27/2024 (Tuesday) at 10:50 AM, R128 was seen leaving the facility for dialysis treatment. R128 was in the wheelchair and indicated the usual schedule for dialysis treatment was Monday, Wednesday, and Friday (MWF) and was going today due to missing yesterday's treatment due to not feeling well. [...]
- D
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Inspectors wroteBased on observation, interview, record review and document review the facility failed to ensure 1) a consent was obtained prior to administering the psychotropic medication for 1 of 34 sampled residents (Resident 80), 2) a valid consent (with signature of the resident or representative) for the use of psychotropic medication for 1 of 34 sampled residents (Resident 91) was obtained, and 3) a consent for the use of psychotropic medication was obtained for 1 of 34 sampled residents (Resident 150). The deficient practice had a potential for a resident/resident representative not being properly informed of the risk and benefits of a prescribed psychotropic medication.
- 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 observation, interview, record review and document review, the facility failed to ensure 1) a resident had orders and assessment for self-medicating and medications were properly secured in the resident's room for 1 of 34 sampled residents (Resident 94). and 2) biologicals such as vaccines were stored in accordance with manufacturer's guidelines. The deficient practices had a potential for a resident to improperly administer and store medications and improper vaccine storage could potentially affect the potency and effectiveness of the medications.
November 30, 2023Complaint inspection · 4 citations
- D
Honor the resident's right to organize and participate in resident/family groups in the facility.
Inspectors wroteBased on interview and document review, the facility failed to ensure concerns raised by the resident group regarding call light response times were communicated to the Administrator, the facility's response and actions were communicated back to the resident group, and the resident group response was obtained and documented in accordance with the facility's policy. The deficient practice potentially denied the facility's leadership from verifying, tracking, and developing meaningful interventions to address the resident's ongoing issues regarding call light response times.
- D
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Inspectors wroteBased on interview, record review and document review, the facility failed to ensure a resident was not restrained to the bed frame for 1 of 14 sampled residents (Resident 5). The deficient practice had the potential to cause the resident physical, emotional and mental distress.
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on observation, interview, record review, and document review, the facility failed to provide necessary services for personal hygiene for 1 of 14 sampled residents (Resident 12) who was unable to carry out activities of daily living including elimination. The deficient practice had the potential to cause adverse physical and mental outcomes such as skin damage and loss of dignity. Resident 12 (R12) R12 was admitted on [DATE] and readmitted on [DATE] with diagnoses including fracture of the sacrum, and multiple other fractures, and difficulty walking. The Minimum Data Set (MDS) assessment dated [DATE] indicated the resident required assistance of two persons to transfer, assist of one person to ambulate, and required the assistance of one person for toileting and hygiene care. [...]
- D
Provide medically-related social services to help each resident achieve the highest possible quality of life.
Inspectors wroteBased on interview, record review and document review, the facility failed to ensure an admission social services assessment was completed for 1 of 14 sampled residents (Resident 3) and failed to ensure there were sufficient number of social services staff members in accordance with the facility assessment. The deficient practice had the potential for the facility not meeting the social services needs of the residents.
Fire safety inspections
30 fire safety citations on file: 6 on March 27, 2026, 9 on March 18, 2025, 15 on March 1, 2024.
Every fire safety citation30 citations
- F
Address subsistence needs for staff and patients.
E 15 · March 27, 2026 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · March 27, 2026 · Corrected (the home has a date of correction)
- F
Have proper medical gas storage and administration areas.
K 923 · March 27, 2026 · Corrected (the home has a date of correction)
- E
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · March 27, 2026 · Corrected (the home has a date of correction)
- E
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · March 27, 2026 · Corrected (the home has a date of correction)
- D
Have properly installed electrical wiring and gas equipment.
K 511 · March 27, 2026 · Corrected (the home has a date of correction)
- E
Address subsistence needs for staff and patients.
E 15 · March 18, 2025 · Corrected (the home has a date of correction)
- E
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · March 18, 2025 · Corrected (the home has a date of correction)
- E
Have properly installed electrical wiring and gas equipment.
K 511 · March 18, 2025 · Corrected (the home has a date of correction)
- E
Ensure that testing and maintenance of electrical equipment is performed.
K 921 · March 18, 2025 · Corrected (the home has a date of correction)
- D
Install emergency lighting that can last at least 1 1/2 hours.
K 291 · March 18, 2025 · Corrected (the home has a date of correction)
- D
Inspect, test, and maintain automatic sprinkler systems.
K 353 · March 18, 2025 · Corrected (the home has a date of correction)
- D
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
K 761 · March 18, 2025 · Corrected (the home has a date of correction)
- C
Follow proper procedures when the fire alarm was out of service for more than 4 hours.
K 346 · March 18, 2025 · Corrected (the home has a date of correction)
- C
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
K 354 · March 18, 2025 · Corrected (the home has a date of correction)
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · March 1, 2024 · Corrected (the home has a date of correction)
- E
Develop and maintain an Emergency Preparedness Program (EP).
E 4 · March 1, 2024 · Corrected (the home has a date of correction)
- E
Establish policies and procedures including evacuation.
E 20 · March 1, 2024 · Corrected (the home has a date of correction)
- E
Develop a communication plan.
E 29 · March 1, 2024 · Corrected (the home has a date of correction)
- E
Establish emergency prep training and testing.
E 36 · March 1, 2024 · Corrected (the home has a date of correction)
- E
Follow proper procedures when the fire alarm was out of service for more than 4 hours.
K 346 · March 1, 2024 · Corrected (the home has a date of correction)
- E
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
K 354 · March 1, 2024 · Corrected (the home has a date of correction)
- E
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
K 914 · March 1, 2024 · Corrected (the home has a date of correction)
- E
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · March 1, 2024 · Corrected (the home has a date of correction)
- E
Ensure that testing and maintenance of electrical equipment is performed.
K 921 · March 1, 2024 · Corrected (the home has a date of correction)
- D
Provide properly protected cooking facilities.
K 324 · March 1, 2024 · Corrected (the home has a date of correction)
- D
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
K 521 · March 1, 2024 · Corrected (the home has a date of correction)
- D
Provide a written emergency evacuation plan.
K 711 · March 1, 2024 · Corrected (the home has a date of correction)
- D
Have simulated fire drills held at unexpected times.
K 712 · March 1, 2024 · Corrected (the home has a date of correction)
- D
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
K 761 · March 1, 2024 · Corrected (the home has a date of correction)