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
0J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
8D
22E
1F
Potential for minimal harm
0A
0B
0C
July 24, 2025Standard inspection · 4 citations
- E
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 interviews, record reviews, and facility policy review, the facility failed to ensure Care Plans were updated for two (Resident #11 and Resident #12) of two residents reviewed for Care Plan accuracy.
- 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 food stored in the freezer and dry storage area were covered or sealed, one of one ice scoop holder was maintained in a sanitary manner, and dietary staff washed their hands between dirty and clean tasks and before handling clean equipment for one of one meal observed.
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on record reviews, interviews, and facility policy review, the facility failed to ensure a smoking assessment was completed for one (Resident #12) of two residents reviewed for smoking safety.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, record review, interview, and facility policy review, the facility failed to ensure Enhanced Barrier Precautions (EBP) were followed during high contact care to prevent the risk of cross contamination and infection for one (Resident #41) of one resident observed. Specifically, nursing staff failed to wear a gown while administering medication, feeding, and flushing a gastrostomy tube with water.
January 16, 2025Standard inspection · 12 citations
- E
Keep residents' personal and medical records private and confidential.
Inspectors wroteBased on observations, interviews, record review, and facility policy review the facility failed to ensure the personal and medical information was protected for 3 (Resident #1, #40, #236) of 4 sampled residents potentially violating the Health Insurance Portability and Accountability Act (HIPPA).
- 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 interviews, record review, and facility policy review, it was determined that the facility failed to ensure care plans were revised to reflect residents' most recent care needs for 2 (Residents #24 and #45) of 18 sampled residents whose care plans were reviewed.
- E
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the use of a physical restraint was used to treat a resident's medical symptoms, and was not being used for staff convenience for 1 (Resident #28) of 2 sampled residents (Residents #1 and #28) reviewed for physical restraint use and failed to perform a side rail assessment prior to installing side rails for 2 (Residents #1 and #28) of 2 (Residents #1 and #28) sampled residents reviewed for side rail use.
- E
Ensure medication error rates are not 5 percent or greater.
Inspectors wroteBased on observations, interviews, record review, and facility policy review, the facility failed to ensure the medication error rate was not greater than 5%. The Medication error occurred with 2 (Resident #44, #6) of 4 sampled residents observed for medication administration. Medication error rate was calculated at 7.14%.
- E
Ensure that residents are free from significant medication errors.
Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure the facility was free of significant medication errors for 1 (Resident #44) of 1 sampled resident who was administered the wrong dose of [calcium channel blocker medication name] for the entire month of January 2025 and failed to ensure [long acting insulin name] insulin was not administered past 28 days of use for 1 (Resident #66) of 1 sampled resident reviewed for insulin 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 observations, interviews, record review, and facility policy review, the facility failed to ensure medications and biologics were securely stored away at all times to prevent unauthorized individuals from potentially gaining access to the medication and/or biologics and failed to discard insulin after 28 days in use for 1 (Resident #66) 1 sampled resident reviewed for [long-acting insulin name] insulin use.
- 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 1 of 1 meal observed.
- 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, record review, and facility policy review, the facility failed to ensure food items in the refrigerator, freezer and storage room were covered, and sealed; leftovers meat products were used in a manner to maintain food quality; dented cans were promptly removed from stock; 1 of 2 ice machines was maintained in clean and sanitary condition; dietary staff washed their hands before handling food or clean equipment; ceiling tiles, air vents, dish washer wall , kitchen door frames were free of, debris, dirt, rust, stains, baseboards were secured, and hot food items were maintained at temperature of 135 degrees or above for 1 of 1 meal observed.
- E
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview, record review and facility policy review the facility failed to ensure enhanced barrier precautions (EBP) were being followed to prevent the spread of possible infection for one (Resident #28) of four sampled residents who were on EBP.
- 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 observations, interviews, record review, and facility policy review the facility failed to ensure the care planned positioning device was in place to prevent further contracture for 1 of 1 sampled (Resident #27) resident reviewed for positioning.
- 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 record review, interview, and facility policy review the facility failed to ensure gradual psychotropic (anti-anxiety) dose reductions (GDR) were attempted in the absence of a physician's documented evaluation of the specific risks versus benefits of continuing the as needed (PRN) medication past 14 days and a documented explanation as to why a dose reduction attempt would be contraindicated, in order to ascertain the smallest effective dose and minimize the potential for adverse drug effects for 1 (Resident #27) of 5 sampled residents reviewed for unnecessary medications.
- D
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 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.
July 18, 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 observation and interview, the facility failed to ensure dirty trash cans were stored away from the food storage racks; kitchen sink was free of leaks; the walk-in freezer floor was free of ice buildup; the ice machine and ice scoop were maintained in clean and sanitary conditions to prevent potential growth of harmful bacteria that could be transferred to the residents food; opened food items in the refrigerator, freezer and storage room were covered, sealed, and dated; and expired foods were promptly removed from stock to maintain freshness and prevent potential cross contamination; dietary staff practiced good hand hygiene to prevent potential cross contamination of food and clean dishes; and hot food item was maintained at the required temperature on the steam table and serving line to prevent potential foodborne illness. [...]
- E
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure a refund was received by the resident or responsible party within 30 days from the date of discharge for 2 (Residents #230 and #231) sampled residents within 30 days from the date of discharge.
- 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 G Hall shower room and the beauty shop were locked to prevent residents from being harmed from the ingestion of the chemicals present.
- 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 physician ordered rate to prevent respiratory complications for 2 (Residents #25 and #60) of 2 sampled residents who received oxygen.
- E
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Inspectors wroteBased on observation, record review and interview, the facility failed to ensure staff were trained on how to monitor residents on a high-risk medication (anticoagulants), Apixaban (Eliquis), for 1 (Resident #37) of 1 sampled resident.
- 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 observation, record review, and interview, the facility failed to show a monthly Medication Regimen Review was completed on a monthly basis as required for 4 (Residents #3, #24, #25, and #41) sampled residents.
- 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, record review, and interview, the facility failed to ensure medications were stored behind a locked door; medications were not left at the bedside for 2 (Resident #13 and Resident #56) of 2 residents reviewed for medication storage at the bedside; and narcotic medications were stored in a permanently affixed compartment to prevent the potential of misappropriation of resident property.
- 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 1 of 1 meal observed. The failed practices had the potential to affect 11 residents who received pureed diets, and 6 residents who received mechanical soft diets from 1 of 1 kitchen according to a list provided by the Dietary Manager on 07/17/2024 at 3:11 PM.
- 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 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 11 residents who received pureed diet, as documented on the list provided by the Dietary Supervisor on 07/17/2024.
- E
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure the physician's plan of care for chopped meat was followed for 8 residents who had a physician's order for chopped meat diets. The failed practice had the potential to affect 8 residents who had physician orders for chopped meat diets (census of 78), according to a list provided by the Dietary Manager on 07/17/2024.
- E
Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse.
Inspectors wroteBased on interview, and record review, the facility failed to ensure the Binding Arbitration Agreement stated the resident or resident representative were not required to sign the binding arbitration agreement as a condition of admission or as a requirement to continue to receive care at the facility.
- E
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, record review and interview, the facility failed to ensure a water management program was put in place to prevent the growth of Legionella and other opportunistic waterborne pathogens in the water system or ways to intervene in the instance of a Legionella outbreak for 1 of 1 facility; failed to ensure enhanced barrier precautions were in place for 1 (Resident #29) of 1 sampled resident with a Percutaneous Endoscopic Gastrostomy (PEG) tube and open wound; failed to ensure proper hand hygiene during meal service to prevent cross contamination for 1 (Resident #15) to prevent cross contamination; failed to ensure upper dentures were stored in a closed container with denture cleaner to prevent infection, and germs for 1 (Resident #71); [...]
- 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 ensure interventions for a hand device was consistently used for 1 (Resident #39) of 1 sampled resident who had a hand contracture.
- D
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 dental care was provided for 1 (Resident #71) of 1 sampled (Resident #71) to promote good oral hygiene.
- 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, and record review, the facility failed to ensure all bodily areas were cleansed during incontinent care to promote cleanliness and good personal hygiene to prevent the potential infection for 1 (Resident #277) of 1 sampled resident reviewed for incontinent care.
Fire safety inspections
6 fire safety citations on file: 3 on January 16, 2025, 3 on July 18, 2024.
Every fire safety citation6 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 · January 16, 2025 · Corrected (the home has a date of correction)
- F
Install a fire alarm system that can be heard throughout the facility.
K 341 · January 16, 2025 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · January 16, 2025 · Corrected (the home has a date of correction)
- F
Implement emergency and standby power systems.
E 41 · July 18, 2024 · Corrected (the home has a date of correction)
- F
Provide properly protected cooking facilities.
K 324 · July 18, 2024 · Corrected (the home has a date of correction)
- F
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
K 761 · July 18, 2024 · Corrected (the home has a date of correction)