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
2G
0H
0I
Potential for more than minimal harm
16D
3E
1F
Potential for minimal harm
0A
3B
1C
May 6, 2025Standard inspection, Complaint inspection · 13 citations
- G
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on interviews, review of the clinical record, facility documentation, and facility policy for 1 of 5 residents (Resident #24) reviewed for falls, the facility failed to provide a transfer according to physician orders which resulted in a fall with injury and failed ensure all appropriate doors were secured on the locked memory care unit.
- F
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on the tour of the Dietary Department and Nourishment Rooms, staff interviews, and review of facility policies, the facility failed to ensure opened items were labeled and dated when opened, food that was expired was discarded and the 3 of 3 nourishment refrigerator/freezer/ice makers were sanitary.
- E
Provide or obtain dental services for each resident.
Inspectors wroteBased on observation, review of the clinical record, facility policy and interviews for 1 of 2 residents (Resident #33) reviewed for dental services, the facility failed to ensure timely dental services were provided related to non-restorable teeth.
- E
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observations, staff interview, review of the clinical record and facility policy for 6 residents (Resident #4/Resident #36 (roommates), Resident #13/Resident #25 (roommates)and Resident #33/Resident #37 (roommates) on isolation precautions, the facility failed to ensure the nursing staff donned the appropriate Personal Protective Equipment (PPE) and for 1 of 6 sampled residents (Resident #36) reviewed for infection control documentation, the facility failed to ensure documentation was accurate and consistent regarding the type of precautions Resident #36 required.
- D
Provide doctor's orders for the resident's immediate care at the time the resident was admitted.
Inspectors wroteBased on observation(s), review of the clinical record, facility documentation, facility policy and interviews for the only sampled resident (Resident #286) reviewed for non-pressure skin conditions, the facility failed to obtain wound treatment orders upon admission for a resident with a surgical wound and a venous stasis ulcer.
- 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 interviews, clinical record review, and facility policy for one of three residents (Resident #22) reviewed for advanced directives, the facility failed to ensure the Resident Care Plan accurately reflected Resident #22's code status.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on review of the clinical record, facility documentation, facility policy and interviews for 1 of 4 residents (Resident #53) reviewed for accidents, the facility failed to ensure orthostatic blood pressures were monitored per the physician's order for a resident with postural hypotension and history of repeated falls.
- D
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Inspectors wroteBased on observations, review of clinical records, facility documentation, facility policy and interview for 2 of the 2 residents reviewed for infection control, the facility failed to ensure the peripheral lines had appropriate physician orders in place to rotate access site every 96 hours and as needed or the site was to be removed. 1. Resident #19's diagnosis included Covid 19, myocardial infarction, and hyponatremia. The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #19 was cognitively intact, required maximal assistance for toileting, set up assistance for oral hygiene and eating. Also identified that Resident #19 was dependent on showering and transfers. Further identifying Resident #19 was not receiving intravenous 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 observations, interviews and review of facility policy for two of three medication storage rooms, the facility failed to ensure expired medication was disposed of and supplies and medications were stored properly.
- D
Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
Inspectors wroteBased on review of the clinical record, facility policy and interviews for 1 of 5 residents (Resident #33) reviewed for vaccinations, the facility failed to ensure the appropriate time was provided between COVID-19 vaccination administration.
- C
Dispose of garbage and refuse properly.
Inspectors wroteBased on staff interview, observation and facility policy of the dumpster area, the facility failed to properly dispose of garbage and refuse.
- B
Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.
Inspectors wroteBased on staff and resident interviews and observations within the secured unit, the facility failed to ensure state survey results were available and accessible on the secured unit for those residents who resided there.
- B
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 review of facility policy for two of three medication storage rooms, the facility failed to ensure the medication rooms were clean. a. Interview and observation of the 4th floor medication room with Licensed Practical Nurse (LPN) #2 on [DATE] at 10:40 AM identified the medication room floor was dirty with dried spilled liquids and debris. Additionally, 20 hemoccult cards were observed that had an expiration date of 8/2023 and a bottle of hemoccult developer that expired in 8/2021 in the cabinet drawer. LPN #2 identified that it was housekeeping's responsibility to clean the medication room floor, but the floor was not cleaned often. An interview with the Director of Facilities Housekeeping on [DATE] at 12:30 PM identified it was the responsibility of housekeeping staff to dust and mop the floors and clean other areas in the medication rooms daily. [...]
September 19, 2024Complaint inspection · 4 citations
- G
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on a review of clinical records, facility documentation, facility policy, and interviews for one (1) of three (3) residents (Resident #1) reviewed for accidents, the facility failed to provide adequate assistance during a bed linen change and as a result, the resident rolled out of bed onto the floor sustaining a left hip fracture.
- D
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Inspectors wroteBased on review of the clinical record, facility documentation, facility policy, and interviews for one (1) of three (3) residents (Resident #3) reviewed for abuse, the facility failed to ensure a resident with known wandering behaviors was supervised to prevent an incident of sexual abuse.
- 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 review of the clinical record, facility documentation, facility policy, and interviews for one (1) of three (3) residents (Resident #4) reviewed for pressure injury, the facility failed to develop a comprehensive care plan with interventions to prevent skin breakdown when the resident was identified at high risk for developing pressure injuries.
- 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 review of the clinical record, facility documentation, facility policy, and interviews for one (1) of three (3) residents (Resident #2) reviewed for behaviors, the facility failed to review and revise a resident's care plan when the resident was identified as wandering in and out of other resident's rooms.
July 13, 2023Standard inspection · 8 citations
- 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, review of maintenance logs, and staff interview for 1 of 8 rooms (room [ROOM NUMBER]) observed during tour, the facility failed to ensure the air conditioner grill was not exposed and was free from dust/debris/sediment.
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on clinical record review, review of facility policy and interviews for one sampled resident (Resident #68) who was at risk for falls, the facility failed to ensure the resident had adequate supervision during ambulation resulting in the resident sustaining a fall.
- D
Provide enough food/fluids to maintain a resident's health.
Inspectors wroteBased on record review, observations and staff interviews for 1 of 3 sampled residents (Resident #61) reviewed for nutrition, the facility failed to provide large portions per Dietician recommendations.
- 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 clinical record review, observations, review of facility documentation and interviews for one sampled resident (Resident #30) who had a gastrostomy tube in place and received enteral nutrition on a continuous basis, the facility failed ensure that the enteral nutrition was administered continuously as ordered resulting in the resident not receiving the enteral nutrition for more than three hours.
- D
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 review facility documentation and staff interviews, the facility failed to ensure Registered Nurse (RN) #2 was working with a current nursing license.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, review of clinical record, review of facility documentation, facility policy, and interviews for one sampled resident (Resident #20) who was administered insulin, the facility failed to ensure that the glucometer was cleaned in an appropriate manner to maintain acceptable infection prevention and transmission precautions and for one nurse's aide (NA #1) observed with long nails, the facility failed to ensure the nurses' aide's nails were of an appropriate length to prevent the potential transmission of infection.
- D
Make sure that a working call system is available in each resident's bathroom and bathing area.
Inspectors wroteBased on observation, record review and staff interview for 1 of 10 sampled residents (Resident #64) observed during the initial screening process, the facility failed to ensure Resident #64's call bell was within reach and accessible.
- B
Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home.
Inspectors wroteBased on clinical record review, facility policy review, and interviews for 1 of 2 residents (Resident #17) reviewed for resident trust accounts, the facility failed to ensure quarterly statements were provided.
June 23, 2021Standard inspection · 1 citation
- 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, review of facility policy, and interviews, the facility failed to ensure that proper handwashing and glove use occurred during the handling of soiled and clean dishes to prevent cross contamination.
Fire safety inspections
5 fire safety citations on file: 3 on May 6, 2025, 1 on July 13, 2023, 1 on June 23, 2021.
Every fire safety citation5 citations
- D
Install corridor and hallway doors that block smoke.
K 363 · May 6, 2025 · Corrected (the home has a date of correction)
- D
Meet other general requirements that are deficient.
K 500 · May 6, 2025 · Corrected (the home has a date of correction)
- D
Meet requirements for the installation and maintenance of electrical systems.
K 911 · May 6, 2025 · Corrected (the home has a date of correction)
- D
Meet requirements for the installation and maintenance of electrical systems.
K 911 · July 13, 2023 · Corrected (the home has a date of correction)
- D
Properly select, install, inspect, or maintain portable fire extinguishes.
K 355 · June 23, 2021 · Corrected (the home has a date of correction)