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 17 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
11D
5E
0F
Potential for minimal harm
0A
1B
0C
February 26, 2026Standard inspection · 7 citations
- E
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Inspectors wroteBased on observation, record review, and interviews with staff, the Consultant Pharmacist, and the Physician Assistant, the facility failed to evaluate the continued need for a medication prescribed for wheezing. This deficient practice had the potential to result in residents receiving medications without clinical indication, ongoing monitoring, or justification of continued use for 1 of 6 residents reviewed unnecessary medications (Resident #75).
- E
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, record review and staff interviews the facility failed to implement their infection prevention program policies and procedures and follow their Hand Hygiene policy when Nurse #3 failed to perform hand hygiene and change gloves when flushing a peripherally inserted central catheter (PICC) line (a long thin flexible tube inserted through an arm vein near the heart for long term intravenous access) and connecting the intravenous (IV) antibiotic tubing to the PICC line tubing. In addition, the Wound Treatment Nurse failed to change the disposable gloves and perform hand hygiene during wound care observation for Resident #2 and Resident #22. The deficient practice occurred for 2 of 4 staff observed for infection control practices (Nurse #3 and Wound Nurse).
- D
Ensure each resident receives an accurate assessment.
Inspectors wroteBased on record review and staff interviews, the facility failed to accurately code the Minimum Data Set (MDS) Assessments for 3 of 29 residents whose MDS assessments were reviewed for accuracy (Resident #2, Resident #28 and Resident #38).
- 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, record review and staff interviews, the facility failed to place a resting hand orthosis ([NAME], a device designed to support the hand, wrist, and fingers in a functional position) to the right hand for contracture management for 1 of 3 resident reviewed for position, mobility and range of motion (Resident #6).
- 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, record review and resident and staff interviews, the facility failed to secure the indwelling urinary catheter tubing to prevent tugging or pulling for 1 of 1 resident reviewed for indwelling urinary catheter (Resident #22). Resident #22 was admitted to the facility on [DATE] with diagnoses that included neuromuscular dysfunction of bladder and urinary retention. A physician's order dated 9/5/2025 indicated Resident #11 had an indwelling urinary catheter for urinary retention. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #22 was cognitively intact. He was coded as having an indwelling urinary catheter. An observation was conducted of wound care on 02/24/2026 at 2:17 PM with the Wound Nurse. During the observation Resident #22 did not have a leg band in place to secure the tubing for his indwelling urinary catheter. [...]
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observation, record review and staff and resident interviews, the facility failed to obtain a physician order for supplemental oxygen for 1 of 2 residents reviewed for respiratory care (Resident #28).
- 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 record review, observations, and staff interviews the facility failed to date open medications for 1 of 3 medication carts reviewed for medication storage (Hall 100 medication cart).
November 21, 2024Standard inspection · 5 citations
- 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, resident, and staff interviews, the facility failed to provide written documentation for advance directive information and the opportunity to formulate an advance directive for 13 of 22 residents reviewed for advanced directives. Residents #57, #71, #58, #55, #70, #68, #29, #72, #38, #52, #65, #61, #45.
- D
Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made.
Inspectors wroteBased on record review, staff and resident interviews, the facility failed to provide written notification of a roommate change for 1 of 1 resident reviewed for notification of a change (Resident #37).
- D
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Inspectors wroteBased on record review and staff interviews, the facility failed to refer a resident with a serious mental illness for a Level II Preadmission Screening and Resident Review (PASRR) for 1 of 2 residents reviewed for PASRR (Resident #34).
- 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, staff interviews, the facility failed to dispose/discard expired medications in 1 of 3 medication carts (600 Hall medication cart) observed for medication storage.
- B
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 staff interviews, the facility failed to provide written notification for reason of discharge to the Ombudsman for 4 of 6 residents reviewed for hospitalization (Resident #38, Resident #51, Resident #61, Resident #71).
September 14, 2023Standard inspection, Complaint inspection · 5 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 observations, record review and staff interviews the facility failed to maintain food service equipment without a build up of debris on 3 of 4 pieces of cookline equipment (top/bottom convection oven, gas range oven) observed for cleanliness, and failed to remove excessive ice buildup and clean 2 of 2 nourishment refrigerators observed for cleanliness. These practices had the potential to affect facility residents.
- E
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Inspectors wroteBased on observations, record review and staff interview the facility's Quality Assessment and Assurance (QAA) Committee failed to maintain implemented procedures and monitor interventions the committee put in place following a recertification and complaint survey of 4/8/2022. This was for one recited deficiency on the current recertification and complaint survey in the area of Food and Nutrition Services (F812). The continued failure during two federal surveys of record shows a pattern of the facility's inability to sustain an effective QAA program.
- 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, record review, and staff interviews the facility failed to develop a written individualized person-centered care plan in the area of pressure ulcer for 1 of 4 residents reviewed for pressure ulcers (Resident #58).
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observations, record review, resident interviews, staff interviews, and Medical Director interview, the facility failed to obtain a physician order for supplemental oxygen for 2 of 3 residents reviewed for oxygen (Resident #26 and Resident #45).
- 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, staff interviews, Physician interviews, Hospice Administrator interview, and Pharmacy Consultant interview, the facility failed to ensure Physician orders for as needed (PRN) psychotropic medications were time limited in duration for 1 of 5 residents reviewed for unnecessary medication (Resident #45).
Fire safety inspections
12 fire safety citations on file: 6 on February 26, 2026, 4 on November 21, 2024, 2 on September 14, 2023.
Every fire safety citation12 citations
- F
Install corridor and hallway doors that block smoke.
K 363 · February 26, 2026 · Corrected (the home has a date of correction)
- E
Use approved construction type or materials.
K 161 · February 26, 2026 · Corrected (the home has a date of correction)
- E
Have properly installed electrical wiring and gas equipment.
K 511 · February 26, 2026 · Corrected (the home has a date of correction)
- D
Inspect, test, and maintain automatic sprinkler systems.
K 353 · February 26, 2026 · 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 · February 26, 2026 · Corrected (the home has a date of correction)
- D
Have proper medical gas storage and administration areas.
K 923 · February 26, 2026 · Corrected (the home has a date of correction)
- D
Use approved construction type or materials.
K 161 · November 21, 2024 · Corrected (the home has a date of correction)
- D
Keep aisles, corridors, and exits free of obstruction in case of emergency.
K 211 · November 21, 2024 · Corrected (the home has a date of correction)
- D
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
K 321 · November 21, 2024 · Corrected (the home has a date of correction)
- D
Install corridor and hallway doors that block smoke.
K 363 · November 21, 2024 · Corrected (the home has a date of correction)
- D
Install corridor and hallway doors that block smoke.
K 363 · September 14, 2023 · Corrected (the home has a date of correction)
- D
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · September 14, 2023 · Corrected (the home has a date of correction)