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 41 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
35D
3E
1F
Potential for minimal harm
0A
1B
1C
April 2, 2026Standard inspection · 9 citations
- 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 follow infection control guidelines. Specifically, staff failed to properly disinfect goggles used in droplet precaution isolation rooms for 3 of 9 residents (Resident (R) 34, R51, and R77), failed to wear the required mask while in a droplet precaution isolation room for 1 of 9 residents (R34), and failed to ensure glucometer [blood sugar testing device] checks were performed in a manner to prevent infection for one resident (R60). These failures had the potential to result in the spread of infection to staff and residents.
- E
Implement a program that monitors antibiotic use.
Inspectors wroteBased on record review, interviews, document review, and review of McGeer's criteria, the facility failed to have an Antibiotic Stewardship Program consistent with current standards of practice for the prescribing of an antibiotic for 4 of 4 residents (Resident (R) 83, R33, R126, and R85) reviewed for antibiotic stewardship out of a total sample of 33 residents. This failure had the potential to result in the unnecessary use of antibiotics, increasing the risk of antibiotic resistance and adverse medication-related side effects for residents.
- D
Allow residents to self-administer drugs if determined clinically appropriate.
Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure medication at the bedside was assessed for self-administration for 1 of 33 sampled residents (Resident (R) 60). This failure placed the resident at risk of receiving more medication than prescribed.
- D
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Inspectors wroteBased on interviews, record review, and review of facility policy, the facility failed to ensure 1 of 33 sampled residents (Resident (R)114) was given the opportunity to make choices regarding his shower preference. This failure placed the resident at risk for a diminished quality of life.
- 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 interview, record review, and review of facility policy, the facility failed to develop a care plan related to activities for 1 of 3 residents (Residents (R) 114) reviewed for activities out of a total sample of 33 residents. This failure placed residents at risk for a diminished quality of life.
- 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 observations, interviews, record review, and review of the facility policy, the facility failed to ensure the Comprehensive Care Plan was updated/revised for 3 of 33 sampled residents (Residents (R) 8, R56 and R68). The facility failed to update/revise the Behavior Care Plan to include resident specific interventions/approaches for R8 and R56. In addition, the facility failed to update/revise the care plan related to respiratory services for R68. These failures placed residents at risk for unmet care needs and a diminished quality of life.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on record review and interview, the facility failed to initiate a care plan for heart failure, notify the physician of weight gain experienced in a five day period, follow and document the 1500 milliliter fluid restriction ordered, document why physician orders were not carried out by staff, and document a change in condition for one of one resident (Resident (R) 160) reviewed for congestive heart failure out of a total sample of 33 residents. Despite R160's diagnosis of congestive heart failure, recent six-pound weight gain in five days, and ordered fluid restriction, intravenous (IV) fluids were prescribed without documented reassessment of fluid status, intake/output monitoring, or evidence the order was carried out. These failures had the potential for R160 to experience fluid overload, decompensation, or the risk of rehospitalization.
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure oxygen and respiratory therapies were administered in accordance with physician orders and professional standards of practice. The facility also failed to ensure staff recognized and intervened when ordered respiratory treatments were not delivered effectively for 2 of 33 sampled residents (Resident (R) 68 and R138). This deficient practice placed residents at risk for low oxygen levels, ineffective treatment, respiratory compromise, infection, and impaired cognition.
- D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Inspectors wroteBased on observation, record review, interview, and policy review, the facility failed to update physician orders and ensure medication labels accurately reflected the current route of administration of medication when a resident with a feeding tube began taking medications by mouth for 1 of 5 residents (Resident (R) 84) reviewed for medication administration out of a sample of 33 residents. This deficient practice placed the resident at risk for aspiration, ineffective medication delivery, and adverse outcomes related to improper route of administration.
June 11, 2025Complaint inspection · 5 citations
- D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteBased on interview, clinical record review, and document review, the facility failed to protect a resident's right to a dignified existence without discrimination when a resident-to-resident verbal altercation involved the use of racial slurs for 1 of 11 sampled residents (Resident #11). This deficient practice had the potential to result in psychosocial harm.
- D
Respond appropriately to all alleged violations.
Inspectors wroteBased on interview, clinical record review, and document review, the facility failed to ensure an allegation of verbal abuse was investigated and reported to the State Agency (SA) for 1 of 11 sampled residents (Resident #11). This deficient practice had the potential to result in psychosocial harm due to allegations of abuse not being thoroughly investigated and protections not put in place to prevent future 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 interview, clinical record review, and document review, the facility failed to ensure a resident with a history of nicotine dependence had a care plan to address the resident's stated plans to continue smoking for 1 of 11 sampled residents (Resident #2). This deficient practice had the potential to result in facility staff being unaware of a resident's behavior and stated desire to continue smoking while wearing oxygen with the potential for the resident to suffer severe harm or death from burns as the result of smoking with oxygen in use from lack of care planned interventions to prevent adverse outcomes associated with the behavior.
- 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 interview, clinical record review, and document review, the facility failed to ensure resident care plans were updated after a resident-to-resident altercation for 2 of 11 sampled residents (Residents #10 and #11). This deficient practice has the potential to result in a resident not receiving care and services to meet their needs and prevent further altercations and psychosocial harm.
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on interview, clinical record review, and document review, the facility failed to ensure a resident with a history of nicotine dependence and stated plans to continue smoking was adequately supervised to prevent the resident from experiencing a preventable accident while smoking with oxygen in place for 1 of 11 sampled residents (Resident #2) and two residents were not near Resident #2 while the resident was smoking with oxygen in place (Resident #3 and #4). This deficient practice had the potential to result in residents suffering burns causing severe pain and a decline in quality of life.
January 13, 2025Standard inspection · 11 citations
- F
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, interview, clinical record review and document review, the facility failed to ensure a comfortable ambient air temperature was provided to residents (Resident #59, #19, #76, #30, #123, #104, #1, #2, #106, and #41) using the communal shower rooms in 3 of 3 facility shower rooms with temperatures of 62.1 degrees Fahrenheit (F), 62.4 F, and 67.6 F. This deficient practice had the potential to cause residents widespread discomfort before, during and after showers.
- 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 and interview, the facility failed to ensure expired medications were removed from 2 of 3 medication storage rooms, and a wound care cart containing potentially hazardous opened treatment items remained secured. The opened items in the unsecured wound care cart had the potential to be available to resident's in and around the 400 Hall and the 400 Hall nurses' station.
- D
Keep residents' personal and medical records private and confidential.
Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure the facility's electronic health record was not left open and accessible on a computer attached to a medication cart with a resident's identifiers and medication administration record visible while staff were not in attendance or sight of the cart for 1 of 21 residents residing on the 800 hall (Resident #15). This deficient practice had the potential to result in a resident's confidential information being accessed by unauthorized individuals including other residents or visitors without the resident's permission.
- 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, clinical record review, and document review the facility failed to ensure a care plan was developed related to the care of a Foley catheter for 1 of 28 sampled residents (Resident #123). This deficient practice had the potential to result in residents not receiving care and services to meet their needs related to indwelling devices.
- 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 interview, clinical record review, and document review the facility failed to ensure a care plan was updated to include new interventions for the prevention of falls for 1 of 28 sampled residents (Resident #448). This deficient practice had the potential to result in residents not receiving care and services to meet their needs and help prevent falls.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on interview, clinical record review, and document review the facility failed to ensure physician ordered wound care was performed for 1 of 28 sampled residents (Resident #448). This deficient practice had the potential for a resident's wound to worsen and/or delay healing.
- D
Provide or obtain dental services for each resident.
Inspectors wroteBased on observation, interview, clinical record review, and document review, the facility failed to ensure a resident's requests for a dentist appointment to address broken teeth and pain with chewing food were addressed and efforts were made to schedule the resident for a dental appointment for 1 of 28 sampled residents (Resident #59). This deficient practice had the potential to result in a resident with dental concerns experiencing increased pain with chewing food or infection from cracked and broken teeth.
- D
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Inspectors wroteBased on observation, document review, and interview the facility failed to demonstrate effective administration by not ensuring the Administrator and the Director of Engineering adequately addressed the low ambient temperatures in 3 of 3 shower rooms.
- D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteResident #198 Resident #198 was admitted to the facility on [DATE], with diagnoses including fusion of the spine, lumbar region, encounter for orthopedic aftercare, other spondylosis, lumbar region, and intervertebral dis disorders with radiculopathy, lumbar region. Resident #198's December 2024 Treatment Administration Record (TAR) documented wound treatment: clean left lower back surgical incision with normal saline, pat dry, apply skin, cover with island dressing every Monday, Wednesday, and Friday, and as needed if dressing becomes soiled or dislodged. The start date was 12/20/2024. There was no wound treatment documented for 12/23/2024. Resident #198's December 2024 TAR documented wound treatment: [...]
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, clinical record review, interview, and document review, the facility failed to ensure an employee donned proper personal protective equipment (PPE) prior to entering a resident's room on isolation contact-based precautions for 1 of 2 residents on contact-based precautions (Resident #119). This deficient practice of lack of proper infection control practices had the potential to spread infection and affect all residents within the facility.
- C
Post nurse staffing information every day.
Inspectors wroteBased on observation, interview, and document review the facility failed to ensure current nursing hours were posted for the facility. This deficient practice had the potential to result in a lack of awareness for residents and visitors regarding the number of nursing staff on duty.
December 5, 2024Complaint inspection · 2 citations
- D
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Inspectors wroteBased on interview, clinical record review, and document review, the facility failed to ensure a resident was protected from verbal and physical abuse by a Certified Nursing Aide (CNA) when the CNA yelled at and threw an object at 1 of 5 sampled residents (Resident #1). This deficient practice had the potential to result in physical and psychosocial harm.
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on clinical record review, interview, and document review, the facility failed to ensure a resident with a stage four pressure ulcer was evaluated timely by the facility's Registered Dietician and a physician ordered nutritional supplement was administered to the resident (Resident #1). This deficient practice had the potential to result in a pressure ulcer to not receive the services and treatment to promote healing and prevention.
June 27, 2024Complaint inspection · 1 citation
- D
Protect each resident from the wrongful use of the resident's belongings or money.
Inspectors wroteBased on interview, clinical record review and document review, the facility failed to ensure a resident was free from misappropriation of property when a Housekeeper asked for money from a resident for 1 of 11 Facility Reported Incidents (FRI) (Resident #1).
February 6, 2024Standard inspection · 12 citations
- D
Ensure that residents are fully informed and understand their health status, care and treatments.
Inspectors wroteBased on observation, interview, clinical record review and document review, the facility failed to ensure a resident or resident representative gave informed consent prior to placing a resident's bed on the floor, against the wall and a resident had been provided with an informed consent for a psychoactive medication prior to the administration of the medication for 3 of 26 sampled residents (Resident #102, #40 and #87).
- 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 grievances and complaints documented from Resident Council meetings related to missing and misplaced laundry were addressed and acted upon for 5 of 10 months of Resident Council meeting minutes.
- 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, clinical record review, and document review, the facility failed to ensure a care plan was developed 1) for a psychotropic medication (Residents #87), 2) to address a resident's phantom limb sensations and pain (Resident #322), 3) for the use and management of an anticoagulant (Resident #45), 4) regarding wound care and the care of a skin graft (Resident #96), and 5) the administration and monitoring of oxygen and the use of siderails (Resident #79) for 5 of 26 sampled residents.
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observation, clinical record review, interview and document review, the facility failed to follow a physician's order for respiratory care for 1 of 26 sampled residents (Resident #49).
- D
Provide safe, appropriate pain management for a resident who requires such services.
Inspectors wroteBased on observation, interview, clinical record review, and document review, the facility failed to ensure a resident with phantom limb sensations and severe pain had non-pharmacological interventions to manage the resident's pain for 1 of 26 sampled residents (Resident #322).
- D
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, record review and document review, the facility failed to ensure alternatives were attempted and informed consent was obtained prior to installation of side rails for 1 of 26 sampled residents (Resident #79).
- D
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 interview, clinical record review, and document review, the facility failed to ensure a recommendation from a drug regimen review had a follow up response or rationale from the prescriber for 2 of 26 sampled residents (Resident #87 and #79).
- 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 interview, clinical record review, and document review, the facility failed to ensure a psychotropic medication was prescribed to a resident for an appropriate indication for 1 of 26 sampled residents (Resident #87).
- 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, clinical record review, and document review the facility failed to ensure unsecured medications were not left in a resident's room for 1 of 26 sampled residents (Resident #10) and failed to ensure expired medications were removed from 1 of 6 medication carts.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview, clinical record review, and document review, the facility failed to ensure a resident with a peripherally inserted continuous catheter (PICC) line had the PICC line dressing changed per facility policy for 1 of 26 sampled residents (Resident #319).
- D
Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members.
Inspectors wroteBased on interview and document review, the facility failed to ensure training related to communication was provided to 2 of 20 sampled employees (Certified Nursing Assistant (CNA) CNA1 and CNA2).
- B
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on observation, clinical record review, interview, and document review, the facility failed to complete Treatment Administration Records (TAR) for the administration of care of a urinary catheter for 2 of 26 sampled residents (Resident #40 and #72), and for the administration of care of a gastrostomy tube (G-tube) for 1 of 26 sampled residents (Resident #85), and failed to ensure resident information was not visible on an unattended computer screen facing a public area for 1 of 26 sampled residents (Resident #6).
December 21, 2023Complaint inspection · 1 citation
- D
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Inspectors wroteBased on observation, interview, clinical record review, and document review the facility failed to administer medications per a physician's order for 2 of 7 sampled residents (Resident #2 and #3).
Fire safety inspections
26 fire safety citations on file: 7 on April 2, 2026, 8 on January 13, 2025, 11 on February 6, 2024.
Every fire safety citation26 citations
- E
Inspect, test, and maintain automatic sprinkler systems.
K 353 · April 2, 2026 · Corrected (the home has a date of correction)
- E
Install corridor and hallway doors that block smoke.
K 363 · April 2, 2026 · Corrected (the home has a date of correction)
- E
Have properly installed electrical wiring and gas equipment.
K 511 · April 2, 2026 · Corrected (the home has a date of correction)
- D
Properly select, install, inspect, or maintain portable fire extinguishes.
K 355 · April 2, 2026 · Corrected (the home has a date of correction)
- D
Install smoke barrier doors that can resist smoke for at least 20 minutes.
K 374 · April 2, 2026 · Corrected (the home has a date of correction)
- D
Have simulated fire drills held at unexpected times.
K 712 · April 2, 2026 · Corrected (the home has a date of correction)
- D
Have proper medical gas storage and administration areas.
K 923 · April 2, 2026 · Corrected (the home has a date of correction)
- E
Inspect, test, and maintain automatic sprinkler systems.
K 353 · January 13, 2025 · Corrected (the home has a date of correction)
- E
Install corridor and hallway doors that block smoke.
K 363 · January 13, 2025 · Corrected (the home has a date of correction)
- E
Have properly installed electrical wiring and gas equipment.
K 511 · January 13, 2025 · Corrected (the home has a date of correction)
- E
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
K 521 · January 13, 2025 · Corrected (the home has a date of correction)
- E
Ensure proper usage of power strips and extension cords.
K 920 · January 13, 2025 · Corrected (the home has a date of correction)
- D
Meet other general requirements.
K 200 · January 13, 2025 · 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 · January 13, 2025 · Corrected (the home has a date of correction)
- D
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · January 13, 2025 · Corrected (the home has a date of correction)
- F
Have a battery powered remote alarm panel in a location accessible by operating personnel.
K 916 · February 6, 2024 · Corrected (the home has a date of correction)
- E
Inspect, test, and maintain automatic sprinkler systems.
K 353 · February 6, 2024 · Corrected (the home has a date of correction)
- E
Have properly installed electrical wiring and gas equipment.
K 511 · February 6, 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 · February 6, 2024 · Corrected (the home has a date of correction)
- D
Install an approved automatic sprinkler system.
K 351 · February 6, 2024 · Corrected (the home has a date of correction)
- D
Properly select, install, inspect, or maintain portable fire extinguishes.
K 355 · February 6, 2024 · Corrected (the home has a date of correction)
- D
Install corridor and hallway doors that block smoke.
K 363 · February 6, 2024 · Corrected (the home has a date of correction)
- D
Install smoke barrier doors that can resist smoke for at least 20 minutes.
K 374 · February 6, 2024 · Corrected (the home has a date of correction)
- D
Have simulated fire drills held at unexpected times.
K 712 · February 6, 2024 · Corrected (the home has a date of correction)
- D
Meet requirements for the installation and maintenance of electrical systems.
K 911 · February 6, 2024 · Corrected (the home has a date of correction)
- D
Ensure proper usage of power strips and extension cords.
K 920 · February 6, 2024 · Corrected (the home has a date of correction)