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 25 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
1J
0K
0L
Actual harm
1G
0H
0I
Potential for more than minimal harm
19D
4E
0F
Potential for minimal harm
0A
0B
0C
June 30, 2026Standard 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 review of resident medical records, staff interviews and review of facility policy, the facility failed to ensure staff was knowledgeable about advanced directive procedures. This affected four of four residents (#1, #22, #24, and #46) reviewed for advanced directives. The facility census was 42 residents.
- E
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Inspectors wroteBased on record review, and staff interview the facility failed to timely implement physician recommendations per the Medication Regimen Review (MRR) for three residents, (#1, #4, and #24) of five reviewed for unnecessary medications. The facility also failed to ensure the MRR were reviewed by the physician in a timely manner for three residents, (#4, #24, and #46) of five reviewed for unnecessary medications. The facility census was 42.
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on record review, interviews, and facility policy review, the facility failed to implement interventions to prevent pressure ulcers. This affected one resident, (#24), of three residents reviewed for pressure ulcers. The facility census was 42.
- D
Provide enough food/fluids to maintain a resident's health.
Inspectors wroteBased on review of resident medical records, staff interviews, and review of facility policy, the facility failed to monitor the nutrition status quarterly for one resident (#22). The facility failed to complete nutrition assessments timely for two residents, (#7 and #22). The facility failed to identify a significant weight loss for one resident, (#7). The facility also failed to notify the physician of significant weight losses for two residents, (#03 and #7). This affected three of four residents reviewed for nutrition. The facility census was 42 residents.
- D
Implement a program that monitors antibiotic use.
Inspectors wroteBased on record review, staff interview and review of McGreer Criteria, the facility failed to ensure one resident, (#35) was not prescribed antibiotics unnecessarily. This affected one of five residents reviewed for infection control. The facility census was 42. Review of Resident # 35's medical record revealed an admission date of 02/21/25 with diagnoses that included but were not limited to encephalopathy, altered mental status, dementia with anxiety and obstructive uropathy. Review of Resident # 35's current care plans revealed the resident was cognitively impaired and required assistance from staff with toileting and dressing. Review of Resident # 35's Urine Culture and Sensitivity (UA C/S) dated 02/18/26 revealed the culture was positive for 60,000 colony-forming units per milliliter (col/ml) of Proteus mirabilis and 50,000 col/ml of staphylococcus aureus. [...]
November 24, 2025Complaint inspection · 3 citations
- 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 record review, observation, and interviews, the facility failed to ensure expired medications were not available for use, failed to ensure medications were labeled accurately, and failed to store medications securely. This affected three residents (#5, #10, and #34) and had the potential to affect all residents who may be ordered facility stock medication. The facility census was 43.
- D
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Inspectors wroteBased on record review, and interviews, the facility failed to ensure timely assistance was provided to complete activities of daily living. This affected one resident (Resident #34) of seven residents reviewed for activities of daily living. The facility census was 43. Findings Include:Review of the medical record for Resident #34 revealed an admission date of 11/14/24 with diagnoses that included chronic obstructive pulmonary disease, asthma, irritable bowel syndrome, rheumatoid arthritis, altered mental status, abnormalities of gait, unsteadiness on feet, repeated falls, muscle weakness, hypertension, hypotension, congestive heart failure, Type II Diabetes, osteoarthritis, anxiety disorder, major depressive disorder, and need for personal assistance with personal care. [...]
- D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Inspectors wroteBased on record review, observation, and staff interview, the facility failed to provide the physician ordered medication for one, (Resident # 5) of three reviewed for medications. The facility census was 43. Findings Include: Review of the medical record for Resident #5 revealed a current admission date of 08/14/25 with diagnoses to include of acute respiratory failure with hypercapnia, muscle weakness, dysphagia, Type II Diabetes Mellitus, hypertension, and atherosclerotic heart disease. Review of Resident #5's care plan revealed Resident #5 required assistance with medication administration. Review of facility provided physician orders for Resident #5 revealed an order for Insulin Aspart U-100 (fast acting insulin with onset in five to 10 minutes) Insulin pen 100 units/milliliter (ml) (3ml); [...]
May 20, 2025Standard inspection, Complaint inspection · 5 citations
- G
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on observation, record review, and interviews, the facility failed to develop and implement a comprehensive, effective and individualized resident centered pressure ulcer prevention and treatment program for Resident #15 to prevent the development of pressure ulcers, to ensure treatments were completed as ordered and to promote timely and optimal healing of pressure ulcers. Actual Harm occurred on 03/17/25 when Resident #15, who was dependent on staff , was assessed to have an unstageable pressure ulcer (the left heel without evidence of interventions being implemented as ordered. The pressure ulcer required manual debridement resulting in the wound classification change to a Stage IV without evidence the physician ordered treatment was implemented for 10 days. This affected one resident (Resident #15) of three residents reviewed for pressure ulcers.
- D
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, policy review and staff interview, the facility failed to ensure advanced directives were clearly reflected in the medical record. This affected one resident (#23) of 16 residents reviewed for advanced directives. The facility census was 44.
- 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 safe oxygen administration practices were implemented. This affected one resident (Resident #13) of eleven receiving oxygen in the facility. The facility census was 44.
- D
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Inspectors wroteBased on record review, interview, and policy review, the facility failed to ensure medication parameters were followed for Resident #15 and failed to ensure Resident #20 receive d an appropriate antibiotic for a urinary tract infection. This affected two residents (Resident #15 and #20) of six residents reviewed for unnecessary medications. Facility census was 44.
- D
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Inspectors wroteBased on observation, interview and record review the facility failed to provide a clean and sanitary environment. This affected one resident (Resident #194) of three residents reviewed for environment. The facility census was 44.
February 11, 2025Complaint inspection · 2 citations
- J
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Inspectors wroteBased on closed medical record review, hospital record review, drug information review, review of the American Heart Association Journal at ahajournals.org, review of the facility policy Anticoagulant Therapy and interview, the facility failed to ensure anti-coagulant medication was monitored to ensure it was administered at a therapeutic dose and timely held in the presence of adverse consequences. This resulted in Immediate Jeopardy and actual harm beginning on [DATE] when Resident #44, who had a history of atrial fibrillation and an artificial heart valve managed with the anticoagulant medication, Coumadin (warfarin) and had been diagnosed and treated for a subdural hematoma prior to her admission to the facility, was ordered to resume her Coumadin at a higher dose than previously administered and without an ordered neurology consultation before resuming the anticoagulant medication. [...]
- D
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Inspectors wroteBased on closed medical record review, hospital record review, facility policy review and interview, the facility failed to ensure Resident #44's physician was notified timely of missed consultation appointments and laboratory studies. This affected one resident (#44) of seven sampled residents. The facility census was 43.
September 4, 2024Complaint inspection · 1 citation
- E
Provide and implement an infection prevention and control program.
Inspectors wroteBased on medical record review, observation, staff interview and review of facility policy, the facility failed to ensure staff followed infection control procedures including the proper use of personal protective equipment (PPE) to prevent transmission of COVID 19. This had the potential to affect all thirteen residents (Resident #14, Resident #15, Resident #16, Resident #17, Resident #18, Resident #19, Resident #20, Resident #21, Resident #22, Resident #23, Resident #24, Resident #25, and Resident #26) residing in Resident #26's assigned care area.
December 13, 2023Complaint inspection · 1 citation
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on medical record review, hospital record review, and staff interview, this facility failed to ensure glucose monitoring was completed for a resident who had a diagnosis of type two diabetes mellitus with hyperglycemia (elevated blood glucose levels) and was prescribed a medication that would cause hyperglycemia in patients with diabetes. This affected one (Resident #60) of the four residents reviewed for glucose monitoring. The facility census was 28.
September 7, 2023Standard inspection · 8 citations
- D
Assess the resident when there is a significant change in condition
Inspectors wroteBased on interview and record review the facility failed to ensure a significant change assessment was completed when Resident #19 was admitted to hospice. This affected one resident (#19) of one resident reviewed for change in condition. The facility census was 35.
- 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 implement a care plan related to hospice needs and oxygen status for Resident #19 and did not implement a care plan for anticoagulant use for Resident #16. This affected two residents (#16 and #19) of 19 residents whose care plans were reviewed. The facility census was 35.
- 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 record review, observation, interview, and facility policy review the facility failed to revise Resident #14's care plan with changes to meet the need of resident care interventions as determined by the resident's need or as requested by the resident. This effected one resident (# 14) of 19 resident's for plans of care reviewed. The census was 35.
- D
Provide appropriate foot care.
Inspectors wroteBased on interview, observation and record review the facility failed to ensure Resident #18 was provided proper podiatry care and services. This affected one resident (Resident #18) out of one resident reviewed for podiatry care and services. This had the potential to affect 35 residents residing at the facility.
- D
Provide enough food/fluids to maintain a resident's health.
Inspectors wroteBased on medical record review and staff interview, the facility failed to adequately monitor and provide oversight for resident's nutritional status. This affected one (Resident #141) of three residents reviewed for nutrition. The census was 35. Findings Include: Resident #141 was admitted to the facility on [DATE]. His diagnoses were fracture of unspecified part of neck of right femur, muscle weakness, dysphagia, chronic obstructive pulmonary disease, end stage renal disease, atherosclerosis, chronic kidney disease, hypokalemia, hypoosmolality and hyponatremia, hypertension, cardiac murmur, osteoarthritis, bacterial pneumonia, anemia, hyperlipidemia, metabolic encephalopathy, vertigo, melena, shortness of breath, and alcohol abuse. Review of Resident #141 weights, dated 08/18/23 to 08/28/23, revealed the following weights: [...]
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observation, interview, medical record review, and review of facility policies the facility failed to ensure physician's orders were in place prior to oxygen administration and failed to ensure oxygen tubing was dated for Resident #19. This affected one resident (#19) of one resident reviewed for respiratory care. The facility census was 35.
- D
Provide safe, appropriate pain management for a resident who requires such services.
Inspectors wroteBased on medical record review, staff interview, and facility policy review, the facility failed to provide proper parameters for as needed pain medications and did not attempt non-pharmacological interventions prior to the administration of as needed pain medications. This affected three (Residents #136, #143, and #185) of six residents reviewed for unnecessary medications. The census was 35.
- D
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Inspectors wroteBased on medical record review, staff interview, and facility policy review, the facility failed to obtain proper justification for the use of antibiotic medications. This affected two (Residents #136 and #143) of three residents reviewed for infections. The census was 35. Findings Include: 1. Resident #136 was admitted to the facility on [DATE]. His diagnoses were metabolic encephalopathy, lobar pneumonia, altered mental status, retention of urine, dysphagia, urinary tract infection, atherosclerotic heart disease, hypertension, hypoosmolality and hyponatremia. His Minimum Data Set (MDS) assessment had not been completed to determine his cognitive status. Review of Resident #136 physician orders revealed he was ordered the medication Amoxicillin 875-125 milligrams, one tablet twice daily. [...]
Fire safety inspections
10 fire safety citations on file: 5 on June 30, 2026, 2 on May 20, 2025, 3 on September 7, 2023.
Every fire safety citation10 citations
- F
Develop and maintain an Emergency Preparedness Program (EP).
E 4 · June 30, 2026 · Corrected (the home has a date of correction)
- F
Address subsistence needs for staff and patients.
E 15 · June 30, 2026 · Corrected (the home has a date of correction)
- F
Conduct testing and exercise requirements.
E 39 · June 30, 2026 · Corrected (the home has a date of correction)
- F
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · June 30, 2026 · Corrected (the home has a date of correction)
- E
Ensure proper usage of power strips and extension cords.
K 920 · June 30, 2026 · Corrected (the home has a date of correction)
- F
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
K 761 · May 20, 2025 · Corrected (the home has a date of correction)
- E
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
K 321 · May 20, 2025 · Corrected (the home has a date of correction)
- F
Meet requirements for sections of health care facilities separated by fire resistive construction.
K 131 · September 7, 2023 · Waiver
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · September 7, 2023 · Corrected (the home has a date of correction)
- E
Install corridor and hallway doors that block smoke.
K 363 · September 7, 2023 · Corrected (the home has a date of correction)