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 32 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
1G
0H
0I
Potential for more than minimal harm
23D
7E
0F
Potential for minimal harm
0A
0B
1C
March 25, 2026Standard inspection, Complaint inspection · 6 citations
- G
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Inspectors wroteBased on interview and record review, the facility failed to protect the resident's right to be free from physical and mental abuse by another resident when one resident grabbed another resident's neck. Using the reasonable person concept, this action would likely lead to fear and distress for 1 of 2 residents reviewed for abuse. (Resident 127)
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on observation, interview and record review, the facility failed to assist residents with fingernail care and facial hair removal for 2 of 6 residents reviewed for Activities of Daily Living (Resident J and Resident K).
- D
Provide safe, appropriate pain management for a resident who requires such services.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents' pain were assessed, monitored and addressed for 2 of 3 residents for pain management. (Resident C and Resident D)
- D
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Inspectors wroteBased on observation, interview, and record review, the facility failed to timely updated the individualized plan of care for residents who displayed behaviors, document non-pharmacological interventions attempted prior to the administration of an as needed anti-anxiety medications, and to document effectiveness of interventions attempted to alleviate behaviors for 2 of 3 residents reviewed for dementia care (Resident 6 and Resident 97).
- D
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Inspectors wroteBased on interview and record review, the facility failed to ensure a resident received the correct medications for 1 of 6 residents reviewed for unnecessary medications. (Resident 51)
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure gloves were doffed and hand hygiene was performed timely during incontinent care and that a resident's urinary catheter tubing was not dragging on the floor for 2 of 3 residents reviewed for activities of daily living (Resident 54 and Resident 102).
July 1, 2025Complaint inspection · 1 citation
- D
Allow residents to self-administer drugs if determined clinically appropriate.
Inspectors wroteBased on observation, interview, and record review, the facility failed to timely have the interdisciplinary team (IDT) determine and document self-administration of medications and treatments were clinically appropriate for 2 of 2 randomly observed residents. (Resident 10 and Resident 20)
February 25, 2025Standard inspection · 8 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 observation, interview, and record review, the facility failed to remove discontinued resident medications, refrigerate a medication requiring refrigeration, and label open medications in 2 of 3 medication carts observed (Residents 22, 49, 60, 75, 76, 105).
- D
Ensure each resident receives an accurate assessment.
Inspectors wroteBased on interview and record review, the facility failed to accurately complete a Minimum Data Set (MDS) assessment for 1 of 1 resident reviewed for dental services, 1 of 1 resident reviewed for Preadmission Screening and Resident Review, and 1 of 1 resident reviewed for skin conditions (Resident 22, Resident 49, and Resident 329).
- 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 develop a person-centered care plan timely for refusal to change clothes for 1 of 9 residents reviewed for activities of daily living (ADL) care. (Resident 19)
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on interview and record review, the facility failed to ensure lidocaine patches were administered as ordered for 1 of 1 resident reviewed for pain, and to obtain weights three times weekly and inform the physician of weight changes, as ordered by the physician, for 1 of 1 resident reviewed for edema (Resident 3 and Resident 63).
- 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 observation, interview, and record review, the facility failed to apply splints, as care-planned, for 1 of 1 resident reviewed for limited range of motion (ROM) (Resident 40).
- D
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Inspectors wroteBased on observation, interview, and record review, the facility failed to timely develop a person-centered behavior management care plan with individualized interventions and document approaches to care for a resident with dementia who exhibited behaviors for 1 of 1 resident reviewed for behaviors. (Resident 62)
- D
Provide medically-related social services to help each resident achieve the highest possible quality of life.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure appropriate social services follow-up, related to a previous allegation of abuse of a resident by a family member, for 1 of 1 resident reviewed for dementia care. (Resident 62)
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff donned personal protective equipment (PPE) prior to a wound dressing for 1 of 1 random observation. (Resident 5)
January 10, 2024Standard inspection, Complaint inspection · 17 citations
- E
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteBased on observation, interview and record review, the facility failed to ensure staff provided care services in a manner that promoted privacy, respect, and dignity, and to provide an environment where residents were able to express grievances without fear of reprisal for 11 of 12 residents reviewed for dignity. (Residents' B, C, D, S, T, SS, 45, 69, 80, 85 and an Anonymous Resident)
- E
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on observation, interview and record review, the facility failed to ensure timely assistance was provided with eating, nail care, incontinent care, residents getting out of bed, and ensure residents that need assistance with incontinence was provided 1 incontinent brief at a time for 8 of 12 residents reviewed for Activities of Daily Living. (Residents' B, H, J, K, M, R, S and SS)
- E
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on interview and record review, the facility failed to administer medications as ordered for 1 of 5 residents reviewed for unnecessary medications and 4 of 5 randomly reviewed residents' for medications administrations; ensure physician orders were followed regarding elevation of bilateral lower extremities (BLE) for 1 of 1 resident reviewed for pressure ulcers, and to timely update and administer a physician's order for a wound treatment and to apply podus (pressure relief) boots as ordered by a physician for 1 of 3 residents reviewed for urinary catheters.(Residents' B, H, T, 40, 44, 83 and 118,)
- E
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Inspectors wroteBased on observation, interview, and record review, the facility failed to provide sufficient nursing staff with appropriate competencies or skill sets to ensure ADL (Activities of Daily Living) care was provided in accordance with the plan of care for 8 of 12 residents reviewed for ADL care (Residents B, H, J, K, M, R, S, and SS) and physician orders were effectively provided in accordance with the plan of care for 7 of 14 reviewed for medication administration and treatments (Residents' B, H, T, 40, 44, 83 and 118)
- 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, interview, and record review, the facility failed to ensure medications stored in the facility's medication carts were not expired and/or had current orders for their use and/or were labeled with an opened date; a medication lock box was permanently affixed for narcotics in the medication fridge; and a medication cart remained locked during medication administration for 3 of 6 medication carts and 1 of 2 medication rooms reviewed within the facility. (Facility)
- E
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview and record review, the facility failed to maintain infection control by not ensuring gloves were changed and hand hygiene was completed appropriately during incontinent care, while assisting residents to eat, and while passing medications for 1 of 12 residents reviewed for ADL care, 3 of 5 residents randomly observed during medication pass, 3 residents randomly observed for 1 of 1 dinning observations. (Residents' 8, 10, 22, 80, 108, 111 and R).
- D
Allow residents to self-administer drugs if determined clinically appropriate.
Inspectors wroteBased on observation, interview and review, the facility failed to timely have the interdisciplinary team (IDT) determine and document that self-administration of medications and treatments were clinically appropriate for 2 of 2 randomly observed residents. (Resident 58 and Resident P)
- 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 observation, interview and record review, the facility failed to ensure residents got out of bed and showered as preference for 2 of 2 residents reviewed for choices. (Resident B and Resident 105)
- D
Provide appropriate foot care.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident was provided the necessary foot care for 1 of 6 residents reviewed for ADLs (activities of daily living.) (Resident G)
- 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 a resident's wheelchair had 2 functioning anti-tippers and ensure fall interventions were in place for 3 of 4 residents reviewed for accidents. (Residents' K, L and Y)
- 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 interview and record review, the facility failed to ensure residents with a urinary catheter had physician orders for such catheters; staff were monitoring and documenting the urinary outputs, and to timely notify the physician of decreased urinary output and urine leaking from a urinary catheter for 2 of 3 residents reviewed for urinary catheters (Residents' 75 and T).
- D
Provide enough food/fluids to maintain a resident's health.
Inspectors wroteBased on observation, interview, and record review, the facility failed to assure weights were obtained accurately for 1 of 4 residents reviewed for nutrition (Resident BB).
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observation, interview, and record review, the facility failed to administer a resident's oxygen, as ordered, and ensure accuracy of his current oxygen orders in the clinical record for 1 of 4 residents reviewed for respiratory care. (Resident F)
- 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, interview, and record review, the facility failed to ensure medication labels were not altered (Resident 103); facility stock of clear needleless connectors and leur lock caps were not expired (Facility); the disposition medications for discharged and/or expired residents was completed timely (Residents 330 and 331); and a resident's home medications were stored appropriately (Resident 119).
- 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 observation, interview, and record review, the facility failed to ensure an appropriate justification was in place for the continued utilization of an antipsychotic medication, follow up with the family in regards to side effects of antipsychotic medication, and follow up with an abnormal AIMS (abnormal involuntary movement scale) assessment for 1 of 5 residents reviewed for unnecessary medications. (Resident L)
- D
Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
Inspectors wroteBased on observation, interview, and record review, the facility failed to timely notify hospice of a resident's falls for 1 of 1 resident reviewed for hospice. (Resident F)
- C
Dispose of garbage and refuse properly.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure trash was contained in receptacles for 124 of 124 residents in the facility
Fire safety inspections
39 fire safety citations on file: 15 on March 25, 2026, 5 on February 25, 2025, 19 on January 10, 2024.
Every fire safety citation39 citations
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · March 25, 2026 · Corrected (the home has a date of correction)
- F
Properly select, install, inspect, or maintain portable fire extinguishes.
K 355 · March 25, 2026 · Corrected (the home has a date of correction)
- E
Keep aisles, corridors, and exits free of obstruction in case of emergency.
K 211 · March 25, 2026 · Corrected (the home has a date of correction)
- E
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
K 222 · March 25, 2026 · Corrected (the home has a date of correction)
- E
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
K 225 · March 25, 2026 · Corrected (the home has a date of correction)
- E
Have corridors or aisles that are unobstructed and are at least 8 feet in width.
K 232 · March 25, 2026 · Corrected (the home has a date of correction)
- E
Meet other general requirements that are deficient.
K 300 · March 25, 2026 · Corrected (the home has a date of correction)
- E
Have properly installed hallway dispensers for alcohol-based hand rub.
K 325 · March 25, 2026 · Corrected (the home has a date of correction)
- E
Install an approved automatic sprinkler system.
K 351 · March 25, 2026 · Corrected (the home has a date of correction)
- E
Ensure that waiting areas, nurse’s stations, gift shops, and cooking facilities, open to the corridor are properly protected.
K 361 · March 25, 2026 · Corrected (the home has a date of correction)
- E
Install corridor and hallway doors that block smoke.
K 363 · March 25, 2026 · 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 · March 25, 2026 · Corrected (the home has a date of correction)
- E
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
K 761 · March 25, 2026 · Corrected (the home has a date of correction)
- E
Ensure proper usage of power strips and extension cords.
K 920 · March 25, 2026 · 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 · March 25, 2026 · 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 · February 25, 2025 · Corrected (the home has a date of correction)
- E
Inspect, test, and maintain automatic sprinkler systems.
K 353 · February 25, 2025 · Corrected (the home has a date of correction)
- E
Install smoke barrier doors that can resist smoke for at least 20 minutes.
K 374 · February 25, 2025 · Corrected (the home has a date of correction)
- E
Provide properly sized and located linen or trash receptacles.
K 754 · February 25, 2025 · Corrected (the home has a date of correction)
- C
Have simulated fire drills held at unexpected times.
K 712 · February 25, 2025 · Corrected (the home has a date of correction)
- F
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
K 222 · January 10, 2024 · Corrected (the home has a date of correction)
- F
Meet other general requirements that are deficient.
K 300 · January 10, 2024 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · January 10, 2024 · Corrected (the home has a date of correction)
- F
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
K 741 · January 10, 2024 · Corrected (the home has a date of correction)
- E
Meet other general requirements.
K 100 · January 10, 2024 · Corrected (the home has a date of correction)
- E
Keep aisles, corridors, and exits free of obstruction in case of emergency.
K 211 · January 10, 2024 · 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 · January 10, 2024 · Corrected (the home has a date of correction)
- E
Provide properly protected cooking facilities.
K 324 · January 10, 2024 · Corrected (the home has a date of correction)
- E
Install an approved automatic sprinkler system.
K 351 · January 10, 2024 · Corrected (the home has a date of correction)
- E
Properly select, install, inspect, or maintain portable fire extinguishes.
K 355 · January 10, 2024 · Corrected (the home has a date of correction)
- E
Install corridor and hallway doors that block smoke.
K 363 · January 10, 2024 · Corrected (the home has a date of correction)
- E
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · January 10, 2024 · Corrected (the home has a date of correction)
- E
Have properly installed electrical wiring and gas equipment.
K 511 · January 10, 2024 · Corrected (the home has a date of correction)
- E
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
K 761 · January 10, 2024 · Corrected (the home has a date of correction)
- E
Have restrictions on the use of portable space heaters.
K 781 · January 10, 2024 · Corrected (the home has a date of correction)
- E
Ensure proper usage of power strips and extension cords.
K 920 · January 10, 2024 · Corrected (the home has a date of correction)
- E
Have proper fire barriers, ventilation and signs for the transfilling of oxygen.
K 927 · January 10, 2024 · Corrected (the home has a date of correction)
- C
Provide emergency officials' contact information.
E 31 · January 10, 2024 · Corrected (the home has a date of correction)
- C
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · January 10, 2024 · Corrected (the home has a date of correction)