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 28 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
24D
3E
1F
Potential for minimal harm
0A
0B
0C
January 30, 2026Standard inspection · 10 citations
- F
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 maintain a safe and sanitary environment in resident rooms and resident areas for three of four halls. (100 Hall, 200 Hall and 400 Hall)
- 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 were secure on 2 of 4 carts observed and in 1 of 16 resident rooms) (Wound Cart, South Treatment Cart and Resident 14's room)
- D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteBased on observation and interview, the facility failed to ensure a resident's right to communicate with staff providing services was protected for 1 of 3 residents reviewed for Resident's rights. (Resident 36)
- 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 observation, record review, and interview, the facility failed to notify the physician of a significant weight loss for 1 of 1 resident reviewed for nutrition.
- 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 and record review, the facility failed to ensure a person-centered comprehensive care plan was updated for a resident with a significant weight loss for 1 of 1 residents reviewed for nutrition. (Resident 52)
- 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 provide showers or bed baths for a dependent resident for 1 of 4 residents who were reviewed for Activities of Daily Living needs. (Resident 3)
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on observation, record review and interview, the facility failed to implement physician recommendations in a timely manner after a fall with injury for 1 of 1 resident reviewed for falls. (Resident 5)
- D
Provide enough food/fluids to maintain a resident's health.
Inspectors wroteBased on observation, record review, and interview, the facility failed to complete a timely nutritional assessment and initiate interventions to prevent weight loss for 1 of 1 residents reviewed for nutrition. (Resident 52) This resulted in continued significant weight loss of 15.38% over the previous 5 months.
- D
Provide timely, quality laboratory services/tests to meet the needs of residents.
Inspectors wroteBased on record review and interview, the facility failed to obtain ordered laboratory orders for 1 of 5 residents reviewed for unnecessary medications. (Resident 1)
- D
Provide or obtain dental services for each resident.
Inspectors wroteBased on interview and record review, the facility failed to complete dental recommendations from the in-house dentist for 1 of 1 resident reviewed for dental care. (Resident 77)
December 20, 2024Complaint inspection · 1 citation
- E
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 and record review, the facility failed to ensure room temperatures were at the appropriate temperatures on the Behavior Unit (BHU). This deficient practice had the potential to affect 27 of 27 residents residing on the BHU.
October 25, 2024Standard inspection, Complaint inspection · 10 citations
- 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 observation, record review and interview, the facility failed to ensure care plans related to respiratory status were revised for 1 of 25 residents reviewed. (Resident 7)
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on observation, record review and interview, the facility failed to provide showering, shaving and nail care services related to ADL's (activities of daily living) for 2 of 8 residents reviewed for ADL's. (Resident D and 4)
- 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, record review and interview, the facility failed to provide splinting to prevent further contractures of a resident's upper extremity for 1 of 3 residents reviewed for mobility. (Resident 18)
- 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 interview and record review, the facility failed to check gastric residual volumes (GRV) and contact the resident's physician as ordered for 1 of 1 resident reviewed for tube feedings. (Resident 3)
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observation, interview and record review, the facility failed to ensure proper labeling and storage of respiratory equipment and provide necessary respiratory services according to physician orders for 2 of 2 residents reviewed for respiratory care. (Residents 7 and 238)
- 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 and interview, the facility failed to transcribe and administer ordered comfort medications for 1 of 1 resident reviewed for hospice services. (Resident B) and failed to ensure controlled narcotics were reconciled, counted and documented every shift for 2 of 3 narcotic count log books reviewed. ([NAME] Terrace & Behavioral Unit)
- D
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Inspectors wroteBased on observation, record review and observation, the facility failed to ensure the use of an appetite stimulant medication was necessary for 1 of 5 residents reviewed for unnecessary medications. (Resident C)
- 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 and interview, the facility failed to limit an as needed (PRN) antianxiety medication to 14 days for 1 of 5 residents reviewed for unnecessary medications. (Resident B)
- D
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on observation and interview, the facility failed to provide sanitary serving of food plates for 1 of 3 dining rooms observed during the lunch meal service. This had the potential to affect 14 residents on the dementia unit.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview and record review, the facility failed to ensure safe infection control practices were followed regarding obtaining a blood sugar sample and administering insulin for 1 of 2 residents observed administering insulin. (Residents 43)
September 29, 2023Standard inspection, Complaint inspection · 7 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 observation, interview and record review, the facility failed to ensure expired liquids and spices were not in use, failed to ensure the pantry and activity refrigerators were clean and without undated, unnamed foods, in 1 of 1 kitchens and 2 of 2 pantries observed. (Main kitchen, nourishment and activity cafe' pantry)
- 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 record review and interview, the facility failed to notify the physician of significant weight losses, abnormal blood glucose levels and failed to notify the family of a hospitalization and change of condition in 3 of 3 residents reviewed for physician notification. (Resident 21, C & D)
- D
Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.
Inspectors wroteBased on record review and interview, the facility failed to ensure accurate clinical information was provided to the hospital for a hospital transfer, failed to obtain an order to transfer a resident to the hospital causing an unnecessary emergency room visit, and failed to obtain a physicians order to discharge to the hospital for 3 of 3 residents reviewed for hospitalization. (Residents 21)
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on observation, record review, and interview the facility failed to provide personal hygiene to a resident unable to complete per self for 1 of 5 residents reviewed for activities of daily living. (Resident 21).
- 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 record review and interview, the facility failed to provide education to the nursing staff on care of nephrostomy tubes for 1 of 26 residents reviewed. (Resident C)
- D
Provide enough food/fluids to maintain a resident's health.
Inspectors wroteBased on observation, record review and interview, the facility failed to provide water at the bed side for 1 of 2 residents reviewed for hydration. (Resident 20)
- 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 and record review, the facility failed to ensure an insulin cart and a treatment cart were kept locked when unattended during 2 of 2 random observations. (100 and 200 Halls)
Fire safety inspections
46 fire safety citations on file: 22 on January 30, 2026, 10 on October 25, 2024, 14 on September 29, 2023.
Every fire safety citation46 citations
- F
Create arrangements with other facilities to receive patients.
E 25 · January 30, 2026 · Corrected (the home has a date of correction)
- F
Conduct testing and exercise requirements.
E 39 · January 30, 2026 · Corrected (the home has a date of correction)
- F
Install a fire alarm system that can be heard throughout the facility.
K 341 · January 30, 2026 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · January 30, 2026 · Corrected (the home has a date of correction)
- F
Meet other general requirements that are deficient.
K 500 · January 30, 2026 · Corrected (the home has a date of correction)
- F
Have simulated fire drills held at unexpected times.
K 712 · January 30, 2026 · 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 30, 2026 · Corrected (the home has a date of correction)
- F
Ensure that testing and maintenance of electrical equipment is performed.
K 921 · January 30, 2026 · Corrected (the home has a date of correction)
- E
Keep aisles, corridors, and exits free of obstruction in case of emergency.
K 211 · January 30, 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 · January 30, 2026 · Corrected (the home has a date of correction)
- E
Conform to length requirements for dead end corridors.
K 251 · January 30, 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 · January 30, 2026 · Corrected (the home has a date of correction)
- E
Provide properly protected cooking facilities.
K 324 · January 30, 2026 · Corrected (the home has a date of correction)
- E
Properly select, install, inspect, or maintain portable fire extinguishes.
K 355 · January 30, 2026 · Corrected (the home has a date of correction)
- E
Install smoke barrier doors that can resist smoke for at least 20 minutes.
K 374 · January 30, 2026 · Corrected (the home has a date of correction)
- E
Have properly installed electrical wiring and gas equipment.
K 511 · January 30, 2026 · Corrected (the home has a date of correction)
- E
Have restrictions on the use of highly flammable decorations.
K 753 · January 30, 2026 · Corrected (the home has a date of correction)
- E
Provide properly sized and located linen or trash receptacles.
K 754 · January 30, 2026 · Corrected (the home has a date of correction)
- E
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
K 761 · January 30, 2026 · Corrected (the home has a date of correction)
- E
Ensure proper usage of power strips and extension cords.
K 920 · January 30, 2026 · Corrected (the home has a date of correction)
- D
Install corridor and hallway doors that block smoke.
K 363 · January 30, 2026 · Corrected (the home has a date of correction)
- C
Establish staff and initial training requirements.
E 37 · January 30, 2026 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · October 25, 2024 · Corrected (the home has a date of correction)
- E
Meet other general requirements.
K 100 · October 25, 2024 · Corrected (the home has a date of correction)
- E
Provide properly protected cooking facilities.
K 324 · October 25, 2024 · Corrected (the home has a date of correction)
- E
Install an approved automatic sprinkler system.
K 351 · October 25, 2024 · Corrected (the home has a date of correction)
- E
Install corridor and hallway doors that block smoke.
K 363 · October 25, 2024 · Corrected (the home has a date of correction)
- E
Install smoke barrier doors that can resist smoke for at least 20 minutes.
K 374 · October 25, 2024 · Corrected (the home has a date of correction)
- E
Have properly installed electrical wiring and gas equipment.
K 511 · October 25, 2024 · Corrected (the home has a date of correction)
- E
Have restrictions on the use of portable space heaters.
K 781 · October 25, 2024 · Corrected (the home has a date of correction)
- E
Ensure proper usage of power strips and extension cords.
K 920 · October 25, 2024 · Corrected (the home has a date of correction)
- D
Meet other general requirements.
K 200 · October 25, 2024 · Corrected (the home has a date of correction)
- F
Conduct testing and exercise requirements.
E 39 · September 29, 2023 · Corrected (the home has a date of correction)
- F
Install emergency lighting that can last at least 1 1/2 hours.
K 291 · September 29, 2023 · Corrected (the home has a date of correction)
- F
Have simulated fire drills held at unexpected times.
K 712 · September 29, 2023 · Corrected (the home has a date of correction)
- F
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
K 761 · September 29, 2023 · Corrected (the home has a date of correction)
- F
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
K 914 · September 29, 2023 · Corrected (the home has a date of correction)
- E
Keep aisles, corridors, and exits free of obstruction in case of emergency.
K 211 · September 29, 2023 · 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 · September 29, 2023 · Corrected (the home has a date of correction)
- E
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
K 223 · September 29, 2023 · Corrected (the home has a date of correction)
- E
Have properly located and lighted "Exit" signs.
K 293 · September 29, 2023 · Corrected (the home has a date of correction)
- E
Properly select, install, inspect, or maintain portable fire extinguishes.
K 355 · September 29, 2023 · Corrected (the home has a date of correction)
- E
Install smoke barrier doors that can resist smoke for at least 20 minutes.
K 374 · September 29, 2023 · Corrected (the home has a date of correction)
- E
Have proper medical gas storage and administration areas.
K 923 · September 29, 2023 · Corrected (the home has a date of correction)
- C
Install a fire alarm system that can be heard throughout the facility.
K 341 · September 29, 2023 · Corrected (the home has a date of correction)
- C
Inspect, test, and maintain automatic sprinkler systems.
K 353 · September 29, 2023 · Corrected (the home has a date of correction)