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 18 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
1G
0H
0I
Potential for more than minimal harm
11D
6E
0F
Potential for minimal harm
0A
0B
0C
October 21, 2025Complaint inspection · 3 citations
- G
Provide care or services that was trauma informed and/or culturally competent.
Inspectors wroteBased on observation, record review, and interviews, the facility did not ensure the care plan was updated and individualized interventions were in place after a reportable adverse event, that resulted in re-traumatization, for one resident (#1) out of one resident reviewed.
- E
Respond appropriately to all alleged violations.
Inspectors wroteBased on interviews and record review, the facility did not ensure two allegations of abuse were investigated thoroughly for two residents (#1 and #2) out of four residents with reportable incidents reviewed.
- D
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Inspectors wroteBased on interviews and record review, the facility did not ensure the grievance process was followed by failing to document a grievance for one resident (#4) out of three residents reviewed.
August 28, 2025Complaint inspection · 3 citations
- E
Ensure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge.
Inspectors wroteBased on record review and interview, the facility failed to ensure a safe and orderly discharge for one residents (#1) and failed to follow up post discharge for two residents (#1 and #10) out of three residents sampled.
- E
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Inspectors wroteBased on interview and record review, the facility failed to maintain accurate records of controlled substances and ensure narcotics were reconciled as required for three residents (#2, #3, and #4) out of three sampled residents.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure treatment and care were provided after an upper extremity fracture in accordance with professional standards of practice for one resident (#2) of three sampled residents.
January 25, 2024Standard inspection · 2 citations
- D
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Inspectors wroteBased on record review, staff interview, and policy review, the facility failed to ensure the Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNF-ABN) was issued to 1 of 2 sampled residents reviewed for beneficiary notices. (Resident #136)
- 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, record review, and policy review, the facility failed to obtain and/or act upon pharmacy recommendations in July and December 2023 for 4 of 5 sampled residents. (Residents #26, #46, #60, #70)
December 22, 2021Standard inspection · 9 citations
- E
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, staff and resident interview, and medical record review, the facility failed to ensure one resident (#15) of thirty-two sampled residents received services to maintain or promote further range of motion for a contracture related to not applying a hand splint for three (12/20/2021, 12/21/2021, and 12/22/2021) of three days.
- E
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteF812 Based on observations, record reviews, and interviews, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety related to male staff members not wearing hair restraints to cover beards, expired and undated food in the walk-in cooler, and black build up and condensation leaking from vents above the serving line and food prep table in one of one kitchen, and undated food and spillage in the nourishment refrigerator on one wing (East), and an uncovered ice scoop stored in one nourishment room on one wing (West) out of a total of two nourishment rooms.
- 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 reviews, and interviews, the facility failed to ensure that its Quality Assurance plan was effective related to 1. Failure to prepare, distribute, and serve food in accordance with professional standards for food service safety related to a staff member not wearing hair restraints, condensation leaking from vents above the serving line and food prep table in one of one kitchen, and an uncovered ice scoop stored in one of two nourishment rooms (West Wing); and 2. Failure to provide one (Resident #4) of four sampled residents with timely narcotic pain medication related to not submitting a prescribed narcotic prescription to the pharmacy timely.
- D
Reasonably accommodate the needs and preferences of each resident.
Inspectors wroteBased on observation, resident interview, staff interview and record review the facility failed to accommodate the need to maintain eyeglasses in good repair for one resident (#11) out of 32 sampled residents.
- D
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Inspectors wroteBased on observations, interviews, and record review, the facility failed to assist one resident (#43) of thirty-two sampled residents with Activities of Daily Living (ADLs) related to not assisting Resident #43 up and out from bed daily for three days (12/20/2021, 12/21/2021 and 12/22/2021) of three days observed.
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on observation, resident interview, staff interview and record review the facility failed to ensure necessary services to maintain good nutrition related to meal assistance for one resident (#324) out of 32 sampled residents.
- D
Provide activities to meet all resident's needs.
Inspectors wroteBased on observations, staff and resident family interviews, and medical record review, the facility failed to ensure implementation of care planned preferences of activities for one resident (#43) of thirty-two sampled residents related to failing to offer or assist Resident #43 to group music activities for three days (12/20/2021, 12/21/2021, and 12/22/2021) of three days observed.
- D
Provide safe, appropriate pain management for a resident who requires such services.
Inspectors wroteBased on resident interview, staff interview and record review the facility failed to provide scheduled pain medication refills for a Baclofen pump for one resident (#39) out of 32 sampled residents.
- 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 and record review the facility failed to review one resident (#9) out of 5 residents reviewed for unnecessary medications. Resident #9's anxiolytic medication was ordered as needed with no stop date and administered for longer than 14 days.
March 13, 2020Standard inspection · 1 citation
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on observations, staff/resident interviews and medical record review, the facility failed to ensure one (#182) of twenty-five sampled residents was free from hot liquid accident/injury hazard during one (3/10/2020) of four days observed.
Fire safety inspections
10 fire safety citations on file: 3 on January 25, 2024, 4 on December 22, 2021, 3 on March 13, 2020.
Every fire safety citation10 citations
- 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 25, 2024 · Corrected (the home has a date of correction)
- D
Have exits that are accessible at all times.
K 271 · January 25, 2024 · Corrected (the home has a date of correction)
- D
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
K 741 · January 25, 2024 · Corrected (the home has a date of correction)
- F
Establish roles under a Waiver declared by secretary.
E 26 · December 22, 2021 · Corrected (the home has a date of correction)
- D
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 · December 22, 2021 · Corrected (the home has a date of correction)
- D
Have exits that are accessible at all times.
K 271 · December 22, 2021 · Corrected (the home has a date of correction)
- D
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
K 741 · December 22, 2021 · Corrected (the home has a date of correction)
- D
Inspect, test, and maintain automatic sprinkler systems.
K 353 · March 13, 2020 · Corrected (the home has a date of correction)
- D
Properly select, install, inspect, or maintain portable fire extinguishes.
K 355 · March 13, 2020 · Corrected (the home has a date of correction)
- D
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
K 741 · March 13, 2020 · Corrected (the home has a date of correction)