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 45 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
9G
0H
0I
Potential for more than minimal harm
30D
4E
2F
Potential for minimal harm
0A
0B
0C
July 23, 2026Complaint inspection · 1 citation
- G
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that a resident was free from physical abuse by staff for one of three residents (R2) reviewed for abuse when a Certified Nursing Assistant (CNA) thrust an unused folded incontinence brief into R2's face and mouth while he was lying in bed, resulting in a distressing moment for the resident, who was made to feel humiliated and afraid for his safety.
July 18, 2026Complaint inspection · 1 citation
- D
Provide doctor's orders for the resident's immediate care at the time the resident was admitted.
Inspectors wroteBased on interviews and record review, the facility failed to not follow their Facilities Physician Orders Policy to ensure all resident/patient medications, treatment and plan of care must be in accordance to the licensed physician's order and failed to ensure to follow physician orders as it is written in the POS (physician order summary). This failure affected 1 resident (R8) out of 3 residents (R4 and R9) reviewed for Quality of Care/Treatment. Based on interviews and record review, the facility failed to not follow their Facilities Physician Orders Policy to ensure all resident/patient medications, treatment and plan of care must be in accordance to the licensed physician's order and failed to ensure to follow physician orders as it is written in the POS (physician order summary). [...]
February 26, 2026Complaint inspection · 1 citation
- G
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on interview and record review, the facility failed to ensure monitoring and supervision of a bedbound, high fall-risk resident on strict COVID isolation, and failed to consistently implement required fall prevention interventions. This failure affected one (R1) of four residents reviewed for safety and supervision and resulted in R1 not being visually observed or assessed for a period of over two hours and culminated in R1 being found unresponsive on the floor and pronounced deceased in the facility.
June 18, 2025Complaint inspection · 5 citations
- G
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteBased on observation, interviews and record review, the facility failed to ensure that a cognitively and visually impaired resident (R1) of 3 residents reviewed in the sample of 3, was treated with respect and dignity during the provision of care. This failure resulted in physical harm when two Certified Nursing Assistants (CNAs) were observed on video being physically rough with R1, including forcefully pushing the resident's head and torso down on the bed while resident was actively resisting and crying out, threatening the resident to stop screaming, and slapping the resident's face during care.
- G
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Inspectors wroteBased on observation, interviews and record review, the facility failed to train/monitor staff on behavior de-escalation, failed to protect a cognitively and visually impaired resident from abuse for 1 (R1) of 3 residents reviewed for abuse in the sample of 3. This failure resulted in physical and emotional harm inflicted on a vulnerable resident when two Certified Nursing Assistants (CNAs) were observed on video footage being physically rough with R1, including forceably pinning the resident's head and torso down on the bed while resident was actively resisting and crying out, threatening the resident to stop screaming, and slapping the resident's face during care.
- 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 the care plan interventions related to behavioral management for one (R1) of 3 residents reviewed for care plans in the sample of 3 cognitively impaired residents. Two Certified Nursing Assistants (CNAs) did not follow the care-planned strategies for managing care-resistant behavior, resulting in a care interaction that placed the resident at risk for emotional distress and escalation.
- D
Ensure services provided by the nursing facility meet professional standards of quality.
Inspectors wroteBased on observation, interviews, and record review, the facility failed to ensure that services provided to one (R1) of 3 residents in the sample of 3 with cognitively impairment met professional standards of quality; specifically two Certified Nursing Aides (CNAs) did not follow the established plan of care for managing care-resistant behavior, engaged in physically rough handling of the resident during care, and failed to utilize person-centered behavior interventions resulting in care interaction that did not meet accepted clinical practice standards.
- D
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Inspectors wroteBased on observation, interviews and record reviews, the facility failed to ensure that two Certified Nursing Assistants (CNA's) demonstrated the necessary competency in dementia care and behavior management techniques for one (R1) of 3 residents reviewed in the sample of 3, who exhibited care-resistant behaviors, did not apply de-escalation strategies as directed in the resident's care plan, placing the resident at risk for increased agitation and emotional distress.
April 17, 2025Standard inspection · 6 citations
- F
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 interviews and record review, the facility failed to provide a sufficient number of nursing staff to ensure call lights were answered in a timely manner to assist with activities of daily living care, toileting, and overall care. This failure has the potential to affect all 154 residents currently residing at the facility.
- E
Inform each resident of his or her visitation rights and ensure that all visitors enjoy equal visitation privileges.
Inspectors wroteBased on interview and record review, the facility failed to follow their visitation policy allowing residents to receive 24-hour visitation privileges. This failure has the potential to affect all 154 residents currently residing in the facility.
- 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 that staff provide scheduled shower and grooming for residents who are dependent on staff for Activities of Daily Living (ADL). This failure affected four (R41, R70, R108 and R129) of eight residents reviewed for ADL care.
- D
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident was free from threats and mental abuse. This failure applied to one of one (R113) residents reviewed for abuse and resulted in psychosocial and emotional harm to R113 as evidenced by emotional distress and physical anxiety.
- D
Respond appropriately to all alleged violations.
Inspectors wroteBased on interview and record review, the facility failed to properly investigate an allegation of abuse. This failure applied to one of one (R113) resident reviewed for abuse.
- 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 ensure that staff provide ordered service to a resident with decreased range of motion by failing to apply ordered splints to resident's hands. This failure affected one (R129) of one resident reviewed for rehabilitation services.
March 12, 2025Complaint inspection · 3 citations
- 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 interview and record review the facility failed to notify resident's family member of discontinuation of medication after holding the hypertensive medication. The facility also failed to notify the physician of increase in resident's blood pressure. This deficiency affects one (R1) of three residents reviewed for Notification for change in condition.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on observation, interview, and record review the facility failed to provide necessary treatment and care in a timely manner to resident with language barrier who has been refusing to get up for Restorative walking program, scheduled shower, and complaint of severe pain (during therapy evaluation) after a fall incident to identify fracture of sacrum. This deficiency affects one (R1) of three residents reviewed for Quality of care.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview, and record review the facility failed to ensure appropriate infection control practices after providing shower to a resident in the shower room. This deficiency affects one of three common shower rooms in resident's unit reviewed for resident clean environment.
November 6, 2024Complaint inspection · 1 citation
- 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 appropriate staffing for Certified Nursing Assistants in two units within the facility. This failure applied to three of three (R1, R2, R3) residents reviewed for staffing and has the potential to affect 29 residents currently residing in the two units (Suites North and Suites South).
October 30, 2024Complaint inspection · 1 citation
- G
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wrote- Based on interviews and records reviewed, the facility failed to ensure fall prevention interventions were utilized to include nonskid footwear and other appropriate interventions for 1 resident (R3) and provide assistance to one resident (R2) during transfer from wheelchair to bed. R3 has a cognitive communication disorder, poor safety awareness, and impaired cognition. R2 has a history of alcohol abuse, gait disorder, and neuropathy. These failures affected two of three (R2, R3) residents reviewed for falls. These failures resulted in harm, with R2 sustaining a laceration requiring two sutures to the left eyebrow region, and R3 was admitted to the hospital for Subdural Hematoma and received 7 staples to the left occipital region.
August 18, 2024Complaint 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, interviews, and records reviewed the facility failed to provide effective resident centered interventions for residents identified to be at high risk for falls. This affected two of three residents (R1, R3) reviewed for fall prevention.
April 19, 2024Standard inspection · 7 citations
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on observation, interview and record review the facility failed to implement intervention to prevent skin impairment to residents who is at high risk for developing pressure ulcer. This deficiency affects two (R64 and R107) of three residents in the sample of 30 reviewed for Pressure Ulcer Prevention Program.
- 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 in observation, interview and record review the facility failed to follow physician order and implement care plan intervention to apply hand splint and palm protector to a totally dependent resident who has contractures on affected hands. The facility also failed to accurately complete resident restorative assessment reflecting resident's condition. This deficiency affects two (R10 and R107) of three residents in the sample of 30 reviewed for Restorative program.
- 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 keeping of resident's smoking materials when not being used. This deficiency affects one (R84) of two residents in the sample of 30 reviewed for Safe Smoking policy.
- 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 observation, interview and record review the facility failed to position resident in fowler's position at all times while infusing enteral feeding and failed to hold enteral feeding administration during incontinence care. This deficiency affects one (R107) of three residents in the sample of 30 reviewed for Enteral Tube Feeding Care.
- 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 interviews and records reviewed the facility failed to document the reason why the dose reduction is contraindicated for one resident (R126) of an antidepressant medication. This failure affected one resident of two reviewed for psychotropic medications on the sample of 30.
- D
Have a policy regarding use and storage of foods brought to residents by family and other visitors.
Inspectors wroteBased on observation, interview and record review the facility failed to ensure daily refrigerator temperature checks were completed. This deficiency affects two (R10 and R64) of three residents in the sample of 30 reviewed for Resident safe food storage.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview and record review the facility failed to perform hand hygiene during incontinence care. This deficiency affects one (R107) of three residents in the sample of 30 reviewed for Infection control protocol.
March 7, 2024Complaint inspection · 1 citation
- G
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on observation, interviews and record reviews, the facility failed to follow a resident care plan related to use of helmet for one (R3) of five residents reviewed for falls and injuries. This failure resulted in R3 sustaining a right subdural hematoma after a fall incident.
October 31, 2023Complaint inspection · 2 citations
- G
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on interview and record review the facility failed to notify the physician of an opened surgical wound for treatment orders. This affected one of three residents (R1) reviewed for quality of care of a surgical site. This failure resulted in R1's wound becoming infected with live insect larva and being sent to the local hospital for evaluation and treatment.
- 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 interview and record review the facility failed to follow their change in condition policy and notify the physician for a change in condition of a surgical wound that opened. This affected one of three (R1) residents reviewed for physician notification of an acute change in condition.
September 23, 2023Complaint inspection · 1 citation
- D
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure 2 of 3 residents (R1 and R2) were free of resident to resident physical and verbal abuse in the sample of 3 reviewed for abuse.
March 31, 2023Standard inspection · 14 citations
- G
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Inspectors wroteBased on observation, interview and record review the facility failed to follow its policy in using restraints and failed to prevent a physical restraint from being used for staff convenience for one resident (R140) in the sample of 31 residents reviewed for restraints. These failures resulted in psychosocial harm in that, a reasonable person would react to such physical restraint with feelings of agitation, anxiety, frustration, fearfulness, humiliation, and punishment.
- G
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 provide adequate supervision to residents who are at high risk for fall and has history of falls. This failure caused one resident ( R117) to be hospitalized for surgery due to a fracture. The facility also failed to implement fall preventive intervention care plan. This deficiency affects 2 (R48, R117) residents in a sample of 31 reviewed for Fall prevent management.
- F
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 resident review, the facility failed to label and date food items in the refrigerators, maintain freezer temperature in the kitchen, maintain refrigerator temperature in resident's refrigerator on the units and also failed to provide a clean scoop holder for the ice bucket located on the south unit. This failure has the potential to affect all 145 residents receiving food from the facilities' kitchen and all 27 residents from the north and south units receiving ice.
- 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 ensure that the controlled medication sheet was reconciled for four residents (R51, R54, R97, and R133) out of 36 residents reviewed for controlled medication reconciliation in the sample of 36.
- D
Reasonably accommodate the needs and preferences of each resident.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that the call light was within reach for one resident (R110) out of eight residents reviewed for accommodation of needs in the sample of 31. Findings Include: On 03/28/2023 at 11:20 am, surveyor observed R110 lying in bed with her call light on the floor. Surveyor asked R110 if she is able to use her call light and she said yes if she can reach the call light. On 03/28/2023 at 11:25 am, V2 (Assistant Administrator) confirmed that R110's call light was on the floor and not within easy reach of R110. V2 picked up the call light and gave it to R110. V2 said that the call light should be within easy reach to R110. On 03/27/2023 at 2:00 pm, V3 (DON) said that her expectation is for staff to place residents call light within easy reach of the residents. [...]
- 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 and record review the facility failed to keep residents free from being physically abused by another resident. This failure applied to two of two (R18 and R20) residents reviewed for abuse.
- D
Ensure services provided by the nursing facility meet professional standards of quality.
Inspectors wroteBased on observation, interview and record review the facility failed to follow its pacemaker policy to ensure necessary follow up is done to ensure that resident pacemaker is in good working condition. The facility failed to implement care plan interventions. This deficiency affects one (R27) of one resident in the sample of 31 reviewed for Pacemaker management.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on observation, interview and record review the facility failed to change the Gastrostomy tube dressing daily as ordered. This deficiency affects one (R126) of four residents in the sample of 31 reviewed for Enteral tube feeding management.
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on observation, interview and record review the facility failed to follow its policy in skin care treatment regimen by failure to obtain appropriate topical treatment for identified skin impairment and updating care plan. The facility also failed to follow manufacturing recommendation for usage of low air loss mattress. This deficiency affects two (R48 and R140) of three residents in the sample of 31 reviewed for Pressure Ulcer/Wound care management.
- 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 hand splint to prevent further contractures for 1 resident (R115) reviewed for splint application in a sample of 31 residents.
- 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 interview and record review, the facility failed to ensure that expired medications for (R6, and R62) were removed from one cart out of four carts reviewed for expired medications. Also, the facility failed to date when an inhaler was opened for (R6).
- 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 provide, collaborate and coordinate hospice care services. This deficiency affects one (R48) of three residents in the sample of 31 reviewed for hospice services.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview and record review, the facility failed to perform hand hygiene during wound care for one of two residents (R69) observed for wound care in a sample of 31.
- D
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Inspectors wroteBased on interview and record review the facility failed to offer required pneumococcal immunizations to one resident (R60) of five residents reviewed for immunizations in the sample of 31.
Fire safety inspections
26 fire safety citations on file: 7 on April 17, 2025, 8 on April 19, 2024, 11 on March 31, 2023.
Every fire safety citation26 citations
- F
Install a two-hour-resistant firewall separation.
K 133 · April 17, 2025 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · April 17, 2025 · Waiver
- F
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · April 17, 2025 · Corrected (the home has a date of correction)
- F
Ensure proper usage of power strips and extension cords.
K 920 · April 17, 2025 · Corrected (the home has a date of correction)
- E
Keep aisles, corridors, and exits free of obstruction in case of emergency.
K 211 · April 17, 2025 · Corrected (the home has a date of correction)
- E
Have properly located and lighted "Exit" signs.
K 293 · April 17, 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 · April 17, 2025 · Corrected (the home has a date of correction)
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · April 19, 2024 · Corrected (the home has a date of correction)
- E
Keep aisles, corridors, and exits free of obstruction in case of emergency.
K 211 · April 19, 2024 · 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 · April 19, 2024 · Corrected (the home has a date of correction)
- E
Install an approved automatic sprinkler system.
K 351 · April 19, 2024 · Corrected (the home has a date of correction)
- E
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
K 362 · April 19, 2024 · Corrected (the home has a date of correction)
- E
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · April 19, 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 · April 19, 2024 · Corrected (the home has a date of correction)
- E
Ensure proper usage of power strips and extension cords.
K 920 · April 19, 2024 · Corrected (the home has a date of correction)
- F
Install a two-hour-resistant firewall separation.
K 133 · March 31, 2023 · Corrected (the home has a date of correction)
- F
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 31, 2023 · Corrected (the home has a date of correction)
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · March 31, 2023 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · March 31, 2023 · Corrected (the home has a date of correction)
- F
Ensure gas and vacuum piping is labeled.
K 909 · March 31, 2023 · Corrected (the home has a date of correction)
- E
Keep aisles, corridors, and exits free of obstruction in case of emergency.
K 211 · March 31, 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 · March 31, 2023 · Corrected (the home has a date of correction)
- E
Have properly located and lighted "Exit" signs.
K 293 · March 31, 2023 · Corrected (the home has a date of correction)
- E
Properly select, install, inspect, or maintain portable fire extinguishes.
K 355 · March 31, 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 · March 31, 2023 · Corrected (the home has a date of correction)
- E
Have restrictions on the use of portable space heaters.
K 781 · March 31, 2023 · Corrected (the home has a date of correction)