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 35 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
2G
0H
0I
Potential for more than minimal harm
26D
7E
0F
Potential for minimal harm
0A
0B
0C
March 20, 2026Standard inspection, Complaint inspection · 7 citations
- E
Provide or get specialized rehabilitative services as required for a resident.
Inspectors wroteBased on observation, interview and record review, the facility failed to ensure skilled rehab services were delivered in accordance with resident evaluations and treatment plans for 3 of 4 residents (8,91,119) reviewed for rehab and restorative services. This failure placed residents at risk for delay in recovery and/or discharge and decreased quality of life.
- 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 interview and record review the facility failed to ensure resident grievances were filed and addressed for 1 of 5 residents (Resident 29) reviewed for grievances. This failure to address and resolve resident grievances placed residents at risk for diminished dignity, unresolved missing property and diminished quality of life.
- D
Ensure each resident receives an accurate assessment.
Inspectors wroteBased on observation, interview and record review, the facility failed to accurately complete the Minimum Data Set, (MDS, an assessment tool that was used to develop the resident centered care plan) for 1 of 2 residents (Resident 2) reviewed for communication and 2 of 3 residents (Resident 22 and 86) reviewed for insulin (a hormone that body secretes to regulate the amount of sugar in the blood) use. Failure to accurately complete the MDS placed residents at risk for inappropriate medical care and decreased quality of life.
- D
Provide activities to meet all resident's needs.
Inspectors wroteBased on observation, interview and record review, the facility failed to ensure 1 of 1 resident (Resident 11) reviewed for activities had an accurate assessment of recreational care needs and received an ongoing program of activities to meet the individual resident's physical and mental needs. Based on the reasonable person concept, not having adequate recreation and/or sensory stimulation placed the resident at risk for social isolation, lack of stimulation and diminished quality of life.
- 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 1 of 2 residents (Resident 24) reviewed for limited Range of Motion (ROM) received necessary care and services. The facility failed to ensure residents received appropriate services to prevent further decrease in range of motion and hand contracture (a permanent tightening of the muscles, tendons, skin and nearby tissues that causes the joints to shorten and become very stiff). This failure placed residents at risk for decline in mobility and function, increased dependence on staff, and a decreased quality of life.
- D
Observe each nurse aide's job performance and give regular training.
Inspectors wroteBased on interview and record review the facility failed to ensure one of five staff reviewed, (Staff H) received timely annual performance evaluations. Failure to complete timely evaluations of nursing staff performance, conduct education and in-services based on those evaluations had the potential to result in decreased quality of resident care.
- D
Ensure medication error rates are not 5 percent or greater.
Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a medication error rate of less than 5%. Two medication errors were identified for 2 of 4 residents (Resident 97 and 39) observed during 25 medication opportunities which resulted in an error rate of 8%. Failure to provide medications on an empty stomach as ordered and failure to prime the needle prior to administration of insulin (synthetic hormone that allows sugar to enter cells and regulates the amount of sugar in the blood) placed residents at risk of decreased medication efficacy.
December 20, 2024Standard inspection · 6 citations
- E
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Inspectors wroteBased on record review and interview, the facility failed to provide 4 of 5 residents (Resident 28, 86, 35, 508) with a summary of their baseline care plan. This failure placed residents at risk of not being informed of their initial plan for delivery of care and services and placed them at risk for unmet needs and possible complications.
- E
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, interview, and record review the facility failed to review and revise care plans for 1 of 2 sampled residents (Resident 69) reviewed for activities of daily living (ADLs), 1 of 1 sampled residents (Resident 75) reviewed for discharge planning, 1 of 2 sampled residents (Resident 9) reviewed for communication, 1 of 4 sampled residents (Resident 18) reviewed for dementia care, 1 of 1 sampled residents (Resident 40) reviewed for dental services, and 1 of 1 sampled residents (Resident 83) reviewed for urinary management. These failures placed the residents at risk for lack of consistent interventions, unmet care needs, adverse health effects, and a diminished quality of life.
- 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 accommodate resident preferences for 3 of 5 sampled residents (Resident 508, 35, and 92) regarding important daily routines and health care. The failure of the facility to honor resident choice placed residents at risk for a diminished quality of life.
- 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 interview and record review, the facility failed to promptly report and document resident grievances for 1 of 3 sampled residents (Resident 35) reviewed for grievance resolution. The failure of staff to initiate resident grievances resulted in delays in grievance resolution and an extended period where a resident went without their missing property and placed residents at risk for frustration and diminished quality of life.
- 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 ensure 1 of 1 resident (Resident 82) reviewed for blood sugar (BS) monitoring received BS checks per standards of practice/care. This failure exposed residents to an increased risk of inaccurate insulin administration and the potential for decreased blood sugar. Finding Included . A review of the facility policy, titled Timely Administration of Insulin, dated June 2020, stated that insulin administration will be coordinated with mealtimes and snacks. Resident 82 admitted to the facility on [DATE] with diagnoses to include diabetes type 2 (a chronic disease that occurs when the sugar level in the blood stream was too high.) In an observation and interview on 12/19/2024 at 12:56 PM, Staff Q, Licensed Practical Nurse (LPN) assessed Resident 82's BS after they had eaten their lunch. [...]
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observation, interview, and record review the facility failed to provide respiratory care consistent with professional standards of practice for 1 of 2 sampled residents (Resident 40) reviewed for respiratory care. Failure to follow provider's orders for oxygen (O2) therapy placed the resident at risk for unmet needs, potential negative outcomes and a diminished quality of life.
May 2, 2024Complaint 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 interview, and record review, the facility failed to ensure 2 of 2 sampled residents (Residents 1 and 2), who resided on a secured Special Care Unit (SCU), were free from sexual abuse. Resident 2 experienced pyshcosocial harm in the form of emotional distress, applying the reasonable person approach, when the facility failed to prevent sexual activity between two residents with cognitive deficits who were unable to consent to sexual relations. This failure placed all residents on the unit at risk of unwanted sexual contact, injury and psychological harm.
October 31, 2023Standard inspection · 21 citations
- G
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on observation, interview, and record review, the facility failed to provide necessary treatment and services to prevent the occurrence of avoidable Pressure Ulcer/Pressure Injury (PU/PI) for 1 of 4 sampled residents (Resident 32) who was admitted without a PU/PI and had multiple co-morbidities with an increased risk for PU/PI development. Resident 32 experienced harm when they developed a Stage 3 (defined as full thickness loss of tissue) PU/PI to the resident's coccyx (tailbone region). The facility did not document refusals to reposition, or recognize the need to evaluate/modify the interventions to prevent a PU/PI when Resident 32 was non-compliant with repositioning. Thes failures placed other residents at risk for developing PU/PI's, medical complications, and unmet care needs.
- 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 provide a dignified and homelike dining experience in 2 of 3 (Southeast and South) dining rooms during 3 of 3 dining observations for dignity. These failures placed residents at risk for feelings of frustration, diminished self-worth, embarrassment, and a potential decline in nutritional status.
- 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 interview and record review, the facility failed to obtain, provide, and/or assist with completing Advance Directives (AD's) for 5 of 12 sampled residents (Residents 160, 32, 75, 6 and 100) reviewed for AD's. This failure placed residents at risk for losing their right to have their healthcare preferences and/or decisions honored.
- E
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 ensure 4 of 5 residents (Resident 86, 14, 83, and 73) were free of unnecessary drugs due to: 1) lack of specific target behavior monitoring, 2) not obtaining the monthly orthostatic vital signs, 3) not developing and implementing non-medical behavioral interventions, and 4) not having appropriate indication, documentation, and goals for use of psychotropic medications. These failures placed residents at risk for receiving unnecessary medications and for experiencing medication-related adverse side effects.
- 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 monitor the medication refrigerator temperatures and ensure medications were stored in the medication room refrigerator under proper temperature controls in 2 of 3 (Central/South and Southeast) medication refrigerator observed. This failure placed residents at risk for receiving compromised or ineffective vaccines and medications with unknown potency.
- D
Reasonably accommodate the needs and preferences of each resident.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents had access to their call lights for 2 of 3 sample residents (Resident 75 and 94), reviewed for quality of life. This failure placed residents at risk of unmet care needs and diminished quality of life.
- D
Respond appropriately to all alleged violations.
Inspectors wroteBased on interview and record review, the facility failed to implement their abuse/neglect policy and procedure to thoroughly investigate injuries of unknown source for potential abuse/neglect for 2 of 4 residents (Resident 57 and 75) reviewed. Failure to thoroughly investigate injuries of unknown source placed residents at risk for continued abuse/neglect.
- D
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Inspectors wroteBased on interview and record review, the facility failed to provide a written notice of transfer to the resident and/or the resident's representative describing the reason for transfer for 2 of 2 sampled residents (Residents 48 and 6) reviewed for transfer notifications regarding hospitalization. This failed practice disallowed the residents and/or their representative an opportunity to fully understand the rationale and resident rights associated with the discharges.
- D
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Inspectors wroteBased on interview and record review, the facility failed to provide a bed hold notice in writing at the time of transfer to the hospital or within 24 hours of transfer to the hospital for 1 of 2 residents (Resident 48) reviewed for hospitalizations. This failed practice placed residents at risk for lack of knowledge regarding the right to hold their beds while they were at the hospital.
- D
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Inspectors wroteBased on interview and record review, the facility failed to complete an updated Pre-admission Screening and Resident Review (PASRR - a screening tool used to determine if a person has an intellectual disability or has indicators for serious mental illness) for 1 of 5 residents (Resident 73) reviewed for PASRR accuracy who required a Level II evaluation (Level II evaluation - more in depth mental health evaluation than the screening PASRR) due to a new mental health diagnosis. This failed practice placed the resident at risk of not receiving specialized mental health services, for unidentified needs, and for a decrease in their quality of life.
- 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 interview, and record review, the facility failed to develop and implement comprehensive, person-centered care plans to meet the needs of 2 of 4 residents (Resident 86 and 32) reviewed for care planning. This failure placed residents at risk for weight loss, inadequate tube feeding (a flexible tube placed into the stomach to help get nutrition when a person was unable to eat) management, unmanaged pain, not honoring resident's preferences, not receiving necessary care and services, and a diminished quality of life.
- 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, interview and record review, the facility failed to review and revise care plans for 2 of 5 residents (Resident 53 and 57) reviewed for care planning. These failures placed the residents at risk for unmet care needs, adverse health effects and a diminished quality of life.
- 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 ensure oral hygiene was performed for 1 of 1 resident (Resident 33) reviewed for Activities of Daily Living (ADLs). This failure placed the resident at risk for poor oral hygiene, dental complications, decreased self-esteem, and diminished quality of life.
- 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 thoroughly provide professional standards of care and services for 2 of 5 residents (Resident 28 and 73) reviewed for unnecessary medications and 1 of 1 resident (Resident 86) reviewed for medication management. The facility failed to obtain laboratory samples per physician orders, and to recognize low blood pressure (BP) results, reassess abnormal BP values, and notify the provider of abnormal findings. This failed practice placed residents at risk for medication complications, and a diminished quality of life.
- 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 services were provided to maintain, increase, and/or prevent further decrease in range of motion for 1 of 1 resident (Resident 100) reviewed for limited range of motion. This failure placed the resident at risk for a decline in their functional ability and their quality of life.
- 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 observation, interview, and record review the facility failed to ensure 3 of 3 (Resident 53, 33, and 67) residents reviewed for urinary catheters (flexible tubes inserted into the bladder to drain urine) received the necessary care and services to achieve their optimal level of urinary function. Failure to identify the reason for a resident's treatment with a urinary catheter, to maintain documentation to support why an indwelling catheter was replaced and a trial void order was not completed as ordered, there was a lack of documentation why the physician was not notified per their physician order when there was a low urinary output, and there was a failure to documentation the facility had counseled the resident/representative of the risks and benefits of a urinary catheter. [...]
- 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 1 of 1 resident (Resident 32) reviewed for respiratory care and services were provided care consistent with professional standards of practice. The facility failed to ensure the resident received oxygen as it was prescribed by the physician and failed to ensure oxygen (O2) administration tubing was appropriately maintained, changed regularly, and dated. This failure placed residents at risk for contaminated care equipment, not receiving physician ordered services, unmet care needs and a diminished quality of life.
- 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 and record review, the facility failed to provide an adequate rationale for not following pharmacist recommendations for 3 of 5 residents (Resident 86, 310, and 14) reviewed for unnecessary medications. This failure placed the residents at risk for experiencing the use of unnecessary medications and a potential diminished quality of life.
- D
Ensure that residents are assessed for appropriateness for a feeding assistant program, receive services as per their plan of care, and feeding assistants are trained and supervised.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure cognitively impaired residents were fed by assistants that were properly trained for 2 of 4 sampled staff (Staff W and Staff X) observed providing feeding assistance to residents (Resident 26 and 28). This failure placed residents at risk of choking and aspiration (inhalation of food or fluid into the lungs) and a diminished quality of life.
- 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 store food in accordance with professional standards for food service safety for 1 of 4 nutrition refrigerators/freezers (North Hall) reviewed for food storage. Failure to label foods with dates they were opened or discard dates, and discard expired food, placed residents at risk for food-borne illness.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interviews, and record review, the facility failed to follow infection control standards during medication administration for 1 of 5 residents (Resident 116) observed for medication administration, and 1 of 1 residents (Resident 67) observed during care of a urinary catheter (a tube inserted into the bladder to drain urine.) This failure placed residents at risk for developing infections and for experiencing a decreased quality of life.
Fire safety inspections
19 fire safety citations on file: 3 on March 20, 2026, 3 on December 20, 2024, 13 on October 31, 2023.
Every fire safety citation19 citations
- E
Keep aisles, corridors, and exits free of obstruction in case of emergency.
K 211 · March 20, 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 · March 20, 2026 · Corrected (the home has a date of correction)
- D
Have proper medical gas storage and administration areas.
K 923 · March 20, 2026 · Corrected (the home has a date of correction)
- F
Establish policies and procedures including evacuation.
E 20 · December 20, 2024 · Corrected (the home has a date of correction)
- F
Conduct testing and exercise requirements.
E 39 · December 20, 2024 · Corrected (the home has a date of correction)
- D
Ensure proper usage of power strips and extension cords.
K 920 · December 20, 2024 · Corrected (the home has a date of correction)
- F
Develop Emergency Preparedness policies and procedures.
E 13 · October 31, 2023 · Corrected (the home has a date of correction)
- F
Establish policies and procedures for medical documentation.
E 23 · October 31, 2023 · Corrected (the home has a date of correction)
- F
Establish methods for sharing information.
E 33 · October 31, 2023 · Corrected (the home has a date of correction)
- F
Provide a means of sharing information on occupancy/needs.
E 34 · October 31, 2023 · Corrected (the home has a date of correction)
- F
Establish staff and initial training requirements.
E 37 · October 31, 2023 · Corrected (the home has a date of correction)
- F
Conduct testing and exercise requirements.
E 39 · October 31, 2023 · Corrected (the home has a date of correction)
- F
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · October 31, 2023 · Corrected (the home has a date of correction)
- E
Provide properly protected cooking facilities.
K 324 · October 31, 2023 · Corrected (the home has a date of correction)
- E
Inspect, test, and maintain automatic sprinkler systems.
K 353 · October 31, 2023 · Corrected (the home has a date of correction)
- D
Install a fire alarm system that can be heard throughout the facility.
K 341 · October 31, 2023 · Corrected (the home has a date of correction)
- D
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · October 31, 2023 · Corrected (the home has a date of correction)
- D
Properly select, install, inspect, or maintain portable fire extinguishes.
K 355 · October 31, 2023 · Corrected (the home has a date of correction)
- D
Ensure proper usage of power strips and extension cords.
K 920 · October 31, 2023 · Corrected (the home has a date of correction)