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 39 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
1G
0H
0I
Potential for more than minimal harm
29D
7E
2F
Potential for minimal harm
0A
0B
0C
May 1, 2026Complaint inspection · 2 citations
- G
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Inspectors wroteBased on observation, interview and record review, the facility failed to ensure hot coffee was served at a safe temperature for 1 of 3 residents reviewed for accidents, resulting in a resident sustaining skin burns when coffee was spilled on her lap, (Resident B). This deficient practice had the potential to affect 112 of 112 residents who could choose to receive daily hot coffee from the facility kitchen.
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on record review and interview, the facility failed to ensure an unusual occurrence was reported to the State Agency, when 1 of 3 residents reviewed for accidents was burned by hot coffee when the resident spilled the coffee in her lap, (Resident B).
January 16, 2026Complaint inspection · 2 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 record review and interview, the facility failed to notify a personal representative at the request of the resident of new orders and a change of condition for 1 of 3 residents reviewed for notification of changes. (Resident B)
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on record review and interview, the facility failed to ensure physician's orders regarding blood pressure medications were followed for 1 of 3 residents reviewed for quality of care. (Resident B)
October 2, 2025Complaint 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 interview and record review, the facility failed to ensure a resident was free from verbal abuse, for 1 of 3 residents reviewed for abuse and neglect. (Resident B).
August 12, 2025Standard 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 and interview, the facility failed to dispose of expired foods in a timely manner within the main kitchen's walk-in cooler. This deficient practice had the potential to affect 112 of 114 residents who consumed food from the kitchen.
- D
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, record review and interview, the facility failed to ensure a clean, sanitary and comfortable environment was maintained on 2 of 4 units. (400 hall and 500 hall).
- D
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
Inspectors wroteBased on record review and interview, the facility failed ensure 2 of 6 residents reviewed for medications were free from unnecessary medications related to having an appropriate diagnosis for the use of an antipsychotic medication and a PRN (as needed) antianxiety medication used for greater than 14 days without adequate documentation. (Resident 125 and 72).1. The closed record for Resident C was completed on 8/10/2025 at 2:45 P.M. Diagnoses included but were not limited to: fracture to the left femur, diabetes, end stage renal disease, depression and anxiety. Resident C's medication orders included Olanzapine (an antipsychotic medication) Oral Tablet 5 MG, 1 tablet by mouth at bedtime for Depression. During an interview, on 8/11/2025 at 12:10 P.M., the Director of Nursing indicated depression was not an appropriate diagnoses for the medication. [...]
- 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 record review and interview, the facility failed to ensure a care plan related to pressure ulcers was initiated timely for 1 of 3 residents reviewed for pressure ulcers. (Resident 7) In addition, the facility failed to ensure a comprehensive plan of care initiated for post traumatic stress disorder had personalized interventions for 1 of 1 residents reviewed .for post traumatic stress disorder (Resident 46) 1. A record review for Resident 7 was completed, on 8/6/2025 at 11:11 A.M. Diagnoses included, but not limited to, cardiac arrest, ischemia of lower extremity resulting in left leg gangrene and amputation, right leg extensive debridement and resulting foot drop, cardiomyopathy, sarcoidosis of the heart, type 2 diabetes, atrial fibrillation and sleep apnea. [...]
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on record review and interview, the facility failed to ensure medication orders were followed correctly regarding administering blood pressure medications and insulin and blood glucose assessments for 5 of 7 residents whose medications were reviewed. (Residents 87, 122, 2, 53 and 13) 1. The record for Resident 87 was completed on 8/4/2025 at 11:48 A.M. Diagnoses included, but were not limited to end stage renal disease, orthostatic hypotension, hypertension and aortic valve stenosis. Resident 87's Physician's Order, dated 7/21/2025, indicated to administer Midodrine (medication to treat low blood pressure) 10 milligrams (mg), 1 tablet three times a day for hypotension. The order indicated the following parameter: Do not give if SBP (systolic blood pressure) is greater than 100. The Medication Administration Record (MAR) from July 22- 29, 2025, indicated the following: [...]
- 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 ensure interventions were implemented to prevent contractures for 1 of 3 residents reviewed for range of motion. (Resident 95)
- D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Inspectors wroteBased on record review and interview, the facility failed to ensure medications were available and administered as ordered (Resident B) and failed to ensure a residents reviewed for medications was assessed for potential adverse side effects. (Resident 13) This deficient practice affected 2 of 7 residents reviewed for medications. (Resident B and 13)
January 23, 2025Complaint inspection · 1 citation
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on interview and record review, the facility failed to implement their policy related to reporting an allegation of abuse for 1 of 3 residents reviewed for abuse. (Resident B)
October 4, 2024Complaint inspection · 1 citation
- F
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Inspectors wroteBased on observation, record review and interview, the facility failed to ensure food was served at palatable temperatures in 1 of 1 kitchens observed (Main Kitchen). This deficient practice potentially affected 110 of 120 residents who consumed food from the main kitchen.
August 5, 2024Standard inspection · 14 citations
- 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 record review, the facility failed to ensure food was handled appropriately, foods were sealed appropriately, and failed to date foods when opened. This had the potential to affect 114 residents of 115 residents who received meals from the kitchen.
- E
Honor the resident's right to manage his or her financial affairs.
Inspectors wroteBased on interview and record review, the facility failed to ensure resident funds were available on the same day of the request and for the desired amount for 4 of 4 residents reviewed for facility-managed personal funds. (Residents 18, 5, 31 and 8)
- E
Assure the security of all personal funds of residents deposited with the facility.
Inspectors wroteBased on record review and interview, the facility failed to ensure a surety bond sufficiently covered the total monies in the Resident Fund account. This had the potential to affect the 56 residents who had resident fund accounts managed by the facility.
- 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 ensure baseline care plans were initiated for a resident receiving dialysis, a resident with falls and edema, and a resident with a wound, and failed to ensure baseline care plans were completed timely for a resident with an enteral feeding tube, for 4 of 27 residents reviewed for baseline care plans. (Residents 36, 107, 14 and 99)
- E
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 record review and interview, the facility failed to ensure comprehensive person-centered plans of care were created related to behaviors, a urinary tract infection, constipation, impaired vision and edema for 5 of 23 residents reviewed for comprehensive care plans. (Residents 28, 10, 14, 66 & 215)
- D
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 record review and interview, the facility failed to provide accurate orders for resuscitative wishes for 2 of 3 resident reviewed for advanced directives. (Residents 94 & 36)
- D
Provide activities to meet all resident's needs.
Inspectors wroteBased on observation, record review, and interview, the facility failed to provide resident-centered activities for 1 of 3 residents reviewed for activities. (Resident 93)
- 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 ensure edema was monitored for 1 of 1 residents reviewed for edema. (Resident 14) and failed to ensure antibiotic medication was administered timely for 1 of 2 residents reviewed for antibiotic use. (Resident 99)
- 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 a range of motion program to prevent further contractures for 1 of 2 residents reviewed for range of motion. (Resident 93)
- D
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Inspectors wroteBased on observation, record review, and interview, the facility failed to provide a peripherally inserted central catheter care for 1 of 5 residents reviewed for infection control (Resident 266)
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observation, record review, and interview, the facility failed to provide adequate tracheostomy care for 1 of 1 resident reviewed for tracheostomy/ventilation. (Resident 93)
- 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 verify controlled substance counts for 1 of 1 medication cart observed. (SW Unit)
- 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 ensure an appropriate diagnosis for a resident who received an antipsychotic medication for 1 of 5 residents reviewed for unnecessary medications. (Resident 28)
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview and record review, the facility failed to ensure staff change gloves and complete hand hygiene when providing perineal care for 1 of 1 resident reviewed for personal care. (Resident 47)
July 27, 2023Standard inspection · 11 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 ensure medications were kept in a locked cart when unattended, failed to ensure medication storage areas were free from loose medications; failed to date medications when opened during medication storage reviews for 4 of 4 medication carts observed and 2 of 3 medication rooms observed. (500, 300, 400 and 200 medication carts, 200 and 300 medication rooms)
- 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 the ceiling, oven, counters, and floor were clean and in good condition in the main kitchen; failed to ensure refrigerated foods were held at safe temperatures in the walk-in cooler; failed to dispose of expired foods; failed to ensure a refrigerator was clean; and failed to label and date foods brought in by residents, in 2 of 4 pantries (400 & 500 Halls) and the main kitchen. This deficient practice had the potential to affect 95 of 95 residents who received meals out of the kitchen.
- D
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 ensure the Physician Orders for Scope of Treatment (POST) forms were accurately completed for 3 of 3 residents whose Advanced Directives were reviewed. (Resident 71, 72, & 4)
- 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 a plysician timely of missed doses of unavailable medication for 2 of 5 residents whose medications were reviewed. ( Resident 26 & B)
- 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 ensure pertinent transfer and resident clinical information was completed for 1 of 3 residents reviewed for transfers. (Resident 72)
- 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 record review and interview, the facility failed to provide transfer form information for 1 of 3 residents reviewed for hospitalization. (Resident 72)
- 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, record review, and interview, the facility failed to provide a care plan for the use of a continuous positive airway pressure (C-Pap) device for 1 of 28 residents reviewed for care plans. (Resident 15)
- 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 ensure showers were provided timely for 1 of 3 residents reviewed for activity of daily living (ADL) care. (Resident 47)
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observation, record review, and interview, the facility failed to provide sanitation of the continuous positive airway pressure (C-Pap) equipment for 1 of 3 residents reviewed for supportive respiratory usage. (Resident 15)
- 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 and interview, the facility failed to ensure medications were available from the pharamacy for 2 of 4 residents reviewed for pain. (Resident 26 & B)
- D
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 ensure a safe, clean, and comfortable environment was maintained, related to a broken towel rack, plastic wrapped around the cord of a power strip, stained ceiling tiles, broken heater, dead bugs in the light covers, and black mold on vents. (room [ROOM NUMBER], 217, 303, and 200, 400 and 500 Hall)
Fire safety inspections
25 fire safety citations on file: 9 on August 12, 2025, 7 on August 5, 2024, 9 on July 27, 2023.
Every fire safety citation25 citations
- F
Have exits that are accessible at all times.
K 271 · August 12, 2025 · Corrected (the home has a date of correction)
- F
Install proper backup exit lighting.
K 281 · August 12, 2025 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · August 12, 2025 · Corrected (the home has a date of correction)
- F
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
K 354 · August 12, 2025 · Corrected (the home has a date of correction)
- F
Have simulated fire drills held at unexpected times.
K 712 · August 12, 2025 · Corrected (the home has a date of correction)
- F
Have proper medical gas storage and administration areas.
K 923 · August 12, 2025 · Corrected (the home has a date of correction)
- F
Have proper fire barriers, ventilation and signs for the transfilling of oxygen.
K 927 · August 12, 2025 · Corrected (the home has a date of correction)
- E
Provide properly protected cooking facilities.
K 324 · August 12, 2025 · Corrected (the home has a date of correction)
- E
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · August 12, 2025 · Corrected (the home has a date of correction)
- F
Provide primary/alternate means for communication.
E 32 · August 5, 2024 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · August 5, 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 · August 5, 2024 · Corrected (the home has a date of correction)
- F
Have proper fire barriers, ventilation and signs for the transfilling of oxygen.
K 927 · August 5, 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 · August 5, 2024 · Corrected (the home has a date of correction)
- E
Have properly located and lighted "Exit" signs.
K 293 · August 5, 2024 · Corrected (the home has a date of correction)
- E
Install an approved automatic sprinkler system.
K 351 · August 5, 2024 · Corrected (the home has a date of correction)
- F
Implement emergency and standby power systems.
E 41 · July 27, 2023 · Corrected (the home has a date of correction)
- F
Have simulated fire drills held at unexpected times.
K 712 · July 27, 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 · July 27, 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 · July 27, 2023 · Corrected (the home has a date of correction)
- E
Have properly located and lighted "Exit" signs.
K 293 · July 27, 2023 · Corrected (the home has a date of correction)
- E
Install a fire alarm system that can be heard throughout the facility.
K 341 · July 27, 2023 · Corrected (the home has a date of correction)
- E
Install corridor and hallway doors that block smoke.
K 363 · July 27, 2023 · Corrected (the home has a date of correction)
- E
Have proper fire barriers, ventilation and signs for the transfilling of oxygen.
K 927 · July 27, 2023 · Corrected (the home has a date of correction)
- D
Ensure proper usage of power strips and extension cords.
K 920 · July 27, 2023 · Corrected (the home has a date of correction)