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
2G
0H
0I
Potential for more than minimal harm
23D
2E
1F
Potential for minimal harm
0A
0B
0C
June 26, 2026Complaint 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 resident record review, review of the of the facility Self-Reported Incident (SRI) form, interviews, and review of facility policy, the facility failed to ensure an incident of resident elopement was appropriately identified and addressed according to the policy implemented by the facility. This affected one resident (#90) out of the three residents reviewed for elopement. The facility census was 88.
August 28, 2025Standard inspection · 3 citations
- E
Ensure each resident receives an accurate assessment.
Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure Minimum Data Set (MDS) assessments were accurately completed. This affected four residents (#9, #11,#27, and #86) out of the 26 residents whose MDS assessments were reviewed during the annual survey. The facility census was 85.
- 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,observation, and interview the facility failed to ensure the dental status care plan was completed accurately. This affected two residents (#27 and #35) of three residents reviewed for dental care. The facility census was 85.
- 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 observations, interviews, and record reviews, the facility failed to ensure resident medications were not left at the bedside unattended. This affected one resident (#13) out of the 24 residents observed during the initial pool process. The facility census was 85.
January 24, 2025Complaint inspection · 3 citations
- D
Ensure each resident receives an accurate assessment.
Inspectors wroteBased on record review, resident and staff interview the facility failed to complete an accurate comprehensive assessment for Resident #28, #47 and #74. This affected three residents (Resident #28, #47 and #74) of thirteen reviewed for comprehensive assessments. The facility census was 86 in house.
- 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 develop and implement a comprehensive and individualized range of motion program to timely identify and implement therapy recommendations to treat and prevent potential worsening of a right-hand contracture for Resident #47, a resident admitted to the facility with diagnosis of cerebral infarction, hemiplegia/hemiparesis affecting the right side. This affected one resident (#47) of one resident reviewed for range of motion. The facility census was 86.
- D
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Inspectors wroteBased on review of the Self Reporting Incident (SRI), record review, and interview the facility failed to implement individualized interventions and revise the care plan to address the Resident #69's dementia care needs related to sexual behaviors. This affected one resident (Resident #69) of one reviewed for dementia care. The facility census was 86.
May 8, 2024Complaint inspection · 1 citation
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on medical record review, staff interview, observation, and facility policy review, this facility failed to ensure enhanced barrier protection including gloves were in place during wound care. This affected one (Resident #126) of the three residents reviewed for wound care. The facility census was 91.
February 29, 2024Complaint inspection · 3 citations
- G
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on observation, medical record review, staff interview, and policy review, the facility failed to monitor Resident #36's skin under a splint/boot on the left foot to prevent the development of a pressure ulcer. Actual harm occurred on 12/26/23 when Resident #36, who was cognitively impaired was identified to have a deep tissue injury (DTI) pressure ulcer (described as intact skin with a localized area of persistent non-blanchable deep red, maroon, purple discoloration due to damage of underlying soft tissue) to the left foot caused by a splint. The splinting device had been implemented following a fracture on 12/18/23. However, staff failed to monitor/assess the resident's skin integrity under the splint resulting in the DTI pressure ulcer development. [...]
- G
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on medical record review, staff interview, and policy review, the facility failed to ensure Resident #36 received adequate staff assistance during a staff assisted transfer from bed to chair to prevent a fall with injury. Actual harm occurred on 12/18/23 when Resident #36, who was cognitively impaired, at risk for falls and required substantial/maximal assistance from staff for transfers sustained a fall during a one-person staff assisted transfer. At the time of the transfer, the nursing assistant, (NA) #170 failed to use a gait belt and the resident fell to the floor with a resulting fracture of the left ankle. This affected one resident (#36) of four residents reviewed for falls. The facility census was 92.
- 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 medical record review and staff interview, the facility failed to develop a comprehensive care plan that included the level of staff assistance required for transfers. This affected one of three sampled residents (Resident #36). The facility census was 92.
December 14, 2023Standard inspection · 6 citations
- D
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Inspectors wroteBased on staff interview and record review, the facility failed to include all the mental health diagnoses on the preadmission screening and resident review (PASARR) for Resident #8. This affected one (#8) of three residents reviewed for PASARR. The facility census was 90.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on observations, resident and staff interviews, record reviews, and review of the facility policy, the facility failed to identify and implement treatment for residents with skin alterations. This affected two (#3 and #20) of the two residents reviewed for non-pressure skin alterations during the annual survey. The facility census was 90.
- D
Provide enough food/fluids to maintain a resident's health.
Inspectors wroteBased on staff interview, record review, and facility policy review, the facility failed to ensure Resident #31 was provided a speech therapy screen or evaluation as recommended by the dietitian on admission. This affected one (Resident #31) of three residents reviewed for nutrition. The facility census was 89.
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observations, staff interviews, and record review, the facility failed to ensure physicians orders were in place for the administration of oxygen therapy. This affected one (Resident #9) of two residents reviewed for respiratory care during the annual survey. The facility census was 90.
- 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 staff interview and record review, the facility failed to ensure there was an appropriate diagnosis for the administration of an antipsychotic medication for Resident #52. This affected one (#52) of five residents reviewed for unnecessary medications. The facility census was 90.
- 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 observations and staff interviews, the facility failed to ensure resident's bathroom tiles remained in good repair. This affected one bathroom that was shared by three residents in two rooms (rooms [ROOM NUMBERS]). The facility identified the three residents in rooms [ROOM NUMBERS] who were ambulatory and used the bathroom. The facility census was 90.
April 11, 2022Standard inspection · 11 citations
- F
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, record review, facility policy and procedure review, review of the Centers for Disease Control (CDC) guidance and interview the facility failed to maintain acceptable infection control practices, including the proper use of personal protective equipment (PPE) and isolation precautions to prevent the potential spread of COVID-19. This affected two residents (#49 and #185) and had the potential to affect all 84 residents residing in the facility. Findings Include: 1. Review of Resident #49's medical record revealed an initial admission date of 01/21/22 with the latest readmission of 04/01/22 with the admitting diagnoses of non-pressure chronic ulcer of foot, diabetes mellitus, plantar fascia affirmations, constipation, obstructive sleep apnea and chronic peripheral venous insufficiency. [...]
- E
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 and interview the facility failed to maintain a clean and functional environment for all residents with evidence of poor repair to five rooms that required wall repairs and paint. This affected seven residents who resided in Rooms 38, 32, 28, 157 and 165. The facility census was 84. Findings Include: On 04/06/22 at 4:35 P.M. observation of room [ROOM NUMBER] revealed the west wall of the room had paint that was visually bubbled up and peeling away from the wall. Some areas had exposed dry wall and other exposed areas from missing paint. Observation and interview with Maintenance Director #237 and Maintenance Technician #318 at the time of the observation verified the finding. On 04/06/22 at 4:38 P.M. observation of room [ROOM NUMBER] revealed the south wall and the west wall of this room had bubbled paint that extended from the ceiling to the floor. [...]
- D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteBased on observation, record review and staff interview the facility failed to maintain Resident #136's dignity when the resident's indwelling urinary catheter collection bag was uncovered and visible. This affected one resident (#136) of two residents reviewed for dignity. Findings Include: Review of Resident #136' medical record revealed an initial admission date of 02/22/22 with the latest readmission of 03/29/22 and diagnoses including sepsis, diabetes mellitus, osteomyelitis, hyperlipidemia, begin prostate hypertrophy (BPH) with obstruction, fracture of lumbar vertebra and non-displaced fracture of first cervical vertebra. Review of an admission seven day evaluation, dated 03/01/22 revealed the resident was admitted to the facility with an indwelling urinary catheter for (BPH) with obstruction. [...]
- D
Reasonably accommodate the needs and preferences of each resident.
Inspectors wroteBased on observation, record review and interview the facility failed to reasonably accommodate Resident #69's seating/positioning needs to address physical limitations for the resident to ensure the resident maintained her highest level of functioning. This affected one resident (#69) of three residents reviewed for positioning. Findings Include: Record review for Resident #69 revealed the resident was admitted to the facility on [DATE] and had diagnoses including dementia with behavioral disturbances, anxiety, depression, bipolar disorder, unsteadiness on feet, unspecified psychosis, dysphagia, cellulitis, need for assistance with personal care, abnormal posture and delusional disorders. [...]
- 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 record review, facility policy and procedure review and interview the facility failed to ensure Resident #2 and Resident #25 received their preferred frequency and method of bathing. This affected two residents (#2 and #25) of four residents reviewed for choices. Findings Include: 1. Review of Resident #2's medical record revealed an initial admission date of 12/02/21 with the latest readmission of 02/19/22. Resident #2 had diagnoses including atrial fibrillation, diabetes mellitus, congestive heart failure, severe morbid obesity, repeated falls, chronic obstructive pulmonary disease, major depressive disorder, anxiety disorder and hypertension. Review of the plan of care, dated 12/13/21 revealed the resident had an activity of living (ADL) care performance deficit; [...]
- 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 Resident #3 with a bed hold notification prior to hospital stay. This affected one resident (#3) of four residents reviewed for notification of bed hold. Findings Include: Review of the medical record for Resident #3 revealed an admission date of 08/09/21 with diagnoses including chronic obstructive pulmonary disorder (COPD), morbid obesity, diabetes mellitus, depression, congestive heart failure and atrial fibrillation. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 03/01/22 revealed Resident #3 was cognitively intact with no behaviors. The resident had clear speech, was understood and understands. Review of the nursing progress notes revealed on 10/24/21 at 4:17 P.M. [...]
- D
PASARR screening for Mental disorders or Intellectual Disabilities
Inspectors wroteBased on record review and interview the facility failed to complete a Pre-admission Screening and Resident Review (PASARR) as required. This affected one resident (#74) of two sampled residents reviewed for PASARR Findings Include: Review of the medical record for Resident #74 revealed an admission date of 08/17/21 with diagnoses including paranoid schizophrenia, anxiety, delusional disorder and the need for assistance with personal care. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 03/31/22 revealed Resident #74 had clear speech, was understood and understands. The assessment revealed Resident #74 was cognitively intact with no behaviors. Resident #74 required two person physical assistance with bed mobility, transfers, dressing, toileting, personal hygiene and bathing. [...]
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on observation, record review, facility policy and procedure review and interview the facility failed to ensure Resident #25 and Resident #8, who required staff assistance for activities of daily living receiving timely and adequate assistance with bathing, nail care and/or dressing to maintain proper hygiene and grooming. This affected two residents (#8 and #25) of six residents reviewed for activities of daily living (ADL) care. Findings Include: 1. Review of Resident #25's medical record revealed an admission date of 01/31/22 with admitting diagnoses of congestive heart failure, asthma, benign prostatic hyperplasia with lower urinary tract symptoms, chronic ischemic heart disease, insomnia, atrial fibrillation, hypothyroidism and hypertension. Review of an evaluation, dated 01/31/22 revealed the resident preferred showers in the evening two days a week. [...]
- 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 timely identify new areas of non-pressure related skin impairment for Resident #69 and failed to ensure non-pressure related wound care treatments were completed as ordered for Resident #67. This affected two residents (#67 and #69) of three residents reviewed for non-pressure related skin conditions. Findings Include: 1. Record review for Resident #67 revealed the resident was admitted to the facility on [DATE] and had diagnoses including iron deficiency anemia, acute gastritis with bleeding, type two diabetes mellitus with hyperglycemia, insomnia, presence of cardiac pacemaker, history of falls, unsteadiness on feet, weakness, need for assistance with personal care, gastrointestinal hemorrhage, unspecified dementia with behavioral disturbances, atrial fibrillation and hypertension. [...]
- D
Provide or obtain dental services for each resident.
Inspectors wroteBased on observation, record review, facility policy and procedure review and interview the facility failed to provide routine dental services for Resident #8. This affected one resident (#8) of one resident reviewed for dental services. Findings Include: Review of the medical record for Resident #8 revealed an admission date of 01/31/17 with diagnoses including Parkinson's disease, congestive heart failure, bipolar disorder, schizophrenia disorder, and chronic obstructive pulmonary disorder. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 01/10/22 revealed Resident #8 had clear speech, was understood and understands. Resident #8 was cognitively intact with no behaviors. Resident #8 required extensive assistance of one person for bed mobility, transfers, dressing, toileting, personal hygiene and bathing. [...]
- D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on record review and staff interview the facility failed to ensure Resident #2's medical record was complete and accurate related to the resident's diagnoses. This affected one resident (#2) of 25 sampled residents whose medical records were reviewed. Findings Include: Review of Resident #2's medical record revealed an initial admission date of 12/02/21 with the latest readmission of 02/19/22. Resident #2 had diagnoses including atrial fibrillation, diabetes mellitus, congestive heart failure, severe morbid obesity, repeated falls, chronic obstructive pulmonary disease, major depressive disorder, anxiety disorder and hypertension. Review of the acute care hospital Discharge summary, dated [DATE] failed to identify a diagnoses of seizures. [...]
Fire safety inspections
22 fire safety citations on file: 3 on August 28, 2025, 6 on December 14, 2023, 13 on April 11, 2022.
Every fire safety citation22 citations
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · August 28, 2025 · Corrected (the home has a date of correction)
- F
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · August 28, 2025 · Corrected (the home has a date of correction)
- E
Install smoke barrier doors that can resist smoke for at least 20 minutes.
K 374 · August 28, 2025 · Corrected (the home has a date of correction)
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · December 14, 2023 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · December 14, 2023 · Corrected (the home has a date of correction)
- E
Have corridors or aisles that are unobstructed and are at least 8 feet in width.
K 232 · December 14, 2023 · Corrected (the home has a date of correction)
- E
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · December 14, 2023 · Corrected (the home has a date of correction)
- E
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
K 761 · December 14, 2023 · Corrected (the home has a date of correction)
- E
Have proper medical gas storage and administration areas.
K 923 · December 14, 2023 · Corrected (the home has a date of correction)
- F
Have simulated fire drills held at unexpected times.
K 712 · April 11, 2022 · Corrected (the home has a date of correction)
- F
Have restrictions on the use of flammable curtains.
K 751 · April 11, 2022 · Corrected (the home has a date of correction)
- E
Meet requirements for sections of health care facilities separated by fire resistive construction.
K 131 · April 11, 2022 · 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 11, 2022 · Corrected (the home has a date of correction)
- E
Have exits that are accessible at all times.
K 271 · April 11, 2022 · 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 11, 2022 · Corrected (the home has a date of correction)
- E
Construct fire resistant interior walls.
K 331 · April 11, 2022 · Corrected (the home has a date of correction)
- E
Install an approved automatic sprinkler system.
K 351 · April 11, 2022 · 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 11, 2022 · Corrected (the home has a date of correction)
- E
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · April 11, 2022 · Corrected (the home has a date of correction)
- E
Have properly installed electrical wiring and gas equipment.
K 511 · April 11, 2022 · Corrected (the home has a date of correction)
- E
Have an externally vented heating system.
K 522 · April 11, 2022 · Corrected (the home has a date of correction)
- E
Ensure proper usage of power strips and extension cords.
K 920 · April 11, 2022 · Corrected (the home has a date of correction)