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 40 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
1J
0K
0L
Actual harm
2G
0H
0I
Potential for more than minimal harm
12D
23E
1F
Potential for minimal harm
0A
1B
0C
February 6, 2026Standard inspection · 8 citations
- F
Provide and implement an infection prevention and control program.
Inspectors wroteBased on review of select facility policy, the facility's infection control log, and staff interview, it was determined the facility failed to maintain and implement a comprehensive infection prevention and control program.
- E
Allow resident to participate in the development and implementation of his or her person-centered plan of care.
Inspectors wroteBased on review of facility policies, clinical record review, and interviews with residents and staff, it was determined the facility failed to ensure residents were afforded the right to participate in the planning of their care and treatment, including failure to conduct care plan conferences and failure to invite residents to participate in the interdisciplinary care planning process, for two of 25 residents reviewed (Residents 80 and 36).
- E
Provide safe, appropriate pain management for a resident who requires such services.
Inspectors wroteBased on review of facility policy, clinical records, and interviews with residents and staff, it was determined the facility failed to ensure effective pain management and failed to implement, monitor, and revise pain interventions to maintain each resident's highest practicable level of well-being for two of 25 residents reviewed (Residents 11 and 4).
- E
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Inspectors wroteBased on a review of facility policy, clinical record review, observations, and staff interviews, it was determined the facility failed to ensure the availability of required emergency dialysis supplies for one resident (Resident 5) and failed to plan individualized care for a resident receiving hemodialysis to ensure the resident's care plan was consistent with physician orders for one resident (Resident 14) out of two residents sampled who received hemodialysis.
- 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, review of select facility policy, and staff interviews, it was determined the facility failed to adhere to acceptable storage and labeling for multi-dose medications in one of three medication storage rooms (first floor medication room).
- E
Have policies on smoking.
Inspectors wroteBased on a review of clinical records, select facility policy, and staff interviews, it was determined the facility failed to implement procedures for smoking safety, as evidenced by two out of six residents sampled for smoking. (Residents 5 and 53).
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on a review of clinical records, select facility policy, observation, and staff interviews, it was determined the facility failed to ensure oxygen therapy was administered per physician's orders for one resident out of 25 sampled (Resident 45).
- D
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Inspectors wroteBased on a review of clinical records, select facility policy, and staff interview, it was determined the facility failed to timely act upon a recommendation to reduce an antianxiety medication (medication used to calm the nervous system and balance brain chemistry) for one of 25 residents sampled (Resident 9).
November 18, 2025Complaint inspection · 2 citations
- E
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 and resident and staff interviews, it was determined the facility failed to provide housekeeping and maintenance services to maintain a safe, clean and homelike environment in resident areas on two of two resident floors (first floor shower room and second floor dining room and residential units).
- 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 a review of nursing staffing hours and staff to resident ratios, resident census, clinical records, select facility policy, and resident and staff interviews, it was determined that the facility failed to provide sufficient nursing staff to ensure that each resident received timely, person-centered care, services, and supervision necessary to maintain the physical, mental, and psychosocial well-being of the resident population for five of 18 sampled residents (Residents 1, 2, 3, 7, and 9).
October 17, 2025Complaint inspection · 2 citations
- J
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on clinical record review, facility policy review, staff interviews, and observation, it was determined the facility failed to ensure adequate supervision and implementation of safety interventions to prevent elopement for one resident (Resident 1). These failures placed 12 residents identified at risk for wandering and elopement (Residents 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, and 12) in an Immediate Jeopardy situation in which the facility's noncompliance has caused, or is likely to cause, serious injury, harm, impairment, or death.
- D
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Inspectors wroteBased on observations, review of clinical records, review of select facility policies, review of job descriptions, documentation provided by the facility, and interviews with residents and staff, it was determined the facility's administration failed to effectively use its resources to ensure resident safety and maintain the highest practicable physical and mental well-being of residents. The facility failed to ensure that measures were implemented to prevent one of twelve residents identified as being at risk for wandering (Resident 1) from exiting the building unattended into an unsafe environment. This deficient practice placed all residents at risk for harm and resulted in immediate jeopardy to residents' health and safety.
September 10, 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 review of the facility's abuse prohibition policy, clinical records, information submitted by the facility, and select investigative reports and staff interview, it was determined the facility failed to assure that three residents (Residents 2,3, and 4) out of 3 sampled were free from physical abuse perpetrated by another resident (Resident 1).
April 11, 2025Standard inspection, Complaint inspection · 12 citations
- E
Reasonably accommodate the needs and preferences of each resident.
Inspectors wroteBased on observations, a review of clinical records, and resident and staff interviews, it was determined the facility failed to reasonably accommodate residents' need for call bell accessibility for four out of 30 residents sampled (Residents 35, 77, 75, and 83) and to ensure the accessibility of resident room display boards as expressed by 2 out of 6 residents during a resident group interview (Residents 24 and 45).
- E
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on a review of clinical records and select facility policy, observations, and resident and staff interview it was determined the facility failed to ensure that a resident dependent on staff for assistance with activities of daily living (ADLs) consistently was provided showers as planned to maintain good personal hygiene and failed to provide a resident dependent on staff for ADLs, the necessary services to maintain good nutrition for two residents out of 30 sampled (Residents 35 and 103).
- E
Ensure the activities program is directed by a qualified professional.
Inspectors wroteBased on staff interview and a review of employee personnel records it was determined the facility failed to ensure the qualified part-time professional activities director responsibilities included directing the development, implementation, supervision and ongoing evaluation of the activities program, which includes the completion and/or directing/delegating the completion of the activities component of the comprehensive assessment; and contributing to and/or directing/delegating the contribution to the comprehensive care plan goals and approaches that are individualized to match the skills, abilities, and interests/preferences of each resident.
- E
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on clinical record review, select facility policy, and resident and staff interviews, it was determined the facility failed to provide person-centered care for diabetes management and professional standards of practice for one resident out of 30 sampled (Resident 45).
- E
Provide safe, appropriate pain management for a resident who requires such services.
Inspectors wroteBased on a review of clinical records, select facility policy, and resident and staff interviews, it was determined the facility failed to ensure that pain management is provided to residents consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for one resident out of 30 sampled (Resident 36).
- E
Have policies on smoking.
Inspectors wroteBased on a review of clinical records and select facility policy and staff interviews, it was determined the facility failed to implement procedures for smoking safety, as evidenced by three out of the three residents sampled for smoking.(Residents 45, 51, and 79).
- D
Ensure each resident receives an accurate assessment.
Inspectors wroteBased on a review of clinical records, the Resident Assessment Instrument (RAI), and staff interview, it was determined the facility failed to ensure the Minimum Data Set Assessments accurately reflected the status of one resident out of 30 sampled (Resident 106).
- 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 clinical record review and staff interview, it was determined the facility failed to ensure that a resident's comprehensive care plan was reviewed and revised as needed to accurately reflect their current needs and services required by one of 30 residents sampled (Resident 101).
- D
Plan the resident's discharge to meet the resident's goals and needs.
Inspectors wroteBased on a review of clinical records, select facility policy, and resident and staff interviews, it was determined the facility failed to develop and implement an effective discharge planning process that focuses on the resident's discharge goals for one out of the 30 residents sampled (Resident 36).
- D
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Inspectors wroteBased on a review of clinical records and staff interviews it was determined the facility failed to ensure a resident's drug regimen was free of unnecessary antibiotic drugs for one out of 30 residents sampled (Resident 105).
- D
Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.
Inspectors wroteBased on a review of select facility policy, clinical records and staff interviews it was determined the facility failed to timely notify the physician of abnormal lab results for one resident out of 30 sampled (Resident 96).
- D
Provide or obtain dental services for each resident.
Inspectors wroteBased on observation, clinical record review, payor source data, and resident and staff interview, it was determined the facility failed to provide timely and necessary dental services for one resident who is a Medicaid recipient (Resident 35) out of 30 residents reviewed.
May 10, 2024Standard inspection · 11 citations
- G
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Inspectors wroteBased on a review of the facility's abuse prohibition policy, select incident reports and clinical records, and staff interviews, it was determined that the facility failed to ensure that one resident (Resident 25) out of 20 sampled residents was free from sexual abuse perpetrated by another resident (Resident 46).
- G
Provide enough food/fluids to maintain a resident's health.
Inspectors wroteBased on a review of clinical records and staff interviews, it was determined that the facility failed to provide enteral feedings as ordered to maintain acceptable nutritional parameters and prevent a significant unplanned weight loss for one resident out of 20 residents sampled (Resident 83).
- E
Honor the resident's right to organize and participate in resident/family groups in the facility.
Inspectors wroteBased on a review of Food Committee Minutes (completed in addition to Resident Council meetings) and resident and staff interviews, it was determined that the facility failed to put forth sufficient efforts to promptly resolve continued resident complaints and grievances expressed during resident group meetings, including those voiced by three of the six residents interviewed during a group interview (Residents 32, 62, and 69) and one resident out of the 20 sampled (Resident 54).
- E
Ensure each resident receives an accurate assessment.
Inspectors wroteBased on a review of clinical records and the Resident Assessment Instrument and staff interviews, it was determined that the facility failed to ensure the Minimum Data Set Assessments (MDS - a federally mandated standardized assessment conducted at specific intervals to plan resident care) accurately reflected the status of two residents out of 20 sampled (Residents 7 and 13).
- E
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on a review of select facility policy and clinical records and staff interview it was determined that the facility failed to provide services consistent with professional standards of practice by failing to follow physician orders for bowel protocol for two residents out 20 sampled (Residents 89 and 50) to promote normal bowel activity to the extent possible
- E
Provide medically-related social services to help each resident achieve the highest possible quality of life.
Inspectors wroteBased on clinical record review and resident and staff interviews, it was determined the facility failed to provide therapeutic social services to promote the highest practicable mental and psychosocial well-being of two of the 20 residents reviewed (Residents 46 and 54).
- 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, a review of select facility policy and clinical records, and staff interviews, it was determined that the facility failed to adhere to acceptable storage and use by dates for multi-dose medication and herbal supplements on one of three medication carts and one of three medication storage rooms observed (west short cart, first floor storage room - Residents 9, and 77).
- E
Have policies on smoking.
Inspectors wroteBased on a review of clinical records and the facility's smoking policy and staff interview, it was determined that the facility failed to implement established procedures to accurately assess residents for safe smoking ability for three residents out of three identified as a current smoker (Resident 50, 54, and 58).
- D
PASARR screening for Mental disorders or Intellectual Disabilities
Inspectors wroteBased on clinical record review and staff interview, it was determined that the facility failed to accurately complete the PASRR (Preadmission Screening and Resident Review) according to the resident assessment for one of six residents reviewed related to PASRR assessments (Resident 58).
- D
Provide care or services that was trauma informed and/or culturally competent.
Inspectors wroteBased on a review of clinical records and staff interview, it was determined that the facility failed to develop and implement an individualized person-centered plan to render trauma informed care to a resident with a diagnosis of Post-Traumatic Stress Disorder for one out of 20 residents reviewed (Resident 58).
- B
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Inspectors wroteBased on a review of clinical records and facility documentation and staff interview, it was determined that the facility failed to provide the required advance notice, a Notice of Medicare Non-Coverage (CMS 10123-NOMNC), regarding the termination of Medicare services for one of the three residents sampled (Resident 241).
October 17, 2023Complaint inspection · 3 citations
- E
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteBased on review clinical records and resident and staff interviews it was determined that the facility failed to provide care in a manner and environment, which promotes each resident's quality of life by failing to respond timely to residents' request for assistance as evidenced by experiences reported by seven residents out of 15 interviewed (Residents 8, 21, 22, 23, 73, 74, and 102).
- E
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, resident and staff interviews, it was determined that the facility failed to provide housekeeping and maintenance services to maintain a clean and orderly environment on three of the three nursing units (Nursing Units 1, 2 and 3).
- E
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Inspectors wroteBased on observations, facility provided documents and staff interview, it was determined that the facility failed to maintain an effective pest control program.
September 8, 2023Complaint inspection · 1 citation
- E
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Inspectors wroteBased on test tray results and resident and staff interview, it was determined that the facility failed to serve foods at palatable temperatures.
Fire safety inspections
14 fire safety citations on file: 3 on February 6, 2026, 7 on April 11, 2025, 4 on May 10, 2024.
Every fire safety citation14 citations
- E
Keep aisles, corridors, and exits free of obstruction in case of emergency.
K 211 · February 6, 2026 · Corrected (the home has a date of correction)
- E
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
K 225 · February 6, 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 · February 6, 2026 · Corrected (the home has a date of correction)
- F
Conduct risk assessment and an All-Hazards approach.
E 6 · April 11, 2025 · 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, 2025 · Corrected (the home has a date of correction)
- E
Use approved construction type or materials.
K 161 · April 11, 2025 · Corrected (the home has a date of correction)
- E
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
K 225 · April 11, 2025 · Corrected (the home has a date of correction)
- E
Have properly located and lighted "Exit" signs.
K 293 · April 11, 2025 · Corrected (the home has a date of correction)
- E
Inspect, test, and maintain automatic sprinkler systems.
K 353 · April 11, 2025 · Corrected (the home has a date of correction)
- E
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
K 741 · April 11, 2025 · Corrected (the home has a date of correction)
- E
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
K 223 · May 10, 2024 · Corrected (the home has a date of correction)
- E
Inspect, test, and maintain automatic sprinkler systems.
K 353 · May 10, 2024 · Corrected (the home has a date of correction)
- E
Properly select, install, inspect, or maintain portable fire extinguishes.
K 355 · May 10, 2024 · Corrected (the home has a date of correction)
- E
Install corridor and hallway doors that block smoke.
K 363 · May 10, 2024 · Corrected (the home has a date of correction)