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
0J
0K
0L
Actual harm
6G
0H
0I
Potential for more than minimal harm
27D
5E
0F
Potential for minimal harm
0A
0B
2C
June 4, 2026Standard inspection · 14 citations
- D
Honor the resident's right to manage his or her financial affairs.
Inspectors wroteBased on interview and record review, the facility failed to ensure residents who had personal fund accounts established received accrued interest in those accounts for 2 of 3 sampled residents (Residents 34 and 36) reviewed for Trust Funds interest accrued. This failure placed residents at risk not to receive, or have access to, monies owed to them.
- D
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
Inspectors wroteBased on interview and record review, the facility failed to complete an AIMS (Abnormal Involuntary Movement Scale) test (a rating scale used to assess the severity of involuntary movements that sometimes develop as a side effect of treatment with antipsychotic medications [drugs used primarily to treat symptoms such as hallucinations and delusions]) for 1 of 5 sampled residents (Resident 51) reviewed for unnecessary medications. This failure placed residents at risk for adverse medication side-effects, medical complications, and a diminished quality of life.
- D
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Inspectors wroteBased on interview and record review, the facility failed to provide a written Bed-Hold notice to residents and/or residents' representative at the time of transfer to the hospital for 2 of 2 sampled residents (Residents 39 and 3) reviewed for hospitalization. This failure placed residents at risk for lack of knowledge regarding their right to hold their bed while in the hospital.
- D
Ensure each resident receives an accurate assessment.
Inspectors wroteBased on interview and record review, the facility failed to ensure the Minimum Data Set (MDS, an assessment tool) was completed accurately to reflect a resident's health status and/or care needs for 1 of 5 sampled residents (Resident 46) reviewed for activities of daily living; failed to identify Hospice services for 1 of 2 sampled residents (Resident 14) reviewed for Hospice; and 1 of 5 sampled residents (Resident 52) reviewed for unnecessary medications. This failure placed residents at risk for unidentified and/or unmet care needs and a diminished quality of life.
- D
Notify the appropriate authorities when residents with MD or ID services has a significant change in condition.
Inspectors wroteBased on interview and record review, the facility failed to notify the state mental health authority coordinator of a significant change in physical condition, for 1 of 5 residents (Resident 7) reviewed for PASARR process (Preadmission Screening and Resident Review, a screening tool used to identify mental health needs). This failure placed the residents at risk for unmet care needs 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 ensure resident care plans were revised to accurately reflect care needs for 1 of 2 sampled residents (Resident 7) reviewed for hospice and 1 of 1 sampled resident (Resident 39) reviewed for skin conditions. This failure placed residents at risk for unmet care needs and a diminished quality of life.
- D
Ensure services provided by the nursing facility meet professional standards of quality.
Inspectors wroteBased on interview and record review, the facility failed to ensure services provided met professional standards by not following physician's orders for 1 of 5 residents (Resident 51) reviewed for unnecessary medications. This failure placed residents at risk for unmet care needs, medical complications, and a diminished quality of life.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on observation, interview, and record review, the facility failed to obtain physician and/or treatment orders for skin and/or wound care for 1 of 1 sampled resident (Resident 39) reviewed for skin conditions. This failure placed residents at risk of injury, unmet care needs, and a diminished quality of life.
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observation, interview, and record review, the facility failed to obtain physician orders for oxygen and/or BiPAP (Bi-level Positive Airway Pressure, a non-invasive ventilator that delivers air and oxygen into the lungs using a mask to help people breathe more easily) use for 1 of 2 sampled residents (Resident 39) and failed to change oxygen tubing as ordered for 1 of 2 sampled residents (Residents 60) reviewed for respiratory care. This failure placed residents at risk for worsening health complications, 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 ensure monthly pharmacy review recommendations were addressed as indicated for 1 of 5 residents (Resident 51) reviewed for unnecessary medications. This failure placed residents at risk of inadequately monitored medications, adverse effects, and a diminished quality of life.
- D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on interview, and record review, the facility failed to ensure resident's medical records were accurate and up to date for 1 of 2 sampled residents (Resident 7) reviewed for hospice and 1 of 5 sampled residents (Resident 7) reviewed for pre-admission screening and resident review (PASARR, An assessment used to identify individuals [residents] with serious mental issues, intellectual disabilities, or related conditions are not inappropriately placed in nursing facilities for long term care). This failure placed residents at risk for unmet care needs and a diminished quality of life.
- D
Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
Inspectors wroteBased on interview and record review, the facility failed to offer the Covid-19 (Coronavirus disease 2019, an infectious respiratory illness caused by a virus) vaccine and/or provide education regarding risks, benefits, and potential side effects associated with the vaccine, for 1 of 5 sampled residents (Resident 52) reviewed for unnecessary medications. This failure placed residents at risk for contracting Covid-19 infections, related complications, and a diminished quality of life.
- C
Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
Inspectors wroteBased on observation, interview and record review, the facility failed to provide eating assistance in a manner that promoted resident respect and dignity for 1 of 9 residents (Resident 14) reviewed for dining. This failure place residents at risk for diminished self-worth, embarrassment, and a deceased quality of life.
- C
Provide timely, quality laboratory services/tests to meet the needs of residents.
Inspectors wroteBased on observation, interview and record review, the facility failed to maintain a current Clinical Laboratory Improvement Amendments (CLIA Waiver- also known as a Medical Test Site Certificate of Waiver License, a license that allows the facility to legally perform certain simple, low risk medical tests like blood glucose checks and COVID-19 [Corona Virus Disease 2019, a respiratory illness] tests). This failure placed residents at risk for substandard care, delayed diagnosis and incorrect medical treatment.
June 9, 2025Complaint inspection · 2 citations
- G
Ensure that residents are free from significant medication errors.
Inspectors wroteBased on interview and record review, the facility failed to ensure residents were free from significant medication errors for 1 of 3 sampled residents (Resident 1) reviewed for medication errors when another resident's medication(s) were left unattended and then taken by/ingested by the wrong resident. Resident 1 experienced harm when they became unresponsive and required intensive care level hospitalization and mechanical ventilation. This failure placed all residents at risk for medical complications.
- 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 report a significant medication error to the State Survey Agency, as required for 1 of 3 residents (Resident 1) reviewed for medication administration and resulted in hospitalization and ventilator support. The failure to report a serious incident delayed appropriate oversight and investigation, placing residents at risk for harm.
May 7, 2025Standard inspection · 11 citations
- E
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure bed placement and bed side rails were assessed, physician ordered and had an informed consent for 3 of 8 sampled residents (29, 47 & 250) reviewed for physical restraints. This failure placed residents at risk for injury, unmet care needs, and a diminished quality of life.
- 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 observations and interviews, the facility failed to ensure medication carts were locked when without supervision for 3 of 4 medication carts (on 200 Hall and 300 Hall) reviewed for medication storage. This failure placed residents at risk of having access to medications, and/or misappropriation of narcotic medications.
- D
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 ensure a resident's personal privacy was protected and maintained when a privacy curtain was not installed for 1 of 2 sampled residents (200) reviewed for resident rights. This failure placed residents at risk for diminished self-worth, self-esteem and overall well-being.
- D
Keep residents' personal and medical records private and confidential.
Inspectors wroteBased on observation, interview and record review, the facility failed to ensure personal privacy was maintained by not having a privacy curtain installed for 1 of 2 sampled residents (200) reviewed for personal privacy. This failure placed residents at risk for loss of privacy during personal care, embarrassment and decreased quality of life.
- D
Respond appropriately to all alleged violations.
Inspectors wroteBased on interview and record review, the facility failed to ensure a thorough investigation was conducted for 1 of 3 sampled residents (35) reviewed for accident and incident investigations. This failure placed residents at risk for identified abuse and neglect, inappropriate corrective actions, recurrent falls, 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 ensure resident care plans were revised to accurately reflect care needs for 1 of 8 sampled residents (29) reviewed for care plan revisions. This failure placed residents at risk for unidentified and unmet care needs and a diminished quality of life.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on observation, interview and record review, the facility failed to ensure physician orders were followed to obtain weights for 1 of 5 sampled residents (35), and failed to follow physician orders and resident's care plan to label intravenous (IV, a way to give a drug through a needle or tube inserted into a vein) bag and/or tubing for 1 of 1 sampled residents (250) reviewed for quality of care related to following physician orders and/or resident's care plan. This failure placed residents at risk for medical complications, inaccurate physician treatment plan and a diminished quality of life.
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a safe environment was maintained and free from hazards related to a bed and/or linens against a baseboard heater on the wall for 1 of 8 beds reviewed for accident hazards. This failure placed residents at risk for avoidable accidents and injuries, negative health outcomes, and a diminished quality of life.
- 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 supplemental oxygen use was accurately documented in the Electronic Health Record (EHR) and oxygen tubing was changed for 1 of 2 sampled residents (47) reviewed for respiratory care. This failure placed residents at risk of not receiving accurate assessments, worsening health complications, and a decreased quality of life.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff properly donned (putting on) personal protective equipment for 1 of 2 sampled residents (37) reviewed for infection prevention and control. This failure placed residents at risk for the spread of infection transmission in the facility and a diminished quality of life.
- D
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Inspectors wroteBased on interview and record review, the facility failed to ensure the pneumococcal vaccine was administered for 1 of 5 sampled residents (8) reviewed for immunizations. This failure placed residents at risk for developing pneumonia with potential negative outcomes and a diminished quality of life.
April 18, 2025Complaint inspection · 1 citation
- E
Ensure that residents are free from significant medication errors.
Inspectors wroteBased on interview and record review, the facility failed to ensure residents were free from significant medication errors when medications were not administered in accordance with provider orders for 5 of 5 sampled residents (Residents 1, 2, 3, 4, & 5) reviewed for significant medication errors. This failure placed residents at risk of adverse medical conditions, a change in health condition, and a diminished quality of life.
August 6, 2024Complaint inspection · 2 citations
- G
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on interview and record review, the facility failed to ensure residents were free from avoidable accidents during resident bed mobility assistance for 1 of 3 sampled residents (Resident 1) reviewed for accident hazards. Resident 1 experienced harm when the resident was found to have a fractured femur (thighbone) after a fall that required medical intervention when facility staff did not use two-person assistance with bed mobility as indicated as necessary by the comprehensive care plan. This failure placed residents at risk for injury and a diminished quality of life.
- D
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Inspectors wroteBased on interview and record review, the facility failed to ensure a resident's representative was notified of a significant change of condition for 1 of 3 sample residents (Resident 1) reviewed for notification of change. This failure placed residents and their representatives at risk of not being able to participate in resident care decisions and a diminished quality of life.
July 11, 2024Standard inspection, Complaint inspection · 4 citations
- E
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Inspectors wroteBased on interview and record review, the facility failed to ensure issue and/or complete a Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNF ABN) and/or a Notice of Medicare Non-Coverage (NOMNC) was completed and issued timely, at least two calendar days before Medicare services ended, for 3 of 3 sampled residents (33, 49, & 214) reviewed for SNF ABN and NOMNC notification. This failure placed residents and their representatives at risk for not having adequate information to make financial decisions related to a continued stay in the facility and a diminished quality of life.
- D
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure grooming assistance was provided for 1 of 6 sampled residents (44) reviewed for activities of daily living (ADLs). This failure placed residents at risk for unmet care needs, poor hygiene, and a diminished quality of life.
- D
Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
Inspectors wroteBased on observation, interview and record review, the facility failed to ensure policies and procedures were in place to reflect resident's choices and facility procedures failed to ensure residents' preferences and physician orders were accurately addressed and communicated for 4 of 6 sampled residents (Residents 8,10, 11 & 36) reviewed for code status documentation and facility wide communication. This failure placed residents at risk for increased harm and decreased quality of life.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on observation, interview, and record review, the facility failed to follow physician's orders and/or resident's care plan to label intravenous (IV, a way to give a drug through a needle or tube inserted into a vein) and tube feeding (TF) bags and/or tubing for 1 of 2 sampled residents (8) reviewed for TF and antibiotics, and failed to implement physician's orders when bowel protocol was not followed to address constipation for 2 of 5 sampled residents (10 & 23) reviewed for unnecessary medications. These failures placed residents at risk for inaccurate physician treatment plan, unrelieved constipation, and a diminished quality of life.
March 7, 2024Complaint inspection · 2 citations
- G
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on interview and record review, the facility failed to assess and provide preventative equipment interventions to prevent further pressure injury development and deterioration for 1 of 6 sampled residents (Resident 1) reviewed for pressure injuries. [...]
- G
Provide timely, quality laboratory services/tests to meet the needs of residents.
Inspectors wroteBased on interviews and record review, the facility failed to ensure timely laboratory services were provided for 1 of 6 sampled residents (1) reviewed for laboratory services. This caused harm to Resident 1 when STAT (immediate) lab tests were not completed timely (three days after the STAT order) and the resident required a hospital evaluation for high lab values. This failure placed residents at risk for delay in treatment, decline in medical conditions and a diminished quality of life.
January 8, 2024Complaint inspection · 4 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 interview and record review, the facility failed to ensure a resident was free from sexual abuse by a staff member for 1 of 5 sampled residents (Resident 1) reviewed for abuse. Resident 1 experienced harm when the facility failed to take timely action once allegations of potential staff to resident abuse were first identified and suspected by staff in order to protect the resident from the potential of further abuse. This failure placed residents at risk for abuse and a diminished quality of life.
- G
Respond appropriately to all alleged violations.
Inspectors wroteBased on interview and record review, the facility failed to timely initiate and complete an investigation of potential staff-to-resident abuse and put interventions in place to prevent further potential resident abuse at the time the alleged abuse was suspected for 1 of 5 sampled residents (Resident 1) reviewed for investigation to prevent alleged abuse. This caused harm to Resident 1 when the facility's delay in investigation of potential sexual abuse allowed the alleged staff member, in a position of power (caregiver), to continue to have access to Resident 1 and did not protect the resident from further potential abuse after they were first aware of a pattern of questionable behavior. This failure placed residents at risk for abuse, having allegations of abuse not being responded to and thoroughly investigated, and a diminished quality of life.
- E
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 ensure all staff reported multiple allegations of abuse immediately to the State Survey Agency causing a delay in investigating alleged staff to resident abuse for 1 of 5 sampled residents (Resident 1) reviewed for reporting of allegations of abuse. This failure placed residents at risk for lack of protection from being abused 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 toileting was provided for 1 of 3 sampled residents (Resident 2) reviewed for activities of daily living (ADLs). This placed residents at risk for skin impairments, loss of dignity and a diminished quality of life.
Fire safety inspections
29 fire safety citations on file: 7 on June 4, 2026, 9 on May 7, 2025, 13 on July 11, 2024.
Every fire safety citation29 citations
- F
Include a process for Emergency Preparedness collaboration.
E 9 · June 4, 2026 · Corrected (the home has a date of correction)
- F
Conduct testing and exercise requirements.
E 39 · June 4, 2026 · Corrected (the home has a date of correction)
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · June 4, 2026 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · June 4, 2026 · Corrected (the home has a date of correction)
- F
Install smoke barrier doors that can resist smoke for at least 20 minutes.
K 374 · June 4, 2026 · Corrected (the home has a date of correction)
- F
Ensure that testing and maintenance of electrical equipment is performed.
K 921 · June 4, 2026 · Corrected (the home has a date of correction)
- D
Establish policies and procedures including evacuation.
E 20 · June 4, 2026 · Corrected (the home has a date of correction)
- F
Conduct testing and exercise requirements.
E 39 · May 7, 2025 · Corrected (the home has a date of correction)
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · May 7, 2025 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · May 7, 2025 · Corrected (the home has a date of correction)
- F
Have simulated fire drills held at unexpected times.
K 712 · May 7, 2025 · Corrected (the home has a date of correction)
- F
Ensure proper usage of power strips and extension cords.
K 920 · May 7, 2025 · Corrected (the home has a date of correction)
- F
Ensure that testing and maintenance of electrical equipment is performed.
K 921 · May 7, 2025 · Corrected (the home has a date of correction)
- F
Have proper medical gas storage and administration areas.
K 923 · May 7, 2025 · Corrected (the home has a date of correction)
- D
Provide properly protected cooking facilities.
K 324 · May 7, 2025 · Corrected (the home has a date of correction)
- D
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
K 914 · May 7, 2025 · Corrected (the home has a date of correction)
- F
Meet other general requirements.
K 100 · July 11, 2024 · Corrected (the home has a date of correction)
- F
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
K 321 · July 11, 2024 · Waiver
- F
Have a complete alarm system manually initiated and initiated by fire sprinkler system connection.
K 342 · July 11, 2024 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · July 11, 2024 · Corrected (the home has a date of correction)
- F
Install corridor and hallway doors that block smoke.
K 363 · July 11, 2024 · Waiver
- F
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
K 761 · July 11, 2024 · 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 11, 2024 · Corrected (the home has a date of correction)
- F
Have proper medical gas storage and administration areas.
K 923 · July 11, 2024 · Corrected (the home has a date of correction)
- F
Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk.
K 926 · July 11, 2024 · Corrected (the home has a date of correction)
- E
Install smoke barrier doors that can resist smoke for at least 20 minutes.
K 374 · July 11, 2024 · Corrected (the home has a date of correction)
- E
Have properly installed electrical wiring and gas equipment.
K 511 · July 11, 2024 · Corrected (the home has a date of correction)
- D
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
K 914 · July 11, 2024 · Corrected (the home has a date of correction)
- D
Ensure proper usage of power strips and extension cords.
K 920 · July 11, 2024 · Corrected (the home has a date of correction)