Health inspections
Federal rules call for a standard inspection at least every 15 months, plus a visit whenever a complaint is filed. Each mark below is one citation, colored by how serious inspectors rated it. How to read a citation.
Under each citation, the quoted text is the inspector's own summary from the federal statement of deficiencies (CMS form 2567), word for word apart from a privacy scrub; CMS removes residents' and staff names before it publishes the text. The full notes are on Medicare.gov.
Potential for minimal harm Potential for more than minimal harm Actual harm Immediate jeopardy Found on a complaint visit
Where its citations fall on CMS's grid
CMS rates every citation by how much harm it caused (rows) and how many residents it touched (columns). The count in each box is this home's, across all 35 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
1J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
29D
3E
2F
Potential for minimal harm
0A
0B
0C
April 24, 2026Complaint inspection · 1 citation
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on closed record review, and interview the facility failed to ensure a wound treatment was implemented timely. This affected one (Resident #93) of three residents reviewed for wounds. The facility census was 91.
January 8, 2026Standard inspection, Complaint inspection · 11 citations
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on record review, review of facility risk management investigations, interview, and policy review, the facility failed to ensure allegations/ incidents of potential resident to resident physical abuse were reported to the State survey agency as required. This affected one (Resident #1) of two residents reviewed for abuse.
- 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, resident and staff interviews, and policy review, the facility failed to ensure resident-centered care plans were individualized and comprehensively addressed all areas of the residents' care this affected two residents (Residents #17 and #65) of 28 residents reviewed for care plans. The facility census was 88. Findings Include: 1. Review of the medical record for Resident #17 revealed an admission date of 04/05/2024 with diagnoses including Ogilvie syndrome (intestinal pseudo-obstruction), schizoaffective disorder, major depressive disorder, suicidal ideations, insomnia, hypertensive heart disease, and anxiety disorder. Review of the quarterly Minimum Data Set (MDS) assessment completed on 12/22/25 revealed Brief Interview for Mental Status (BIMS) score of 15 indicating he was cognitively intact. [...]
- D
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Inspectors wroteBased on record review, observations and interviews the facility failed to ensure residents were provided with timely hygiene care to removing facial hair. This affected two residents (Residents #36 and #55) of the four residents reviewed for activities of daily living. The facility census was 88.
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on record review, observation, policy review, and staff interview, the facility failed to ensure a wound was properly identified as a pressure ulcer. This affected one (Resident #4) of three residents reviewed for pressure ulcers. The facility census was 88. Findings Include:Review of the medical record for Resident #4 revealed an admission date of 06/06/25 with diagnoses including inflammatory disorders of scrotum, gangrene Fournier, dementia, and cerebral infarction. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #4 was at risk for pressure ulcers and the resident had one or more pressure ulcers. [...]
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on record review, observation, staff interview, and policy review, the facility failed to ensure residents did not smoke in an area that also had residents with portable oxygen on. This affected one (Resident #23) of one residents reviewed for smoking. The facility also failed to ensure fall prevention interventions were implemented as per the plan of care for a resident with the history of falls. This affected one (Resident #35) of four residents reviewed for falls.
- D
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Inspectors wroteBased on interview, record review, and review of facility policy the facility failed to timely complete an ordered urinalysis laboratory test and appropriately address a urinary tract infection (UTI) for Resident #52. This affected one resident (#52) of three residents reviewed for UTI's. The facility census was 88.
- D
Provide enough food/fluids to maintain a resident's health.
Inspectors wroteBased on record review, staff interview, and policy review, the facility failed to adequately monitor the nutritional status of a resident with the history of a significant weight loss. This affected one (Resident #37) of one residents reviewed for nutrition. The census was 88.
- D
Provide safe, appropriate pain management for a resident who requires such services.
Inspectors wroteBased on interview and record review the facility failed to prevent duplicate pain medication orders and when administering as needed medications they failed to attempt nonpharmacological interventions and describe the pain for Resident #2 and #5. This affected two residents (#2 and #5) of one of five residents reviewed for unnecessary medications and one of one resident reviewed for pain. The facility census was 88.
- D
Ensure medication error rates are not 5 percent or greater.
Inspectors wroteBased on observation, medical record review, staff interview, manufacturer guide review, and facility policy review, the facility failed to ensure medication error rate was less than five percent. There were two observed medication errors of 28 opportunities observed, resulting in a 7.14 percent medication error rate. This affected one Resident (#103) out of three residents reviewed for medication administration and had the potential to affect 15 residents who received insulin at the facility. Facility census was 88. Findings Include:Review of the medical record for Resident #103 revealed an admission date of 12/31/25 with diagnoses including alcoholic hepatitis without ascites, Type II Diabetes Mellitus, and heart failure. [...]
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview and record review, the facility failed to follow enhanced barrier precautions (EBP) as guided by the Centers for Disease Control and Prevention (CDC) for Resident #4 and failed to ensure hand hygiene was performed during catheter care for Resident #9. This affected two of five residents reviewed for infection control. The facility census was 88.
- 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 and interview the facility failed to ensure Resident #52 ' s wheelchair was maintained in a clean and sanitary manner. This affected one resident (#52) of three residents reviewed for environment. The facility census was 88.
November 17, 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 observations, medical record review, staff interview, and facility policy review, the facility failed to report an alleged violation to the state department of health in a timely manner. This affected one (Resident #43) of three incidents reviewed. The census was 93. Findings Include: Observation on 11/17/25 at approximately 11:55 A.M. revealed Resident #43 lying in bed with a white towel lying over her right shoulder/upper arm area. She was observed with a slight grimace as if in pain. Resident #43 was admitted to the facility on [DATE]. [...]
August 19, 2025Complaint inspection · 2 citations
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on observations, interviews, record reviews, and review of facility policy, the facility failed to ensure wound care treatment and assessments were appropriately implemented and completed. This affected one resident (#76) out of three residents reviewed for wound care. The facility census was 93. Record review for Resident #76 revealed the resident was admitted to the facility on [DATE] and had diagnoses which included Parkinsonism, dementia, and dysphagia. Review of the quarterly Minimum Data Set (MDS) assessment, dated 07/01/25, revealed the resident was assessed to have impaired cognition. Review of the nurses' progress note, dated 04/07/25, revealed right thigh healed. Treatment orders discontinued. Review of the care plan, revised 06/25/25, revealed the resident was at risk for impaired skin integrity. Interventions included blister to right thigh (05/10/25). [...]
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on record reviews and staff interview, the facility failed to ensure residents remained free from burns. This affected one resident (#76) out of three residents reviewed for accidents. The facility census was 93. Record review for Resident #76 revealed the resident was admitted to the facility on [DATE] and had diagnoses which included Parkinsonism, dementia, and dysphagia. Review of the quarterly Minimum Data Set (MDS) assessment, dated 07/01/25, revealed the resident was assessed to have impaired cognition. Review of the nurses progress note, dated 02/20/25, revealed Resident #76 had spilled coffee on himself during lunch. The resident would not allow staff to remove his pants to assess the area where coffee had spilled. Review of the nurse progress note, dated 02/20/25, revealed Resident #76 had been brought back from the dining area after he had spilled coffee on himself. [...]
June 24, 2025Complaint inspection · 1 citation
- D
Provide timely, quality laboratory services/tests to meet the needs of residents.
Inspectors wroteBased on interview and closed medical record review, the facility failed to ensure blood draw orders were obtained for Resident #110 who was receiving Vancomycin (strong antibiotic) intravenously per standards of care. This affected one (Resident #110) of three residents reviewed for intravenous medication administration. The facility census was 97.
May 6, 2025Complaint inspection · 9 citations
- E
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteBased on observation, medical record review, policy review and interview, the facility failed to ensure residents were treated with dignity and respect. This affected three residents (#12, #30 and #31) observed for incontinence care and one resident (#45) of one resident self-propelling in the hallway. The facility census was 87.
- E
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Inspectors wroteBased on observation, medical record review, controlled drug sheet review, policy review and interview, the facility failed to ensure a comprehensive program to safeguard controlled substances and ensure medications were administered as ordered. This affected four residents (#18, #21, #38 and #102) sampled during reconciliation of controlled substances and one resident (#36) of three residents reviewed for infection. The census was 87.
- D
Protect each resident from the wrongful use of the resident's belongings or money.
Inspectors wroteTHE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on observation, self-reported incident (SRI) review, medical record review, policy review and interview, the facility failed to safeguard controlled substances to prevent misappropriation. This affected one resident (Resident #13) of three residents identified in a self-reported incident. The facility census was 87.
- D
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Inspectors wroteBased on observation, medical record review, policy review and interview, the facility failed to timely assess an indwelling catheter, treat urinary tract infections and provide adequate incontinence care. This affected one resident (#13) of three residents reviewed for urinary tract infections and one resident (#12) of one resident observed for incontinence care. The facility census was 87.
- D
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Inspectors wroteBased on observation, medical record review, policy review and interview, the facility failed to provide adequate care and services for a gastrostomy tube during medication administration. This affected one resident (#51) of three residents with an enteral tube observed for medication administration. The facility census was 87.
- D
Ensure medication error rates are not 5 percent or greater.
Inspectors wroteBased on observation, medical record review, policy review and interview, the facility failed to provide adequate care and services for a gastrostomy tube. This affected one resident (#51) of three residents observed for medication administration with 12 errors out of 25 opportunities resulting in an error rate of 48%. The census was 87.
- 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 observation, medical record review, policy review and interview, the facility failed to ensure medications were labeled as required. This affected one resident (#21) of four residents sampled during reconciliation of controlled substances. The census was 87.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on medical record review, policy review and interview, the facility failed to monitor/log infections and possible trends and failed to perform handwashing when indicated. This affected one resident (#30) of three residents observed for incontinence care and one resident (#36) of three residents reviewed for urinary tract infections. The census was 87.
- D
Implement a program that monitors antibiotic use.
Inspectors wroteBased on medical record review, policy review and interview, the facility failed to implement appropriate antibiotic stewardship. This affected one resident (#13) of three residents sampled for infections. The facility census was 87.
June 10, 2024Complaint inspection · 1 citation
- J
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on observation, clinical record review, review of hospital progress notes, staff interview, resident interview, resident representative interview, and review of facility policy, the facility failed to maintain a safe outdoor smoking area for residents assessed to be independent with smoking, failed to ensure Resident #100 was accurately assessed for the ability to safely smoke without supervision, failed to ensure Resident #100 was appropriately assessed for the ability to extinguish herself in the event of a fire (she had hemiplegia and hemiparalysis of the left arm and leg and required assistance from two staff members for transfers), failed to ensure the resident had reasonable access to a fire blankets and/or fire extinguisher, and failed to ensure the resident had the means to obtain assistance in the event of a fire. [...]
May 16, 2024Standard inspection · 4 citations
- F
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, staff interview and facility policy review, the facility failed to ensure multi use vials of tuberculin purified protein derivative (PPD) were dated when they were opened. This had the potential to affect all 93 residents in the facility. The census was 93.
- 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, staff interview, and facility policy review, the facility failed to ensure food was not expired and was stored appropriately. Additionally, the facility failed to ensure staff practiced proper hand hygiene when handling food. This had the potential to affect all 93 residents who resided in the facility. The facility identified all 93 residents received meals from the kitchen. The census was 93.
- E
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Inspectors wroteBased on review of the menu, review of the dietary spreadsheet, observations, staff interview, and review of facility policy, the facility failed to ensure the menu was followed. This affected 23 residents (Residents #1, #3, #6, #10, #13, #18, #22, #32, #36, #40, #41, #43, #45, #50, #59, #63, #69, #77, #81, #85, #153, #247, and #299) who were ordered a dysphagia advanced, mechanical soft, or pureed diet. The facility census was 93.
- D
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Inspectors wroteTHIS DEFICIENCY REPRESENTS AN INCIDENCE OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on medical record review, review of a Self-Reported Incident, resident interview, staff interview, and facility policy review, the facility failed to ensure a resident was free from physical restraints. This affected one (Resident #56) out of one resident reviewed for abuse. The census was 93.
June 30, 2022Standard inspection · 5 citations
- D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteBased on medical record review, staff interview, and facility policy review, the facility failed to allow a resident who smoked, the opportunity to smoke. This affected one resident (Resident #86) of one resident reviewed for resident rights. Findings Include: Resident #86 was admitted to the facility on [DATE] with diagnoses including cerebral infarctions, dissection of vertebral artery, hemiplegia and hemiparesis, visual field defects, muscle weakness, tobacco use, hyperlipidemia, and acute ischemic heart disease. Resident #86 was discharged from the facility on 05/04/22. Review of Resident #86 medical records revealed a progress note dated 05/04/22 indicated the resident was to discharge from the facility because he was unable to smoke while in isolation. Review of Resident #86's medical record revealed no evidence the resident was assessed for smoking safely at the facility. [...]
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on observation, interview, and facility policy review, the facility failed to provide adequate nail care and removal of facial hair for Resident #63. This affected one resident (Resident #63) out of two residents reviewed for activities of daily living. Findings Include: Review of the medical record for Resident #63 revealed an admission date of 12/28/20 with diagnoses including chronic obstructive pulmonary disorder, thrombocytopenia, anxiety and schizoaffective disorder. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #63 had moderate cognitive impairment and required extensive assistance of two persons for personal hygiene and was totally dependent on staff for bathing. Review of the plan of care for activities of daily living revealed Resident #63 required assistance with grooming such as shaving and nail care. [...]
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on record review and interview, the facility failed to accurately monitor Resident #61's pressure ulcer. This affected one (Resident #61) out of four reviewed for pressure ulcers. Findings Include: Review of medical record revealed Resident #61 was admitted on [DATE] with diagnoses that included intraspinal abscess and granuloma, sepsis, and scoliosis. Review of Resident #61's admission assessment on 05/11/22 revealed Resident #61 had an area to right buttock that measured two centimeters (cm) long and 6.5 cm wide. Review of a Body assessment dated [DATE] revealed Resident #61 had a suspected deep tissue injury (SDTI) to the right buttock that measured two cm long and 6.5 cm wide. The Skin Integrity Report dated 05/12/22 revealed Resident #61 had a deep tissue injury (DTI) to right buttock that measured 6.5 cm long and two cm wide. [...]
- D
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Inspectors wroteBased on medical record review, staff interview, and facility policy review, the facility failed to provide adequate indication for use of as needed pain medications. This affected two residents (Residents #34 and #80) of five residents reviewed for unnecessary medications. Findings Include: 1. Resident #34 was admitted to the facility on [DATE] with diagnoses including chronic kidney disease, severe sepsis, cellulitis of left lower limb, hypomagnesemia, type II diabetes, atrial fibrillation, morbid obesity, cirrhosis of liver, hypothyroidism, chronic ischemic heart disease, fibromyalgia, anxiety disorder, hypoexmia, cystitis, myoclonus, osteoarthritis, hyperkalemia, anemia, hyperlipidemia, major depressive disorder, dysphagia, hypotension, and edema. Review of Resident #34's Minimum Data Set (MDS) 3.0 assessment, dated 06/23/22, revealed she was cognitively intact. [...]
- D
Provide or obtain dental services for each resident.
Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to provide as needed dental service for Resident #73. This affected one resident (Resident #73) out of two residents reviewed for dental services. Findings Include: Review of the medical record for Resident #73 revealed an admission date of 05/16/22 with diagnoses including chronic respiratory failure, protein calorie malnutrition, lupus and chronic pain. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #73 was cognitively intact with no behaviors. Resident #73 had no problems with chewing or swallowing. Resident #73 had frequent moderate pain and received scheduled and as needed pain medication. [...]
Fire safety inspections
21 fire safety citations on file: 8 on January 8, 2026, 8 on May 16, 2024, 5 on June 30, 2022.
Every fire safety citation21 citations
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · January 8, 2026 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · January 8, 2026 · Corrected (the home has a date of correction)
- F
Have properly installed electrical wiring and gas equipment.
K 511 · January 8, 2026 · 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 · January 8, 2026 · Corrected (the home has a date of correction)
- F
Have a battery powered remote alarm panel in a location accessible by operating personnel.
K 916 · January 8, 2026 · Corrected (the home has a date of correction)
- F
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · January 8, 2026 · Corrected (the home has a date of correction)
- E
Install corridor and hallway doors that block smoke.
K 363 · January 8, 2026 · Corrected (the home has a date of correction)
- E
Ensure proper usage of power strips and extension cords.
K 920 · January 8, 2026 · Corrected (the home has a date of correction)
- F
Provide properly protected cooking facilities.
K 324 · May 16, 2024 · Corrected (the home has a date of correction)
- F
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
K 521 · May 16, 2024 · Waiver
- F
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · May 16, 2024 · Corrected (the home has a date of correction)
- E
Use approved construction type or materials.
K 161 · May 16, 2024 · Corrected (the home has a date of correction)
- E
Have exits that are accessible at all times.
K 271 · May 16, 2024 · Corrected (the home has a date of correction)
- E
Properly install and monitor supervisory attachments on automatic sprinkler systems.
K 352 · May 16, 2024 · Waiver
- E
Inspect, test, and maintain automatic sprinkler systems.
K 353 · May 16, 2024 · Corrected (the home has a date of correction)
- E
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · May 16, 2024 · Corrected (the home has a date of correction)
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · June 30, 2022 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · June 30, 2022 · Corrected (the home has a date of correction)
- F
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
K 521 · June 30, 2022 · Corrected (the home has a date of correction)
- F
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
K 761 · June 30, 2022 · Corrected (the home has a date of correction)
- E
Provide properly protected cooking facilities.
K 324 · June 30, 2022 · Corrected (the home has a date of correction)