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 42 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
1J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
16D
16E
3F
Potential for minimal harm
0A
1B
5C
April 16, 2026Complaint inspection · 1 citation
- D
Ensure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge.
Inspectors wroteBased on review of clinical records, facility policy, and staff interviews, it was determined that the facility failed to permit one of three residents reviewed to return to the facility after hospitalization (Resident R1).
March 13, 2026Standard inspection · 2 citations
- E
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 clinical records, medication regimen reviews, and staff interviews, it was determined that the facility failed to respond in a timely manner to pharmacy recommendations for two of five residents (Resident R2 and R22).
- D
Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.
Inspectors wroteBased on review of facility document, personnel in-service training records, and staff interviews it was determined that the facility failed to provide training on the Quality Assurance and Performance Improvement (QAPI) program for three of ten staff members (Employee E1, E2, E3).
May 29, 2025Complaint inspection · 1 citation
- D
Ensure that residents are free from significant medication errors.
Inspectors wroteBased on review of facility policy, clinical record review, and staff interview, it was determined that the facility failed to make certain that residents are free of significant medication errors for one of three residents (Resident R1). Review of facility policy Medication Monitoring dated 3/14/25, indicated staff monitor and document events including medication error. Review of the clinical record indicated Resident R1 was admitted to the facility on [DATE]. Review of the Minimum Data Set (MDS - periodic assessment of resident care needs) dated 3/12/25, included diagnoses of peritoneal abscess (abscess near the large bowel), colitis (inflammation in the colon), and high blood pressure. Review of the provider orders reveal the residents Total Parenteral Nutrition (TPN) is to run a cycle for twelve hours from 9 p.m. to 9 a.m. daily. [...]
April 18, 2025Standard inspection, Complaint inspection · 22 citations
- F
Observe each nurse aide's job performance and give regular training.
Inspectors wroteBased on review of personnel records and staff interview it was determined that the facility failed to provide nursing staff annual performance evaluations based on the date of hire for five of five nurse aides (Employees E11, E12, E13, E14, and E15).
- E
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteBased on facility policy, resident interviews, observation, and staff interviews, it was determined that the facility failed to provide prompt assistance to meet residents care needs for three of fourteen residents who require care (Residents R63, R67, and R8).
- E
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on review of facility policy, facility records, and resident and staff interviews, it was determined that the facility failed to provide Activity of Daily Living (ADL) assistance for 15 of 22 residents as required (Resident R500, R501, R502, R503, R504, R505, R506, R507, R508, R509, R8, R68, R69, R125, and R243).
- 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 review of facility policy, observations, and staff interview, it was determined that the facility failed to make certain that medications were properly stored and/or disposed of in the unused dining room on the first floor.
- 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 a review of facility policies, the Four-week Spring Summer (SS) cycle menu diet extension sheets, and staff interviews it was determined that the facility failed to follow a preplanned cycle menu (lunch meal on 4/14/25), as required and failed to provide resident's their preferences and standing order food choices (Residents R47 and R90).
- E
Include as part of its infection prevention and control program, mandatory training that includes written standards, policies, and procedures for the program.
Inspectors wroteBased on review of facility policy, personnel in-service training records, and staff interview, it was determined that the facility failed to provide training on Infection Control for seven of ten staff members (Employee E11, E13, E14, E15, E16, E17, and E18).
- E
Provide behavior health training consistent with the requirements and as determined by a facility assessment.
Inspectors wroteBased on review of facility policy, personnel in-service training records, and staff interview, it was determined that the facility failed to provide training on behavioral health for eight of ten staff members (Employee E11, E12, E13, E15, E16, E17, E18, and E19).
- 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 review of facility policy, clinical records, and resident and staff interviews, it was determined that the facility failed to notify the resident representative of changes in appointment and transportation times for one of four residents (Resident R69).
- D
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Inspectors wroteBased on review of facility policy , observations, and staff interviews it was determined that the facility failed to maintain a homelike environment in the facility (resident dining rooms) for one of four resident dining locations (first floor nursing unit).
- D
Ensure the activities program is directed by a qualified professional.
Inspectors wroteBased on staff interviews and review of facility provided documentation, it was determined the facility failed to provide a qualified professional to direct the activities program as required for one of 12 months (3/3/25 through 4/14/25).
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on review of facility policies and documents, clinical records, and staff interviews, it was determined that the facility failed to provide care and services after hospitalization for one of three residents (Resident R68). Review of the clinical record indicated that Resident R68 was admitted to the facility on [DATE]. Review of the Minimum Data Set (MDS - periodic assessment of resident care needs) dated 3/24/25, included diagnoses of anemia (too little iron in the body causing fatigue), chronic kidney disease (gradual loss of kidney function), and osteomyelitis (inflammation of bone or bone marrow, usually due to infection). Review of hospital discharge instructions dated 3/19/25, indicated for the facility to reinforce the dressing. No direction for changing the dressing was documented. Review of a progress note dated 3/20/25, at 9:07 a.m. [...]
- D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Inspectors wroteBased on review of facility policy, clinical records, and staff interview, it was determined that the facility failed to implement procedures to ensure availability of prescribed medications for one of five residents (Residents R244).
- D
Make sure that a working call system is available in each resident's bathroom and bathing area.
Inspectors wroteBased on review of facility policy, observations, and staff interviews, it was determined that the facility failed to ensure that the call bell system was in full working order for one of four nursing units (Second Floor Nursing unit).
- 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 staff interview, it was determined that the facility failed to ensure a safe, functional and clean environment for two of 33 residents of the Third floor B wing nursing unit (Resident R99 and R112).
- D
Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.
Inspectors wroteBased on review of facility policy, personnel in-service training records, and staff interview, it was determined that the facility failed to provide training on Prevention of Abuse and Neglect for one of ten staff members (Employee E18).
- D
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
Inspectors wroteBased on review of facility policy, staff education records, and staff interviews, it was determined that the facility failed to conduct at least 12 hours of in-service education, within 12 months of their hire date anniversary, for nurse aides as required for two of five nurse aides (Employees Employee E11 and E15).
- C
Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.
Inspectors wroteBased on observation and staff interview, it was determined the facility failed to ensure the Department of Health most recent survey results were readily accessible to residents and visitors, for four of four locations (first floor lobby, nursing units ground, second and third floors). Findings Include: During an observation on 4/14/25, at 9:20 a.m. in the lobby, no survey result book could be located. During an observation on 4/14/25, at 9:25 a.m. on the second floor, no survey result book could be located. During an observation on 4/14/25, at 9:28 a.m. on the third floor, no survey result book could be located. During an observation on 4/14/25, at 9:32 a.m. on the ground floor, no survey result book could be located. During an interview on 2/12/25, at 9:25 a.m. [...]
- C
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Inspectors wroteBased on review of facility policy, posted documents, observations, resident and staff interviews, it was determined that the facility failed to make certain grievance/concern forms can be filed anonymously for all residents and/or their representatives on five of five locations where grievance/complaint forms are provided (four nursing units and the lobby).
- C
Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members.
Inspectors wroteBased on review of facility policy, personnel in-service training records, and staff interview, it was determined that the facility failed to provide training on Effective Communication for seven of eight staff members (Employee E11, E12, E13, E14, E15, E16, and E19).
- C
Ensure that staff members are educated on resident rights and facility responsibilities to properly care for its residents.
Inspectors wroteBased on review of facility policy, personnel in-service training records, and staff interview, it was determined that the facility failed to provide training on Resident Rights for eight of ten staff members (Employee E11, E12, E13, E14, E15, E16, E17, E19, and E20).
- C
Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.
Inspectors wroteBased on review of facility policy, personnel in-service training records, and staff interview, it was determined that the facility failed to provide training on Quality Assurance and Performance Improvement (QAPI) for ten of ten staff members (Employee E11, E12, E13, E14, E15, E16, E17, E18, E19, and E20).
- B
Provide training in compliance and ethics.
Inspectors wroteBased on review of facility policy, personnel in-service training records, and staff interview, it was determined that the facility failed to provide training on Compliance and Ethics for four of ten staff members (Employee E11, E15, E16, and E19).
December 19, 2024Complaint inspection · 4 citations
- E
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on observations and resident and staff interviews, it was it was determined that the facility failed to make certain that residents were provided appropriate treatment and care for five of ten residents (Resident R1, R2, R3, R4, and R5).
- 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 review of facility policy and resident interviews and observations, it was determined that the facility failed to ensure sufficient staffing to meet resident need for ten of thirteen residents (Resident R2, R6, R7, R8, R9, and R10, and four confidential residents: RB, RC, RD, and RE).
- D
Have a plan that describes the process for conducting QAPI and QAA activities.
Inspectors wroteBased on a review of facility documentation, cited deficiencies from previous surveys, review of plan of correction documentation, and staff interview, it was determined that the facility ' s Quality Assurance and Performance Improvement (QAPI) program failed to correct previously cited deficiencies. This has the potential to affect 16 of 140 residents.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, manufacturer ' s instructions, and staff interviews, it was determined that the facility failed to consistently maintain an infection prevention and control program, which ensured proper cleaning and disinfecting of glucometers (a device used to test the amount of sugar in a person's blood) to prevent the potential for cross-contamination for one of three medication carts (Third Floor Cart Rooms 308-321).
October 11, 2024Complaint inspection · 1 citation
- J
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 review of the American Heart Association (AHA) Guidelines, clinical records, facility policies, and staff interviews it was determined that the facility failed to ensure consistent care by initiating Cardio Pulmonary Resuscitation (CPR) to an unresponsive resident for one of eighty-seven residents (Resident R1), resulting in immediate jeopardy.
July 9, 2024Complaint inspection · 1 citation
- F
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 staff interviews, it was determined that the facility failed to ensure a clean, sanitary, functional environment in the main laundry room.
April 8, 2024Complaint 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 clinical and facility record review, facility submitted documents, and staff interviews, it was determined that the facility failed to provide adequate supervision to be aware of resident's departure from the facility for one of seven residents (Resident R1). Review of the clinical record revealed Resident R1 was admitted to the facility on [DATE]. Review of the Minimum Data Set (MDS - periodic assessment of resident care needs) dated 2/11/24, included diagnoses of high blood pressure and obesity. Review of an Elopement Risk Assessment completed on 11/10/23, indicated Resident R1 was not risk for elopement. Review of Resident R1's plan of care for Potential for Discharge initiated 11/9/23, indicated that Resident R1 will be discharged home when clinical and rehabilitation goals are met. [...]
March 22, 2024Standard inspection · 9 citations
- F
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on review of dish machine temperature/sanitation logs, observations, and staff interviews, it was determined that the facility failed to follow proper sanitation and temperature procedures for the dish machine operation allowing for the potential for cross contamination in the main kitchen for seven of nine months (July 2023, August 2023, October 2023, November 2023, January 2024, February 2024 and March 2024).
- E
Honor the resident's right to organize and participate in resident/family groups in the facility.
Inspectors wroteBased on review of facility policy, resident group meeting and resident and staff interview, it was determined that the facility failed to demonstrate a response to grievances for resident group meeting for five of six residents held during the annual survey (Residents R100, R101, R102, R103, R104).
- E
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Inspectors wroteBased on review of the facility policy and clinical records and staff interviews, it was determined that the facility failed to provide the opportunity to formulate an advance directive (written instructions such as a living will or durable power of attorney for health care for when the individual is incapacitated) for eight of the twelve residents reviewed (Resident R16, R21,R29, R32, R39, R44, R47, R67, R68, R127, R134, R142). Findings Include: A review of the facility policy Advanced Directives on 7/19/2023, 1/23/2024, indicated the facility will comply with the requirements related to maintaining written policies and procedures regarding advance directives, including provisions to inform and provide written information to all adult residents concerning the right to accept or refuse medical or surgical treatment and formulate an advance directive. [...]
- E
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Inspectors wroteBased on the facility policy, observations, Resident group meeting and staff interview, it was determined that the facility failed to provide residents access to grievance forms, failed to provide the right to file grievances anonymously, and failed to post the name of the Grievance Official for residents to file a grievance orally (meaning spoken) for 155 of 155 residents at the facility.
- E
Respond appropriately to all alleged violations.
Inspectors wroteBased on review of facility policy, review of resident council meeting minutes, facility concern/grievance log and clinical records, and resident and staff interviews, it was determined that the facility failed to investigate potential abuse and/or neglect for three of 35 residents(Resident R209, R302 and R37).
- E
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on observations and resident and staff interviews, it was it was determined that the facility failed to make certain that residents were provided appropriate treatment and care for four of four residents (Resident R20, R45, R83, and R145).
- 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 review of facility policy, Centers for Disease Control (CDC) documents, observations, and staff interview, it was determined that the facility to make certain that medications and medical supplies were properly stored and/or disposed of on one of two nursing units (Second-Floor Nursing Unit).
- E
Provide and implement an infection prevention and control program.
Inspectors wroteBased on facility policy, observation, and staff interview, it was determined that the facility failed to provide a safe and sanitary environment to help prevent the potential for cross-contamination for two of four medication carts (2nd A/B Hall Treatment Cart and B/C Hall Treatment Cart).
- D
Provide enough food/fluids to maintain a resident's health.
Inspectors wroteBased on review of clinical records and staff interviews, it was determined that the facility failed to make certain that weight loss was identified and addressed and failed to identify needs for increased nutrition for one of five residents (Residents R78).
Fire safety inspections
34 fire safety citations on file: 18 on March 13, 2026, 6 on April 18, 2025, 10 on March 22, 2024.
Every fire safety citation34 citations
- F
Establish emergency prep training and testing.
E 36 · March 13, 2026 · Corrected (the home has a date of correction)
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · March 13, 2026 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · March 13, 2026 · Corrected (the home has a date of correction)
- F
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
K 914 · March 13, 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 · March 13, 2026 · 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 · March 13, 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 · March 13, 2026 · Corrected (the home has a date of correction)
- E
Install corridor and hallway doors that block smoke.
K 363 · March 13, 2026 · Corrected (the home has a date of correction)
- E
Install smoke barrier doors that can resist smoke for at least 20 minutes.
K 374 · March 13, 2026 · Corrected (the home has a date of correction)
- D
Have properly located and lighted "Exit" signs.
K 293 · March 13, 2026 · Corrected (the home has a date of correction)
- D
Have an enclosure around a vertical opening shaft.
K 311 · March 13, 2026 · Corrected (the home has a date of correction)
- D
Provide properly protected cooking facilities.
K 324 · March 13, 2026 · Corrected (the home has a date of correction)
- D
Meet requirements for the installation and maintenance of electrical systems.
K 911 · March 13, 2026 · Corrected (the home has a date of correction)
- D
Have power receptacles that are properly grounded.
K 912 · March 13, 2026 · Corrected (the home has a date of correction)
- C
Conduct testing and exercise requirements.
E 39 · March 13, 2026 · Corrected (the home has a date of correction)
- C
Meet other general requirements.
K 100 · March 13, 2026 · Corrected (the home has a date of correction)
- C
Install emergency lighting that can last at least 1 1/2 hours.
K 291 · March 13, 2026 · Corrected (the home has a date of correction)
- C
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
K 761 · March 13, 2026 · Corrected (the home has a date of correction)
- E
Inspect, test, and maintain automatic sprinkler systems.
K 353 · April 18, 2025 · Corrected (the home has a date of correction)
- D
Have power receptacles that are properly grounded.
K 912 · April 18, 2025 · Corrected (the home has a date of correction)
- C
Address patient/client population and determine types of services needed.
E 7 · April 18, 2025 · Corrected (the home has a date of correction)
- C
List the names and contact information of those in the facility.
E 30 · April 18, 2025 · Corrected (the home has a date of correction)
- C
Establish staff and initial training requirements.
E 37 · April 18, 2025 · Corrected (the home has a date of correction)
- C
Conduct testing and exercise requirements.
E 39 · April 18, 2025 · Corrected (the home has a date of correction)
- E
Provide properly protected cooking facilities.
K 324 · March 22, 2024 · Corrected (the home has a date of correction)
- D
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
K 321 · March 22, 2024 · Corrected (the home has a date of correction)
- D
Inspect, test, and maintain automatic sprinkler systems.
K 353 · March 22, 2024 · Corrected (the home has a date of correction)
- D
Install corridor and hallway doors that block smoke.
K 363 · March 22, 2024 · Corrected (the home has a date of correction)
- C
Establish staff and initial training requirements.
E 37 · March 22, 2024 · Corrected (the home has a date of correction)
- C
Implement emergency and standby power systems.
E 41 · March 22, 2024 · Corrected (the home has a date of correction)
- C
Have properly located and lighted "Exit" signs.
K 293 · March 22, 2024 · Corrected (the home has a date of correction)
- C
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · March 22, 2024 · Corrected (the home has a date of correction)
- C
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
K 521 · March 22, 2024 · Corrected (the home has a date of correction)
- C
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · March 22, 2024 · Corrected (the home has a date of correction)