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 31 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
1L
Actual harm
1G
0H
0I
Potential for more than minimal harm
20D
7E
2F
Potential for minimal harm
0A
0B
0C
June 25, 2026Complaint inspection · 1 citation
- D
Ensure services provided by the nursing facility meet professional standards of quality.
Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure physician's orders were followed, failed to ensure medications were available from the pharmacy and failed to notify the provider of not giving medications as ordered for 1 of 5 residents (Resident 1) whose medication regimens were reviewed. The failure to ensure orders were followed and medications were made available, placed residents for unnecessary pain, and other negative health outcomes.
April 20, 2026Complaint inspection · 1 citation
- E
Provide or get specialized rehabilitative services as required for a resident.
Inspectors wroteBased on observation, interview and record review, the facility failed to ensure specialized rehabilitative services were provided as determined by the physician's order and the residents' plan of care for 2 of 3 residents (Residents 1 & 2) reviewed for Occupational Therapy (OT) services. This failure placed residents at risk of not attaining, maintaining, or restoring their highest practicable level of physical, mental, functional, and psychosocial well-being.
April 21, 2025Standard inspection · 12 citations
- F
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
Inspectors wroteBased on interview and record review, the facility failed to maintain a Quality Assessment and Assurance (QAA) committee that included the required participants. This failure put residents at risk for unmet care needs due to ongoing non-compliance with federal regulations and detracted from the interdisciplinary effectiveness of the team.
- E
Keep residents' personal and medical records private and confidential.
Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents' medical information was maintained in a manner to ensure privacy and confidentiality when staff failed to properly secure medical records for 3 of 16 sampled residents (Resident 59, 7, & 50) reviewed for privacy and confidentiality and 7 supplemental residents (Residents 30, 66, 264, 9, 38, 56, & 55). The failure to ensure residents' medical appointment and weight information were stored in a secure manner placed residents at risk for a loss of privacy and a diminished quality of life. <Findings> <Facility Policy> Record review of the facility's December 2016 Resident Rights policy showed facility staff were prohibited from disclosing Protected Health Information (PHI - any information that could be used to identify someone and their health care status). [...]
- 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 provide care and services in a manner that maintained and promoted dignity for 1 of 16 sample residents reviewed (Resident 214). This failure placed residents at risk for a diminished sense self-worth and overall well-being.
- D
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Inspectors wroteBased on interview and record review, the facility failed to ensure a system by which residents received required written notices at the time of transfer/discharge, or as soon as practicable for 3 (Residents 63, 23, & 29) of 4 residents reviewed for hospitalizations. Failure to ensure written notification was provided to the resident and/or the resident's representative, in a language and manner they understood, placed residents at risk for not having an opportunity to make informed decisions about transfers/discharges. Additionally, the facility failed to ensure a system by which the Office of the State Long-Term Care Ombudsman (LTCO, an advocacy group for individuals residing in nursing homes) received required resident discharge/transfer information for 3 (Residents 63, 23, & 29) of 4 residents reviewed for hospitalization. [...]
- D
PASARR screening for Mental disorders or Intellectual Disabilities
Inspectors wroteBased on interview and record review, the facility failed to ensure Pre-admission Screening and Resident Review (PASRR - a mental health screening required prior to admission to a nursing home) assessments were completed as required for 2 of 5 residents (Resident 45 & 50) reviewed for PASRR screening. The failure to ensure PASRR screenings were complete and accurate left residents at risk for inappropriate placement and/or not receiving timely and necessary services to meet their mental health care needs.
- 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 observation, interview, and record review the facility to ensure comprehensive Care Plans (CPs) were developed to address all identified resident care needs for 4 (Residents 58, 214, 14, & 45) of 16 residents whose CPs were reviewed. This failure placed residents at risk for unmet care needs and frustration.
- 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 physician's orders were followed for 1 of 5 (Resident 45) residents whose medication regimens were reviewed. The failure to ensure orders were followed placed residents for unneeded treatment, and other negative health outcomes
- 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 provide assistance with Activities of Daily Living (ADLs - daily hygiene and other self-care tasks) for 2 (Residents 13 & 7) of 6 sample residents reviewed for ADLs. The failure to provide ADL assistance residents were assessed to require placed residents at risk for poor hygiene, diminished feelings of self-worth, and other negative health outcomes.
- 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 fall interventions were removed timely when assessed to be unbeneficial for 1 of 3 residents (Resident 50) reviewed for accident hazards and failed to ensure resident mattresses fit the bedframe for 1 of 5 residents (Resident 31) reviewed for positioning. These failures placed residents at risk for falls, injury, and discomfort.
- D
Provide enough food/fluids to maintain a resident's health.
Inspectors wroteBased on interview and record review, the facility failed to ensure 1 of 4 residents (Resident 27), reviewed for nutrition, received timely evaluation of weights, and implementation of effective interventions, to maintain adequate nutrition. This failure placed the residents at risk for ongoing weight loss and poor nutrition and potential harm.
- 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, record review, and interview the facility failed to ensure residents were provided the artificial nutrition they were assessed to require for 1 of 1 residents (Resident 114) reviewed for tube feeding. The failure to ensure the full volume of artificial nutrition ordered was provided daily placed Resident 114 at risk for weight loss and other negative health outcomes.
- D
Provide medically-related social services to help each resident achieve the highest possible quality of life.
Inspectors wroteBased on interview and record review the facility failed to ensure medically-related social services were provided for 1 of 4 residents (Residents 29) reviewed for nutrition. The failure to involve facility social workers for residents demonstrating behaviors of rejection of care placed residents at risk for unmet health needs and other negative health outcomes.
August 13, 2024Complaint inspection · 6 citations
- L
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 staff performed Cardiopulmonary Resuscitation (CPR- an emergency procedure consisting of chest compressions combined with giving breaths of air when the resident's heart stops and they stop breathing) to 1 of 3 residents (Resident 1) reviewed for unexpected death in the facility. [...]
- G
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteBased on interview and record review the facility failed to treat residents with dignity and respect and provide a dignified existence that promoted quality of life for 1 of 1 resident (Resident 2) reviewed for resident rights. The failure to have a process for staff to provide a comfortable environment for residents after the death of a roommate, placed residents at risk of feeling scared, unsafe, distressed, and have a diminished quality of life. Resident 2 was harmed, using the reasonable person concept, when their roommate (Resident 1) died and they were left in the same room with the deceased resident from 10:00 PM on [DATE] until 5:30 PM on [DATE], 19.5 hours. Resident 2 was placed in a situation to cause harm to their mental well-being, safety, and dignity when they were not separated from their dead roommate's body.
- F
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Inspectors wroteBased on interview and record review the facility failed to ensure nursing staff and nursing aide staff had the appropriate competencies and skill sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physician, mental and psychosocial well-being of each resident according to the facility assessment, resident-specific assessments and resident plans of care for 11 of 11 staff (Staff K, L, E, M, H - Certified Nursing Assistants and Staff C, N, G, D, O, P - Licensed Nurses) reviewed for competency. The failure to develop and implement a process to evaluate staff's competency and skills to perform job expectations placed residents at risk for accidents, injuries, infections, diminished quality of life, and diminished quality of care.
- 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 violations of alleged neglect, involving serious bodily injury, were reported immediately to the state survey agency in accordance with State law for 1 of 3 residents (Resident 1) who did not receive CPR when there was a Physician Order (PO) directing staff to perform Cardiopulmonary Resuscitation (CPR- an emergency procedure consisting of chest compressions combined with giving breaths of air when the resident's heart stops and they stop breathing). The facility's failure to identify and report alleged neglect after a catastrophic change in condition, that involved the death of Resident 1, placed 39 of 48 other residents who had POs to receive CPR, at serious risk of harm including death.
- E
Respond appropriately to all alleged violations.
Inspectors wroteBased on interview and record review the facility failed to timely initiate, document, and complete a thorough investigation involving an incident of serious bodily injury for 1 of 3 residents (Resident 1) reviewed for investigations of abuse and neglect. There was no investigation completed to rule out abuse or neglect or to determine the need for system interventions. The failure to investigate the system failure related to the lack of implementing the facility CPR policy placed 39 of 48 other residents at serious risk of harm, including death.
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on interview and record review the facility failed to ensure 1 of 3 residents (Resident 3) received care, consistent with professional standards of practice, to prevent Pressure Ulcers/Pressure Injuries (PU/PI, localized damage to the skin and underlying tissue from prolonged pressure, friction, or shear, causing pain). The failure to identify individual risk factors related to diagnoses, implement resident-specific interventions and ensure prevention of PU/PIs placed residents at risk for harm related to serious injury, development of pressure ulcers, medical complications, and diminished quality of life. [...]
March 22, 2024Standard inspection · 8 citations
- E
PASARR screening for Mental disorders or Intellectual Disabilities
Inspectors wroteBased on interview and record review, the facility failed to ensure a Pre-admission Screening and Resident Review (PASRR - a process to determine if a potential nursing home resident had mental health/intellectual disability needs which required further assessment/treatment) assessment was accurate to reflect the residents' mental health conditions for 3 of 5 (Resident 16, 111, & 35) residents reviewed for PASRR. This failure placed residents at risk for inappropriate nursing home placement and/or not receiving timely and necessary services to meet their mental health needs.
- 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 observation, interview, and record review, the facility failed to have sufficient nurse staff to provide and supervise care of residents as evidenced by information provided in a Resident/Surveyor interview, for 4 residents (Residents 35, 37, 46, & 4) interviewed for call light response time. This failure to ensure staff answered residents call lights in a timely manner placed residents at risk for unmet care needs and accidents.
- E
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 records were complete, accurate, and readily accessible for 6 (Residents 7, 11, 31, 5, 25, & 35) of 17 residents whose records were reviewed. The failure to ensure resident records were complete and up to date to reflect the current resident conditions and care provided placed residents at risk for inaccurate assessments, poor coordination of care and unmet needs.
- D
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 interview and record review the facility failed to ensure residents had the appropriate Advance Directive (AD) in place for 3 of 5 residents (Residents 33, 35, & 50) reviewed for ADs. The facility failed to obtain a copy from residents (Resident 33, 35, & 50) with an existing AD and make the documentation readily available in the medical records and accessible to facility staff. These failures placed residents at risk of losing their right to have their stated preferences/decisions honored regarding medical treatment and end-of-life care.
- D
Assess the resident when there is a significant change in condition
Inspectors wroteBased on interview and record review, the facility failed to ensure a Significant Change in Status Assessment (SCSA), including Care Area Assessments, were completed within 14 days for 1 of 1 resident (Resident 31) reviewed for a recent hospitalization, decline in nutritional intake, and a change in skin integrity. Failure to identify Resident 31's change in status and to complete a SCSA placed the resident at risk for unidentified and/or unmet care needs.
- D
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Inspectors wroteBased on interview and record review, the facility failed to complete and/or transmit the required Minimum Data Set (MDS - an assessment tool) data to the Center for Medicare and Medicaid Services (CMS) within the required time frames for 4 of 7 sampled residents with discharges (Residents 34, 65, 63 & 64) reviewed for resident assessments.
- D
Ensure each resident receives an accurate assessment.
Inspectors wroteBased on observation, interview, and record review the facility failed to ensure 3 (Residents 31, 11, & 35) of 17 residents Minimum Data Set (MDS - an assessment tool) were completed accurately to reflect the resident's condition. This failure placed residents at risk for unidentified and/or unmet needs.
- D
Ensure services provided by the nursing facility meet professional standards of quality.
Inspectors wroteBased on observation, interview, and record review the facility failed to ensure Physician's Orders (POs): were obtained prior to administration of medications for 1 (Resident 110) of 3 sample residents; were clarified for 1 (Resident 111) of 14 sample residents; were not administered outside of parameters for 2 (Resident 31 & 7) of 14 sample residents reviewed. These failures placed residents at risk for medication errors, delayed treatment, and adverse outcomes.
February 24, 2023Standard inspection · 3 citations
- D
Ensure services provided by the nursing facility meet professional standards of quality.
Inspectors wroteBased on observation, interview, and record review the facility failed to ensure services provided met professional standards of practice for 4 of 12 (Residents 17, 20, 23, & 39) residents reviewed. Nursing staff failed to follow or clarify physician's orders when indicated and failed to complete an oral assessment and identify safety risks of loose teeth/dentures. These failures placed residents at risk for treatment errors, delayed treatment, omission of treatments, and adverse outcomes.
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on observation, interview, and record review the facility failed to ensure 2 of 3 residents (Residents 5 & 23) reviewed for Pressure Ulcers (PUs) received the necessary treatment and services consistent with professional standards of practice. The failure to initiate appropriate and timely interventions left residents at risk for unidentified wound decline, discomfort, and diminished quality of life.
- D
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Inspectors wroteBased on observation, interview, and record review the facility failed to ensure restorative services were consistently provided for 1 of 2 sampled residents (Resident 20) reviewed for range of motion (ROM) treatment and services. This failure placed residents at risk of further decline in ROM, loss of function, and/or permanent immobility.
Fire safety inspections
27 fire safety citations on file: 13 on April 21, 2025, 3 on March 22, 2024, 11 on February 24, 2023.
Every fire safety citation27 citations
- F
Address subsistence needs for staff and patients.
E 15 · April 21, 2025 · Corrected (the home has a date of correction)
- F
Establish policies and procedures for sheltering.
E 22 · April 21, 2025 · Corrected (the home has a date of correction)
- F
Establish policies and procedures for medical documentation.
E 23 · April 21, 2025 · Corrected (the home has a date of correction)
- F
Establish methods for sharing information.
E 33 · April 21, 2025 · Corrected (the home has a date of correction)
- F
Provide a means of sharing information on occupancy/needs.
E 34 · April 21, 2025 · Corrected (the home has a date of correction)
- F
Provide family notifications of emergency plan.
E 35 · April 21, 2025 · Corrected (the home has a date of correction)
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · April 21, 2025 · Corrected (the home has a date of correction)
- F
Provide a written emergency evacuation plan.
K 711 · April 21, 2025 · Corrected (the home has a date of correction)
- F
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · April 21, 2025 · Corrected (the home has a date of correction)
- E
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
K 761 · April 21, 2025 · 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 · April 21, 2025 · Corrected (the home has a date of correction)
- D
Inspect, test, and maintain automatic sprinkler systems.
K 353 · April 21, 2025 · Corrected (the home has a date of correction)
- D
Ensure proper usage of power strips and extension cords.
K 920 · April 21, 2025 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · March 22, 2024 · Corrected (the home has a date of correction)
- D
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · March 22, 2024 · Corrected (the home has a date of correction)
- D
Install properly constructed and protected linen or trash chutes.
K 541 · March 22, 2024 · Corrected (the home has a date of correction)
- F
Develop and maintain an Emergency Preparedness Program (EP).
E 4 · February 24, 2023 · Corrected (the home has a date of correction)
- F
Establish procedures for tracking staff and patients during an emergency.
E 18 · February 24, 2023 · Corrected (the home has a date of correction)
- F
Establish emergency prep training and testing.
E 36 · February 24, 2023 · Corrected (the home has a date of correction)
- F
Establish staff and initial training requirements.
E 37 · February 24, 2023 · Corrected (the home has a date of correction)
- F
Conduct testing and exercise requirements.
E 39 · February 24, 2023 · Corrected (the home has a date of correction)
- F
Have simulated fire drills held at unexpected times.
K 712 · February 24, 2023 · 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 · February 24, 2023 · Corrected (the home has a date of correction)
- F
Ensure that testing and maintenance of electrical equipment is performed.
K 921 · February 24, 2023 · 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 · February 24, 2023 · Corrected (the home has a date of correction)
- D
Meet other general requirements.
K 100 · February 24, 2023 · Corrected (the home has a date of correction)
- D
Install corridor and hallway doors that block smoke.
K 363 · February 24, 2023 · Corrected (the home has a date of correction)