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 39 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
30D
8E
0F
Potential for minimal harm
0A
0B
1C
March 10, 2026Standard inspection, Complaint inspection · 15 citations
- E
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Inspectors wroteBased on observation and interview, the facility failed to ensure that the floors in resident bathrooms were in good repair. This affected 19 (Residents #10, #11, #20, #23, #31, #32, #35, #37, #52, #57, #61, #65, #66, #68, #76, #79, #87, #89, and #93) residents. The facility census was 80.
- E
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Inspectors wroteBased on observation, and interview, the facility failed to ensure food was served at an appetizing temperature and acceptable palatability. This had the potential to affect 78 residents who received meals in the facility. The facility identified Residents #87 and #93 as not receiving food from the kitchen. The facility census was 80.
- E
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on observation, interview and policy review, the facility failed to properly store food. This had the potential to affect 78 residents who received meals in the facility. The facility identified Residents #87 and #93 as not receiving food from the kitchen. The facility census was 80.
- E
Provide and implement an infection prevention and control program.
Inspectors wroteBased on record reviews, staff interview, review of facility infection surveillance logs, and review of facility policy, the facility failed to ensure residents with in-house acquired Clostridium Difficile (C-Diff) infections were reviewed for patterns and trends to decrease the spread of infection. This affected seven residents (#36, #42, #52, #71, #103, #104, and #228) identified by the facility as having acquiring C-Diff infections in the facility since 11/01/2025. The facility census was 80.
- 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 ensure psychotropic medications were ordered for appropriate diagnoses. This affected one resident (#7) out of five reviewed for unnecessary medications. The facility census was 80 at the time of survey.
- 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 record reviews, interviews, and policy review, the facility failed to develop a care plan to address elopement risk. This affected one resident (Resident #61) of one resident reviewed for care plan accuracy. The facility identified five residents at risk for elopement. The facility census was 80.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on medical record review and resident and staff interviews, the facility failed to monitor resident's blood sugars. This had the potential to affect one (Resident #99) of 15 residents the facility identified as diagnosed Type 2 Diabetes Mellitus (T2DM). The facility census was 80 residents.
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on observations, interviews, record reviews, and review of facility policy, the facility failed to ensure wound care orders for the treatment of pressure ulcers were implemented timely and appropriately. This affected one resident (#93) out of the three residents reviewed for pressure ulcers. The facility census was 80.
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on record reviews, interviews, and policy reviews, the facility failed to ensure one resident (Resident #61) was free of elopements. This affected one resident (#61) of four residents reviewed for elopements. The facility census was 80.
- 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 observations, interviews, record reviews, and review of facility policy, the facility failed to ensure tube feedings were administered at the rate ordered by the physician. This affected two residents (#87 and #93) out of the three residents reviewed for tube feeding. The facility census was 80.
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on interview, observation, record review, and facility policy review, the facility failed to ensure orders were in place for oxygen administration. This affected one resident (#6) out of three reviewed for oxygen administration. The facility census was 80 at the time of survey. Findings Include:Review of the medical record revealed Resident #6 was admitted to the facility on [DATE]. Diagnoses included acute and chronic respiratory failure with hypoxia, chronic obstructive pulmonary disorder, type II diabetes mellitus with diabetic neuropathy, and hepatic encephalopathy. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident was mildly cognitively impaired with a BIMS of 08 out of 15, had no behaviors, did not reject care, and did not wander. Observation of Resident #6 on 03/02/2026 at 10:18 A.M. [...]
- D
Ensure that residents are free from significant medication errors.
Inspectors wroteBased on closed record reviews, review of hospital discharge orders, staff interview, and facility policy review, the facility failed to ensure medications were not administered longer than prescribed by the physician. This affected one resident (#103) out of the nine residents reviewed for Clostridium difficile (C-Diff) infections. The facility census was 80.
- 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 record reviews, interviews, and policy reviews, the facility failed to ensure that medications were not left unattended at a resident's bedside. This affected one resident (Resident #31) of 19 residents observed during initial observations. The facility census was 80.
- D
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 medical record review and resident and staff interviews, the facility failed to honor resident meal preferences. This had the potential to affect one (Resident #99) of 78 residents at the facility that receives meals from the kitchen. The facility identified Residents #87 and #93 as not receiving food from the kitchen. The facility census was 80 residents. Observation on 03/03/26 at 12:15 P.M. revealed Resident #99 received lunch meal which included beef tips and mashed potatoes with gravy. Review of Resident #99's meal ticket lists dislikes that included broccoli-cauliflower, asparagus, pork and gravy. Interview on 03/02/26 at 12:15 P.M. revealed Resident #99 waved down surveyor and stated, why give facility list of likes and dislikes if facility is not going to honor preferences. [...]
- D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on record reviews, interviews, and policy review, the facility failed to ensure an accurate medical record. This affected one resident (Resident #61) of 24 residents reviewed for accuracy of medical records. The facility census was 80.
September 3, 2025Complaint inspection · 1 citation
- D
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Inspectors wroteTHE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on medical record review, staff interview, and policy review, the facility failed to ensure the physician was immediately notified of a resident's change of condition. This affected one (#120) of three residents reviewed for change of condition. The facility census was 70.
July 18, 2024Standard inspection, Complaint inspection · 12 citations
- E
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Inspectors wroteBased on observation, resident interview, staff interview and review of facility policy, the facility failed to ensure bathroom flooring and resident room doors were maintained in a clean and safe condition. Additionally, the facility failed to ensure linens were changed upon being soiled in a timely manner. This affected eight (#20, #23, #35, #75, #235, #236, and #238) of eight residents reviewed for environment. The facility census was 87.
- E
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 review of facility policy, the facility failed to ensure food was prepared in a manner to prevent food-borne illness. This had the potential to affect all residents residing in the facility, with the exception of two residents (#48 and #237) identified by the facility as having no food by mouth (NPO). The facility census was 87.
- D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteBased on observations, resident interview and staff interview, the facility failed to ensure resident dignity was maintained during dining experiences. This affected two (#36 and #242) of two residents observed for dining. The facility census was 87.
- D
Allow resident to participate in the development and implementation of his or her person-centered plan of care.
Inspectors wroteBased on medical record review, resident interview, staff interview and review of facility policy, the facility failed to ensure residents were invited to care conferences. This affected one (#23) of one residents reviewed for care conferences. The facility census was 87.
- D
Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.
Inspectors wroteBased on medical record review and staff interview, the facility failed to ensure the appropriate records and documentation were completed and sent with the resident upon transfer to the hospital. This affected one (#13) of the three residents reviewed for hospitalizations. The facility census was 87.
- D
Ensure each resident receives an accurate assessment.
Inspectors wroteBased on medical record review and staff interview, the facility failed to ensure the Minimum Data Set (MDS) assessment was accurately coded. This affected one (#82) of three residents reviewed for resident assessments. The facility census was 87.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on observation, resident interview, staff interview and review of the medical record, the facility failed to ensure a new skin impairment was assessed and monitored to promote healing. This affected one (#20) of four residents reviewed for skin assessments. The facility census was 87.
- D
Provide care or services that was trauma informed and/or culturally competent.
Inspectors wroteBased on medical record review and staff interview, the facility failed to ensure a resident with Post Traumatic Stress Disorder (PTSD) was appropriately assessed to identify the source of the resident's PTSD and minimize triggers and/or re-traumatization. This affected one (#48) of one residents identified by the facility as having a diagnosis of PTSD/trauma. The facility census was 87.
- 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 review of pharmacy recommendations, medical record review and staff interview, the facility failed to timely act upon pharmacy recommendations for laboratory values to be drawn. This affected one (#25) of five residents reviewed for unnecessary medications. The facility census was 87.
- D
Ensure medication error rates are not 5 percent or greater.
Inspectors wroteBased on observation, medical record review and staff interview, the facility failed to ensure medication error rates were not greater than 5% when staff crushed extended release medications for Residents #27 and #46. This affected two (#27 and #46) of five residents reviewed for medication administration. The facility had two errors out of 30 opportunities, for a medication error rate of 6.67%. The facility census was 87.
- D
Provide or obtain dental services for each resident.
Inspectors wroteBased on medical record review, review of dental notes, resident interview and staff interview, the facility failed to ensure dental recommendations were followed-up on timely. This affected one (#23) of one residents reviewed for dental services. The facility census was 87.
- D
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Inspectors wroteBased on medical record review, staff interview and review of the Centers for Disease Control and Prevention (CDC) guidance, the facility failed to ensure residents were timely offered, provided, and educated on pneumococcal vaccinations. This affected three (#23, #25, and #58) of five residents reviewed for vaccination status. The facility census was 87.
May 9, 2022Standard inspection · 11 citations
- E
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Inspectors wroteBased on medical record review, staff interview, and policy review the facility failed to ensure residents who received psychoactive medications identified specific target behaviors, reduced the medication when the reduction was not clinically contraindicated, and had not ruled out causes of newly emergent behaviors before administering psychoactive medications. This affected four residents (#04, #45, #46, and #55) of six sampled resident reviewed for unnecessary drugs. The facility census was 75.
- E
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview and policy review the facility failed to ensure the glucometer was cleaned effectively between use. This had the potential to affect 12 residents (#27, #49, #17, #32, #35, #53, #20, #28, #215, #07, #25 and #14) of 22 residents residing on the hallway who required blood glucose monitoring. The facility census was 75.
- D
Ensure that residents are fully informed and understand their health status, care and treatments.
Inspectors wroteBased on medical record review, review of the [NAME] Nursing Drug book, and staff and resident interview, the facility failed to ensure residents were informed of the indication and side effects of medication to make an informed decision. This affected one resident (#12) of 20 residents reviewed. The facility census was 75.
- D
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Inspectors wroteBased on medical record review and staff interview the facility failed to refer a resident with a newly evident mental disorder for a level II resident review with a significant change in status assessment. This affected one resident (#55)of six residents reviewed for pre-admission screening and resident review (PASRR). The facility census was 75.
- D
PASARR screening for Mental disorders or Intellectual Disabilities
Inspectors wroteBased on medical record review, observation, staff interview, and policy review, the facility failed to ensure residents with diagnoses of mental disorders or intellectual disabilities were correctly identified during the Preadmission Screening and Resident Review (PASRR) and the facility failed to reassess residents with expired level one determinations. This affected two residents (#02 and #45) of seven residents reviewed during the annual survey for PASARR. The facility census was 75.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on medical record review, observations, and staff and resident interviews, the facility failed to ensure care planned skin alteration prevention interventions were in place and failed to ensure residents edema was being monitored. This affected two residents (#57 and #51) out of the five residents reviewed for edema and skin conditions. The facility census was 75.
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on observation, medical record review, and staff interview the facility failed to ensure a resident's bed was positioned to prevent the resident from falling out of bed between the bed and the wall. This affected one resident (#04) of three sampled residents reviewed for accidents. The facility census was 75.
- D
Provide enough food/fluids to maintain a resident's health.
Inspectors wrote3. Review of medical record for resident #02 revealed an admission date of 11/25/21. Diagnoses included chronic obstructive pulmonary disease, other recurrent depressive disorders, atrial fibrillation, dementia, muscle weakness, cognitive communication deficit, gastrointestinal hemorrhage, dysphagia, and anemia. Review of Resident #02's weights revealed on 04/07/2022 the resident weighed 158.2 pounds. On 04/27/2022, the resident weighed 149.0 pounds which is a -5.82 % loss. And further review of Resident #02's weights revealed on 01/07/2022 the resident weighed 177.0 lbs. On 04/27/2022, the resident weighed 149 pounds which is a -15.82 % loss. Review of Resident #02's orders revealed an order for ProMod Liquid 30 milliliters by mouth two times daily for wound healing and an order for Dronabinol 2.5 milligrams by two times daily for poor appetite. [...]
- D
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Inspectors wroteBased on medical record review, staff interview, and policy review the facility failed to evaluate a resident's need for an opioid analgesic prior to the administration of the medication. This affected one resident (#265) of one resident's reviewed for pain. The facility census was 75.
- D
Ensure medication error rates are not 5 percent or greater.
Inspectors wroteBased on medical record review, observation, staff interview, and policy review the facility failed to ensure medications were administered without error. There were 38 opportunities for error with three observed errors for a calculated error rate of 7.89 percent. This affected one resident (#17) of three residents observed for medication administration. The facility census was 75.
- C
Not hire anyone with a finding of abuse, neglect, exploitation, or theft.
Inspectors wroteBased on personnel file review and staff interview, the facility failed to ensure prospective employees were cross checked on all registries prior to hire. This affected two employee personnel files of 11 personnel files reviewed. This had the potential to affect all residents residing in the facility. The facility census was 75.
Fire safety inspections
10 fire safety citations on file: 3 on March 10, 2026, 4 on July 18, 2024, 3 on May 9, 2022.
Every fire safety citation10 citations
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · March 10, 2026 · 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 · March 10, 2026 · Corrected (the home has a date of correction)
- F
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
K 761 · March 10, 2026 · Corrected (the home has a date of correction)
- E
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
K 222 · July 18, 2024 · Corrected (the home has a date of correction)
- E
Inspect, test, and maintain automatic sprinkler systems.
K 353 · July 18, 2024 · Corrected (the home has a date of correction)
- E
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
K 362 · July 18, 2024 · Corrected (the home has a date of correction)
- E
Ensure proper usage of power strips and extension cords.
K 920 · July 18, 2024 · Corrected (the home has a date of correction)
- F
Install a fire alarm system that can be heard throughout the facility.
K 341 · May 9, 2022 · Corrected (the home has a date of correction)
- E
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
K 222 · May 9, 2022 · Corrected (the home has a date of correction)
- E
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
K 521 · May 9, 2022 · Corrected (the home has a date of correction)