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 36 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
1K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
25D
8E
1F
Potential for minimal harm
0A
0B
1C
January 12, 2026Standard 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 and interview, it was determined that the facility failed to provide a clean and homelike environment. This was evident in 1 (C) of 2 shower rooms, 6 (14, 24, 52, 54, 55, and 57) out of 12 resident rooms, and the C/D Nourishment Room observed during the recertification survey.
- E
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on kitchen observation, record review, and staff interview, it was determined that the facility failed to ensure that food storage complied with professional standards of food safety. This practice had the potential to impact all residents eating food prepared in the kitchen.
- E
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, it was determined that the facility failed to provide a functional and sanitary environment. This was evident for 1 (C) out of 4 shower rooms observed during the recertification survey. On 01/07/2026 at 9:35 AM, the surveyors observed two drains covered in multicolored hair and a metal panel coming off of the bathroom wall. Unit Manager #10 and the Maintenance Regional Director acknowledged the concerns and stated the shower rooms are scheduled for renovation. On 01/07/2026 at 10:11 AM, the surveyors observed a dirty and stained floor with trash in the C/D Nourishment Room. On 01/07/2026 at 11:37 AM, The Nursing Home Administrator (NHA), Maintenance Regional Director, and Maintenance Supervisor acknowledged the concerns in the C/D Nourishment Room. [...]
- E
Have enough outside ventilation via a window or mechanical ventilation, or both.
Inspectors wroteNumber of residents sampled: Number of residents cited: Based on observations and interviews with facility staff, it was determined that the facility failed to maintain clean and operational ventilation systems, thereby impairing proper airflow throughout the premises. This deficiency was observed in 4 of the 5 unit ventilation systems reviewed during the annual survey.
- D
Give the resident's representative the ability to exercise the resident's rights.
Inspectors wroteNumber of residents sampled:Number of residents cited:Based on record review and interview it was determined that the facility failed to provide a Resident's Representative the right to be involved in informed consent process. This was found evident in 1 (Resident #16) of 4 residents reviewed for advanced directives.
- D
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
Inspectors wroteBased on record review and interviews, it was determined that the facility failed to attempt a recommended gradual dose reduction for a psychotropic medication and/or failed to document contraindication rationale for why gradual dose reduction was not attempted. This was found evident in 1 (Resident #30) out of 6 residents reviewed for unnecessary medications.
- D
Ensure each resident receives an accurate assessment.
Inspectors wroteBased on record review, and interviews, it was determined that the facility failed to accurately document a Minimum Data Set (MDS) assessment in a Resident's medical record. This was found evident of 1 (Resident #5) of 33 residents reviewed in the survey.
- D
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Inspectors wroteNumber of residents sampled:Number of residents cited:Based on observation, interviews, and record review, it was determined that the facility failed to review and revise a Resident's care plan after a Resident's situation changed. This was found evident of 1 (Resident #9) out of 1 Residents reviewed for hearing and vision during the survey.
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on observations, record reviews, and interviews, it was determined that the facility failed to provide necessary services to maintain good personal hygiene for dependent residents. This was evident in 2 (Resident #66 and Resident #93) of 2 Residents reviewed for Activity of Daily Living (ADL) care during the annual survey.
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observation, interviews, facility policy review, and record review, it was determined that the facility failed to provide respiratory care consistent with professional standards for oxygen administration. This was found evident of 1 (Resident #1) out of 2 residents reviewed for respiratory care during the survey. Pulse oximeter - a device that uses a light source to analyze the light that passes through a finger and can determine the percentage of oxygen in the red blood cells, referred to as a pulse ox (pox) Peripheral Oxygen Saturation (SPO2). Nasal cannula- a medical device used to provide supplemental oxygen therapy to people who have lower oxygen levels.
- 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 review and interviews, it was determined that the facility failed to maintain medical records in accordance with acceptable professional standards and practices by keeping complete documentation. This was found evident in 2 (Resident #1 and #7) out of 33 residents reviewed during the survey.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation and interview, it was determined that the facility failed to maintain a sanitary environment in resident shared areas and the laundry room. This was evident in 2 (C, D) out of 4 shower rooms and the laundry room observed during the recertification survey.
July 12, 2024Standard inspection, Complaint inspection · 12 citations
- K
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Inspectors wroteBased on medical record review and interview, and facility policy review, the facility staff failed to recognize abuse and take action to prevent abuse to residents (Resident #921, #919, #77, #905, #912, #916, #927, #2, #17, #66, #303) reviewed for abuse for 11 out of a total sample of 21 residents. These actions resulted in the finding of an Immediate Jeopardy which was identified on 7/10/24 at 4:30 PM. An IJ summary tool was provided to the facility on 7/10/24 at 4:48 PM. The facility submitted a draft of their plan to remove the immediacy on 7/10/24 at 6:30 PM and it was not accepted. The facility submitted a 2nd draft of their plan to remove the immediacy on 7/10/24 at 7:36 PM and it was not accepted. The facility submitted a 3rd plan on 7/10/24 at 8:30 PM and it was accepted by the state agency at 8:40 PM. [...]
- F
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Inspectors wroteBased on interviews, review of the facility documentation, and review of the facility policy, the facility failed to ensure policies and procedures were implemented to address the facility's Quality Assessment and Performance Improvement (QAPI) plan and program, in which data was gathered, analyzed, developed, implemented, and re-evaluated to address adverse events related to potential deficient practice of abuse. This had the potential to affect all 105 residents residing in the facility at the time of the survey.
- 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 interviews, record review, and facility policy review, the facility failed to ensure that grievances were promptly resolved and ensure all written grievance decisions included the date of the grievance, a summary of the resident's grievance, a summary of the findings, a statement as to whether the grievance was confirmed or not confirmed, corrective action taken as a result of the grievance, and the date the decision was issued. Specifically, the facility failed to ensure grievances voiced by residents during resident council were documented, investigated, resolved, and followed up on by the facility of 105 residents. This failure had the potential to cause further grievances to be unresolved for residents throughout the facility.
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wrote2) Review of R303's Face Sheet, located in the electronic medical record (EMR) under the Profile tab, revealed R303 was admitted to the facility on [DATE] with a diagnosis of a rib fracture and adjustment disorder with anxiety. Review of R303's admission MDS with an ARD of 06/24/24 located in the EMR under the MDS tab, revealed R303 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated the resident was cognitively intact. Per the MDS, the resident did not exhibit any behavior during the assessment period. During an interview on 07/08/24 at 11:50 PM, R303 stated sometimes at night she was told by staff to go to the bathroom in her brief. She stated it felt awful and she did not like doing it. She stated sometimes she also had a bowel movement in her brief which felt very uncomfortable. She stated she would wiggle in the chair. [...]
- D
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Inspectors wroteBased on interviews, record review, and review of facility policy, the facility failed to revise the care plan to include recommendations from the dental consult on 05/11/24 for one of 21 sample residents (Resident (R) 73) reviewed for care plan revision. This failure caused staff to be unaware of recommendations from the dentist or possible tooth pain for R73.
- C
Post nurse staffing information every day.
Inspectors wroteBased on observation and interview, the facility failed to ensure staffing information was posted daily and readily accessible to residents and visitors, during the first three days of the survey for 105 census residents.
- E
Respond appropriately to all alleged violations.
Inspectors wroteBased on record review and interview it was determined that the facility failed to have a process in place to ensure the resident's safety directly following an allegation of abuse and to conduct a thorough investigation of the allegation. Evident for 3 (#913, #921 and #928) and Evident for 4 (#905, #911, #919 and #924) of 26 residents reviewed for abuse allegations during a recertification and complaint survey.
- D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteBased on record review and interview it was determined that the facility staff failed to allow a resident the right to have a dignified existence by failing to be listening to the Resident during his/her care (Resident #911). This was evident for 1 of 73 residents reviewed during a complaint and recertification survey.
- D
Honor the resident's right to organize and participate in resident/family groups in the facility.
Inspectors wroteBased on record review and staff interview it was determined that the facility failed to ensure that residents and/or resident representatives were afforded the right to file a grievance and receive a response regarding the action taken by the facility (Resident #906). This was evident for 1 of 3 residents reviewed during a recertification and complaint 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 medical record review and interview with facility staff, it was determined that the facility failed to review and implement a care plan when there were noted changes in condition requiring further facility services and follow-up (Resident #905). This was evident for 1 of 73 residents reviewed during a complaint and recertification survey. A care plan is a comprehensive and personalized document that outlines the specific needs, goals, and preferences of a patient. Care plans also address the specific services needed to attain and maintain a resident's highest practicable well-being through focus, goals and interventions.
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on record review and interview it was determined that facility staff failed to provide activities of daily living (ADLs: bathing, personal hygiene, toileting, getting in and out of bed) for a resident who was dependent on them for care (Resident #906). This was evident for 1 (MD00186681) of 11 complaints reviewed during a recertification and complaint survey.
- D
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Inspectors wroteBased on observation, medical record review and interview it was determined that the facility failed to 1) complete an admission nursing assessment thoroughly and therefore implement the correct interventions for a resident with known dementia history (Resident #917) This was evident for 1 of 1 resident reviewed for elopement and 2) ensure that residents residing on their dementia care unit had activities to help them achieve their highest practicable physical, mental, and psychosocial well-being. This was evident for 1 (#906) of 4 residents reviewed for dementia care.
May 24, 2019Standard inspection · 12 citations
- E
Observe each nurse aide's job performance and give regular training.
Inspectors wroteBased on reviews of administrative records and staff interview, it was determined that the nursing administrative staff failed to 1) conduct a yearly performance review on the entire geriatric nursing assistant staff for the year of 2018, and 2) ensure that all geriatric nursing assistant (GNA) staff completed a minimum of 12 hours of education per year.
- 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 and interviews of facility staff, it was determined that food service employees failed to ensure that sanitary and safe food handling practices were followed to reduce the risk of foodborne illness. This deficient practice has the potential to affect all residents.
- D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteBased on dining observation and interview, it was determined the facility staff failed to provide residents with the most dignified existence with dining. This was evident for 2 (Resident #49 and #4) of 12 residents observed for dignity during an annual recertification survey.
- D
Reasonably accommodate the needs and preferences of each resident.
Inspectors wroteBased on observation and interview, the facility staff failed to ensure that call bells were within reach for Resident (#47 and #68). This was evident for 2 of 53 residents selected for review during the annual recertification survey.
- D
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Inspectors wroteBased on medical record review and interview it was determined the facility staff failed to provide showers to Resident (#71). This was evident for 1 of 2 resident reviewed for choices during the annual survey process and 1 of 53 residents selected for review.
- 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 medical record review and interview, it was determined the facility staff failed to 1) notify the physician of a finger stick above 400 as ordered by the physician for Resident (#47), 2) notify the physician of a delay in obtaining a stat x-ray for Resident (#71) and 3) notify a resident's physician and the facility nutritionist when a resident was identified with a significant weight loss for Resident #26. This was evident for 3 of 53 residents selected for review during the annual survey process.
- D
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Inspectors wroteBased on reviews of a medical record, it was determined that the facility failed to accurately evaluate and revise a resident nutritional care plan. This was evident for 1 (Resident #26) of 11 residents reviewed for nutrition during an annual recertification survey.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on record review, observation and interview, it was determined the facility staff failed to provide care to promote the highest well-being for Residents (#47 and #71). This was evident for 1 of 2 residents selected for review of skin conditions and 2 of 53 residents selected for review during the annual survey process for quality of care.
- 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 and interview, it was determined the facility staff failed to provide an environment free from potential accidents for Residents (#5 and #47). This was evident for 2 of 53 residents selected for review during the annual survey process.
- D
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Inspectors wroteBased on medical record review and interview, it was determined the facility staff failed to document the heart rate and blood pressure for Resident #35 when the physician ordered parameters. This was evident for 1 of 6 residents selected for un-necessary medication review and 1 of 53 residents selected for review during the annual survey process.
- D
Dispose of garbage and refuse properly.
Inspectors wroteBased on observation during tour of the facility's dumpster area, it was determined the facility staff failed to dispose of garbage and refuse properly. This deficient practice has the potential to affect all residents.
- D
Put firmly secured handrails on each side of hallways.
Inspectors wroteBased on surveyor observation during a tour of E wing, it was determined that the facility failed to ensure hand rails were secured firmly to the wall. This deficient practice has the potential to affect all residents within the unit.
Fire safety inspections
35 fire safety citations on file: 9 on January 12, 2026, 17 on July 12, 2024, 9 on May 24, 2019.
Every fire safety citation35 citations
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · January 12, 2026 · Corrected (the home has a date of correction)
- E
Keep aisles, corridors, and exits free of obstruction in case of emergency.
K 211 · January 12, 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 · January 12, 2026 · Corrected (the home has a date of correction)
- E
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
K 761 · January 12, 2026 · Corrected (the home has a date of correction)
- D
Provide properly protected cooking facilities.
K 324 · January 12, 2026 · Corrected (the home has a date of correction)
- D
Install an approved automatic sprinkler system.
K 351 · January 12, 2026 · Corrected (the home has a date of correction)
- D
Inspect, test, and maintain automatic sprinkler systems.
K 353 · January 12, 2026 · Corrected (the home has a date of correction)
- D
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
K 362 · January 12, 2026 · Corrected (the home has a date of correction)
- D
Have properly installed electrical wiring and gas equipment.
K 511 · January 12, 2026 · Corrected (the home has a date of correction)
- F
Provide properly protected cooking facilities.
K 324 · July 12, 2024 · Corrected (the home has a date of correction)
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · July 12, 2024 · Corrected (the home has a date of correction)
- F
Install an approved automatic sprinkler system.
K 351 · July 12, 2024 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · July 12, 2024 · Corrected (the home has a date of correction)
- F
Meet other general requirements that are deficient.
K 500 · July 12, 2024 · Corrected (the home has a date of correction)
- F
Have simulated fire drills held at unexpected times.
K 712 · July 12, 2024 · Corrected (the home has a date of correction)
- F
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
K 761 · July 12, 2024 · Corrected (the home has a date of correction)
- F
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · July 12, 2024 · Corrected (the home has a date of correction)
- E
Keep aisles, corridors, and exits free of obstruction in case of emergency.
K 211 · July 12, 2024 · Corrected (the home has a date of correction)
- E
Install proper backup exit lighting.
K 281 · July 12, 2024 · 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 · July 12, 2024 · Corrected (the home has a date of correction)
- E
Install a fire alarm system that can be heard throughout the facility.
K 341 · July 12, 2024 · Corrected (the home has a date of correction)
- E
Install corridor and hallway doors that block smoke.
K 363 · July 12, 2024 · Corrected (the home has a date of correction)
- E
Have properly installed electrical wiring and gas equipment.
K 511 · July 12, 2024 · Corrected (the home has a date of correction)
- E
Have proper medical gas storage and administration areas.
K 923 · July 12, 2024 · Corrected (the home has a date of correction)
- D
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 · July 12, 2024 · Corrected (the home has a date of correction)
- D
Properly provide smoke detection systems in areas open to corridors.
K 347 · July 12, 2024 · Corrected (the home has a date of correction)
- F
Provide properly protected cooking facilities.
K 324 · May 24, 2019 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · May 24, 2019 · Corrected (the home has a date of correction)
- F
Meet other general requirements that are deficient.
K 500 · May 24, 2019 · Corrected (the home has a date of correction)
- F
Meet requirements for operating features, such as evacuation plans, fire drills, smoking regulations, draperies, decorations and the inspection, testing and maintenance of fire doors.
K 700 · May 24, 2019 · Corrected (the home has a date of correction)
- F
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
K 761 · May 24, 2019 · Corrected (the home has a date of correction)
- F
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · May 24, 2019 · Corrected (the home has a date of correction)
- E
Have properly installed electrical wiring and gas equipment.
K 511 · May 24, 2019 · Corrected (the home has a date of correction)
- D
Meet other general requirements.
K 100 · May 24, 2019 · Corrected (the home has a date of correction)
- D
Meet requirements for the use of electrical equipment.
K 919 · May 24, 2019 · Corrected (the home has a date of correction)