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
0K
0L
Actual harm
3G
0H
0I
Potential for more than minimal harm
26D
3E
4F
Potential for minimal harm
0A
0B
0C
March 27, 2026Complaint inspection · 1 citation
- D
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Inspectors wroteBased on record review, interview, and policy review, the facility failed to ensure residents received refunds due to the residents within 30 days. This affected two residents (#1 and #2) of three residents reviewed for refunds. The facility census was 80.
March 5, 2026Complaint inspection · 5 citations
- F
Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.
Inspectors wroteBased on record review and interview, the facility failed to accurately reflect on the facility assessment the overall number of facility staff needed to ensure sufficient number of qualified staff are available to meet each resident's needs as identified through resident assessments and care plans. This had the potential to affect all residents of the facility. The facility census was 83.
- D
Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
Inspectors wroteBased on observation, interview and record review, the facility failed to protect residents dignity. This affected one resident (#25) of the memory care unit. The facility census was 83.
- D
Keep residents' personal and medical records private and confidential.
Inspectors wroteBased on review of medical records, review of facility policies, observation, and interview, the facility failed to maintain the privacy of personal health information for three residents (#7, #42, and #79) of 83 residents residing in the facility. The facility census was 83.
- D
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, record review, and interview, the facility failed to have sufficient nursing staff to maintain the highest practicable psychosocial well-being of each resident when a resident was brought to the dining room in a hospital gown which was opened in the back or to assist the resident with breakfast in a reasonable time. This affected one resident (#25) of six residents residing on the memory care unit. The facility census was 83.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview and policy review, the facility failed to maintain an environment free from risk of infection by allowing a dog to be at the lunch table with residents eating their meal. This affected two residents (#77, #65) sitting together in the memory care dining area at lunchtime. The facility census was 83.
April 22, 2025Standard inspection, Complaint inspection · 9 citations
- G
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteTHE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on closed record review, facility policy review and interview, the facility failed to provide a timely assessment and necessary and timely treatment for Resident 3181 following an unwitnessed fall with injury. This affected one resident (#181) of two residents reviewed for accident hazards. Actual harm occurred on 02/07/25 at 7:30 P.M. when Certified Nursing Assistant (CNA) observed Resident #181 on the floor in front of her wheelchair. The CNA notified Registered Nurse (RN) #109 of the resident having an unwitnessed fall; however, the RN failed to assess and provide needed treatment to the resident thereby delaying necessary treatment including transfer to the hospital. [...]
- G
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on medical record review and interview, the facility failed to ensure Resident #8's bedroom furniture was maintained in a safe manner to prevent the resident from sustaining an injury when her foot hit the board as she was attempting to sit up. This affected one resident (#8) of two residents reviewed for edema. Actual harm occurred on 05/21/24 when Resident #8 required seven sutures to the top of her right foot as a result of her foot being cut on the footboard of her bed. Following the incident, the facility identified the footboard was in need of repair as it was torn and rough in texture. Findings Include: Record review revealed Resident #8 was admitted to the facility on [DATE] with diagnoses including respiratory failure, chronic obstructive pulmonary disease, and type II diabetes. Review of a nursing note dated 05/21/24 at 3:48 A.M. [...]
- G
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on record review, hospital record review and interview, the facility failed to provide adequate and timely respiratory care and treatment for Resident #2, related to a decline in the resident's respiratory status and need for oxygen use. This affected one resident (#2) of one resident reviewed for edema. Actual harm occurred beginning on 03/10/25 when the facility failed to adequately and timely treat respiratory complications exhibited by Resident #2 which included shortness of breath, abnormal lung sounds and decreased oxygen saturation. On 03/11/25 staff had increased the resident's oxygen to seven liters (the resident had an order for oxygen at one to five liters at that time) with no additional intervention noted. On 03/14/25 at 11:45 P.M. [...]
- E
Implement a program that monitors antibiotic use.
Inspectors wroteBased on medical record review, interview, and policy review the facility failed to ensure antibiotics usage met criteria. This affected four residents (#7, #28, #51, and #54) of four residents reviewed for antibiotic use.
- 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 the facility failed to notify the resident representative of an unwitnessed fall that resulted in the resident's injury. This affected one resident (#181) of four residents reviewed for accidents. The facility census was 75.
- D
Provide enough food/fluids to maintain a resident's health.
Inspectors wroteBased on observation, medical record review, interview, and policy review the facility failed to ensure dialysis dietary recommendation to administer protein snack at night was implemented and failed to ensure meal intakes were adequately monitored and documented. This affected two residents (#44 and #51) of three residents reviewed for nutrition.
- D
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Inspectors wroteBased on medical record review, interview, and policy review the facility failed to ensure dialysis orders to hold medications were clarified and implemented. This affected one resident (#51) of one resident reviewed for dialysis.
- D
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Inspectors wroteBased on medical record review and interview the facility failed to ensure medications were reconciled correctly on admission. This affected one resident (#181) of one resident reviewed for psych/opioid medication review. The census was 75.
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on observation, medical record review, review of operational manual, observation, and interview the facility failed to ensure a pressure relieving air mattress was accurately set per the resident's weight and maintained per the manufacturer's guidelines. This affected one resident (#34) of four residents reviewed for pressure ulcers.
September 25, 2023Standard inspection · 9 citations
- F
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview, facility document review and facility policy review the facility failed to ensure staff wore the appropriate personal protective equipment (PPE) when caring for COVID-19 positive residents, performed hand hygiene and disposed of sharps appropriately, and failed to ensure the disinfectant wipes outside of COVID-19 isolation rooms was not expired. Staff not wearing the appropriate PPE and the expired disinfectant wipes had the potential to affect all 56 residents residing in the facility who had not tested positive for COVID-19. The hand hygiene concern affected Resident #233 and the improper disposal of sharps had the potential to affect all residents residing in the facility. The facility census was 69.
- D
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Inspectors wroteBased on record review, review of liability notices, and staff interview, the facility failed to ensure a resident received appropriate notice prior to the end of their Medicare (MCR) Part A services and residents that opted to receive those services continued to receive them while MCR was billed for an official decision on payment. This affected two residents (#1 and #48) of three residents reviewed for liability notices.
- D
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Inspectors wroteBased on resident record review, interview, and facility policy review, the facility failed to ensure residents who were being transferred to the local emergency room for care received a copy of the bed hold notice. This affected two residents (#24 and #66) of two residents reviewed for hospitalization. The facility census was 69.
- 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 ensure all resident Pre-admission Screening and Resident Review (PASARR) documents were accurate to resident current conditions and diagnoses. This affected three residents (#44, Resident #9, and Resident #15) of three residents reviewed for PASARR documents. The census was 69. Findings Include: 1. Medical record review revealed Resident #44 was admitted to the facility on [DATE] with diagnoses including hemiplegia and hemiparesis, osteomyelitis, major depressive disorder, bipolar disorder, and dementia. Review of the Minimum Data Set (MDS) 3.0 assessment, dated 09/01/23, revealed the resident was cognitively intact, and had diagnoses of dementia, depression and bipolar disorder. Review of Resident #44's PASARR document, dated 10/27/22, revealed under Section E, there were no diagnoses listed. [...]
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on record review, observation, and staff interview, the facility failed to ensure a resident who was dependent on staff for personal care received the assistance needed with the removal of unwanted facial hair. This affected one resident (#48) of three residents reviewed for activities of daily living (ADL's).
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on record review, interview, and policy review, the facility failed to ensure Resident #32's constipation was treated timely. This affected one resident (#32) of two residents reviewed for constipation.
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on record review, observation, interview, and policy review, the facility failed to properly store Resident #19's nebulizer machine, tubing, and mouthpiece and failed to ensure Resident #31 received the correct dosage of oxygen as ordered by the physician. This affected two residents (#19 and #31) of two residents reviewed for respiratory care.
- D
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Inspectors wroteBased on record review, review of the dialysis contract, and staff interview, the facility failed to ensure dialysis communication forms were completed by the facility and the dialysis center to maintain good communication of the resident's condition and services rendered during dialysis treatments. This affected one resident (#1) of one resident reviewed for hemodialysis treatments.
- D
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Inspectors wroteBased on medical record review and interview the facility failed to ensure residents were free from unnecessary medications. This affected two residents (#11 and #15) of seven residents reviewed for unnecessary medication. The facility census was 69.
September 1, 2023Complaint inspection · 4 citations
- D
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Inspectors wroteBased on observation, record review, staff interview, facility self-reported incident (SRI) review, and policy review, the facility failed to ensure residents were free from abuse by Resident #73, a resident with a known history of aggressive behaviors. In addition, the facility failed to ensure residents were free from verbal abuse from State Tested Nurse Aide (STNA) #300. This affected six residents (#44, #53, #75, #76, #77, and #78) of eight residents reviewed for abuse. The facility census was 73.
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on record review, staff interview, facility self-reported incident (SRI) review, and policy review, the facility failed to report physical abuse to the state agency. This affected four residents (#44, #53, #73, #75).
- D
Respond appropriately to all alleged violations.
Inspectors wroteBased on record review, staff interview, facility self-reported incident (SRI) review, and policy review, the facility failed to have evidence that allegations of physical abuse was thoroughly investigated. This affected four residents (#44, #53, #73, #75).
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on record review and interview the facility failed to ensure residents were adequately supervised to assist in the prevention of resident to resident altercations. This affected one resident (#73) of three residents reviewed for resident-to-resident abuse.
October 25, 2021Standard inspection · 8 citations
- F
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, record review and interview the facility failed to maintain sufficient levels of nursing staff to meet the total care needs of all residents. This affected seven residents (#13, #14, #50, #162, #48, #55 and #165) and had the potential to affect all 68 residents residing in the facility.
- F
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Inspectors wroteBased on review of department head schedules and interview the facility failed to ensure the Director of Nursing only served as a charge nurse when the census was 60 residents or fewer. This affected all 68 residents.
- E
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Inspectors wroteBased on observation, record review and interview the facility failed to ensure resident preferences for bathing and/or rising time were honored. This affected five residents (#13, #14, #50, #55 and #165) of 11 residents interviewed regarding choices and one additional resident (Resident #48). The facility census was 68.
- E
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, record review, facility admission Guidance review and interview the facility failed to maintain acceptable infection control practices, including the proper use, cleaning and disposal of personal protective equipment when entering the room of a resident (Resident #214) who was in quarantine for COVID-19 precautions to prevent the potential spread of COVID-19. This had the potential to affect all 36 residents (#3, #4, #7, #12, #13, #14, #15, #16, #17, #18, #20, #21, #22, #23, #24, #28, #35, #36, #39, #42, #43, #48, #49, #50, #54, #55, #57, #58, #162, #163, #164, #165, #166, #213, #214 and #215) who resided on the East Hall.
- 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 record review, review of facility policy and procedure and interview the facility failed to exercise reasonable care for the protection of Resident #55's property from loss or theft and ensure timely follow up regarding missing/lost items. This affected one resident (#55) of two residents reviewed for missing property.
- 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 record review and interview the facility failed to ensure Resident #53 and Resident #55 and/or their responsible parties were notified timely and invited to participate in quarterly care conferences. This affected two residents (#53 and #55) of four residents reviewed for care planning conferences.
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observation, record review, facility policy and procedure review and interview the facility failed to ensure Resident #25 received oxygen therapy as ordered. This affected one resident (#25) of three residents reviewed who had orders for oxygen.
- D
Implement a program that monitors antibiotic use.
Inspectors wroteBased on medical record review and staff interview the facility failed to ensure antibiotics were prescribed based on culture and sensitivity results to ensure appropriate antibiotic use. This affected two residents (#6 and #47) of five residents reviewed for unnecessary medication use.
Fire safety inspections
8 fire safety citations on file: 2 on April 22, 2025, 3 on September 25, 2023, 3 on October 25, 2021.
Every fire safety citation8 citations
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · April 22, 2025 · Corrected (the home has a date of correction)
- E
Have power receptacles that are properly grounded.
K 912 · April 22, 2025 · 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 · September 25, 2023 · Corrected (the home has a date of correction)
- E
Construct fire resistant interior walls.
K 331 · September 25, 2023 · Corrected (the home has a date of correction)
- E
Install corridor and hallway doors that block smoke.
K 363 · September 25, 2023 · Corrected (the home has a date of correction)
- F
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 · October 25, 2021 · Corrected (the home has a date of correction)
- F
Have properly sized and located compartments to protect residents from smoke.
K 371 · October 25, 2021 · Corrected (the home has a date of correction)
- E
Have properly installed electrical wiring and gas equipment.
K 511 · October 25, 2021 · Corrected (the home has a date of correction)