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
2G
0H
0I
Potential for more than minimal harm
21D
10E
1F
Potential for minimal harm
0A
1B
1C
February 27, 2026Standard inspection · 7 citations
- E
Provide enough food/fluids to maintain a resident's health.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents' with fluid restrictions had fluid intake monitoring to avoid fluid overload for 3 of 3 sampled residents (Residents 94, 100, and 111) when reviewed for nutrition. This failure placed residents at risk of fluid overload, avoidable discomfort, and a diminished quality of life.
- D
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Inspectors wroteBased on interview and record review, the facility failed to implement Abuse Prohibition policies and procedures including but not limited to identification, investigation, protection and reporting for 1 of 3 sampled residents (Resident 1) when reviewed for abuse. These failures placed residents at risk for unidentified abuse, neglect, and/or injury.
- D
Ensure each resident receives an accurate assessment.
Inspectors wroteBased on interview and record review, the facility failed to ensure the minimum data set assessment (MDS) accurately reflected the status for 2 of 19 sampled residents (Residents 11 and 8) when reviewed for accuracy of assessments. Failure to accurately reflect Resident 11's hospice status and Resident 8's pressure ulcer/skin injury status placed the residents at risk for unmet care, inaccurate medical record data, and a diminished quality of life.
- D
Provide safe, appropriate pain management for a resident who requires such services.
Inspectors wroteBased on interview and record review, the facility failed to provide nonpharmacological interventions (NPI) prior to the use of as needed pain medications for 1 of 6 sampled residents (Resident 7) when reviewed for pain management. This failure placed the residents at risk of receiving unneeded medications and a diminished quality of life.
- 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 observation, interview, and record review the facility failed to consistently maintain the medication refrigerator temperature log in 1 of 3 medication rooms (Transitional Care Unit/TCU), to ensure resident's were assessed to self-administer medications for 1 of 1 sampled residents (Resident 6), and 2 of 6 medication/treatments carts (TCU treatment and TCU medication carts) , when reviewed for medication storage. These failures placed the residents at risk of receiving compromised or ineffective medications, drug diversion, and potential loss of medications/treatments.
- D
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Inspectors wroteBased on observation, interview, and record review, the facility failed to provide food in accordance with preferences for 1 of 1 sampled resident (Resident 94) when reviewed for preferences. This failure placed residents at risk for reduced nutritional intake and a diminished quality of life.
- C
Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.
Inspectors wroteBased on observation and interview, the facility failed to post the location of the survey results and place the binder in identifiable location. This failure prevented residents, family members and visitors from exercising their right to review past survey results and the facility's plans of correction to evaluate the quality of care provided by the facility.
January 9, 2026Complaint inspection · 1 citation
- E
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 an environment that is free from accident hazards by not following their fall protocol, which included bed height placement, fall assessment, and call light within reach for 7 of 12 residents (Residents 2, 4, 5, 6, 7, 8, and 10) reviewed for falls. This failure placed residents at risk of increased falls, significant injury with fall, and a diminished quality of life.
August 18, 2025Complaint inspection · 1 citation
- G
Ensure that residents are free from significant medication errors.
Inspectors wroteBased on interview and record review, the facility failed to ensure residents were administered their ordered anticoagulation (blood thinner-to reduce the risk of the formation of blood clots) medication for 3 of 15 sampled residents (Resident 1, 2, and 3) reviewed for significant medication errors. Resident 3 experienced harm when they did not receive anticoagulation medication as ordered for 17 days due to a medication reconciliation error and had a decline in condition that included signs and symptoms of a stroke (a medical condition that occurs when blood flow to the brain is interrupted or reduced, leading to brain tissue damage) that required transport to the emergency room (ER) for evaluation and treatment. This failure placed residents who were prescribed anticoagulant medications at risk for medical complications, injury and a decreased quality of life.
January 13, 2025Standard inspection · 18 citations
- F
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on observation, interview, and record review, the facility failed to prepare and store food in a sanitary manner in the main kitchen and 3 of 3 resident refrigerators (West, East, and Transitional Care Unit) when reviewed for kitchen. This failure placed residents at risk of consuming expired or spoiled food, foodborne illness, avoidable discomfort, and a diminished quality of life.
- E
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 provide written notification of the reason for transfer to the hospital to the Office of State Long-Term Care Ombudsman (SLTCO, an advocacy group for residents in a nursing home) and/or to the resident/resident representative of discharges for 4 of 4 sampled residents (Residents 32, 54, 95, and 26) reviewed for hospitalization and/or discharge. These failures placed residents at risk for being inappropriately discharged , lack of access to an advocate who could inform them of their options and rights, and to ensure that the SLTCO and resident/ resident representative was aware of facility practices and activities related to transfers and discharges.
- E
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 interview and record review, the facility failed to provide a bed-hold notice in writing at the time of transfer/discharge to the hospital and/or to provide/complete bed-hold notices within 24 hours of transfer/discharge to the hospital for 3 of 4 sample residents (Residents 32, 26, and 95) reviewed for hospitalization/discharge. This failure placed the residents at risk for a lack of knowledge regarding the right to a bed-hold while they were hospitalized .
- E
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 (PASARR) assessments were accurately completed for 3 of 6 sampled residents (Residents 29, 49 and 40) reviewed for PASARRs and unnecessary medications. This failure placed the residents at risk for unidentified mental health care needs.
- E
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 observation, interview, and record review, the facility failed to ensure care plans were reviewed and revised after each quarterly assessment for 3 of 4 sampled residents (Residents 32, 50, and 22) when reviewed for care planning. This failure placed residents at risk of not receiving required care, avoidable decrease in health status, and a diminished quality of life.
- E
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure there was a system to provide care and services consistent with standards of quality of care for 2 of 3 sampled residents (Residents 57 and 71) when reviewed for edema/heart failure, for 4 of 8 sampled residents (Residents 7, 40, 57 and 78) when reviewed for bowel management, for 1 of 1 sampled residents (Resident 40) when reviewed for hospice service, and for 1 of 3 sampled residents (Resident 32) when reviewed for hospitalization. [...]
- E
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications and biologicals were securely locked for 3 of 26 sampled residents (Residents 90, 9, and 64) when reviewed for environment. This failure placed the resident at risk for consuming non-prescribed medications, unintended side effects of medications, medical complications, and a diminished quality of life.
- 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 periodically review residents advanced directive (AD, a legal document that states your wishes for medical care if you are unable to make decisions for yourself) for 1 of 4 sampled residents (Resident 32) when reviewed for advanced directive. This failure placed the resident at risk of not having an established decisionmaker, lack of ability to direct care, and a diminished quality of life.
- 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 observation, interview, and record review, the facility failed to ensure residents' personal items were safe for 1 of 5 sampled residents (Resident 64) when reviewed for Personal Property and failed to ensure residents' rooms were homelike for 1 of 6 sampled residents (Resident 50) when reviewed for environment. These failures placed residents at risk of financial exploitation, feelings of worthlessness, decreased mood, and a diminished quality of life.
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on observation, interview, and record review, the facility failed to implement pressure ulcer care for 2 of 4 sampled residents (Residents 78 and 72) reviewed for pressure injuries (injuries to skin and underlying tissue resulting from prolonged pressure on the skin). This failure placed the resident at risk for worsening pressure injuries, pain, and a decreased quality of life.
- D
Provide enough food/fluids to maintain a resident's health.
Inspectors wroteBased on observation, interview, and record review, the facility failed to provide adequate fluids to maintain hydration for 1 of 2 sampled residents (Resident 40) when reviewed for hydration and failed to monitor and accurately document fluids consumed to ensure fluid restrictions were implemented per provider's orders for 1 of 5 sampled residents (Residents 32) reviewed for nutrition and/or dialysis (treatment to filter wastes and water from the blood). This failure placed residents at risk for over hydration, avoidable discomfort, and a diminished quality of life. Resident 40 Review of the electronic health record (EHR) showed Resident 40 admitted to the facility on [DATE] with diagnoses to include dementia and traumatic subarachnoid hemorrhage (a bleed in the brain). [...]
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observation, interview, and record review, the facility failed to manage oxygen therapy consistent with professional standards of practice and the comprehensive person-centered care plan by not ensuring provider's orders and care plans were in place and/or followed for 2 of 4 sampled residents (Residents 71 and 72) when reviewed of respiratory care. These failures placed residents at risk for unmet needs and a decreased quality of life. Resident 71 Review of the electronic health record (EHR) showed Resident 71 admitted to the facility on [DATE] with a diagnosis of congestive heart failure (CHF, when the heart is not able to pump enough blood causing fluid to build up in the lungs and/or limbs). The resident was able to make needs known. Review of the EHR on 01/08/2025 at 4:45 PM showed no care plan had been initiated for oxygen use. [...]
- D
Provide safe, appropriate pain management for a resident who requires such services.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff provided adequate pain management in a timely manner for 1 of 3 sampled residents (Resident 29) when reviewed for pain management. This failure had the potential for the resident to have a delay in treatment to receive the necessary pain medication as ordered, a diminished quality of life and unmet needs.
- D
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Inspectors wroteBased on interview and record review, the facility failed to obtain an agreement/contract with a resident's dialysis provider to ensure all care and services necessary were being provided and coordinated for 1 of 1 sampled resident (Resident 32) reviewed for dialysis (treatment to filter waste and water from the blood). This failure placed the resident at risk for inadequate quality of care and decreased quality of life.
- D
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Inspectors wroteBased on observation, interview, and record review, the facility failed to consistently initiate non-pharmacological interventions prior to the administration of as needed pain medication for 2 of 5 sample residents (Residents 18 and 398) reviewed for unnecessary medications. These failures placed residents at risk for receiving unnecessary medications and a diminished quality of life.
- D
Provide routine and 24-hour emergency dental care for each resident.
Inspectors wroteBased on observation, interview, and record review, the facility failed to provide dental services for 1 of 3 sample residents (Resident 78) reviewed for dental. This failure placed the resident at risk of difficulty eating and a diminished quality of life.
- D
Provide or obtain dental services for each resident.
Inspectors wroteBased on observation, interview, and record review, the facility failed to provide prompt dental services for 1 of 3 sample residents (Resident 50) reviewed for dental services. This failure placed the resident at risk for continued dental problems and a diminished quality of life.
- D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure resident's medical records were accurately documented according to professional standards of practice for 2 of 26 sampled residents (Residents 398 and 71) when reviewed for medical records. This failure placed the residents at risk for isolation, unmet care needs, and diminished quality of life.
May 30, 2024Complaint inspection · 1 citation
- D
Ensure services provided by the nursing facility meet professional standards of quality.
Inspectors wroteBased on observation, interview and record review, facility failed to ensure professional standards were met for 2 of 2 sampled residents (Resident 1 & 2) reviewed for physicians orders and care of residents with peripherally inserted central catheter lines (PICC, lines placed through the upper arm in a large vein near the heart). Failure to follow physician orders and professional standards of care when assessing and performing PICC line dressing changes placed residents at risk for medical complications including bloodstream infections.
February 8, 2024Standard inspection · 7 citations
- E
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on observation and interview, the facility failed to maintain mechanical lifts in good repair for 3 of 3 mechanical lifts when reviewed for accident hazards. This failure placed residents at risk of falling when using the mechanical lift, avoidable injury, and a diminished quality of life.
- E
Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.
Inspectors wroteBased on observation, interview and record review, the facility failed to ensure 3 of 5 residents (Residents 49, 68 and 96) received their physician-ordered therapeutic diets to support the resident's plan of care. This failure placed residents at risk for medical complications, nutritional deficits, and weight gain.
- D
Ensure that residents are fully informed and understand their health status, care and treatments.
Inspectors wroteBased on interview and record review, the facility failed to ensure 1 of 5 sampled residents (Resident 6), reviewed for unnecessary medications, and/or her representative, were fully informed of the potential risks associated with use of a psychotropic medication (medication which alters thought processes). This failure placed the resident at risk for adverse medication side effects, and the resident and/or their representative at risk for not being able to make an informed decision about a medication.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on observation, interview, and record review, the facility failed to provide care and services that met professional standards for 1 of 1 resident (Resident 12) reviewed for hydration. Failure to accurately monitor fluid intake for residents who required fluid restriction and failure to monitor daily weights for a resident with congestive heart failure (a disease were the heart can not pump blood well enough, and blood and fluids collect in the lungs and legs over time) placed the residents at risk for acute medical complications and a diminished quality of life.
- D
Provide or obtain dental services for each resident.
Inspectors wroteBased on observation, interview, and record review, the facility failed to provide assistance and follow up on an appointment for dental care services for 1 of 3 Residents (Residents 64) reviewed for dental services. This failure placed the resident at potential risk for continued dental problems and decreased the quality of life.
- D
Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
Inspectors wroteBased on interview and record review, the facility failed to obtain and incorporate a hospice plan of care into the resident's facility plan of care for 1 of 1 resident (Resident 4) when reviewed for hospice. This failure placed the resident at risk of a lack of needed services, discoordination of care, and a diminished quality of life.
- B
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Inspectors wroteBased on observation and interview, the facility failed to provide food in accordance with preferences for 3 of 6 residents (Residents 68, 94, and 95) reviewed during meal service. This failure placed residents at risk for potential dissatisfaction with meals and a diminished quality of life.
October 26, 2023Complaint inspection · 1 citation
- G
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on interview and record review, the facility failed to provide care and services according to professional standards of practice to prevent pressure injury for 1 of 3 residents (Resident 1) reviewed for pressure injuries. Resident 1 experienced harm when the facility failed to monitor the integrity of Resident 1's skin under a removable leg/knee immobilizer brace which developed into a lower leg pressure injury that was unstageable and contained dead tissue in the wound bed.
Fire safety inspections
27 fire safety citations on file: 9 on February 27, 2026, 8 on January 13, 2025, 10 on February 8, 2024.
Every fire safety citation27 citations
- F
Provide properly protected cooking facilities.
K 324 · February 27, 2026 · Corrected (the home has a date of correction)
- F
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · February 27, 2026 · 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 27, 2026 · Corrected (the home has a date of correction)
- E
Ensure that testing and maintenance of electrical equipment is performed.
K 921 · February 27, 2026 · Corrected (the home has a date of correction)
- D
Keep aisles, corridors, and exits free of obstruction in case of emergency.
K 211 · February 27, 2026 · Corrected (the home has a date of correction)
- D
Have restrictions on the use of highly flammable decorations.
K 753 · February 27, 2026 · Corrected (the home has a date of correction)
- D
Have restrictions on the use of portable space heaters.
K 781 · February 27, 2026 · Corrected (the home has a date of correction)
- D
Ensure proper usage of power strips and extension cords.
K 920 · February 27, 2026 · Corrected (the home has a date of correction)
- D
Have proper medical gas storage and administration areas.
K 923 · February 27, 2026 · Corrected (the home has a date of correction)
- F
Conduct testing and exercise requirements.
E 39 · January 13, 2025 · Corrected (the home has a date of correction)
- F
Have corridors or aisles that are unobstructed and are at least 8 feet in width.
K 232 · January 13, 2025 · Corrected (the home has a date of correction)
- F
Provide properly protected cooking facilities.
K 324 · January 13, 2025 · Corrected (the home has a date of correction)
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · January 13, 2025 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · January 13, 2025 · Corrected (the home has a date of correction)
- E
Have properly installed electrical wiring and gas equipment.
K 511 · January 13, 2025 · Corrected (the home has a date of correction)
- D
Have restrictions on the use of highly flammable decorations.
K 753 · January 13, 2025 · Corrected (the home has a date of correction)
- D
Ensure proper usage of power strips and extension cords.
K 920 · January 13, 2025 · Corrected (the home has a date of correction)
- F
Provide properly protected cooking facilities.
K 324 · February 8, 2024 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · February 8, 2024 · Corrected (the home has a date of correction)
- F
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · February 8, 2024 · Corrected (the home has a date of correction)
- F
Install smoke barrier doors that can resist smoke for at least 20 minutes.
K 374 · February 8, 2024 · 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 · February 8, 2024 · Corrected (the home has a date of correction)
- F
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
K 761 · February 8, 2024 · 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 8, 2024 · Corrected (the home has a date of correction)
- D
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 · February 8, 2024 · Corrected (the home has a date of correction)
- D
Install a fire alarm system that can be heard throughout the facility.
K 341 · February 8, 2024 · Corrected (the home has a date of correction)
- D
Ensure proper usage of power strips and extension cords.
K 920 · February 8, 2024 · Corrected (the home has a date of correction)