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 50 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
8G
0H
0I
Potential for more than minimal harm
27D
12E
3F
Potential for minimal harm
0A
0B
0C
May 26, 2026Complaint inspection · 5 citations
- E
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on interview and record review the facility failed to report an allegation of physical abuse from a staff member to one (R8) resident to the State Agency and failed to report an allegation of resident (R6) to resident (R9) verbal abuse to the Abuse Coordinator out of five residents reviewed for Abuse in a sample list of nine residents.
- E
Respond appropriately to all alleged violations.
Inspectors wroteBased on interview and record review the facility failed to complete a thorough investigations for allegations of abuse for three (R5, R6, R8) residents out of five residents reviewed for Abuse in a sample list of nine residents.
- D
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Inspectors wroteBased on interview and record review the facility failed to ensure the resident's right to be free from verbal abuse for one (R9) resident by another resident (R6) out of five residents reviewed for Abuse in a sample list of nine residents.
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on observation, interview and record review the facility failed to provide a safe transfer for one (R8) resident causing a bruise out of five residents reviewed for Abuse in a sample list of nine residents.
- D
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Inspectors wroteBased on observation, interview and record review the facility failed to provide timely incontinence care and failed to prevent cross contamination during incontinence care for one (R2) resident out of three residents reviewed for Activities of Daily Living (ADL) in a sample list of nine residents.
April 22, 2026Complaint inspection · 3 citations
- G
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were free from abuse for two (R4 and R6) of three residents reviewed for resident-to-resident physical contact on a sample list of three residents. The facility failed to assess, care plan, and implement effective interventions following repeated altercations. This failure resulted in a physical injury (skin tear) to R6, with actual harm.
- G
Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure appropriate behavioral health services were provided for two (R4 and R6) of three residents reviewed for behavioral concerns, when the facility failed to implement effective behavioral health interventions, failed to provide coordinated behavioral health services, and failed to ensure adequate assessment and communication regarding psychotropic medication management. These failures resulted in continued unsafe behaviors and a resident-to-resident physical altercation that caused actual harm (skin tear) to R6. Findings Include:Facility has no Policy on Behavioral ServicesReview of the Electronic Health Record (EHR) revealed R4 had diagnoses including Frontotemporal Neurocognitive Disorder, Dementia with Agitation, Mood Disorder, and Anxiety Disorder. [...]
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on record review, observations, and staff interviews, the facility failed to ensure physician-ordered direction and care planning for an indwelling urinary catheter and failed to maintain an accurate and updated care plan reflecting the resident's current clinical condition and skin integrity needs. This deficient practice affected one resident (R1) of three residents on sampled list reviewed. Findings Include: R1 was admitted to the facility on [DATE]. R1's diagnoses include Malignant Neoplasm of the Colon, Malignant Neoplasm of the Breast, Chronic Diastolic Heart Failure, Hypertension, Type 2 Diabetes Mellitus, Coronary Artery Disease, Acute Kidney Failure, Neuromuscular Dysfunction of the Bladder, Generalized Weakness, Muscle Wasting and Atrophy, and is receiving hospice/palliative care services. [...]
December 13, 2025Complaint inspection · 1 citation
- D
Ensure that residents are free from significant medication errors.
Inspectors wroteBased on interview and record review, the facility failed to ensure pain medication was administered as ordered for one (R6) of three residents reviewed for medication administration in the sample of 23.
October 21, 2025Complaint inspection · 1 citation
- G
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 implement interventions to prevent a fall for one resident (R1) of three residents reviewed for falls in a sample list of three residents. This failure caused R1 to fall sustaining an acute nasal Fracture and a laceration to (R1's) nose requiring five sutures to close. Findings Include:R1's Care Plan updated 10/14/25 includes the following diagnoses: Osteoarthritis, Heart Disease, Lumbar Disc Displacement, Anxiety, Vertigo, Repeated Falls, Glaucoma, Type II Diabetes, Difficulty in Walking, and Psychotic Disturbance with Hallucinations. R1 Fall Risk assessment dated [DATE] document R1 as being at high risk for falls and having a recent history of falls. R1 has current physician's orders for the following narcotics and psychotropic medications: [...]
September 24, 2025Standard inspection · 13 citations
- E
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteBased on interview and record review the facility failed to ensure a resident's right to dignity while dining for R20, and by staff talking on cell phones during resident care for R8, R43, and R58. These failures affected four out of 29 residents (R20, R8, R43, and R58) reviewed for dignified care on the sample list of 31.
- 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 record review and interview the facility failed to ensure a resident's right to choose their own wake -up time. This failure affected four of 29 residents (R8, R43, R58 and R74) reviewed for resident rights on the sample list of 31.
- E
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Inspectors wroteBased on observation, interview, and record review the facility failed to ensure care plans were comprehensive to include medications, diagnoses, behaviors, accidents/injuries, and incontinence for three of 18 residents (R6, R8, R45) reviewed for care plans in the sample list of 31. The facility's Care Plan policy dated November 2017 documents A Comprehensive person-centered care plan shall be developed and implemented to meet the resident's preferences and goals, and address the resident's medical, physical, mental and psychosocial needs, while honoring resident rights to choice. This care plan shall include goals, measurable objectives, and interventions to meet identified resident needs. [...]
- E
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Inspectors wroteBased on observation, interview and record review, the facility repeatedly failed to follow a physician order to discontinue the administration of a medication, for one of five residents (R69) reviewed for unnecessary medications on the sample list of 31.
- E
Ensure medication error rates are not 5 percent or greater.
Inspectors wroteBased on observation, interview, and record review the facility failed to follow pharmacy instruction for the safe administration of physician ordered medication, for two of eight residents (R66 and R78) reviewed during medication observation. These failures resulted in three errors out of 29 opportunities for a 10.39 percent medication administration error rate.
- D
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 observation, interview and record review the facility failed to respond to a resident grievance in a timely manner, for one of four residents (R58) reviewed for grievances in the group meeting, on the sample list of 31.
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on interview and record review the facility failed to report an injury of unknown origin to the administrator and the state survey agency for one of one resident (R6) reviewed for abuse in the sample list of 31.
- D
Respond appropriately to all alleged violations.
Inspectors wroteBased on interview and record review the facility failed to investigate an injury of unknown origin for one of one resident (R6) reviewed for abuse in the sample list of 31.
- 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 interview and record review the facility failed to revise a care plan with fall interventions for one of 18 residents (R4) reviewed for care plans in the sample list of 31.
- D
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Inspectors wroteBased on observation, interview, and record review the facility failed to prevent cross-contamination during catheter care for one of two residents (R53) reviewed for urinary catheter care on the sample list of 31. Findings Include:R53's Medical Diagnoses List dated May 20, 2025 documents R53 is diagnosed with Infection and inflammatory reactions due to indwelling urethral catheter and Retention of urine. R53's Minimum Data Set (MDS) dated [DATE] documents R53 has severe cognitive impairment, uses a wheelchair, is always incontinent of bowel, and is dependent on staff for toileting, hygiene, and transfers. R53's Care Plan dated 7/29/25 documents R53 has an indwelling Foley catheter. [...]
- D
Provide enough food/fluids to maintain a resident's health.
Inspectors wroteBased on observation, interview, and record review the facility failed to monitor and record weights and meal intakes for one of three residents (R45) reviewed for weight loss in the sample list of 31.
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observation, interview, and record review the facility failed to change the oxygen tubing and humidifier bottle for one (R63) of three residents reviewed for respiratory care on the sample list of 31.
- D
Ensure that residents are free from significant medication errors.
Inspectors wroteBased on interview and record review the facility failed to accurately transcribe hospital discharge orders resulting in a significant medication error for one of five residents (R6) reviewed for unnecessary medications in the sample list of 31.
April 29, 2025Complaint inspection · 1 citation
- 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 interview and record review, the facility failed to develop and implement a person-centered comprehensive care plan for elopement risk and the use of a departure alert system. This failure affects two (R1 and R3) of three residents reviewed for supervision in the sample list of three.
April 21, 2025Complaint inspection · 1 citation
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on interview and record review the facility failed to provide one staff assistance to prevent a fall for one (R1) of three residents reviewed for accidents in the sample list of five.
December 11, 2024Complaint inspection · 1 citation
- G
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on interview and record review the facility failed to supervise a resident after providing the resident with a hot beverage. This failure affects one (R504) is one of three residents reviewed for supervision in the sample of 3. This failure resulted in R504 spilling hot liquid on R504's lap sustaining redness and 6 blistered areas to R504's bilateral upper extremities requiring subsequent treatment for 3days. Findings Include: R504's Facility Census documents R504 was admitted to the facility on [DATE] and has the following medical diagnoses: [...]
October 23, 2024Standard inspection, Complaint inspection · 10 citations
- G
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on observation, interview and record review the facility failed to provide targeted interventions to prevent skin breakdown, failed to assess, evaluate and document resident skin on a regular basis, and failed to obtain appropriate treatment orders for pressure ulcers for two (R20, R58) of five residents reviewed for pressure ulcers from a total sample list of 44 residents. These failures resulted in one resident (R20) developing a new, unstagable, deep tissue injury and a second resident (R58) developing seven, new stage two pressure wounds.
- G
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteFailures at this level require more than one deficient practice statement. A. Based on interview and record review the facility failed to monitor a resident (R22), with Dysphagia (difficulty swallowing), after administering oral medication. This failure affects one resident (R22) of 7 residents reviewed for medication administration in the sample list of 44. R22 experienced a choking episode when staff had left R22's room after oral medication administration. Upon staff hearing R22's coughing, staff returned to R22's room and performed the Heimlich Maneuver to expel the tablet from R22. B. Based on interview and record review the facility failed to thoroughly investigate falls and document falls in the resident's medical record for one (R17) of nine residents reviewed for accidents in the sample list of 44.
- F
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Inspectors wroteBased on interview and record review the facility failed to develop, implement, measure, act on or analyze a performance improvement program project in the last twelve months. This failure has the potential to affect all 85 residents who reside in the facility.
- F
Provide and implement an infection prevention and control program.
Inspectors wroteBased on interview and record review the facility failed to store, handle, and launder linens that were potentially exposed to scabies. This failure has the potential to affect all 85 residents who reside in the facility. The facility also failed to follow enhanced barrier precautions for two (R4, R39) of six residents reviewed for enhanced barrier precautions from a total sample list of 44 residents.
- E
Ensure medication error rates are not 5 percent or greater.
Inspectors wroteBased on observation, interview, and record review the facility failed to administer medications timely and according to physician's orders and manufacturer's instructions for four (R17, R61, R42, R4) of seven residents reviewed for medication administration in the sample list of 44. These failures resulted in eight medication errors out of 25 opportunities, a 32% medication error rate.
- 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 maintain resident's furniture in a clean manner for two of 24 residents (R74, R61) reviewed for clean, comfortable, homelike environment in the sample list of 44.
- D
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Inspectors wroteBased on observation, interview and record review the facility failed to ensure a resident was free from restraint by not having a Physician's Order, a signed consent form for a restraint and to complete restraint reduction attempts. This affects one of one resident(R74) reviewed for restraints in the sample list of 44.
- D
Assist a resident in gaining access to vision and hearing services.
Inspectors wroteBased on observation, interview, and record review the facility failed to implement hearing devices and develop a care plan for hearing loss for one (R39) of one resident reviewed for communication in the sample list of 44.
- D
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Inspectors wroteBased on observation, interview, and record review the facility failed to check and record gastric residual volume to verify gastrostomy tube placement, and administer and record water flushes and enteral feeding amounts for one (R39) of one resident reviewed for gastrostomy tube in the sample of 44.
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observation, interview, and record review the facility failed to label, store, and change oxygen and nebulizer tubing for three (R17, R39, R84) of three residents reviewed for respiratory care in the sample of 44.
September 23, 2024Complaint inspection · 1 citation
- E
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview, and record review the facility failed to implement infection control measures to prevent the spread of COVID-19 (Human Coronavirus Infection) by failing to stock isolation carts with N95 masks, ensure isolation signage was posted, and ensure staff discarded personal protective equipment (PPE) upon leaving COVID-19 positive resident rooms. The facility also failed to complete COVID-19 symptom monitoring for residents having COVID-19. These failures affect five (R1, R2, R4, R5, R6) of six residents reviewed for infection control in the sample list of eight.
June 23, 2024Complaint inspection · 1 citation
- D
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Inspectors wroteBased on interview and record review, the facility failed to ensure a resident (R2) was not subjected to physical abuse by (R1). R2 is one of 4 residents reviewed for abuse.
February 28, 2024Complaint inspection · 3 citations
- E
Protect each resident from the wrongful use of the resident's belongings or money.
Inspectors wroteBased on interview and record review the facility failed to prevent misappropriation of medications for five (R1, R2, R3, R4 and R5) of five residents reviewed for misappropriation of medications from a total sample list of five residents reviewed.
- E
Not hire anyone with a finding of abuse, neglect, exploitation, or theft.
Inspectors wroteBased on interview and record review the facility failed to follow their abuse policy by employing a nurse with a history of disciplinary action on their license. This failure affects five (R1, R2, R3, R4 and R5) of five residents reviewed for abuse on the sample of five residents.
- D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Inspectors wroteBased on interview and record review the facility failed to dispose of narcotics as directed by their policy. This failure has the potential to affect one (R1) of five residents reviewed for medication disposal on the sample list of five.
September 13, 2023Standard inspection · 9 citations
- G
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 effective pain control and positioning aids for R50. The facility also failed to follow physician orders for R44. R44 and R50 are two of two hospice residents reviewed from a total sample list of 36. These failures resulted in R50 experiencing uncontrolled pain by grimacing, moaning, and closing her eyes while wound treatments were performed on a stage three and an unstageable wound.
- G
Provide enough food/fluids to maintain a resident's health.
Inspectors wroteBased on observation, interview, and record review the facility failed to identify significant weight loss, prevent significant weight loss, develop/implement a care plan including interventions for weight loss, implement nutritional interventions/recommendations, timely implement physician's orders, and report significant weight loss to the physician and registered dietitian for two of five residents (R45, R83) reviewed for nutrition in the sample list of 36. These failures resulted in R45 experiencing a severe weight loss of 13.73 % (percent) in four months.
- F
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
Inspectors wroteBased on interview and record review the facility failed to ensure quarterly Quality Assurance (QA) meetings included all required committee members. This failure affects all 81 residents residing in the facility.
- E
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Inspectors wroteBased on interview and record review the facility failed to timely administer pneumococcal vaccines to ensure residents are up to date with pneumococcal vaccinations for five (R52, R12, R44, R64, R45) of seven residents reviewed for immunizations in the sample list of 36.
- D
Allow residents to self-administer drugs if determined clinically appropriate.
Inspectors wroteBased on observation, interview and record review the facility failed to assess two of two residents (R47, R58) reviewed for safe self-administration of medication in the sample list of 36. Findings Include: The facility's policy Self-Administration of medications reviewed 12/05 states if the resident wishes to self-medicate, the interdisciplinary team (IDT) must assess the resident's cognitive, physical, and visual abilities. 1.) On 9/12/23 at 9:50AM, R47 was in bed finishing breakfast. There was a pill cup with several pills on the bed side table. R47 dumped the pills in R47's mouth and swallowed them with water. R47 stated the nurse leaves my pills here so I can take them after I eat. On 9/12/23 at 10:00AM V6 (Registered Nurse/RN) stated I left (R47's) medication so (R47) could take it after (R47) was finished eating. I thought I could just keep an eye on (R47) from the hall. [...]
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on observation, interview, and record review the facility failed to complete pressure ulcer risk assessments, routinely assess pressure ulcers, update a care plan to include a pressure ulcer and new pressure relieving interventions, and ensure a pressure ulcer was covered with a dressing for resident's wounds. This failure affects three of seven residents (R61, R10, R77) reviewed for pressure ulcers in the sample list of 36.
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on interview and record review the facility failed to complete fall investigations, develop, and implement fall interventions for one of three residents (R77) reviewed for falls in the sample list of 36.
- D
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Inspectors wroteBased on observation, interview and record review the facility failed to secure R24's catheter and failed to provide R24 with hygienic perineal care during catheter care and failed to prevent R77's catheter from dragging on the floor for two of two (R24, R77) residents reviewed for catheter care and urinary tract infections from a total sample list of 36.
- D
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Inspectors wroteBased on observation, interview, and record review the facility failed to maintain a gastrostomy (G-tube) site in a clean sanitary manner for one resident (R38) of one resident reviewed for gastrostomy tubes in a sample list of 36. Findings Include: The facility's policy Enteral/ Tube Feeding Policy dated 2/26/15 states Routine care such as cleansing the healed insertion site and provision of oral hygiene may be performed by non-licensed staff under the supervision of licensed staff following facility procedure. This policy also states, To discourage the transmission of infection, residents receiving tube feedings will receive daily hygiene and skin care to site utilized for feeding. R38's Current physician's orders includes an order to Monitor stoma for cleanliness. Clean as needed. [...]
Fire safety inspections
6 fire safety citations on file: 1 on October 23, 2024, 1 on September 13, 2023, 4 on August 19, 2022.
Every fire safety citation6 citations
- F
Establish roles under a Waiver declared by secretary.
E 26 · October 23, 2024 · Corrected (the home has a date of correction)
- F
Conduct testing and exercise requirements.
E 39 · September 13, 2023 · Corrected (the home has a date of correction)
- F
Address patient/client population and determine types of services needed.
E 7 · August 19, 2022 · Corrected (the home has a date of correction)
- F
Establish methods for sharing information.
E 33 · August 19, 2022 · Corrected (the home has a date of correction)
- F
Provide a means of sharing information on occupancy/needs.
E 34 · August 19, 2022 · Corrected (the home has a date of correction)
- E
Install corridor and hallway doors that block smoke.
K 363 · August 19, 2022 · Corrected (the home has a date of correction)