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 30 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
7J
3K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
12D
7E
1F
Potential for minimal harm
0A
0B
0C
June 18, 2026Complaint inspection · 3 citations
- F
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Inspectors wroteBased on observation, record review, facility policy review and interviews, the facility failed to maintain an effective pest control program so that the facility was free of pests for five (5) of seven (7) sampled residents, Resident #1, Resident #2, Resident #3, Resident #4 and Resident #6.
- D
Reasonably accommodate the needs and preferences of each resident.
Inspectors wroteBased on observation, record review, facility policy review, and interview, the facility failed to ensure that a Spanish-speaking resident had access to language assistance services to prevent cultural and language barriers to care and quality of life for one (1) of (1) Spanish-speaking resident reviewed for communication needs. Resident #1.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observations, record review, facility policy review and interviews the facility failed to ensure that staff followed standard and transmission-based precautions to prevent spread of infections, when an Registered Nurse (RN) did not follow Enhanced Barrier Precautions (EBP) during direct care/replacement of the resident's leaking catheter drainage and collection component for one (1) of two (2) sampled residents with indwelling catheters. Resident #6. Findings Included:Record review of the facility policy titled, Standard Precautions Infection Control with Revision Date 11/14/25 revealed the policy stated, All staff are to assume that all residents are potentially infected or colonized with an organism that could be transmitted during the course of providing resident care services. [...]
October 20, 2025Complaint inspection · 2 citations
- J
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, record review and facility policy review, the facility failed to ensure that residents were free from abuse, neglect, and intimidation when it admitted and retained a resident with known aggressive and violent behaviors (Resident #1) without implementing adequate supervision, behavioral interventions, or protective measures for other residents. The facility's failure to provide necessary psychiatric intervention or to relocate vulnerable roommates placed residents at risk for serious injury, harm, impairment, or death, resulting in an immediate jeopardy to resident health and safety. This deficient practice directly affected three (3) of four (4) sampled residents. Resident #2, Resident #3, and Resident #4. [...]
- J
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 that residents were protected from a resident who was admitted with known aggressive behaviors and failed to provide adequate supervision and interventions for that resident. The facility admitted and continued to retain Resident #1 without ensuring appropriate psychiatric care, enhanced supervision, or reassignment of vulnerable roommates. This systemic failure directly affected three (3) of four (4) sampled residents. Resident #2, Resident #3, and Resident #4. The facility's failure to provide adequate supervision to prevent the exhibited aggressive and combative behaviors of Resident #1 placed this resident, and other residents at risk, in a situation that was likely to cause serious injury, harm, impairment, or death. [...]
August 13, 2025Complaint inspection · 1 citation
- J
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to provide supervision and implement effective elopement prevention strategies for one (1) of four (4) sampled residents (Resident #1), who had a known cognitive impairment and elopement risk, resulting in an incident of elopement. The facility's failure to ensure supervision and implement interventions-including failure to detect the resident's absence promptly, and failure to secure exit doors-resulted in Resident #1 exiting the facility through the front entrance without staff knowledge and being unsupervised in the community for approximately one (1) hour and twenty-nine (29) minutes. The resident was found approximately two (2) miles away at a local business after receiving a ride from an unknown individual. [...]
January 9, 2025Standard inspection · 6 citations
- E
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on observation, staff interview, and facility policy review, the facility failed to securely safeguard hazardous chemicals in two unlocked janitor's closets for one (1) of four (4) days of survey. Findings Include: Review of the facility ' s policy, Overview of Proper Chemical Use, revised 6/2016, revealed, In order to help prevent accidents from occurring you must follow the following guidelines: 6. If you leave chemicals in the janitor's closet the door must be locked . An observation on 01/06/25 at 10:30 AM, revealed the Janitor Closet on the 200 hall was unlocked and there was a full bottle of 3M Concentrated Glass Cleaner in the closet. An observation on 01/06/25 at 11:19 AM, revealed the Janitor Closet on the Intermediate Care (IC) Hall was unlocked and unattended and there were containers of 3M Concentrated Glass Cleaner and 3M Quat Disinfectant. [...]
- E
Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs.
Inspectors wroteBased on observation, resident and staff interview, record review, and facility policy review, the facility failed to ensure dietary staff supported and respected a resident's right to make choices about his or her meal preferences for one (1) of twenty-six (26) sampled residents. Resident #40. Findings Include: Record review of the facility policy Menus revised 10/2022, revealed, .Procedures .2. Menus will be periodically presented for resident review, including the resident council, menu review meetings, or other review board as indicated by the center. The menu will identify the primary meal, the alternate meal, and any always offered food and beverage items . An observation on 1/6/25 at 10:52 AM, revealed a menu hanging in both dining areas that did not include alternate options. [...]
- E
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Inspectors wroteBased on observation, interviews, record review, and facility policy review, the facility failed to provide palatable, appropriately temperature-controlled foods for one (1) of (43) sampled residents.
- E
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interviews, record review, and policy review, the facility failed to prevent the possibility of the spread of infection as evidenced by improper hand hygiene practices and wound care for three (3) of six (6) direct care observations. (Resident #3, Resident #64 and #66)
- D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteBased on observations, staff interview and record review, the facility failed to ensure that the dignity and respect of residents are upheld when feeding during mealtimes for one (1) of 26 sample residents reviewed.
- 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 observation, interviews, record review, and facility policy reviews, the facility failed to implement care plan interventions related to wound care when a nurse cleaned a resident's pressure ulcer wound without patting it dry for one (1) of 43 resident care plans reviewed (Resident #64)
April 17, 2024Complaint inspection · 3 citations
- 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 interviews, record reviews and facility policy reviews, the facility failed to ensure the comprehensive care plan was implemented, as evidenced by failure to provide oral care during Activities of Daily Living (ADLs) for two (2) of six (6) sampled residents. Resident #3 and Resident #6 Findings Include: Review of the facility's policy and procedure titled, Plans of Care, revised 9/25/17, revealed, .Procedure .The Individualized Person-Centered plan of care may include but is not limited to the following .Services to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required by state and federal regulatory requirements . Individualized interventions that honor the resident's preferences and promote achievement of the resident's goals . [...]
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on observation, interviews, and record reviews, the facility failed to ensure dependent residents received Activites of Daily Living (ADL) care to include oral hygiene for two (2) or six (6) sampled residents. Residents #3 and #6 Findings Include: Record review of the facility's policy and procedure titled, Activities of Daily Living, dated 2/1/22, revealed, Policy: To encourage resident choice and participation in activities of daily living (ADL) and provide oversight, cuing and assistance as necessary. ADLs include bathing, dressing, grooming, hygiene, toileting and eating. Procedure: 1. CNA (Certified Nurse Aide) will review the resident [NAME] (facility software that includes individualized resident care) for information on individual care needs and preferences . [...]
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on observation, interviews, record review, and policy review, the facility staff failed to provide treatment and services in a manner to promote the healing and prevent complications of a pressure ulcer for one (1) of four (4) sampled residents with pressure ulcers.
October 20, 2023Complaint inspection · 1 citation
- 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, interviews, and facility policy review, the facility failed to ensure residents were treated with respect and dignity for two (2) of five (5) residents reviewed. Residents #2 and #5.
May 9, 2023Standard inspection · 7 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 observation, interviews, record review, and facility policy review, the facility neglected to provide physician ordered services that were necessary for five (5) of 24 sampled residents. This resulted in actual harm for Residents #31, #75, #87, and #254 and had the likelihood of serious harm for Resident # 34. The facility's failure to provide services necessary to avoid physical harm caused serious harm as Resident #31 experienced decreased range of motion and mobility, Resident #75 was hospitalized for Congestive Heart Failure (CHF), Resident #87 developed a infection of a vascular stent placement, and Resident #254 was hospitalized due to sepsis. There was likelihood of harm for Resident #34 due to a delay in follow-up appointment for a supra pubic catheter placement. [...]
- K
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Inspectors wroteBased on interviews, record review, and job description review, the facility's administration failed to use its resources effectively to ensure residents received physician-ordered services for five (5) of 24 residents reviewed, with the likelihood to affected any resident who needed outside transportation. Resident #31, Resident #34, Resident #75, Resident #87, and Resident #254. Serious harm occurred as a result of the facility's Administration's failure to ensure residents received physician-ordered services which caused Resident #31 to have decreased mobility, Resident #75 to be hospitalized , Resident #87 to have a wound infection, and Resident #254 to have sepsis. There was a likelihood of harm for Resident #34 due to a delay in changing a newly placed supra pubic catheter. [...]
- K
Have a plan that describes the process for conducting QAPI and QAA activities.
Inspectors wroteBased on interviews, record review, and facility policy review, the facility failed to maintain an effective Quality Assurance Performance Improvement (QAPI) program to ensure transportation was provided for outside medical services for five (5) of 24 sampled residents, with the likelihood to affect any resident who required outside transportation. The facility's failure to maintain an effective QAPI program placed residents who require outside transportation at risk for serious injury, serious harm, serious impairment, or death. This caused Resident #31 to experience decreased mobility, Resident #75 to be hospitalized , Resident #87 to develop a wound infection, and Resident #254 to become septic. There was a likelihood of harm for Resident #34 due to the delay in changing a newly placed supra pubic catheter. [...]
- J
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, record review, and facility policy review, the facility failed to develop or implement a comprehensive care plan for residents with a Supra-Pubic Catheter, diagnoses of Chronic Obstructive Pulmonary Disease (COPD) and Congestive Heart Failure (CHF), Range-of-Motion (ROM) related to an Orthopedic Brace, Treatment related to a Vascular Implant, and Orthopedic, Wound and Vascular Appointments for five (5) of 24 care plans reviewed. Resident #31, Resident #34, Resident #75, Resident #87, and Resident #254. Serious harm occurred as a result of the facility's failure to develop or implement a Comprehensive Care Plan which resulted in decreased mobility for Resident #31, hospitalization for Resident #75, a wound infection for Resident #87, and sepsis for Resident #254. [...]
- J
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on interviews and record review, the facility failed to ensure two (2) of 24 sampled residents received outside medical services as ordered to prevent complications and maintain the highest practicable physical, mental, and/or psychosocial wellbeing. Residents #75 and #87. The facility's failure to provide required outside medical services led to the hospitalization of Resident #75 due to Congested Heart Failure (CHF) and Pneumonia and was admitted to the Intensive Care Unit (ICU) and wound infection for Resident #87 caused serious injury, serious harm, and serious impairment to Resident #75 and Resident #87 and placed other residents in a situation that was likely to cause serious injury, harm, impairment or death. [...]
- J
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to provide medical services to prevent an avoidable reduction in range-of-motion (ROM) and loss of mobility for one (1) of 24 sampled residents reviewed for ROM. Resident #31. The facility's failure to provide services to prevent the avoidable loss of ROM for Resident #31 resulted in serious injury, serious harm, and serious impairment and placed other residents in a situation that was likely to cause serious injury, harm, impairment, or death. The situation was determined to be Immediate Jeopardy (IJ) that began on 2/14/23 when Resident #31 missed the first post operative appointment with an orthopedic surgeon. The Facility Administrator was notified of the IJ on 5/5/23 at 12:23 PM and provided an IJ Template. [...]
- J
Make sure that a working call system is available in each resident's bathroom and bathing area.
Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure a functioning call light system was available for residents' bathrooms for 18 residents out of 107 residents that reside in the facility. (Residents #4, #5, #12, #21, #32, #37, #38, #44, #46, #49, #57, #60 #65, #69, #71, #81, #87, and #96) The facility's failure to ensure a functioning call light system was available for residents' bathrooms for 18 residents residing in the facility placed these residents, and other residents, in a situation that was likely to cause serious harm, injury, impairment, or death. The situation was determined to be an Immediate Jeopardy (IJ) that began on 4/16/23 when a maintenance work order was completed for call light issues but was not acted upon. The facility Administrator was notified of the IJ on 5/2/23 at 5:38 PM and provided an IJ Template. [...]
October 24, 2019Standard inspection · 7 citations
- 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, staff interview, and facility policy review, the facility failed to have lids sealed on the Biohazard Trash Cans for Seven (7) of seven (7) trash cans in the Biohazard Room, where staff placed medical waste.
- E
Have policies on smoking.
Inspectors wroteBased on interview, observation, record review, and facility policy review, the facility failed to provide a safe smoking environment as evidenced by plastic trash cans and plastic bags were used in the smoking area for cigarette butt disposal, for three (3) of four (4) observations during survey.
- D
Ensure each resident receives an accurate assessment.
Inspectors wroteBased on staff interview, record review, and facility policy review, the facility failed to accurately complete a Minimum Data Set (MDS) assessment for one (1) of 28 resident records reviewed, Resident #122. Findings Include: Review of the facility's Policies and Procedure policy, revised 9/25/17, revealed to maintain all resident assessments completed within the previous 15 months in the resident's active clinical record, or in a centralized location that is easily and readily accessible. Each person completing a section or portion of MDS signs the Attestation Statement indicating accuracy/completeness. Review of the Discharge MDS, with an Assessment Reference Date (ARD) of 9/20/19, revealed acute hospital was documented as the discharge destination for Resident #122. [...]
- D
PASARR screening for Mental disorders or Intellectual Disabilities
Inspectors wroteBased on staff interview, record review, and facility policy review, the facility failed to complete a Level II Preassessment Screening and Resident Review (PASARR), for a resident with mental illness diagnoses, for one (1) of 28 records reviewed, Resident #53.
- 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 observation, staff interview, record review, and facility policy review, the facility failed to implement the Comprehensive Care Plan related to Catheter Care, for one (1) of five (5) care plans reviewed, Resident #15. Findings Include: A review of the facility's Plans of Care policy, revised 9/25/17, revealed the procedure is to develop a comprehensive plan of care for each resident that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychosocial needs that are identified in the comprehensive assessment. Resident #15 Review of Resident #15's Comprehensive Care Plan, with a focus of Elimination, implemented 3/18/19, with a target date of 11/15/19, revealed Resident #15 with altered bladder elimination and an intervention to perform catheter care, as ordered, per Nursing Aide. [...]
- 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, staff interview, record review, and facility policy review, the facility failed to prevent cross contamination during catheter care as evidence by incorrect cleaning technique of the catheter tubing for one (1) of five (5) catheter care observations, Resident #15. Findings Include: A review of facility policy titled Catheter care, Urinary revised 9/5/17, revealed the procedure for catheter care was to clean the catheter tubing with soap and water, starting close to the urinary meatus, cleaning in a circular motion along its length for about four (4) inches, moving away from the body. Rinse well using the same motion. Resident #15 An observation on 10/21/19 at 10:45 AM, revealed Certified Nursing Aide (CNA) #1, assisted by CNA #2, entered the room to perform catheter care on Resident #15. [...]
- D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Inspectors wroteMS #16272 Based on staff interview, record review, facility policy, and resident interview, the facility failed to obtain and provide Resident #61's pain medication in a timely manner for one (1) of four (4) residents reviewed for pain. Resident #61 did not have Norco available for pain, as ordered by the physician, for nine (9) scheduled doses. Findings Include: A review of the facility's, LTC Receiving Pharmacy Products and Services from Pharmacy, revised 10/31/16, revealed new orders for Schedule II controlled substances required a written prescription prior to dispensing, unless there is an emergency situation. An emergency situation is one in which the prescribing Practioner determines that immediate administration of the Schedule II controlled substance is necessary for proper treatment of the intended ultimate user. [...]
Fire safety inspections
6 fire safety citations on file: 1 on January 9, 2025, 1 on May 9, 2023, 4 on October 24, 2019.
Every fire safety citation6 citations
- F
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · January 9, 2025 · Corrected (the home has a date of correction)
- F
Install smoke barrier doors that can resist smoke for at least 20 minutes.
K 374 · May 9, 2023 · Corrected (the home has a date of correction)
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · October 24, 2019 · Corrected (the home has a date of correction)
- F
Have a battery powered remote alarm panel in a location accessible by operating personnel.
K 916 · October 24, 2019 · Corrected (the home has a date of correction)
- D
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
K 321 · October 24, 2019 · Corrected (the home has a date of correction)
- D
Install corridor and hallway doors that block smoke.
K 363 · October 24, 2019 · Corrected (the home has a date of correction)