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 35 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
29D
2E
3F
Potential for minimal harm
0A
0B
1C
February 20, 2026Complaint inspection · 1 citation
- E
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 record review and interviews, the facility failed to ensure incontinent care was provided at least once every shift. This affected five (Resident #1, #2, #3, #4, and #17) out of nine residents reviewed for incontinence care. The facility census was 78.
July 28, 2025Standard inspection, Complaint inspection · 9 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, staff interview, and facility policy review, the facility failed to ensure staff wore hair nets in the kitchen as required. This had the potential to affect 88 residents in the facility. The facility identified one resident (#03) who did not receive food from the kitchen. The facility census was 89. 1. Observation on 07/23/25 at 7:20 A.M. revealed [NAME] #168 assisting [NAME] #119 with obtaining food temperatures on the steam table. [NAME] #168 was observed with braids which extended approximately 18 inches down her back and was not wearing a hair net. Observation on 07/23/25 at 7:36 A.M., [NAME] #168 was observed briefly leaving the kitchen and returned, wearing a hair net, however her braids still remained hanging outside of the hairnet. [NAME] #168 was then observed tending to food items on the facility stove. Interview on 07/23/25 at the time of the observation. [...]
- D
Reasonably accommodate the needs and preferences of each resident.
Inspectors wroteBased on observation and staff interview, the facility failed to ensure residents had access to their call lights. This affected two (#01 and #28) of two residents reviewed for access to call lights. The facility census was 89. 1. Review of the medical record of Resident #28 revealed an admission date of 06/01/19. Diagnoses included acute and chronic respiratory failure with hypoxia, cerebral infarction, hemiplegia and hemiparesis following cerebrovascular disease, aphasia, hypothyroidism, anxiety, depression. Review of the quarterly minimum data set (MDS) assessment dated [DATE] revealed the resident had severely impaired cognition. The resident required supervision with eating, substantial/maximal assistance with toileting, bed mobility, and was dependent on staff for bathing and transfers. [...]
- 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, staff interview, and facility policy review, the facility failed to ensure a resident's responsible party was notified of a new order for a therapy evaluation. This affected one (#97) of one residents reviewed for a change in condition. The facility census was 89. Review of the medical record of Resident #97 revealed an admission date of 10/15/21. The resident discharged from the facility on 07/15/25. Diagnoses included chronic obstructive pulmonary disease, morbid obesity, hemiplegia and hemiparesis following cerebral infarction affecting left-non-dominant side, hyperlipidemia, atrial fibrillation, depression, dementia, anxiety, legal blindness, mood disorder, insomnia, and dysphagia. Review of the quarterly minimum data set (MDS) assessment dated [DATE] revealed the resident had moderately impaired cognition. [...]
- D
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Inspectors wroteBased on medical record review and staff interview, the facility failed to ensure admission comprehensive Minimum Data Set (MDS) assessments were completed within the required timeframes. This affected two (#03 and #37) of three residents reviewed for resident assessment. The facility census was 89. 1. Review of the medical record of Resident #37 revealed an admission date of 12/24/24. The resident transferred to the hospital on [DATE] and returned to the facility on [DATE]. Diagnoses included amyotrophic lateral sclerosis and dementia. Review of the medicare 5-day MDS assessment dated [DATE] revealed the resident had severely impaired cognition. Further review of completed MDS assessments revealed the resident's admission MDS assessment dated [DATE] was not completed until 01/10/25. The resident's discharge MDS assessment dated [DATE] was not completed until 02/10/25. [...]
- D
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Inspectors wroteBased on medical record review and staff interview, the facility failed to ensure entry and discharge Minimum Data Set (MDS) assessments were completed in a timely manner. This affected two (#37 and #40) of three residents reviewed for resident assessment. The facility census was 89. Findings Include:1. Review of the medical record of Resident #37 revealed an admission date of 12/24/24. The resident transferred to the hospital on [DATE] and returned to the facility on [DATE]. Diagnoses included amyotrophic lateral sclerosis and dementia. Review of the Medicare 5-day MDS assessment dated [DATE] revealed the resident had severely impaired cognition. Further review of completed MDS assessments revealed the resident's discharge MDS assessment dated [DATE] was not completed until 02/10/25. The resident's entry MDS assessment dated [DATE] was not completed until 02/10/25. [...]
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on observations, interviews , medical record review and facility policy review, the facility failed to ensure fall interventions were in place for one, (Resident #76) of one reviewed for falls. The facility census was 89. Review of the medical record for Resident #76 revealed an admission date of 06/08/23. The record revealed the resident had severe cognitive deficits. Resident #76's diagnoses included dementia, chronic obstructive pulmonary disease, heart disease, anemia, depression, and chronic kidney disease. The resident was documented to require one-to-two-person assistance with activities of daily living and ambulation, and the resident had a history of falls. Review of Resident #76's nurse progress notes revealed on 05/29/25 the nurse was called by certified nursing assistant (CNA) at 12:40 P.M. to report he had seen Resident #76 on the floor in bedroom. [...]
- D
Provide specialized rehabilitative services by qualified personnel, when ordered for a resident by a doctor.
Inspectors wroteBased on medical record review, resident interview, and staff interview, the facility failed to timely provide a physical therapy evaluation. This affected one (#04) of two residents reviewed for abuse. The facility census was 89.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation , interview and facility policy review the facility failed to follow proper infection control policies when an outbreak of a contagious skin infection occurred in the facility. This affected two residents (#46 and #87) out of 13 residents who resided in the three hundred unit. The facility also failed to follow appropriate infection control practices by not performing proper hand hygiene after performing catheter care for one resident (#6) . The census was 89. 1. Review of the medical record for Resident #87 revealed an admission date of 04/23/24 with a brief interview of mental status (BIMS) score of 99 indicating severe cognitive deficits. Diagnoses included cerebral infarction, malignant neoplasm, paroxysmal atrial fibrillation, anxiety, hyperlipidemia , dementia, gastro esophageal reflux disease (GERD) and hypertension. [...]
- C
Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.
Inspectors wroteBased on observation and staff interview, the facility failed to ensure State Agency survey results were maintained, updated, and available for viewing. This had the potential to affect all 89 residents in the facility.
October 10, 2024Complaint inspection · 1 citation
- D
Respond appropriately to all alleged violations.
Inspectors wroteBased on staff interview, record review, review of the facility's Self-Reported Incidents and investigations, and policy review, the facility failed to thoroughly investigate and obtain statements from staff for an injury of unknown origin for Resident #50 and Resident #101. This affected two (Resident #50 and #101) of three residents reviewed for abuse. The facility census was 85.
March 13, 2024Standard inspection · 15 citations
- F
Provide and implement an infection prevention and control program.
Inspectors wroteBased on review of monthly infection control surveillance logs, staff interview, and facility policy review, the facility failed to to maintain a complete and accurate tracking system for all infections. This had the potential to affect all 86 residents residing in the facility. The census was 86. Findings Include: Review of the facility infection control monthly surveillance log on 03/13/24 revealed the facility failed to document the results of cultures for residents with suspected or actual infections from May 2023 through February 2024. On 03/13/24 at 10:20 A.M., interview with the Director of Nursing (DON) and the Regional Nurse #200 verified the infection control log was not tracking the bacteria being treated for community acquired and facility acquired infections. [...]
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on medical record review, review of investigations, review of self-reported incidents, staff interview, and review of a facility policy, the facility failed to timely report an injury of unknown origin to the State Survey Agency. This affected one (#6) of one residents reviewed for skin conditions. The facility census was 86.
- D
Respond appropriately to all alleged violations.
Inspectors wroteBased on medical record review, review of investigations, staff interview, and policy review, the facility failed to thoroughly investigate an injury of unknown origin. This affected one (#6) of one resident reviewed for skin conditions. The facility census was 86.
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on observation, medical record review, and staff interviews, the facility failed to ensure adequate nail care was provided for dependent residents. This affected two (#22 and #42) of seven residents reviewed for activities of daily living. The facility census was 86. Findings Include: 1. Review of the medical record for Resident #22 revealed an initial admission date of 06/01/19 with the latest readmission date of 12/02/22. Diagnoses included acute and chronic respiratory failure with hypoxia, cerebrovascular accident (CVA) with right sided hemiplegia, aphasia, hypothyroidism, hypertension, gastro-esophageal reflux disease, anemia, and anxiety disorder. [...]
- D
Provide activities to meet all resident's needs.
Inspectors wroteBased on medical record review, staff interview, review of activity calendars, and policy review, the facility failed to ensure activities were offered to residents throughout the week based on assessment, care plan, and resident preference to promote resident well-being. This affected two (#6 and #55) of two residents reviewed for activities. The facility census was 86.
- D
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 policy review, the facility failed to ensure fall interventions were in place and resident transfers were performed in a manner to prevent falls. This affected two (#12 and #50) of seven residents reviewed for falls. The census was 86.
- D
Provide enough food/fluids to maintain a resident's health.
Inspectors wroteBased on observation, medical record review, and staff interview, the facility failed to ensure adequate fluids were available and provided throughout the day to promote hydration. This affected one (#6) of seven residents reviewed for nutrition. The facility census was 86. Findings Include: Review of the medical record for Resident #6 revealed an admission date of 01/16/23 with diagnoses including Alzheimer's disease, depression, gastro-esophageal reflux disease, and senile degeneration of the brain. Review of Resident #6's nutrition assessment dated [DATE] revealed the resident required 2190 milliliters (ml) of fluid a day. Review of Resident #6's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was rarely or never understood. The resident was on a mechanically altered and therapeutic diet. [...]
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observation, medical record review, staff interview, and review of a facility policy, the facility failed to administer supplemental oxygen as ordered. This affected one (#339) of one residents reviewed for oxygen administration. The facility census was 86.
- D
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Inspectors wroteBased on medical record review and staff interview, the facility failed to ensure dialysis services were completed thoroughly including obtaining resident weights before and after dialysis services. This affected one (#8) of one residents reviewed for dialysis. The census was 86. Findings Include: Review of the medical record revealed Resident #8 was admitted to the facility on [DATE]. Diagnoses included chronic obstructive pulmonary disease, chronic respiratory failure with hypoxia, type II diabetes, unspecified hemorrhoids, lack of coordination, weakness, dysphagia, end stage renal disease, atrial fibrillation, and dependence on renal dialysis. Review of Resident #8's Minimum Data Set (MDS) assessment, dated 01/11/24, revealed the resident was cognitively intact. [...]
- D
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Inspectors wroteBased on medical record review and staff interview, the facility failed to ensure adequate monitoring was completed for a medication as ordered. This affected one (#35) of six residents reviewed for medications. The facility census was 86.
- D
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Inspectors wroteBased on medical record review, staff interview, and facility policy review, the facility failed to identify and monitor target behaviors for the use of psychotropic medications. This affected one (#73) of six residents reviewed for medications. The facility census was 86. Findings Include: Review of Resident #73's plan of care dated 11/07/22 revealed the resident had trauma related to unwanted sexual contact. Resident #73 had triggers of hearing other people screaming at each other/other people becoming physical with each other. Interventions included consistent staff members, consult with psychiatry/psychology, and include the resident in decision making process. Review of the plan of care dated 02/08/22 revealed Resident #73 was at risk for adverse effects related to psychoactive medication use, dementia with behaviors, depression, and mood disorder. [...]
- D
Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.
Inspectors wroteBased on medical record review, review of an email correspondence document, staff interview, and policy review, the facility failed to timely complete an order for laboratory values and failed to notify the physician of abnormal laboratory results. This affected one (#78) of two residents reviewed for infections. The facility census was 86.
- D
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, medical record review, and staff interview, the facility failed to serve residents therapeutic diets as ordered. This affected one (#42) of seven residents reviewed for nutrition. The facility census was 86. Findings Include: Review of the medical record for Resident #42 revealed an initial admission date of 01/12/24 with diagnoses including senile degeneration of the brain, diabetes mellitus, obstructive sleep apnea, chronic kidney disease, anemia, hyperlipidemia, atrial fibrillation, hypertension, benign prostatic hyperplasia, and altered mental status. Review of the admission assessment and baseline care plan dated 01/12/24 revealed Resident #42's admission weight was 193.4 pounds. The assessment indicated the resident was alert and confused. The assessment indicated the resident was edentulous and was dependent on staff for eating. [...]
- D
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Inspectors wroteBased on observation and staff interview, the facility failed to maintain a clean and sanitary environment. This affected two (#6 and #42) of five residents reviewed for environment. The facility census was 86.
- D
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Inspectors wroteBased on observation, medical record review, review of facility pest control records, resident family and staff interview, and review of the facility pest control policy, the facility failed to maintain a pest free environment. This affected one (#13) of 24 resident's rooms observed. The census was 86. Findings Include: Review of Resident #13's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses included chronic respiratory failure, emphysema, type II diabetes, unspecified protein-calorie malnutrition, complete traumatic amputation of one lesser toe, muscle weakness, dysphagia, bipolar disorder, and congestive heart failure. Review of Resident #13's Minimum Data Set (MDS) assessment, dated 02/20/24, revealed the resident had a mild cognitive impairment. Interview with Resident #13's family member on 03/10/24 at 2:05 P.M. [...]
October 14, 2023Complaint 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, resident record review, video and audio footage review, and facility policy review the facility failed to ensure a resident was not verbally abused by staff. This affected one resident (#65) of three residents reviewed for abuse. The facility census was 87.
August 31, 2021Standard inspection · 8 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 observations, staff interviews, and facility policy review, the facility failed to ensure food was prepared and served in a sanitary manner. This had the potential to affect all 80 residents who received food from the kitchen. Findings Include: 1. Observation of dining in the locked dementia unit on 08/23/21 at 12:27 P.M. during the lunch meal revealed Activities Aide (AA) #101 washed her hands at the sink and donned clean gloves. AA #101 was observed touching the handle of the serving cart with her gloved hands to wheel the resident's food around to the tables and serve the residents. AA #101 was observed serving ravioli to each resident and then reached into a plastic bag of dinner rolls and removed one roll for each resident and placed it on each resident's place without changing her gloves or washing her hands after touching the serving cart. [...]
- E
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observations, staff interviews, record review, review of the Center for Disease Control (CDC) guidelines and COVID-19 Nursing Home data, and facility policy review, the facility failed to follow infection control protocols when they did not maintain transmission-based precautions (TBP) for two residents (Residents #334 and #337), failed to use appropriate signs to inform visitors and staff of isolation precautions for one resident (Resident #39), and failed to ensure staff were wearing appropriate eye protection while administering medications. This affected four residents (#12, #39, #334, and #337) reviewed for infection control. The facility census was 80.
- 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 medical record review, staff interview, and facility policy review, the facility failed to provide a bed hold notification to a resident who was discharged to the hospital. This affected one (Resident #84) of two residents reviewed for hospitalization. The facility census was 80.
- D
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, resident and staff interview, and record review, the facility failed to apply a physician ordered palm guard device for Resident #55. This affected one resident (#55) of one resident reviewed for range of motion. The facility identified 22 residents with contractures. The facility census was 80.
- D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Inspectors wroteBased on review of the facility's policy, staff interview and record review, the facility failed to administer a physician ordered medication for Resident #12. This affected one (Resident #12) of six residents reviewed for physician ordered medications. The facility census was 80.
- D
Ensure medication error rates are not 5 percent or greater.
Inspectors wroteBased on review of the facility's policy, observation, staff interview, and record review, the facility failed to ensure their medication error rate was less than five percent. There were 26 medications administered with four errors made, resulting in a medication error rate of 14.8%. This affected three residents (Residents #22, #33, and #44) of four residents reviewed for medication administration. The facility census was 80.
- D
Ensure that residents are free from significant medication errors.
Inspectors wroteBased on observation, staff interview, record review, and facility policy review, the facility failed to ensure residents were free from significant medication errors when one resident (#44) was administered the wrong doses of insulin. This affected one resident (#44) of four residents observed for medication administration.
- D
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Inspectors wroteBased on review of resident diets, review of dietary spreadsheets, observation, and staff interview, the facility failed to follow the dietary spreadsheet for residents on a pureed diet. This affected four (Residents #1, #7, #40, and #47) of four residents who were prescribed a pureed diet. The facility census was 80. Findings Include: Review of the Diet Type Report, dated 08/23/21, revealed Residents #1, #7, #40, and #47 were prescribed a pureed diet. Review of the dietary spreadsheet for the lunch meal on 08/25/21 revealed residents on a pureed diet were to receive eight ounces of pureed tortilla casserole, one pureed corn shape, six ounces of tomato juice, two ounces of pureed cornmeal muffin, 2.67 ounce of pureed snickerdoodle cookie, four ounces of milk, eight ounces of water, one packet of margarine, and two tablespoons of sour cream. Observation on 08/25/21 from 12:00 P.M. [...]
Fire safety inspections
16 fire safety citations on file: 8 on July 28, 2025, 3 on March 13, 2024, 5 on August 31, 2021.
Every fire safety citation16 citations
- F
Conduct testing and exercise requirements.
E 39 · July 28, 2025 · 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 · July 28, 2025 · Corrected (the home has a date of correction)
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · July 28, 2025 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · July 28, 2025 · Corrected (the home has a date of correction)
- E
Keep aisles, corridors, and exits free of obstruction in case of emergency.
K 211 · July 28, 2025 · Corrected (the home has a date of correction)
- E
Install an approved automatic sprinkler system.
K 351 · July 28, 2025 · Corrected (the home has a date of correction)
- E
Install corridor and hallway doors that block smoke.
K 363 · July 28, 2025 · Corrected (the home has a date of correction)
- E
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · July 28, 2025 · Corrected (the home has a date of correction)
- F
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · March 13, 2024 · Corrected (the home has a date of correction)
- E
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · March 13, 2024 · Corrected (the home has a date of correction)
- E
Have proper medical gas storage and administration areas.
K 923 · March 13, 2024 · 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 · August 31, 2021 · Corrected (the home has a date of correction)
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · August 31, 2021 · 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 · August 31, 2021 · Corrected (the home has a date of correction)
- E
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
K 321 · August 31, 2021 · Corrected (the home has a date of correction)
- E
Install a fire alarm system that can be heard throughout the facility.
K 341 · August 31, 2021 · Corrected (the home has a date of correction)