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 44 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
2G
0H
0I
Potential for more than minimal harm
29D
10E
1F
Potential for minimal harm
0A
1B
1C
May 14, 2026Complaint inspection · 4 citations
- E
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 and interviews with staff, residents, and a family member, the facility failed to ensure linens were available for 4 of 4 residents who were interviewed or their family member was interviewed regarding linens (Residents # 9, # 10, # 11, and # 12).
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on record review and interviews with staff, Responsible Party (RP), Physicians, and Wound Nurse Practitioner, the facility failed to obtain supplies and implement the Wound Nurse Practitioner's treatment plan for a resident with a pressure sore. This was for 1 of 3 sampled residents reviewed for pressure sores (Resident # 4).
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on record review, and interviews with staff and Responsible Party, the facility failed to 1) identify in their accident investigation that an assigned staff member had not been on duty when Resident # 2 fell and thereby evaluate how this might have contributed to the accident occurring in order to take corrective action and 2) failed to toilet Resident # 2 at bedtime as directed by the resident's care plan in order to try and prevent future falls. This was for 1 of 3 sampled residents reviewed for falls (Resident # 2).
- D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Inspectors wroteBased on record review and interviews with staff and Physician, the facility failed to have effective systems in place to ensure ordered medications were acquired from the pharmacy and available for administration and the backup supply of medications was utilized for medications that had not been received from the pharmacy for 1 of 1 resident whose medications were reviewed (Resident #1).
March 25, 2026Standard inspection · 7 citations
- F
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Inspectors wroteBased on record review and staff interviews, the facility failed to provide Registered Nurse (RN) coverage for 8 consecutive hours for 2 of 142 days reviewed for staffing (12/28/25 and 1/24/26).
- D
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
Inspectors wroteBased on record review and staff, Medical Director, and Consultant Pharmacist interviews, the facility failed to provide ongoing Abnormal Involuntary Movement Scale (AIMS) assessments for potential adverse reactions to antipsychotic medications for 1 of 5 residents reviewed for unnecessary medications (Residents #3).
- D
Ensure each resident receives an accurate assessment.
Inspectors wroteBased on record review and facility staff interviews, the facility failed to accurately code Minimum Data Set (MDS) for 1 of 62 residents reviewed for accuracy of assessments (Resident #84).
- D
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Inspectors wroteBased on record review and an interview with the Pharmacy Consultant, the Pharmacy Consultant failed to identify and report irregularities when conducting monthly drug regimen reviews for 1 of 5 residents reviewed for unnecessary medications (Resident #3).
- D
Ensure that residents are free from significant medication errors.
Inspectors wroteBased on record review and staff, Dialysis Dietician/Nurse Practitioner, and Medical Director interviews, the facility failed to ensure medications were administered in accordance with physician orders for 1 of 9 residents reviewed for medications (Resident #7).
- D
Make sure that a working call system is available in each resident's bathroom and bathing area.
Inspectors wroteBased on observation, record review, and resident and staff interviews, the facility failed to ensure the resident call light system was functioning properly for 3 of 97 residents observed for resident call system (Resident #78, Resident #4, and Resident #94).
- C
Post nurse staffing information every day.
Inspectors wroteBased on record review and staff interviews, the facility failed to ensure daily nurse staffing sheets were complete and accurate for 36 of 53 days reviewed for 12/1/25 through 3/22/26 (12/12/25, 12/17/25, 2/2/26, 2/4/26, 2/5/26, 2/6/26, 2/9/26, 2/10/26, 2/11/26, 2/13/26, 2/15/26, 2/16/26, 2/17/26, 2/18/26, 2/19/26, 2/21/26, 2/24/26, 2/25/26, 2/26/26, 2/27/26, 2/28/26, 3/3/26, 3/4/26, 3/5/26, 3/7/26, 3/9/26, 3/10/26, 3/11/26, 3/12/26, 3/13/26, 3/14/26, 3/15/26, 3/17/26, 3/18/26, 3/21/26, 3/22/26).
September 11, 2025Complaint inspection · 3 citations
- G
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on observation, record review, and interviews with resident, staff, and a representative from the company that manufactures the mechanical lifts used at the facility, the facility failed to ensure a resident was safely transferred by a mechanical lift. A mechanical lift sling broke while Resident # 3 was being transferred resulting in Resident # 3 sustaining a fractured humerus (large bone of the upper arm). This was for 1 of 3 residents reviewed for accidents (Resident # 3).
- E
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 observation, record review, and interviews with staff and Physicians the facility failed to notify the physician when residents developed pressure sores for 2 of 3 sampled residents with pressure sores (Residents # 1 and Resident #8).
- E
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on observation, record review, and interviews with staff and physicians the facility failed to 1) ensure Nurse Aides reported skin breakdown to a nurse prior to the wound bed being unstageable (Resident # 1); 2) ensure effective communication amongst nursing staff and the Wound Physician to ensure orders were obtained, initiated, and carried out for pressure sore treatments per the Wound Care Physician's plan of care (Resident # 1 and Resident #8); 3) ensure further diagnostic studies were completed per the Wound Care Physician's directions when a wound continued not to heal (Resident # 1), and 4) ensure the settings of a pressure relieving air mattress were set correctly for pressure relief (Resident # 8). This was for 2 of 3 of three sampled residents with pressure sores (Residents # 1 and # 8).
December 19, 2024Standard inspection · 7 citations
- D
Allow resident to participate in the development and implementation of his or her person-centered plan of care.
Inspectors wroteBased on record review, resident, Resident Representative (RR), and staff interviews, the facility failed to invite a resident to participate in the development of his plan of care for 1 of 3 residents were reviewed for care planning (Resident #271).
- D
Assure that each resident’s assessment is updated at least once every 3 months.
Inspectors wroteBased on record review and staff interviews, the facility failed to complete a quarterly Minimum Data Set (MDS) assessment within 14 days following the Assessment Reference Date (ARD, last day of the assessment period) for 1 of 2 residents reviewed for assessments (Resident #48).
- D
Ensure each resident receives an accurate assessment.
Inspectors wroteBased on record review and staff interviews, the facility failed to accurately code a Minimum Data Set (MDS) assessment for antipsychotic use, hospice status, and wound status for 3 of 18 resident assessments reviewed (Resident #50, Resident #58, and Resident #173).
- 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 record review and staff interviews, the facility failed to develop and implement a comprehensive care plan for a resident that exhibited aggressive verbal behaviors, a resident prescribed an antipsychotic medication, and a resident that had a surgical wound, for 3 of 18 residents reviewed for development and implementation of a comprehensive care plan (Resident #55, Resident #62 and Resident #58).
- 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 observations, record review, and staff interviews, the facility failed to store the wet syringe separately from the barrel when Nurse #3 did not separate a bolus enteral feeding syringe (a large 2 part syringe used to administer oral medications or liquid feedings) used for medication administration through a gastrostomy tube (a hollow tube inserted directly through the skin of the abdomen into the stomach to deliver nutrition, hydration, and medication) for one of one resident (Resident #21). The deficient practice occurred for one of one staff member observed for medication administration via a gastrostomy tube.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observations, record review, and staff interviews, the facility failed to implement their policy for Enhanced Barrier Precautions (EBP) when Nurse #3, the Wound Nurse, and the Wound Physician failed to apply a gown before entering residents' rooms to provide high contact care activities for two of two residents (Resident #21 and Resident #58). The deficient practice occurred for three of three caregivers observed for infection control practices. These deficient practices placed residents at risk for infection.
- D
Include as part of its infection prevention and control program, mandatory training that includes written standards, policies, and procedures for the program.
Inspectors wroteBased on record review and staff interviews, the facility failed to follow their infection control policy and procedure to ensure facility staff received infection control training on Enhanced Barrier Precautions (EBP) to know what required EBP and when to implement EBP for 1 of 1 staff reviewed for infection control training (Wound Care Nurse).
September 18, 2024Complaint 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 record review and staff interview the facility failed to develop and implement a comprehensive care plan for 1 of 1 resident reviewed for physical environment (Resident #6).
April 5, 2024Complaint inspection · 7 citations
- G
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on observation, record review, and interviews with staff, Physician, Psychiatric Nurse Practitioner, and the facility's Pharmacy Consultant the facility failed to 1) analyze Resident #2's falls to determine causative factors and implement interventions to reduce the risk for further falls and 2) ensure a paraplegic resident (Resident # 1) did not roll out of bed during care. Resident # 2 was identified to have an impacted arm fracture (a fracture that generally occurs following a fall). This was for two of three sampled residents reviewed for accidents.
- E
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 record review, staff interviews, and an emergency room physician interview the facility failed to provide care to a feeding tube site for one (Resident #1) of three sampled residents reviewed for feeding tube care.
- E
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Inspectors wroteBased on record review, staff interview, Medical Director/Physician interview, and Pharmacist interview the facility failed to remove narcotic pain medications from the medication cart within the parameters set by the physician's orders for narcotic medication; failed to follow procedures for disposal of wasted narcotic medication; and failed obtain an order for narcotic pain medication prior to removing narcotic pain medication from the medication cart. Additionally, the facility failed to have effective safeguards and systems in place to control for, account for, and periodically reconcile controlled medications to protect the residents right to be free from potential drug diversion. This was for three residents, (Resident #6, Resident #7, Resident #8) of three residents reviewed for pharmacy services for narcotic medication.
- E
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on record review, staff interview, and Pharmacist interview the facility failed to document the administration of narcotic medication in the medication administration record for 3 (Resident #6, Resident #7, and Resident #8) of 3 residents reviewed for accuracy of documentation of narcotic medication.
- E
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Inspectors wroteBased on observation, record review, staff interviews, hospice staff interview, physician interview, pharmacy consultant interview, and psychiatric nurse practitioner interview the facility's Quality Assessment and Assurance Committee failed to maintain implemented procedures and monitor the interventions that the committee put into place following the recertification and complaint investigation of 4/13/2021, the recertification and complaint survey of 6/30/2022, the recertification and complaint investigation of 11/2/2023, and the complaint investigation of 2/27/2024. This was for 3 repeat deficiencies in the areas of supervision to prevent accidents, hospice services, and pharmacy services. The continued failure of the facility during four federal surveys showed a pattern of the facility's inability to sustain an effective Quality Assessment and Assurance Program.
- D
Protect each resident from the wrongful use of the resident's belongings or money.
Inspectors wroteBased on record review, staff interviews, resident interviews, Medical Director interview, and Pharmacist interview the facility failed to protect residents right to be free from potential diversion of a total of seventeen narcotic tablets for two (Resident #7 and Resident #6) of three residents reviewed for diversion of narcotics.
- 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 observation, record review, staff interview, hospice staff interview, and physician interview the facility failed to communicate and coordinate with hospice to identify a resident had sustained a dislocated finger. This was for one (Resident # 3) of two sampled hospice residents.
February 27, 2024Complaint inspection · 7 citations
- E
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Inspectors wroteBased on observation, record review, staff interview, pharmacy consultant interview, and pharmacy operations manager interview the facility failed to provide pharmacy services within the time frame for a scheduled dose of a medication for one (Resident #6) of four residents observed during a medication pass observation.
- E
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Inspectors wroteBased on observations, record review, resident, and staff interview the facility's Quality Assessment and Assurance (QAA) committee failed to maintain implemented procedures and monitor the interventions that the committee put into place following the recertification survey and complaint investigation completed on 11/2/2023, the recertification survey and complaint investigation completed on 6/30/2022, and the recertification survey and complaint investigation completed on 4/13/2021. [...]
- D
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Inspectors wroteBased on record review, staff interview, and resident interview the facility failed to protect a resident's right to be free from mistreatment when an employee (Housekeeper #2) hit Resident #5 with a cell phone charging cord causing pain. This was for one (Resident #5) of three residents reviewed for abuse.
- D
Respond appropriately to all alleged violations.
Inspectors wroteBased on record review and staff interview the facility failed to complete a thorough investigation of an allegation of staff to resident abuse by not obtaining a written statement from the perpetrator for 1 (Resident #5) of 3 residents reviewed for abuse investigations.
- 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, record review, and staff interview the facility failed to use the urinary tract prevention method of keeping the drainage bag and tubing off the floor for 1 of 3 (Resident #4) residents reviewed for indwelling catheter care.
- D
Ensure medication error rates are not 5 percent or greater.
Inspectors wroteBased on observations, interviews with staff and the consultant pharmacist and record reviews the facility failed to have a medication error rate of less than 5% as evidenced by 2 medication errors out of 25 opportunities resulting in a medication error rate of 8% for 2 (Resident #6 and Resident #8) of 4 residents observed during the medication administration observation.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation and staff interview the facility failed to follow infection control procedures for the cleaning and disinfecting of a glucometer during a medication pass observation for one (Nurse #1) of two nurses observed for infection control procedures during medication pass.
November 2, 2023Standard inspection · 8 citations
- E
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on record review, observations, resident interview and staff interviews, the facility failed to provide supervision to a resident (Resident # 47), who was assessed as a supervised smoker, while Resident #47 was smoking in the designated smoking area, secure Resident #47's smoking materials and complete quarterly smoking assessments for a resident (Resident #7 ), who was assessed as not requiring supervision when smoking, for 2 of 2 residents reviewed for accidents.
- D
Ensure each resident receives an accurate assessment.
Inspectors wroteBased on record review and staff interviews, the facility failed to accurately assess cognitive patterns, anticoagulant medication use, and mood for 3 of 20 Minimum Data Set (MDS) assessments reviewed (Resident #55, Resident #47, and Resident #62).
- D
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Inspectors wroteBased on record review and staff interviews, the facility failed to complete a Preadmission Screening and Resident Review (PASRR) screening for 1 of 1 resident reviewed for PASRR (Resident #51).
- D
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Inspectors wroteBased on record review and staff interviews, the facility failed to ensure an individualized person-centered care plan was accurate for smoking for 1 of 19 residents reviewed for comprehensive care plan (Resident #47).
- 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 record review, observations, resident interview and staff interviews, the facility failed to attach an indwelling urinary catheter tubing to a secure device to prevent tension and possible injury, to position the urinary collection bag at a lower level than the urinary bladder to allow gravity drainage of urine into the collection bag, to ensure the urinary tubing was not touching the floor for 1 of 2 residents reviewed for urinary catheter (Resident #47).
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on record review, observations, resident and staff interviews, the facility failed to administer supplemental oxygen as prescribed by the physician and failed to place signage indicating the use of oxygen for 1 of 1 resident reviewed for oxygen use (Resident #269).
- D
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Inspectors wroteBased on observations, record review and resident and staff interview, the facility's Quality Assessment and Assurance Committee failed to maintain implemented procedures and monitor interventions that the committee had previously put in place following the recertification and complaint surveys of 6/30/22 and 4/13/21. This was for 5 recited deficiencies in the areas of Accuracy of Assessments (F641), Preadmission Screening and Resident Review (PASRR) (F644), Baseline Care Plans (F655), Care Plan Timing and Revision (F657), and Free of Accident Hazards/ Supervision/Devices (F689). The continued failure during 2 or more federal surveys of record showed a pattern of the facility's inability to sustain an effective Quality Assurance Program.
- B
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 observations and staff interviews, the facility failed to maintain bathroom and closet doors in good repair in 5 of 13 rooms (Rooms 302, 304, 306, 313 and 316) on the 300 hallway.
Fire safety inspections
21 fire safety citations on file: 11 on March 25, 2026, 2 on December 19, 2024, 8 on November 2, 2023.
Every fire safety citation21 citations
- E
Install corridor and hallway doors that block smoke.
K 363 · March 25, 2026 · deficient, provider has
- E
Have properly installed electrical wiring and gas equipment.
K 511 · March 25, 2026 · deficient, provider has
- E
Have simulated fire drills held at unexpected times.
K 712 · March 25, 2026 · deficient, provider has
- E
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
K 914 · March 25, 2026 · deficient, provider has
- E
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · March 25, 2026 · deficient, provider has
- D
Use approved construction type or materials.
K 161 · March 25, 2026 · deficient, provider has
- D
Keep aisles, corridors, and exits free of obstruction in case of emergency.
K 211 · March 25, 2026 · deficient, provider has
- D
Have properly located and lighted "Exit" signs.
K 293 · March 25, 2026 · deficient, provider has
- D
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · March 25, 2026 · deficient, provider has
- D
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · March 25, 2026 · deficient, provider has
- D
Have proper medical gas storage and administration areas.
K 923 · March 25, 2026 · deficient, provider has
- D
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
K 521 · December 19, 2024 · Corrected (the home has a date of correction)
- D
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
K 914 · December 19, 2024 · Corrected (the home has a date of correction)
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · November 2, 2023 · Corrected (the home has a date of correction)
- F
Properly install and monitor supervisory attachments on automatic sprinkler systems.
K 352 · November 2, 2023 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · November 2, 2023 · 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 · November 2, 2023 · Corrected (the home has a date of correction)
- F
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · November 2, 2023 · Corrected (the home has a date of correction)
- E
Have proper medical gas storage and administration areas.
K 923 · November 2, 2023 · 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 · November 2, 2023 · Corrected (the home has a date of correction)
- D
Have a fire alarm with audible and visual signals that transmits the alarm automatically to notify emergency forces in event of fire.
K 343 · November 2, 2023 · Corrected (the home has a date of correction)