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
0J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
21D
7E
2F
Potential for minimal harm
0A
0B
0C
May 5, 2026Standard inspection · 5 citations
- E
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on observation, staff and resident interview, and record review, the facility did not ensure 4 residents (R) (R1, R18, R53, and R41) of 4 sampled residents received the necessary care and services to prevent pressuries injuries from developing or worsening and/or promote healing. R1 was admitted to the facility with stage 3 and 4 pressure injuries. During wound care, Registered Nurse (RN)-H applied ointment to the wound bed of R1's stage 4 left buttock pressure injury with a soiled glove. R18's specialty air mattress was not turned on during an observation on 5/3/26. In addition, R18 did not have an order for the mattress and the setting wasn't indicated in R18's medical record. R53 and R41's specialty air mattresses were not set correctly.
- D
PASARR screening for Mental disorders or Intellectual Disabilities
Inspectors wroteBased on staff interview and record review, the facility did not ensure a Pre-admission Screening and Resident Review (PASRR) Level I Screen was accurately completed and a Level II Screen was completed for 1 resident (R) (R8) of 7 sampled residents. R8 was admitted to the facility with diagnoses including schizoaffective disorder and anxiety disorder and was prescribed antianxiety medication. The facility did not correctly identify R8's mental illness diagnoses or medication on a PASRR Level I Screen and did not submit for a Level II Screen.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on staff and resident interview and record review, the facility did not ensure their bowel protocol was followed or daily weights were obtained for 2 residents (R) (R30 and R15) of 2 sampled residents. R30 went 4 days without a bowel movement. R30 was not offered medication to help promote a bowel movement on day 3 per facility protocol. R15 was not weighed daily in accordance with a physician's order.
- 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, and record review, the facility did not ensure 2 residents (R) (R7 and R1) of 3 sampled residents received appropriate care and services to prevent urinary tract infections (UTIs). The facility did not ensure R7 and R1 received catheter care in a manner that decreased the risk for infection. R7's catheter bag and tubing were on the floor on multiple occasions. R1's uncovered catheter bag was also on the floor.
- D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Inspectors wroteBased on observation, staff and resident interview, and record review, the facility did not ensure the accurate administration of medication for 1 resident (R) (R15) of 6 sampled residents. R15 did not receive gabapentin (an anticonvulsant medication often used to treat pain) in a timely manner. In addition, R15 did not receive the correct dose on 5/1/26 after the physician changed the order on 4/30/26.
November 25, 2025Complaint inspection · 3 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 record review, the facility did not ensure food was stored and prepared in a safe and sanitary manner. This practice had the potential to affect all 72 residents residing in the facility. Food was not sealed, labeled, or dated appropriately. Food temperatures were not consistently documented prior to meal service. Kitchen cookware was not stored properly. In addition, kitchen equipment and the floor were not in clean condition. The rehab unit refrigerator was not in clean condition and contained undated and expired resident food. Staff touched ready-to-eat food with soiled gloves during lunch service.
- E
Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.
Inspectors wroteBased on observation, staff and resident interview, and record review, the facility did not ensure meals were served timely. This practice had the potential to affect more than 4 of the 72 residents residing in the facility. On 11/25/25, the lunch meal was served late.
- D
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Inspectors wroteBased on observation, staff interview, and record review, the facility did not provide meals according to prescribed diets for 3 residents (R) (R9, R10, and R11) of 3 sampled residents. R9, R10, and R11 had orders for a consistent carbohydrate diet. On 11/25/25, residents on consistent carbohydrate diets were supposed to receive a half slice of garlic toast. R9, R10, and R11 received a full slice of garlic toast.
July 29, 2025Complaint inspection · 2 citations
- 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 and resident interview, and record review, the facility did not ensure 2 residents (R) (R2 and R9) of 3 sampled residents received the appropriate care and services to prevent urinary tract infections (UTIs). The facility did not initiate or transcribe an admission order to change R2's Foley catheter monthly and as needed. The facility did not initiate or transcribe a urology clinic order to change R9's Foley catheter monthly and as needed. In addition, R9 was not placed on enhanced barrier precautions (EBP) despite having an indwelling medical device.
- D
Provide timely, quality laboratory services/tests to meet the needs of residents.
Inspectors wroteBased on staff interview and record review, the facility did not ensure 1 resident (R) (R2) of 1 sampled resident received timely laboratory services. The facility did not complete physician orders for R2 to prevent potential cancellation or delay of a medical procedure.
July 1, 2025Complaint inspection · 1 citation
- D
Respond appropriately to all alleged violations.
Inspectors wroteBased on staff and resident interview and record review, the facility did not ensure an allegation of neglect was thoroughly investigated for 1 resident (R) (R2) of 15 sampled residents. R2 alleged that Certified Nursing Assistant (CNA)-H left R2 naked and without a gown on the 6/18/25 night shift. The facility did not thoroughly investigate the allegation of neglect.
March 26, 2025Standard inspection, Complaint inspection · 8 citations
- E
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 record review, the facility did not ensure food was stored and prepared in a safe manner. This practice had the potential to affect more than 4 of the 71 residents residing in the facility. Holding temperatures were not completed for all items served.
- E
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, staff interview, and record review, the facility did not establish and maintain an infection prevention and control program designed to prevent the development and transmission of communicable disease and infection for 5 residents (R) (R121, R124, R127, R58, and R19) of 6 sampled residents observed during medication administration and the provision of care. During observations of medication administration and/or care for R121, R124, R127, and R58, Licensed Practical Nurse (LPN)-D did not complete appropriate hand hygiene. Staff did not abide by enhanced barrier precautions (EBP) when providing catheter care for R19.
- D
Allow resident to participate in the development and implementation of his or her person-centered plan of care.
Inspectors wroteBased on staff and resident representative interview and record review, the facility did not ensure 2 residents and their representatives (R) (R1 and R6) of 20 sampled residents were informed of care conferences. R1 and R6's representatives were not informed of R1 and R6's care conferences.
- D
Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made.
Inspectors wroteBased on staff and resident representative interview and record review, the facility did not ensure written notification for a roommate was provided for 1 resident (R) (R6) of 2 sampled residents. R6 received a roommate on 3/20/25. R6's representative was not notified prior to the move.
- 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, staff interview, and record review, the facility did not ensure a clean or home-like environment for 1 resident (R) (R41) of 20 sampled residents. R41's bedside tray table was not in a clean condition.
- 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 staff and resident interview and record review, the facility did not ensure care plans were updated for 3 residents (R) (R41, R10, and R37). R41 had an order to float heels. R41's care plan was not updated with the order and R41's heels were not floated. R10 and R37 had a known conflict with each other. R10's and R37's care plans did not reflect the conflict and did not contain interventions for redirection or how to avoid altercations.
- 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 staff interview and record review, the facility did not ensure range of motion exercises were completed in accordance with a range of motion program for 1 resident (R41) of 20 sampled residents. Documentation for R41's range of motion (ROM) program was not completed accurately and/or was not completed.
- D
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Inspectors wroteBased on staff interview and record review, the facility did not ensure 1 resident (R) (R56) of 5 sampled residents received influenza and COVID-19 vaccines as indicated. Upon admission to the facility, R56's Power of Attorney for Health Care (POAHC) signed a consent form for R56 to receive influenza and COVID-19 vaccines. The vaccines were not administered.
August 21, 2024Complaint inspection · 6 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 record review, the facility did not provide a safe, functional, sanitary, and comfortable environment for residents on 3 of 3 units. Utility rooms on all 3 units contained dust, debris, stains, and an odor of bodily waste, In addition, Surveyor observed risks of cross-contamination.
- D
Allow residents to self-administer drugs if determined clinically appropriate.
Inspectors wroteBased on observation, staff interview, and record review, the facility did not ensure 2 Residents (R) (R14 and R18) of 7 residents observed during medication pass were assessed as able to safely and accurately self-administer medication. On 8/21/24, Licensed Practical Nurse (LPN)-E left medication at R14 and R18's bedsides for R14 and R18 to self-administer. R14 and R18 did not have physician orders, self-administration of medication assessments, or care plans that indicated R14 and R18 could safely and accurately self-administer medication.
- D
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Inspectors wroteBased on staff interview and record review, the facility did not implement policies and procedures that prohibit and prevent abuse for 1 of 8 staff reviewed for background checks. The facility did not ensure a thorough and timely caregiver background check was completed for Certified Nursing Assistant (CNA)-F.
- D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Inspectors wroteBased on staff interview and record review, the facility did not ensure the accurate administration of medication for 1 Resident (R) (R2) of 8 sampled residents. On 2/24/24, Licensed Practical Nurse (LPN)-C gave R2 another resident's medication. Following the medication error, the facility did not ensure blood pressures were taken per the physician's order and provide education to LPN-C.
- D
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Inspectors wroteBased on observation, staff interview, and record review, the facility did not ensure medications were labeled and stored in accordance with manufacturers' recommendations for 3 Residents (R) (R12, R17, and R18) of 7 residents observed during medication pass. On 8/21/24, Registered Nurse (RN)-D left a medication cup that contained eleven medications on R12's bedside table while RN-D left the room to attend to another resident. During observations of medication administration, Licensed Practical Nurse (LPN)-E administered open and undated medication to R17 and R18.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, staff interview, and record review, the facility did not maintain an infection prevention and control program designed to help prevent the development and transmission of disease and infection for 2 Residents (R) (R12 and R13) of 7 residents observed during the administration of medication. On 8/21/24, Registered Nurse (RN)-D did not complete proper hand hygiene during medication administration for R12. In addition, RN-D did not wear gloves as ordered during the administration of methimazole (used to treat hyperthyroidism). On 8/21/24, RN-D did not complete proper hand hygiene during medication administration for R13.
February 6, 2024Standard inspection · 5 citations
- F
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 observation, staff interview, and record review, the facility did not ensure menu serving sizes were followed for protein, vegetable, and starch servings for mechanically altered (minced and moist) and regular consistency diets. This practice had the potential to affect 67 of 70 residents residing in the facility. During the lunch meal on 2/4/24, the facility served smaller serving portions than the lunch menu and diet tray cards indicated for 6 residents who received mechanically altered diets and 61 residents who received regular consistency diets.
- 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 staff and resident interview, the facility did not provide a safe, clean, comfortable, home-like environment for 4 Residents (R) (R40, R46, R34, and R10) of 20 sampled residents with the potential to affect other residents who use common areas in the facility. During an observation of R40's room, Surveyor noted garbage, dried spills, and a urine odor. During an observation of R46's room, Surveyor noted dirt and debris on the floor. During an observation of R34's room, Surveyor noted debris on the floor. During an observation of R10's room, Surveyor noted food and debris on the floor and a urine odor. During an observation of the 100 wing activity room, Surveyor noted food, garbage, debris, and peeled wallpaper. During an observation of the 100 wing dining room, Surveyor noted garbage, debris, and structural damage to the walls and floors. [...]
- E
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 record review, the facility did not ensure food was stored and prepared in a safe and sanitary manner. This practice had the potential to affect multiple residents residing in the facility. The facility did not ensure proper methods to rapidly cool or document cooling temperatures of time/temperature control for safety food not held hot or not for consumption within 4 hours.
- 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 and staff interview, the facility did not provide appropriate care services for 1 Resident (R) (R48) of 2 sampled residents with an indwelling catheter. R48's uncovered catheter drainage bag was observed in direct contact with the floor.
- D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Inspectors wroteBased on observation, staff and resident interview, and record review, the facility did not ensure the accurate and safe administration of medication for 1 Resident (R) (R49) of 20 sampled residents. On 2/4/24, Surveyor observed medication left at R49's bedside. R49 did not have a self-administration of medication assessment or a physician's order to self-administer medication.
Fire safety inspections
46 fire safety citations on file: 4 on May 5, 2026, 19 on March 26, 2025, 23 on February 6, 2024.
Every fire safety citation46 citations
- F
Have correct number of accessible exits for each story.
K 241 · May 5, 2026 · Not yet corrected
- F
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
K 321 · May 5, 2026 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · May 5, 2026 · Corrected (the home has a date of correction)
- F
Have properly installed electrical wiring and gas equipment.
K 511 · May 5, 2026 · Corrected (the home has a date of correction)
- F
Develop and maintain an Emergency Preparedness Program (EP).
E 4 · March 26, 2025 · Corrected (the home has a date of correction)
- F
Conduct risk assessment and an All-Hazards approach.
E 6 · March 26, 2025 · Corrected (the home has a date of correction)
- F
Develop Emergency Preparedness policies and procedures.
E 13 · March 26, 2025 · Corrected (the home has a date of correction)
- F
Establish policies and procedures including evacuation.
E 20 · March 26, 2025 · Corrected (the home has a date of correction)
- F
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
K 321 · March 26, 2025 · Corrected (the home has a date of correction)
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · March 26, 2025 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · March 26, 2025 · Corrected (the home has a date of correction)
- F
Provide a written emergency evacuation plan.
K 711 · March 26, 2025 · Corrected (the home has a date of correction)
- F
Have simulated fire drills held at unexpected times.
K 712 · March 26, 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 26, 2025 · Corrected (the home has a date of correction)
- E
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 · March 26, 2025 · Corrected (the home has a date of correction)
- E
Install emergency lighting that can last at least 1 1/2 hours.
K 291 · March 26, 2025 · Corrected (the home has a date of correction)
- E
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · March 26, 2025 · Corrected (the home has a date of correction)
- E
Have properly installed electrical wiring and gas equipment.
K 511 · March 26, 2025 · Corrected (the home has a date of correction)
- E
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
K 521 · March 26, 2025 · Corrected (the home has a date of correction)
- E
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
K 741 · March 26, 2025 · Corrected (the home has a date of correction)
- D
Have correct number of accessible exits for each story.
K 241 · March 26, 2025 · Waiver
- D
Install a fire alarm system that can be heard throughout the facility.
K 341 · March 26, 2025 · Corrected (the home has a date of correction)
- C
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
K 914 · March 26, 2025 · Corrected (the home has a date of correction)
- F
Establish procedures for tracking staff and patients during an emergency.
E 18 · February 6, 2024 · Corrected (the home has a date of correction)
- F
Establish policies and procedures for sheltering.
E 22 · February 6, 2024 · Corrected (the home has a date of correction)
- F
Establish methods for sharing information.
E 33 · February 6, 2024 · Corrected (the home has a date of correction)
- F
Provide properly protected cooking facilities.
K 324 · February 6, 2024 · Corrected (the home has a date of correction)
- F
Install a fire alarm system that can be heard throughout the facility.
K 341 · February 6, 2024 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · February 6, 2024 · Corrected (the home has a date of correction)
- F
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · February 6, 2024 · Corrected (the home has a date of correction)
- F
Provide a written emergency evacuation plan.
K 711 · February 6, 2024 · Corrected (the home has a date of correction)
- F
Have restrictions on the use of highly flammable decorations.
K 753 · February 6, 2024 · Corrected (the home has a date of correction)
- F
Meet requirements for the installation and maintenance of electrical systems.
K 911 · February 6, 2024 · Corrected (the home has a date of correction)
- F
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · February 6, 2024 · Corrected (the home has a date of correction)
- E
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
K 222 · February 6, 2024 · Corrected (the home has a date of correction)
- E
Have corridors or aisles that are unobstructed and are at least 8 feet in width.
K 232 · February 6, 2024 · Corrected (the home has a date of correction)
- E
Have exits that are accessible at all times.
K 271 · February 6, 2024 · 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 · February 6, 2024 · Corrected (the home has a date of correction)
- E
Install corridor and hallway doors that block smoke.
K 363 · February 6, 2024 · Corrected (the home has a date of correction)
- E
Install smoke barrier doors that can resist smoke for at least 20 minutes.
K 374 · February 6, 2024 · Corrected (the home has a date of correction)
- E
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
K 521 · February 6, 2024 · Corrected (the home has a date of correction)
- E
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
K 741 · February 6, 2024 · Corrected (the home has a date of correction)
- D
Have correct number of accessible exits for each story.
K 241 · February 6, 2024 · Waiver
- D
Install proper backup exit lighting.
K 281 · February 6, 2024 · Corrected (the home has a date of correction)
- D
Have proper medical gas storage and administration areas.
K 923 · February 6, 2024 · Corrected (the home has a date of correction)
- C
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · February 6, 2024 · Corrected (the home has a date of correction)