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 36 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
19D
16E
1F
Potential for minimal harm
0A
0B
0C
June 15, 2026Complaint inspection · 5 citations
- F
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure residents had access to the grievance procedure and file an anonymous grievance. The DON identified 61 residents resided in the facility.
- 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 interview, the facility failed to:a. develop a comprehensive person-centered care plan, andb. include the resident and/or representative for care planning for 1 (#3) of 11 sampled residents whose care plans were reviewed. The administrator identified 61 residents resided in the facility.
- 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 interview, the facility failed to provide adequate supervision to prevent an elopement for 1 (#6) of 3 sampled residents reviewed for elopement. The DON identified two residents at high risk for elopement.
- 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 interview, the facility failed to administer intravenous medication as ordered for 1 (#2) of 4 sampled residents reviewed for medication administration. The DON identified 61 residents resided in the facility and one resident received intravenous medication.
- D
Provide timely, quality laboratory services/tests to meet the needs of residents.
Inspectors wroteBased on record review and interview, the facility failed to provide laboratory services as ordered by a physician for 1 (#1) of 3 sampled residents reviewed for laboratory services. The DON identified 61 residents resided in the facility.
April 10, 2025Standard inspection · 7 citations
- E
Ensure each resident receives an accurate assessment.
Inspectors wroteBased on record review and interview, the facility failed to ensure assessments were coded accurately for 4 (#19, 23, 25 and #69) of 17 sampled residents whose assessments were reviewed. The administrator reported 68 residents resided in the facility.
- E
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Inspectors wroteBased on observation, record review and interview, the facility failed to develop a smoking care plan for 2 (#19 and 25) of 3 sampled residents reviewed for smoking. The DON identified six smokers resided in the facility.
- E
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 interview, the facility failed to evaluate residents for smoking safely for 2 (#19 and #25) of 3 sampled residents reviewed for smoking. The DON reported six residents were smokers.
- E
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure No smoking/Oxygen in use signs were posted for 3 (#19, 175, and #176) of 3 residents sampled for respiratory care. The administrator reported 68 residents resided in the facility.
- E
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, record review, and interview, the facility failed to use the required PPE for residents on enhanced barrier precautions for 2 (#31 and #50) of 3 sampled residents reviewed for infection control. The DON reported 68 residents resided in the facility.
- E
Make sure that a working call system is available in each resident's bathroom and bathing area.
Inspectors wroteBased on observation and interview, the facility failed to have a call system available for resident use in one of three shower rooms observed. The DON reported 68 residents resided in the facility.
- 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, record review, and interview, the facility failed to ensure the exterior building was maintained in good repair. The administrator identified 68 residents resided in the facility.
January 30, 2025Complaint inspection · 1 citation
- 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 interview, the facility failed to ensure an order for pain medication was submitted to the pharmacy in a timely manner for 1 (#1) of 3 sampled residents reviewed for having pain medications ordered in a timely manner. The administrator identified 65 residents resided in the facility.
November 15, 2024Complaint inspection · 2 citations
- 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 and interview, the facility failed to ensure: a. incident reports involving residents were accessible to the SA for two (#1 and #7); and b. resident records were complete and accurate for two (#1 and #7) of three sampled residents reviewed for falls. The wound care nurse identified 57 residents resided in the facility. The Incidents by Incident Type reports, dated 11/14/24, documented 30 residents experienced a fall for the months of September, October, and November 2024.
- 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 record review and interview, the facility failed to provide evidence a resident representative was notified after the resident experienced a fall for one (#7) of three sampled residents reviewed for falls. The wound care nurse identified 57 residents resided in the facility. The Incidents by Incident Type reports, dated 11/14/24, documented 30 residents experienced a fall for the months of September, October, and November 2024.
June 14, 2024Complaint inspection · 3 citations
- D
Plan the resident's discharge to meet the resident's goals and needs.
Inspectors wroteBased on record review and interview, the facility failed to ensure a resident's critical post discharge medical equipment was ordered and received in a timely manner for one (#1) of two sampled residents whose discharge planning process was reviewed. The DON identified 65 residents resided in the facility.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on record review and interview, the facility failed to administer medications and treatments in a timely manner for two (#4 and #5) of six residents reviewed for receiving medications and treatments for scabies. The DON identified 65 residents resided in the facility.
- 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 interview, the facility failed to administer treatment as ordered for one (#5) of six sampled residents reviewed for receiving medication or treatment for scabies. The DON identified 65 residents resided in the facility.
April 19, 2024Complaint inspection · 2 citations
- 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 record review and interview, the facility failed to ensure staff notified the physician of a resident with an ongoing rash and no treatment prescribed for one (#6) of six residents reviewed for infection control. The Administrator identified 59 residents resided in the facility.
- E
Provide and implement an infection prevention and control program.
Inspectors wroteBased on record review and interview, the facility failed to implement their infection control policy for surveillance of scabies for four (#3, 4, 5 and #36) of six sampled residents reviewed for infection control. The Administrator identified 59 residents resided in the facility.
March 7, 2024Complaint inspection · 1 citation
- E
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Inspectors wroteBased on record review and interview, the facility failed to implement their abuse policy for three (#4, 13, and #14) of four sampled residents reviewed for abuse. The DON identified 63 residents resided in the facility.
December 13, 2023Standard 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 and interview, the facility failed to administer medication as ordered: a. for one (#9) of five sampled residents reviewed for unnecessary medications; and b. for one (#48) of five sampled residents observed during medication pass. The DON identified 64 residents resided in the facility.
- E
Ensure that residents are free from significant medication errors.
Inspectors wroteBased on record review, observation, and interview, the facility failed to ensure a significant medication error did not occur for one (#9) of five sampled residents for unnecessary medication regimen review. The DON identified 64 residents resided in the facility.
- 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, record review, and interview, the facility failed to ensure: a. the ice machine was in sanitary condition in accordance with professional standards for food safety and service for one of two ice machines observed; and b. food was handled under sanitary conditions in accordance with professional standards for food safety and service for one of one kitchen observations. The DON identified 63 residents received nutritional services from the kitchen in the facility.
- D
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Inspectors wroteBased on record review and interview, the facility failed to complete pre-employment screening for history of abuse and neglect per their abuse policy for one (housekeeping and laundry supervisor) of five employee files reviewed. The current employee list, undated, documented 97 facility employees.
- D
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Inspectors wroteBased on observation, record review and interview, the facility failed to ensure nutrition via tube feeding was administered as ordered for one (#55) of five sampled residents observed during medication pass. The DON identified 64 residents resided in the facility and two residents received their nutrition through tube feeding.
- D
Ensure medication error rates are not 5 percent or greater.
Inspectors wroteBased on observation, record review and interview, the facility failed to ensure the medication error rate was less than 5%. A total of 25 opportunities were observed with two errors. The total medication error rate was 8%. The DON identified 64 residents resided in the facility.
- 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 record review, observation and interview, the facility failed to ensure residents received a therapeutic diet as ordered for one (#163) of two sampled residents reviewed for nutrition. The DON identified 64 residents resided in the facility.
November 8, 2023Complaint inspection · 1 citation
- E
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on record review and interview, the facility failed to ensure residents received their bath/shower per schedule for two (#3 and #7) of three sampled residents reviewed for bathing. The ADON identified 54 residents resided in the facility.
October 13, 2022Standard inspection · 7 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 oberservation, record review, and interview the facility failed to ensure: a. proper storage and labeling for food-handling practices; and b. ice and coffee machines were in sanitary conditions with accordance to professional standards for food safety and service.
- D
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Inspectors wroteBased on record review and interview, it was determined the facility failed to ensure background checks were conducted for one (CNA#1) of five sampled employees reviewed for background checks. The Resident Census and Conditions of Residents report, dated 10/11/22, documented 66 residents resided in the facility.
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on record review and interview, the facility failed to ensure a dependent resident was bathed as scheduled for one (#22) of one sampled resident reviewed for ADLs. The Resident Census and Conditions of Residents report, dated 10/11/22, documented 66 residents resided in the facility and eight residents were dependent for bathing.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on record review and interview, the facility failed to ensure physician's orders were followed to obtain weights three times weekly for one (#31) of one sampled residents reviewed for nutrition. The Resident Census and Conditions of Residents report, dated 10/11/22, documented 66 residents resided in the facility.
- D
Ensure medication error rates are not 5 percent or greater.
Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure a medication error rate of less than 5 percent. The medication error rate was 7.41 percent. The Resident Census and Conditions of Residents report, dated 10/11/22, documented 66 residents resided in the facility.
- 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, record review, and interview, the facility failed to ensure medication carts were secured for one of one treatment/medication cart observed unlocked. The Resident Census and Conditions of Residents report, dated 10/11/22, documented 66 residents resided in the facility.
- D
Keep all essential equipment working safely.
Inspectors wroteBased on oberservation and interview, the facility failed to maintain mechanical and electrical equipment in safe operating condition.
Fire safety inspections
11 fire safety citations on file: 3 on April 10, 2025, 1 on December 13, 2023, 7 on October 13, 2022.
Every fire safety citation11 citations
- 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 · April 10, 2025 · Corrected (the home has a date of correction)
- E
Install an approved automatic sprinkler system.
K 351 · April 10, 2025 · Corrected (the home has a date of correction)
- E
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
K 362 · April 10, 2025 · Corrected (the home has a date of correction)
- E
Have proper medical gas storage and administration areas.
K 923 · December 13, 2023 · Corrected (the home has a date of correction)
- F
Properly provide smoke detection systems in areas open to corridors.
K 347 · October 13, 2022 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · October 13, 2022 · Corrected (the home has a date of correction)
- F
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
K 761 · October 13, 2022 · 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 · October 13, 2022 · Corrected (the home has a date of correction)
- E
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · October 13, 2022 · Corrected (the home has a date of correction)
- E
Have an externally vented heating system.
K 522 · October 13, 2022 · Corrected (the home has a date of correction)
- C
Have simulated fire drills held at unexpected times.
K 712 · October 13, 2022 · Corrected (the home has a date of correction)