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 45 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
1G
0H
0I
Potential for more than minimal harm
18D
26E
0F
Potential for minimal harm
0A
0B
0C
July 14, 2026Complaint inspection · 2 citations
- 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 and interview, the facility failed to ensure a resident was free from verbal abuse for 1 (#3) of 3 sampled residents reviewed for abuse. The admissions coordinator identified 72 residents resided in the facility.
- 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 interview, the facility failed to revise a care plan to include fall interventions for 1 (#3) of 3 sampled residents reviewed for fall interventions. The admissions coordinator identified 72 residents resided in the facility.
January 5, 2026Complaint inspection · 1 citation
- 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 complete a Nursing admission Data Collection (an assessment used for elopement risk timely for 1 (#1) of 1 sampled resident reviewed for elopement. The administrator identified 71 residents resided in the facility.
April 9, 2025Complaint inspection · 6 citations
- G
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 a urinalysis order was completed and an antibiotic was transcribed as ordered for 1 (#5) of 3 sampled residents reviewed for care and treatment. The administrator identified 63 residents resided in the facility.
- E
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Inspectors wroteBased on observation, record review, and interview, the facility failed to provide care consistent with professional standards of practice and in accordance with physician orders for: a. a PICC line for 1 (#1) of 3 sampled residents reviewed for infection control; and b. the administration of IV fluids for 1 (#12) of 3 sampled residents reviewed for medications as ordered. The DON identified six residents with IV lines resided in the facility.
- E
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, record review, and interview, the facility failed to follow the menu for one of one meal service observed. The DON identified 63 residents who received their meals from the kitchen.
- E
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure infection control was maintained during the provision of incontinent care and PICC line dressing change for 2 (#1 and #9) of 3 sampled residents reviewed for infection control. The administrator identified 63 residents resided in the facility.
- 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 ensure a resident's: a. emergency contact and physician were notified of a resident's refusal of urine specimen collection for urinalysis for 1 (#5); and b. physician was notified of a resident's low blood sugar as ordered for 1 (#5) of 3 sampled residents reviewed for care and treatment. The administrator identified 63 residents resided in the facility.
- D
Provide timely, quality laboratory services/tests to meet the needs of residents.
Inspectors wroteBased on record review and interview, the facility failed to ensure a urinalysis order was completed in a timely manner for 1 (#7) of 3 sampled residents reviewed for care and treatment. The administrator identified 63 residents resided in the facility.
December 13, 2024Standard inspection · 8 citations
- E
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 interview, the facility failed include and update a careplan for one (#27) of eight sampled residents whose careplans were reviewed. The administrator identified 64 residents 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 record review and interview, the facility failed to ensure a smoking assessment was completed for one (#27) of 19 residents sampled for smoking assessments. The DON identified 64 residents who resided in the facility.
- 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 and interview, the facility failed to ensure: a. the correct inhaler medication was provided to a resident for one (#21) of one sampeld resident reviewed for medication administration; b. medications were administered according to physicians orders for two (#37 and #116); and c. a resident's chart was updated with a new antibiotic order to be continued after an ER visit for one (#116) of two sampled residents reviewed for UTI's.
- E
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 and interview, the facility failed to ensure a medication cart was securely locked and attended to according to facility policy and procedure. The administrator 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. hair nets were worn appropriately; b. the kitchen was kept clean and maintained in good repair; c. food items were labeled, dated, and stored according to facility policy; and d. hand washing and glove usage were appropriate. The DON identified 60 residents ate from the kitchen.
- E
Implement a program that monitors antibiotic use.
Inspectors wroteBased on record review and interview, the facility failed to follow the antibiotic stewardship policy by ensuring a standardized tool for initiation of antibiotics was completed for the treatment of UTI's for one (#37) of three sampled residents reviewed for UTI's. The administrator identified 64 residents resided in the facility.
- E
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Inspectors wroteBased on record review and interview, the facility failed to provide documentation pneumococcal vaccines were offered and/or administered for two (#37 and #216) of five sampled residents reviewed for immunizations. The administrator identified 64 residents resided in the facility.
- E
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Inspectors wroteBased on observation, record review, and interview, the facility failed to maintain effective pest control. The administrator identified 64 residents resided in the facility.
October 12, 2024Complaint inspection · 2 citations
- 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 and interview, the facility failed to ensure residents were free from abuse for one (#2) of two sampled residents reviewed for abuse. The DON identified 58 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 ensure medications were administered as ordered for one (#10) of three sampled residents reviewed for misappropriation of property. The DON identified 58 residents resided in the facility.
June 17, 2024Complaint inspection · 1 citation
- E
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on observation, record review, and interview, the facility failed to provide ulcer care as ordered by the physician for two (#1 and #3) of three residents sampled for ulcer care. LPN #1 identified 61 residents resided in the facility.
May 17, 2024Complaint inspection · 2 citations
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on observation and interview, the facility failed to ensure ADL assistance was provided in a timely manner for one (#7) of four resident call lights observed for staff assistance in a timely manner. The administrator identified 51 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 observation, record review, and interview, the facility failed to administer pain and nausea medication as ordered in a timely manner for one (#6) of three sampled residents reviewed for medication administration. The Administrator identified 65 residents resided in the facility. A Medication Administration and General Guidelines policy, read in part, Medications are administered in accordance with written orders of the attending physician. A physician's order dated 05/13/24, documented Norco 10-325 mg every 6 hours as needed for pain. A physician's order dated 05/13/24, documented Ondansetron 4 mg every 6 hours as needed for n/v. Review of Resident #6 MAR did not document the administration of prn pain nor nausea medications. Resident #5 had diagnosis which included senile degeneration of the brain and dysphagia. [...]
February 5, 2024Complaint inspection · 6 citations
- E
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on record review and interview, the facility failed to provide pressure ulcer treatment as ordered for three (#3, 5, and #8) of three sampled residents reviewed for pressure ulcers. The Resident Matrix, dated 02/01/24, documented two residents had pressure ulcers in the facility.
- 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 and interview, the facility failed to ensure medications were administered as ordered for two (#5 and #8) of three sampled residents reviewed for medication administration. The Resident Matrix, dated 02/01/24, documented 73 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 medications were not stored at a resident's bedside for one (#8) of three sampled residents reviewed for medication administration. The Resident Matrix, dated 02/01/24, documented 73 residents resided in the facility. The Administrator identified no residents in the facility with orders for bedside medications.
- D
Provide timely, quality laboratory services/tests to meet the needs of residents.
Inspectors wroteBased on record review and interview, the facility failed to obtain a physician ordered urinalysis for one (#3) of three sampled residents reviewed for a change in condition. The Resident Matrix, dated 02/01/24, documented 73 residents resided in the facility.
- 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 observation, record review, and interview, the facility failed to ensure adequate portion sizes were offered to residents for one of one meal service observed. The DON identified 69 residents received services from the kitchen in the facility.
- D
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 wound care treatment was accurately documented for one (#8) of three sampled residents reviewed for pressure ulcers. The Resident Matrix, dated 02/01/24, documented two residents with pressure ulcers resided in the facility.
August 18, 2023Standard inspection · 13 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 notify the physician when: a. a resident's FSBS was out of range and when they administered glucagon for one (#44); b. a resident refused insulin administration for one (#44); c. a resident's routine insulin was held for one (#44); and d. a resident experienced a fall for one (#29) of 16 sampled residents reviewed for physician notification. The Resident Census and Conditions of Residents report, dated 08/14/23, documented 62 residents resided in the facility. The facility Resident Matrix, dated 08/14/23, documented 23 residents who received insulin resided in the facility.
- E
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on record review and interview, the facility failed to: a. intervene per physician's order when a resident's FSBS was out of range; and b. monitor blood pressure for a resident who received two medications to treat blood pressure and who received renal dialysis for one (#44) of eight sampled residents reviewed for medications administered as ordered. The Resident Census and Conditions of Residents report, dated 08/14/23, documented 62 residents resided in the facility. The facility Resident Matrix, dated 08/14/23, documented 23 residents who received insulin resided in the facility.
- E
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on observation, record review, and interview, the facility failed to provide pressure ulcer treatment as ordered for one (#7) of three sampled residents reviewed for pressure ulcers. The Resident Census and Conditions of Resident report, dated 08/14/23, documented three residents with pressure ulcers, excluding stage one, resided in the facility.
- 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 observation, record review, and interview, the facility failed to ensure: a. a tube feeding bag administering nutrition and hydration contained the date, time, and name of the staff who hung the feeding for administration for one (#29); b. a resident was provided tube feedings as ordered by the physician for one (#44); c. staff documented by mouth intake for a resident who had tube feeding orders for by mouth intake of less than 50 percent for one (#44); and d. tube feeding water flush order was implemented for one (#53) of four sampled residents reviewed for nutrition. The Resident Census and Conditions of Residents report, dated 08/14/23, documented five residents who received tube feedings resided in the facility.
- 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 and interview, the facility failed to ensure medications were administered as ordered for two (#29 and #44) of eight sampled residents reviewed for medication administration. The Resident Census and Conditions of Residents report, dated 08/14/23, documented 62 residents resided in the facility.
- E
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, record review, and interview, the facility failed to follow the menu for two of two meals observed. The DON identified 56 residents who received their meals from the kitchen.
- 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: a. record food temperatures; b. ensure staff wore beard restraint during meal preparation; and c. ensure ice was stored in a manner to prevent cross contamination. The Resident Census and Conditions of Residents report, dated 08/14/23, documented 62 residents resided in the facility. The DON reported six residents were NPO.
- E
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure: a. the cap to prevent cross contamination was present on a tube feeding port for one (#29) of four sampled resident's reviewed for nutrition; b. linens contaminated with bodily fluids were removed from a resident's bed for one (#41) of 28 sampled residents observed for clean environment; and c. incontinent care was provided in a manner to prevent cross contamination for one (#1) of three sampled residents observed for incontinent care. The Resident Census and Conditions of Residents report, dated 08/14/23, documented 62 residents resided in the facility.
- D
Reasonably accommodate the needs and preferences of each resident.
Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure a call light was in reach for one (#29) of 28 sampled residents reviewed for call lights. The Resident Census and Conditions of Residents report, dated 08/14/23, documented 62 residents resided in the facility.
- 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, record review, and interview, the facility failed to provide a clean, sanitary, homelike environment for one (#29) of 28 sampled residents reviewed for homelike environment. The Resident Census and Conditions of Residents report, dated 08/14/23, documented 62 residents resided in the facility.
- D
Ensure each resident receives an accurate assessment.
Inspectors wroteBased on record review and interview, the facility failed to ensure MDS Resident Assessments were accurate for one (#48) of 21 sampled residents reviewed for MDS resident assessments. The Resident Census and Conditions of Residents report, dated 08/14/23, documented 62 residents resided in the facility.
- D
Provide enough food/fluids to maintain a resident's health.
Inspectors wroteBased on observation, record review and interview, the facility failed to ensure: a. physician ordered weekly weights were obtained for one (#170) of three sampled residents reviewed for weight loss, and b. physician ordered supplement of high protein high calorie was provided for one (#170) of four sampled residents reviewed for nutrition. The Resident Census and Conditions of Residents report, dated 08/14/23, documented 62 residents resided in the facility.
- D
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 and interview, the facility failed to offer bedtime snacks for one snack service observed. The DON identified 56 residents who received their meals from the kitchen.
December 21, 2021Standard inspection · 4 citations
- E
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on observation, interview, and record review, the facility failed to follow physician's orders for four (#26, 46, 47, and #51) of four sampled residents reviewed for following physician's orders. The Census and Conditions of Residents Report documented 65 residents resided in the facility.
- E
Provide enough food/fluids to maintain a resident's health.
Inspectors wroteBased on observation, interview, and record review, the facility failed to a. identify significant weight loss and intervene for one (#47), and b. identify a therapeutic diet preference and intervene for one (#51) of four residents reviewed for nutrition. The Census and Conditions of Residents Report documented 65 residents resided in the facility.
- E
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 a. provide a separately locked, permanently affixed compartment for storage of controlled drugs; b. monitor the medication room temperature daily in one of one medication storage room observed for medication storage; c. store drugs in a containers labeled with a resident's name and identification of the drug; and d. discard medications from the medication cart for destruction after a resident was discharged from the facility and discard expired medications for three of four medication carts observed for medication storage. The Census and Conditions of Residents Report identified 65 residents who 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, and interview, the facility failed to a. remove expired food from the refrigerator, and b. store and label food in a safe manner for two of two refrigerators observed for food storage and labeling. The Director of Nursing reported 65 residents received meals from the kitchen.
Fire safety inspections
8 fire safety citations on file: 2 on December 13, 2024, 4 on August 18, 2023, 2 on December 21, 2021.
Every fire safety citation8 citations
- F
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · December 13, 2024 · Corrected (the home has a date of correction)
- E
Inspect, test, and maintain automatic sprinkler systems.
K 353 · December 13, 2024 · Corrected (the home has a date of correction)
- F
Install emergency lighting that can last at least 1 1/2 hours.
K 291 · August 18, 2023 · 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 · August 18, 2023 · 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 18, 2023 · Corrected (the home has a date of correction)
- E
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · August 18, 2023 · Corrected (the home has a date of correction)
- E
Install corridor and hallway doors that block smoke.
K 363 · December 21, 2021 · Corrected (the home has a date of correction)
- E
Have an externally vented heating system.
K 522 · December 21, 2021 · Corrected (the home has a date of correction)