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 34 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
1J
0K
1L
Actual harm
0G
0H
0I
Potential for more than minimal harm
16D
16E
0F
Potential for minimal harm
0A
0B
0C
February 24, 2026Standard inspection · 4 citations
- E
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 interview and record review the facility failed to ensure resolution of grievances for 2 of 3 residents (Residents 87 and 46) and 1 of 1 resident group reviewed for grievances. Failure to thoroughly investigate, log and provide resolution related to individual and resident group grievances placed residents at risk for recurrent unresolved concerns and decreased quality of life.
- 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 observation, interview and record review, the facility failed to ensure residents' care plans were revised and accurately reflected the resident's care needs for 3 out of 18 sampled residents (Residents 8, 9 and 38) when reviewed for care planning and revision of care plans. This failure placed the residents at risk for unmet care needs, medical complications, inaccurate care plan documentation, and a diminished quality of life.
- D
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Inspectors wroteBased on interview and record review, the facility failed to ensure residents received assistance for activities of daily living for 1 of 3 residents (Resident 9) reviewed for activities of daily living. Failure to provide Resident 9 assistance with ambulation per the resident's preferences and therapy recommendations, placed them and other residents at risk for decline in function and decreased quality of life.
- D
Provide activities to meet all resident's needs.
Inspectors wroteBased on observation, interview and record review, the facility failed to ensure 1 of 2 residents (Resident 16) reviewed for activities had an accurate assessment of recreational care needs and received an ongoing program of activities to meet the individual resident's physical and mental needs. Based on the reasonable person concept, not having adequate recreation and/or sensory stimulation placed the resident at risk for social isolation, lack of stimulation and diminished quality of life.
August 29, 2025Standard inspection, Complaint inspection · 5 citations
- E
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Inspectors wroteBased on interview and record review, the facility failed to provide written bed hold notice to residents at the time of transfer to the hospital for 3 of 4 sampled residents (Residents 2, 11, 45) reviewed for hospitalization. This failure placed residents at risk for lacking knowledge regarding their right to hold their bed while in the hospital and diminished quality of life.
- 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, interview, and record review, the facility failed to ensure proper storage and labeling of insulin (injectable medication that regulates blood sugar) in 3 of 5 medication carts (Carts 3, 5, and 4) when reviewed for medication storage. This failure placed residents at risk of receiving expired medications, ineffective treatment, and a diminished quality of life.
- E
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on interviews, record reviews, and observations the facility failed to maintain accurate and complete medical records and ensure the medical record contained the required information for 1 of 4 residents (Resident 1) reviewed for restorative services, and 1 of 3 residents (Resident 45) reviewed for change of conditions. These failures placed residents at risk for delay in care, unmet care needs, and a diminished quality of life.
- D
Reasonably accommodate the needs and preferences of each resident.
Inspectors wroteBased on observation, interview and record review, the facility failed to ensure call lights (an alerting device for staff to assist residents in need) were within reach for 1 of 1 resident (Resident 4), reviewed for accommodation of needs. This failure placed residents at risk for delayed care, potential avoidable accidents, and diminished quality of life.
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that care planned interventions for fall management were in place for 1 of 2 residents (Resident 5) reviewed for falls. This failure placed resident at an increased risk of injury if a fall occurred.
March 17, 2025Standard inspection, Complaint inspection · 14 citations
- E
Respond appropriately to all alleged violations.
Inspectors wroteBased on observation, interview and record review, the facility failed to conduct thorough investigations for 4 of 8 residents (Residents 58, 71, 73 and 78) whose investigations were reviewed for thorough investigations. The failure to conduct thorough investigations placed residents at risk for repeat incidents, injury, and for unmet care needs due to a lack of thorough investigations after incident occurred, and there was a failure to preserve evidence necessary for thorough investigations. These failures placed residents at risk for repeat incidents and injury.
- E
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Inspectors wroteBased on interview and record review, the facility failed to ensure the Resident Assessment Instrument (RAI), an assessment of a resident's needs, strengths, goals, and preferences, were completed within the required timeframes and/or included thorough summaries of the Care Area Assessments (CAA's), an assessment of a specific resident care or medical issue, to holistically analyze the plan of care for nine of sixteen residents (Residents 13, 58, 66, 67, 71, 73, 78, 80, and 334) reviewed for comprehensive assessments. This failure placed the residents at risk of not having appropriate services provided based on the resident's individualized needs and placed all other residents at risk of their needs and preferences not met.
- E
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 interview and record review, the facility failed to act on the consultant pharmacist's monthly medication regimen review (MRR) recommendations in a timely manner for 1of 5 residents (Resident 13) reviewed for unnecessary medications and 1 of 6 months (November) reviewed for timely completion. Failure to act timely on the pharmacist's recommendations placed all residents at risk for experiencing adverse side effects, medical complications, and a decreased quality of life.
- 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, interview and record review, the facility failed to ensure drugs and biologicals were removed when expired in 3 of 5 medication carts. The facility failed to monitor daily temperatures for 2 of 3 refrigerators that stored medications. The facility failed to ensure Schedule II-V (Substances with a high potential for abuse which may lead to severe physical or psychological dependence) controlled medications were in a separate locked permanently affixed compartment not accessible to others. The facility failed to ensure 1 of 1 resident (Resident 78) was assessed for self-medication program. These failures placed residents at risk for receiving expired medications and vaccines, and potential for drug diversion from not securely locking controlled medications.
- E
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on interview and record review the facility failed to ensure a system in which residents' records were complete, accurate, accessible, and systematically organized for 4 of 5 residents (Residents 40, 52, 71 and 78) reviewed for unnecessary medication. This failure included incomplete assessments, restorative care and incomplete documentation involving resident incidents. This placed residents at risk for unmet needs, condition deterioration, unrecognized changes in condition and adverse outcomes.
- D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a dignified existence was maintained for 1 of 1 sampled resident (Resident 58) reviewed for resident rights. The facility failed to ensure Resident 58's dignity, based on reasonable person as their roommate (Resident 29) watched and listened to pornography video (sexually explicit) on their laptop that could be overheard in the hallway. This failure placed all residents at risk for a diminished self-worth and a diminished quality of life.
- D
Reasonably accommodate the needs and preferences of each resident.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure call lights (an alerting device for staff to assist residents in need) were within reach for 3 of 4 residents (Residents 47, 71 and 78), reviewed for accommodation of needs. This failure placed the residents at risk for delayed care, accidents/falls, anxiety and a diminished quality of life.
- D
PASARR screening for Mental disorders or Intellectual Disabilities
Inspectors wrote<Resident 74> Resident 74 admitted to the facility on [DATE] with diagnoses to include mild cognitive impairment and bipolar disorder (a mental health condition that causes extreme mood swings). Review of Resident 74's Level 1 PASRR, dated 1/15/2025, showed the resident had a diagnosis of bipolar disorder (a mood disorder). Sections IIA, IIB, and III were blank, and the PASRR was not signed by a physician as required for hospital exemption. Section IV was marked; No Level II evaluation indicated at this time due to exempted hospital discharge: Level II must be completed if scheduled discharge does not occur. A review of Resident 74's records on 3/12/2025 at 1:02 PM showed there was no referral for Level II PASRR, and the resident had admitted on [DATE], 38 days prior. [...]
- D
Ensure services provided by the nursing facility meet professional standards of quality.
Inspectors wroteBased on observation, interview and record review, the facility failed to ensure professional standards were met for 1 of 3 nurses (Staff G) observed for medication administration and 1 of 5 residents (Resident 334) reviewed for blood pressure parameters prior to medication administration. This failure place residents at risk for adverse effects, complications and potential for drug diversion.
- D
Provide activities to meet all resident's needs.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that the resident was assisted by staff with activities as outlined in the care plan for 1 of 4 residents (Resident 43) reviewed for activities. This failed practice placed the resident at risk for isolation and decreased opportunities for a meaningful life in their areas of wellness. <Resident 43> Resident 43 was a long-term resident of the facility. According to the Minimum Data Set assessment dated [DATE], showed the resident was severely cognitively impaired and requires extensive assistance with daily activities. [...]
- D
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 accurately assess and ensure 1 of 1 resident (Resident 28) received the necessary care and services in accordance with professional standards of practice and maintained the highest practicable level of well-being. Failure to ensure that Resident 28 received services related to a midline IV (an 8-12 cm catheter inserted in the upper arm with the tip located just below the armpit) was adequately managed potentially placed Resident 28 at risk for infection and unmet care needs.
- D
Provide medically-related social services to help each resident achieve the highest possible quality of life.
Inspectors wroteBased on interview and record review, the facility failed to provide medically related social services to attain or maintain the highest practicable physical, mental and psychosocial well-being for 1 of 4 residents (Resident 284) reviewed for medically related social services. The Social Worker (SW) was out for an extended absence; a plan was not implemented to ensure continuous social service coverage. Failure to ensure residents were informed of their care, treatment, and services available to them and continuously monitor and thoroughly assess and advocate for residents' rights, placed resident at risk for harm, diminished quality of life and unmet care needs.
- D
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure 1 of 4 residents (Resident 71) were free from unnecessary psychotropic medications (drugs that affect brain activities associated with mental processes and behavior) as required. The facility failed to ensure person-centered behavioral interventions were in place, appropriate indications were present for psychotropic medications and that consents were obtained prior to administration of psychotropic medications. These failures placed the residents at risk for medication-related complications and for receiving unnecessary psychotropic medication.
- D
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Inspectors wroteBased on observation and interview the facility failed to replace sharps containers (a specialized, puncture-resistant, and leak-proof container designed for the safe disposal of sharp medical instruments, like needles, syringes, and scalpels, to prevent accidental injuries and ensure proper waste handling) in 1 of 5 medication carts, 1 of 2 shower rooms, and 1 resident room at Station 2 when it reached the full line when the environment was reviewed for safe and comfortable environment. This failure placed residents and staff at risk for injury, and potential exposure to diseases.
October 1, 2024Complaint inspection · 1 citation
- E
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on observation, interview and record review, the facility failed to immediately report to the state agency potential abuse and/or neglect for 3 of 5 residents (Residents 19, 61, and 62) reviewed for allegations of abuse and/or neglect. Failure to immediately report alleged abuse and/or neglect placed residents at risk for potential unidentified mistreatment and a poor quality of life.
March 6, 2024Complaint inspection · 1 citation
- D
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 interview and record review, the facility failed to promptly resolve grievances for 1 of 1 sampled residents (Resident #1) reviewed for missing property. The facility failed to replace the resident's missing electrolarynx (device that produces voice electronically) timely, and when the missing property was replaced, the replacement item was not given to the resident for four days. Failure to timely replace missing property placed residents at risk for a diminished quality of life.
February 7, 2024Complaint inspection · 3 citations
- J
Ensure that residents are free from significant medication errors.
Inspectors wroteBased on interview and record review, the facility failed to ensure 3 of 4 residents (Residents 1, 2, and 3) reviewed for admission/readmission process remained free of significant medication errors. Failure to accurately review and transcribe admission orders for 2 of 4 residents (Residents 1 and 2) and failure to provide medications within physician prescribed medication parameters for 2 of 4 residents (Residents 2 and, 3). Resident 1's admission medication orders were not reconciled with the hospital discharge documents which resulted in the resident receiving two medications erroneously, including a blood thinner that had been listed as an allergy (with a note in the transfer order to NEVER go on a blood thinner again), which caused gastro-intestinal (GI) bleeding twice before; [...]
- E
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Inspectors wroteBased on interview, and record review, the facility failed to ensure Licensed Nurses (LN) and Nursing Assistants Certified (NAC) had annual evaluations, appropriate skills sets and proficiencies to provide nursing and related services for each resident in accordance with the facility assessment when nursing staff failed to demonstrate the knowledge, skills and abilities to perform nursing services for 4 of 7 sampled staff (Staff C, E, F and H) reviewed for competent nursing staff. This failure placed residents at risk for unmet care needs and a diminished quality of life.
- E
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
Inspectors wroteBased on record review, and interview, the facility failed to ensure 2 of 5 employees, (Staff E and Staff F) reviewed for training, had the required 12 hours per year of in-services and required annual dementia training. This failure placed residents at risk of less than competent care and services from staff.
December 29, 2023Complaint inspection · 2 citations
- E
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Inspectors wroteBased on observation, interview and record review, the facility failed to ensure sufficient nursing staff were available to respond to call lights timely and to meet the toileting, bathing, and repositioning needs for 5 of 6 sampled residents (Residents 1, 2, 3, 4, and 5) reviewed for sufficient nursing staff. This failure resulted in feelings of frustration and vulnerability, diminished quality of life and unmet care needs of the residents.
- D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain medical records that were complete and accurate for 12 of 12 sampled residents (Residents 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, and 18) reviewed for late and/or missed medications. The failure to complete documentation of medication administration at the time they were administered had the potential for clinical decisions to be made on inaccurate information.
September 20, 2023Complaint inspection · 4 citations
- L
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Inspectors wroteBased on observations, interview and record review, the facility failed to provide sufficient qualified staff to provide care and services for 46 of 46 residents (Residents 2, 4, 5, 7, 10, 12, 13, 14, 15, 16, 20, 21, 23, 24, 27, 28, 30, 31, 33, 35, 36, 39, 40,43, 45, 47, 51, 52, 54, 55,56, 57, 58, 64,65, 66, 68, 124, 275, 276, 278, 374, 375, 376 , and 1 anonymous resident and 6 of 6 family members (for Resident 10, 53, 55, 73, and 276, and 1 anonymous) that had concerns related to staffing on 2 of 2 units (Unit 1 and 2) reviewed for sufficient staffing. [...]
- E
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Inspectors wroteBased on interview and record review, the facility failed to implement their Abuse Prohibition policy for 3 of 5 residents (276, 71, and 39) reviewed for incidents and by not ensuring reference checks were conducted prior to hire for four of five employees (Staff O, P, Y and KK ) reviewed for reference checks. Facility staff failed to log and report allegations, to investigate allegations staff had knowledge of and to conduct thorough and timely investigations These failures placed residents at risk for abuse, neglect, unmet care needs, mistreatment by staff and a diminished quality of life. Resident 71's investigation for an unexpected death was non-existent (did not occur).
- E
Respond appropriately to all alleged violations.
Inspectors wroteBased on observation, interview and record review, the facility failed to conduct thorough investigations for 30 of 30 residents (10, 12, 2, 56, 57, 44, 51, 45, 64, 36, 278, 68, 5, 276, 52, 66, 31, 13, 54, 27, 15, 275, 30, 376, 20, 47, 124, 28, 7, 43) whose investigations were reviewed for thorough investigations. The failure to conduct thorough investigations placed residents at risk for repeat incidents, injury, and for unmet care needs due to a lack of thorough investigations after incident occurred, and there was a failure to preserve evidence necessary for thorough investigations. These failures placed residents at risk for repeat incidents and injury.
- E
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on observations, interview and record review, the facility failed to ensure there was adequate supervision for 3 of 3 residents (Resident 10, 12 and 13) reviewed for falls with injury, and failed to ensure call lights were within reach for 7 of 7 residents (Resident 32, 56, 124, 375, 54, 27, and 39) reviewed after their call lights were observed not within their reach for dependent residents. The failure to provide adequate supervision need to ensure the environment is free of environmental hazards placed residents at risk for injuries and unmet care needs.
Fire safety inspections
11 fire safety citations on file: 2 on February 24, 2026, 2 on August 29, 2025, 7 on March 17, 2025.
Every fire safety citation11 citations
- E
Have proper power supply for life support equipment.
K 915 · February 24, 2026 · Corrected (the home has a date of correction)
- D
Ensure proper usage of power strips and extension cords.
K 920 · February 24, 2026 · Corrected (the home has a date of correction)
- F
Ensure that testing and maintenance of electrical equipment is performed.
K 921 · August 29, 2025 · Corrected (the home has a date of correction)
- D
Ensure proper usage of power strips and extension cords.
K 920 · August 29, 2025 · Corrected (the home has a date of correction)
- F
Address subsistence needs for staff and patients.
E 15 · March 17, 2025 · Corrected (the home has a date of correction)
- F
Establish procedures for tracking staff and patients during an emergency.
E 18 · March 17, 2025 · Corrected (the home has a date of correction)
- F
Provide properly protected cooking facilities.
K 324 · March 17, 2025 · Corrected (the home has a date of correction)
- F
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
K 741 · March 17, 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 17, 2025 · Corrected (the home has a date of correction)
- F
Ensure that testing and maintenance of electrical equipment is performed.
K 921 · March 17, 2025 · Corrected (the home has a date of correction)
- D
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · March 17, 2025 · Corrected (the home has a date of correction)