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 35 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
26D
7E
0F
Potential for minimal harm
0A
1B
1C
January 13, 2026Complaint inspection · 2 citations
- D
Let each resident or the resident's legal representative access or purchase copies of all the resident's records.
Inspectors wroteBased on complaint, reviews of administrative and all pertinent documents, and interviews with facility staff members, it was determined that the facility failed to provide Resident #1's representative with a copy of the resident's medical record timely. This was evident for 1 of 2 residents reviewed during a complaint survey.
- 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 complaint, reviews of medical records and all pertinent documents, and staff interview, it was determined that the facility failed to notify 1) Resident #1's representative in a timely manner after a significant change occurred, and 2) immediately notify a resident's physician and representative when a resident developed tachycardia. This was evident for 2 (Resident #1 and #2) of 2 residents reviewed during a complaint survey.
October 22, 2025Complaint inspection · 1 citation
- E
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 reviews of a complaint, a closed medical record and all pertinent documents, and staff interview, it was determined that the facility failed to ensure that a resident with a physician's orders to document the output from a Foley catheter was completed. This was evident for 1 (Resident #1) of 4 residents reviewed during the complaint survey.
August 7, 2025Standard inspection, Complaint inspection · 10 citations
- E
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Inspectors wroteBased on resident medical record reviews and staff interviews, it was determined that the facility failed to provide residents or family representatives with an opportunity to formulate an Advanced Directive. This was evident for 6 (Residents #5, #6, #18, #37, #50 and #56) out of 9 residents reviewed during the recertification survey.
- E
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on observations and interviews with facility staff it was determined the facility failed to: 1) Ensure that the kitchen is clean and free of dirty dishes; 2) Ensure that the low temp dish wash machine maintained the required temperatures for the wash and rinse cycle; 3) Ensure that expired foods were discarded; 4) Remove all standing water located on the floor in the kitchen. This was found to be evident during an initial and follow-up tour of the kitchen survey has the potential to impact residents receiving food prepared in the kitchen.
- 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 reviews, observations, and interviews it was determined the facility failed to: 1) accurately reflect on its facility matrix the number of residents on transmissions precautions, and/or contact precautions, and/or the number of facility acquired pressure ulcers and/or pressure ulcers acquired during a resident's admission. This was evident to be true for the three submissions of the facility matrix presented to the survey team; 2) The facility failed to document the start times on the continuous tube feeding bag. This was evident for 1 (Resident #166) of 2 residents with continuous tube feedings; 3) update residents infection control status in the electronic medical record. [...]
- 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 with staff, it was determined that the facility failed to ensure Geriatric Nursing Assistants (GNAs) completed required annual in-service training timely. This was evident for 3 (GNA #16, #31, and #34) out of 4 employee records reviewed for required in-service training during the annual survey.
- 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 and staff interviews, it was determined that the facility failed to provide a safe environment in residents' rooms. This was evident for 3 out of 26 rooms observed during the survey.
- 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 medical record review and interviews it was determined the facility failed to: 1) develop a comprehensive care plan that addressed the resident's preference for future discharge. This was determined to be true for 1 (Resident #14) out of 34 residents reviewed for discharge planning ; 2) develop and implement a comprehensive care plan that addressed the resident's need for oral hygiene care while on a NPO status. This was evident for 1 (Resident #34) out of 2 residents reviewed for a comprehensive care plan; 3) follow the resident care plan of ensuring that a resident who is dependent on staff for assistance with transfers receives assistance out of bed. This was found to be evident for 1 (Resident # 3) of 46 residents reviewed; 4) develop a person-centered care plan for a resident who had a diagnosis of insomnia. [...]
- 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, record review, and interview with staff, it was determined that the facility failed to ensure a person-centered care plan was reviewed and revised for a resident. This was evident for 1 (Resident #4) out of 37 resident care plans reviewed during the survey.
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on observations, record review, and staff interviews, the facility failed to provide oral hygiene care to residents with nothing by mouth (NPO) status. This was evident for 1 (Resident #34) out of 2 residents observed during the survey. On 8/01/2025 at 9:40 AM, while speaking with Resident #34, the surveyor noted the resident's breath smelled badly and their mouth was very dry, and their lips were cracked. On 8/04/2025 at 9:26 AM, the surveyor observed Resident #34 alert and smiling, and that Resident #34's lips were dry and cracked. After leaving the resident, the surveyor went to speak with the GNA who works with the resident. GNA #32 was asked if she does oral hygiene care for the residents who are NPO. GNA #32 responded that she does oral care when she does her ADLs in the morning with the resident and again in the afternoon before leaving for the day. [...]
- D
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Inspectors wroteBased on observations and interviews with residents, the facility failed to prepare meals that were attractive, flavorful, and appetizing to the residents. This was evident for 2 (Resident #59 and #151) residents out of 5 interviewed for meals during survey. On 7/30/2025 at 11:31 AM, the surveyor spoke with Resident #151 about the food at the facility. Resident #151 stated that the food just isn't that good. I don't eat most of my meals. Resident #151 was unable to provide examples of what they meant. On 8/01/2025 at 1:45 PM, Resident #59 was interviewed about the food at the facility. Resident #59 complained that the food is terrible, with no taste. Resident #59 also stated that they (the facility) need someone better to cook the food. It's either not cooked enough or overcooked. [...]
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observations, record reviews, and interviews it was determined that the facility failed to ensure infection control and prevention policies and procedures were carried out by its employees. This was determined to be true for one (Resident #86) out of six residents reviewed for infection control and prevention during the survey.
October 26, 2022Standard inspection · 19 citations
- E
Perform COVID19 testing on residents and staff.
Inspectors wroteBased on review of residents medical records, facility COVID-19 testing documentation, facility policy interview with facility staff, and interview with residents, it was determined that the facility failed to develop and follow a system of testing residents for COVID-19 according to the recommendations of the Centers for Disease Control (CDC) and the facility's own policies during an outbreak of COVID-19. This deficient practice had the potential to impact all residents.
- 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 record review, interview, and review of pertinent facility documents and policies it was determined that the facility failed to take appropriate actions to thoroughly investigate and follow up on a reported allegation of abuse (Resident # 14). This was evident for 1 of 2 Facility Reported Incidents (FRI) reviewed.
- 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, interview, and review of pertinent facility documents and policies it was determined that the facility failed to ensure that residents were free from abuse or create a safe environment by failing to implement the facility policy on abuse as evidenced by failing to complete in-services on all employees after alleged incidents of abuse occurred in the facility, failing to appropriately investigate an allegation of abuse, and failing to follow-up with a resident grievance. This was found to be true in 1 (Resident #14) of 2 residents reviewed for abuse investigations.
- D
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Inspectors wroteBased on medical record review, facility policy and training record review and interview with facility staff, it was determined that the facility failed to implement their policy on abuse as evidenced by failing to complete in-services on all employees after alleged incidents of abuse occurred in the facility. This was evident during the review of 1 of 2 of 2 Facility Reported Incidents (FRI) on abuse.
- D
Respond appropriately to all alleged violations.
Inspectors wroteBased on record review, interview, and review of pertinent facility documents and policies it was determined that the facility failed to thoroughly investigate an abuse allegation. This was evident for 2 of 9 Facility Reported Incidents (FRI) reviewed.
- D
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Inspectors wroteBased on medical record review and staff interviews, it was determined the facility failed to have a system in place to ensure residents or their responsible party and the local Ombudsman, received written notification of a transfer to the hospital. This was evident for 2 (Resident #58 and Resident #105) of 2 residents reviewed for hospitalization during the investigative stage of the survey.
- 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 reviews and interviews it was determined the facility failed to ensure care plans were revised as required. This was found to be evident for 2 (Resident #28 and Resident #64) out of 33 residents reviewed for care plans during the Annual Survey.
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on observations, interview with staff, and record review, it was determined that the facility failed to implement an intervention, determined to be necessary, for a resident who was identified as a fall risk. This was evident of 1 of 2 residents (Resident #18) reviewed for accidents during the annual survey.
- D
Provide enough food/fluids to maintain a resident's health.
Inspectors wroteBased on interview with staff and review of medical records and the facility's policies, it was determined that the facility failed to: 1) maintain acceptable parameters of nutrition for a resident by failing to implement nutritional recommendations and, 2) effectively address significant weight loss. This was evident of 1 of 11 residents (Resident #62) reviewed for nutrition during the annual survey. This deficient practice affected a resident who had consistent weight loss throughout a two-month stay.
- 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 interview with staff and review of residents' medical records, it was determined that the facility failed to provide appropriate treatments to prevent complications for a resident who required enteral nutrition. This was evident by the facility replacing a resident's gastrostomy tube without appropriate physician's orders and failing to document that gastrostomy tube placement. This was evident for 1 of 2 residents (Resident #18) reviewed for tube feeding during the annual survey.
- D
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
Inspectors wroteBased on observation, record review and interview with facility staff it was determined that the facility failed to complete a risk assessment prior to the use of the siderails. This was evident of 1 of 2 Residents (Resident #18) reviewed for accidents during an annual survey.
- D
Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs.
Inspectors wroteBased on observation and interview it was determined that the facility failed to ensure food was properly prepared for residents with a diet order for pureed food. This deficient practice has the potential to affect all residents who received pureed food.
- 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 interview with Resident #76 the facility failed to deliver low carbohydrate diet recommended for a Resident #76 with diabetes. This was evident for 2 of 3 (Resident #76) residents reviewed for preferences during the survey.
- D
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Inspectors wroteBased on resident interview and observation it was determined the facility failed to provide food at a safe and appetizing temperature. This deficient practice has the potential to affect all residents.
- D
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 with facility staff, it was determined that the facility failed to store and prepare food in a manner that maintains professional standards of food service safety. This practice had the potential to affect all residents eating food prepared by the facility's kitchen.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation and interview with facility staff, it was determined that the facility failed to ensure that facility staff wore face masks, respirators, and face shields in an appropriate manner during a COVID-19 outbreak. This was evident on 3 of 18 days of the annual survey.
- D
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Inspectors wroteBased on observation it was determined that the facility failed to maintain an effective pest control program as evidenced by the presence of insects. This was found to be evident for the kitchen.
- C
Ensure staff are vaccinated for COVID-19
Inspectors wroteBased on review of facility documentation and interview with facility staff, it was determined that the facility failed to maintain a list of all staff persons and identify their COVID-19 vaccination status as vaccinated, exempt, non-exempt, or temporarily delayed.
- B
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Inspectors wroteBased on review of resident medical records, it was determined that the facility failed to identify a reason for declination for influenza and pneumonia vaccinations offered to residents. This was evident for 6 of 6 declination forms reviewed during the survey.
January 16, 2019Standard inspection · 3 citations
- E
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Inspectors wroteBased on observations, resident and staff interviews it was determined that the facility failed to provide a safe, sanitary and comfortable environment. This was evident in 3 out of 40 resident's rooms with spa shower room on the 3rd floor nursing unit during the survey process.
- D
Provide enough food/fluids to maintain a resident's health.
Inspectors wroteBased on observations and interview with resident and responsible party, the facility failed to provide a water cup for Resident # 11 or refill his water cup consistently. This was evident for 1 out of 40 residents observed during the interview and observational part of the survey process.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation and staff interview it was determined the facility failed to ensure that a bathroom faucet mechanism used in the room of Resident #74 was in proper working condition. This was evident in 1 of 4 rooms where handwashing was observed.
Fire safety inspections
33 fire safety citations on file: 11 on August 7, 2025, 17 on October 26, 2022, 5 on January 16, 2019.
Every fire safety citation33 citations
- F
Conduct testing and exercise requirements.
E 39 · August 7, 2025 · Corrected (the home has a date of correction)
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · August 7, 2025 · Corrected (the home has a date of correction)
- F
Have restrictions on the use of portable space heaters.
K 781 · August 7, 2025 · Corrected (the home has a date of correction)
- E
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
K 223 · August 7, 2025 · Corrected (the home has a date of correction)
- E
Have properly located and lighted "Exit" signs.
K 293 · August 7, 2025 · Corrected (the home has a date of correction)
- E
Inspect, test, and maintain automatic sprinkler systems.
K 353 · August 7, 2025 · Corrected (the home has a date of correction)
- E
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · August 7, 2025 · Corrected (the home has a date of correction)
- E
Ensure proper usage of power strips and extension cords.
K 920 · August 7, 2025 · Corrected (the home has a date of correction)
- E
Have proper medical gas storage and administration areas.
K 923 · August 7, 2025 · Corrected (the home has a date of correction)
- D
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
K 321 · August 7, 2025 · Corrected (the home has a date of correction)
- D
Install corridor and hallway doors that block smoke.
K 363 · August 7, 2025 · Corrected (the home has a date of correction)
- F
Provide properly protected cooking facilities.
K 324 · October 26, 2022 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · October 26, 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 26, 2022 · Corrected (the home has a date of correction)
- F
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · October 26, 2022 · 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 · October 26, 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 26, 2022 · Corrected (the home has a date of correction)
- E
Install an approved automatic sprinkler system.
K 351 · October 26, 2022 · 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 · October 26, 2022 · Corrected (the home has a date of correction)
- E
Have properly installed electrical wiring and gas equipment.
K 511 · October 26, 2022 · Corrected (the home has a date of correction)
- E
Have proper medical gas storage and administration areas.
K 923 · October 26, 2022 · Corrected (the home has a date of correction)
- D
Keep aisles, corridors, and exits free of obstruction in case of emergency.
K 211 · October 26, 2022 · Corrected (the home has a date of correction)
- D
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 · October 26, 2022 · Corrected (the home has a date of correction)
- D
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
K 225 · October 26, 2022 · Corrected (the home has a date of correction)
- D
Have exits that are accessible at all times.
K 271 · October 26, 2022 · Corrected (the home has a date of correction)
- D
Install smoke barrier doors that can resist smoke for at least 20 minutes.
K 374 · October 26, 2022 · Corrected (the home has a date of correction)
- D
Meet other general requirements that are deficient.
K 500 · October 26, 2022 · Corrected (the home has a date of correction)
- D
Meet requirements for the use of electrical equipment.
K 919 · October 26, 2022 · Corrected (the home has a date of correction)
- D
Keep aisles, corridors, and exits free of obstruction in case of emergency.
K 211 · January 16, 2019 · Corrected (the home has a date of correction)
- D
Have an externally vented heating system.
K 522 · January 16, 2019 · Corrected (the home has a date of correction)
- C
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
K 321 · January 16, 2019 · Corrected (the home has a date of correction)
- C
Inspect, test, and maintain automatic sprinkler systems.
K 353 · January 16, 2019 · Corrected (the home has a date of correction)
- B
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
K 225 · January 16, 2019 · Corrected (the home has a date of correction)