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 43 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
2L
Actual harm
1G
0H
0I
Potential for more than minimal harm
32D
8E
0F
Potential for minimal harm
0A
0B
0C
May 13, 2026Standard inspection · 3 citations
- D
Respond appropriately to all alleged violations.
Inspectors wroteBased on interviews and record reviews, the facility failed to ensure a thorough investigation was completed for an allegation of physical abuse for 2 (Resident #21 and Resident #60) of 3 sampled residents reviewed for abuse and/or neglect.
- D
Provide enough food/fluids to maintain a resident's health.
Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure an ordered nutritional supplement was provided for 1 (Resident #5) of 1 sampled resident reviewed for nutritional supplements.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observations, interviews, and record reviews the facility failed to:1. Ensure a Personal Protective Equipment gown was used during intravenous central line (tube placed in a large vein for medication administration) medication administration (Resident #5); and,2. Ensure proper hand hygiene during nephrostomy tube (catheter inserted into the kidney to drain urine) site care (Resident #55). This deficient practice was identified for 1 (Resident #55) of 29 sampled residents observed and/or investigated during the medication administration and/or the infection control tasks.
May 7, 2025Standard inspection · 3 citations
- 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 observations and interviews the facility failed to: 1. ensure expired medications were not available for resident use on 2 (Medication Cart c, Medication Cart e) of 2 (Medication Cart c, Medication Cart e) medication carts observed; 2. ensure expired medications were not available for resident use in 2 (Medication Room h, Medication Room g) of 2 (Medication Room h, Medication Room g) medication rooms observed; and, 3. ensure food items were not stored in the medication room for 1 (Medication Room g) of 2 (Medication Room h, Medication Room g).
- D
Reasonably accommodate the needs and preferences of each resident.
Inspectors wroteBased on observations, interview, and record reviews, the facility failed to ensure a resident's call light was within reach for 2 (Resident #6, Resident #12) of 4 (Resident #6, Resident #12, Resident #37, Resident #51) sampled residents investigated for accommodation of needs.
- 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 observation, interview, and record reviews, the facility failed to ensure a resident's care plan intervention for a low air loss mattress to bed was in place for 1 (Resident #6) of 2 (Resident #6, Resident #30) sampled residents investigated for pressure ulcers (localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device).
March 10, 2025Complaint inspection · 4 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 interviews and record reviews, the facility failed to ensure a resident remained free from neglect when nursing staff failed to provide peri-care for 1(Resident #3) of 3 (Resident #1, Resident #2, Resident #3) sampled residents investigated for neglect.
- D
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Inspectors wroteBased on interviews and record reviews, the facility failed to implement the facility's abuse policy by failing to ensure staff reported an allegation of abuse for 1 (Resident #1) of 3 (Resident #1, Resident #2, Resident #3) sampled residents investigated for abuse.
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on interviews and record reviews, the facility failed to report an allegation of abuse and/or neglect to the State Agency for 1 (Resident #1) of 3 (Resident #1, Resident #2, Resident #3) sampled residents investigated for abuse.
- D
Have a plan that describes the process for conducting QAPI and QAA activities.
Inspectors wroteBased on interview and record review, the Quality Assurance and Performance Improvement (QAPI) committee failed to provide sufficient evidence that ongoing monitoring and evaluations were implemented to ensure corrective actions were put in place after many allegations of abuse and neglect were identified in 2024.
November 6, 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 reviews and interviews, the facility failed to keep a resident free from staff to resident verbal abuse for 1 (Resident #1) of 3 (Resident #1, Resident #2 and Resident #3) sampled residents reviewed for abuse.
- D
Ensure the activities program is directed by a qualified professional.
Inspectors wroteBased on record reviews and interview, the facility failed to ensure the activities program was directed by a qualified professional for 1 (S4Former Activities Director) of 1 (S4Former Activities Director) staff personnel files reviewed for activities director qualifications.
September 18, 2024Complaint inspection · 3 citations
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on interviews and record review the facility failed to ensure the investigation of an allegation of neglect was reported to the State Survey agency within the required time frame for 2 (Resident #1 and Resident #3) of 3 (Resident #1, Resident #2, Resident #3) sampled residents investigated.
- D
Respond appropriately to all alleged violations.
Inspectors wroteBased on interviews and record reviews, the facility failed to ensure a thorough investigation was completed for an allegation of neglect for 2 (Resident #2 and Resident #3) of 3 (Resident #1, Resident #2, and Resident #3) sampled resident investigated for neglect.
- D
Have a plan that describes the process for conducting QAPI and QAA activities.
Inspectors wroteBased on interview and record review, the Quality Assurance and Performance Improvement (QAPI) committee failed to provide sufficient evidence that ongoing monitoring and evaluations were implemented to ensure corrective actions were put in place after identification of residents not receiving incontinence care as needed.
September 5, 2024Complaint inspection · 2 citations
- L
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 properly secure residents in the facility's transportation vehicles for 2 (Resident #5 and Random Resident #6) of 2 (Resident #5 and Random Resident #6) sampled residents reviewed for accident hazards. This deficient practice resulted in an Immediate Jeopardy situation on 08/22/2024 at 11:47 a.m. for Resident #5 when S6Driver failed to properly secure the resident in a forward facing direction in the facility's transportation bus, Resident #5's wheelchair tipped over backwards during transport, and caused Resident #5 to strike the back of her head. Resident #5 was transported to the hospital where she was assessed as having an abrasion to the back of the head and had to receive pain medication. The IJ continued on 09/03/2024 at 12:30 p.m. [...]
- L
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Inspectors wroteBased on observations, record reviews, and interviews, the facility failed to be administered in a manner that enabled it to use its resources effectively and efficiently by failing to have an adequate system in place to ensure residents were properly restrained in the facility's transportation vehicles, vehicle transportation logs were completed as required for the facility's transportation vehicles, and the facility's transportation drivers were competent on the use of the facility's van and bus restraint systems prior to transporting residents. This lack of administrative oversight resulted in an Immediate Jeopardy situation on 08/22/2024 at 11:47 a.m. [...]
August 14, 2024Complaint inspection · 1 citation
- D
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Inspectors wroteBased on interviews and record reviews, the facility failed to protect a resident's right to be free from verbal abuse by staff. This deficient practice was identified for 1 (Resident #1) of 4 (Resident #1, Resident #2, Resident #3, and Resident #4) sampled residents reviewed for abuse.
June 13, 2024Complaint inspection · 3 citations
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on record review and interview the facility failed to report the results of an investigation to the required state agency within 5 working days of a reportable incident for 1 (Resident #6) of 7 (Resident #1, Resident #2, Resident #3, Resident #4, Resident #5, Resident #6, and Resident #7) residents reviewed for abuse and/or neglect.
- D
Respond appropriately to all alleged violations.
Inspectors wroteBased on record review and interviews, the facility failed to ensure an alleged incident of neglect was thoroughly investigated by the facility for 1 (Resident #4) of 7 (Resident #1, Resident #2, Resident #3, Resident #4, Resident #5, Resident #6, and Resident #7) residents reviewed for abuse and/or neglect.
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on record reviews and interviews, the facility failed to ensure a dependent resident received timely incontinence care for 1 (Resident #5) of 4 (Resident #1, Resident #4, Resident #5, and Resident #6) sampled residents investigated for incontinence care .
May 16, 2024Standard inspection, Complaint inspection · 8 citations
- E
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Inspectors wroteBased on record reviews and interviews, the facility failed to: 1. Protect a resident's right to be free from physical abuse by Resident #239 for 1 (Resident #75) of 8 (Resident #11, Resident #37, Resident #43, Resident #47, Resident #75, Resident #239, Resident #20, and Resident #23) sampled residents investigated for abuse and neglect; 2. Protect a resident's right to be free from physical abuse by Resident #43 and Resident #47 for 2 (Resident #43 and Resident #47) of 8 (Resident #11, Resident #37, Resident #43, Resident #47, Resident #75, Resident #239, Resident #20, and Resident #23) sampled residents investigated for abuse and neglect; 3. [...]
- 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 record reviews, observations, and interviews, the facility failed to administer a resident's tube feeding water flush as ordered for 1 (Resident #50) of 1 (Resident #50) sampled residents investigated for tube feeding.
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on record review and interviews, the facility failed to report an injury of unknown origin for 1 (Resident #43) of 8 (Resident #11, Resident #20, Resident #23, Resident #37, Resident #43, Resident #47, Resident #75, and Resident #239) sampled residents investigated for abuse.
- D
Respond appropriately to all alleged violations.
Inspectors wroteBased on record reviews and interviews the facility failed to investigate an injury of unknown origin for 1 (Resident #43) of 8 (Resident #11, Resident #20, Resident #23, Resident #37, Resident #43, Resident #47, Resident #75, and Resident #239) sampled residents investigated for abuse.
- 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 record reviews and interviews, the facility failed to ensure a resident did not have an order for administration of a psychotropic medication (drugs that affect one's mental state) on an as needed basis (PRN) without a physician's documentation of the specified duration of the order for 1 (Resident #46) of 5 (Resident #16, Resident #46, Resident #47, Resident #64, and Resident #82) sampled resident investigated for unnecessary medications.
- D
Ensure that residents are free from significant medication errors.
Inspectors wroteBased on observations, record reviews, and interviews the facility failed to administer a medication for hypertension as ordered by the physician for 1 (Resident #14) of 22 (Resident #11, Resident #14, Resident #16, Resident #21, Resident #37, Resident #43, Resident #46, Resident #47, Resident #48, Resident #50, Resident #52, Resident #54, Resident #57,Resident #62, Resident #64, Resident #69, Resident #75, Resident #82, Resident #87, Resident #88, Resident #239, and Resident #440) residents investigated in the sample.
- D
Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
Inspectors wroteBased on record reviews and interviews, the facility failed to obtain a resident's most recent hospice Plan of Care, recertification of terminal illness, and documentation of hospice services provided for 1 (Resident #50) of 1 (Resident #50) sampled resident reviewed for hospice.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on record review, observations, and interviews, the facility failed to ensure a Certified Nursing Assistant (CNA) completed hand hygiene during incontinence and catheter care for 1 (Resident #57) of 1 (Resident #57) residents reviewed for catheter care.
March 14, 2024Complaint inspection · 4 citations
- G
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Inspectors wroteBased on record reviews and interviews, the facility failed to ensure a resident remained free from neglect and psychosocial harm when nursing staff failed to provide care and services to a newly admitted resident for 1 (Resident #5) of 19 residents (Resident #1, Resident #2, Resident #3, Resident #4, Resident #5, Resident #6, Resident #7, Resident #8, Resident #9, Resident #10, Resident #11, Resident #12, Resident #13, Resident #14, Resident #15, Resident #16, Resident #17, Resident #18, and Resident #19) reviewed for neglect. This deficient practice resulted in actual harm on 02/08/2024 at 10:00 p.m. when S6Licensed Practical Nurse (LPN) and S7Certified Nursing Assistant (CNA) both arrived to work at 10:00 p.m. [...]
- E
Respond appropriately to all alleged violations.
Inspectors wroteBased on record reviews and interviews, the facility failed to conduct a thorough investigation following an allegation of neglect for 6 (Resident #2, Resident #6, Resident #11, Resident #12, Resident #13, and Resident #17) of 19 (Resident #1, Resident #2, Resident #3, Resident #4, Resident #5, Resident #6, Resident #7, Resident #8, Resident #9, Resident #10, Resident #11, Resident #12, Resident #13, Resident #14, Resident #15, Resident #16, Resident #17, Resident #18, and Resident #19) residents investigated for neglect.
- 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 record review and interview the facility failed to ensure staff answered call bells to assist residents timely with toileting and/or incontinence care for 6 residents (Resident #2, Resident #10, Resident #11, Resident #12, Resident #13, and Resident #17) of 19 residents (Residents #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, and #19) sampled for incontinence care and toileting
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on record reviews and interviews, the facility failed to ensure an incontinent resident dependent on staff for incontinence care received timely incontinence care for 1 (Resident #14) of 19 (Resident #1, Resident #2, Resident #3, Resident #4, Resident #5, Resident #6, Resident #7, Resident #8, Resident #9, Resident #10, Resident #11, Resident #12, Resident #13, Resident #14, Resident #15, Resident #16, Resident #17, Resident #18, and Resident #19) sampled residents investigated for incontinence care.
February 15, 2024Complaint inspection · 2 citations
- 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 record reviews and interviews, the facility failed to ensure a plan of care was developed for a resident identified as being at high risk for falls for 1 (Resident #1) of 4 (Resident #1, Resident #2, Resident #3, and Resident #4) sampled residents in which the care plans were reviewed.
- 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 observations, interviews, and record reviews the facility failed to: 1. Ensure a dependent and incontinent resident with a history of urinary tract infections was provided incontinence care per the facility's policy and procedures for 1 (Resident #2) of 4 Residents (#1, #2, #3, #4) sampled. 2. Ensure a resident who completed self-catheterization was monitored for urine output and signs and/or symptoms of urinary tract infections for 1 (Resident #4) of 4 residents (#1, #2, #3, #4) sampled.
January 22, 2024Complaint inspection · 4 citations
- E
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Inspectors wroteBased on record reviews and interviews, the facility failed to: 1. Protect residents (Resident #10 and Resident #12) from resident to resident physical abuse; and, 2. Ensure a resident (Resident #5) was free from neglect by failing to provide incontinence care timely. This deficient practice was identified for 3 (Resident #10, Resident #12, and Resident #5) of 13 (Resident #1, Resident #2, Resident #3, Resident #4, Resident #5, Resident #6, Resident #7, Resident #8, Resident #9, Resident #10, Resident #11, Resident #12, and Resident #13) sampled residents investigated for abuse and neglect.
- D
Protect each resident from the wrongful use of the resident's belongings or money.
Inspectors wroteBased on record review and interview, the facility failed to ensure residents were free from misappropriation of property/financial abuse/Exploitation for 1 (Resident #3) of 13 (Resident #1, Resident #2, Resident #3, Resident #4, Resident #5, Resident #6, Resident #7, Resident #8, Resident #9, Resident #10, Resident #11, Resident #12, and Resident #13) sampled residents investigated for misappropriation of resident property.
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on record review and interviews, the facility failed to ensure allegations of resident neglect were reported to the state agency within 24 hours of the allegation for 2 (Resident #4 and Resident #10) of 13 (Resident #1, Resident #2, Resident #3, Resident #4, Resident #5, Resident #6, Resident #7, Resident #8, Resident #9, Resident #10, Resident #11, Resident #12, and Resident #13) sampled residents investigated for neglect.
- D
Respond appropriately to all alleged violations.
Inspectors wroteBased on record review and interview, the facility failed to conduct a thorough investigation following allegations of neglect for 2 (Resident #4 and Resident #10) of 13 (Resident #1, Resident #2, Resident #3, Resident #4, Resident #5, Resident #6, Resident #7, Resident #8, Resident #9, Resident #10, Resident #11, Resident #12, and Resident #13) sampled residents investigated for neglect.
December 7, 2023Complaint inspection · 2 citations
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on record review and interviews, the facility failed to ensure an alleged violation of physical abuse was reported immediately, but not later than 2 hours after the allegation was made to the State Survey Agency for 1(Resident #4) of 5 (Resident #1, Resident #2, Resident #3, Resident #4, and Resident #R5) sampled residents reviewed for abuse.
- D
Respond appropriately to all alleged violations.
Inspectors wroteBased on record review and interview, the facility failed to ensure an allegation of abuse was thoroughly investigated for 1 (Resident #4) of 5 (Resident #1, Resident #2, Resident #3, Resident #4, and Resident #R5) sampled residents reviewed for abuse.
October 24, 2023Complaint inspection · 2 citations
- 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 reviews and interviews, the facility failed to immediately notify a resident's physician of a change in a resident's ability to tolerate an enteral feeding (a way of delivering nutrition directly to the stomach or small intestine through a tube) for 1 (Resident #1) of 2 (Resident #1 and Resident #3) sampled residents investigated for enteral feedings.
- 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 record reviews and interviews, the facility failed to provide appropriate treatment and services to enhance a resident's tolerance of enteral feedings (a way of delivering nutrition directly to the stomach or small intestine through a tube) for 1 (Resident #1) of 2 (Resident #1 and Resident #3) sampled residents investigated for enteral feedings.
Fire safety inspections
4 fire safety citations on file: 2 on May 13, 2026, 1 on May 7, 2025, 1 on May 16, 2024.
Every fire safety citation4 citations
- D
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · May 13, 2026 · Corrected (the home has a date of correction)
- C
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
K 521 · May 13, 2026 · no revisit needed
- C
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
K 521 · May 7, 2025 · Waiver
- C
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
K 521 · May 16, 2024 · Waiver