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 39 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
4J
1K
1L
Actual harm
2G
0H
0I
Potential for more than minimal harm
20D
6E
5F
Potential for minimal harm
0A
0B
0C
June 24, 2026Standard inspection · 11 citations
- G
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on observation, interview, and record review, the facility failed to identify and implement measures consistent with and in accordance with professional standards of practice to prevent the development of and promote the healing of pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction) for Resident (R) 9, who developed a facility acquired, unstageable, deep tissue injury to her right heel. The staff failed to monitor skin checks weekly, failed to ensure R9's heels were offloaded, and failed to ensure R9 received the required interventions including a low air loss mattress to prevent pressure ulcer development. Additionally, the facility failed to monitor R1's wound for two weeks.
- F
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on observation, interview and record review the facility failed to prepare and serve food under sanitary conditions to prevent the outbreak of foodborne bacteria.
- D
Ensure that residents are fully informed and understand their health status, care and treatments.
Inspectors wroteBased on interview and record review, the facility failed to inform Resident (R) 6 and/or their representatives regarding the risks related to psychotropic (alters mood or thoughts) medications.
- D
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Inspectors wroteBased on record review and interviews, the facility failed to provide form CMS-10055 Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage Form 10055 (SNF-ABN: used to notify Medicare A participants discharging from services of potential charges) and Notification of Medicare Non-Coverage Form 10123 (NOMNC- the form used to notify Medicare A participants of their rights to appeal and the last covered date of service) to the resident or their representative for Resident (R) 18.
- D
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Inspectors wroteBased on observation, interview, and record review the facility failed to provide a written bed hold policy at the time for transfer for Resident (R) 5.
- D
Ensure services provided by the nursing facility meet professional standards of quality.
Inspectors wroteBased on interview, observation, and record review, the facility failed to provide services to meet professional standards of care when staff failed to ensure Resident (R) 11's Electronic Medication Administration Record (EMAR) was signed off with initials after medications were administered. Additionally, the staff failed to ensure R11 received her medications at the ordered time.
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure residents received assistance with activities of daily living (ADL), including facial hair removal for Resident (R) 18 and assistance with nail care for R18, R6, and R11.
- 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 monitor and respond to Resident (R) 25's lack of bowel movements for 13 consecutive days.
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on observations, record review, and interviews, the facility failed to ensure an environment free of chemical hazards for severely cognitively impaired Resident (R) 26 who had a bottle of 91 percent rubbing alcohol on his tray table.
- D
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 observation, interview, and record review, the facility failed to ensure adequate catheter (a flexible tube inserted through a narrow opening into a body cavity, particularly the bladder, for removing fluid) related care for Resident (R) 18 when staff did not ensure each resident's catheter tubing was secure to prevent pulling or dislodgement. The facility additionally failed to ensure R18 had a diagnosis for the indwelling catheter.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview, and record review the facility failed to ensure adequate infection control practices related to urinary catheter (tube inserted into the bladder to drain urine) care, hand hygiene, and glove use with intravenous (IV) medication.
April 22, 2026Complaint inspection · 1 citation
- G
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 Resident (R) 1 remained free of accident hazards on 01/17/26 at approximately 07:30 AM, when R1 fell from a mechanical lift and struck his head. R1 sustained two hematomas (a collection of blood trapped in the tissues of the skin or in an organ, resulting from trauma) on the back of his head.
May 14, 2025Complaint inspection · 1 citation
- L
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteThe facility reported a census of 40 residents, with four residents sampled, including two residents reviewed for accidents related to smoking. Based on observation, interview, and record review, the facility failed to provide adequate supervision to ensure a safe environment free from accident hazards for all residents in the facility on [DATE] at approximately 01:20 PM when cognitively impaired Resident (R) 1 used a cigarette lighter to start a fire in her room; R1 set fire to her recliner. The facility smoke alarm sounded and Certified Nurse Aide (CNA) M and CNA N used the fire extinguisher to put out the fire. All residents were evacuated from the building and Law Enforcement (LE) arrived at the facility and inspected R1's room with Licensed Nurse (LN) G for the source of the fire. [...]
July 24, 2024Standard inspection, Complaint inspection · 15 citations
- K
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Inspectors wroteThe facility reported a census of 37 residents with 17 residents sampled, which included three residents reviewed for abuse and neglect. Based on observation, interview, and record review, the facility deprived Resident (R) 7 care when the facility failed to ensure call lights were working appropriately to address the care needs of all residents residing on one of the four halls. On 07/16/24, during initial screening, multiple residents reported issues with call light response times and the surveyor observed a 42-minute call light response time for R 7. The facility reported they had issues with the call light system for months and used staff at the nurses' station to watch the system; however, on 07/17/24 at 07:25 AM, no staff were at the nurses' station watching the call light system. This failure placed the residents in immediate jeopardy. [...]
- J
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteThe facility reported a census of 37 residents with 17 sampled for review. The sample included one cognitively intact dependent Resident (R) 17 for reporting an allegation of abuse. Based on observation, interview, and record review, the facility failed to report an allegation of sexual assault when R17 reported a sexual assault by 2 male perpetrators on 05/16/24. On 05/24/24 the resident went to the hospital for chest pain and reported to hospital staff she was sexually assaulted in the facility. On 05/29/24 the resident readmitted to the facility. The hospital notified the facility of resident's report of sexual assault 05/24/24 and on discharge 5/29/24. [...]
- J
Respond appropriately to all alleged violations.
Inspectors wroteThe facility reported a census of 37 residents with 17 sampled for review. The sample included one cognitively intact dependent Resident (R) 17 reviewed for investigating an allegation of abuse related to sexual assault. Based on observation, interview and record review, the facility failed to thoroughly investigate R17's allegations of sexual assault and failed to protect R17 from potential further sexual abuse. The resident reported sexual assault by 2 male perpetrators on 05/16/24. On 05/24/24 the resident went to the hospital for chest pain and reported to hospital staff she was sexually assaulted in the facility. On 05/29/24 the resident readmitted to the facility. The hospital notified the facility of resident's report of sexual assault 05/24/24 and on discharge 5/29/24. [...]
- J
Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder.
Inspectors wroteThe facility reported a census of 37 residents, with 17 residents sampled, which included four residents reviewed for Trauma Informed Care. Based on observation, interview, and record review, the facility failed to acknowledge and respond appropriately to R17's allegations of sexual assault and her display of behaviors, which align to a trauma response, based on reasonable person concept, when the resident expressed feelings of fear, anger, and aggressiveness associated with her reported allegation of sexual assault while a resident of the facility. This failure placed R17 in Immediate Jeopardy (IJ) and at risk for untreated trauma and the negative impact to her mental, physical, and psychosocial well-being.
- F
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteThe facility reported a census of 37 residents. Based on observation, interview, and record review, the facility failed to store, prepare, and serve food in a sanitary manner to prevent possible food-borne illness to the residents of the facility.
- F
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Inspectors wroteThe facility identified a census of 37 residents. Based on observations, record reviews, and interviews the facility failed to put in place an effective administration who ensured the facility was administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident who resided at the facility. This deficient practice placed the residents at risk for decreased quality of care, quality of treatment, and sense of well-being.
- F
Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
Inspectors wroteThe facility reported a census of 37 residents. Based on record review and interview, the facility failed to electronically submit to Centers for Medicare and Medicaid Services (CMS) complete and accurate direct care staffing information, including information for agency and contract staff, based on payroll and other verifiable and auditable data in a uniform format according to specifications established by CMS (i.e. Payroll Base Journal [PBJ], related to licensed nursing coverage 24 hours/day and excessively low weekend staffing.
- F
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Inspectors wroteThe facility reported a census of 37 residents. Based on the observations, interview, and record review obtained on the current survey and its numerous findings of deficient practice including 4 Immediate Jeopardy citations which constituted Substandard Quality of Care, and with several of the deficient practice areas noted as repeat citations from the prior survey, the facility failed to demonstrate an effective Quality Assurance and Performance Improvement (QAPI) program. This failure affected all 37 residents of the facility and placed them at risk for a decreased quality of life, decreased quality of care, and continued resident abuse. (See all citations associated with (HEJK11). Findings Included: - During the second day of the onsite recertification survey, the surveyors discovered one Immediate Jeopardy (IJ) concerns which were not identified by the facility. [...]
- E
Assess the resident when there is a significant change in condition
Inspectors wroteThe facility reported a census of 37 residents with 17 residents selected for review. Based on observation, interview, and record review, the facility failed to capture a significant change on Resident (R) 21 when the resident had two areas of decline in activities of daily living and increased behaviors. This deficient practice had the potential to lead negative impacts on the resident's physical, mental and psychosocial well-being.
- E
Ensure each resident receives an accurate assessment.
Inspectors wroteThe facility reported a census of 37 residents with 17 residents selected for review. Based on observation, interview, and record review, the facility failed to accurately complete the Minimum Data Set (MDS) for five sampled residents, Resident (R)7 and R21 related to personal alarm use, R8 related to urinary catheter (tube inserted into the bladder to drain urine into a collection bag), R32 related to antiplatelet medication use and R23 for restraint use. This placed the residents at risk for uncommunicated care needs.
- E
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Inspectors wroteThe facility reported a census of 37 residents with 17 residents sampled, which included five residents identified for restorative nursing services (care provided to maintain a person's highest level of physical, mental, and psychosocial function in order to prevent declines that impact quality of life). Based on observation, interview, and record review, the facility failed to provide treatment and services for four of the five sampled residents (R)4, R 11 R 29, and R 8, related to the lack of restorative nursing programs.
- 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 wroteThe facility reported a census of 37 residents with 17 residents selected for review. Based on observation, interview, and record review, the facility failed to accurately update Resident (R)7's care plan for fall interventions. This placed the residents at risk for uncommunicated care needs.
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteThe facility reported a census of 37 residents with 17 residents selected for review. Based on observation, interview, and record review, the facility failed to provide an environment that remained free from accident hazards for two residents when the facility failed to appropriately place a fall mat on the floor next to Resident (R)21's bed. This deficient practice could potentially result in an injury. R36 the facility failed to ensure a safe transfer for R36, when staff utilized a full body mechanical lift, without a second staff member present. This deficient practice could potentially result in a mechanical lift transfer accident.
- D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Inspectors wroteThe facility reported a census of 37 residents with 17 residents selected for review. Based on observation, interview, and record review, the facility failed to ensure two resident's medications received and documented as ordered by the physician. The facility failed to administer scheduled Tramadol to Resident (R)8 for seven days. Furthermore, the facility failed to administer R16's insulin on one day per sliding scale orders.
- D
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Inspectors wroteThe facility reported a census of 37 residents with 17 residents selected for review. Based on observation, interview, and record review, the facility failed to follow the Consultant Pharmacist recommendation to complete an Abnormal Involuntary Movement Scale (AIMS) (a rating scale to measure involuntary movements known as tardive dyskinesia [TD is abnormal condition characterized by involuntary repetitive movements of the muscles of the face, limbs and trunk]) for one of the five residents reviewed for unnecessary medications. Resident (R)21 who received risperidone, an antipsychotic (class of medications used to treat major mental conditions which cause a break from reality).
March 28, 2024Complaint inspection · 1 citation
- J
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteThe facility reported a census of 40 residents, with four residents sampled, including three residents reviewed for risk of elopement (an incident in which a cognitively impaired resident with poor or impaired decision- making ability/safety awareness leaves the facility without the knowledge of staff). Based on observation, record review, and interview, the facility failed to provide adequate supervision and a safe environment, as free of accident hazards as possible, to prevent the elopement of cognitively impaired and independently mobile Resident (R)2. The facility staff knew R2 was an elopement risk and R2 had been upset and voiced she wanted to go home. The facility staff then left R 2 unsupervised near the front entrance. [...]
October 27, 2022Standard inspection · 10 citations
- E
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Inspectors wroteThe facility reported a census of 32 residents and identified nine residents that discharged to the hospital since 09/07/22. The sample of nine, included one resident sampled for hospitalization. Based on observation, interview, and record review, the facility failed to send a copy of the facility-initiated hospitalization transfer/discharge notice to the representative of the Office of the State Long-Term Care Ombudsman for Resident (R) 15's two hospitalizations as well as the other eight residents discharged to the hospital since 09/07/22.
- E
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Inspectors wroteThe facility reported a census of 32 residents and identified nine residents that discharged to the hospital since 09/07/22. The sample of nine, included one resident sampled for hospitalization. Based on observation, interview, and record review the facility failed to provide a copy of the facility bed hold policy to Resident (R) 15 or their representative when they transferred out of the facility to the hospital, as well as the other eight residents or their representatives that discharged to the hospital since 09/07/22.
- 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 wroteThe facility reported a census of 32 residents. Based on interview and record review, the facility failed to ensure competent nursing staff as evidenced by the lack of required annual evaluation for five direct care staff sampled, Certified Medication Aide (CMA)R, Certified Nurse Aide (CNA) M, CNA Q, CNA N, and CNA O, to identify staff competencies to perform necessary nursing care and services for the residents of the facility.
- D
Allow resident to participate in the development and implementation of his or her person-centered plan of care.
Inspectors wroteThe facility identified a census of 32 residents with 12 residents included in the sample. Based on interview, and record review, the facility failed to ensure the right to include the resident and /or resident representative to participate in the development and implementation of the resident's person-centered plan of care for Resident (R) 131, when they failed to invite the resident/resident representative for the resident's care plan meetings.
- D
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Inspectors wroteThe facility reported a census of 32 residents with 12 residents in the sample. Based on interviews and record reviews, the facility failed to notify the family when Resident (R) 131 returned to the facility from a hospital on [DATE], to ensure the resident representative notified of significant changes in the resident's health status.
- 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 wroteThe facility identified a census of 32 resident with 12 residents included in the sample. Based on observations, interview and record review, the facility failed to revise Resident (R) 21 care plan to reflect shaving preference.
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteThe facility identified a census of 32 resident with 12 residents included in the sample. Based on observations, interview and record review, the facility failed to ensure personal hygiene had been completed for the Resident (R) 21 related to shaving of facial hair.
- D
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Inspectors wroteThe facility census totaled 32 residents with 12 residents in the sample. Based on observation, interview, and record review, the facility failed to consistently apply a right-hand device to maintain proper functional positioning for Resident (R) 2's hand.
- D
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Inspectors wroteThe facility census totaled 32 residents, with 12 residents sampled, including five for unnecessary medications. Based on interview, and record review the facility failed to ensure adequate follow up of the consultant pharmacist recommendations for Resident (R) 15 and R28. Furthermore, the facility failed to ensure each resident was reviewed each month, missing two months for R28. These failures placed the residents at risk for adverse effects related to medication use.
- D
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Inspectors wroteThe facility census totaled 32 residents, with 12 residents sampled, including five for unnecessary medications. Based on interview and record review the facility failed to ensure adequate monitoring of medications for Resident (R) 15 and R28. These failures placed the residents at risk for adverse effects related to medication use.
Fire safety inspections
30 fire safety citations on file: 6 on June 24, 2026, 20 on July 24, 2024, 4 on October 27, 2022.
Every fire safety citation30 citations
- F
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 · June 24, 2026 · Not yet corrected
- F
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
K 321 · June 24, 2026 · Not yet corrected
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · June 24, 2026 · Not yet corrected
- D
Install corridor and hallway doors that block smoke.
K 363 · June 24, 2026 · Not yet corrected
- D
Have properly installed electrical wiring and gas equipment.
K 511 · June 24, 2026 · Not yet corrected
- D
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
K 761 · June 24, 2026 · Not yet corrected
- F
Address patient/client population and determine types of services needed.
E 7 · July 24, 2024 · Corrected (the home has a date of correction)
- F
Provide emergency officials' contact information.
E 31 · July 24, 2024 · Corrected (the home has a date of correction)
- F
Provide primary/alternate means for communication.
E 32 · July 24, 2024 · Corrected (the home has a date of correction)
- F
Establish methods for sharing information.
E 33 · July 24, 2024 · Corrected (the home has a date of correction)
- F
Provide a means of sharing information on occupancy/needs.
E 34 · July 24, 2024 · Corrected (the home has a date of correction)
- F
Provide family notifications of emergency plan.
E 35 · July 24, 2024 · Corrected (the home has a date of correction)
- F
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 · July 24, 2024 · Corrected (the home has a date of correction)
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · July 24, 2024 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · July 24, 2024 · Corrected (the home has a date of correction)
- F
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · July 24, 2024 · Corrected (the home has a date of correction)
- F
Have properly installed electrical wiring and gas equipment.
K 511 · July 24, 2024 · Corrected (the home has a date of correction)
- F
Have simulated fire drills held at unexpected times.
K 712 · July 24, 2024 · Corrected (the home has a date of correction)
- F
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
K 761 · July 24, 2024 · Corrected (the home has a date of correction)
- F
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
K 914 · July 24, 2024 · Corrected (the home has a date of correction)
- F
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · July 24, 2024 · Waiver
- F
Ensure proper usage of power strips and extension cords.
K 920 · July 24, 2024 · Corrected (the home has a date of correction)
- E
Meet other general requirements.
K 100 · July 24, 2024 · Corrected (the home has a date of correction)
- E
Provide properly protected cooking facilities.
K 324 · July 24, 2024 · Corrected (the home has a date of correction)
- E
Have properly installed hallway dispensers for alcohol-based hand rub.
K 325 · July 24, 2024 · Corrected (the home has a date of correction)
- E
Install corridor and hallway doors that block smoke.
K 363 · July 24, 2024 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · October 27, 2022 · Corrected (the home has a date of correction)
- F
Have properly installed electrical wiring and gas equipment.
K 511 · October 27, 2022 · Corrected (the home has a date of correction)
- F
Have simulated fire drills held at unexpected times.
K 712 · October 27, 2022 · Corrected (the home has a date of correction)
- E
Ensure proper usage of power strips and extension cords.
K 920 · October 27, 2022 · Corrected (the home has a date of correction)