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 33 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
21D
12E
0F
Potential for minimal harm
0A
0B
0C
July 21, 2026Complaint inspection · 1 citation
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on interviews, review of clinical record, and review of facility policy and procedure, the facility failed to ensure medications were administered according to physician orders for one of four sampled residents (#2). The deficient practice could result in residents not receiving medications as ordered by the physician, which could lead to worsening of the resident's medical condition.-
March 26, 2026Complaint inspection · 1 citation
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on interview, review of clinical record, and review of facility policy and procedure, the facility failed to ensure one of three sampled residents (#25) was provided quality of care regarding prevention, assessment, and treatment of moisture associated skin damage (MASD), according to professional standards. The deficient practice could lead to worsening of a skin issues, increased pain, and physical harm of a resident.-
January 7, 2026Standard inspection, Complaint inspection · 4 citations
- E
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Inspectors wroteBased on closed record review, staff interviews, and review of facility documentation and policy, the facility failed to ensure that the Ombudsman was notified of the transfer/discharge for 3 of 4 sampled residents (#115, #118, & 110). The deficient practice could lead to notifications and pertinent information regarding the discharge/transfer not being provided.
- E
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Inspectors wroteBased on observation, resident and staff interviews, facility documentation, and policy review, the facility failed to ensure that food items were palatable, and at a safe and appetizing temperature. The deficient practice could decrease residents' desire to eat which could impact their nutrition status and lead to slower recovery from illnesses or injury.
- D
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Inspectors wroteBased on observations, clinical record review, staff interviews, and facility policy review, the facility failed to ensure that medications were not left at the bedside for two residents (#62 and #121). Census was 100. The deficient practice could result in harm to the residents and/or visitors who have access to medications.-Resident #121 was admitted to the facility on [DATE], with diagnoses that included pneumonia (lung infection), atrial fibrillation (irregular heart rate), hypertension (high blood pressure), and need for assistance with personal care. A review of order summary revealed an order dated December 31, 2025, for Metoprolol Tartrate oral tablet 25 MG (milligram) give half a tablet by mouth two times a day for high blood pressure, and an order for Saccharomyces Boulardii (probiotic) capsule 250 mg give 1 capsule by mouth two times a day for probiotic. [...]
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observations, staff interviews, facility documentation, review of facility policies and procedures, the facility failed to ensure infection control standards/protocols related to Transmission Based Precautions (TBP) and hand hygiene were followed by staff. Census was 100. The deficient practice could result in the spread of infection to residents and staff.
October 2, 2024Standard inspection, Complaint inspection · 10 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 observation, interview, and review of the facility's policies, the facility failed to ensure that 7 of 7 sampled residents (#65, #344, #38, #13, #19, #58, and #33) were provided a comfortable and homelike environment. The deficient practice could have a negative psychosocial impact on residents. -Regarding Residents #65 and #344: An observation was conducted on September 30, 2024 at 10:43 AM of room [ROOM NUMBER] belonging to Resident #65 who was not in the room at that time. From the doorway, observation of the wall revealed that paint had been scraped off of behind and surrounding the headboards of both A and B beds. An additional observation was conducted of the wall in room [ROOM NUMBER] later that day on September 30, 2024 at 2:25 PM. Per the floor nurse, Resident #65 was still out at an appointment. [...]
- E
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Inspectors wroteBased on observations, staff and resident interviews, clinical record and policy review, the facility failed to protect the rights of three residents (#22, #54, #89) to be free from abuse. The deficient practice may result in further resident to resident abuse.
- E
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on clinical record review, staff interviews, and facility documentation and policy review, the facility failed to ensure adequate supervision for one resident (#60). The deficient practice resulted in resident wandering into other resident rooms uninvited.
- 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, staff interviews, and policy review, the facility failed to ensure that a medication cart was locked when unattended and that controlled medications in the medication storage room were properly secured according to facility policy. The deficient practice could result in residents or staff members having unrestricted access to medications and controlled substances. -Regarding the medication cart: An observation was conducted on October 01, 2024, at 7:28 AM in the hallway of the 400 unit. It was observed that a medication cart was unlocked without staff presently attending it or in close proximity. A nurse was observed to be in a room across the hall from the med cart, attending to the resident in the bed furthest from the door, looking opposite and away from the cart. An interview was conducted with this Licensed Practical Nurse (LPN, Staff #49) on the same day at 8: [...]
- E
Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs.
Inspectors wroteBased on observations, staff interviews and policy review, the facility failed to provide food within safe serving temperature. The deficient practice could result in foodborne illnesses among residents.
- 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, staff interviews and policy review, the facility failed to ensure the areas used for preparing, cooking and serving food were cleaned and maintained sanitary in accordance with professional standards for food service safety. The deficient practice could result in foodborne illnesses among residents.
- E
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observations, staff interviews and policy review, the facility failed to adhere to infection control policies while serving, preparing, and distributing food to residents, and while providing care to one resident (#65). The deficient practices could result in foodborne illnesses among residents and the transmission of infection. -Regarding food preparation and distribution to residents: On September 30, 2024 at 10:51 a.m., an observation was conducted inside the facility's kitchen with the dietary supervisor (staff #14) who did not have a beard covering. At that time, staff #14 reported that the expectation in the kitchen is proper hand hygiene to prevent foodborne illness, that also includes hair and beard covering. [...]
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observation, record review, interviews, and facility policy review, the facility failed to ensure respiratory services were provided according to professional standards, specifically that an order was obtained for the use of oxygen, for one resident (#339). The deficient practice could result in residents receiving unnecessary supplemental oxygen, and the provider not being aware of the resident's status.
- D
Provide or obtain dental services for each resident.
Inspectors wroteBased on clinical record review, staff interviews, facility documentation and review of facility policy and procedure, the facility failed to ensure dental needs were met for one sampled resident (#58). The deficient practice could result in residents not receiving necessary services for oral and dental care.
- 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 observations, resident and staff interviews, and record review, the facility failed to ensure one resident's (#58) dietary needs were met. The deficient practice could place residents at risk of malnutrition and dissatisfaction with their meals.
August 6, 2024Complaint inspection · 1 citation
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on observations, clinical record reviews, staff interviews and facility policy review, the facility failed to provide resident (#1) with physician ordered necessary wound care services. The deficient practice can put resident at risk for wound infection.
June 24, 2024Complaint inspection · 2 citations
- D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Inspectors wroteBased on clinical record review, resident and staff interviews, and review of facility documentation and policy, the facility failed to ensure that medication was available for administration as ordered by the physician for one resident (#1). The deficient practice could result in the resident not receiving the needed medication.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on clinical record review, resident and staff interviews, review of facility documentation and policy, the facility failed to ensure that infection control guidelines related to oxygen use was followed for one resident (#2). The deficient practice could result in the spread of spread of disease to residents.
March 13, 2024Complaint inspection · 1 citation
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on review of facility documentation, staff interviews, personnel files, and facility policy, the facility failed to ensure that one resident (#5) received treatment and care in accordance with professional standards of practice. This deficient practice may result in resident not receiving trearment and care.
January 25, 2024Complaint inspection · 2 citations
- E
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Inspectors wroteBased on observations, staff interviews, and the facility's policy, the facility failed to ensure that all resident shower rooms were in good repair.
- D
Ensure services provided by the nursing facility meet professional standards of quality.
Inspectors wroteBased on observation, interviews and policy review, the facility failed to ensure that one resident's medications were administered as ordered by the provider based on standards of practice for one resident (#350). The deficient practice could result in residents not receiving prescribed doses of medications.
October 11, 2023Complaint inspection · 3 citations
- E
Ensure services provided by the nursing facility meet professional standards of quality.
Inspectors wroteBased on clinical record review, staff interviews, and the rules of the State Board of Nursing, the facility failed to administer medications as ordered by the physician for two residents (#4 and #5). The deficient practice could result in residents not receiving necessary medications.
- E
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Inspectors wroteBased on clinical record review, staff interviews, and the rules of the State Board of Nursing, the facility failed to ensure that an accurate accounting of controlled medications was maintained and reconciled for one resident (#5). The deficient practice could result in potential diversion of residents controlled medications.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, staff interviews, and policy review, the facility failed to ensure infection prevention and control standards were maintained during medication administration. The deficient practice could result in the transmission of infection.
January 13, 2023Standard inspection · 8 citations
- D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteBased on resident and staff interviews, clinical record review, and facility policy and procedure, the facility failed to ensure one resident (#233) was treated with dignity and respect. The deficient practice could result in the resident's rights not promoted and protected.
- 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 resident and staff interviews, review of the clinical record, facility documentation, and policy and procedure, the facility failed to ensure the resident representative for one resident (#234) was notified after he had a significant change in condition and was transferred to acute care facility. The deficient practice may result in resident representatives not notified and make any required decisions according to resident's treatment preferences and choices.
- 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, staff interviews, facility documentation, policy and procedures, the facility failed to ensure adequate and comfortable temperature levels was provided to meet the needs for one resident (#50). The deficient practice could result in the resident's room not having a homelike and comfortable environment. The facility census was 88 and the sample was 18.
- D
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Inspectors wroteBased on clinical record review, facility documentation, staff interviews, and policy, the facility failed to ensure one resident (#184) was free from abuse.
- D
Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.
Inspectors wroteBased on clinical record review, staff interviews, and facility policies and procedures, the facility failed to ensure information was provided to the receiving provider during transfer to hospital for one resident (#234). The deficient practice could result in the delay in treatment at the receiving facility because of lack of information regarding the reason for the transfer/discharge.
- 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 clinical record review, staff interviews, and facility policies and procedures, the facility failed to notify the Ombudsman regarding transfer/discharge to the hospital for one resident (#234). The deficient practice could result in Ombudsman not being informed of the reason for the transfer/discharge.
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on clinical record review, staff interviews, and policy and procedure, the facility failed to ensure consistent treatments were provided to two residents (#13, #233) with pressure ulcers.
- D
Provide safe, appropriate pain management for a resident who requires such services.
Inspectors wroteBased on resident and staff interviews, review of the clinical record, facility documentation, and policy and procedure, the facility failed to ensure pain management consistent with professional standards of practice was provided for one resident (#234). The deficient practice could result in unmanaged pain for residents.
Fire safety inspections
4 fire safety citations on file: 2 on January 7, 2026, 2 on January 13, 2023.
Every fire safety citation4 citations
- E
Conduct testing and exercise requirements.
E 39 · January 7, 2026 · Corrected (the home has a date of correction)
- E
Install corridor and hallway doors that block smoke.
K 363 · January 7, 2026 · Corrected (the home has a date of correction)
- E
Ensure proper usage of power strips and extension cords.
K 920 · January 13, 2023 · Corrected (the home has a date of correction)
- D
Install corridor and hallway doors that block smoke.
K 363 · January 13, 2023 · Corrected (the home has a date of correction)