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 38 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
3G
0H
0I
Potential for more than minimal harm
33D
1E
1F
Potential for minimal harm
0A
0B
0C
December 23, 2025Complaint inspection · 2 citations
- G
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on record review and interview, the facility failed to follow the plan of care for a resident with a history of falls. This deficient practice resulted in a resident falling and sustaining multiple injuries, including bilateral (affecting both sides) small acute subarachnoid hemorrhage along the temporal lobes, a small acute intraventricular hemorrhage in occipital horns, a 0.7 centimeter subdural hematoma and an acute right occipital bone fracture extending into the forearm magnum. (Resident B)
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on interview and record review, the facility failed to provide showers timely for a dependent resident for 1 of 4 residents who were reviewed for showers. (Resident D)During an interview on 12/16/2025 at 2:40 P.M., Resident D could not recall the last time he had had a shower. Resident D's record review was completed on 12/18/2025 at 2:45 P.M. Diagnoses included, but were not limited to: displaced fracture of cervical vertebra, Lewy Bodies dementia, Parkinson's disease and right foot drop. An admission Minimum Data Set (MDS) assessment, dated 9/19/2025, indicated Resident D had intact cognition and was dependent on staff for showering. Resident D's record lacked the documentation that he had been given a shower on 11/17, 11/20, 11/27, 12/1 and 12/15/2025 as scheduled. [...]
August 11, 2025Complaint inspection · 2 citations
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on record review and interview, the facility failed to provide wound care as directed by the physician for 1 of 3 residents reviewed for wounds.(Resident D).
- D
Ensure that residents are free from significant medication errors.
Inspectors wroteBased on record review and interview, the facility failed to ensure 1 of 3 residents reviewed for medication administration was free from significant medication errors. (Resident B) This deficient practice resulted in the resident experiencing nausea and vomiting and requiring the administration of an additional medication to treat the adverse side effect of the medication errors. Finding Includes:Resident B's clinical record was reviewed on 8/7/25 at 9:11 A.M., diagnoses included but were not limited to a history of stroke with hemiplegia, heart disease, constipation, gastroenteritis, colitis. Resident B was admitted to the facility for respite care from home and under hospice care on 6/3/25. Hospice Physician's orders dated 6/3/25, on admission, included but were not limited to; [...]
May 23, 2025Standard inspection · 15 citations
- E
The resident has the right to receive notices in a format and a language he or she understands.
Inspectors wroteBased on interview, observation and record review, the facility failed to ensure residents were informed of where the Ombudsman and other state agencies phone numbers were located. This had the potential to affect 145 of 145 residents who resided in the facility.
- D
Ensure that residents are fully informed and understand their health status, care and treatments.
Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure 1 of 3 residents reviewed for resident rights were informed of treatment and medication changes. (Resident 36)
- D
Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
Inspectors wroteBased on observation, record review and interview, the facility failed to provide a dignity bag to cover a urinary drainage bag for 1 of 2 residents reviewed for urinary catheters. (Resident 36)
- D
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
Inspectors wroteBased on record review and interview, the facility failed to limit an as needed psychotropic medication to a 14-day duration without required documentation for continued use of the psychotropic med for 1 of 5 residents reviewed for unnecessary medications. (Resident 36)
- D
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Inspectors wroteBased on record review and interview, the facility failed to ensure required transfer and resident clinical information was completed for 2 of 4 residents reviewed for transfers. (Residents 140 &148)
- 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 review and interview, the facility failed to develop person centered care plans for a new pressure area and refusal to have facial hair removed for 2 of 31 residents whose care plans were reviewed. (Resident 94 and 33)
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on observation, record review and interview the facility failed to ensure medications were administered based on manufacturers guidelines for 1 of 5 residents reviewed for medication administration (Resident 37).
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on interview, observation and record review, the facility failed to ensure a resident who was at risk for pressure ulcers did not develop a stage II pressure ulcer and failed to implement a treatment for 1 of 2 residents reviewed for pressure ulcers. (Resident 94)
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on observation, record review and interview, the facility failed to ensure a safe smoking assessment was completed, smoking materials were locked up and safe disposal of cigarette butts was designated for 1 of 1 resident reviewed for accidents and hazards. (Resident 73)
- D
Provide enough food/fluids to maintain a resident's health.
Inspectors wroteBased on observation, record review and interview, the facility failed to provide identified interventions to promote consumption of meals for 1 of 3 residents reviewed for nutrition. (Resident 31)
- 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 review and interview, the facility failed to follow and administer physician ordered hydration orders for 1 of 1 resident reviewed for tube feeding. (Resident 52)
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observation, record review and interview, the facility failed to store respiratory equipment in a sanitary manner for 1 of 2 residents reviewed for respiratory care. (Resident 66)
- D
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Inspectors wroteBased on record review and interview, the facility failed to provide daily fistula checks for 1 of 1 resident reviewed for dialysis. (Resident 75)
- 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 wrote8. During an observation in Resident 94's bathroom, on 5/21/2025 at 2:50 P.M., there was a small bottle sitting on the sink counter. The container had a label indicating it was nystatin powder for the residents' abdominal folds. The record for Resident 94 was completed on 5/21/2025 at 3:16 P.M. Diagnoses included but were not limited to hypertension, hemiplegia, anxiety, depression, and renal insufficiency. Current Physician Orders included 100,000 unit/gram topical powder-apply topical twice a day (BID) as needed for rash and redness in abdominal folds. During an observation of Resident 94's bathroom, on 5/22/2525 at 3:33 P.M., the Nystatin bottle remained on the counter in the bathroom. During an interview, on 5/22/2025 at 3:35 P.M., the Households Unit manager indicated the nystatin should not have been in the residents' room. [...]
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, record review and interview, the facility failed to provide enhanced barrier precautions for 1 of 2 residents reviewed for urinary catheters. (Resident 36)
September 20, 2024Complaint inspection · 2 citations
- F
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Inspectors wroteBased on interviews and record review, the facility failed to ensure hot food temperatures were assessed and logged consistently in the main kitchen to ensure food was served at palatable temperatures. This deficient practice had the potential to affect 155 of 155 residents in nursing care who were served from the main kitchen.
- 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 interview and record review, the facility failed to ensure a resident's responsible party was notified in a timely manner after a fall for 1 of 3 residents reviewed for falls, (Resident C).
June 13, 2024Complaint inspection · 2 citations
- G
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on observation, record review and interviews, the facility failed to ensure 1 of 3 residents reviewed for accidents was provided safe transfer assistance utilizing a mechanical stand lift This deficient practice resulted in a significant injury which required a transfer to an acute care center for treatment, hospice admission and death, (Resident B).
- D
Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
Inspectors wroteBased on interview and record review, the facility failed to ensure a resident rights were respected regarding photos taken by a facility staff member posted on social media without the resident's knowledge or permission for 1 of 3 resident's reviewed for resident's rights, (Resident F) Finding Includes: A record review for Resident F was completed on 6/14/24 at 1:00 P.M. Diagnoses included but were not limited to: dementia, breast cancer, heart failure, spinal stenosis, depression, and cerebrovascular disease. An Annual Minimum Data Set (MDS) assessment, dated 5/3/24, indicated Resident F was cognitively intact, required moderate assistance for most Activities of Daily Living (ADLs), and utilized a wheelchair for locomotion. [...]
May 31, 2024Standard inspection, Complaint inspection · 9 citations
- 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, record review, and interview, the facility failed to develop a person-centered care plan for the use and refusal of a splint for 1 of 30 residents whose care plans were reviewed. (Resident 90)
- 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 interview and record review, the facility failed to update a care plan regarding the use of a Continuous Positive Airway Pressure (CPAP) machine for 1 of 33 residents reviewed for care plans. (Resident 254)
- 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 ensure physician orders were in place for a resident using a Continuous Positive Airway Pressure (CPAP) for 1 of 1 resident reviewed for quality of care. (Resident 254)
- 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 observation, interview and record review, the facility failed to provide proper G-tube (artificial opening placed in the stomach to provide nutritional support and/or gastric decompression) care per professional standards and facility policy related to G-tube feedings for 1 of 1 resident who was reviewed for G-Tube feeding. (Resident 67)
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure continuous positive airway pressure (CPAP) equipment was properly stored when not in use, cleaned and the distilled water was dated when opened for 1 of 1 resident reviewed for respiratory care. (Resident 254) Finding Includes: During an observation on 5/23/2024 at 2:40 P.M., Resident 254's CPAP mask and tubing was hanging over the headboard and the distilled water container was on the bathroom floor under the sink, opened without an open date. During an observation and interview on 5/28/2024 at 1:03 P.M., Resident 254 indicated the mask and tubing had never been placed in a plastic bag, and the tubing had not been cleaned. The water was kept on the floor in the bathroom under the sink. She did not always get the water put in the machine, there were times she ran it without the water. [...]
- D
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Inspectors wroteBased on observation, interview and record review, the facility failed to provide ongoing assessment of the resident and monitoring for complications by completing Pre Dialysis Evaluations and Post Dialysis Evaluations assessments for 2 of 2 residents reviewed for dialysis. (Residents 354 & 88 ).
- D
Ensure that residents are free from significant medication errors.
Inspectors wroteBased on interview and record review, the facility failed to prevent a significant medication error related to a resident being given an incorrect insulin pen for 1 of 2 residents who were reviewed for insulin use. (Resident 101)
- 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 observation, interview, and record review the facility failed to properly label medications with an open date for 3 of 5 medication carts observed. ([NAME] Vesta cart 2, [NAME] cart 1, [NAME] cart 2) In addition, the facility failed to ensure treatments, and inhaler were separated from oral medication for 2 out of 5 medication carts and 1 out of 3 medication room refrigerators reviewed.
- D
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Inspectors wroteBased on record review and interview, the facility failed to obtain a declination form for a resident who refused the pneumococcal vaccine for 1 of 5 residents reviewed for vaccinations. (Resident 101)
September 19, 2023Complaint inspection · 1 citation
- G
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on observation, interview and record review, the facility failed to prevent a pressure ulcer from developing on the heel and buttock, for 1 of 3 residents reviewed for pressure ulcers. (Resident F)
May 23, 2023Standard inspection · 5 citations
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on observation, record review, and interview, the facility failed to report allegations of alleged verbal abuse for 1 of 1 resident reviewed for abuse. (Resident 90)
- D
Respond appropriately to all alleged violations.
Inspectors wroteBased on observation, record review, and interview, the facility failed to throughly investigate an allegation of alleged verbal abuse for 1 of 1 resident reviewed for abuse. (Resident 90)
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on observation, interview, and record review, the facility failed to complete interventions ordered for pressure ulcer prevention for 1 of 4 resident's reviewed for pressure ulcers. (Resident 159)
- 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 wroteBased on record review, observation and interview, the facility failed to ensure a resident on restorative nursing received her hand splint and carrot device per plan of care for 1 of 3 residents reviewed for position and mobility. (Resident 30)
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observation, record review and interview, the facility failed to ensure proper storage of nebulizer masks, obtain orders for nebulizer and oxygen tubing changes, and failed to have an identifier on the door indicating oxygen was in use for 2 out of 3 residents reviewed for respiratory care. (Resident 91 & 159)
Fire safety inspections
30 fire safety citations on file: 6 on May 23, 2025, 16 on May 31, 2024, 8 on May 23, 2023.
Every fire safety citation30 citations
- F
Conduct testing and exercise requirements.
E 39 · May 23, 2025 · Corrected (the home has a date of correction)
- F
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
K 761 · May 23, 2025 · Corrected (the home has a date of correction)
- F
Ensure that testing and maintenance of electrical equipment is performed.
K 921 · May 23, 2025 · Corrected (the home has a date of correction)
- E
Meet other general requirements that are deficient.
K 300 · May 23, 2025 · Corrected (the home has a date of correction)
- E
Provide properly protected cooking facilities.
K 324 · May 23, 2025 · Corrected (the home has a date of correction)
- E
Ensure proper usage of power strips and extension cords.
K 920 · May 23, 2025 · Corrected (the home has a date of correction)
- F
Meet other general requirements that are deficient.
K 300 · May 31, 2024 · Corrected (the home has a date of correction)
- F
Provide a written emergency evacuation plan.
K 711 · May 31, 2024 · Corrected (the home has a date of correction)
- E
Have horizontal exits used in accordance with safety requirements.
K 226 · May 31, 2024 · Corrected (the home has a date of correction)
- E
Conform to length requirements for dead end corridors.
K 251 · May 31, 2024 · Corrected (the home has a date of correction)
- E
Have exits that are accessible at all times.
K 271 · May 31, 2024 · Corrected (the home has a date of correction)
- E
Install proper backup exit lighting.
K 281 · May 31, 2024 · Corrected (the home has a date of correction)
- E
Install emergency lighting that can last at least 1 1/2 hours.
K 291 · May 31, 2024 · Corrected (the home has a date of correction)
- E
Have properly located and lighted "Exit" signs.
K 293 · May 31, 2024 · 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 · May 31, 2024 · Corrected (the home has a date of correction)
- E
Provide properly protected cooking facilities.
K 324 · May 31, 2024 · Corrected (the home has a date of correction)
- E
Inspect, test, and maintain automatic sprinkler systems.
K 353 · May 31, 2024 · Corrected (the home has a date of correction)
- E
Properly select, install, inspect, or maintain portable fire extinguishes.
K 355 · May 31, 2024 · Corrected (the home has a date of correction)
- E
Have properly installed electrical wiring and gas equipment.
K 511 · May 31, 2024 · Corrected (the home has a date of correction)
- E
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
K 521 · May 31, 2024 · Waiver
- E
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
K 741 · May 31, 2024 · Corrected (the home has a date of correction)
- D
Ensure proper usage of power strips and extension cords.
K 920 · May 31, 2024 · Corrected (the home has a date of correction)
- E
Meet other general requirements.
K 100 · May 23, 2023 · Corrected (the home has a date of correction)
- E
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 · May 23, 2023 · Corrected (the home has a date of correction)
- E
Provide properly protected cooking facilities.
K 324 · May 23, 2023 · Corrected (the home has a date of correction)
- E
Inspect, test, and maintain automatic sprinkler systems.
K 353 · May 23, 2023 · Corrected (the home has a date of correction)
- E
Ensure that waiting areas, nurse’s stations, gift shops, and cooking facilities, open to the corridor are properly protected.
K 361 · May 23, 2023 · Corrected (the home has a date of correction)
- E
Have properly installed electrical wiring and gas equipment.
K 511 · May 23, 2023 · Corrected (the home has a date of correction)
- E
Have proper medical gas storage and administration areas.
K 923 · May 23, 2023 · Corrected (the home has a date of correction)
- D
Ensure proper usage of power strips and extension cords.
K 920 · May 23, 2023 · Corrected (the home has a date of correction)