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 48 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
1J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
28D
18E
1F
Potential for minimal harm
0A
0B
0C
July 1, 2026Complaint inspection · 2 citations
- J
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on observations, review of clinical records, facility policies, facility investigative documentation, video surveillance, and resident and staff interviews, it was determined that the facility failed to ensure the environment remained as free of accident hazards as possible by failing to provide adequate supervision and implement effective interventions to prevent an avoidable elopement for one of 12 residents reviewed (Resident CR1). This deficient practice placed Resident CR1 and other residents (Resident 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, & 12) identified by the facility as being at risk for elopement in Immediate Jeopardy due to the likelihood of serious injury, serious harm, impairment, or death.
- E
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Inspectors wroteBased on observations, review of clinical records, select facility policies, job descriptions, facility-provided documentation, and interviews with residents and staff, it was determined the facility administration failed to effectively use available resources and provide the leadership, oversight, and coordination necessary to ensure residents attained or maintained their highest practicable physical, mental, and psychosocial well-being. Specifically, the facility failed to ensure effective administrative oversight and implementation of systems to protect residents identified as being at risk for wandering or elopement. As a result, one of twelve residents identified by the facility as being at risk for wandering (Resident CR1) exited the building without staff knowledge or supervision and entered an unsafe environment. [...]
January 14, 2026Standard inspection, Complaint inspection · 9 citations
- F
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on observations and staff interview, it was determined the facility failed to maintain acceptable practices for the storage and service of food to prevent the potential for contamination and microbial growth in food, which increased the risk of food-borne illness in the food and nutrition services department.
- E
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on a review of clinical records, observations, and resident and staff interviews, it was determined the facility failed to ensure residents who were dependent on staff for assistance with activities of daily living were provided showers as planned to maintain acceptable standards of personal hygiene for three of 26 residents sampled (Residents 5, 119, and 11).
- E
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on a review of clinical records, select facility policies, observations, and staff, resident, and family member interviews, it was determined the facility failed to provide nursing services consistent with professional standards of practice. Specifically, the facility failed to ensure licensed nurses accurately administered prescribed medication for one of 26 residents sampled (Resident 5), failed to ensure consistent implementation of a physician-ordered therapeutic positioning device for one of 26 residents sampled (Resident 106), and failed to provide appropriate wound care, treatment, and monitoring for one of 26 residents sampled (Resident 9).
- 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 observation, review of clinical records, facility staffing records, and resident and staff interviews, it was determined the facility failed to provide sufficient nursing staff to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care, for eight out of 26 residents sampled (Residents 53, 76, 104, 87, 5, 119, 11, and 103).
- E
Provide and implement an infection prevention and control program.
Inspectors wroteBased on a review of clinical records, observations, and resident and staff interviews, it was determined the facility failed to consistently implement infection prevention and control practices and failed to ensure that reusable medical equipment intended for oral use was stored in a manner that prevented contamination for one of 26 sampled residents (Resident 16). The facility also failed to evaluate infection surveillance data to determine potential contributing factors and identify the need for corrective actions.
- 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, review of clinical records, and staff interview, it was determined that the facility failed to develop and implement a comprehensive, person-centered care plan to address the identified medical and treatment needs of one out of 26 residents sampled (Resident 5).
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on a review of clinical records, select facility policies, observations, and staff interviews, it was determined that the facility failed to consistently implement planned measures to prevent the development or worsening of pressure ulcers for one of 26 residents sampled (Resident 27).
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on a review of clinical records, facility-provided investigative documentation, and staff interviews, it was determined the facility did not demonstrate consistent reassessment and modification of care interventions for one of 26 residents sampled (Resident 72) following the identification of an injury risk during routine care.
- D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on a review of clinical records, facility-provided documentation, and employee interviews, it was determined that the facility failed to ensure the accuracy and completeness of resident medical records for two of 26 residents sampled (Residents 90 and 102).
November 25, 2025Complaint inspection · 2 citations
- E
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on review of clinical records, select facility policy, state professional nursing standards, and staff interview, it was determined the facility failed to ensure nursing services were provided in accordance with professional standards of quality by not ensuring licensed nurses accurately administered a prescribed medication within the physician-ordered parameters for one of four sampled residents (Resident 1).
- E
Ensure that residents are free from significant medication errors.
Inspectors wroteBased on review of clinical records, select facility policy, pharmacy records and staff and resident interviews, it was determined that the facility failed to ensure a resident's medication regime was free from significant medication errors for one of four residents reviewed (Resident 2).
July 24, 2025Complaint inspection · 3 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 a review of facility's abuse policy, clinical records, and select investigative reports and staff interview it was determined the facility failed to assure that one resident (Resident 2) was free from sexual abuse/harassment perpetrated by another resident (Resident 1) and out of 9 residents sampled.
- D
Respond appropriately to all alleged violations.
Inspectors wroteBased on a review of select facility policy, facility investigative reports, clinical records and staff interviews it was determined the facility failed to ensure a complete and accurate investigation into sexual abuse was completed for one resident out of 9 sampled (Resident 2).
- D
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Inspectors wroteBased on a review of the facility's plan of correction from the survey ending July 24, 2025, the outcome of the activities of the facility's quality assurance committee, a review of clinical records, and staff interviews, it was determined the facility failed to maintain compliance with nursing home regulations and ensure that plans to improve the delivery of care and services effectively addressed recurring deficiencies for one of six residents reviewed related to ensuring residents are free from sexual abuse (Resident 3) perpetrated by another resident (Resident 1).
June 17, 2025Complaint inspection · 2 citations
- E
Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made.
Inspectors wroteBased on clinical record review and resident and staff interviews, it was determined that the facility failed to ensure that written notice, including the reason for a room change, was provided to residents and/or their resident representatives prior to a facility-initiated room change for three of eight residents reviewed (Residents CR1, 3, and 4).
- E
Ensure that residents are free from significant medication errors.
Inspectors wroteBased on review of clinical records, medication error reports, and staff interview it was determined that the facility failed to provide nursing services consistent with professional standards of practice by failing to follow physician's orders and assure that two residents out of eight reviewed were free of significant medication errors (Resident CR1 and Resident 2).
April 16, 2025Standard inspection · 11 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 wroteBased on review of clinical records, facility-initiated transfer notices, and staff interview, it was determined the facility failed to provide copies of written notice of facility-initiated hospital transfer notces for residents to a representative of the Office of the State Ombudsman for three out of 12 residents reviewed (Residents 1, 23, and 90).
- 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 observation, clinical record review, resident and staff interviews, and a review of nurse staffing data, it was determined the facility failed to provide sufficient nursing staff to ensure timely and quality care for 5 of 28 residents sampled (Residents 11, 17, 25, 59, and 97), and failed to ensure adequate response times and care provision as reported by 3 of 6 residents interviewed during a group resident interview (Residents 7, 21, and 41).
- D
Keep residents' personal and medical records private and confidential.
Inspectors wroteBased on observations, clinical record review, and resident and staff interviews, it was determined the facility failed to maintain residents' rights to privacy and confidentiality by placing health care information in a place compromising the resident's privacy for one out of the 28 residents sampled (Resident 205) and failed to ensure that mail was delivered unopened to one of the 28 residents interviewed (Resident 3).
- D
Ensure each resident receives an accurate assessment.
Inspectors wroteBased on a review of clinical records, the Resident Assessment Instrument (RAI), and staff interview, it was determined the facility failed to ensure the Minimum Data Set Assessments (MDS - a federally mandated standardized assessment conducted at specific intervals to plan resident care) accurately reflected the status of two residents out of 28 sampled (Residents 101 and 102).
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on a review of select facility policy, clinical records, facility-provided documentation, and staff interviews, it was determined the facility failed to provide services in accordance with professional standards of practice by failing to follow physician orders for wound treatments for one resident out of 28 residents reviewed. (Resident 255)
- D
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Inspectors wroteBased on observation, clinical record review, facility policy review, and staff interviews, it was determined the facility failed to ensure the ready availability of necessary emergency dialysis supplies for one of two residents reviewed who received hemodialysis (Resident 48).
- D
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
Inspectors wroteBased on observation, clinical record review, select facility policy, and staff and resident interviews, it was determined the facility failed to ensure the correct installation of bed rails was implemented for one out of the 28 residents sampled (Resident 33).
- D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Inspectors wroteBased on a review of clinical records and staff interviews, it was determined the facility failed to implement procedures to ensure the timely acquisition and administration of a prescribed medication for one of 28 sampled residents (Resident 74).
- D
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Inspectors wroteBased on observation, a review of the facility's planned menus, and resident and staff interviews, it was determined that the facility failed to accommodate individual food preferences, to the extent possible, to increase resident satisfaction with meals for residents, which included two residents out of the 28 residents sampled (Residents 11 and 60), as expressed by one out of six residents during a resident group interview (Resident 21).
- D
Provide special eating equipment and utensils for residents who need them and appropriate assistance.
Inspectors wroteBased on observation, clinical record review, and staff interview, it was determined the facility failed to ensure the provision of adaptive dining equipment as prescribed to support safe eating for one of 28 sampled residents (Resident 59).
- D
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on observations and staff interview, it was determined the facility failed to maintain acceptable practices for the storage and service of food to prevent the potential for contamination and microbial growth in food, which increased the risk of food-borne illness in the food and nutrition services department.
January 2, 2025Complaint inspection · 1 citation
- D
Allow resident to participate in the development and implementation of his or her person-centered plan of care.
Inspectors wroteBased on a review of select facility policy, clinical record review, and staff interviews, it was determined the facility failed to afford a resident and their designated representative the right to participate in the development of the resident's plan of care for one resident out of seven residents sampled (Resident 3).
June 21, 2024Complaint inspection · 1 citation
- D
Have a plan that describes the process for conducting QAPI and QAA activities.
Inspectors wroteBased on review of select facility policy and reports and clinical records and resident and staff interviews, it was determined that the facility failed to demonstrate the implementation of ongoing QAPI programs, to include the use of systems for investigating and analyzing the root cause of adverse events as evidenced by one resident out of six sampled (Resident B1).
May 17, 2024Standard inspection, Complaint inspection · 16 citations
- E
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteBased on clinical record review and resident and staff interviews, it was determined that the facility failed to provide care in a manner and environment that promotes each resident's quality of life by failing to respond timely to residents' requests for assistance as evidenced by four residents out of 18 sampled (Residents 3, 26, 40 and 79).
- E
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Inspectors wroteBased on observations and staff interview, it was determined that the facility failed to maintain a clean and orderly environment in resident areas on two of two resident units (West and East Nursing Units).
- E
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observations, a review of clinical records, and staff interviews, it was determined that the facility failed to provide supplemental oxygen administration as ordered for one of 18 residents reviewed (Resident 64).
- E
Provide safe, appropriate pain management for a resident who requires such services.
Inspectors wroteBased on clinical record review and staff interview, it was determined that the facility failed to ensure that physician orders for individual pain management regimens were followed for five of 18 residents reviewed for pain management (Resident 54, 86, 64, 17 and 190).
- E
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Inspectors wroteBased on a review of clinical records and controlled drug medication sheets, and staff interview, it was determined that the facility failed to implement procedures to promote accurate accounting of controlled medications for three of four residents sampled (Resident 64, 54, and 52).
- E
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Inspectors wroteBased on observation, resident and staff interviews, and test tray results it was determined that the facility failed to serve meals that are palatable, attractive, and at a safe and appetizing temperature.
- E
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Inspectors wroteBased on observation, a review of the facility's planned menus and grievances submitted to the facility, and resident and staff interview it was determined that the facility failed to provide preferred food as planned and accommodate individual food preferences to the extent possible to increase satisfaction with meals for seven residents out of 18 sampled (Residents 40, 3, 28, 69, 45, and 19).
- D
Ensure each resident receives an accurate assessment.
Inspectors wroteBased on a review of clinical records and the Resident Assessment Instrument and staff interview, it was determined that the facility failed to ensure the Minimum Data Set Assessments (MDS - a federally mandated standardized assessment conducted at specific intervals to plan resident care) accurately reflected the status of one resident out of 18 sampled (Resident 17).
- 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 review of clinical records and staff interview, it was determined that the facility failed to revise the residents' comprehensive plan in response to a change in condition for two residents out of 18 reviewed (Resident 77 and 17).
- 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 a review of clinical records, and staff interview, it was determined that the facility failed to accurately assess bowel and bladder function and implement individualized approaches to restore normal bowel and bladder function to the extent possible for one out of 18 sampled residents (Resident 86).
- D
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Inspectors wroteBased on observation, review of clinical records, and staff interview, it was determined that the facility failed to provide person-centered care for one resident receiving hemodialysis services out of 18 sampled (Resident 80).
- D
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 wroteBased on a review of select facility reports and clinical records and staff interview it was determined that the facility failed to assure that nursing staff possessed the necessary knowledge, competencies, and skill sets to provide care to meet a resident's individualized needs as identified in the resident's current plan of care for one resident out of 18 sampled (Resident 22).
- D
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Inspectors wroteBased on a review of clinical records and staff interview, it was determined that the facility failed to develop and implement an effective individualized person-centered plan to address a resident's dementia-related behavioral symptoms for one out of 18 residents reviewed (Resident 20).
- 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 clinical record review and staff interview it was determined that the facility failed to ensure accurate medication labeling for one of 18 residents sampled (Resident 54).
- D
Provide timely, quality laboratory services/tests to meet the needs of residents.
Inspectors wroteBased on clinical record review and staff interview it was determined that the facility failed to timely obtain prescribed laboratory services for one resident out of 18 sampled (Resident 39).
- D
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on observation and staff interview, it was determined that the facility failed to maintain acceptable practices for the storage and service of food to prevent the potential for contamination and microbial growth in food, which increased the risk of food-borne illness in the food and nutrition services department.
January 24, 2024Complaint inspection · 1 citation
- D
Give the resident's representative the ability to exercise the resident's rights.
Inspectors wroteBased on clinical record review and staff interview it was determined that the facility failed to afford a resident's designated representative the right to make health care decisions on the resident's behalf for one resident out of six sampled (Resident CR1).
Fire safety inspections
19 fire safety citations on file: 6 on January 14, 2026, 5 on April 16, 2025, 1 on May 22, 2024, 7 on May 17, 2024.
Every fire safety citation19 citations
- E
Install a two-hour-resistant firewall separation.
K 133 · January 14, 2026 · Corrected (the home has a date of correction)
- E
Inspect, test, and maintain automatic sprinkler systems.
K 353 · January 14, 2026 · Corrected (the home has a date of correction)
- E
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
K 362 · January 14, 2026 · Corrected (the home has a date of correction)
- E
Install corridor and hallway doors that block smoke.
K 363 · January 14, 2026 · Corrected (the home has a date of correction)
- E
Install smoke barrier doors that can resist smoke for at least 20 minutes.
K 374 · January 14, 2026 · Corrected (the home has a date of correction)
- E
Have proper medical gas storage and administration areas.
K 923 · January 14, 2026 · Corrected (the home has a date of correction)
- E
Inspect, test, and maintain automatic sprinkler systems.
K 353 · April 16, 2025 · Corrected (the home has a date of correction)
- E
Install corridor and hallway doors that block smoke.
K 363 · April 16, 2025 · Corrected (the home has a date of correction)
- E
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · April 16, 2025 · Corrected (the home has a date of correction)
- E
Install smoke barrier doors that can resist smoke for at least 20 minutes.
K 374 · April 16, 2025 · Corrected (the home has a date of correction)
- E
Have proper medical gas storage and administration areas.
K 923 · April 16, 2025 · Corrected (the home has a date of correction)
- E
Keep aisles, corridors, and exits free of obstruction in case of emergency.
K 211 · May 22, 2024 · Corrected (the home has a date of correction)
- E
Keep aisles, corridors, and exits free of obstruction in case of emergency.
K 211 · May 17, 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 17, 2024 · Corrected (the home has a date of correction)
- E
Have properly installed hallway dispensers for alcohol-based hand rub.
K 325 · May 17, 2024 · Corrected (the home has a date of correction)
- E
Inspect, test, and maintain automatic sprinkler systems.
K 353 · May 17, 2024 · Corrected (the home has a date of correction)
- E
Have simulated fire drills held at unexpected times.
K 712 · May 17, 2024 · Corrected (the home has a date of correction)
- E
Have proper medical gas storage and administration areas.
K 923 · May 17, 2024 · Corrected (the home has a date of correction)
- D
Install corridor and hallway doors that block smoke.
K 363 · May 17, 2024 · Corrected (the home has a date of correction)