Health inspections
Federal rules call for a standard inspection at least every 15 months, plus a visit whenever a complaint is filed. Each mark below is one citation, colored by how serious inspectors rated it. How to read a citation.
Under each citation, the quoted text is the inspector's own summary from the federal statement of deficiencies (CMS form 2567), word for word apart from a privacy scrub; CMS removes residents' and staff names before it publishes the text. The full notes are on Medicare.gov.
Potential for minimal harm Potential for more than minimal harm Actual harm Immediate jeopardy Found on a complaint visit
Where its citations fall on CMS's grid
CMS rates every citation by how much harm it caused (rows) and how many residents it touched (columns). The count in each box is this home's, across all 43 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
34D
9E
0F
Potential for minimal harm
0A
0B
0C
April 15, 2026Complaint inspection · 2 citations
- D
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Inspectors wroteBased on clinical record review, staff interviews and review of facility policy and procedures, the facility failed to ensure one out of three samples residents (#1) remained free from self-harm by failing to immediately assess, report, investigate, and implement protective interventions after staff observed injuries. The deficient practice could delay in identification of resident's suicide attempt and could place residents at risk for continued self harm, serous injury or death. Findings Include:Resident #1 was admitted on [DATE], with diagnoses that included acute and chronic respiratory failure with hypoxia, heart failure, paroxysmal atrial fibrillation, muscle weakness, reduced mobility, gout, depression, hyperlipidemia, and hypertension. [...]
- D
Respond appropriately to all alleged violations.
Inspectors wroteBased on clinical record review, staff interviews, facility investigation review, and review of facility policies and procedures, the facility failed to conduct a thorough investigation into neglect involving one of the three sampled residents (#1). The deficient practice could lead to failure in preventing further potential neglect. Findings Include: Resident #1 was admitted on [DATE], with diagnoses that included acute and chronic respiratory failure with hypoxia, heart failure, paroxysmal atrial fibrillation, muscle weakness, reduced mobility, gout, depression, hyperlipidemia, and hypertension. A care plan dated February 9, 2026, identified communication impairment related to hearing deficit and included interventions for communication support, safety monitoring and cognitive observation. [...]
January 23, 2026Standard inspection, Complaint 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 clinical record review, staff interviews, and review of facility documentation and policies, the facility failed to protect the rights of one resident (#54) to be free from physical abuse by another resident (#13). The deficient practice could result in further physical abuse of residents when appropriate actions are not taken. Findings Include:-Regarding Resident #13 (alleged perpetrator):Resident #13 was admitted to the facility on [DATE] with diagnoses that included dementia, major depressive disorder, and anxiety disorder. The care plan dated October 2, 2025, revealed that the resident has a behavior problem of making sexually inappropriate comments to female staff and persistent yelling out, verbal and physical aggression toward staff during care related to Dementia. [...]
- D
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 review of facility documentation and policies, the facility failed to ensure that one resident (Resident #99) was provided adequate supervision and interventions to prevent a preventable fall. The deficient practice places residents at risk for falls with serious injury. Findings Include:Resident # 99 was originally admitted to the facility on [DATE], with the most recent admission on [DATE]. The resident has diagnoses that consist of: type 2 diabetes mellitus without complications, other acute osteomyelitis, right ankle and foot, spinal stenosis, cervical region, major depressive disorder, recurrent, unspecified Bipolar disorder, current episode depressed, severe, without psychotic features. Acquired absence of the left leg below the knee. Morbid (severe) obesity due to excess calories. [...]
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observations, staff interviews, facility documentation, and review of facility's policy, the facility failed to ensure that enhanced barrier precautions(EBP) were followed during wound care for one resident(#6). The deficient practice could result in the spread of infection.
December 24, 2025Complaint inspection · 1 citation
- D
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Inspectors wroteBased on clinical record review, staff interviews, facility documentation, and policy review, the facility failed to ensure that 1 of 2 sampled residents (Resident #1) was free from abuse by staff members (Staff #163 and Staff #202). The deficient practice could result in other residents being abused.
November 12, 2025Complaint inspection · 1 citation
- D
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Inspectors wroteBased on clinical record review, staff interviews, facility documentation, and policy review, the facility failed to ensure 2 of 5 sampled residents (Resident #1 and #4) was free from abuse by another staff member & another resident (Staff #201 and Resident #5). The deficient practice could result in other residents being abused.
September 12, 2025Complaint inspection · 7 citations
- E
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Inspectors wroteBased on clinical record reviews, interviews, and review of facility policy and procedures, the facility failed to implement their policies and procedures on resident protection, abuse reporting and investigation of an allegation of verbal and physical abuse for one resident (#1) by another resident (#2). The deficient practice resulted in further abuse of resident #1
- E
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on clinical record reviews, interviews, and review of facility policy and procedures, the facility failed to ensure allegations of verbal and physical abuse of one resident (#1) by another resident (#2) was reported to the State Agency (SA) and Adult Protective Services (APS). The deficient practice could result in abuse not investigated and resident not protected from further abuse.
- E
Respond appropriately to all alleged violations.
Inspectors wroteBased on clinical record reviews, interviews and review of facility documentation, policies and procedures, the facility failed to ensure allegations of verbal and physical abuse of one resident (#1) by another resident (#2) were thoroughly investigated and appropriate corrective actions were taken. The deficient practice could result in resident not protected from further abuse.
- 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 clinical record review, staff and family interviews, facility documentation and policy review, the facility failed to ensure the care plan for one resident (#2) was revised with interventions to address the resident's verbal and physical aggression towards other residents. The deficient practice could result in resident not meeting their needs according to their comprehensive assessment. Resident #2 was admitted on [DATE] with diagnoses including unspecified dementia, major depressive disorder, anxiety disorder. schizoaffective disorder-bipolar type and other idiopathic peripheral autonomic neuropathy. Review of the care plan dated October 17, 2024, revealed resident was dependent on staff and family for all emotional, intellectual, physical, and social needs. [...]
- D
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 wroteBased on observations, clinical record reviews, interviews, and a review of facility policies and procedures, the facility failed to take steps to remove or reduce Resident #2's exposure to a known behavioral trigger. As a result, Resident #2 continued to be exposed to the trigger, leading to aggressive behaviors.
- D
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Inspectors wroteBased on observations, clinical record reviews, interviews, and a review of facility policies and procedures, the facility failed to develop and implement a person-centered care plan that addressed resident compatibility and environmental triggers for Resident #1. As a result, the facility failed to provide an environment that supported Resident #1's highest practicable physical, mental, and psychosocial well-being. Resident #1 continued to be exposed as a known behavioral trigger for Resident #2.
- D
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Inspectors wroteBased on interviews, facility documentation and postings, the facility failed to ensure the assistant administrator was duly appointed by the governing board. The deficient practice could contribute to actions, inactions or decisions regarding facility deficiencies, as related to attaining or maintaining the highest practicable physical, mental and psychosocial well-being of each resident.
March 19, 2025Complaint inspection · 1 citation
- D
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Inspectors wroteBased on a closed clinical record review, interviews, facility documentation, and review of facility policy, the facility failed to ensure that abnormal respiratory rates for resident #7 were monitored and that a change in condition was relayed to the physician. The deficient practice could result in resident injury if abnormal vitals are neglected.
January 22, 2025Complaint inspection · 3 citations
- E
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on staff interviews, clinical record review and facility policy, the facility failed to ensure that resident #16 was provided with assistance with activities of daily living (ADL) to maintain personal hygiene. Failure to meet this requirement could lead to issues with skin integrity and impairing resident dignity.
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on staff interviews, clinical record review and facility policy, the facility failed to ensure that an allegation of abuse was reported in a timely manner.
- D
Respond appropriately to all alleged violations.
Inspectors wroteBased on staff interviews, clinical record review and facility policy, the facility failed to ensure that a thorough investigation was conducted for resident #21.
October 24, 2024Standard inspection, Complaint inspection · 18 citations
- E
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Inspectors wroteBased on clinical record review, resident and staff interviews, and policy review, the facility failed to ensure that abuse policies were implemented for two resident to resident abuse incidents, one involving resident (#222) and(#169); and the other involving residents (#223) and (#49). This deficient practice could result in further instances of resident to resident abuse. -Regarding Residents #222 and #169 -Resident #222 was initially admitted to the facility on [DATE] with diagnoses that included unspecified dementia, bipolar disorder, major depressive disorder, paroxysmal atrial fibrillation, and chronic obstructive pulmonary disease. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed that resident #222 had a Brief Interview for Mental Status (BIMS) score of 13, which indicated intact cognitive impairment. [...]
- E
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on clinical record review, resident and staff interviews, and review of facility policy, the facility failed to ensure that an incident involving abuse between resident (#222) and resident (#169) was reported accurately and in a timely manner, and, that an investigation of an allegation of abuse is reported within five (5) working days for two residents (#223 & #49). The deficient practice could result in further incidents of resident to resident abuse and allegations of abuse not being reported to the SA timely and accurately. Regarding Resident #222 and Resident #169: -Resident #222 was initially admitted to the facility on [DATE] with diagnoses that included unspecified dementia, bipolar disorder, major depressive disorder, paroxysmal atrial fibrillation, and chronic obstructive pulmonary disease. [...]
- E
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Inspectors wroteBased on observations, staff interviews, and policy review, the facility failed to properly discard expired medication in the medication room. this deficient practice could result in expired medication to be administered to residents against professional standards. During a medication admission observation conducted on [DATE] at 7:10a.m. with Registered Nurse (RN/Staff #64), a controlled substance (Lyrica) had an unseal capsule taped behind the medication blister pack. The RN stated that it is not part of the facility best practice to have taped medication behind the medication blister pack during this observation. A follow up interview was conducted on [DATE] at 10:48 a.m with the Registered Nurse (RN/Staff #64) who stated that the risk of having medication taped back onto the blister pack can contaminate the medication. [...]
- 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 that food was stored under sanitary conditions that maintained freshness in the kitchen and nourishment refrigerators. The deficient practice could result in potential foodborne illness.
- D
Ensure that residents are fully informed and understand their health status, care and treatments.
Inspectors wroteBased on clinical record review, staff interviews, and the facilities policy, the facility failed to ensure one resident (resident #2) was informed of the risks and benefits of and had consented to the usage of a psychotropic medication. This deficient practice could result in further violations of resident rights.
- 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, resident and staff interviews, and policy review, the facility failed to ensure two residents (#222) was free from abuse by another resident (#169). This deficient practice could result in further incidents of resident to resident abuse. -Resident #222 was initially admitted to the facility on [DATE] with diagnoses that included unspecified dementia, bipolar disorder, major depressive disorder, paroxysmal atrial fibrillation, and chronic obstructive pulmonary disease. A care plan revised on October 22, 2021 revealed a focus related to a history of behavior problems with an intervention to place her in a secured memory care unit and administer medications as ordered. [...]
- D
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Inspectors wroteBased on clinical record review and staff interviews, the facility failed to ensure one Resident (#2) with a diagnosis of a serious mental illness was referred to the appropriate state-designated mental health or intellectual disability authority for review. The deficient practice could result in necessary specialized services not being provided in accordance with professional standards.
- 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 clinical record review, staff interviews, and policies and procedures, the facility failed to ensure that a comprehensive person-centered care plan with interventions was developed for one resident (#225). This deficient practice could result in further care plan's not being updated timely in accordance with professional standards. Resident #225 was initially admitted to the facility on [DATE]. She was later re-admitted to the facility on [DATE] with diagnoses including COPD, acute and chronic respiratory failure with hypoxia, and history of falling. Review of the Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 14, indicating intact cognition. The MDS also revealed that the resident was taking an anticoagulant medication. [...]
- D
Provide enough food/fluids to maintain a resident's health.
Inspectors wroteBased on clinical record review, staff and resident interviews, and observation of current facility practice, the facility failed to ensure nutritional status was assessed and managed in accordance with facility policy for one resident (#60). The deficient practice could result in a decline in nutritional status being missed and untreated for other residents. Resident #60 was admitted to the facility on [DATE] with diagnoses including major depressive disorder, muscle weakness (generalized), and essential hypertension. Review of the Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident had no cognitive impairments. The MDS also revealed the resident had no issues with swallowing or chewing food, and no weight loss or weight gain had been noted. [...]
- D
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Inspectors wroteBased on clinical record review, staff interviews and facility documentation, the facility failed to ensure one resident (# 32) received dialysis care consistent with professional standards. This deficient practice could result in residents not being provided with necessary treatment in accordance with professional standards.
- 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 interviews, personnel record review, facility assessment review, and facility policies, the facility failed to ensure 2 out of 6 sampled nursing staff (staff #6 and #82) possessed the competencies and skills needed to care for residents' needs. The deficient practice could result in delayed care and inadequate care for residents.
- D
Ensure that a resident does not develop patterns of decreased social interaction and/or increased withdrawn, angry, or depressive behaviors, unless unavoidable.
Inspectors wroteBased on interviews, closed record review and facility policy, the facility failed to ensure a sampled resident (#219) received behavioral health services when resident reported concerns and grievances to staff for one of one sampled resident. This deficient practice can result in lasting emotional disturbance for the resident.
- 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, facility documentation, staff interview, policy review, the facility failed to ensure to include procedures that medication were recorded accurate to professional standard of care. During an observation on October 14, 2024 at 7:25AM on Unit Golding medication cart the Narcotic Count Sheet sheet revealed that there were days where Out-Going Nurse signature was missing with an In-coming nurse signature missing. The record was not recorded properly in the the following days for: September 5, 2024 at 10:00 PM - 06:00 AM September 6, 2024 at 10:00 PM - 6:00 AM October 22, 2024 at 10:00 PM - 6:00 AM October 24, 2024 at 2:00 PM - 10:00 PM October 24.2024 at 10:00 PM - 6:00 AM An interview was conducted on October 14, 2024 at 7:25AM with Licensed Practical Nurse (LPN/Staff # 76). [...]
- D
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Inspectors wroteBased on clinical record review, interviews, and review of policies and procedures, the facility failed to reduce or discontinue anticoagulant therapy for Resident #325 in the presence of adverse consequences. This deficient practice can result in harm related to unnecessary medications.
- D
Ensure medication error rates are not 5 percent or greater.
Inspectors wroteBased on observations, clinical record review, staff interview, and policy review, the facility failed to ensure the medication error rate did not exceed 5%. The medication error rate was 6.9%. The deficient practice could result in additional medication errors.
- D
Ensure that residents are free from significant medication errors.
Inspectors wroteBased on observation, record review, staff interview, and review of policy and procedures the facility failed to ensure that one of one sampled residents (#32) was free from significant medication errors. The deficient practice could result in residents receiving unnecessary medication.
- D
Provide timely, quality laboratory services/tests to meet the needs of residents.
Inspectors wroteBased on clinical record review, facility documentation, staff interview, policy review, the facility failed to ensure that glucometer controls were consistently completed. During an observation on October 23, 2024 at 12:41 p.m. with Registered Nurse (RN/staff #82) on Unit Rich with medication Cart 2 the Quality Control Record sheet had revealed that glucometer controls were not consistently completed. An interview was conducted on October 23, 2024 at 1:00 p.m. with the Assistant Director of Nursing (ADON/Staff #94). The ADON stated that glucometer quality controls were not consistently completed. An Interview was conducted on October 23, 2024 at 1:02 p.m. with the a Register Nurse (RN/Staff#112) The RN stated that the glucometer controls were not consistently completed on the following days in September 2024: 14,15,19,21,22, 26,27,28 and 29. [...]
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on clinical record review, observations, interviews, and review of policy, the facility failed to appropriately implement their enhanced barrier precaution (EBP) program on two residents (#38 and #64). This deficient practice can result in harmful transmission of pathogens to other residents.
September 4, 2024Complaint inspection · 1 citation
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on observations, clinical record reviews, resident and staff interviews, and facility documentation, policy and procedures, the facility failed to ensure 3 residents (#5, 24, 40) were free from preventable falls. The deficient practice put the residents at increased risks for serious injury and harm.
June 20, 2024Complaint inspection · 1 citation
- D
Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy.
Inspectors wroteBased on clinical record review, staff interviews, and policy reviews, the facility failed to ensure one resident (#60) was allowed to return to the facility following hospitalization. This deficient practice could result in unsafe discharges for future residents.
September 28, 2023Standard inspection · 5 citations
- 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, the facility failed to ensure multiple food items were stored in accordance with professional standards and wet cleaning rags were not left on the top of counters or carts. The deficient practice could result in placing residents at risk for food-borne illnesses.
- D
Honor the resident's right to organize and participate in resident/family groups in the facility.
Inspectors wroteBased on resident and staff interviews, facility documentation, policy and procedures, the facility failed to act upon grievances voiced during resident council meetings. The facility census was 73. The deficient practice could result in residents' concerns, views, grievances or recommendations not being considered or acted upon.
- D
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 review of facility policy and procedure, the facility failed to ensure that one resident (#21) was appropriately transferred using a mechanical lift. The deficient practice could result in preventable accidents such as falls.
- 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 staff interviews, and facility policy, the facility failed to ensure that one agency staff (#81) had appropriate competency and skill sets necessary to transfer one resident (#21) using a sit to stand lift. The deficient practice could result in resident injury and staff not having the skills to provide the care the resident needs.
- D
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Inspectors wroteBased on clinical record review, staff interviews, and review of facility policy and procedure, the facility failed to ensure pain medication was administered according to physician ordered parameters for one resident (#67). The deficient practice could result in residents receiving unnecessary medication and adverse side effects.
Fire safety inspections
18 fire safety citations on file: 1 on January 23, 2026, 13 on October 24, 2024, 4 on September 28, 2023.
Every fire safety citation18 citations
- E
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · January 23, 2026 · Corrected (the home has a date of correction)
- E
Install corridor and hallway doors that block smoke.
K 363 · October 24, 2024 · Corrected (the home has a date of correction)
- E
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · October 24, 2024 · Corrected (the home has a date of correction)
- D
Develop and maintain an Emergency Preparedness Program (EP).
E 4 · October 24, 2024 · Corrected (the home has a date of correction)
- D
Conduct risk assessment and an All-Hazards approach.
E 6 · October 24, 2024 · Corrected (the home has a date of correction)
- D
Develop Emergency Preparedness policies and procedures.
E 13 · October 24, 2024 · Corrected (the home has a date of correction)
- D
Establish policies and procedures including evacuation.
E 20 · October 24, 2024 · Corrected (the home has a date of correction)
- D
Establish policies and procedures for sheltering.
E 22 · October 24, 2024 · Corrected (the home has a date of correction)
- D
Establish policies and procedures for volunteers.
E 24 · October 24, 2024 · Corrected (the home has a date of correction)
- D
Establish roles under a Waiver declared by secretary.
E 26 · October 24, 2024 · Corrected (the home has a date of correction)
- D
List the names and contact information of those in the facility.
E 30 · October 24, 2024 · Corrected (the home has a date of correction)
- D
Provide family notifications of emergency plan.
E 35 · October 24, 2024 · Corrected (the home has a date of correction)
- D
Conduct testing and exercise requirements.
E 39 · October 24, 2024 · Corrected (the home has a date of correction)
- D
Inspect, test, and maintain automatic sprinkler systems.
K 353 · October 24, 2024 · Corrected (the home has a date of correction)
- F
Ensure that testing and maintenance of electrical equipment is performed.
K 921 · September 28, 2023 · Corrected (the home has a date of correction)
- E
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · September 28, 2023 · Corrected (the home has a date of correction)
- E
Inspect, test, and maintain automatic sprinkler systems.
K 353 · September 28, 2023 · Corrected (the home has a date of correction)
- E
Install corridor and hallway doors that block smoke.
K 363 · September 28, 2023 · Corrected (the home has a date of correction)