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
1G
0H
0I
Potential for more than minimal harm
26D
6E
10F
Potential for minimal harm
0A
0B
0C
July 1, 2026Complaint inspection · 1 citation
- E
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on interview and record review, the facility failed to notify the physician and/or pharmacy when a medication was unavailable and the resident did not receive it for 4 of 4 residents reviewed (R1, R2, R3, and R4) for medication administration.
January 14, 2026Complaint 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 interview and record review, the facility failed to prevent an elopement for one of three resident's (Resident #100) reviewed for accidents and hazards. The deficient practice was corrected on 01/06/26, prior to the start of this survey and, therefore, this deficiency is considered Past Noncompliance. Resident #100 (R100)Review of an admission Record revealed R100 was an [AGE] year-old female, admitted to the facility on [DATE], with pertinent diagnoses of a recent hip fracture and Alzheimer's disease. During an interview on 01/14/26 at 8:20 AM, R100 laid in bed resting with her eyes open. R100 stated that she remembered being outside the building last week but I couldn't tell you why I did that, I just did. R100 stated that she was not harmed and felt safe and that she wouldn't be doing that again. Review of a Facility Reported Incident dated 01/05/26 reflected the following: [...]
December 4, 2025Standard inspection, Complaint inspection · 5 citations
- 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, interview, and record review, the facility failed to secure prescription medications according to professional standards and facility policies for 5 of 5 resident's (Resident #25, Resident #10, Resident #39, Resident #56, and Resident #45) and for one of four medication carts reviewed.
- D
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Inspectors wroteThis citation pertains to intake 2680029. Based on observation, interview and record review, the facility failed to create and implement person centered care plans for two (R27 and R63) of 13 residents reviewed for care plans.
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteThis citation pertains to intake 2680029. Based on interview and record review, the facility failed to provide showers for one (R27) of 3 residents reviewed for activities of daily living (ADL).
- D
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Inspectors wroteBased on observation, interview and record review, the facility failed to implement a person-centered toileting program for one (R63) of 1 resident reviewed for toileting.
- D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Inspectors wroteBased on interview and record review the facility failed to maintain accurate documentation regarding the disposition of controlled substances for 1 of 2 resident's (Resident #62) reviewed.
October 8, 2024Standard inspection · 10 citations
- G
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on observation, interview, and record review, the facility failed to provide pressure ulcer care and treatment consistent with professional standards of practice for one resident (Resident #37) of 3 residents reviewed for care and treatment of pressure ulcers, resulting in harm and the deterioration of Resident #37's pressure ulcer.
- F
Ensure services provided by the nursing facility meet professional standards of quality.
Inspectors wroteBased on interview and record review, the facility failed to provide medications upon admission in a timely manner for 1 resident (Resident #207) of 13 residents reviewed for professional standards of practice.
- F
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Ensure working spray bottles are labeled as to content, 2. Ensure water filters were being replaced as required on equipment, 3. Ensure ice machines food contact surface/equipment are clean and maintained, and 4. Ensure the 2nd & 3rd floor kitchenette/pantries flooring is clean and free of debris and the cooler unit's door, door seals, openings and bottoms, resulting in an increased potential of contaminated foods and an increased risk of food borne illness possibly affecting 52 residents that consume food from the kitchen and kitchenettes/pantries.
- E
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteThis citation contains 2 Deficient Practice Statements (DPS), DPS A and DPS B. DPS A Based on observation, interview, and record review, the facility failed to implement their smoking policy and procedure for 1 resident (Resident #25) of 1 resident reviewed for smoking.
- E
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure respiratory equipment was maintained according to professional standards of practice for 4 residents (Resident #26, Resident #27, Resident #43 and Resident #48) out of 4 residents reviewed for respiratory care.
- E
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure licensed personnel followed medication administration policy and procedures when a nurse pre-poured medications for eight residents (R9, R27, R30, R31, R35, R39, R50) and documented the administration of medications that had not been given to residents.
- D
Allow residents to self-administer drugs if determined clinically appropriate.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two Residents (R20 and R26) of five residents reviewed for medication were properly assessed and monitored for self-administration of medication and failed to securely store and document medication self-administration after use.
- 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 assess, monitor and notify the physician of clinical changes in condition for 1 resident (Resident #48) out of 13 residents reviewed for quality care from a total sample of 13 residents.
- D
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Inspectors wroteBased on interview and record review, the facility failed to ensure antipsychotic medications were prescribed to treat a condition as diagnosed and documented with rationale in the clinical record for 1 resident (Resident #24) out of 5 residents reviewed for unnecessary medications.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview, and record review, the failed to ensure proper use of Personal Protective Equipment (PPE) for residents in Enhanced Barrier Precautions for 1 resident (Resident #37) of 13 residents reviewed for infection control.
May 21, 2024Complaint inspection · 9 citations
- F
The resident has the right to receive notices in a format and a language he or she understands.
Inspectors wroteThis citation pertains to M100142556, M100143537, and M100143672. Based on interview and record review, the facility failed to provide residents a list of pertinent contact information to the State Agencies (SA), advocacy groups and the like, a description of the requirements and procedures for establishing eligibility for Medicaid, and Medicare/Medicaid coverage, and how to file a complaint with the SA, how to file a grievance, and resources for information regarding returning to the community for 4 (Resident #1, Resident #5, Resident #11, Resident #12) of 4 residents reviewed. This deficient practice affects all 54 residents who reside at the facility. Resident #1 (R1) Review of a Face Sheet revealed R1 admitted to the facility on [DATE]. [...]
- F
Not require residents to give up Medicare or Medicaid benefits, or pay privately as a condition of admission; and must tell residents what care they do not provide.
Inspectors wroteThis citation pertains to intakes M100143672 AND M100142556. Based on interview and record review, the facility failed to have an admission policy and procedure and provide admission packets for 3 (Resident #5, Resident #11, Resident #12) of 3 residents reviewed, resulting in residents being uninformed of their rights and resources, and the absence of written information available to the resident/responsible party regarding costs, policies, procedures, and services. This deficient practice affects all residents admitted to the facility.
- F
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 wroteThis citation pertains to intakes M100142556, 143537, and 143672. Based on interview and record review, the facility failed to prepare for discharges, provide a safe home discharge, and allow a readmission post hospitalization for 2 (Resident #4 and Resident #5) of 3 residents reviewed for discharges, resulting in both residents needing to find placement at another long-term care facility.
- F
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Inspectors wroteThis citation pertains to intakes M100142556, M100143537, and M100143672 Based on interview and record review, the facility failed to operationalize policies and procedures and notify the Office of the State Long-Term Care Ombudsman of monthly discharges that includes the reason for transfer or discharge, date and the receiving entity. This deficient practice affects all residents discharged from the facility since July 2023.
- F
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Inspectors wroteThis citation pertains to intakes M100142556 and M100143672. Based on interview and record review, the facility failed to provide Bed Hold policies to residents upon admission and transfers to acute care or therapeutic leave for 12 (Resident #1, Resident #2, Resident #3, Resident #4, Resident #5, Resident #6, Resident #7, Resident #8, Resident #9, Resident #10, Resident #11, and Resident #12). This deficient practice affects all residents admitted to the facility and residents who get sent out for acute care or therapeutic leave. Findings Include: Review of a Notice of Bed Hold Policy revealed ***This document must be signed by the patient upon discharge to the hospital or therapeutic leave*** If unable to sign, notification from the patient and/or family/DPOA (Designated Power of Attorney) must be documented. Complete top section upon admission with resident or responsible party. [...]
- D
Give the resident's representative the ability to exercise the resident's rights.
Inspectors wroteThis citation pertains to intake M100143672. Based on observation, interview and record review, the facility failed to have an effective telephone communication system to the facility for 1 (Resident #5) of 3 residents reviewed for communication from outside the facility. This deficient practice has the potential to affect all residents who reside at the facility.
- D
Provide information about how to apply for and use Medicare and Medicaid benefits.
Inspectors wroteThis citation pertains to intake M100143672. Based on interview and record review, the facility failed to assist and provide written information on how to apply for and use Medicare and Medicaid benefits for 1 (Resident #5) of 1 resident reviewed, resulting in the resident/representative not having Medicaid coverage in a timely manner and had an out-of-pocket expense.
- D
Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy.
Inspectors wroteThis citation pertains to intakes M100142672 AND M100142556. Based on interview and record review, the facility failed to readmit 1 (Resident #5) of 3 residents reviewed for readmissions after hospitalization, resulting in a resident who was pending Medicaid needing to find placement at another facility.
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteThis citation pertains to intake M100144078. Based on observation, interview and record review, the facility failed to provide care and services for pressure ulcers for 2 (Resident #8 and Resident #6), that required repositioning, assessment and monitoring, daily dressing care and/or wound vac (vacuum) care (a treatment that uses a special dressing and a pump to apply suction to a wound and promote healing).
January 17, 2024Complaint inspection · 1 citation
- D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteBased on interview and record review, the facility failed to ensure respectful and dignified treatment of two facility residents (Resident #1 (R1) and R2) by a Certified Nurse Aide (CNA F) providing cares in an unprofessional manner.
October 6, 2023Standard inspection · 13 citations
- F
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 secure 1 of 3 medication carts (100 Hall Medication Cart) and properly label a medication in 1 of 3 medication carts (100 Hall Medication Cart), resulting in the potential for misappropriation of medications and the potential for complications from administration of expired or contaminated medications.
- F
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Clean food and non-food contact surfaces to sight and touch; 2. Ensure proper concentration of quaternary ammonium sanitizer; and 3. Properly store chemicals to minimize the risk of contamination. These conditions resulted in an increased risk of contaminated foods and an increased risk of food borne illness that affected 55 residents who consume food from the kitchen. Findings Include: 1. During the initial tour of the facility, at 9:15 AM on 10/3/23, it was observed that an accumulation of debris was found on the underside corners of the juice machine in the kitchen. When asked how often this piece of equipment gets cleaned, Kitchen Supervisor (KS) N stated every Friday. [...]
- F
Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
Inspectors wroteBased on interview and record review, the facility failed to timely submit Payroll-Based Journal (PBJ) information for the Fiscal Year Quarter 3, 2023 (April 1 - June 30) resulting in no staffing data that is auditable or verifiable and the potential for inaccurate staffing information to be known to the state and federal entities.
- E
Provide and implement an infection prevention and control program.
Inspectors wroteThis citation has 2 parts. Part A Based on observation, interview, and record review, the facility failed to protect clean and sanitary items from contamination and have an active and ongoing plan for reducing the risk of legionella and other opportunistic pathogens of premise plumbing (OPPP). This deficient practice has the increased potential to result in contamination of clean and sanitary supplies and an increased risk of water borne pathogens to exist and spread in the facility's plumbing system possibly affecting any or all of the 55 residents in the facility. During a walkthrough of the facility, with Maintenance Director (MD) O, at 2:45 PM on 10/3/23, observation of the laundry room found an accumulation of trash and debris underneath the false bottom of the laundry bin. Further observation found a spray bottle containing a blue solution that was not labeled with a common name. [...]
- D
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Inspectors wroteBased on interview and record review, the facility failed to ensure a valid Advance Directive was in place for one Resident (R192), resulting in the Durable Power of Attorney (DPOA), that had not been activated, signing paperwork without the authority to do so and the potential for the Advance Directives to not reflect the medical wishes of all facility residents.
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on interview and record review, the facility failed to follow facility policy on the prevention of abuse resulting in an allegation of abuse to be not reported and investigated and the potential for allegations of abuse to not be identified for all facility residents.
- 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 interview and record review, the facility failed to develop and implement a baseline and comprehensive care plan for one post-surgical resident (R32) at risk for falls, resulting in a Resident with a history of falls with injury to remain at unmitigated risk for falls.
- 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 revise the At risk Comprehensive Care Plan for changing skin integrity for one Resident (R28), resulting in no care plan for actual wounds under treatment and the potential for all facility residents to not have their plan of care reflect their current physical or mental status.
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on observation, interview and record review, the facility failed to implement care planned interventions, evaluate and analyze hazards and risks after falls and implement effective interventions to mitigate accident hazards and prevent falls for one resident (Resident #3) out of 2 residents reviewed for falls, resulting in injury from repeated falls.
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observation, interview, and record review, the facility failed to provide necessary respiratory care and services for 1 resident (R97) utilizing a CPAP (continuous positive airway pressure) machine, resulting in R97's CPAP equipment not being cleaned per facility policy and the potential for the spread of illness and disease.
- D
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Inspectors wroteBased on interview and record review, the facility failed to implement and/or timely implement a pharmacy recommendation for 1 of 5 residents (R8), resulting in R8 not receiving a medication as per pharmacy recommendations and physician approval and a delay in implementing a pharmacy recommendation.
- D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on observation, interview, and record review, the facility failed to safeguard the confidentiality of medical records for one resident (R32), resulting in the potential for unauthorized access to the medical records, and the potential for the loss of resident privacy and confidentiality of their personal health information.
- D
Make sure that a working call system is available in each resident's bathroom and bathing area.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure 1 of 14 sampled residents (R94) had a means to contact staff in the case of needing assistance, resulting in R94 having no way to contact staff for help when in distress and the potential for a serious negative outcome.
September 21, 2023Complaint inspection · 3 citations
- D
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Inspectors wroteBased on interview and record review, the facility failed to address 2 Residents (R3 and R4) concerns in a timely manner resulting in R3 not receiving her medications as ordered and R4's concern of neglect and abuse not getting addressed.
- D
Respond appropriately to all alleged violations.
Inspectors wroteBased on interview and record review, the facility failed to conduct a complete and thorough investigation regarding incidents involving 3 Residents (Resident#2, Resident#4, Resident#7) resulting in mental anguish and discomfort for the residents with the potential for ongoing abuse and neglect for all residents living at the facility.
- D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Inspectors wroteBased on interviews and record review, the facility failed to provide 1 Resident (R3) medications as ordered, resulting in R3 not sleeping well.
Fire safety inspections
14 fire safety citations on file: 5 on December 4, 2025, 4 on October 8, 2024, 5 on October 6, 2023.
Every fire safety citation14 citations
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · December 4, 2025 · Corrected (the home has a date of correction)
- F
Follow proper procedures when the fire alarm was out of service for more than 4 hours.
K 346 · December 4, 2025 · Corrected (the home has a date of correction)
- F
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
K 354 · December 4, 2025 · Corrected (the home has a date of correction)
- F
Have elevators that firefighters can control in the event of a fire.
K 531 · December 4, 2025 · Corrected (the home has a date of correction)
- F
Have simulated fire drills held at unexpected times.
K 712 · December 4, 2025 · Corrected (the home has a date of correction)
- F
Properly select, install, inspect, or maintain portable fire extinguishes.
K 355 · October 8, 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 · October 8, 2024 · Corrected (the home has a date of correction)
- E
Provide properly protected cooking facilities.
K 324 · October 8, 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 8, 2024 · Corrected (the home has a date of correction)
- F
Provide properly protected cooking facilities.
K 324 · October 6, 2023 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · October 6, 2023 · Corrected (the home has a date of correction)
- F
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
K 761 · October 6, 2023 · 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 · October 6, 2023 · Corrected (the home has a date of correction)
- E
Have properly installed electrical wiring and gas equipment.
K 511 · October 6, 2023 · Corrected (the home has a date of correction)