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 35 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
4G
0H
0I
Potential for more than minimal harm
25D
3E
3F
Potential for minimal harm
0A
0B
0C
June 23, 2026Complaint inspection · 1 citation
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on staff and resident interviews, record review, and review of the policy titled, Compliance with Reporting Allegations of Abuse/Neglect/Exploitation, the facility failed to report an allegation of sexual abuse for one resident (R) (R14) of a total of 17 sampled residents. The deficient practice had the potential for continued episodes of unreported abuse, which posed potential for physical harm and/or mental anguish.
December 3, 2025Standard inspection · 11 citations
- F
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Inspectors wroteBased on observations, interviews, facility document review and facility policy review, the facility failed to ensure food was monitored and served at appropriate temperatures to prevent food borne illness. This deficient practice had the potential to affect 80 of 80 residents receiving meals prepared in the kitchen.
- 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, staff interviews, and policy review, the facility failed to ensure food was dated, labeled, stored properly, not expired, and that the facility's ice machine was maintained in a sanitary manner. These failures had the potential to increase the prevalence and spread of foodborne illness and infection among all 80 residents' receiving meals from the kitchen.
- D
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Inspectors wroteBased on record review, staff interviews, and facility policy review, the facility failed to ensure residents were free of verbal and physical abuse for two of two residents (R) (R13 and R 45) reviewed for resident-to-resident altercations from a sample of 34. These failures had the potential to place residents at risk of physical injury and psychosocial harm.
- D
Ensure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge.
Inspectors wroteBased on record review and staff interviews, the facility failed to ensure an appropriate discharge plan for one of four residents (R) (R86) reviewed for transfer and discharge. The facility issued an Against Medical Advice (AMA) discharge but failed to arrange for necessary care and services to include post discharge follow-up. The failure had the potential to affect the well-being and safety of R86.
- 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 resident interviews, record review, review of facility policy, the facility failed to ensure two of 32 sampled residents (R) (R16 and R40) were invited to their care plan meeting to review their care plans. This failure created the potential that residents will not obtain their highest practicable level of functioning.
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on observation, interview, record review, and review of the facility's policies, the facility failed to ensure residents were free of accidents and hazards for two of three sampled residents (R) (R45 and R11) reviewed for smoking at the facility, out of 32 sampled residents. These failures had the potential to cause serious adverse outcomes, including significant injury to all 80 residents residing in the facility.
- 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 record review, and interviews, the facility failed to ensure a physician's order was obtained for the use of an indwelling urinary catheter device for one of three residents (R) (R69) reviewed for urinary catheter devices. This failure created the potential for R69 to go without appropriate care and services.
- 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 observations, interviews, record review, and facility policy review, the facility failed to properly assess and initiate side rails before alternatives were attempted for three of three residents (R) (R10, R25 and R66) reviewed for accidents/hazards out of 34 sampled residents. This failure had the potential to increase their risk of accidents.
- 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 facility policy review, the facility failed to ensure overflow medications were secured for one of two medication supply rooms on the south hall. This failure placed 30 residents' medications at risk of diversion.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on review of facility policy, record review, observation and interviews, the facility failed to ensure their infection control program was followed for two of six residents (R) (R69 and R16) reviewed for infection control. Specifically, personal protective equipment (PPE) was not worn for contact isolation. In addition, a foley catheter bag with tubing was touching the floor. These failures created the potential for cross contamination and spread of infection among residents and staff.
- D
Implement a program that monitors antibiotic use.
Inspectors wroteBased on record review interviews and policy review, the facility failed to ensure antibiotics were used in accordance with current evidence-based antibiotic use indications for one of six residents (R) R27 reviewed for antibiotic stewardship. The failure had the potential to increase the risk of adverse events, including the development of antibiotic-resistant organisms, from unnecessary or inappropriate antibiotic use.
August 5, 2025Complaint inspection · 5 citations
- D
Protect each resident from the wrongful use of the resident's belongings or money.
Inspectors wroteBased on staff interviews, record review and review of the facility's policy titled Abuse, Neglect and Exploitation, the facility failed to obtain a consent to become the representative payee (someone who manages the resident's Social Security benefits to make sure the resident's basic needs were met) for one out of 15 sampled residents (R) (R9).
- D
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Inspectors wroteBased on record review, staff and resident interviews, and review of the facility policy titled, Abuse, Neglect and Exploitation, the facility failed to implement the protection of resident and reporting/response components of their abuse policy when one resident (R) (R1) alleged R2 struck him five times on his left side. The total sample was 15.
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on staff interviews, record review and review of the facility's policy titled, Abuse, Neglect and Exploitation, the facility failed to ensure that an allegation of abuse was reported to law enforcement for one out of 15 sampled residents (R) (R1).
- 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 resident and staff interviews, record review, and review of the facility's policy titled Comprehensive Care Plans, the facility failed to revise the care plan for one out of 15 sampled residents (R) (R1). Specifically, the facility failed to address R1's psychological needs related to an allegation of physical abuse.
- D
Provide medically-related social services to help each resident achieve the highest possible quality of life.
Inspectors wroteBased on resident and staff interviews, record review, and review of the Social Worker job description, the facility failed to assess the psychosocial status and provide medically related social services to one out of 15 sampled residents (R) (R1) after an allegation of physical abuse.
March 12, 2025Complaint inspection · 3 citations
- G
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 observations, medical records, and staff interviews, the facility failed to implement the care plan related to wound treatment for two of three sampled residents (R1 and R3) who had stage IV wounds. Harm was determined to have occurred on 3/5/2025 when R1 and R3 experienced pain that was not addressed during wound care treatment.
- G
Provide safe, appropriate pain management for a resident who requires such services.
Inspectors wroteBased on observations, record review, staff interviews, and a review of the facility policy titled Administering Pain Management, the facility failed to ensure that two of three sampled residents (R) (R1 and R3) were free from pain during wound care treatment. Harm was determined to have occurred on 3/5/2025 when R1 and R3 experienced pain that was not addressed during wound care treatment.
- E
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observations, record review, staff interviews, and a review of the facility policy titled Infection Prevention and Control Program, the facility failed to ensure that the staff wore the appropriate personal protective equipment (PPE) while providing care for three of three sampled residents (R) (R1, R2, and R3) during wound care and perineal care.
July 2, 2024Complaint inspection · 2 citations
- G
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 record review and staff interviews, the facility failed to develop care plan interventions to address the transfer needs of one resident (R) (R1) who required the use of a mechanical swing lift during transfers from a sample of 11 residents. This failure resulted in actual harm on 6/13/2024 when R1 slid down in the sling of a stand lift causing a chest wall hematoma with subsequent anemia requiring a blood transfusion.
- G
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on record review, staff interviews, and review of policy titled Lifting Machine, Using a Mechanical and Accidents and Incidents-Investigating and Reporting, the facility failed to transfer a resident with the correct transfer lift for one of 11 sampled residents (R) (R1). This failure resulted in actual harm on 6/13/2024 when R1 slid down in the sling of a stand lift causing a chest wall hematoma with subsequent anemia requiring a blood transfusion.
April 2, 2024Standard inspection, Complaint inspection · 8 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, staff interviews, record review, and review of the facility's policy titled, Food Receiving and Storage the facility failed to label and date food items stored in the freezer, failed to ensure that uncooked raw meat is stored so that juices are not dripping onto other foods, failed to ensure food products are discarded on or before the expiration date. In addition, the facility also failed to maintain the appropriate concentration of sanitizing solution in the three-compartment sink. The deficient practice had the potential to affect 73 of 79 residents receiving an oral diet.
- E
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on observations, staff interviews, and review of the facility's policy titled, Oxygen Safety, the facility failed to provide a safe environment by ensuring the storage of oxygen tanks for three of 52 residents rooms.
- 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 interview, and record review the facility failed to ensure there were no expired medications in one of one facility Medication Storage Rooms. Specifically, the facility failed to ensure calcium 600 mg (Milligrams) aspirin 325mg, and liquid multivitamin were discarded before the expiration date.
- D
Allow residents to self-administer drugs if determined clinically appropriate.
Inspectors wroteBased on observations, resident and staff interviews, record review, and review of the facility policy titled, Self-Administration of Medications by Patients/Residents, the facility failed to ensure one of 23 residents (R) R42 did not have unsecured unauthorized medications stored at the bedside. This deficient practice had the potential to allow unauthorized access of medications to other residents and visitors in the facility.
- 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 observations, staff interviews, record review, and review of the facility policy titled, Comprehensive Care Plans, the facility failed to implement the care plan for two of five Residents (R) (R3 and R64) receiving oxygen therapy. Specifically, the facility failed to ensure the care plans for R3 and R64 were followed in reference to the oxygen flow rate for each resident.
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteF695 Based on observations, staff and resident interviews, record review, and review of the facility policy titled, Oxygen Administration , the facility failed to ensure two of twenty three residents (R)receiving oxygen therapy,, R3 and R64 were administered oxygen in accordance with the physician order. Specifically, that residents received oxygen at the rate as prescribed by the physician and ensured connection of a humidifer water bottle. to the oxygen concentrator for one resident, R64.
- D
Ensure medication error rates are not 5 percent or greater.
Inspectors wroteBased on observations, staff interviews, record reviews, and a review of the policy titled, Documentation of Medication Administration, the facility failed to ensure a medication error rate of less than 5% for three residents, R69, R63, and R243. There were 32 opportunities observed resulting in three medication errors. The medication error rate was 9.38%.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observations, staff interviews, and a review of the facility's policy titled, Disinfection of Bedpans and Urinals,, the facility failed to ensure resident's personal care items were stored in a manner to prevent cross-contamination in two adjoining bathrooms room [ROOM NUMBER] and 126 and rooms [ROOM NUMBERS]. The deficient practice had the potential to increase the probability of the spread of infection in the residents living area.
January 15, 2023Standard inspection · 5 citations
- D
PASARR screening for Mental disorders or Intellectual Disabilities
Inspectors wroteBased on record review and staff interviews, the facility failed to submit an application for Level II PASRR (Preadmission Screening and Resident Review) for evaluation and determination of specialized services for two of two residents (R) #15, and R#51 that had a positive Level I PASRR for mental illness. Specifically, R#15 had a diagnosis of persistent mood affective disorder and, R#51 had a diagnosis of schizoaffective disorder prior to and on admission to the facility.
- 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, interviews, record review, and review of the facility policy titled, Care Plans, Comprehensive Person-centered the facility failed to develop a comprehensive care plan related to use of oxygen for one of 24 residents (R) (#66). The deficient practice had the potential to affect the plan of care for residents receiving oxygen therapy.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on observations, record review, staff and resident interviews, family interview, and facility policy review titled, Encouraging and Restricting Fluids the facility failed to ensure that fluid restriction guidelines were followed as ordered by physician for one of one resident (R) (R#62). Specifically, the facility failed to ensure that R#62 fluid restrictions were monitored, documented, and communicated as ordered by the physician.
- 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 observation, record review, staff interview, and review of the facility policy titled, Restorative Nursing Services the facility failed to provide left hand splint to prevent further contractures as recommended by the Occupational Therapist (OT) for one of two residents (R) (R#12) reviewed for limited range of motion. The deficient practice had the potential to inhibit optimal independence and safety for residents requiring splint use to prevent contractures.
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observation, record review, review of the facility policy titled, Oxygen Administration, and staff interviews, the facility failed to follow a Physician's Order for one of 24 residents (R) (#66), the facility also failed to ensure one resident (R#83) of 24 residents reviewed had a physician order for oxygen use. Specifically, the facility failed to ensure oxygen was administered to R#66 as prescribed by the physician and that R#83 had a written order for oxygen use.
Fire safety inspections
20 fire safety citations on file: 11 on December 3, 2025, 6 on April 2, 2024, 3 on January 15, 2023.
Every fire safety citation20 citations
- F
Install a fire alarm system that can be heard throughout the facility.
K 341 · December 3, 2025 · Corrected (the home has a date of correction)
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · December 3, 2025 · Corrected (the home has a date of correction)
- F
Properly install and monitor supervisory attachments on automatic sprinkler systems.
K 352 · December 3, 2025 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · December 3, 2025 · Corrected (the home has a date of correction)
- F
Have simulated fire drills held at unexpected times.
K 712 · December 3, 2025 · Corrected (the home has a date of correction)
- F
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
K 761 · December 3, 2025 · Corrected (the home has a date of correction)
- E
Have properly installed electrical wiring and gas equipment.
K 511 · December 3, 2025 · Corrected (the home has a date of correction)
- D
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
K 223 · December 3, 2025 · Corrected (the home has a date of correction)
- D
Have properly located and lighted "Exit" signs.
K 293 · December 3, 2025 · Corrected (the home has a date of correction)
- D
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
K 321 · December 3, 2025 · Corrected (the home has a date of correction)
- D
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · December 3, 2025 · Corrected (the home has a date of correction)
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · April 2, 2024 · Corrected (the home has a date of correction)
- E
Have properly installed electrical wiring and gas equipment.
K 511 · April 2, 2024 · Corrected (the home has a date of correction)
- D
Have corridors or aisles that are unobstructed and are at least 8 feet in width.
K 232 · April 2, 2024 · Corrected (the home has a date of correction)
- D
Install emergency lighting that can last at least 1 1/2 hours.
K 291 · April 2, 2024 · Corrected (the home has a date of correction)
- D
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
K 321 · April 2, 2024 · Corrected (the home has a date of correction)
- D
Have proper medical gas storage and administration areas.
K 923 · April 2, 2024 · Corrected (the home has a date of correction)
- E
Inspect, test, and maintain automatic sprinkler systems.
K 353 · January 15, 2023 · Corrected (the home has a date of correction)
- E
Have properly installed electrical wiring and gas equipment.
K 511 · January 15, 2023 · Corrected (the home has a date of correction)
- D
Properly select, install, inspect, or maintain portable fire extinguishes.
K 355 · January 15, 2023 · Corrected (the home has a date of correction)