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 37 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
24D
13E
0F
Potential for minimal harm
0A
0B
0C
July 29, 2026Complaint inspection · 1 citation
- D
Ensure that residents are fully informed and understand their health status, care and treatments.
Inspectors wroteBased on closed record review, interviews, and review of the facility's policies and procedures, the facility failed to provide discharge information to the Resident's Representative (RR) in a language she understood for one of 2 sampled residents (Resident #4) regarding resident's rights. The deficient practice could result in the RR not understanding the resident's post-discharge care needs and instructions, potentially leading to unmet care needs following discharge.
March 3, 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 clinical record reviews, staff interviews, facility documentation, and review of facility policies and procedures, the facility failed to ensure adequate supervision to prevent elopement for one (#21) of three sampled residents. The deficient practice could result in avoidable accidents, injury, or harm to residents.
November 13, 2025Standard inspection, Complaint inspection · 4 citations
- E
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteBased on a review of the clinical record, staff interviews, and policies and procedures, the facility failed to ensure that residents were treated with dignity and respect during meal service for four out of six residents observed receiving dining assistance (Residents #10, #61, #72, and #107). The universe was 106, and the sample size was 22. This deficient practice could potentially affect all residents needing meal assistance by diminishing their sense of dignity and personhood.-Regarding Resident #10Resident #10 was admitted on [DATE], with the diagnosis that included chronic respiratory failure with hypoxia, tracheostomy status, quadriplegia, C1-C4 incomplete, hypertensive heart disease without heart failure, generalized anxiety disorder, major depressive disorder, recurrent adjustment disorder, unspecified, and schizoaffective disorder, bipolar type. [...]
- E
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 the clinical record, staff interviews, and a review of policies and procedures, the facility failed to maintain and make accessible complete medical records necessary to investigate the cases of 7 residents reviewed (Resident #137, #138, #139, #140, #141, #142, and #144). The universe was 106, and the sample size was 22. The deficient practice prevented a thorough investigation and posed a potential risk to the current quality and safety of resident care.-Regarding Resident #137Resident #137 was admitted on [DATE], with a diagnosis that included osteomyelitis, pressure ulcer of the right lower back, unspecified stage, and central cord syndrome at C4, subs. An admission Minimum Data Set (MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) of 15, indicating that Resident #137's cognition had been intact. [...]
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on interview, review of clinical record, and review of facility policy and procedure, the facility failed to ensure an allegation of abuse was reported to mandated entities within 2 hours for one resident (#100). The deficient practice could lead to a delay in the investigation of an allegation of abuse leading to continued harm of a resident.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on clinical record review, interviews, facility documentation and policy, the facility failed to ensure one resident (#145) received glaucoma medication according to admission orders. The deficient practice could lead to an increase in eye pressure, causing potentially worsening vision.
August 12, 2025Complaint inspection · 3 citations
- E
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Inspectors wroteBased on clinical record reviews, staff and resident interviews, facility documentation and policy reviews, the facility failed to implement their written abuse policies and procedure for two residents (#1, #2). The deficient practice could place resident at risk for further abuse.
- E
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on clinical record review, staff and resident interviews, facility documentation and policy review, the facility failed to ensure that an allegation of abuse for two resident (#1, #2) was reported to the State Agencies in a timely manner. The deficient practice could place residents at risk for further abuse.
- E
Respond appropriately to all alleged violations.
Inspectors wroteBased on clinical record review, staff and resident interviews, facility documentation and policy review, the facility failed to investigate an allegation of abuse in a timely manner for two residents (#1, #2). The deficient practice could place residents at risk for further abuse.
March 24, 2025Complaint inspection · 1 citation
- D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on record reviews, staff interviews, and facility policy and procedure review, the facility failed to maintain accurate documentation surrounding the death of two residents (#2 and #6). The sample size was 3. The deficient practice can result in inadequate records being kept regarding the extent of a resident's death in the facility.
October 22, 2024Complaint inspection · 1 citation
- 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, interviews, and review of the facility policies, the facility failed to ensure that the care plan for one resident (#22) was updated according to the resident's preferences following a five-day investigation of a complaint. The deficient practice could result in suboptimal care planning to meet the resident's preferences.
August 1, 2024Complaint inspection · 1 citation
- D
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 wroteBased on closed record review, staff interviews, review of facility documentation and policy, and the State Agency (SA) complaint tracking system, the facility failed to ensure a safe and appropriate transfer of one resident (#1). The deficient practice could result in residents not receiving appropriate care and services during the transition of care.
May 6, 2024Standard inspection · 13 citations
- E
Provide activities to meet all resident's needs.
Inspectors wroteBased on documentation, staff interviews, and the facility policy and procedures, the facility failed to provide and ongoing program of activities designed to meet the interest and the physical, mental, and psychological well-being of two residents (#48 and #37). The deficient practice could result in a decline in physical and social skills.
- E
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Inspectors wroteBased on clinical record review, staff interviews, and the facility policy and procedures, the facility failed to ensure pain medications were administered as ordered for one resident (#68). The deficient practice could result in resident receiving unnecessary medication and overmedicated.
- 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 the facility policy and procedures, the facility failed to ensure that food items that were unsafe for resident consumption were discarded; and, the facility failed to ensure a clean and sanitary environment was maintained in the kitchen. The facility census was 98. The deficient practice could result in a potential for food borne illness and resident safety.
- E
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on clinical record review, staff interviews, review of facility documentation, and policy, the facility failed to ensure that the electronic health record for resident #48 was complete and accurately documented. The sample size was 20. The deficient practice could result in incomplete and/or inaccurate clinical records.
- E
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Inspectors wroteBased on staff interviews, and review of facility documentation and policies, the facility failed to ensure that the QAA (quality assessment and assurance) committee developed and implemented action plans on identified problem related to PRN (as needed) pain medication administration.
- 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 review of the clinical record, staff interviews, facility documentation, policy and procedure, the facility failed to ensure that one resident's (#48) communication deficit was appropriately care planned and implemented. The deficient practice could result in a plan of care that did not meet the resident's needs.
- D
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Inspectors wroteBased on observations, clinical record review, family and staff interviews, and facility policy and procedure, the facility failed to provide care and services related to communication for one resident (#48) assessed with communication/language deficit. The deficient practice could result in residents not maintaining their communication abilities.
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on observations, clinical record review, staff interviews, and review of policy and procedure, the facility failed to ensure assistance with meals was provided to one resident (#48). The sample size was 20. The deficient practice could result in resident not receiving adequate nutrition.
- D
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 record review, staff interviews, and the facility policy and procedures, the facility failed to provide documentation of nursing and non-nursing staff working hours. The deficient practice could result in a lack of sufficient staffing and impact the residents' treatment and care.
- D
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Inspectors wroteBased on documentation, staff interviews, and the facility policy and procedures, the facility failed to ensure that a registered nurse (RN) worked at least 8 consecutive hours per day.
- D
Provide routine and 24-hour emergency dental care for each resident.
Inspectors wroteBased on clinical record review, staff interviews, and review of facility policy and procedure, the facility failed to ensure dental needs were met for one sampled resident (#14). The deficient practice could result in residents not receiving care and services for oral/dental conditions.
- D
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Inspectors wroteBased on observations, interviews and policy review the facility failed to ensure a resident's (#48) food was served warm and palatable. The sample size was 20. The deficient practice has the potential for residents to refuse meals and or potentially impact the resident's nutritional intake as well as weight.
- D
Develop, implement, and/or maintain an effective training program for all new and existing staff members.
Inspectors wroteBased on documentation, staff interviews, and facility policies the facility failed to ensure that staff were trained in communication skills needed to communicate with one resident (#48). The deficient practice could result in staff not understanding the medical and care needs of the residents.
April 11, 2024Complaint inspection · 1 citation
- D
Ensure services provided by the nursing facility meet professional standards of quality.
Inspectors wroteBased on observation, interviews and policy review, the facility failed to ensure that medications were administered as ordered by the physician for one resident (#400). The deficient practice could result in residents not receiving prescribed doses of medications.
January 10, 2024Complaint inspection · 1 citation
- E
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observations, staff interviews, facility documents, and resident records, the facility failed to ensure there was adequate oxygen for 6 residents. The sample size was 6. This deficiency could result in significant harm to the residents.
December 15, 2022Standard inspection · 10 citations
- E
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 wrote-Resident #44 was admitted to the facility on [DATE] with diagnoses that included intracranial injury with loss of consciousness, personal history of traumatic brain injury, restlessness and agitation, and anxiety disorder. The admission Minimum Data Set (MDS) assessment dated [DATE] revealed the Brief Interview for Mental Status (BIMS) was not assessed, but the assessment indicated the resident was severely impaired for daily decision making. The order summary included an order dated October 10, 2022 for lorazepam (an antianxiety medication) 1 milligram (mg) tablet via Gastrostomy tube (G-tube) every 6 hours as needed for anxiety. This order did not include a stop date. [...]
- E
Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
Inspectors wroteBased on facility documentation, interviews, policy, and Centers for Disease Control (CDC) guidance, the facility failed to ensure the Infection Preventionist (IP) had completed infection control training. The deficient practice could lead to unqualified staff acting as the IP and improper infection prevention practices within the facility.
- D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteBased on observations, clinical record review, interviews, and policy, the facility failed to ensure one resident's (#255) dignity was maintained by failing to ensure the resident's catheter bag was covered. The deficient practice could result in residents not being treated with respect and dignity.
- D
Ensure services provided by the nursing facility meet professional standards of quality.
Inspectors wroteBased on observations, clinical record review, interviews, policy and manufacturer guidelines, the facility failed to ensure medication orders met one resident's needs (#255) according to professional standards of care and the facility failed to ensure glucometers were disinfected properly. The deficient practice could result in unmet resident needs and improperly disinfected glucometers.
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on clinical record review, interviews, and facility policy, the facility failed to provide timely continence care for one resident (#2). The deficient practice could affect residents' self-esteem and cause skin breakdown.
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observations, clinical record review, interviews, and policy, the facility failed to provide respiratory care and treatment as ordered by the physician for one resident (#255). The deficient practice could result in unmet respiratory needs.
- D
Ensure medication error rates are not 5 percent or greater.
Inspectors wroteBased on observations, staff interviews, clinical record reviews, review of medlineplus.gov, and policy, the facility failed to ensure the medication error rate was not 5% or greater by failing to administer a medication as ordered for one of five sampled residents (#51) and by crushing a medication tablet that was not supposed to be crushed for one resident (#47). The medication error rate was 8%. The deficient practice could result in additional medication errors.
- D
Ensure that staff members are educated on resident rights and facility responsibilities to properly care for its residents.
Inspectors wroteBased on personnel file reviews, staff interviews, and policy, the facility failed to provide evidence that 3 of 10 sampled staff (#182, #176, and #45) were provided resident rights training. The deficient practice could result in residents not being afforded their rights.
- D
Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.
Inspectors wroteBased on personnel file reviews, interviews, and policy, the facility failed to provide evidence that 3 of 10 sampled staff (#182, #176, and #45) were provided training on abuse, neglect, exploitation, misappropriation of resident property, and dementia management. The deficient practice could result in staff not being educated to protect residents from abuse and to provide the appropriate services to residents with dementia.
- D
Include as part of its infection prevention and control program, mandatory training that includes written standards, policies, and procedures for the program.
Inspectors wroteBased on personnel file reviews, staff interviews, and policy, the facility failed to provide evidence that 3 of 10 sampled staff (#182, #176, and #45) were provided training on infection control. The deficient practice could result in the spread of infection.
Fire safety inspections
29 fire safety citations on file: 1 on November 13, 2025, 1 on May 6, 2024, 27 on December 15, 2022.
Every fire safety citation29 citations
- E
Provide rooms that can be unlocked from inside without a key.
K 221 · November 13, 2025 · Corrected (the home has a date of correction)
- D
Ensure that testing and maintenance of electrical equipment is performed.
K 921 · May 6, 2024 · 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 15, 2022 · Corrected (the home has a date of correction)
- E
Conduct risk assessment and an All-Hazards approach.
E 6 · December 15, 2022 · Corrected (the home has a date of correction)
- E
Include a process for Emergency Preparedness collaboration.
E 9 · December 15, 2022 · Corrected (the home has a date of correction)
- E
Establish policies and procedures including evacuation.
E 20 · December 15, 2022 · Corrected (the home has a date of correction)
- E
List the names and contact information of those in the facility.
E 30 · December 15, 2022 · Corrected (the home has a date of correction)
- E
Conduct testing and exercise requirements.
E 39 · December 15, 2022 · 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 · December 15, 2022 · Corrected (the home has a date of correction)
- E
Provide properly protected cooking facilities.
K 324 · December 15, 2022 · Corrected (the home has a date of correction)
- E
Have proper medical gas storage and administration areas.
K 923 · December 15, 2022 · Corrected (the home has a date of correction)
- D
Develop and maintain an Emergency Preparedness Program (EP).
E 4 · December 15, 2022 · Corrected (the home has a date of correction)
- D
Address subsistence needs for staff and patients.
E 15 · December 15, 2022 · Corrected (the home has a date of correction)
- D
Establish roles under a Waiver declared by secretary.
E 26 · December 15, 2022 · Corrected (the home has a date of correction)
- D
Provide emergency officials' contact information.
E 31 · December 15, 2022 · Corrected (the home has a date of correction)
- D
Provide a means of sharing information on occupancy/needs.
E 34 · December 15, 2022 · Corrected (the home has a date of correction)
- D
Meet other general requirements.
K 100 · December 15, 2022 · Corrected (the home has a date of correction)
- D
Keep aisles, corridors, and exits free of obstruction in case of emergency.
K 211 · December 15, 2022 · Corrected (the home has a date of correction)
- D
Install emergency lighting that can last at least 1 1/2 hours.
K 291 · December 15, 2022 · Corrected (the home has a date of correction)
- D
Inspect, test, and maintain automatic sprinkler systems.
K 353 · December 15, 2022 · Corrected (the home has a date of correction)
- D
Properly select, install, inspect, or maintain portable fire extinguishes.
K 355 · December 15, 2022 · Corrected (the home has a date of correction)
- D
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · December 15, 2022 · Corrected (the home has a date of correction)
- D
Have properly installed electrical wiring and gas equipment.
K 511 · December 15, 2022 · Corrected (the home has a date of correction)
- D
Have elevators that firefighters can control in the event of a fire.
K 531 · December 15, 2022 · Corrected (the home has a date of correction)
- D
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
K 741 · December 15, 2022 · Corrected (the home has a date of correction)
- D
Ensure medical gas and vacuum systems have documented maintenance programs.
K 907 · December 15, 2022 · Corrected (the home has a date of correction)
- D
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · December 15, 2022 · Corrected (the home has a date of correction)
- D
Ensure proper usage of power strips and extension cords.
K 920 · December 15, 2022 · Corrected (the home has a date of correction)
- D
Ensure that testing and maintenance of electrical equipment is performed.
K 921 · December 15, 2022 · Corrected (the home has a date of correction)