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
31D
9E
3F
Potential for minimal harm
0A
0B
0C
April 8, 2026Complaint inspection · 2 citations
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on interview, and record review, it was determined the facility failed to ensure ongoing assessments were conducted for non-pressure skin wounds for 1 of 3 sampled residents (#4) reviewed for non-pressure skin wounds. This placed residents at risk for worsening wounds.
- 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 interview and record review, it was determined the facility failed to provide adequate catheter care for 1 of 3 sampled residents (#1) reviewed for catheter care. This placed residents at risk for unmet catheter needs. Resident 1 was admitted to the facility in 12/2025 with diagnoses including obstructive and reflux uropathy (disease of the urinary system caused by blockage and backward urine flow). The 1/2026 TAR indicated for staff to change the suprapubic catheter every 30 days. On 1/12/26 the TAR indicated to hold the treatment and referred the reader to Administration Notes. A 1/12/26 Administration Note indicated the suprapubic catheter was not changed because staff were waiting for pending special instructions from the in-house provider because of a penile implant (device surgically inserted into the penis). [...]
January 30, 2026Standard inspection · 7 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 it was determined the facility failed to ensure proper labeling of biologicals for 2 of 3 treatment carts reviewed for medication storage and failed to ensure treatment carts were properly secured during a random observation. This placed residents at risk for reduced efficacy of medication and unauthorized access to medications.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on interview and record review it was determined the facility failed to follow the facility bowel protocol and administer medication as ordered for 2 of 5 sampled residents (#s 5 and 8) reviewed for medication. This placed residents at risk for constipation.
- D
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 it was determined the facility failed to ensure residents' narcotic drug records were in order and an account of all controlled drugs was maintained for 2 of 3 medication carts reviewed for medication storage. This placed residents at risk for inaccurate clinical records related to narcotics and drug diversion.
- D
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Inspectors wroteBased on interview and record review the facility failed to ensure residents were free from unnecessary medications for 1 of 5 sampled residents (#5) reviewed for medication. This placed residents at risk for adverse drug events.
- D
Ensure medication error rates are not 5 percent or greater.
Inspectors wroteBased on observation, interview and record review it was determined the facility failed to maintain a medication error rate of less than 5%. There were 2 errors in 27 opportunities resulting in a 7% error rate. This placed residents at risk for adverse medication side effects.
- D
Provide or obtain dental services for each resident.
Inspectors wroteBased on interview and record review it was determined the facility failed to provide dental services for 1 of 3 sampled residents (#7) reviewed for dental services. This placed residents at risk for unmet dental needs.
- D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on interview and record review it was determined the facility failed to ensure medical records were accurate for 1 of 5 sampled residents (#5) reviewed for medication. This placed residents at risk for medication errors.
December 5, 2025Complaint inspection · 4 citations
- D
Respond appropriately to all alleged violations.
Inspectors wroteBased on interview and record review, it was determined the facility failed to investigate a potential case of abuse and investigate a fall in a timely manner for 2 of 4 sampled residents (#103 and 113) reviewed for accidents and abuse. This placed residents at risk for abuse and neglect.
- 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 it was determined the facility failed to maintain a safe environment free from accident hazards for 1 of 3 sampled residents (#103) reviewed for accidents. This placed residents at risk for injury.
- D
Provide enough food/fluids to maintain a resident's health.
Inspectors wroteBased on observation, interview, and record review it was determined the facility failed to provide assistance with eating as care planned for 1 of 3 resident (#112) reviewed for hydration. This placed residents at risk for unmet needs.
- D
Provide timely, quality laboratory services/tests to meet the needs of residents.
Inspectors wroteBased on interview and record review it was determined the facility failed to process physician laboratory orders timely for 1 of 1 sampled resident (#113) reviewed for abuse. This placed residents at risk for untreated medical needs.
August 30, 2024Standard inspection, Complaint inspection · 11 citations
- F
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Inspectors wroteBased on observation, interview and record review it was determined the facility failed to ensure a system was in place to honor resident food preferences for 4 of 4 sampled residents (#s 17, 19, 21, and 37) reviewed for dietary needs. This placed residents at risk for unmet nutritional needs and lessened quality of life. 1. Resident 17 was admitted to the facility in 2016 with diagnoses including diabetes. On 8/27/24 at 10:36 AM Resident 17 stated she/he was not given a menu to select her/his preferred meals. On 8/29/24 at 10:38 AM Staff 22 (CNA) stated about one month ago the facility stopped providing residents with a menu to choose between the main or alternate meal. Staff 22 stated several residents, including Resident 17, were upset about this as their opportunity to make a choice was taken away. [...]
- 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 and interview it was determined the facility failed to ensure the kitchen was cleaned, failed to ensure food was stored appropriately and discarded in a timely manner, and failed to monitor refrigerator temperatures for 1 of 1 kitchen and 1 of 2 refrigerators reviewed for sanitary conditions. This placed residents at risk for foodborne illness.
- E
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Inspectors wroteBased on observation, interview, and record review it was determined the facility failed to ensure a resident rooms were in good repair and free of odors for 5 of 5 sampled residents (#s 6, 19, 27, 32 and 33) reviewed for environment. This placed residents at risk for lack of a homelike environment.
- E
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 observation, interview and record review it was determined the facility failed to ensure Staff 13 (LPN) had the appropriate competencies and skills for infection control during CBG checks and administration of insulin. This placed residents at risk for bloodborne illness and reduced efficacy of medications.
- E
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 interview and record review it was determined the facility failed to ensure an RN was available for at least eight consecutive hours per day for 3 of 31 days reviewed for RN coverage. This placed residents at risk for delayed nursing assessments.
- 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 it was determined the facility failed to ensure proper storage temperatures were maintained for 1 of 2 medication storage refrigerators, and proper labeling of biologicals and securing of treatment carts for 1 of 3 treatment carts reviewed for medication storage. This placed residents at risk for reduced efficacy of medication and unauthorized access to medications.
- D
Ensure that residents are fully informed and understand their health status, care and treatments.
Inspectors wroteBased on interview and record review it was determined the facility failed to provide risk and benefit information for a psychotropic medication for 1 of 5 sampled residents (#37) reviewed for unnecessary medications. This placed the residents at risk for lack of ability to make informed decisions about their care.
- 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 it was determined the facility failed to obtain information related to advance directives and health care decisions for 3 of 4 sampled residents (#s 17, 34 and 37) reviewed for advance directives. This placed residents at risk for not having their health care decisions honored.
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observation, interview, and record review it was determined the facility failed to ensure oxygen was administered as ordered and failed to ensure residents' respiratory equipment was maintained for 2 of 2 sampled residents (#s 6 and 10) reviewed for respiratory care, ADLs and dialysis. This placed residents at risk for respiratory concerns.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview and record review it was determined the facility failed to ensure the community use CBG glucometer was properly cleaned and sanitized between resident uses for 1 of 1 sampled resident (#24) reviewed during CBG checks. This placed all residents who required CBG checks at risk for bloodborne illness.
- D
Keep all essential equipment working safely.
Inspectors wroteBased on observation and interview it was determined the facility failed to maintain essential kitchen equipment in safe operating condition for 1 of 1 kitchen reviewed for kitchen services.
December 7, 2023Complaint inspection · 2 citations
- D
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Inspectors wroteBased on interview and record review it was determined the facility failed to notify the resident's family after a change of condition and transfer to a local hospital for 1 of 3 sampled residents (#23) reviewed for change of condition. This placed residents at risk for lack of notification.
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBassed on interview and record review it was determined the facility failed to provide ADL care for 1 of 8 (#13) sampled residents reviewed for ADLs. This placed other residents at risk for lack of daily care.
March 24, 2023Standard inspection · 17 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 observation, interview and record review it was determined the facility failed to ensure the kitchen was cleaned and standard food safety practices were followed for 1 of 1 kitchen. This placed residents at risk for food borne illnesses.
- E
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on observation, interview and record review it was determined the facility failed to follow physicians' orders and care plan interventions for 5 of 16 sampled residents (#s 7, 21, 25, 38 and 44) reviewed for edema, medications, constipation/diarrhea, ADLs and accidents. This placed residents at risk for unmet needs.
- E
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 interview and record review it was determined the facility failed to ensure RN coverage for eight consecutive hours in a 24-hour period for 17 out of 29 days reviewed for staffing. This placed residents at risk for unassessed needs and lack of care.
- E
Observe each nurse aide's job performance and give regular training.
Inspectors wroteBased on interview and record review it was determined the facility failed to ensure the required annual training and annual performance reviews were completed for 4 of 4 sampled CNA staff (#s 15, 25, 28 and 29) reviewed for staffing. This placed residents at risk for unmet needs.
- E
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview and record review it was determined the facility failed to follow transmission based precautions for aerosol generating procedures for 1 of 4 halls (East Hall) reviewed for infection control and failed to follow infection control standards for 2 of 4 halls (South and West) reviewed for infection control. This placed residents at risk for exposure and contraction of infectious diseases.
- D
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Inspectors wroteBased on interview and record review it was determined the facility failed to provide written notification to 2 of 3 sampled residents (#s 303 and 304) reviewed for beneficiary notification. This placed residents at risk for unknown financial liabilities.
- D
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Inspectors wroteBased on observation, interview and record review it was determined the facility failed to comprehensively assess 1 of 2 sampled residents (# 3) reviewed for positioning and mobility. This placed residents at risk for lack of proper care and services.
- D
Ensure each resident receives an accurate assessment.
Inspectors wroteBased on observation, interview and record review it was determined the facility failed to accurately assess 1 of 1 sampled resident (#s 12) reviewed for privacy. This placed residents at risk for lack of proper care and services.
- 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 it was determined the facility failed to develop a comprehensive care plan for 1 of 5 sampled residents (#34) reviewed for medications. This placed residents at risk for unmet needs.
- 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 it was determined the facility failed to revise care plans for 3 of 5 sampled residents (#s 24, 28 and 38) reviewed for ADLs, nutrition and accidents. This placed residents at risk for unmet needs.
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on observation, interview and record review it was determined the facility failed to ensure dependent residents received required assistance with ADLs for 2 of 6 sampled residents (#s 14 and 44) reviewed for ADLs. This placed resident at risk for unmet needs.
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on observation, interview and record review it was determined the facility failed to accurately assess, identify and provide treatment to wounds for 2 of 2 sampled residents (#s 4 and 28) reviewed for pressure ulcers. This place residents at risk for unmet wound care needs.
- D
Provide appropriate foot care.
Inspectors wroteBased on observation, interview and record review it was determined the facility failed to ensure appropriate foot care was provided for 1 of 6 sampled residents (#14) reviewed for ADLs. This placed residents at risk for unmet foot care needs.
- 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, interview and record review it was determined the facility failed to providerange of motionservices and care for contractures for 3 of 7 sampled residents (#s 3, 7 and 9) reviewed for ROM and ADLs. This placed residents at risk for ROM decline.
- D
Provide care or services that was trauma informed and/or culturally competent.
Inspectors wroteBased on interview and record review it was determined the facility failed to ensure a resident who was a trauma survivor received trauma-informed care for 1 of 1 sampled resident (#44) reviewed for behavioral needs. This placed residents at risk for unmet trauma needs and a decrease in their quality of life.
- D
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
Inspectors wroteBased on observation, interview and record review, it was determined the facility failed to complete a person-centered care plan, provide ongoing behavioral health needs and timely address mood symptoms for 1 of 1 sampled resident (#44) reviewed for behavioral needs. This placed residents at risk for unmet behavioral health needs and decrease in their quality of life.
- D
Provide medically-related social services to help each resident achieve the highest possible quality of life.
Inspectors wroteBased on interview and record review it was determined the facility failed to provide medically related social services to attain or maintain the highest practicable mental and psychosocial well-being for 1 of 1 resident (#44) reviewed for behavioral and emotional needs. This placed residents at risk for unmet needs.
Fire safety inspections
8 fire safety citations on file: 1 on January 30, 2026, 4 on August 30, 2024, 3 on March 24, 2023.
Every fire safety citation8 citations
- D
Provide properly protected cooking facilities.
K 324 · January 30, 2026 · Corrected (the home has a date of correction)
- F
Develop Emergency Preparedness policies and procedures.
E 13 · August 30, 2024 · Corrected (the home has a date of correction)
- F
Keep aisles, corridors, and exits free of obstruction in case of emergency.
K 211 · August 30, 2024 · Corrected (the home has a date of correction)
- F
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · August 30, 2024 · 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 · August 30, 2024 · Corrected (the home has a date of correction)
- F
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · March 24, 2023 · Corrected (the home has a date of correction)
- E
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · March 24, 2023 · Corrected (the home has a date of correction)
- D
Ensure proper usage of power strips and extension cords.
K 920 · March 24, 2023 · Corrected (the home has a date of correction)