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 45 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
3J
0K
1L
Actual harm
9G
0H
0I
Potential for more than minimal harm
14D
2E
15F
Potential for minimal harm
0A
0B
1C
April 24, 2026Standard inspection · 7 citations
- G
Provide enough food/fluids to maintain a resident's health.
Inspectors wroteBased on observation, interview, and record review, the Facility failed to ensure nutritional interventions were in place to prevent weight loss for 1 of 3 residents (R40) reviewed for nutrition in the sample of 34. This failure resulted in R40 losing 13.6% body weight over four months which is significant and undesirable.
- 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 accurately date a vial of Tuberculin solution to determine the expiration date. This has the potential to affect all 54 residents living in the facility. Findings Include:On 4/21/2026 at 2:14 PM the facility's medication room was observed with V3, Licensed Practical Nurse (LPN). An open, partially used multi-dose vial of Tuberculin (TB) Purified Protein Derivative Diluted/Aplisol 5TU/0.1mL noted in a House Stock bin in the medication refrigerator with no open date on the vial or medication box. V3 stated the vial is a stock vial of TB solution the facility uses, and she is unsure how long the vial has been open due to the vial not having an open date written on it. V3 stated once a vial is open, the vial should have the date it was opened written on it. [...]
- 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 store and prepare foods in a manner that prevents potential contamination. This has the potential to affect all 54 residents living in the Facility.
- F
Provide and implement an infection prevention and control program.
Inspectors wroteBased on interview and record review the facility failed to provide a system of surveillance designed to identify possible communicable diseases or infections before they can spread to other residents in the facility. This failure has potential to affect the 54 residents in 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 interview and record review the facility failed to timely answer call lights for 2 of 2 (R7, R60) residents reviewed for resident rights in a sample of 34. Findings Include:1. R7's Undated Face Sheet documents R7 an admission date of 10/3/2025 and has a medical diagnosis including End Stage Renal Disease, Type 2 Diabetes Mellitus, Chronic Pain, Obsessive-Compulsive Disorder, Peripheral Vascular Disease, Unspecified injury of right forearm, and Acute pulmonary edema. R7's Minimum Data Set (MDS) dated [DATE] documents R7 is moderately cognitively impaired, is always incontinent of bladder and bowel, and requires substantial/maximal assistance with toileting hygiene, sitting to standing, and chair/bed to chair transfers. R7's Care Plan Edited 4/2/2026 documents Problem: R7 is at risk for skin breakdown or pressure ulcers related to decreased mobility. [...]
- D
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
Inspectors wroteBased on observation, interview and record review, the Facility failed to provide food in a form to meet needs for 1 of 1 residents (R39) reviewed for nutritional services in the sample of 34.
- D
Implement a program that monitors antibiotic use.
Inspectors wroteBased on interview and record review the facility failed to develop and implement protocols to optimize the treatment of infections by ensuring that residents who require an antibiotic are prescribed the appropriate antibiotic for 2 of 4 (R28, R37) residents investigated for infection control in a sample of 30.
November 12, 2025Complaint inspection · 1 citation
- G
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on interviews, observations, and record reviews the facility failed to evaluate, implement and monitor effectiveness of fall interventions to prevent falls for 1 out of 3 residents (R2); reviewed for accident hazards/supervision/devices in a sample of 4. This failure resulted in R2 sustaining depressed skull, orbital, maxillary and temporal fractures, a scalp laceration, a subdural hematoma, a subarachnoid hematoma and an intraparenchymal hematoma of the brain.
September 16, 2025Complaint inspection · 2 citations
- J
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteThe facility failed to ensure its door alarms were loud enough to be heard from areas away from the 200 hall exit door and its outside gait latch was in working order to prevent elopement in 1 of 4 residents (R2) reviewed for elopement in the sample of 4. This led to R2 eloping from the facility, which is located on a busy intersection and approximately 100 yards from an active railroad track. The Immediate Jeopardy began on 8/22/25, when R2 eloped from the facility. On 9/16/25 at 10:45 AM, V1, Administrator, and V2, DON, were notified of the Immediate Jeopardy. The surveyor confirmed by observation, interview and record review, the Immediate Jeopardy was removed on 9/16/25 but remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training. [...]
- F
Keep all essential equipment working safely.
Inspectors wroteBased on interview and record review, the facility failed to ensure its courtyard gait latch was in proper working order when reviewing for mechanical equipment in working order. This failure has the potential to affect all 50 residents residing in the facility. Findings Include:On 9/12/25 at 11:20 AM, V3, R2's Son, stated on that Friday 8/22/25, R2 had exited the facility without staff and he and V4, LPN (Licensed Practical Nurse) went outside to the fenced in courtyard and did not see her. A young lady called and stated the facility had a patient out on the road behind the facility. V3 stated the courtyard gate to the fenced in area outside the 200-hall door was not locked or latched. V3 stated when he asked about this, he was told that they could not lock/latch it because it was illegal because it could prevent residents from exiting in the event of a fire. [...]
June 10, 2025Complaint inspection · 2 citations
- G
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on Interview, and Record Review the facility failed to timely report and treat a change in condition for 1 (R3) of 3 residents reviewed for change in condition in the sample of 5. This resulted in R3 experiencing an increase in pain and not being seen by a physician and diagnosed with a pubic fracture for 8 days.
- 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 assure fall interventions were in place for 1 (R3) of 3 residents reviewed for falls in the sample of 5.
February 28, 2025Standard inspection, Complaint inspection · 10 citations
- G
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 provide progressive fall interventions and to complete a fall investigation for 1(R28) of 2 residents in the sample of 21. This failure resulted in R28 sustaining a displaced fracture of greater trochanter of left femur.
- G
Provide enough food/fluids to maintain a resident's health.
Inspectors wroteBased on observation, interview and record review, the facility failed to obtain monthly weights on 2 of 3 residents (R13, R41), reviewed for nutrition in the sample of 21. This failure resulted in R13 having a significant weight loss of 15.6% from 11/8/24 to 2/26/25.
- 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 ensure food was prepared, stored and distributed in a manner that prevents foodborne illness. This has the potential to affect all 48 residents living in the Facility.
- E
Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.
Inspectors wroteBased on observation, interview, and record review, the Facility failed to serve meals in a timely manner for 4 of 4 residents (R14, R29, R19, R32) reviewed for nutritional services in the sample of 21.
- D
Reasonably accommodate the needs and preferences of each resident.
Inspectors wroteBased on observation, interview and record review, the facility failed to provide access to a sink in a resident bathroom to maintain their independence for 1 of 3 residents (R34) reviewed for accommodation of needs in the sample of 21.
- D
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Inspectors wroteBased on interview and record review, the Facility failed to ensure residents were free from abuse for 2 of 2 residents (R15, R4) reviewed for abuse in the sample of 21.
- D
Respond appropriately to all alleged violations.
Inspectors wroteBased on interview and record review, the Facility failed to investigate allegations of abuse for 2 (R15, R42) of 2 residents reviewed for abuse, neglect and exploitation in the sample of 21.
- D
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Inspectors wroteBased on observation, interview and record review the facility failed to serve meals at a desirable temperature to 2 of 2 residents (R14, R41), reviewed for preferred temperature in the sample of 21.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview, and record review, the Facility failed to ensure use of proper PPE (Personal Protective Equipment) for 2 of 3 isolated residents (R39, R42) reviewed for infection control in the sample of 21.
- C
Post nurse staffing information every day.
Inspectors wroteBased on observation, interview and record review, the facility failed to post it's licensed and unlicensed staffing that are responsible for resident care when reviewed for posted nurse staffing. This failure has the potential to affect all 48 residents residing in the facility.
November 26, 2024Complaint inspection · 1 citation
- D
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Inspectors wroteBased on interview, observations, record review the facility failed to assess and monitor a Gastrostomy tube site for 1 of 2 residents (R2) reviewed for feeding tubes in a sample of 6.
October 10, 2024Complaint inspection · 6 citations
- J
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Inspectors wroteBased on interview and record review, the facility failed to protect residents from sexual abuse for 2 of 5 residents (R3, R4) reviewed for abuse in the sample of 15. This failure resulted in immediate jeopardy on 7/31/24 when the facility first identified the sexual behaviors between R3 and R4 and failed to put interventions in place to ensure every effort was taken to protect R3. This failure resulted in R4 displaying sexual behaviors towards R3, including fondling her breasts, placing his hand in her pants and R3 and R4 observed in R4's room, both with their pants and underwear down and R4 kneeling in front of R3. R3 and R4 have moderate cognitive impairment and the inability to consent to sexual relations. [...]
- J
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 provide supervision/monitoring to prevent an elopement for 1 of 6 residents (R5) reviewed for supervision to prevent elopement in the sample of 15. This failure resulted in Immediate Jeopardy on 9/20/24 when R5, eloped from the facility sometime after 3:00 AM and was found by a passerby at 6:20 AM and returned to the facility. The Immediate Jeopardy began on 9/20/24, when R5 eloped from the facility sometime after 3:00 AM and was found by a passerby at 6:20 AM and was returned to the facility. On 10/9/24 at 12:35 PM, V1, Administrator, V2, DON (Director of Nurses), V25, BOM (Business Office Manager), and V26, Regional Director, were notified of the Immediate Jeopardy. [...]
- G
Respond appropriately to all alleged violations.
Inspectors wroteBased on interview and record review, the facility failed to investigate allegations of potential abuse to prevent further sexual abuse for 2 of 5 residents (R3, R4) reviewed for investigating/implementing interventions to prevent further abuse in the sample of 15. This failure resulted in R4 displaying sexual behaviors towards R3, including fondling her breasts, placing his hand in her pants and R3 and R4 observed in R4's room, both with their pants and underwear down and R4 kneeling in front of R3. R3 and R4 have moderate cognitive impairment and the inability to consent to sexual relations.
- F
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Inspectors wroteBased on interview and record review, the facility failed to implement its abuse policy to protect a resident's right to be free from sexual abuse by a known male with sexual behaviors. This failure has the potential to affect all 47 residents residing in the facility.
- F
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 interview, observation and record review, the facility failed to have a sufficient number of Certified Nursing Assistants (CNA) working to ensure the needs of the residents were met. This failure has the potential to affect all 47 residents residing in the facility.
- 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 report potential sexual abuse to the local police department and (State Agency) for 2 of 5 residents (R3, R4) reviewed for reporting of abuse allegations in the sample of 15.
August 13, 2024Complaint inspection · 1 citation
- 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 the facility failed to ensure a urinary tract infection (UTI) was addressed and monitored in a timely manner for 1 of 3 residents (R2) reviewed for urinary tract infections in the sample of 6.
March 11, 2024Standard inspection · 12 citations
- L
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview, and record review, the facility failed to implement a system to track and trend infections, failed to implement a system for testing for the spread of COVID-19, and failed to implement infection control procedures including isolation precautions and personal protective equipment (PPE) to prevent the spread of COVID-19. These failures resulted in 23 residents developing COVID-19, including 5 residents (R37, R51, R207, R208, and R209) who expired after becoming positive with COVID-19. Two residents (R19, and R40), and one staff member (V27, Certified Nursing Assistant/CNA) are currently positive with COVID-19. These failures have the potential to affect all 52 residents in the facility. The Immediate Jeopardy began on [DATE], when R35 developed COVID-19 and the facility failed to conduct testing and surveillance to prevent the spread of COVID-19. [...]
- G
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on observation, interview, and record review, the facility failed to assess/monitor, provide treatments as ordered, and provide pressure relief to prevent pressure ulcers for 1 of 2 residents (R30) reviewed for pressure ulcers in the sample of 52. This failure resulted in R30 developing two facility acquired unstageable pressure ulcers to R30's left and right heels, and a Stage II pressure ulcer to his buttocks.
- G
Provide appropriate foot care.
Inspectors wroteBased on observation, interview and record review, the facility failed to provide foot care, including providing current treatment and consulting with a Podiatrist for further treatment, for 1 of 1 resident (R31) reviewed for foot care in the sample of 52. This failure caused R31 to be in severe pain and have a severely reddened, swollen, and very tender fourth toe and/or foot for a long period of time.
- G
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 put progressive interventions in place and provide supervision to prevent falls for 2 of 3 residents (R30, R31) reviewed for falls. This failure resulted in R30 falling and sustaining a fractured hip, and R31 falling and sustaining a fractured arm.
- F
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Inspectors wroteBased on observation, interview, and record review, the facility failed to follow the meals recipe and use the proper scoop size to ensure residents are getting the proper amount of nutrition. This failure has the potential to affect all 52 residents residing in the facility.
- 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 record review, the facility failed to store food products in a manner to ensure food quality and avoid cross contamination. This failure has the potential to affect all 52 residents residing in the facility.
- F
Have a plan that describes the process for conducting QAPI and QAA activities.
Inspectors wroteBased on interview and record review, the facility failed to implement a QAPI (Quality Assurance Performance Improvement) program and identify problems and implement interventions for issues identified. This failure has the potential to affect all 52 residents residing at the facility.
- F
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Inspectors wroteBased on interview and record review, the facility failed to implement a QAPI (Quality Assurance Performance Improvement) activities, and identify problems and implement interventions for issues identified. This failure has the potential to affect all 52 residents residing at the facility.
- F
Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
Inspectors wroteBased on interview and record review, the facility failed to designate a qualified individual(s) onsite, who is responsible for assessing, developing, implementing, monitoring, and managing the Infection Prevention and Control Program (IPCP) to prevent and control infections in the facility. This has the potential to affect all 52 residents living in the Facility. The Findings Include: On 2/28/24 at 2:11 PM, a Infection Control Meeting was held with V2, Director of Nursing (DON), V3, Minimum Data Set (MDS) Nurse, and V16, Regional Nurse. V16 stated V3 is the facility's Infection Control Preventionist, but is not certified yet. On 3/5/24 at 9:57 AM, V3 stated, I have taken the infection control modules for certification, but have not taken the test yet, because I do not have the time. [...]
- F
Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
Inspectors wroteBased on interview and record review, the facility failed to offer and provide COVID vaccines or boosters. This failure has the potential to affect all 52 residents residing in the building.
- 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 and record review, the facility failed to provide complete incontinent care for 1 of 3 residents (R15) reviewed for incontinent care in the sample of 52.
- 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 record review, the facility failed to date multi-use insulin pens and vials for 3 of 5 residents (R7, R33, R36) reviewed for medication storage in the sample of 52.
October 19, 2023Complaint inspection · 2 citations
- F
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 observation, interview, and record review, the facility failed to provide sufficient staff to assist with residents' Activities of Daily Living (Activities of Daily Living), including showers, grooming, and hygiene and answering call lights to meet residents' needs. This has the potential to affect all 52 residents living in the facility.
- E
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on observation, interview, and record review, the facility failed to provide assistance with bathing, grooming, and hygiene, for 5 of 5 residents (R3, R4, R5, R7, R8) reviewed for assistance with Activities of Daily Living (ADLs) care in the sample of 11.
September 27, 2023Complaint inspection · 1 citation
- F
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Inspectors wroteBased on interview, observation, and record review, the facility failed to post menus for all meals to be seen by residents and families. This has the potential to affect all 50 residents residing at the facility.
Fire safety inspections
19 fire safety citations on file: 5 on April 24, 2026, 10 on February 28, 2025, 4 on March 11, 2024.
Every fire safety citation19 citations
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · April 24, 2026 · Corrected (the home has a date of correction)
- F
Have simulated fire drills held at unexpected times.
K 712 · April 24, 2026 · Corrected (the home has a date of correction)
- F
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · April 24, 2026 · Corrected (the home has a date of correction)
- E
Provide properly protected cooking facilities.
K 324 · April 24, 2026 · Corrected (the home has a date of correction)
- E
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
K 354 · April 24, 2026 · Corrected (the home has a date of correction)
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · February 28, 2025 · Corrected (the home has a date of correction)
- F
Install corridor and hallway doors that block smoke.
K 363 · February 28, 2025 · Corrected (the home has a date of correction)
- F
Have simulated fire drills held at unexpected times.
K 712 · February 28, 2025 · Corrected (the home has a date of correction)
- F
Have restrictions on the use of portable space heaters.
K 781 · February 28, 2025 · Corrected (the home has a date of correction)
- E
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
K 222 · February 28, 2025 · Corrected (the home has a date of correction)
- E
Have properly located and lighted "Exit" signs.
K 293 · February 28, 2025 · 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 · February 28, 2025 · Corrected (the home has a date of correction)
- E
Provide properly protected cooking facilities.
K 324 · February 28, 2025 · Corrected (the home has a date of correction)
- E
Have restrictions on the use of highly flammable decorations.
K 753 · February 28, 2025 · Corrected (the home has a date of correction)
- E
Ensure proper usage of power strips and extension cords.
K 920 · February 28, 2025 · Corrected (the home has a date of correction)
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · March 11, 2024 · Corrected (the home has a date of correction)
- F
Have simulated fire drills held at unexpected times.
K 712 · March 11, 2024 · Corrected (the home has a date of correction)
- F
Have a battery powered remote alarm panel in a location accessible by operating personnel.
K 916 · March 11, 2024 · Corrected (the home has a date of correction)
- E
Provide properly protected cooking facilities.
K 324 · March 11, 2024 · Corrected (the home has a date of correction)