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 49 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
2G
0H
0I
Potential for more than minimal harm
26D
13E
6F
Potential for minimal harm
0A
0B
2C
July 30, 2026Complaint inspection · 8 citations
- G
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Inspectors wroteBased on interview and record review, the facility failed to ensure medications were free from unnecessary use by administering Narcan (naloxone) without a physician order or documented clinical indication for 1 (#4) of 1 resident reviewed for unnecessary medications. The failure resulted in precipitated opioid withdrawal symptoms, increased resident distress, and hospitalization, and the resident received additional medical treatment.
- E
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 ensure Facility-Reported Incidents were reported to the State Survey Agency within the required timeframe for 2 (#s 10 and 14), and failed to submit the results of investigations to the State Survey Agency within the required five-working-day timeframe for 9 (#s 4, 5, 9, 10, 11, 12, 13, 14 and 16) of 19 residents reviewed for Facility-Reported Incidents. The failures delayed the State Survey Agency's receipt of information necessary to evaluate the facility's response to allegations involving resident safety, placing residents at increased risk due to delayed regulatory oversight.
- E
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on interview and record review, the facility failed to provide timely toileting and activities of daily living (ADL) assistance for 3 (#s 2, 5, and 6) of 6 sampled residents who required staff assistance with toileting and personal care. The failure resulted in resident #2 remaining on the toilet for a prolonged period and residents #5 and #6 not receiving required toileting and ADL assistance, placing the residents at risk for discomfort, loss of dignity, unmet care needs, pain, skin impairment, and injury.
- E
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Inspectors wroteBased on interview and record review, the facility failed to ensure an effective system for timely reporting of allegations of abuse and neglect following a previous F609 deficiency for the same concern. The facility's continued failure to timely report allegations after implementing corrective measures demonstrated ineffective administrative oversight and failure to implement, monitor, and sustain the reporting process for 9 (#s 4, 5, 9, 10, 11, 12, 13, 14 and 16) of 19 residents. The failure placed residents at risk for delays in notification, investigation, protection, and response following allegations of abuse or neglect. Review of the facility's previous F609 deficiency dated 1/29/26 showed the facility was cited for late reporting for allegations of neglect and abuse for three residents. The facility submitted a plan of correction for the deficient practices identified. [...]
- D
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Inspectors wroteBased on interview and record review, the facility failed to implement a system to ensure a resident's current Physician Orders for Life-Sustaining Treatment (POLST) form was immediately available to staff during a medical emergency for 1 (#12) of 5 sampled residents reviewed for advance directives. The failure resulted in CPR being initiated despite the resident's documented wishes to forgo resuscitation.
- D
Respond appropriately to all alleged violations.
Inspectors wroteBased on observation, interview, and record review, the facility failed to thoroughly investigate allegations of abuse and neglect for 1 (#3) of 9 sampled residents reviewed for abuse or neglect. The failure resulted in an incomplete investigation that did not demonstrate the facility adequately evaluated the allegation, determined the facts, or documented findings and corrective actions, placing residents at risk for unaddressed abuse and inadequate protection.
- 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 provide supervision and assistance during bathing and transfers consistent with the resident's assessed needs and care plan for 1 (#14) of 3 residents sampled for falls. The failure resulted in resident #14 falling forward from a shower chair, placing the resident at risk for injury.
- D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Inspectors wroteBased on interview and record review, the facility failed to provide pharmacy services that ensured stock emergency medications were obtained, available, and administered only as authorized by physician orders for 1 (#4) of 1 resident reviewed for pharmacy services. The failure increased the risk residents could receive emergency medications without appropriate authorization or clinical indication.
January 29, 2026Standard inspection, Complaint inspection · 23 citations
- 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 utilize and maintain a QAPI system to identify performance improvement issues related to grievances, abuse and neglect allegations, Bowel and Bladder care for dependent residents, and infection control; and failed to show how the QAPI committee was involved in addressing these quality of care issues and the lack of policies and procedures which could negatively affect many, or all, of the 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 have an annual improvement project that focuses on high risk or problem-prone areas identified through the data collection and analysis.
- F
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure infection control practices were followed when providing incontinence care for 1 (#21); hand hygiene practices were followed for 1 (#7); posted PPE requirements were followed for 1 (#21); transporting of dirty linens; storage of clean linens; and maintained cleanable surfaces for 34 sampled residents. These deficient practices place all residents at increased risk of infection.
- F
Implement a program that monitors antibiotic use.
Inspectors wroteBased on interview and record review, the facility failed to implement and maintain an antibiotic stewardship program in order to promote the appropriate use of antibiotics. This deficient practice increased the risk for residents to develop drug-resistant organisms and/or complications.
- E
Honor the resident's right to organize and participate in resident/family groups in the facility.
Inspectors wroteBased on interview and record review, the facility failed to provide evidence to show the facility took action to acknowledge and resolve, or attempt to resolve, all concerns brought forth by the resident council. The failure affected any resident who had concerns that remained unresolved, or who had an interest in the council's activities.
- E
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Inspectors wroteBased on interviews and record review, the facility failed to ensure grievances either voiced or provided to the facility were followed up on and resolved, and this was a system failure, to include: not assisting with verbal grievances, not identifying concerns and resolving them, not notifying the party filing the grievance of the resolution, not documenting steps taken to resolve the grievance, and not maintaining the grievance for 3 years from the date the grievance decision was issued for 1 (#21) of 34 sampled residents. This deficient practice affected all residents with grievances related to concerns or quality-of-care issues, which could negatively affect many or all of the residents residing at the facility.
- E
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure residents were free from abuse and/or neglect for 5 (#s 7, 11, 18, 21, and 62) of 34 sampled residents. This deficient practice resulted in psychosocial distress for resident #7 feeling intimidated and scared to return to her room; on-going psychosocial distress with resident #11 feeling scared due to the physical and verbal abuse (with fear of a repeat event occurring with a fellow resident); resident #21 having her head hit the wall during peri care (with fear of a repeat event occurring); and neglecting to provide resident #s 7, 18 and 21 proper toileting care, which may have contributed to a urinary tract infection for resident #21.
- E
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on observations, interviews, and record review, the facility failed to report allegations of neglect and abuse to the State Survey Agency for 3 (#s 7, 18, and 21) of 34 sampled residents. This deficient practice resulted in resident #7 having fear of going to her room, resident #21 had fear of having her head hit the wall during care sessions, and for resident #21 voiced fear of having her head hit the wall during care (recurrent), and neglect of care related to care and services not being provided as needed for #s 7, 18, and 21. Refer to F600 for more information on failure to prevent abuse/neglect.
- 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 ensure proper ADL (Activities of Daily Living) cares were completed, specifically for 1 (#28) who was not receiving toenail care while her roommate #5 received toenail care biweekly; and for 3 (#s 11, 59, and 77) were not receiving showers from the facility. This deficient practice resulted in a resident feeling unclean and unkept.
- D
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 interview and record review, the facility failed to exercise reasonable care for the protection of a resident's property from loss or theft for 1 (#6) of 34 sampled residents. This deficient practice placed resident #6 at risk for continued loss of personal property and lack of resolution for reported concerns.
- D
Respond appropriately to all alleged violations.
Inspectors wroteBased on interview and record review, the facility failed to fully investigate an abuse allegation for 2 (#s 11 and 62) of 34 sampled residents. This deficient practice resulted in psychosocial distress for resident #11 who was feeling scared due to the physical and verbal abuse (with fear of a repeat event occurring with a fellow resident).
- 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 interview and record review, the facility failed to permit each resident to remain in the facility and not transfer or discharge the resident from the facility without written notice and a safe discharge plan for 1 (#72) of 3 discharged residents subsampled.
- D
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Inspectors wroteBased on interview and record review, the facility failed to notify the resident and or the resident's representative, in writing, of the reason for transfer when transferring a resident to the hospital, for 1 (#35) of 34 sampled residents.
- D
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Inspectors wroteBased on interview and record review, the facility failed to ensure a resident's PTSD triggers were noted on the resident's Care Plan for 1 (#61) of 34 sampled residents.
- D
Provide activities to meet all resident's needs.
Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure residents with hearing and vision limitations were provided group and individual activities to meet their needs and preferences for 1 (#1) of 34 sampled residents. This deficient practice resulted in resident #1 self-isolating.
- D
Assist a resident in gaining access to vision and hearing services.
Inspectors wroteBased on observation, interview, and record review, the facility failed to offer and ensure hearing aids were properly working for 1 (#63) of 34 sampled residents.
- D
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure incontinent residents received treatment and services to prevent urinary tract infections, avoid skin breakdown, and maintain continence to the degree possible for 3 (#s 7, 18, and 21) of 34 sampled residents. This deficient practice may have contributed to resident #21 developing a urinary tract infection and resident #7 developing a red, inflamed rash in two areas above and below her pannus.
- D
Provide enough food/fluids to maintain a resident's health.
Inspectors wroteBased on observation, interview, and record review, the facility failed to offer fluids and nutrition to a dependent resident for 1 (#59) of 34 sampled residents.
- 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 observation, interview, and record review, the facility failed to ensure tube feed bags were changed every 24 hours for 1 (#11) of 2 sampled residents receiving tube feedings.
- D
Provide care or services that was trauma informed and/or culturally competent.
Inspectors wroteBased on interview and record review, the facility failed to ensure a resident with post-traumatic stress disorder received trauma-informed care, accounting for resident's experiences and preferences in order to eliminate or mitigate triggers that may cause re-traumatization of the resident for 1 (#61) of 34 sampled residents.
- D
Ensure medication error rates are not 5 percent or greater.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a medication error rate was less than 5% during 2 (#s 25 and 74) of 26 observed medication administrations. There was an observed medication error rate of 7.41%.
- D
Provide or obtain dental services for each resident.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure dental services were offered in a timely manner for 2 (#'s 4 and 57) of 34 sampled residents. The failure placed residents at elevated risk for oral pain, infection, impaired nutrition, and decline in oral health.
- D
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, the facility failed to provide a resident preference for Jello to 1 (#11) of 34 sampled residents.
May 6, 2025Complaint inspection · 3 citations
- 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 identify or correct deficient practice(s) through the utilization of their QAPI process related to facility-reported events and personal belongings inventory management for 1 (#57) of 6 sampled residents. The deficient practice placed all residents at elevated risk for theft or loss of personal belongings.
- D
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 interview and record review, the facility failed to exercise reasonable care for the protection of a cognitively impaired resident's property from loss or theft, when the resident admitted with a very large sum of money, which was in his possession, but was not returned or found upon the resident's death, for 1 (#57) of 6 sampled residents.
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on interview and record review, facility staff failed to report investigative findings for a reportable event, within the required timeframe, for 1 (#4) of 6 sampled residents.
December 19, 2024Standard inspection, Complaint inspection · 5 citations
- F
Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
Inspectors wroteBased on interview and record review, the facility failed to submit the mandatory staffing information for the fourth quarter of federal fiscal year 2024, as required by the Centers for Medicare and Medicaid.
- E
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Inspectors wroteBased on interview and record review, the facility failed to ensure all controlled substance medications were accurately administered, accounted, and documented for 4 (#s 24, 27, 38, and 109) of 4 sampled and supplemental residents receiving physician ordered controlled substances.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff practiced proper hand hygiene and appropriate use of personal protective equipment, during care of residents on enhanced barrier precautions, for 1 (#43) of 18 sampled residents. During an observation on 12/18/24 at 9:04 a.m., staff member F was training a new staff nurse, staff member G, on medication pass for residents. Staff member F went into resident #43's room to set up an area to administer scheduled medications by enteral (tube) feeding. Staff member F put on a pair of gloves before entering resident #43's room to administer the medications. Staff member F left resident #43's room to go to a supply room to obtain supplies for the tube feeding with the same pair of gloves on. [...]
- C
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Inspectors wroteBased on interview and record review, the facility failed to provide a written notice of the reason for a facility-initiated transfer to the resident or the resident's representative, for 3 (#s 7, 37, and 111) of 18 sampled residents.
- C
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Inspectors wroteBased on interview and record review, the facility failed to provide the required bed hold notice to the resident or the resident's representatives prior to, or timely after, a transfer, for 3 (#s 7, 37 and 111) of 18 sampled residents.
February 14, 2024Complaint inspection · 3 citations
- E
Ensure services provided by the nursing facility meet professional standards of quality.
Inspectors wroteBased on interview and record review, the facility nursing staff failed to meet professional standards of quality by not ensuring all controlled substance medications were accurately accounted for and documented in a resident's EHR, for 3 (#s 1, 4, and 7) of 3 sampled residents for medications. This deficient practice affected the accuracy of medication administration records, had the potential to result in administration errors, and to allow unidentified controlled substance diversion to occur.
- E
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Inspectors wroteBased on interview and record review, the facility failed to develop and implement a system that accounted for all Schedule II controlled substance medications, from receipt to administration or destruction, for 3 (#s 1, 4, and 7) of 3 sampled residents for medications. The deficient practice resulted in a discrepancy between the number of doses removed from secure storage, and the number of doses administered to a resident, which allowed for an increased risk for diversion of controlled substance medications.
- D
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were free from abuse by a staff member for 1 (#2) of 3 sampled residents.
December 7, 2023Standard inspection · 2 citations
- D
Ensure each resident receives an accurate assessment.
Inspectors wroteBased on interview and record review, the facility failed to ensure resident medications were accurately coded on the resident's MDS for 1 (#21) of 5 sampled residents.
- D
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Inspectors wroteBased on interview and record review, the facility failed to revise a resident's care plan after completion of a course of antibiotics for tooth pain, for 1 (#22) of 1 sampled residents.
October 12, 2023Complaint inspection · 5 citations
- G
Ensure that residents are free from significant medication errors.
Inspectors wroteBased on interview and record review, the facility failed to ensure 1 (#3) of 14 sampled residents was free from a significant medication error requiring hospitalization. Resident #3 was given 22.5 mls of Methadone instead of the ordered 10 mls.
- 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 ensure the bathing and dining needs were completed for those residents requiring assistance for 5 (#s 6, 8, 10, 13, and 14) of 14 sampled residents. This failure resulted in a delay of residents receiving showers, and a delay in residents receiving meals and assistance, in a timely manner.
- E
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 ensure an adequate number of staff were available for necessary care and services for bathing and dining needs for 5 (#s 6, 8, 10, 13, and 14) of 14 sampled residents. This failure resulted in residents not receiving showers and a delay in residents receiving meals and assistance in a timely manner.
- 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 protect a resident from neglect by a staff member by not providing care when answering a call light for 1 (#8) of 5 sampled residents.
- D
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a wheel chair was evaluated as a possible restraint for 1 (#10) of 14 sampled residents. Resident #10 was not able to use the wheel chair for mobility and relied on staff to get her from her room to activities and meals.
Fire safety inspections
21 fire safety citations on file: 7 on January 29, 2026, 8 on December 19, 2024, 6 on December 7, 2023.
Every fire safety citation21 citations
- F
Establish staff and initial training requirements.
E 37 · January 29, 2026 · Corrected (the home has a date of correction)
- F
Conduct testing and exercise requirements.
E 39 · January 29, 2026 · Corrected (the home has a date of correction)
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · January 29, 2026 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · January 29, 2026 · Corrected (the home has a date of correction)
- F
Have simulated fire drills held at unexpected times.
K 712 · January 29, 2026 · Corrected (the home has a date of correction)
- D
Keep aisles, corridors, and exits free of obstruction in case of emergency.
K 211 · January 29, 2026 · Corrected (the home has a date of correction)
- D
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 · January 29, 2026 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · December 19, 2024 · Corrected (the home has a date of correction)
- F
Ensure that testing and maintenance of electrical equipment is performed.
K 921 · December 19, 2024 · Corrected (the home has a date of correction)
- E
Install smoke barrier doors that can resist smoke for at least 20 minutes.
K 374 · December 19, 2024 · Corrected (the home has a date of correction)
- D
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 · December 19, 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 · December 19, 2024 · Corrected (the home has a date of correction)
- D
Have properly installed hallway dispensers for alcohol-based hand rub.
K 325 · December 19, 2024 · Corrected (the home has a date of correction)
- D
Properly select, install, inspect, or maintain portable fire extinguishes.
K 355 · December 19, 2024 · Corrected (the home has a date of correction)
- D
Have proper medical gas storage and administration areas.
K 923 · December 19, 2024 · Corrected (the home has a date of correction)
- F
Provide properly protected cooking facilities.
K 324 · December 7, 2023 · Corrected (the home has a date of correction)
- E
Inspect, test, and maintain automatic sprinkler systems.
K 353 · December 7, 2023 · Corrected (the home has a date of correction)
- E
Install corridor and hallway doors that block smoke.
K 363 · December 7, 2023 · Corrected (the home has a date of correction)
- E
Install smoke barrier doors that can resist smoke for at least 20 minutes.
K 374 · December 7, 2023 · Corrected (the home has a date of correction)
- E
Ensure that smoke control systems are tested and documented in accordance with established engineering principles.
K 771 · December 7, 2023 · Corrected (the home has a date of correction)
- D
Meet requirements for the installation and maintenance of electrical systems.
K 911 · December 7, 2023 · Corrected (the home has a date of correction)