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 32 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
2G
0H
0I
Potential for more than minimal harm
15D
13E
0F
Potential for minimal harm
0A
2B
0C
December 30, 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 interviews and record reviews, the facility failed to ensure the resident's medical record was complete for 1 (Resident #1) of 3 sampled residents reviewed for activities of daily living documentation.
August 7, 2025Standard inspection · 9 citations
- G
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 reviews, the facility failed to protect a resident's right to be free from verbal and mental abuse by another resident for 1 (Resident #30) of 3 (Resident #15, Resident #30, Resident #33) sampled residents investigated for abuse. This deficient practice resulted in an actual harm on 07/06/2025 at approximately 9:30PM, when Resident #15, a resident with known aggressive behaviors towards staff and other residents, was overheard by her roommate, Resident #30, during a telephone conversation where Resident #15 used racial slurs so loudly that Resident #30 overheard the conversation. On 07/07/2025 at approximately 2:30PM, Resident #30 was observed by staff crying. Resident #30 informed S9Certified Nursing Assistant (CNA) of the conversation that was overheard on 07/06/2025 when Resident #15 used racial slurs. [...]
- E
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Inspectors wroteBased on observation, interviews, and record reviews, the facility failed to:1. Ensure expired medications were not available for resident use (Medication Cart A);2. Ensure the facility's shift verification of controlled substances count sheet was completed every shift (Medication Cart A); and,3. Ensure medications were documented as administered on the electronic Medication Administration Record (eMAR) when administered (Resident #83). This deficient practice was identified for 1 (Medication Cart A) of 2 (Medication Cart A, Medication Cart B) sampled medication carts observed during medication storage observations and 1 (Resident #83) of 1 (Resident #83) sampled residents investigated for hospice.
- E
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to:1. Ensure the scoop used to serve ice did not have the handle submerged in the residents' ice (Ice Chest A); 2. Ensure staff properly handled soiled linen (S12Certified Nursing Assistant); and, 3. Ensure staff implemented Enhanced Barrier Precautions (EBP) for a resident (Resident #76). This deficient practice was identified for 1 (Ice Chest A) of 2 (Ice Chest A, Ice Chest B) ice chests used to provide ice to residents; 1 (S12CNA) of 1 (S12CNA) CNAs observed during random linen handling observations; and, 1 (Resident #76) of 12 (Resident #5, Resident #9, Resident #10, Resident #17, Resident #32, Resident #70, Resident #76, Resident #77, Resident #81, Resident #85, Resident #90, Resident #91) sampled residents observed on EBP.
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on interviews and record reviews, the facility failed to report an allegation of verbal and mental abuse to the state agency for 1 (Resident #30) of 3 (Resident #15, Resident #30, Resident #33) sampled residents reviewed for abuse.
- D
Respond appropriately to all alleged violations.
Inspectors wroteBased on interviews and record reviews, the facility failed to have documented evidence a thorough investigation was completed following allegations of verbal and mental abuse for 1 (Resident #30) of 3 (Resident #15, Resident #30, Resident #33) sampled residents investigated for abuse.
- D
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to implement interventions for residents who were identified at risk for falls for 2 (Resident #3, Resident #7) of 8 (Resident #3, Resident #7, Resident #8, Resident #12, Resident #16, Resident #17, Resident #30, Resident #73) sampled residents investigated for accidents.
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to:1. Follow a physician's order for oxygen administration (Resident #33, Resident #63); and, 2. Ensure oxygen tubing was changed and dated weekly (Resident #33, Resident #63). This deficient practice was identified for 2 (Resident #33, Resident #63) of 2 (Resident #33, Resident #63) sampled residents investigated for respiratory care.
- D
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on observations, interviews, and record review, the facility failed to: 1. ensure food stored in the facility's refrigerator was labeled with an opened date and/or discarded prior to the item's expiration date; and,2. ensure scoops were not stored inside the dry goods storage bins.
- B
Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.
Inspectors wroteBased on observation, interview, and record review, the facility failed to post the most recent survey results in a place readily accessible to residents.
April 3, 2025Complaint inspection · 2 citations
- 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 interviews and record reviews, the facility failed to ensure the required number of nursing staff members were present and working in the facility for 22 (10/19/2024, 10/20/2024, 10/26/2024, 10/27/2024, 11/02/2024, 11/03/2024, 11/10/2024, 11/16/2024, 02/16/2025, 02/18/2025, 02/22/2025, 02/23/2025, 02/24/2025, 03/01/2025, 03/02/2025, 03/03/2025, 03/04/2025, 03/05/2025, 03/07/2025, 03/08/2025, 03/09/2025, 03/13/2025) of 53 (10/05/2024, 10/06/2024, 10/12/2024, 10/13/2024, 10/19/2024, 10/20/2024, 10/26/2024, 10/27/2024, 11/02/2024, 11/03/2024, 11/09/2024, 11/10/2024, 11/16/2024, 11/17/2024, 11/23/2024, 11/24/2024, 11/30/2024, 12/07/2024, 12/08/2024, 12/14/2024, 12/15/2024, 12/21/2024, 12/22/2024, 12/28/2024, 12/29/2024, 02/16/2025, 02/17/2025, 02/18/2025, 02/19/2025, 02/20/2025, 02/21/2025, 02/22/2025, 02/23/2025, 02/24/2025, 02/25/2025, 02/26/2025, 02/27/2025, 02/28/2025, [...]
- D
Provide or get specialized rehabilitative services as required for a resident.
Inspectors wroteBased on interviews and record reviews, the facility failed to ensure a resident received the required physical therapy services for 1 (Resident #1) of 3 (Resident #1, Resident #2, Resident #3) residents investigated for rehabilitation services.
August 22, 2024Standard inspection · 6 citations
- G
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on observation and interview, the facility failed to ensure residents were supervised and kept free from thermal burns for 2 (Resident #19 and Resident #49) of 2 (Resident #19 and Resident #49) sampled residents investigated for an accident/hazard related to burns. This deficient practice resulted in actual harm when on 02/04/2024 for Resident #49 and on 02/21/2024 for Resident #19, when Resident #19 and Residnet #49 were left unsupervised and sustained first degree superficial burns from spilled coffee.
- E
Provide and implement an infection prevention and control program.
Inspectors wroteBased on record review, observations, and interviews, the facility failed to ensure: 1. S8Certified Nursing Assistant (CNA) performed hand hygiene after providing incontinence care for 1 (Resident #19) of 1 (Resident #19) sampled residents observed during incontinence care; 2. S5Treatment Nurse (TN) performed hand hygiene during wound care for 2 (Resident #5 and Resident #17) of 3 (Resident #5, Resident #14, and Resident #17) sampled residents observed for wound care; 3. S6Licensed Practical Nurse (LPN) did not handle Resident #86's medication with ungloved hands for 1 (S6LPN) of 3 (S6LPN, S7LPN, and S11LPN) nurses observed during medication administration; 4. S6LPN performed hand hygiene after removing her gloves and prior to applying clean gloves for 1 (S6LPN) of 3 (S6LPN, S7LPN, and S11LPN) nurses observed during medication administration; 5. [...]
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on observations, record review, and interviews, the facility failed to ensure a pressure reducing wheelchair cushion was being utilized for a resident assessed as being at high risk for skin breakdown for 1 (Resident #5) of 3 (Resident #5, Resident #14, and Resident #17 sampled residents investigated for pressure injuries, pressure ulcers, or skin integrity.
- 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, record reviews, and interviews the facility failed to ensure S6Licensed Practical Nurse (LPN) disposed of a resident's medication as required for 1 (S6LPN) of 3 (S6LPN, S7LPN, and S11LPN) nurses observed during medication administration.
- D
Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
Inspectors wroteBased on record reviews and interviews, the facility failed to: 1. Ensure a resident's most recent hospice plan of care and recertification of terminal illness was obtained from the contracted hospice agency (Resident #13); and, 2. Ensure facility staff were aware of the contracted hospice agency's responsibilities in implementing the hospice plan of care (Resident #13). This deficient practice was identified for 1 (Resident #13) of 1 (Resident #13) sampled resident reviewed for hospice services.
- B
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Inspectors wroteBased on record reviews and interview, the facility failed to ensure Minimum Data Set (MDS) assessments were transmitted within 14 days of completion for 3 (Resident #28, Resident #44, and Resident #241) of 5 (Resident #4, Resident #28, Resident #44, Resident #73, and Resident #241) residents reviewed for resident assessments.
October 5, 2023Standard inspection · 14 citations
- E
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Inspectors wroteBased on interviews and record review, the facility failed to ensure a baseline care plan was initiated with 48 hours of admission for 3 (Resident #21, Resident #74, and Resident #237) of 19 (Resident #1, Resident #5, Resident #6, Resident #7, Resident #9, Resident #11, Resident #12. Resident #14, Resident #19, Resident #21, Resident #27, Resident #36, Resident #49, Resident #69, Resident #72, Resident #74, Resident #82, Resident #235, and Resident #237) sampled residents whose care plan was reviewed in the final investigation sample.
- E
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 record review, observation, and interviews, the facility failed to administer a resident's water flush per physician orders for 1 (Resident #11) of 1 (Resident #11) sampled residents investigated for enteral feedings.
- E
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a resident's continuous positive airway pressure (CPAP) mask was contained for 1 (Resident #6) of 4 (Resident #5, Resident #6, Resident #27, and Resident #237) sampled residents reviewed for respiratory care.
- E
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Inspectors wroteBased on record review and interviews, the facility failed to ensure the accurate dispensation of controlled medications for 1 (medication cart c) of 2 medication carts (medication cart a and medication cart c) observed and reviewed for accurate dispensation of controlled medications.
- 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 record reviews, observations, and interviews, the facility failed to ensure expired medications and dressings were not available for residents use.
- E
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: 1. Ensure expired food was not available for resident consumption; and 2. Appropriately date and label food that was opened and available for use.
- E
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on record review and interviews the facility failed to ensure staff did not present a medical record as being accurate prior to a resident's death and ensure staff did not alter a medical record after a resident had expired. This deficient practice was identified for 1 (Resident #74) of 3 (Resident #19, Resident #74, and Resident #82) closed records reviewed.
- E
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observations, interviews, and record reviews the facility failed to: 1. Ensure S26Certified Nurse Assistant (CNA) performed hand hygiene during catheter care for 1 (Resident #234) of 4 residents (Resident #21, Resident #27, Resident #234, and Resident #236) investigated for infection control; 2. Ensure proper use of personal protective equipment (PPE) for 3 Coronavirus Disease 2019 (COVID-19) positive residents (Resident #21, Resident #27, and Resident #236) of 7 (Resident #5, Resident #16, Resident #21, Resident #27, Resident #39, Resident #41, and Resident #236) COVID-19 positive residents; 3. Identify and test residents and staff that were in close contact with COVID-19 positive residents per the facility's COVID-19 Policy; and 4. Ensure signage was placed at the front door to notify family and visitors of the current COVID-19 outbreak.
- E
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
Inspectors wroteBased on record review and interviews, the facility failed to provide in-service training for nurse aides to ensure the continuing competence of nurse aides and no less than 12 hours per year for 1 (S11Certified Nurse Assistant (CNA) Coordinator) of 5 (S11Certified Nurse Coordinator, S12Certified Nurse Assistant, S13Certified Nurse Assistant, S14Certified Nurse Assistant, S24Agency Certified Nurse Assistant) staff training records reviewed for in-service training.
- 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 record review and interviews, the facility failed to develop and implement a comprehensive person-centered care plan for 3 ( Resident #12, Resident #19, and Resident #69) of 19 (Resident #1, Resident #5, Resident #6, Resident #7, Resident #9, Resident #11, Resident #12, Resident #14, Resident #19, Resident #21, Resident #27, Resident #36, Resident #49, Resident #69, Resident #72, Resident #74, Resident #82, Resident #235, and Resident #237) sampled residents whose care plan was reviewed in the final investigation sample.
- 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 record review and interview the facility failed to ensure the facility had eight consecutive hours per day of registered nurse (RN) services for 2 of the 40 days reviewed for RN staffing hours.
- D
Post nurse staffing information every day.
Inspectors wroteBased on observation and interview, the facility failed to have the nurse staffing data was not located in a prominent place that was readily accessible to residents and visitors.
- D
Have a plan that describes the process for conducting QAPI and QAA activities.
Inspectors wroteBased on record review and interview, the facility failed to ensure an effective Quality Assurance and Performance Improvement program was developed, implemented, and/or maintained.
- D
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
Inspectors wroteBased on record review and interview, the facility failed to: 1. Ensure the Quality Assessment and Assurance committee met at least quarterly to identify facility issues and coordinate and evaluate performance improvement projects; and, 2. Ensure the Quality Assessment and Assurance committee included the required members.
Fire safety inspections
21 fire safety citations on file: 2 on August 7, 2025, 3 on August 22, 2024, 16 on October 5, 2023.
Every fire safety citation21 citations
- D
Inspect, test, and maintain automatic sprinkler systems.
K 353 · August 7, 2025 · Corrected (the home has a date of correction)
- C
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
K 521 · August 7, 2025 · Corrected (the home has a date of correction)
- D
Inspect, test, and maintain automatic sprinkler systems.
K 353 · August 22, 2024 · Corrected (the home has a date of correction)
- D
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
K 761 · August 22, 2024 · Corrected (the home has a date of correction)
- C
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
K 521 · August 22, 2024 · Waiver
- F
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
K 521 · October 5, 2023 · Corrected (the home has a date of correction)
- E
Install an approved automatic sprinkler system.
K 351 · October 5, 2023 · Corrected (the home has a date of correction)
- E
Inspect, test, and maintain automatic sprinkler systems.
K 353 · October 5, 2023 · Corrected (the home has a date of correction)
- E
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · October 5, 2023 · Corrected (the home has a date of correction)
- E
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
K 741 · October 5, 2023 · Corrected (the home has a date of correction)
- D
Establish an Emergency Preparedness Program (EP).
E 1 · October 5, 2023 · Corrected (the home has a date of correction)
- D
Develop and maintain an Emergency Preparedness Program (EP).
E 4 · October 5, 2023 · Corrected (the home has a date of correction)
- D
Conduct risk assessment and an All-Hazards approach.
E 6 · October 5, 2023 · Corrected (the home has a date of correction)
- D
Develop Emergency Preparedness policies and procedures.
E 13 · October 5, 2023 · Corrected (the home has a date of correction)
- D
Establish procedures for tracking staff and patients during an emergency.
E 18 · October 5, 2023 · Corrected (the home has a date of correction)
- D
Establish policies and procedures for sheltering.
E 22 · October 5, 2023 · Corrected (the home has a date of correction)
- D
Provide primary/alternate means for communication.
E 32 · October 5, 2023 · Corrected (the home has a date of correction)
- D
Establish methods for sharing information.
E 33 · October 5, 2023 · Corrected (the home has a date of correction)
- D
Establish emergency prep training and testing.
E 36 · October 5, 2023 · Corrected (the home has a date of correction)
- D
Conduct testing and exercise requirements.
E 39 · October 5, 2023 · Corrected (the home has a date of correction)
- D
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · October 5, 2023 · Corrected (the home has a date of correction)