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 36 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
29D
7E
0F
Potential for minimal harm
0A
0B
0C
October 28, 2025Complaint inspection · 2 citations
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on record review and interview, the facility failed to ensure there was adequate monitoring and interventions implemented for constipation related to a delay in treatment for a resident with no documented bowel movements for over 5 days for 1 of 3 residents reviewed for change in condition. (Resident J)
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observation, record review and interview, the facility failed to ensure a resident received the necessary care and treatment related to incorrect oxygen flow rate for 1 of 3 residents reviewed for respiratory care. (Resident E)
August 8, 2025Standard inspection · 10 citations
- E
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Inspectors wroteBased on observation and interview, the facility failed to ensure the residents' environment was clean and in good repair related to dirty floors, bed rails, baseboards, and ceiling vents, loose trim on floors and baseboards, and marred walls and doors in 2 of 2 units. (The East and [NAME] Units)
- D
Allow residents to self-administer drugs if determined clinically appropriate.
Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure residents had physician's orders for medications and an assessment to self-administer their own medications for 1 of 2 residents reviewed for self-administration of medication. (Resident 20)
- 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 record review and interview, the facility failed to promptly notify the resident's physician of multiple refusals of sliding scale insulin for 1 of 5 residents reviewed for unnecessary medication. (Resident 4)
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure a wound vacuum and tubing were kept off the floor and treatments were in place for a non-pressure skin area for 1 of 2 residents reviewed for non-pressure skin areas, a resident was treated for constipation for 1 of 1 resident reviewed for constipation and a resident with a NG tube was assessed and monitored for complications for 1 of 1 resident reviewed for hospice. (Residents 90, 4, and 11)
- D
Assist a resident in gaining access to vision and hearing services.
Inspectors wroteBased on record review and interview, the facility failed to ensure a resident received routine eye care and was seen by an Optometrist for 1 of 1 resident reviewed for vision. (Resident 4)
- D
Provide appropriate foot care.
Inspectors wroteBased on record review and interview, the facility failed to ensure residents received foot care and routine visits with the podiatrist for 1 of 1 resident reviewed for foot care. (Resident 4)
- D
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
Inspectors wroteBased on record review and interview, the facility failed to ensure psychological services were offered for a resident exhibiting signs and symptoms of depression for 1 of 1 resident reviewed for mood and behavior. (Resident 5)
- 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 review, and interview, the facility failed to store over the counter medications and insulin securely in a locked medication cart for 2 of 2 residents reviewed for medication storage. (Residents 42 and 3)
- D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on observation, record review and interview, the facility failed to maintain clinical records that were complete and accurately documented related to a lack of documentation of blisters for 1 of 1 resident reviewed for non-pressure skin conditions (Resident 67), and inaccurate meal consumption documentation for a resident who was NPO (nothing by mouth) for 1 of 1 resident reviewed for hospice. (Resident 11)
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, record review and interview, the facility failed to ensure infection control practices were in place and implemented related to enhanced barrier precautions (EBP) not followed while assisting a resident who had a Foley catheter to the bathroom and emptying an indwelling Foley catheter during random infection control observations. (Residents 5 and 56)
March 31, 2025Complaint 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 record review and interview, the facility failed to ensure the responsible party was notified of a unwitnessed fall in a timely manner for 1 of 3 residents reviewed for accidents. (Resident B)
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure fall interventions were updated to prevent injury for a resident with multiple falls for 1 of 3 residents reviewed for accidents. (Resident D)
September 11, 2024Complaint inspection · 2 citations
- D
Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
Inspectors wroteBased on record review and interview, the facility failed to ensure a discharge summary was completed at the time of discharge for a resident going home who required home health services for 1 of 3 residents reviewed for discharge (Resident B).
- D
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Inspectors wroteBased on record review and interview, the facility failed to ensure there was an adequate indication for use of a scheduled antifungal powder for 1 of 3 residents reviewed for non-pressure skin conditions (Resident B)
June 14, 2024Standard inspection · 3 citations
- D
Assist a resident in gaining access to vision and hearing services.
Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure a resident received the assistive devices needed to maintain hearing related to hearing aids not administered to a resident as per the physician's order for 1 of 2 residents reviewed for vision/hearing. (Resident 4)
- D
Provide enough food/fluids to maintain a resident's health.
Inspectors wroteBased on record review and interview, the facility failed to ensure food consumption logs were completed for residents with a history of weight loss for 3 of 5 residents reviewed for nutrition. (Residents 59, 14, and 42)
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure oxygen was at the correct flow rate for 2 of 3 residents reviewed for oxygen use. (Residents 42 and 48)
April 2, 2024Complaint inspection · 4 citations
- E
Allow residents to self-administer drugs if determined clinically appropriate.
Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure residents had an assessment and Physician's Orders to self-administer their own medications, for 4 of 4 residents reviewed for self-administration of medication. (Residents C, F, G and H)
- E
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure a resident was sent to the hospital in a timely manner, related to complaints of increased pain and leg swelling, for 1 of 3 residents reviewed for accidents. The facility also failed to ensure treatments were completed for diabetic ulcers and an assessment was completed for new non-pressure wounds to the toes, for 3 of 3 residents reviewed for skin conditions non-pressure related. (Residents D, B, C, and F)
- 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 record review and interview, the facility failed to ensure the resident's Physician was notified in a timely manner of increased pain and leg swelling, for 1 of 3 residents reviewed for accidents. (Resident D)
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on record review and interview, the facility failed to ensure adequate supervision was provided in the shower for a resident who was leaning in their shower chair, for 1 of 3 residents reviewed for accidents. (Resident D)
April 28, 2023Standard inspection · 13 citations
- E
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure skin tears and areas of bruising were assessed, monitored, and treatments were completed as ordered for 4 of 5 residents reviewed for skin conditions non-pressure related and 1 of 2 residents reviewed for anticoagulant (a blood thinner) medication side effects. The facility also failed to ensure an edema glove was in use as ordered for 1 of 1 residents reviewed for edema and treatment was completed timely for 1 of 1 residents reviewed for a change in condition. (Residents 1, 74, 181, 59, and 384)
- E
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure oxygen was set at the correct flow rate and positioned correctly for 5 of 5 residents reviewed for oxygen. (Residents 1, 132, 59, 69, and 37)
- 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 and interview, the facility failed to ensure a sanitary kitchen related to two dishes of food sitting open and not covered on the top of the stove and an accumulation of grease and dried food spillage in and around the stove in 1 of 1 kitchen observed. (Main Kitchen). This had the potential to affect 87 residents who received food from the kitchen.
- E
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Inspectors wroteBased on observation and interview, the facility failed to ensure the kitchen area was clean and in good repair related to dirty floors, cabinets, pipes and walls in 1 of 1 kitchens observed. (Main Kitchen)
- D
Allow residents to self-administer drugs if determined clinically appropriate.
Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure residents had an assessment to self-administer their own medications for 2 random residents reviewed for self-administration of medication. (Residents 50 and 74)
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure dependent residents received assistance with activities of daily living (ADLs) related to nail care. (Resident 69)
- D
Provide activities to meet all resident's needs.
Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure the resident received 1 to 1 activities at least 3 times a week for 1 of 1 residents reviewed for activities. (Resident 6)
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure a resident with pressure ulcers received the treatment and services necessary to promote healing related to treatments not being completed as ordered and pressure reduction devices not being used for 2 of 3 residents reviewed for pressure ulcers. (Residents 1 and 50)
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure a resident was free from accidents and received supervision with medications related to proper interventions not in place to prevent the resident from falling and not staying with the resident until all of her medications were consumed for 1 of 3 residents reviewed for accidents. (Resident 27)
- D
Provide enough food/fluids to maintain a resident's health.
Inspectors wroteBased on record review and interview, the facility failed to ensure residents maintained acceptable parameters of nutritional status related to meal consumption records not completed for a resident with a history of weight loss for 1 of 1 residents reviewed for nutrition. (Resident 74)
- D
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Inspectors wroteBased on record review and interview, the facility failed to ensure psychotropic medications were monitored for side effects and effectiveness as well as ensuring Abnormal Involuntary Movement Scale (AIMS) assessments were completed for 1 of 5 residents reviewed for unnecessary medications. (Resident 47)
- D
Ensure that residents are free from significant medication errors.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident was free from significant medication errors related to the incorrect administration of insulin for 1 of 5 residents observed during medication pass. (Resident 331)
- 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 and interview, the facility failed to ensure medications were properly stored for safety, labeled, and dated for 1 of 1 medication storage rooms observed. (West Wing Medication Storage Room).
Fire safety inspections
23 fire safety citations on file: 7 on August 8, 2025, 3 on June 14, 2024, 13 on April 28, 2023.
Every fire safety citation23 citations
- F
Meet other general requirements that are deficient.
K 300 · August 8, 2025 · Corrected (the home has a date of correction)
- E
Provide properly protected cooking facilities.
K 324 · August 8, 2025 · Corrected (the home has a date of correction)
- E
Install a fire alarm system that can be heard throughout the facility.
K 341 · August 8, 2025 · Corrected (the home has a date of correction)
- E
Install an approved automatic sprinkler system.
K 351 · August 8, 2025 · Corrected (the home has a date of correction)
- E
Install corridor and hallway doors that block smoke.
K 363 · August 8, 2025 · Corrected (the home has a date of correction)
- E
Ensure proper usage of power strips and extension cords.
K 920 · August 8, 2025 · Corrected (the home has a date of correction)
- E
Have proper medical gas storage and administration areas.
K 923 · August 8, 2025 · Corrected (the home has a date of correction)
- E
Meet other general requirements.
K 100 · June 14, 2024 · Corrected (the home has a date of correction)
- E
Install an approved automatic sprinkler system.
K 351 · June 14, 2024 · Corrected (the home has a date of correction)
- E
Ensure proper usage of power strips and extension cords.
K 920 · June 14, 2024 · Corrected (the home has a date of correction)
- F
Develop and maintain an Emergency Preparedness Program (EP).
E 4 · April 28, 2023 · Corrected (the home has a date of correction)
- F
Develop Emergency Preparedness policies and procedures.
E 13 · April 28, 2023 · Corrected (the home has a date of correction)
- F
Establish procedures for tracking staff and patients during an emergency.
E 18 · April 28, 2023 · Corrected (the home has a date of correction)
- F
Develop a communication plan.
E 29 · April 28, 2023 · Corrected (the home has a date of correction)
- F
Establish emergency prep training and testing.
E 36 · April 28, 2023 · Corrected (the home has a date of correction)
- F
Install emergency lighting that can last at least 1 1/2 hours.
K 291 · April 28, 2023 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · April 28, 2023 · Corrected (the home has a date of correction)
- F
Have proper fire barriers, ventilation and signs for the transfilling of oxygen.
K 927 · April 28, 2023 · Corrected (the home has a date of correction)
- E
Provide properly protected cooking facilities.
K 324 · April 28, 2023 · Corrected (the home has a date of correction)
- E
Properly select, install, inspect, or maintain portable fire extinguishes.
K 355 · April 28, 2023 · Corrected (the home has a date of correction)
- E
Install corridor and hallway doors that block smoke.
K 363 · April 28, 2023 · Corrected (the home has a date of correction)
- E
Have properly installed electrical wiring and gas equipment.
K 511 · April 28, 2023 · Corrected (the home has a date of correction)
- C
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · April 28, 2023 · Corrected (the home has a date of correction)