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 35 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
31D
4E
0F
Potential for minimal harm
0A
0B
0C
July 14, 2026Complaint inspection · 1 citation
- D
Ensure services provided by the nursing facility meet professional standards of quality.
Inspectors wroteBased on observation, interview and record review, the facility failed to provide care and services according to professional standards for 1 of 4 residents (Resident 1) reviewed for quality of care, when the facility failed to assess and document respiratory status for a newly admitted resident. This failure placed residents at risk for unidentified and/or unmet care needs, negative health outcomes, and a decreased quality of life
June 2, 2026Complaint inspection · 1 citation
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on interview and record review, the facility failed to obtain labs as ordered, review and report to provider abnormal labs timely, and failed to fully implement neurological assessments for 1 of 4 residents (Resident 1) reviewed for Quality of Care. This failure places all residents at risk of unmet care needs, decreased quality of life, and other potential health complications.
April 10, 2026Standard inspection · 15 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 interview and record review, the facility failed to ensure sufficient qualified nursing staff were available to provide care and services as evidenced by information provided in Resident/Surveyor interviews for 11 residents (Resident 56, 4, 60, 40, 71, 2, 34, 7, 50, 36 & 97) interviewed, and 3 staff (Staff L, G & M) interviewed. The facility had insufficient staff to ensure residents received assistance with care in a timely manner without long wait times. These failures placed residents at risk for unmet care needs and a diminished quality of life.
- E
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 provide food that was palatable, attractive, and served at an appetizing temperature for 4 of 4 sampled Halls (Halls A, B, North 1 and North 2) reviewed for food . This failure placed residents at risk of weight loss, depressed mood, and a diminished quality of life.
- D
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Inspectors wroteBased on interview and record review, the facility failed to notify the resident's representative of a new medication order and a doctor's appointment for 1 of 2 residents (Resident 6) reviewed for notification of change. This failure placed the resident at risk for not having their representative involved in their health care decision making and a diminished quality of life.
- D
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 interview and record review, the facility failed to initiate, investigate, and resolve a grievance for 1 of 1 sampled resident (Resident 3) reviewed for personal property and grievances. This failure placed the residents at risk for emotional distress and a diminished quality of life.
- D
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
Inspectors wroteBased on interview and record review, the facility failed to ensure pharmacy recommended gradual dose reductions (GDR, a stepwise tapering of a dose to determine if symptoms, conditions, or risks can be managed by a lower dose or if the dose or medication can be discontinued) of psychotropic medications (prescription drugs that alter chemical levels in the brain, affecting mood, perception, thoughts, and behavior) were carried out, or if declined, a clinical rationale that indicated why a GDR attempt was likely to impair function or cause psychiatric instability in the individual was documented by the provider in the residents record, for 1 of 5 residents (Resident 56) reviewed for unnecessary medications. [...]
- D
Ensure each resident receives an accurate assessment.
Inspectors wroteBased on interview and record review, the facility failed to ensure the Minimum Data Set (MDS), an assessment tool, accurately reflected the status for 2 of 18 sampled residents (Resident 28 & 5) reviewed for accuracy of assessments. This failure placed the residents at risk for unmet care needs and a diminished quality of life.
- D
PASARR screening for Mental disorders or Intellectual Disabilities
Inspectors wroteBased on interview and record review the facility failed to ensure Pre-admission Screening and Resident Review (PASRR) assessments were accurately completed for 1 of 5 residents (Resident 3) reviewed for PASRRs and unnecessary medications. This failure placed the residents at risk for inaccurate mental health diagnoses and a diminished quality of life.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on interview and record review, the facility failed to ensure residents received the bowel care in accordance with provider orders for 2 of 7 residents (Resident 97 &1) reviewed for bowel management, and routine assessment and monitoring of edema (swelling caused by excess fluid trapped in the body's tissues) occurred for 1 of 2 residents (Resident 1) reviewed for edema management. These failures placed residents at risk for abdominal pain/discomfort, nausea, decreased appetite, delayed identification of fluid volume changes and other negative health outcomes.
- D
Provide enough food/fluids to maintain a resident's health.
Inspectors wroteBased on observation, interview, and record review the facility failed to monitor and accurately document fluids consumed to ensure fluid restrictions (a diet which limits the amount of daily fluid intake) was implemented per provider's orders for 2 of 4 residents (Resident 48 and 96) reviewed for nutrition. These failures placed the residents at risk for medical complications and a diminished quality of life.
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observation, interview and record review, the facility failed to ensure respiratory services were provided according to professional standards of practice for 1 of 2 sampled residents (Residents 2) reviewed for respiratory care. Failure to have a provider's order for oxygen placed residents at risk for discomfort, unmet needs and a diminished quality of life.
- D
Observe each nurse aide's job performance and give regular training.
Inspectors wroteBased on interview and record review, the facility failed to complete Certified Nursing Assistant's (CNA) annual performance reviews as required for 3 of 5 sampled nursing assistants (Staff H, I, & J) reviewed for performance reviews. This failure placed residents at risk of receiving care from inadequately trained and/or under-qualified care staff, and a diminished quality of life.
- 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 ensure medications were dated when opened for 2 of 3 medication carts (A hall cart & North hall cart) reviewed for medication storage. Additionally, the facility failed to ensure medications were secured for 1 of 1 resident (Resident 28) observed with medications at bedside. These failures placed residents at risk for medication discrepancies and an impaired quality of life.
- D
Provide or obtain dental services for each resident.
Inspectors wroteBased on interview and record review, the facility failed to ensure dental services were provided for 1 of 3 Medicaid residents (Resident 1) reviewed for dental services. The facility's failure to follow up on dental referrals and to assist with appointment scheduling and transportation arrangements that resulted in Resident 1 not receiving the dental services they were assessed to require (tooth extraction(s) and new upper and lower dentures). These failures placed residents at risk for unmet dental needs including difficulty chewing, oral pain, decreased self-image and diminished quality of life.
- D
Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs.
Inspectors wroteBased on observation, interview and record review the facility failed to ensure food preferences related to portion sizes were honored for 7 of 19 sampled residents (Residents 87, 77, 63, 61, 57, 37 and 4) reviewed for resident rights. This failure placed the residents at risk for dissatisfaction and diminished quality of life.
- D
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 interview and record review, the facility failed to implement a system to ensure Certified Nursing Assistants (CNAs) received the required training for continued competency of no less than 12 hours per year for 2 of 5 sampled staff (Staff I & K) reviewed for training. The failure to implement a system to provide mandatory training placed residents at risk for abuse, neglect, emotional distress, physical injury and a diminished quality of life.
March 26, 2025Complaint inspection · 1 citation
- E
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on interview and record review, the facility failed to provide care and services adequate to prevent hospitalization for 2 of 3 residents (Residents 1 & 2) reviewed for hospitalization. The facility failed to provide and monitor for adequate hydration, recognize and intervene when decline occurred, and failed to notify physician and family of abnormal laboratory results. This failure placed residents at risk for dehydration, hospitalization, and a diminished quality of life.
February 28, 2025Standard inspection · 8 citations
- D
Ensure each resident receives an accurate assessment.
Inspectors wroteBased on interview and record review, the facility failed to accurately assess Minimum Data Set (MDS) assessments for 2 of 24 sampled residents (Residents 12 & 39) reviewed. Failure to ensure accurate assessments regarding Preadmission Screening and Resident Review (PASRR) and oxygen requirements, placed residents at risk for unidentified and/or unmet care needs.
- D
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Inspectors wroteBased on interview and record review, the facility failed to ensure baseline care plans were developed and implemented within 48 hours of admission and included the minimum information necessary to properly care for 2 of 6 residents (Residents 131 and 331) reviewed for new admission. This failure placed residents at risk for unidentified and/or unmet care needs, and other negative health outcomes.
- 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 develop and implement individualized comprehensive care plans for 3 of 19 residents (Residents 1, 44, & 59) whose care plans were reviewed. This failure placed residents at risk for unmet care needs and other potential negative outcomes.
- D
Ensure services provided by the nursing facility meet professional standards of quality.
Inspectors wroteBased on observation, interview and record review, the facility failed to ensure services provided met professional standards of practice for 4 of 19 sample residents (Residents 1, 21, 331 and 59) reviewed. The facility's failure to obtain, follow and clarify physicians' orders when indicated, and to only sign for tasks they completed or validated were complete, placed residents at risk for medication errors, delays in treatment, unmet care needs, and potential negative outcomes.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on interview and record review, the facility failed to implement or document on the bowel protocol (how the facility intervenes to a resident with no bowel movement over a certain amount of time) for 2 of 3 sampled residents (Residents 59 & 1) reviewed for constipation. This failure placed residents at risk for unidentified care needs, discomfort, lack of monitoring, and a diminished quality of life.
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on observation, interview and record review, the facility failed to appropriately monitor pressure ulcers in a manner consistent with professional standards of practice for 2 of 5 sampled residents (Residents 59 and 44) reviewed for pressure ulcers. This failure placed residents at risk of worsening conditions, unnecessary treatment, pain, and a diminished quality of life.
- D
Ensure that residents are free from significant medication errors.
Inspectors wroteBased on interview and record review, the facility failed to ensure 1 of 3 residents (Resident 21) reviewed for insulin administration were free of significant medication errors. The failure to administer insulin in accordance with physician orders, and to hold insulin when blood glucose (BG) levels were below the ordered parameters for administration, placed residents at risk for hypoglycemia, seizures, coma and death.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observations, interview and record review, the facility failed to enforce Enhanced Barrier Precautions (EBP) for 1 of 8 sampled residents (Resident 331) reviewed for infection control practices, to prevent residents' urinary catheter/foley (tube that goes into the bladder to drain urine) tubing or bags from touching the ground for 2 of 2 residents (Resident 331 &39) reviewed for urinary catheters, to ensure contact precautions were understood and followed outside of resident rooms for 2 of 2 sampled residents (Resident 39 & 131) reviewed, and to ensure staff complied with current infection control guidelines and standards of practice regarding proper hand hygiene/gloving practices for 1 of 1 sampled resident (Resident 22) reviewed for wound care. [...]
June 18, 2024Complaint inspection · 1 citation
- D
Provide timely, approved x-ray services, or have an agreement with an approved provider to obtain them.
Inspectors wroteBased on interview and record review, the facility failed to obtain a physician ordered x-ray, in a timely manner, for 1 of 3 residents (Resident 1) reviewed for radiology and other diagnostic services. This failure placed residents at risk for a delay in assessment and treatment of declining respiratory status.
April 23, 2024Complaint inspection · 1 citation
- D
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 ensure safe transfers for 1 of 3 residents (Resident 1) reviewed for accidents when the facility did not use the mechanical lift's manufacturer's recommended sling when transferring a resident, resulting in the resident sliding from the sling. This failure placed residents at risk for unsafe transfers, potential injury, and decreased quality of life.
December 11, 2023Standard inspection · 7 citations
- E
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 observation, interview and record review, the facility failed to ensure residents did not receive unnecessary medications for 3 of 5 sample Residents (25, 30, 62) reviewed for unnecessary medication use. The facility failure to attempt a Gradual Dose Reduction (GDR) of an antipsychotic medication or provide evidence a reduction had been attempted placed residents at risk for receiving an unneeded medication and potentially experiencing side effects related to the use of the medication.
- 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 observation, interview, and record review, the facility failed to ensure resident care plans were reviewed, revised, and accurately reflected residents' care needs for 4 of 21 residents (Residents 12, 132, 25 and 13) whose care plans were reviewed. These failures placed residents at risk for unmet care needs and a diminished quality of life.
- D
Ensure services provided by the nursing facility meet professional standards of quality.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure services provided met professional standards of practice for 3 of 21 sampled residents (Residents 61, 64 and 132) reviewed. The failure to follow and/or clarify incomplete physician's orders when indicated, and to only sign for those tasks completed, placed residents at risk for medication errors and unmet care needs.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on interview and record review, the facility failed to provide the necessary care and services to maintain residents' highest practicable level of well-being for 2 of 8 residents (Residents 64 and 132) reviewed for bowel management and 1 of 4 residents (Resident 13) reviewed for non-pressure skin conditions. The failure to initiate bowel care in accordance with physician's orders and to implement ordered treatments for non-pressure skin conditions, placed residents at risk for pain/discomfort, delayed wound healing, and a diminished quality of life.
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on observation, interview and record review the facility failed to ensure 1 of 3 residents (Resident 13) reviewed for pressure ulcers received care and services in accordance with the physician's orders. The failure to implement a physician ordered treatment placed residents at risk for infection, unmet care needs and diminished quality of life.
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observation, interview and record review, the facility failed to ensure oxygen services were provided in accordance with professional standards of practice for 1 of 1 resident (Residents 12) reviewed for respiratory care. The facility's failure to maintain oxygen concentrator filters (used to protect the resident from inhaling dust and particulate matter) in a clean functional condition, to ensure oxygen tubing was routinely changed, labeled/dated and ensure residents' humidifier bottles had enough fluid to maintain functionality, placed residents at risk for inhalation of contaminants, respiratory infections, bloody noses and other potential negative healthcare outcomes.
- D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on interview and record review, the facility failed to ensure resident medical records were complete, accurate and readily accessible for 2 of 21 sampled residents (Residents 132 and 13) reviewed for medical records. The failure to ensure resident wound assessments were accurate, timely obtained from consulting wound care services, and filed and accessible in residents' medical records, prevented facility staff and providers from accessing complete and accurate health information on residents under their care. These failures placed residents at risk for delayed identification of changes in wound characteristics, medical decisions being made on incomplete or inaccurate information, unmet care needs and other adverse health outcomes.
Fire safety inspections
14 fire safety citations on file: 5 on April 10, 2026, 2 on February 28, 2025, 7 on December 11, 2023.
Every fire safety citation14 citations
- F
Have properly located and lighted "Exit" signs.
K 293 · April 10, 2026 · Corrected (the home has a date of correction)
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · April 10, 2026 · Corrected (the home has a date of correction)
- F
Ensure that testing and maintenance of electrical equipment is performed.
K 921 · April 10, 2026 · Corrected (the home has a date of correction)
- D
Install corridor and hallway doors that block smoke.
K 363 · April 10, 2026 · Corrected (the home has a date of correction)
- D
Have restrictions on the use of highly flammable decorations.
K 753 · April 10, 2026 · Corrected (the home has a date of correction)
- F
Ensure proper storage of liquid oxygen.
K 930 · February 28, 2025 · Corrected (the home has a date of correction)
- D
Install smoke barrier doors that can resist smoke for at least 20 minutes.
K 374 · February 28, 2025 · Corrected (the home has a date of correction)
- F
Address subsistence needs for staff and patients.
E 15 · December 11, 2023 · Corrected (the home has a date of correction)
- F
Establish procedures for tracking staff and patients during an emergency.
E 18 · December 11, 2023 · Corrected (the home has a date of correction)
- F
Establish policies and procedures including evacuation.
E 20 · December 11, 2023 · Corrected (the home has a date of correction)
- F
Provide primary/alternate means for communication.
E 32 · December 11, 2023 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · December 11, 2023 · Corrected (the home has a date of correction)
- F
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · December 11, 2023 · Corrected (the home has a date of correction)
- F
Ensure that testing and maintenance of electrical equipment is performed.
K 921 · December 11, 2023 · Corrected (the home has a date of correction)