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
2J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
33D
0E
1F
Potential for minimal harm
0A
0B
0C
May 27, 2026Standard inspection, Complaint inspection · 10 citations
- J
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on interview, record review and document review, the facility failed to ensure 1) blood glucose (BG) levels were obtained on admission, 2) discharge summary recommendations for diabetes management were discussed or clarified with the attending physician, and orders for BG monitoring and Insulin sliding scale were obtained for a resident with type one diabetes mellitus, 3) BG levels were obtained during a change of condition, and 4) the facility had a clear diabetes management process or protocol for 1 of 40 sampled residents (Resident 161). The deficient practice potentially resulted in diabetic-related complication requiring hospitalization.
- J
Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit.
Inspectors wroteBased on interview, record review and document review, the facility failed to ensure the attending physician conducted an independent, thorough review of a hospital discharge summary for a resident admitted with Type one diabetes mellitus for 1 of 40 sampled residents (Resident 161). The deficient practice resulted in the resident experiencing diabetic-related complications which required rehospitalization.
- 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 observation, interview, record review and document review, the facility failed to ensure resident rooms and bathrooms were in good repair for 9 of 72 resident rooms. The deficient practice had the potential to negatively impact on the residents' quality of life.
- 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 observation, interview, record review and document review, the facility failed to ensure care and management of a resident's intravenous line (IV) were included in the resident's baseline care plan for 1 of 40 sampled residents (Resident 171). The deficient practice placed the resident at risk for infection.
- 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, record review and document review, the facility failed to ensure physician orders were followed for an indwelling catheter for 1 of 40 sampled residents (Resident 2). The deficient practice placed the resident at risk for a urinary tract infection (UTI).
- D
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Inspectors wroteBased on observation, interview, record review and document review, the facility failed to ensure care and management orders were entered for a resident who was admitted with an intravenous (IV) line for 1 of 40 sampled residents (Resident 171). The deficient practice placed the resident at risk for infection.
- D
Observe each nurse aide's job performance and give regular training.
Inspectors wroteBased on interview and document review, the facility failed to ensure an annual performance evaluation for 2 of 2 Certified Nurse Aides (CNA1 and CNA2) was completed at least once every 12 months. The deficient practice had the potential to limit the facility's ability to evaluate competency, identify training needs and allow performance deficits to go unaddressed.
- D
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Inspectors wroteBased on interview, record review and document review, the facility failed to ensure 1) indication for use for psychotropic medications were appropriate 2) side effect and behavior monitoring was in place 3) an informed consent was obtained for psychotropic medication use and 4) an Abnormal Involuntary Movement Scale (AIMS) Assessment was conducted for 1 of 40 sampled residents (R174). The deficient practiced placed the resident at risk of unnecessary medication use and potential adverse side effects.
- D
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 document review the facility failed to ensure the kitchen was maintained in a sanitary manner. The deficient practice placed residents at risk for foodborne illness.
- D
Provide or get specialized rehabilitative services as required for a resident.
Inspectors wroteBased on observation, interview, record review and document review, the facility failed to ensure orders for physical therapy (PT) and occupational therapy (OT) were followed for 3 of 40 sampled residents(Residents 63, 73 and 169) and speech therapy (ST) for 1 of 40 sampled residents (Resident 48). The deficient practice placed the residents at a potential for slower progression towards goals.
April 13, 2026Complaint inspection · 3 citations
- 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, record review, and document review, the facility failed to ensure a discharge was completed including a home health referral was accepted by an agency prior to discharging for a resident requiring wound dressing changes for one of five sampled residents (Resident 2). The deficient practice placed the resident at risk for wound complications including infection.
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on observation, interview, record review, and document review, the facility failed to ensure scheduled showers were provided for residents who were assessed to require assistance with showers for 3 of 5 sampled residents (Residents 3, 4 and 5). The deficient practice had the potential to negatively impact on the residents' quality of life.
- D
Provide timely, approved x-ray services, or have an agreement with an approved provider to obtain them.
Inspectors wroteBased on interview, record review and document review, the facility failed to ensure a physician order for computed tomography (CT) scan was carried out for 1 of 5 sampled residents (Resident 1). The deficient practice had the potential to delay or negatively impact the resident's plan of care.
June 13, 2025Standard inspection, Complaint inspection · 10 citations
- F
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on observation, interview and document review, the facility failed to properly date resident drink containers in 2 of 2 nourishment refrigerators and employee food stored in the resident freezer. This deficient practice has the potential to lead bacterial growth and foodborne illnesses.
- D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteBased on observation, interview, record review and document review, the facility failed to maintain dignity for 1 of 24 sampled residents (Resident 362). The deficient practice had the potential to result in unnecessary disclosure of resident care needs and failed to promote respect and individuality.
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on interview, record review, and document review, the facility failed to ensure an incident of resident elopement was reported to the State Agency (SA) within the required timeframe for 1 of 24 sampled residents (Resident 84). The deficient practice had the potential to place residents at risk for further incidents and to not be adequately protected.
- 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 observation, interview, record review and document review, the facility failed to ensure a resident baseline care plan fit the needs for 1 of 24 residents. The deficient practice had the potential to significantly impact the resident's well-being and safety.
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on observation, interview, record review, and document review, the facility failed to ensure incontinent care was provided to a dependent resident who was soiled, wet, and had requested assistance for 1 of 24 sampled residents (Resident 111). This deficient practice had the potential to result in skin breakdown, infections, discomfort, and a diminished quality of life. Resident 111 (R111) R111 was admitted on [DATE] and discharged on 04/02/2025 with diagnoses including multiple sclerosis, difficulty walking, and need for assistance with personal care. On 06/04/2025 the State Agency received a report detailing concerns related to R111. The report alleged R111 had been left in a soiled incontinence brief for several hours on 03/17/2025 while at the facility. An admission minimum data set (MDS) assessment dated [DATE] documented R111: [...]
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on observation, interview, record review and document review, the facility failed to obtain physician orders for 2 of 24 sampled residents (Resident 84 and Resident 51) and schedule a follow-up appointment as recommended for 1of 24 sampled residents (Resident 51). The deficient practice had the potential for inappropriate discharge and to delay treatment and healing of a fracture.
- D
Provide enough food/fluids to maintain a resident's health.
Inspectors wroteBased on interview, record review and document review, the facility failed to ensure weekly weights were obtained in accordance with physician's order for 1 of 24 sampled residents (Resident 3). The failure potentially delayed identification of a significant weight change, nutritional re-assessment by a Registered Dietitian (RD) and appropriate interventions by the inter-disciplinary team (IDT).
- D
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Inspectors wroteBased on observation, interview, record review, and document review, the facility failed to: 1) follow a physician order for intravenous (IV) site care and 2) obtain a physician order for the use or removal of IV access for 2 of 24 sampled residents (Residents 9 and 261). This deficient practice had the potential to result in infection, phlebitis, infiltration, and compromised venous access.
- D
Ensure medication error rates are not 5 percent or greater.
Inspectors wroteBased on observation, interview, record review, and document review the facility failed to ensure it was free of a medication error rate of less than five percent (%) for four residents (Resident 88, 29, 361, and 94). The deficient practice posed a potential risk of injury or harm to the resident.
- 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 document review, the facility failed to dispose expired medications. This deficient practice has the potential to cause adverse reactions or worsened health conditions to residents.
January 22, 2025Complaint inspection · 2 citations
- 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 document review, the facility failed to ensure medications were secured in 1 of 2 central supply rooms. The deficient practice had the potential risk of unauthorized access to medications, theft, or misuse of medication within the facility.
- 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 interview, record review and document review, the facility failed to complete a nutritional assessment including food preferences within 72-hours of admission per facility policy for 1 of 2 sampled residents (Resident 2). The failure to honor resident food preferences could potentially cause residents to lose interest in eating their meals.
August 9, 2024Standard inspection, Complaint inspection · 9 citations
- D
Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.
Inspectors wroteBased on interviews, record review, and document review, the facility failed to ensure a safe discharge was planned and occurred for 2 of 2 unsampled residents (R214 and R219). This deficient practice had the potential for residents to be placed in an improper home setting and not receive the required care.
- 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 observation, interview, record and document review, the facility failed to ensure comprehensive care plans were implemented for the management of falls for 1 of 24 sampled residents (Resident 50). The deficient practice had the potential for staff not to provide personalized care for the resident.
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on observation, interview, record review, and document review, the facility failed to ensure scheduled showers were provided to dependent residents for 1 of 24 sampled residents (Resident 246) and 2 unsampled residents (Residents 215 and 213). This deficient practice could potentially compromise resident hygiene and comfort, and increase the risk of skin breakdown and infections.
- 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, interviews, record review, and document review, the facility failed to ensure a resident with a urinary catheter had appropriate diagnosis and a bladder training program was implemented for 1 of 24 sampled residents. The deficient practice had the potential for increased risk of infection.
- D
Provide enough food/fluids to maintain a resident's health.
Inspectors wroteBased on observation, interview, record review, and document review, the facility failed to ensure the ordered fluid restriction was followed for a dialysis dependent resident and the actual fluid intake or consumption was monitored for 1 of 24 sampled residents (Resident 14). The deficient practice could have the potential to result in adverse health outcomes, including fluid overload, increased blood pressure, and complications related to the resident's dialysis treatment.
- 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, record review and document review, the facility failed to account for narcotics (opioid) signed out on the controlled drug record for one unsampled resident (R213). The deficient practice had the potential to delay a resident's pain management and increase the risk for physical and psychosocial harm.
- D
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Inspectors wroteBased on interviews, record review, and document review, the facility failed to ensure a physician order to discontinue medication was completed for 1 of 24 sampled residents. The deficient practice had the potential for adverse effects on the resident and unnecessary medications.
- D
Ensure medication error rates are not 5 percent or greater.
Inspectors wroteBased on observation, interview, record review and document review, the facility failed to ensure it was free of a medication error rate of five percent (%) or greater for one unsampled resident (Resident 37). Failure to administer medications as prescribed could have delayed the therapeutic treatment for the resident.
- D
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 document review, the facility failed to ensure stored foods were labeled and dated and food items were stored properly. This deficient practice posed a potential risk to safety and health standards which could lead to contamination, inadequate storage, and place residents at risk of foodborne illness.
November 15, 2023Complaint inspection · 2 citations
- 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 observation, interview, record review and document review, the facility failed to ensure fall prevention interventions were included in the baseline care plan of a resident who was at risk for falls for 1 of 10 sampled residents (Resident 7). The deficient practice potentially contributed to an actual fall.
- D
Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
Inspectors wroteBased on interview, record review, and document review, the facility failed to 1) document evidence at discharge of medication education, instructions, and reconciliation, 2) follow-up for durable medical equipment (DME) recommendation, and 3) lacked a physician's discharge summary for 1 of 10 sampled residents (Resident 9). The deficient practice potentially contributed to the resident's lack of knowledge regarding their medication and delayed the resident from obtaining the recommended medical equipment.
Fire safety inspections
69 fire safety citations on file: 26 on May 27, 2026, 22 on June 13, 2025, 19 on August 9, 2024, 2 on February 23, 2024.
Every fire safety citation69 citations
- F
Develop and maintain an Emergency Preparedness Program (EP).
E 4 · May 27, 2026 · Corrected (the home has a date of correction)
- F
Address patient/client population and determine types of services needed.
E 7 · May 27, 2026 · Corrected (the home has a date of correction)
- F
Create arrangements with other facilities to receive patients.
E 25 · May 27, 2026 · Corrected (the home has a date of correction)
- F
Develop a communication plan.
E 29 · May 27, 2026 · Corrected (the home has a date of correction)
- F
List the names and contact information of those in the facility.
E 30 · May 27, 2026 · Corrected (the home has a date of correction)
- F
Provide emergency officials' contact information.
E 31 · May 27, 2026 · Corrected (the home has a date of correction)
- F
Provide primary/alternate means for communication.
E 32 · May 27, 2026 · Corrected (the home has a date of correction)
- F
Conduct testing and exercise requirements.
E 39 · May 27, 2026 · Corrected (the home has a date of correction)
- F
Install a fire alarm system that can be heard throughout the facility.
K 341 · May 27, 2026 · Corrected (the home has a date of correction)
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · May 27, 2026 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · May 27, 2026 · Corrected (the home has a date of correction)
- F
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
K 521 · May 27, 2026 · Corrected (the home has a date of correction)
- F
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
K 761 · May 27, 2026 · Corrected (the home has a date of correction)
- F
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · May 27, 2026 · Corrected (the home has a date of correction)
- E
Satisfy building requirements after a repair, renovation, modification, or change of user/occupancy.
K 111 · May 27, 2026 · Corrected (the home has a date of correction)
- E
Install emergency lighting that can last at least 1 1/2 hours.
K 291 · May 27, 2026 · Corrected (the home has a date of correction)
- E
Have properly located and lighted "Exit" signs.
K 293 · May 27, 2026 · Corrected (the home has a date of correction)
- E
Properly select, install, inspect, or maintain portable fire extinguishes.
K 355 · May 27, 2026 · Corrected (the home has a date of correction)
- E
Have properly installed electrical wiring and gas equipment.
K 511 · May 27, 2026 · 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 · May 27, 2026 · Corrected (the home has a date of correction)
- E
Have power receptacles that are properly grounded.
K 912 · May 27, 2026 · Corrected (the home has a date of correction)
- E
Have proper medical gas storage and administration areas.
K 923 · May 27, 2026 · 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 · May 27, 2026 · Corrected (the home has a date of correction)
- D
Follow proper procedures when the fire alarm was out of service for more than 4 hours.
K 346 · May 27, 2026 · Corrected (the home has a date of correction)
- D
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
K 354 · May 27, 2026 · Corrected (the home has a date of correction)
- D
Install corridor and hallway doors that block smoke.
K 363 · May 27, 2026 · Corrected (the home has a date of correction)
- F
Conduct risk assessment and an All-Hazards approach.
E 6 · June 13, 2025 · Corrected (the home has a date of correction)
- F
Address subsistence needs for staff and patients.
E 15 · June 13, 2025 · Corrected (the home has a date of correction)
- F
Have proper medical gas storage and administration areas.
K 923 · June 13, 2025 · Corrected (the home has a date of correction)
- E
Address patient/client population and determine types of services needed.
E 7 · June 13, 2025 · Corrected (the home has a date of correction)
- E
Develop Emergency Preparedness policies and procedures.
E 13 · June 13, 2025 · Corrected (the home has a date of correction)
- E
Establish policies and procedures including evacuation.
E 20 · June 13, 2025 · Corrected (the home has a date of correction)
- E
List the names and contact information of those in the facility.
E 30 · June 13, 2025 · Corrected (the home has a date of correction)
- E
Provide a means of sharing information on occupancy/needs.
E 34 · June 13, 2025 · Corrected (the home has a date of correction)
- E
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
K 321 · June 13, 2025 · Corrected (the home has a date of correction)
- E
Install a fire alarm system that can be heard throughout the facility.
K 341 · June 13, 2025 · Corrected (the home has a date of correction)
- E
Inspect, test, and maintain automatic sprinkler systems.
K 353 · June 13, 2025 · Corrected (the home has a date of correction)
- E
Have properly installed electrical wiring and gas equipment.
K 511 · June 13, 2025 · Corrected (the home has a date of correction)
- E
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
K 761 · June 13, 2025 · 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 · June 13, 2025 · Corrected (the home has a date of correction)
- D
Install emergency lighting that can last at least 1 1/2 hours.
K 291 · June 13, 2025 · Corrected (the home has a date of correction)
- D
Provide properly protected cooking facilities.
K 324 · June 13, 2025 · Corrected (the home has a date of correction)
- D
Construct fire resistant interior walls.
K 331 · June 13, 2025 · Corrected (the home has a date of correction)
- D
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
K 354 · June 13, 2025 · Corrected (the home has a date of correction)
- D
Properly select, install, inspect, or maintain portable fire extinguishes.
K 355 · June 13, 2025 · Corrected (the home has a date of correction)
- D
Install corridor and hallway doors that block smoke.
K 363 · June 13, 2025 · Corrected (the home has a date of correction)
- D
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
K 741 · June 13, 2025 · Corrected (the home has a date of correction)
- D
Ensure that any exit in an area undergoing construction, repair, or improvements shall be inspected daily to ensure its ability to be used instantly in case of emergency.
K 791 · June 13, 2025 · Corrected (the home has a date of correction)
- F
Develop and maintain an Emergency Preparedness Program (EP).
E 4 · August 9, 2024 · Corrected (the home has a date of correction)
- F
Address subsistence needs for staff and patients.
E 15 · August 9, 2024 · Corrected (the home has a date of correction)
- F
Develop a communication plan.
E 29 · August 9, 2024 · Corrected (the home has a date of correction)
- F
Provide primary/alternate means for communication.
E 32 · August 9, 2024 · Corrected (the home has a date of correction)
- F
Conduct testing and exercise requirements.
E 39 · August 9, 2024 · Corrected (the home has a date of correction)
- F
Construct fire resistant interior walls.
K 331 · August 9, 2024 · Corrected (the home has a date of correction)
- F
Have restrictions on the use of flammable curtains.
K 751 · August 9, 2024 · Corrected (the home has a date of correction)
- F
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
K 761 · August 9, 2024 · Corrected (the home has a date of correction)
- F
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
K 914 · August 9, 2024 · Corrected (the home has a date of correction)
- F
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · August 9, 2024 · Corrected (the home has a date of correction)
- F
Ensure that testing and maintenance of electrical equipment is performed.
K 921 · August 9, 2024 · Corrected (the home has a date of correction)
- E
Conduct risk assessment and an All-Hazards approach.
E 6 · August 9, 2024 · Corrected (the home has a date of correction)
- E
Inspect, test, and maintain automatic sprinkler systems.
K 353 · August 9, 2024 · Corrected (the home has a date of correction)
- E
Have simulated fire drills held at unexpected times.
K 712 · August 9, 2024 · Corrected (the home has a date of correction)
- D
Address patient/client population and determine types of services needed.
E 7 · August 9, 2024 · Corrected (the home has a date of correction)
- D
Install emergency lighting that can last at least 1 1/2 hours.
K 291 · August 9, 2024 · Corrected (the home has a date of correction)
- D
Follow proper procedures when the fire alarm was out of service for more than 4 hours.
K 346 · August 9, 2024 · Corrected (the home has a date of correction)
- D
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
K 354 · August 9, 2024 · Corrected (the home has a date of correction)
- D
Ensure gas and vacuum systems are inspected and tested as part of a maintenance program.
K 908 · August 9, 2024 · Corrected (the home has a date of correction)
- E
Properly select, install, inspect, or maintain portable fire extinguishes.
K 355 · February 23, 2024 · Not yet corrected
- E
Meet requirements for operating features, such as evacuation plans, fire drills, smoking regulations, draperies, decorations and the inspection, testing and maintenance of fire doors.
K 700 · February 23, 2024 · Not yet corrected