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 38 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
1G
0H
0I
Potential for more than minimal harm
27D
8E
1F
Potential for minimal harm
0A
1B
0C
February 20, 2026Standard 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 observations, interviews and record review, the facility failed to ensure the Resident's environment was free from accident hazards, for one Resident #126, out of a sample of 30 Residents. Specifically, the facility failed to implement a fall care plan intervention which led to Resident #126 falling and sustaining a fracture.
- D
Ensure services provided by the nursing facility meet professional standards of quality.
Inspectors wroteBased on observation and interview, the facility failed to ensure that services provided met professional standards of practice for one Resident (#31) out of a total sample of 30 Residents. Specifically, for Resident #31 the facility failed to administer medications timely and in accordance with physician's orders.
- 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 residents who are unable to carry out activities of daily living receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for two Residents (#11 and #14) out of a total of 30 sampled residents. Specifically,1. For Resident #11 the facility failed to provide assistance to shave unwanted facial hair. 2. For Resident #14 the facility failed to provide assistance to cut fingernails.
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on observation, record review and interview the facility failed to implement interventions to prevent pressure ulcers from developing for one Resident (#40) out of a total sample of 30 residents. Specifically, the facility failed to ensure Resident #40's heels were elevated off the mattress.
- D
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Inspectors wroteBased on observation, record review and interview the facility failed to provide care consistent with professional standards of practice for one Resident (#132) with a peripherally inserted central catheter (PICC) line (a long, flexible catheter inserted into a vein in the upper arm and threaded into a large central vein near the heart to deliver medications, fluids, or nutrition and to draw blood) out of a total sample of 30 Residents. Specifically, the facility failed to change the PICC line dressing on admission as indicated in the physician's orders or when the PICC line dressing was lifting on the edges.
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observation, record review and interview the facility failed provide for one Resident (#79) the necessary respiratory care and services that is in accordance with professional standards of practice and the Resident's care plan out of a total sample of 30 residents. Specifically, the facility failed to ensure Resident #79's oxygen was administered according to physician orders.
February 14, 2025Standard inspection · 23 citations
- F
Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
Inspectors wroteBased on record review and interview, the facility failed to electronically submit direct care staffing data to the Centers for Medicare and Medicaid Services (CMS) for the entire reporting period, Fiscal Year (FY) Quarter 4 2024 (July 1 - September 30), in accordance with the schedule specified by CMS.
- E
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on record review and interviews, the facility failed to report allegations of potential abuse (injuries of unknown, and an allegation of neglect) to the State Agency for three Residents (#87, #118, and #55) out of a sample of 30 Residents. 1. For Resident #87, the facility failed to report an X-ray (X-radiation-images created inside of a body by passing beams of radiation through the body) positive for a fracture from an unknown origin to the State Agency within two hours. 2. For Resident #118 the facility failed to notify the state agency of an injury of unknown within 2 hours once the Director of Nursing became of a new fracture (an acute right intertrochanteric [thigh bone] fracture) of unknown origin. 3. For Resident #55 the facility failed to notify the state agency of an allegation of neglect.
- E
Ensure medication error rates are not 5 percent or greater.
Inspectors wroteBased on observations, interviews, and record reviews for three Residents (#22, #376 and #70) out of four residents observed, the facility failed to ensure it was free from a medication error rate of greater than 5%. Three out of four nurses observed made 3 errors out of 33 opportunities resulting in a medication error rate of 9.09%. Specifically, 1.) For Resident #22, Nurse #1 administered the incorrect dose of a medication spray (Fluticasone, medication used for allergies) 2.) For Resident #376, Nurse #4 did not follow manufacture's recommendations and crushed a medication (metoprolol extended-release tablet, cardiac medication that once crushed becomes immediate release) which indicated do not crush. 3.) For Resident #70, Nurse #5 administered the incorrect medication (calcium with vitamin D) that was also expired.
- 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 observations and interviews the facility failed to ensure drugs and biologicals were stored in accordance with acceptable professional standards of practice. Specifically: 1. Nursing failed to secure the medication carts on 2 of 3 units. 2. Nursing failed to ensure medication was stored in the packaging containers or other dispensing system in which it was received. 3. Nursing failed to ensure medications were dated once opened, and stored according to manufacturer's guidelines, in two of three medication carts observed.
- 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 store food in accordance with professional standards for food service safety. Specifically, the facility failed to ensure that staff dated resident food and drinks in three of three unit kitchenette refrigerators.
- 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 staff interview and record review, the facility failed to ensure the Nursing staff completed the required 12 hours (no less than ) of annual training, which at minimum includes dementia training for 4 out of 5 employee records reviewed.
- D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteBased on observation, record review and interview the facility failed to provide a dignified existence for one Resident (#110) out of a total sample of 30 residents. Specifically: For Resident #110, who is dependent on staff for feeding, the staff stood beside the bed, looking down at Resident #110, rather than seated at eye level while feeding him/her meals.
- D
Keep residents' personal and medical records private and confidential.
Inspectors wroteBased on observations and interviews, the facility failed to ensure resident protected health information (PHI) was secure and not visible to others on two of three nursing units.
- D
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Inspectors wroteBased on observations, record review and interviews, the facility failed to complete an assessment for an air mattress with bolsters for one Resident #87 out of a sample of 30 Residents. Specifically, the facility failed to complete a restraints assessment before applying an air mattress with bolsters in the Resident's bed.
- D
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Inspectors wroteBased on record review and interviews, the facility failed to report injuries of unknown origin to facility administration for two Residents (#87 and #118) out of a sample of 30 Residents. Specifically: 1. For Resident #87, the facility failed to report an X-ray (X-radiation-images created inside of a body by passing beams of radiation through the body) positive for a fracture from an unknown origin. 2. For Resident #118 the facility failed to implement their abuse policy and notify facility administration of a new fracture (an acute right intertrochanteric [thigh bone] fracture) of unknown origin.
- D
Respond appropriately to all alleged violations.
Inspectors wroteBased on record review and interviews, the facility failed to thoroughly investigate an injury of unknown origin (a fracture), for one Resident (#118) out of a total sample of 30 residents. Specifically for Resident #118 who on 1/4/25 experienced pain which was new and on 1/5/25 Resident #118 was found to have an acute right intertrochanteric (thigh bone) fracture, the facility failed to conduct interviews from staff members (on all shifts) who had contact with the resident during the period of the alleged incident.
- D
Ensure services provided by the nursing facility meet professional standards of quality.
Inspectors wroteBased on record review and interviews, the facility failed to meet professional standards of practice for one Resident (#113) out of a total of sample of 30 residents. Specifically, for Resident #113, the facility failed to ensure nursing clarified a physician's orders for two different suprapubic (SPT) catheter flushes.
- 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 staff interview, the facility failed to document the recapitulation of the Resident's stay that included his/her course of illness/treatment for one Resident (#123), of two closed records
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on observation, interview and record review, the facility failed to provide assistance with activities of daily living (ADLs) for three dependent Residents (#61, #15 and #48) out of a total sample of 30 residents. Specifically, the facility failed to: 1) Provide assistance with grooming for Resident #61. 2) Provide supervision with meals for Resident #15. 3) Provide assistance with grooming for Resident #48. Findings Include: Review of the undated facility policy, titled Activities of Daily Living (ADL), Supporting, revised in March 2018, indicated, but was not limited to, the following: - Residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). [...]
- D
Assist a resident in gaining access to vision and hearing services.
Inspectors wroteBased on observations, interviews, and records reviewed, the facility failed to provide the necessary services to ensure one Resident (#15) out of a total sample of 30 Residents, was able to effectively communicate his/her needs.
- D
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Inspectors wroteBased on observation, record review and interview the facility failed to ensure interventions to treat contracture management were implemented for one Resident (#26) out of a total sample of 30 residents. Specifically, the facility failed to ensure palm protectors were in place.
- 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 implement a physician ordered intervention to mitigate injury from an accident for one Resident (#110) out of a total sample of 30 residents. Specifically, the facility failed to ensure a fall mat was in place when Resident #110 was in bed.
- 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, record review and interview the facility failed to ensure professional standards of practice for Foley catheter care for two residents (#38 and #133) out of a total sample of 30 residents. Specifically: 1. For Resident #38, the facility failed to ensure they obtained physician's orders for the correct indwelling catheter size. 2. For Resident #133, the facility failed to ensure Nurse #8 inserted the correct size suprapubic tube (SPT) into his/her bladder.
- D
Provide enough food/fluids to maintain a resident's health.
Inspectors wroteBased on record review and interview for one Resident (#375) of a total sample of 30 residents, the facility failed to provide sufficient fluid intake as ordered by the physician. Specifically, for Resident #375 the facility failed to ensure nursing provided free water bolus' (FWB) consistently as ordered by the physician.
- 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 that respiratory care and services, consistent with professional standards of practice, were provided for one Resident (#38), out of a total sample of 30 residents. Specifically, for Resident #38, the facility failed to ensure that nursing changed Resident #38's oxygen tubing as ordered by the physician.
- D
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure nursing was competent and had the required skill set to provide necessary care for residents' needs. Specifically, for Resident #60, the facility failed to ensure that nursing prepared medications in a safe manner.
- 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 ensure accuracy of the medical record for two Residents (#110 and #13) out of a total sample of 30 residents. Specifically: 1. For Resident #110 the staff inaccurately documented in the Treatment Administration Record (TAR) regarding a resident fall mat. 2. For Resident #13 staff inaccurately documented that blood pressure readings were taken using the Resident's left arm when they were not.
- B
Follow rules about disclosure of ownership requirements and tell the state agency about changes in ownership and/or administrative personnel.
Inspectors wroteBased on interviews and reviews of the Health Care Facility Reporting System (HCFRS-State Agency reporting system), the facility failed to provide written notice to the State Agency of a change in the Administrator as required.
February 20, 2024Standard inspection · 9 citations
- E
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteBased on observation, policy review, and interview the facility failed to provide a dignified dining experience in the dining room of the third floor unit, and for three Residents (#36, #96, and #102) out of a total sample of 28 residents. Specifically, the facility failed to ensure that residents seated at the same table were served meals at the same time, that staff did not refer to residents as feeds or feeders in the presence of residents, that staff did not refer to clothing protectors as bibs, and that staff did not stand while providing feeding assistance to three Residents (#36, #96, and #102).
- 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, policy review, and interview, the facility failed to store and prepare food in accordance with professional standards for food service safety. Specifically, the facility failed to ensure food was labeled, unpasteurized eggs were cooked thoroughly, and that ready to eat food was not handled using contaminated gloves.
- E
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observations, policy review, and interviews the facility failed to ensure infection control standards of practice for the prevention of infections were implemented. Specifically: 1. The facility failed to ensure nursing staff appropriately discarded contaminated personal protective equipment (PPE) and performed hand hygiene after caring for a Resident on contact precautions. 2. For the Director of Housekeeping, the facility failed to ensure he wore gloves and cleaned his hands after handling soiled clothing.
- D
Honor the resident's right to organize and participate in resident/family groups in the facility.
Inspectors wroteBased on record review, policy review, and interview, the facility failed to ensure that concerns addressed by the Resident Council Group ha sufficient follow-up to address and prevent recurrence.
- 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 and interview, the facility failed to provide a homelike environment on one out of three units. Specifically, the facility served meals on plastic trays and did not use table linens during mealtimes in the dining room of the third floor unit.
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on observations, policy review, record review and interviews for two Residents (#92 and #24) out of a total sample of 28 residents, the facility failed to provide assistance with Activities of Daily Living. Specifically: 1. For Resident #92, the facility failed to provide the needed supervision and assistance with eating. 2. For Resident #24, the facility failed to assist with grooming, specifically removal of chin hair.
- D
Assist a resident in gaining access to vision and hearing services.
Inspectors wroteBased on observation, policy review, record review and interview, the facility failed to offer services to maintain vision for one Resident (#42) out of a total of 28 sampled residents.
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on observations, interviews, policy review, and records reviewed for one Resident (#27), out of 28 total sampled residents, the facility failed to provide the necessary treatment and services to prevent the development and promote healing of pressure ulcers. Specifically, the facility failed to implement a physician's order to offload the heels of Resident #27, who was assessed by nursing to be at high risk for skin breakdown.
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observations, policy review, records reviewed and interviews for two Residents (#72 and #21) of 28 sampled residents, the facility failed to ensure oxygen was administered according to the physicians' orders. Specifically: 1. For Resident #72, the facility failed to obtain a physician's order for the continuous use of oxygen. 2. For Resident #21, the facility failed to administer the correct amount of oxygen, based on the physician's order.
Fire safety inspections
13 fire safety citations on file: 1 on February 20, 2026, 9 on February 14, 2025, 3 on February 20, 2024.
Every fire safety citation13 citations
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · February 20, 2026 · Corrected (the home has a date of correction)
- F
Conduct testing and exercise requirements.
E 39 · February 14, 2025 · Corrected (the home has a date of correction)
- F
Provide properly protected cooking facilities.
K 324 · February 14, 2025 · Corrected (the home has a date of correction)
- F
Install an approved automatic sprinkler system.
K 351 · February 14, 2025 · Corrected (the home has a date of correction)
- F
Properly install and monitor supervisory attachments on automatic sprinkler systems.
K 352 · February 14, 2025 · Corrected (the home has a date of correction)
- F
Install smoke barrier doors that can resist smoke for at least 20 minutes.
K 374 · February 14, 2025 · Corrected (the home has a date of correction)
- F
Have an externally vented heating system.
K 522 · February 14, 2025 · Corrected (the home has a date of correction)
- F
Provide a written emergency evacuation plan.
K 711 · February 14, 2025 · Corrected (the home has a date of correction)
- F
Have simulated fire drills held at unexpected times.
K 712 · February 14, 2025 · Corrected (the home has a date of correction)
- F
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · February 14, 2025 · Corrected (the home has a date of correction)
- E
Install emergency lighting that can last at least 1 1/2 hours.
K 291 · February 20, 2024 · Corrected (the home has a date of correction)
- E
Have a battery powered remote alarm panel in a location accessible by operating personnel.
K 916 · February 20, 2024 · Corrected (the home has a date of correction)
- D
Install an approved automatic sprinkler system.
K 351 · February 20, 2024 · Corrected (the home has a date of correction)