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 57 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
42D
9E
3F
Potential for minimal harm
0A
0B
3C
May 22, 2026Complaint inspection · 3 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 physician and responsible party (RP) were notified of low blood sugars, behaviors, a transfer to a behavioral hospital, and change of condition, for 2 of 3 residents reviewed for notification of change. (Residents C and D)
- D
Have an agreement with an approved laboratory to obtain services, if on-site laboratory services aren't provided.
Inspectors wroteBased on record review and interview, the facility failed to ensure a resident received laboratory services as ordered by the physician for 2 of 3 residents reviewed for laboratory services. (Residents C and D)
- D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on record review and interview, the facility failed to ensure the medical record was complete and accurately documented related to treatment of low blood sugars for 1 of 3 residents reviewed for low blood sugars. (Resident D)
February 26, 2026Complaint inspection · 4 citations
- D
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Inspectors wroteBased on record review and interview, the facility failed to provide the required information and documents to the resident or their representative at the time of discharge for 1 of 3 residents reviewed for discharges. (Resident G)
- 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 a dependent resident received assistance with activities of daily living (ADL's) related to the timeliness of assistance with a breakfast meal for 1 of 3 residents observed for meal intake assistance. (Resident F)
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on record review and interview, the facility failed to ensure a resident's pressure ulcer treatment was provided as ordered for 1 of 3 residents reviewed for pressure ulcers. (Resident D)
- D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on record review and interview, the facility failed to ensure residents' records were completed in a timely manner related to nutritional assessments for 2 of 6 residents reviewed for medical records. (Residents B and C)
November 24, 2025Standard inspection, Complaint inspection · 17 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, record review, and interview, the facility failed to ensure food was stored and served under sanitary conditions related to touching food with bare hands, glove use, beard restraints, dirty food equipment, ice on the freezer floor, food spillage in the walk in cooler, and food brought in by visitors or resident's food that was not labeled for 1 of 1 kitchen and 1 of 2 wings. (The main kitchen and the A Wing)Findings incude:1. During the Brief Kitchen Sanitation Tour on 11/17/2025 at 9:56 a.m. with the Dietary Food Manager (DFM) the following was observed:a. Dietary [NAME] 1 was observed with a disposable glove on her left hand and her right hand was bare. She was observed using her bare right hand reaching into the pan of the cheese and cracker crumbs and was putting it on top of the turkey noodle casserole she had in front of her. [...]
- F
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 keep the kitchen and residents' environment clean and in good repair related to dirty walls, ceilings, floor tile, ceiling vents and adhered dirty against the baseboard for 1 of 1 kitchen (The main kitchen); marred and water-damaged walls, grab bar not secured to the wall, and uncontained basins (Resident Rooms A02, B01, B08)
- 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 treatment to a surgical incision was completed as ordered, areas of bruising and scabbing were assessed and monitored, and interventions were in place for areas of dry scaly skin for 5 of 6 residents reviewed for skin conditions non-pressure related. (Residents D, H, J, F, and G)
- 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 observation, record review and interview, the facility failed to ensure proper medication storage related to insulin pens not labeled when opened, and loose pills observed in the medication carts for 1 of 2 units (A Wing) and medications at the bedside for residents who did not self-administer medications. (Residents G, 71)
- E
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
Inspectors wroteBased on observation, record review and interview, the facility failed to follow the recipe for pureed spinach. This had the potential to affect the 5 residents who received a pureed diet.
- 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 were assessed for self-administration of medications and had a physician's order to self-administer medications, for 1 of 1 resident reviewed for self-administration of medication. (Resident 59)
- D
Reasonably accommodate the needs and preferences of each resident.
Inspectors wroteBased on observation, record review and interview, the facility failed to ensure the call light was in reach for 1 of 14 active residents reviewed who were able to use the call light. (Resident 71)
- D
Ensure each resident receives an accurate assessment.
Inspectors wroteBased on observation, record review and interview, the facility failed to ensure the Minimum Data Set (MDS) comprehensive assessment was accurately completed related to visual impairment for 1 of 1 resident reviewed for sensory / communication. (Resident F)
- 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 a dependent resident received assistance with activities of daily living (ADL's) related to nail care for 1 of 5 residents reviewed for ADL's. (Resident C)
- D
Provide appropriate foot care.
Inspectors wroteBased on observation, record review and interview, the facility failed to ensure residents received foot care and had routine visits with a podiatrist related to long and thick toenails for 3 of 5 residents reviewed for ADL's (activities of daily living). (Residents C, 33, and G)
- 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 provide treatment for limited range of motion related to splints not in place and lack of instructions for use of a splint for 3 of 4 residents reviewed for range of motion. (Residents 1, E, and F)
- 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 precautions were in place for a resident with a history of falls for 1 of 4 residents reviewed for accidents. (Resident 60)
- 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, and record review, the facility failed to ensure an urinary indwelling catheter collection bag was maintained below the level of the bladder for 1 of 3 residents reviewed for urinary catheters. (Resident 71)
- D
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure a resident was positioned with their head elevated while a tube feeding was infusing for 1 of 1 resident reviewed for tube feedings. (Resident E)
- D
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Inspectors wroteBased on record review and interview, the facility failed to ensure an intravenous (IV) access site was assessed upon admission and removed in a timely manner for 1 of 1 resident reviewed for parenteral/IV fluids. (Resident D)
- 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 residents received the necessary care and treatment related to oxygen administration for 2 of 3 residents reviewed for respiratory care. (Residents 1 and 9)
- 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 blood pressure monitoring was completed for residents receiving blood pressure medications with parameters for 2 of 7 residents reviewed for unnecessary medications. (Residents H and D)
July 7, 2025Complaint inspection · 4 citations
- 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, record review, and interview, the facility failed to ensure a resident had a clean and homelike environment, related to a resident lying on soiled bottom sheet on the bed for 1 random observation. (Resident C)
- 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, record review, and interview, the facility failed to ensure a comprehensive care plan was implemented for a resident with a skin condition for 1 of 4 resident care plans reviewed. (Resident C)
- 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 a dependent resident received assistance with activities of daily living (ADLs) related to the timeliness of incontinence care for 1 of 3 residents reviewed for ADLs. (Resident C)
- 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 treatments for pressure ulcers were in place as ordered by the physician for 1 of 3 residents reviewed for pressure ulcers. (Resident C)
June 5, 2025Complaint inspection · 1 citation
- 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 residents received blood sugar monitoring, insulin and hypoglycemic medications as ordered by the Physician for 3 of 3 residents reviewed for diabetes management. (Residents B, C and D)
July 12, 2024Standard inspection, Complaint inspection · 12 citations
- E
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food was prepared in form to meet individual needs related to not following a recipe for pureed food and not making pureed food the correct consistency. This had the potential to affect all 5 residents who received a pureed diet. (Main Kitchen)
- E
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, record review and interview, the facility failed to ensure infection control measures were in place and implemented related to lack of a clothing protector used when sorting soiled laundry, incorrect signage posted for a resident on contact isolation, and not cleaning a shared blood pressure cuff between uses. (Laundry Aide 1, QMA 1, and Resident 23)
- 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 a medication, physician's orders for self-administration of medications, and a self-administration of medications assessment completed for 1 of 2 residents reviewed for self-administration of medication. (Resident 4)
- 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 observation, record review and interview, the facility failed to notify the family/representative of new orders for medications for 1 of 5 residents reviewed for unnecessary medications. (Resident B)
- 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 record review and interview, the facility failed to ensure quarterly care plan meetings were completed and/or family representatives were invited for 3 of 4 residents reviewed for care planning. (Residents D, E and B)
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on interview, observation, and record review, the facility failed to ensure residents received the necessary care for activities of daily living (ADLs) related to the lack of documentation of incontinence care and residents with long, dirty fingernails and toenails for 3 of 11 residents reviewed for ADL care. (Residents 10, 4 and C)
- 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 residents received the necessary care and treatment, related to administering a blood pressure medication out of the prescribed parameters, the lack of assessment and a treatment order for a resident with a bandage, and a resident not wearing preventative heel protectors as ordered, for 1 of 5 residents reviewed for unnecessary medications (Resident 28) and 2 of 4 residents reviewed for non-pressure skin conditions. (Residents 39 and C)
- D
Assist a resident in gaining access to vision and hearing services.
Inspectors wroteBased on record review and interview, the facility failed to ensure residents with impaired hearing received the necessary services for 1 of 1 resident reviewed for hearing. (Resident C)
- 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 a resident received the necessary treatment to prevent decreased range of motion, related to a splint not in place as recommended for 1 of 3 residents reviewed for range of motion. (Resident D)
- D
Provide enough food/fluids to maintain a resident's health.
Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure a resident with dysphagia (difficulty swallowing) received adaptive equipment as ordered during meals for 1 of 2 residents reviewed for nutrition. (Resident D)
- 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 residents received proper treatment and care related to oxygen administration for 1 of 1 resident reviewed for respiratory care. (Resident 1)
- D
Provide safe, appropriate pain management for a resident who requires such services.
Inspectors wroteBased on record review and interview, the facility failed to ensure pain medications were available and administered to a resident per the physician's orders for 1 of 2 residents reviewed for pain. (Resident C)
May 31, 2024Complaint inspection · 1 citation
- E
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure correct Personal Protective Equipment (PPE) was used by a staff members (CNA 1), when providing care to a resident who was in Enhanced Barrier Precautions for 1 of 3 residents observed who were in EBP. (Resident D) This had the potential to affect 34 residents who resided on 1 of 2 Units. (A-Unit)
April 8, 2024Complaint inspection · 1 citation
- 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 the timeliness of incontinence care, for 2 of 3 residents reviewed for ADLs. (Residents B and C)
December 7, 2023Complaint inspection · 4 citations
- F
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Inspectors wroteBased on record review and interview, the facility failed to ensure a Registered Nurse (RN) was scheduled in the facility for at least 8 consecutive hours a day, 7 days a week. This had the potential to affect 64 of 64 residents who resided in the facility.
- 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, record review, and interview, the facility failed to ensure the residents' environment was sanitary and comfortable, related to cob webs, dirt and debris on the floor, liquid feeding dried on IV/feeding pump poles, a feeding pump, and floors, cable and outlet covers loose or off, a soiled over the bed table, an over the bed table with a gouge, a cracked floor mat, a wedge pillow stored on the floor, and an accumulation of dust on a bathroom fan, for rooms on 2 of 2 Units. (B-Unit and A-Unit)
- 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 who was being transferred in a bus to an appointment was secured appropriately in the bus to prevent the wheelchair from tipping over and also failed to ensure a Physician's Order and Care Planned intervention was in place to prevent falls, related to anti-roll back device was not located on a wheelchair for 2 of 3 residents reviewed for accidents. (Residents K and G)
- C
Post nurse staffing information every day.
Inspectors wroteBased on record review and interview, the facility failed to ensure the posted Nurse Staffing Information was up-to-date and current, related to call-offs, no shows, and replacements not updated every shift. This had the potential to affect all of the residents who resided in the facility for the month of November, 2023.
July 28, 2023Standard inspection · 10 citations
- E
Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.
Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure there was sufficient dietary staff available to effectively serve meals in a timely manner. This had the potential to affect 65 residents who received meals from the kitchen. (Main 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 keep the residents' environment clean and in good repair related to dirty floors, damaged walls, peeling non-skin strips, a running toilet, and broken furniture on 2 of 2 units. (The A and B Units)
- D
Honor the resident's right to manage his or her financial affairs.
Inspectors wroteBased on observation and interview, the facility failed to ensure residents had access to their personal funds at all times for 1 of 2 residents reviewed for personal funds. (Resident 67)
- 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, record review, and interview, the facility failed to develop and implement comprehensive, resident-centered Care Plans related to activities, antidepressant medications, diabetes and anticoagulant medications for 2 of 17 resident Care Plans reviewed. (Residents 44 and 34)
- D
Provide activities to meet all resident's needs.
Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure an ongoing activity program was implemented for dependent residents for 3 of 4 residents reviewed for activities. (Residents 44, 34 and 40)
- 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 residents received the necessary treatment and services related to the monitoring and assessment of a resident with a possible change in condition for 1 of 1 residents reviewed for change in condition, monitoring and assessment of skin discolorations for 1 of 2 residents reviewed for non-pressure related skin conditions, and an improper length of a bed for 1 of 1 residents reviewed for positioning. (Residents 63, 43 and 13)
- 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 a pressure ulcer received the necessary treatment and services to promote healing, related to the lack of a timely treatment put into place for 1 of 4 residents reviewed for pressure ulcers. (Resident 40)
- D
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Inspectors wroteBased on observation, record review, and interview, the facility failed to identify or act on an irregularity in a resident's medication regimen related to an unnamed medication being administered for 1 of 5 residents reviewed during medication pass. (Resident 1)
- C
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 a resident with abnormal urine in the indwelling catheter was assessed timely and a resident with a colostomy received daily colostomy care for 2 of 2 residents reviewed for urinary catheters, bowel and bladder care. (Residents 66 and 12)
- C
Post nurse staffing information every day.
Inspectors wroteBased on observation and interview, the facility failed to have accurate and complete daily nurse staffing postings. This had the potential to affect all 67 residents residing in the facility.
Fire safety inspections
25 fire safety citations on file: 14 on November 24, 2025, 7 on July 12, 2024, 4 on July 28, 2023.
Every fire safety citation25 citations
- F
Install emergency lighting that can last at least 1 1/2 hours.
K 291 · November 24, 2025 · Corrected (the home has a date of correction)
- F
Provide properly protected cooking facilities.
K 324 · November 24, 2025 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · November 24, 2025 · Corrected (the home has a date of correction)
- F
Meet other general requirements that are deficient.
K 500 · November 24, 2025 · 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 · November 24, 2025 · Corrected (the home has a date of correction)
- F
Have simulated fire drills held at unexpected times.
K 712 · November 24, 2025 · 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 · November 24, 2025 · Corrected (the home has a date of correction)
- F
Ensure that testing and maintenance of electrical equipment is performed.
K 921 · November 24, 2025 · Corrected (the home has a date of correction)
- E
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 · November 24, 2025 · Corrected (the home has a date of correction)
- E
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
K 223 · November 24, 2025 · Corrected (the home has a date of correction)
- E
Install a fire alarm system that can be heard throughout the facility.
K 341 · November 24, 2025 · Corrected (the home has a date of correction)
- E
Install an approved automatic sprinkler system.
K 351 · November 24, 2025 · Corrected (the home has a date of correction)
- E
Install corridor and hallway doors that block smoke.
K 363 · November 24, 2025 · Corrected (the home has a date of correction)
- E
Have properly installed electrical wiring and gas equipment.
K 511 · November 24, 2025 · Corrected (the home has a date of correction)
- F
Install emergency lighting that can last at least 1 1/2 hours.
K 291 · July 12, 2024 · Corrected (the home has a date of correction)
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · July 12, 2024 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · July 12, 2024 · Corrected (the home has a date of correction)
- F
Have simulated fire drills held at unexpected times.
K 712 · July 12, 2024 · Corrected (the home has a date of correction)
- E
Have corridors or aisles that are unobstructed and are at least 8 feet in width.
K 232 · July 12, 2024 · 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 · July 12, 2024 · Corrected (the home has a date of correction)
- E
Install a fire alarm system that can be heard throughout the facility.
K 341 · July 12, 2024 · Corrected (the home has a date of correction)
- F
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
K 761 · July 28, 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 · July 28, 2023 · Corrected (the home has a date of correction)
- E
Have properly located and lighted "Exit" signs.
K 293 · July 28, 2023 · Corrected (the home has a date of correction)
- E
Ensure proper usage of power strips and extension cords.
K 920 · July 28, 2023 · Corrected (the home has a date of correction)