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 37 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
1J
0K
0L
Actual harm
4G
0H
0I
Potential for more than minimal harm
25D
4E
3F
Potential for minimal harm
0A
0B
0C
July 20, 2026Complaint inspection · 5 citations
- J
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 did not ensure each resident received adequate supervision and assistance to prevent accidents for 1 (R95) of 1 resident reviewed for feeding assistance and 5 (R50, R18, R77, R1, and R3) of 9 residents reviewed for falls. * R95 was assessed to be dependent on staff for eating, requiring a mechanical soft diet, needing assistance with feeding, and needing to take small bites while eating. Speech Therapist (ST)-K informed Surveyor that facility staff should be within 2 feet and at the same table while R95 is eating. On 6/13/26, R95 was in the dining room. Certified Nursing Assistant (CNA)-PP left the dining room to deliver room trays. R95's was served a tuna sandwich which was placed in front of R95 without staff supervision. [...]
- E
Ensure services provided by the nursing facility meet professional standards of quality.
Inspectors wroteBased on interview and record review, the facility did not ensure professional standards of practice were followed for 1 (R95) of 16 Residents that receive an altered textured diet and choked. This deficient practice also has the potential to affect the 16 residents who currently receive altered texture diets. The facility does not follow current standards of practice for altered texture diets by not following IDDSI (International Dysphagia Diet Standardization Initiative). R95's Hospital Speech Language Therapist (SLP) recommended that R95 follow the International Dysphagia Diet Standardization Initiative (IDDSI) level 6 Soft & Bite sized diet, which does not include slices of bread. The facility does not follow the IDDSI standard of practice. Facility staff placed R95 on a mechanical soft diet, which did include soft bread. [...]
- 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 did not ensure 2 (R93 & R9) of 18 residents reviewed for grievances had their grievances investigated and resolved. *R93's family complained of long call light response times. There is no evidence that the facility investigated and resolved this grievance. *The facility documented a grievance for R9 dated 4/7/26, however, the facility did not address the root cause of the grievance.
- D
Respond appropriately to all alleged violations.
Inspectors wroteBased on interview and record review the facility did not ensure 1 (R93) of 2 allegations were thoroughly investigated. On 10/7/25 R93's family alleged neglect. The facility did not thoroughly investigate this allegation as R93 was not interviewed.
- 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 interview and record review the facility did not ensure a resident who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infection and restore continence to the extent possible for 1 (R94) of 2 sampled residents reviewed for bowel and bladder. R94 was admitted to the facility on [DATE] with an indwelling foley catheter. The facility discontinued R94's foley catheter on 11/28/25. The facility did not complete a comprehensive bladder assessment or develop a urinary care plan after R94's foley catheter was discontinued.
September 8, 2025Complaint inspection · 3 citations
- G
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 did not ensure 2 (R1 & R3) of 3 residents received adequate supervision and assistance devices to prevent accidents.*R1 was admitted to the facility on [DATE] with a history of falls. R1 fell on 8/11/25 while attempting to self transfer. The facility did not thoroughly investigate this fall and was aware of R1's multiple attempts to self transfer but did not address R1's self transferring behaviors. On 8/19/25 R1 fell, was transferred to the hospital and diagnosed with a pelvic fracture. R1 returned to the facility on 8/28/25. On 8/31/25 R1 fell. The facility did not thoroughly investigate this fall.*R3's falls on 6/26/25, 7/7/25, 7/13/25, 7/29/25, 8/2/25, 8/20/25, & 8/26/25 were not thoroughly investigated. On 9/4/25 R3 received the incorrect diet for lunch., putting R3 at risk for choking. [...]
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on interviews and record review, the facility failed to develop and/or implement policies and procedures for ensuring the reporting of a reasonable suspicion of a crime in accordance with section 1150B of the Act, the facility did not report 1 of 2 allegations reviewed for neglect/mistreatment to the State Survey Agency during the required timeframe. R2's daughter sent an email to the Nursing Home Administrator regarding a concern of mistreatment and neglect towards R1. This was delayed in being reported to the state agency.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on interview and record review, the facility did not ensure 1 (R2) of 4 residents reviewed for quality of care received treatment and care in accordance with professional standards of practice. * R2 developed a rash and R2's physician was not notified in order for R2 to obtain treatment.
June 26, 2025Complaint inspection · 2 citations
- G
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on interviews and record review the facility did not ensure that each resident receives adequate supervision and assistance devices to prevent accidents for 2 of 2 (R1 and R2) residents reviewed for accidents. R1 was care planned to transfer with a sit to stand mechanical lift and assist of 2 staff. CNA's transferred the resident with 2-person pivot. R1 sustained a leg fracture. R2 was care planned to transfer with a sit to stand mechanical lift and assist of 2 staff. The CNA transferred the resident alone. R2 sustained a fall from the sit to stand resulting in a head laceration requiring staples.
- D
Respond appropriately to all alleged violations.
Inspectors wroteBased on interview and record review, the facility did not thoroughly investigate an allegation of abuse or neglect affecting 1 (R3) of 3 Facility Reported Incidents reviewed. R3 was found to have a large bruise to the back of the base of the neck. Staff members that cared for R3 were not interviewed to determine the cause of the bruise. Administration interviewed other residents to determine if they had safety concerns; no residents from R3's unit or floor were interviewed. The report that was filed with the State Agency documented conflicting dates of when the injury of unknown origin was discovered.
January 21, 2025Standard inspection · 8 citations
- G
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on interview and record review, the facility did not ensure that residents remain free of accident hazards and each resident received adequate supervision and assistance devices to prevent accidents for 1 of 5 residents (R12) reviewed for accidents. R12 sustained a significant injury to her leg which required surgical intervention. The facility did not complete a thorough investigation as to how the injury occurred.
- 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, interviews, and policy review the facility did not utilize a sanitary process for the dishwashing machine. This had the potential to effect all 87 residents in the facility. - The dietary staff was observed handling dirty items and placing them into the dishwashing machine. Then handling the clean items from the dishwashing machine with performing hand hygiene and using the same contaminated hands.
- F
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview and record review, the facility did not implement an effective infection prevention and control program. This had the potential to affect all 87 residents, staff, and visitors in the facility. - The facility did not have documentation they investigated infection outbreaks in the facility. - The facility did not have a system to track all facility staff illnesses. - The facility did not implement enhanced barrier precautions for R1 and R50 identified as having wounds.
- 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, interviews and record review the facility did not ensure that drugs and biological's used in the facility were labeled in accordance with currently accepted professional principles, and include the expiration date when applicable for 3 of 4 medication carts and 2 of 2 medication rooms reviewed. Insulin vials and pens were not dated when opened.
- D
Allow residents to self-administer drugs if determined clinically appropriate.
Inspectors wroteBased on observations, interviews and record review the facility did not ensure it was safe and clinically appropriate for residents to self administer medications for 3 of 3 (R63, R75, and R56) residents observed for self administration of medications. R63 was observed to have medications at bedside. There was no assessment, physicians order or care plan for self administration of medications. R75 was observed to have medications at bedside. There was no assessment, physicians order or care plan for self administration of medications. R56 was observed to have medications at bedside. There was no assessment, physicians order or care plan for self administration of medications
- D
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Inspectors wroteBased on interview and record review, the facility did not ensure 3 (R62, R283, R67) of 7 residents reviewed that required hospitalizations were given written reason for transfer to the hospital and the facility did not send this notification to the ombudsman. R62 was transferred to the hospital on [DATE] for a change in condition. R62 or their representative did not receive written notification of the reason for the transfer to the hospital and appeal rights and the State Ombudsman was not sent a copy of this notice. R283 was transferred to the hospital on [DATE] for a change in condition. R283 or their representative did not receive written notification of the reason for the transfer to the hospital and appeal rights and the State Ombudsman was not sent a copy of this notice. R67 was transferred to the hospital on 6/13/24 for a change in condition. [...]
- D
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Inspectors wroteBased on interview and record review, the facility did not ensure 3 (R62, R283, R67) of 7 residents received a written notice of the bed hold policy when they were transferred to the hospital. R62 was transferred to the hospital on [DATE] and did not receive written notice of the bed hold policy. R283 was transferred to the hospital on [DATE] and did not receive written notice of the bed hold policy. R67 was transferred to the hospital on 6/13/24 and did not receive written notice of the bed hold policy.
- 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 and record review the facility did not ensure that residents who enter the facility with an indwelling catheter or subsequently receives one is assessed for removal of the catheter as soon as possible unless the resident's clinical condition demonstrates that catheterization is necessary for 1 of 2 (R12) residents reviewed for catheters. R12 admitted to the facility without a catheter. R12 was hospitalized and returned to the facility with a Foley catheter. R12 did not have a diagnosis or clinical condition indicating the necessity of the catheter.
November 14, 2024Complaint inspection · 4 citations
- D
Reasonably accommodate the needs and preferences of each resident.
Inspectors wroteBased on observation, interview and record review, the facility did not ensure 1 (R1) of 2 Residents reviewed received reasonable accommodation of needs, potentially affecting 24 of 87 residents. * Slings were not available to transfer R1 out of bed via a Hoyer mechanical lift. Residents using the same size sling that required [NAME] mechanial life transfers were also affected by slings not being availabe.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on interview and record review, the facility did not ensure residents received treatment and care in accordance with professional standards of practice for 1 (R1) of 2 residents reviewed for surgical incision wounds. * R1 was admitted with surgical incision wounds, there were no comprehensive assessments or orders in place for care of the surgical incisions and R1's skin integrity comprehensive care plan did not indicate R1 had surgical wounds.
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on interview and record review, the facility did not ensure residents received adequate supervision and assistance devices were in place to prevent accidents for 1 (R2) of 4 residents reviewed for falls. R2 fell on 7/2/2024 at approximately 7:30 AM and a root cause analysis was not completed to implement an appropriate intervention to prevent future falls. R2 fell on 7/2/2024 at approximately 5:30 PM sustaining lacerations to the face requiring R2 to go to the hospital to be evaluated and treated. A fall mat was not in place at the time of the fall, per R2's care plan to reduce the possibility of injury at the time of the second fall on 7/2/2024.
- 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 interview and record review, the facility did not ensure 1 (R1) of 2 residents reviewed received appropriate treatment and services related to catheter care. * R1 was admitted to the facility on [DATE] with a foley catheter and did not have orders in place until 11/4/2024 for catheter care and monitoring.
November 7, 2023Standard inspection · 6 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 did not ensure food was stored or served in accordance with professional standards for food service safety potentially affecting 87 of 88 residents in the facility. Food stored in the main kitchen walk-in refrigerator, the main kitchen walk-in freezer, and the three unit refrigerators were not labeled, dated, sealed, or had expired with mold present.
- D
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Inspectors wroteBased on interview and record review, the facility did not ensure 1 (R41) of 1 sampled residents reviewed for a facility initiated discharge received a written transfer/discharge notice that included the date of transfer, reason for transfer, location of transfer, appeal rights and contact information of the State Long-Term Care Ombudsman. R41 was transferred to the hospital on 1/29/23. R41 and their representative was not given a transfer notice.
- D
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Inspectors wroteBased on interview and record review the facility did not ensure 2 (R86 and R41) of 2 residents received a written bed hold notice when they were transferred to the hospital. * R86 was transferred to the hospital on 9/21/23. R86 and their responsible party and did not receive a written bed hold notice. * R41 was transferred to the hospital on [DATE] and did not receive written bed hold notice.
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on observation, record review and interviews, the facility did not ensure residents that were dependent on staff for personal hygiene were provided the necessary care. This was observed with 2(R22 and R26) of 4 residents dependent on staff for personal hygiene. - R22 is unable to trim their nails and lotion their feet. R22 was observed with untrimmed nails and extremely dry flaky feet. - R26 is unable to trim their nails. R26 was observed with long nails.
- 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 did not ensure residents received adequate supervision and assistance devices to prevent falls for 1 (R36) of 2 residents reviewed for falls. R36 had a witnessed fall on 3/18/2023 in the hallway while being pushed in the wheelchair and no interventions were implemented with a root cause analysis of the fall. R36 had a witnessed fall on 9/3/2023 where staff were not following R1's care plan to toilet R36 before and after meals. The care plan was not revised for 15 days.
- D
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Inspectors wroteBased on observation, record review, and interview, the facility did not ensure residents who received psychotropic medications had documentation for use, had behavioral interventions, or monitoring of behaviors with the use of the psychotropic medication for 1 (R36) of 5 residents reviewed for unnecessary medications. R36 was prescribed sertraline after admission to the facility with no indications for use, no targeted behavior monitoring, and an increase in dosage without documentation of increased behaviors.
August 10, 2022Standard inspection · 9 citations
- G
Ensure that residents are free from significant medication errors.
Inspectors wroteBased on interview and record review, the facility did not ensure residents were free of a significant medication error for 1 (R86) of 1 resident reviewed for medication errors. R86 did not receive omeprazole as ordered for four weeks resulting in a hospitalization for a gastrointestinal bleed.
- 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, interview and record review the facility did not ensure food was prepared and served under sanitary conditions with the potential to effect 47 residents who eat food served out of the second-floor pantry (satellite kitchen area). *On 8/8/2022 at 12:08 PM, Surveyor observed Dietary Aide-O not clean the thermometer probe between different foods as Dietary Aide-O took the temperature of several food items. *Thermometer in the second-floor pantry was not cleaned or sanitized per facility policy or sanitizing chemical instructions. Thermometer was not completely air dried after being sanitized, before using to take a food temperature.
- E
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation and record review, the facility did not maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. This had the potential to affect 25 Residents on Unit A. *Surveyor observed staff break infection control standards and not don proper Personal Protection Equipment (PPE) in R37's room where PPE use was identified as needed by Droplet Precautions standards due to R37's COVID-Suspected Status. Findings Include: Surveyor reviewed the facility's Infection Control Program policy and procedure last revised 6/21, and notes the following applicable: . D. Preventing Spread of Infection a. Isolation and Precautions-Follow CDC (Centers for Disease Control) recommendations. Surveyor reviewed the CDC recommendations found at https: [...]
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on interview and record review the facility did not ensure 2 (R24 and R88) of 2 allegations of abuse or neglect were reported to the Nursing Home Administrator immediately and to the State Survey Agency. *R24 verbally expressed allegations of abuse consisting of staff making fun of her weight and Certified Nursing Assistant (CNA)-I's treatment towards her. R24 informed Registered Nurse (RN)-D and Social Worker (SW)-G of these allegations, however, they did not immediately report the allegations to the Nursing Home Administrator (NHA)-A, and the facility did not report the allegations to the State Survey Agency. *R88 verbally expressed an allegation Certified Nursing Assistant (CNA)-J did not provide Activities of Daily Living (ADL) assistance to her. [...]
- D
Respond appropriately to all alleged violations.
Inspectors wroteBased on record review and interviews, the facility did not ensure allegations of potential abuse, and neglect were thoroughly investigated for 2 (R24 and R88) of 2 Residents reviewed for allegations of abuse and/or neglect. *R24 had expressed allegations of abuse consisting of staff making fun of R24's weight and allegations of abuse related to Certified Nursing Assistant (CNA-I). Registered Nurse (RN-D) and Social Worker (SW-G) were aware of these allegations, however, a thorough investigation was not completed. *R88 had expressed an allegation CNA-J did not provide Activities of Daily Living (ADL) assistance. Director of Social Services (DSS-M) was made aware of this potential neglect allegation. However, a thorough investigation including was not completed. Findings Include: [...]
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on observation, interview, and record review, the facility did not ensure residents received treatment and services, consistent with professional standards of practice, to prevent pressure injuries, promote healing and prevent infection for 3 (R26, R16, and R15) of 5 residents reviewed for pressure injuries. *R26 was readmitted to the facility on [DATE] with a Stage 2 pressure injury to the coccyx that was not comprehensively assessed or treated until 8/2/2022. *R16 developed an Unstageable pressure injury on 5/16/2022 that was not comprehensively assessed until 5/31/2022. *R15 was readmitted to the facility on [DATE] with pressure injuries that were inaccurately staged, and the locations of the pressure injuries were not indicated.
- 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, interview and record review, the facility did not ensure 1 (R37) of 2 Residents reviewed with limited range of motion, received appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion. R37 is to receive restorative services 5 times (5x) per week and the facility is unable to provide documentation the services have been provided. Findings Include: Surveyor reviewed the facility's Restorative Nursing Program policy and procedure, revised 12/14, and notes the following: Policy: The facility believes that each Resident has the right to become involved in his/her own care and to have the services available to reach their highest practical physical and psychosocial level well-being. All Residents will be evaluated for participation in the restorative nursing program. Procedure: 1. [...]
- D
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
Inspectors wroteBased on observation, interview, and record review the facility did not have a comprehensive assessment or informed consent for repositioning/assist bars for 1 (R14) of 1 residents observed with repositioning/assist bars. *R14 did not have a physician order for their repositioning/assist bars and the facility did not obtain consent or assess the risk of entrapment prior to installation. The facility also did not have evidence that risks, and benefits were discussed with the resident and/or representative. Finding Include: The facility policy, entitled Safe Bed Environment, with a revision date of 11/2019, states: Policy .The use of bedrails/side rails is not the facilities usual practice. The facility promotes the use of alternative measures or options to bed rails/side rails based on individual, resident assessment by the interdisciplinary team. [...]
- D
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Inspectors wroteBased on observation, record review, and interview, the facility did not ensure a comprehensive assessment was completed when using an antipsychotic medication for 1 (R44) of 1 resident reviewed for antipsychotic medication use. R44 did not have an Abnormal Involuntary Movement Scale (AIMS) assessment completed while a resident of the facility and prescribed antipsychotic medication.
Fire safety inspections
8 fire safety citations on file: 4 on January 21, 2025, 3 on November 7, 2023, 1 on August 10, 2022.
Every fire safety citation8 citations
- F
Provide emergency officials' contact information.
E 31 · January 21, 2025 · Corrected (the home has a date of correction)
- F
Implement emergency and standby power systems.
E 41 · January 21, 2025 · Corrected (the home has a date of correction)
- E
Have restrictions on the use of portable space heaters.
K 781 · January 21, 2025 · Corrected (the home has a date of correction)
- D
Have properly installed electrical wiring and gas equipment.
K 511 · January 21, 2025 · Corrected (the home has a date of correction)
- F
Install a fire alarm system that can be heard throughout the facility.
K 341 · November 7, 2023 · Waiver
- E
Install corridor and hallway doors that block smoke.
K 363 · November 7, 2023 · Corrected (the home has a date of correction)
- D
Have exits that are accessible at all times.
K 271 · November 7, 2023 · Corrected (the home has a date of correction)
- E
Ensure proper usage of power strips and extension cords.
K 920 · August 10, 2022 · Corrected (the home has a date of correction)