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
0G
0H
0I
Potential for more than minimal harm
31D
5E
0F
Potential for minimal harm
0A
0B
0C
April 20, 2026Complaint inspection · 1 citation
- D
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Inspectors wroteBased on record review, facility documentation review, and staff interviews for one of three residents (Resident #2) reviewed for discharge planning, the facility failed to ensure the resident was discharged with home care services.
September 23, 2025Complaint inspection · 3 citations
- J
Ensure that residents are free from significant medication errors.
Inspectors wroteBased on review of clinical record, facility documentation, facility policy, and interviews for one of three residents (Resident #1) reviewed for medication errors, the facility failed to ensure Coumadin therapy to adequately maintain INR levels as ordered, failed to monitor the INR levels timely, and failed to act on the INR results timely in accordance with physician orders. The failures resulted in a finding of Immediate Jeopardy.
- 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 clinical record review, facility documentation review, facility policy review, and interviews for two residents (Resident #1 and #2) reviewed for medication error, the facility failed to include anticoagulation therapy in the resident care plan timely for a resident on Coumadin.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on clinical record review, facility documentation review, facility policy review, and interviews for one of three (Resident #2) reviewed for medication error, the facility failed to ensure Coumadin was administered to maintain the INR in accordance with physician orders.
August 27, 2025Complaint inspection · 1 citation
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on observation, review of the clinical record and facility documentation, and interviews for one resident (Resident #1) reviewed for accidents, the facility failed to provide adequate supervision to ensure a resident identified at risk for elopement did not leave the facility without staff knowledge.
June 11, 2025Complaint inspection · 1 citation
- D
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Inspectors wrote\ Based on clinical record review, facility documentation review, facility policy review, and interviews for one resident (Resident #1) reviewed for accidents, the facility failed to ensure the physician was notified timely of an increase in agitation.
April 3, 2025Complaint inspection · 1 citation
- 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 clinical record review, facility documentation review, facility policy review, and interviews for one resident (Resident #1) reviewed for respiratory services, the facility failed to ensure that the medical provider was notified timely of a change in condition.
January 23, 2025Complaint inspection · 1 citation
- D
Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy.
Inspectors wroteBased on record review, facility documentation review, and staff interviews for one of three (Resident #1) reviewed for hospital transfer, the facility failed readmit a resident to the facility following hospitalization.
October 25, 2024Standard inspection · 13 citations
- E
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observations, interviews, review of the clinical record, facility documentation, and facility policy for 1 of 5 residents (Resident #326) reviewed for infection control, the facility failed to implement Enhanced Barrier Precautions (EBP) for a resident with a gastrostomy (feeding) tube and a peripherally inserted central catheter (PICC).
- D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteBased on observations, review of facility policy, and interviews for 1 of 3 sampled residents (Resident #374) reviewed for accidents, the facility failed to ensure that a resident was treated with dignity when requesting wheel chair foot rests/pedals.
- D
Reasonably accommodate the needs and preferences of each resident.
Inspectors wroteBased on observation, staff interviews, review of clinical records, and facility policy for 1 of 1 resident (Resident #525) reviewed for environment, the facility failed to provide a call bell that accommodated Resident #525's physical limitation needs.
- D
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Inspectors wroteBased on staff interviews, clinical record review, and facility policy for 1 of 1 sampled resident (Resident #374) reviewed for dialysis, the facility failed to implement a baseline care plan that met the immediate needs of a hemodynamically managed resident.
- 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 interviews, a review of the clinical record, and facility policy for 1 of 2 sampled residents (Resident #175) reviewed for Activities of Daily Living (ADLs), the facility failed to ensure Resident #175 was assisted with bed mobility according to the physician's orders and the resident's needs.
- D
Ensure services provided by the nursing facility meet professional standards of quality.
Inspectors wroteBased on interviews, review of the clinical record, facility documentation, and facility policy for the only sampled resident (Resident #326) reviewed for tube feeding, the facility failed to ensure medication orders indicated an appropriate route of administration for a resident who was to have nothing by mouth (NPO).
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on observations, review of the clinical record, facility documentation, facility policy and interviews for 1 of 3 residents (Resident #1) reviewed for accidents, the facility failed to implement bumper guards and floor mats per the physician's order for a resident on seizure precautions and for 1 of 2 sampled residents (Resident #11) reviewed edema, facility failed to follow physicians order for the application of heel booties.
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on clinical record review, review of facility policy, and interviews for 2 of 3 sampled residents (Resident #374) reviewed for accidents, the facility failed to ensure that appropriate assistance was provided with transfer of a resident, and for the only sampled resident (Resident #624) reviewed for smoking, the facility failed to ensure a smoking assessment was conducted as part of the initial admission assessment. Additionally, the facility failed to ensure appropriate disposal of used cigarette materials.
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observation, clinical record review, review of facility policy, and interviews for 1 of 3 sampled residents (Resident #11) reviewed for respiratory care, the facility failed to administer oxygen per physician orders.
- D
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Inspectors wroteBased on observation, staff interviews, review of clinical records, and facility policy for the only sampled resident (Resident #374) reviewed for dialysis, the facility failed to identify and monitor Resident #374 Arteriovenous (AV) fistula (an artificial connection made between an artery and a vein for dialysis access).
- 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 interviews, review of the clinical record, facility documentation, and facility policy for 1 of 5 residents (Resident #674) reviewed for unnecessary medications, the facility failed to ensure that a resident receiving an antipsychotic medication had an appropriate diagnosis and monitoring. Resident #674 was admitted to the facility in October 2024 with diagnoses that included anxiety/depression disorder, chronic obstructive pulmonary disease, and breast cancer. The Nursing admission assessment dated [DATE] identified Resident #674 was alert and oriented to person, place and time, communicated verbally, speech was clear and was able to understand and be understood when speaking. The Nursing admission Assessment further identified Resident #674's mood was pleasant with no unwanted behaviors. [...]
- D
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Inspectors wroteBased on review of the clinical record and interviews, for 1 of 2 sampled residents (Resident #625) reviewed for food concerns, the facility failed to provide the requested alternative menu option.
- D
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Inspectors wroteBased on staff interviews, review of clinical records, and facility policy for 1 of 5 residents (Resident #624) reviewed for immunizations, the facility failed to offer a resident an influenza vaccine or document a refusal or proof of prior immunization of an influenza vaccine.
March 27, 2024Complaint 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 clinical record review, facility documentation review, facility policy review, and interviews for one of three residents (Resident #1) reviewed for pressure wounds, the facility failed to ensure the responsible party was notified timely when a pressure wound worsened and the treatment plan changed.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on clinical record review, facility documentation review, facility policy review, and interviews for one of three resident (Resident #1) reviewed for pressure wounds, the facility failed to ensure a urine sample and weekly weights were obtained timely, in accordance with physician orders.
- D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on clinical record review, facility documentation review, facility policy review, and interviews for two of three sampled residents (Resident #1 and #2) reviewed for pressure wounds, the facility failed to ensure the record was complete and accurate to include weekly skin assessment results and weights.
July 8, 2022Standard inspection · 10 citations
- E
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 review of staff records, facility documentation, facility policy, and interviews for 4 of 6 sampled staff for NA # 2, NA # 3, LPN #1 and RN # 11) reviewed for staff competencies, the facility failed to provide annual staff competencies and evaluations per the facility assessment.
- 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, review of facility policy and interviews, the facility failed to ensure that proper beard restraint during food handling and preparation and failed to ensure that bottle juice store in the emergency food supply was not expired and that refrigerator/freezer temperature were monitored and maintained.
- E
Provide and implement an infection prevention and control program.
Inspectors wroteBased on review of the facility Infection Control program, observations, review of facility policy and interviews, the facility failed to ensure that an accurate surveillance data tool was in place to track infections and the facility failed to ensure that freshly laundered resident clothing was kept in a clean and sanitary manner.
- D
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Inspectors wroteBased on clinical record review, review of facility documentation, observation, facility policy and interviews for 3 of 16 sampled residents (Residents #15, #31, #242) reviewed for advanced directives, the facility failed to ensure that the clinical record correctly reflected the advanced directive choice selected by the resident.
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on clinical record review, observation, facility documentation review, facility policy review and interviews for 1 of 4 residents (Resident #32) reviewed for skin condition, the facility failed to report an injury of unknown origin to the state agency.
- D
Respond appropriately to all alleged violations.
Inspectors wroteBased on clinical record review, observation, facility documentation review and interviews for 1 of 4 residents (Resident #32) reviewed for skin condition, thoroughly investigate the origin of the resident's open purpura to the left upper arm.
- D
Ensure services provided by the nursing facility meet professional standards of quality.
Inspectors wroteBased on clinical record review , observations facility policy and interviews for one resident ( Resident #744) reviewed for Leave Of Absence (LOA), the facility failed to document and communicate the resident's departure from the facility and one five residents (Resident #35) reviewed for safe medication administration, the facility failed to ensure safe administration of an extended release medication to meet professional standards . The findings indicated: 1. Resident #744's diagnoses included bipolar disorder and cervical disc disorder with radiculopathy high cervical region. [...]
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on clinical record review, observation, facility documentation review, facility policy review and interviews for 1 of 4 residents (Resident #286) reviewed for skin condition, the facility failed to provide appropriate treatment for skin condition timely and the written physician order failed to specify the specific affected site.
- 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 observations, facility policy review and interviews for 3 medication storage rooms reviewed for temperature log maintenance, the facility failed to consistently maintain consistent temperature logs for 3 refrigerators reviewed and the facility failed to ensure that medication carts and medications were secured.
- D
Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
Inspectors wroteBased on clinical record reviews, facility policy review and interviews for 3 of 5 sampled residents (Resident # 193, #196, and #197) reviewed for immunizations, the facility failed to ensure that education regarding the Covid 19 vaccine was provided to the resident, and that documentation regarding refusal of the Covid 19 vaccine was documented in the resident's medical record.
November 27, 2019Standard inspection · 3 citations
- 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, staff interviews and a review of the facility policy, the facility failed to store food in accordance with professional standards for food service safety.
- D
Plan the resident's discharge to meet the resident's goals and needs.
Inspectors wroteBased on a clinical record review, staff interviews, and a review of facility documentation for one of two residents reviewed for discharge (Resident # 182), the facility failed to ensure equipment needed to return to the community was obtained on the planned discharge date that resulted in a delayed discharge.
- D
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Inspectors wroteBased on a review of the clinical record, staff interviews and a review of the facility policy for one of five Residents reviewed for psychotropic medications (Resident #10), the facility failed to properly monitor targeted behaviors.
Fire safety inspections
11 fire safety citations on file: 4 on October 25, 2024, 5 on July 8, 2022, 2 on November 27, 2019.
Every fire safety citation11 citations
- E
Inspect, test, and maintain automatic sprinkler systems.
K 353 · October 25, 2024 · Corrected (the home has a date of correction)
- D
Install an approved automatic sprinkler system.
K 351 · October 25, 2024 · Corrected (the home has a date of correction)
- D
Install corridor and hallway doors that block smoke.
K 363 · October 25, 2024 · 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 · October 25, 2024 · Corrected (the home has a date of correction)
- F
Provide a written emergency evacuation plan.
K 711 · July 8, 2022 · Corrected (the home has a date of correction)
- D
Install emergency lighting that can last at least 1 1/2 hours.
K 291 · July 8, 2022 · Corrected (the home has a date of correction)
- D
Properly select, install, inspect, or maintain portable fire extinguishes.
K 355 · July 8, 2022 · Corrected (the home has a date of correction)
- D
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
K 761 · July 8, 2022 · Corrected (the home has a date of correction)
- D
Have proper fire barriers, ventilation and signs for the transfilling of oxygen.
K 927 · July 8, 2022 · Corrected (the home has a date of correction)
- D
Have an enclosure around a vertical opening shaft.
K 311 · November 27, 2019 · Corrected (the home has a date of correction)
- D
Install corridor and hallway doors that block smoke.
K 363 · November 27, 2019 · Corrected (the home has a date of correction)