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 62 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
1K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
43D
17E
1F
Potential for minimal harm
0A
0B
0C
July 14, 2026Complaint inspection · 1 citation
- D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Inspectors wroteBased on facility documentation reviews, staff interviews and observations, the facility staff failed to maintain an accurate record of the narcotic count record for on-coming and off-going staff for two out of nine medication carts.
November 13, 2025Complaint inspection · 5 citations
- 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 staff interview and clinical record review, the facility staff failed to develop a care plan for one of two residents in a survey sample. The Findings Include: Resident #1 (R1) did not have a care plan for noncompliance to medications, treatments, hygiene, and incontinence care. R1diagnoses include paraplegia, osteomyelitis, urinary tract infection, indwelling catheter, and MRSA (methicillin-resistant-Staphylococcus aureus. The most recent MDS (minimum data set) was a significant change dated 7/24/25 and indicated R1 was cognitively intact. Review of R1's clinical record including medication administration records, treatment administration record, nursing progress notes, physician progress notes, and activity of daily living (ADL) tool indicated R1 was refusing care and treatments, and medications at times. [...]
- D
Ensure services provided by the nursing facility meet professional standards of quality.
Inspectors wroteBased on staff interview, facility document review and clinical record review, the facility staff failed to follow professional standards of care regarding skin assessments for one of two residents in the survey sample (Resident #2).
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on resident interview, staff interview and clinical record review, the facility staff failed to administer medication as ordered by the physician for one of two residents in the survey sample (Resident #2)
- D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on staff interview and clinical record review, the facility staff failed to ensure a complete and accurate clinical record for one of two residents in a survey sample.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, staff interview, facility document review and clinical record review, the facility staff failed to follow infection control practices during dressing changes for one of two residents in the survey sample (Resident #2).
April 9, 2025Complaint inspection · 4 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 staff interview, facility document review and clinical record review, the facility staff failed to notify the responsible party of a change in condition for one of four residents in the survey sample (Resident #3).
- 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 staff interview and facility document review, the facility staff failed to ensure a clean, homelike room environment for one of four residents in the survey sample (Resident #3).
- D
Ensure services provided by the nursing facility meet professional standards of quality.
Inspectors wroteBased on staff interview, facility document review and clinical record review, the facility staff failed to follow professional standards of quality for one of four residents in the survey sample (Resident #3).
- D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on staff interview, facility document review and clinical record review, the facility staff failed to provide a complete and accurate clinical record for one of four residents in the survey sample (Resident #3).
September 12, 2024Standard inspection · 29 citations
- F
Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame.
Inspectors wroteBased on staff interview and facility documentation review, the facility staff failed to implement a bed safety program for the entire facility affecting all residents residing on 3 of 3 units.
- E
Reasonably accommodate the needs and preferences of each resident.
Inspectors wroteBased on observation, staff interview, and resident interview, the facility failed to accommodate the resident's preference to dine in the dining room affecting multiple residents on three of three units.
- E
Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home.
Inspectors wroteBased on Resident interview, staff interview, and facility documentation review, the facility staff failed to provide Residents with quarterly statements of their trust account/bank accounts and failed to allow residents to readily access their trust funds, affecting all 140 residents with trust accounts.
- E
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 resident interview, staff interview and clinical record review, the facility staff failed to review and revise the comprehensive care plan for four of thirty-three residents in the survey sample (Residents #49, #66, #30 and #131).
- E
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on observation, staff interview, clinical record review, and facility document review, the facility staff failed to follow physician orders for five of thirty-three residents in the survey sample (Residents #66, #159, #99, #149, and #92).
- E
Provide care or services that was trauma informed and/or culturally competent.
Inspectors wroteBased on observation, staff interviews, resident interviews, clinical record reviews, and facility documentations the facility staff failed to provide trauma informed care for six residents, (Resident #30-R30, Resident #39-R39, Resident #105-R105, Resident #134-R134, Resident #149-R149 and Resident #367-R367) out of a survey sample of 33 residents.
- E
Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.
Inspectors wroteBased on observation, staff interview, clinical record review, and facility documentation review, the facility staff failed to provide a therapeutic diet as ordered by the physician for four residents (Resident #139, #55, #9, and #30), in a survey sample of 33 residents.
- 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 interview, and facility document review, the facility staff failed to store, prepare and serve food in a sanitary manner from the main kitchen and on one of three units (West unit).
- E
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Inspectors wroteBased on observation, staff interview, and facility document review, the facility staff failed to maintain effective pest control.
- D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteBased on observation and staff interview, the facility staff failed to distribute meals in a manner to maintain and enhance a residents dignity affecting several residents on one of three units.
- D
Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
Inspectors wroteBased on observation, resident interview, staff interview, clinical record review and facility documentation review, the facility staff failed to ensure residents dignity was upheld for one resident, (Resident #99 - R99) in a survey sample of 33 residents.
- D
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Inspectors wroteBased on staff interview, facility documentation review, and clinical record review, the facility staff failed to issue an ABN (Advanced Beneficiary Notice) to one resident (Resident #107-R107) in a survey sample of three residents reviewed for such notices.
- 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, resident interview, staff interview, clinical record review and facility documentation review, the facility staff failed to provide a homelike environment and clean medical equipment for resident use, affecting two residents (Resident #99- R99 and Resident #55- R55) in a survey sample of 33 residents.
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on resident interview, staff interview, clinical record review and facility documentation review, the facility staff failed to report an allegation of abuse to the state survey agency and other officials as required for an incident involving two residents (Resident #14 - R14 and Resident #99 - R99) in a survey sample of 33 residents.
- 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, staff interview, clinical record review and facility documentation review, the facility staff failed to develop a comprehensive resident-centered care plan for one resident (Resident #49-R49) in a survey sample of 33 residents.
- D
Ensure services provided by the nursing facility meet professional standards of quality.
Inspectors wroteBased on observation, staff interview, clinical record review and facility documentation review, the facility staff failed to follow professional standards of practice for three of 33 residents in the survey sample. (Residents #268, #134, #49).
- D
Provide activities to meet all resident's needs.
Inspectors wrote2. For resident #92 (R92), the facility staff failed to provide activities to meet the psychosocial well-being of the resident and in accordance with resident preferences. On 9/9/24 at approximately 11:45 p.m., the surveyor was approached by a certified nursing assistant (CNA #3) who reported for the surveyor to not enter a room [which the CNA identified as R92's room]. CNA #3 reported the resident had behaviors and could be extremely combative. On 9/9/24 at approximately 12:30 p.m., R92 was observed in his room. It was noted that the room was dark, the curtains were pulled, no lights were on, and the resident was sitting in a wheelchair in the middle of the room. The room was noted to be empty with no personal possessions, no television, no radio, no books, magazines or other things for the resident to do to occupy his time. [...]
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on staff interview, and clinical record review, the facility staff failed to implement interventions for care/treatment of pressure ulcer for one of 33 residents in the survey sample (Resident #268).
- D
Provide appropriate foot care.
Inspectors wroteBased on observation, resident interview, staff interview, clinical record review and facility documentation review, the facility staff failed to provide services to maintain good foot health of two residents (resident #49-R49 and resident #30-R30) in a survey sample of 33 residents.
- 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, staff interview, and clinical record review, the facility staff failed to implement interventions for a resident with contractures, to prevent the worsening of contractures for one resident (Resident #49-R49) in a survey sample of 33 residents.
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observation, staff interview, clinical record review, and facility document review, the facility staff failed to ensure suction was in place for respiratory care of a tracheostomy for one of 33 residents, Resident #159 (R159).
- D
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Inspectors wroteBased on resident interview, staff interview, facility document review, and clinical record review, the facility failed to provide physician ordered dialysis services and failed to share/communicate care provided during a dialysis treatment for one of thirty-three residents (Resident #2).
- 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, staff interview, clinical record review, and facility documentation review, the facility staff failed to attempt alternatives prior to implementing the use of bed rails for one resident (Resident #49-R49) in a survey sample of 33 residents.
- D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Inspectors wroteBased on resident interview, staff interview, facility document review, and clinical record review, the facility staff failed to ensure a medication was available for administration for one of thirty-three residents in the survey sample (Resident #79).
- D
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Inspectors wroteBased on observation, staff interview and facility document review, the facility staff failed to label an insulin pen when opened on one of three units (West unit).
- 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 observation, staff interview, resident interview, and clinical record the facility staff failed to provide food in accordance with the menu for one, (Resident #39, R39) out of 33 residents in the survey sample.
- D
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Inspectors wroteBased on observation, resident interview, and staff interviews the facility staff failed to provide food preferences for one of 33 residents. Resident # 69 (R69) was not provided side salads as requested.
- D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on staff interview and clinical record review, the facility staff failed to provide a complete and accurate clinical record for three of thirty-three residents in the survey sample (Resident #268, #30 and #149).
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, staff interviews, clinical record review and facility documentation review the facility staff failed to provide a negative urinalysis prior to removing contact isolation for one resident, Resident #134 (R134) in a survey sample of 33 residents.
April 16, 2024Complaint inspection · 1 citation
- E
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on staff interview, clinical record review, and facility document review, the facility staff failed to ensure resident identifiable information was not released to the public for 41 of 42 residents in the survey sample, Residents 1- 41.
July 1, 2021Standard inspection · 12 citations
- K
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wrote9. Resident #32 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included schizoaffective disorder, hypertension, colon cancer, muscle weakness, unspecified psychosis, major depression disorder, anemia, dysphasia, unspecified severe protein-calorie malnutrition, and Parkinson's disease. The most recent minimum data set (MDS) dated [DATE] was the admission assessment and assessed Resident #32 as moderately impaired for daily decision making with a score of 9 out of 15. On [DATE], Resident #32's clinical record was reviewed. Observed on the physician's order summary was the following order: obtain weekly weight. Order Status: Active. Order Date: [DATE] Observed on the care plans was the following: Nutrition risk r/t (related to) colon cancer/tx (treatment), hx (history) overweight. [...]
- E
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 staff interview and clinical record review, the facility staff failed to notify the physician in a timely manner of medication (Hydrocodone) not given per order, for one of thirteen residents, Resident #201.
- E
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, staff interview, and facility document review, the facility staff failed to review and revise the comprehensive care plan for 5 of 38 Residents, (Resident #10, #23, #133, and #71). Resident #10's care plan was not reviewed and revised regarding hospice services, enhanced droplet precautions, and diabetes mellitus. Resident #23's care plan was not reviewed and revised regarding the resolution of pressure ulcers. Resident #133's care plan did not include hospice services. Resident #86's care plan was not reviewed and revised to include hospice admission and the use of geri-sleeves. Resident #71's care plan was not revised with problems, goals and interventions regarding pressure ulcers.
- E
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Inspectors wroteBased on staff interview and clinical record review, the facility staff failed to ensure medications were available for two of 13 residents, Resident # 201 and Resident # 210. Resident #201 did not receive Hydrocodone three times per day as ordered by the physician because it was not available for administration. Resident # 210 was not administered Ofloxacin three times a day as ordered, and once a day as ordered.
- 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 interview and facility document review, the facility staff failed to store and prepare food in a sanitary manner in the main kitchen.
- D
Ensure each resident receives an accurate assessment.
Inspectors wroteBased on observation, resident interview, staff interview and clinical record review, the facility staff failed to ensure an accurate minimum data set (MDS) for one of 38 residents in the survey sample. An admission MDS for Resident #56 had an inaccurate assessment of the resident's dental issues.
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on observations, complaint investigation, clinical record review, and staff interview, the facility staff failed for three of 38 residents in the survey sample (Residents # 80, 88 and 127), to provide routine foot care. Residents # 80, 88 and 127 had elongated toenails with clearly visible debris under the great toes on their left and right feet.
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observation, staff interview, and clinical record review, the facility staff failed to ensure one of ten residents was administered oxygen as ordered by the physician, Resident #106.
- D
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Inspectors wroteBased on observation, document review, and staff interview, the facility staff failed to ensure expired vaccine was not available for administration on one of 3 units: East unit. A bag containing seven expired vials of Afluria, an influenza vaccine, was in a thermal container in the medication room refrigerator.
- D
Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs.
Inspectors wroteBased on observation, resident interview, and staff interview the facility staff failed to honor food preferences for one of 38 residents in the survey sample: Resident # 18.
- 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 and staff interview, the facility staff failed to ensure a complete and accurate clinical record for two of 38 residents (Resident #285 and Resident #71). Resident #285's clinical record contained another resident's Covid-19 vaccination record, and Resident #71 had an incomplete treatment record for pressure ulcer dressing changes.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, staff interview, facility policy review and clinical record review, the facility staff failed to follow infection control practices during meal tray distribution on one of three nursing units. Staff members on the South wing failed to don gowns and gloves when serving meal trays to residents on droplet precautions.
September 17, 2019Standard inspection · 10 citations
- E
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on observation, staff interview, resident interview, and clinical record review, the facility staff failed to follow physician orders for 4 of 39 residents in the survey sample. A physician ordered knee brace for Resident # 86 was not applied per order; fluid restriction for Resident # 408 was not implemented as ordered; TED hose (compression stockings) were not applied as ordered for Resident # 143; and medications were not administered per physician's orders for Resident #355.
- E
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on observation, staff interview and clinical record review, the facility staff failed to implement interventions for the prevention of pressure ulcers for one of 39 residents in the survey sample. Resident #121, with a recent history of pressure ulcers on both heels, did not have dressings, topical treatment and protective booties applied for 10 consecutive days as required by physician orders and the care plan for pressure ulcer prevention.
- E
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, staff interview, and clinical record review the facility staff failed to provide restorative nursing services for one of 39 residents in the survey sample, Resident # 86.
- E
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on observation, staff interview and clinical record review, the facility staff failed to implement interventions for fall and injury prevention for one of 39 residents in the survey sample. Resident #112's fall mats were not implemented for over a month following an unwitnessed fall from his bed.
- D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteBased on observation and staff interview, the facility staff failed to ensure a dignified dining experience on one of three dining areas. During breakfast in the East unit restorative dining room, facility staff stood over residents while feeding them and fed them without initiating any conversation.
- 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 resident interview, staff interview and clinical record review the facility staff failed to implement the care plan (CP) for Resident # 86 for restorative services, and failed to develop a comprehensive plan of care (CCP) for Resident # 408's fluid restriction.
- 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 observation, staff interview and clinical record review, the facility staff failed to review and revise the comprehensive care plan for two of 39 residents in the survey sample. Resident #112's care plan was not revised to include use of fall mats and an air mattress. Resident #69's care plan was not revised regarding a healed pressure ulcer.
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observation, staff interview, and resident record review, the facility staff failed to follow physician orders for oxygen administration for 2 of 39 resdients in the survey sample, Residents #46 and #114. The Findings Include: 1. Resident #46 was admitted to the facility on [DATE]. Diagnoses for Resident #46 included: Congestive heart failure, diabetes, chronic obstructive pulmonary disease, and sleep apnea. The most current MDS (minimum data set) was a quarterly assessment with an ARD (assessment reference date) of 7/17/19. Resident #46 was assessed as being cognitively intact. On 09/16/19 at 9:12 AM, Resident # 46 was interviewed. During the interview Resident #46 was asked if staff change out oxygen tubing and asked to observed oxygen concentrator. Resident #46 stated that staff do change the oxygen tubing. [...]
- 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, staff interview, facility document review and clinical record review, the facility staff failed to assess one of 39 residents (Resident #112) for entrapment risks prior to use of bed rails with a specialty mattress.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, staff interview and facility document review, the facility staff failed to perform hand hygiene during meal assistance in one of three dining rooms (East unit restorative).
Fire safety inspections
9 fire safety citations on file: 6 on September 12, 2024, 1 on July 1, 2021, 2 on September 17, 2019.
Every fire safety citation9 citations
- D
Install emergency lighting that can last at least 1 1/2 hours.
K 291 · September 12, 2024 · Corrected (the home has a date of correction)
- D
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · September 12, 2024 · Corrected (the home has a date of correction)
- D
Inspect, test, and maintain automatic sprinkler systems.
K 353 · September 12, 2024 · Corrected (the home has a date of correction)
- D
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
K 761 · September 12, 2024 · Corrected (the home has a date of correction)
- D
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · September 12, 2024 · Corrected (the home has a date of correction)
- D
Meet other general requirements.
K 932 · September 12, 2024 · Corrected (the home has a date of correction)
- D
Have proper power supply for life support equipment.
K 915 · July 1, 2021 · Corrected (the home has a date of correction)
- E
Meet other general requirements.
K 200 · September 17, 2019 · Corrected (the home has a date of correction)
- D
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
K 521 · September 17, 2019 · Corrected (the home has a date of correction)