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 46 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
41D
5E
0F
Potential for minimal harm
0A
0B
0C
December 24, 2025Complaint inspection · 2 citations
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on resident interview, observation, staff interview and record review, the facility failed to ensure wound treatments were completed as physician ordered. This affected one (#13) of one resident reviewed for wound treatments. The facility census was 106.
- 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, review of meal tickets, staff and resident interviews, and review of Resident Council meeting minutes, the facility failed to ensure residents received menu items as selected at mealtime. This affected two (#11 and #15) of four residents reviewed for accuracy of meal tray food items. The facility census was 106.
August 21, 2025Standard inspection, Complaint inspection · 13 citations
- E
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteBased on observation, interview, record review, and policy review the facility failed to ensure that residents were served together during dining in the memory care unit. This had the potential to affect all 24 residents who reside on the memory care unit. Additionally the facility failed to ensure a female resident was free from long facial hair. This affected one (#27) of one resident reviewed for facial hair. The facility census was 96.
- D
Ensure that residents are fully informed and understand their health status, care and treatments.
Inspectors wroteBased on record review and interview the facility failed to ensure the psychotropic education form was completed prior to starting medications. This affected one (#30) of five residents reviewed for psychotropic medications. The facility census was 96.
- 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 record review, interview, and policy review the facility failed to ensure the comprehensive care plan included all resident care areas. This affected two (#77 and #98) of 26 residents reviewed for care plans. The facility census was 96.
- D
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Inspectors wroteBased on observation, record review and facility policy review, the facility failed to ensure resident fingernails were cleaned and groomed. This affected one (#68) of three residents reviewed for activities of daily living. The facility census was 96. Findings Include: Review of the medical record for Resident #68 revealed an admission date of 09/20/19 with diagnoses of Alzheimer's disease, chronic obstructive pulmonary disease, and depression. Review of the comprehensive annual Minimum Data Set (MDS) assessment, dated 07/02/25, revealed Resident #68 had intact cognition and was dependent on staff for personal hygiene. Review of the current care plan, updated 07/10/25, revealed Resident #68 required staff participation with personal hygiene. Interview and observation on 08/18/25 at 9:11 A.M. revealed Resident #68 lying in bed. [...]
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to timely ensure a resident's wound was accurately assessed and documented. This affected one (#77) of two residents reviewed for wounds. The facility census was 96.
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on observation, medical record review, staff interview, and facility policy, the facility failed to ensure interventions to prevent skin breakdown were implemented as ordered by the physician. This affected one of two residents (#2) reviewed for pressure ulcer care prevention and treatment. The facility census of 96.
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on observation, staff interview, record review, and policy review, the facility failed to ensure post-fall assessments were completed, including neurological assessments. This affected two (#30 and #78) of four residents reviewed for falls. Additionally, the facility failed to ensure fall prevention measures were in place for one (#12) of four residents reviewed for falls. The facility census was 96. Findings Include:1. Review of the medical record for Former Resident #53 revealed an admission date of 05/19/25 with diagnoses of type 1 diabetes mellitus, kidney transplant failure, and dependence on renal dialysis. Resident #53 discharged home with family on 08/08/25. [...]
- D
Provide enough food/fluids to maintain a resident's health.
Inspectors wroteBased on observation, staff interview, and record review, the facility failed to ensure nutrition supplements were provided as ordered. This affected one (#50) of five residents reviewed for nutrition. The facility census was 96. Findings Include: Review of the medical record for Resident #50 revealed an admission date of 09/27/24 with diagnoses of Parkinson's disease, type II diabetes mellitus, unspecified psychosis, and adult failure to thrive. Resident #50 was under the care of hospice. Review of the significant change comprehensive minimum data set (MDS) assessment, dated 07/21/25, revealed Resident #50 was rarely/never understood and was dependent for all activities of daily life. Review of the physician order dated 01/17/25 revealed Resident #50 received a nutrition supplement (Magic Cup) twice daily with meals. Interview on 08/21/25 at 10:08 A.M. [...]
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observation, staff interview, record review and policy review, the facility failed to ensure proper equipment for residents with a tracheostomy were available at bedside. This affected one (#7) of one resident reviewed for a tracheostomy. Resident #7 was the only resident in the facility with a tracheostomy. The facility census was 96. Findings Include:Review of the medical record for Resident #7 revealed an admission date of 03/15/25 with respiratory failure and tracheostomy status. Review of the quarterly Minimum Data Set (MDS) assessment, dated 07/05/25, revealed Resident #7 had intact cognition and had a tracheostomy. Review of the care plan initiated 03/15/25 for Resident #7 revealed to keep an extra tracheostomy tube and obturator (a curved rod designed to help the tracheostomy tube fit into the trachea) at bedside. [...]
- D
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Inspectors wroteBased on record review, interview, and policy review the facility failed to ensure pre and post dialysis assessments were completed. This affected one (#54) of one resident reviewed for dialysis. The facility census was 96.
- D
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Inspectors wroteBased on record review, physician interview, staff interview, and review of Medscape website the facility failed to ensure residents were not given unnecessary medications. This affected one (#10) of six residents reviewed for unnecessary medications. The facility census was 96.
- D
Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
Inspectors wroteBased on record review, staff interview and policy review, the facility failed to ensure nutrition assessments were completed timely. This affected one (#50) of five residents reviewed for nutrition. The facility census was 96. Findings Include:Review of the medical record for Resident #50 revealed an admission date of 09/27/24 with diagnoses of Parkinson's disease, type II diabetes mellitus, unspecified psychosis, and adult failure to thrive. Review of the significant change comprehensive minimum data set (MDS) assessment, dated 07/21/25, revealed Resident #50 was rarely/never understood and was dependent for all activities of daily life. Review of the physician order dated 07/15/25 revealed Resident #50 was admitted to hospice. Review of the medical record revealed a quarterly nutrition progress note was completed on 04/29/25. [...]
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, staff interview, and review of facility policy, the facility failed to ensure enhanced barrier precautions were practiced during tracheostomy care. This affected one resident (#7) observed for tracheostomy care. The facility identified only one resident with a tracheostomy in the facility. The facility census was 96. Findings Include:Review of the medical record for Resident #7 revealed an admission date of 03/15/25 with respiratory failure, tracheostomy status, and history of methicillin resistant staphylococcus aureus (MRSA) (a drug resistant bacteria) infection. Review of the current physician orders for August 2025 for Resident #7 revealed she did not have an order for Enhanced Barrier Precautions (EBP) (precautions used to prevent infections for residents with areas of enhanced portals of entry such as tracheostomy or wounds). [...]
May 15, 2025Complaint 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 review of facility electronic medical record (EMR), review of external provider documents, staff interview, interview with external provider staff, and policy review, the facility failed to ensure a resident timely received medications upon discharge. Additionally, the facility failed to ensure timely notification of Social Security (SS) of discharge. This affected one (#110) of three residents (#110, #112, and #114) reviewed for discharge rights.
March 26, 2025Complaint inspection · 4 citations
- 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, review of the facility policy, and staff interview, the facility failed to ensure medications were administered via feeding tube per physician orders. This affected one resident (#15) out of 6 residents reviewed for medications. The census was 95.
- D
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Inspectors wroteBased on observation, record review, review of the facility policies, and staff interview, the facility failed to ensure all nursing care was provided in accordance with standards and practices. This affected three residents (#15, #16, and #18) of three residents observed for medication administration. The current census was 95.
- D
Ensure medication error rates are not 5 percent or greater.
Inspectors wroteBased on observation, review of the facility policies, staff interview, and review of medical records, the facility failed to ensure a medication error rate lower than 5%. The error rate on 03/26/24 was 19%, this affected three residents (#15, #17, and #18) of three residents observed for medication administration. The current census is 95.
- D
Ensure that residents are free from significant medication errors.
Inspectors wroteBased on observation, record review, review of the facility policies, and staff interview, the facility staff failed to properly administer insulin medications per the manufacturer's guidelines. This affected one resident (#18) out of five residents observed receiving medications. The current census was 95.
January 14, 2025Complaint inspection · 3 citations
- D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Inspectors wroteBased on review of medical record, staff interview, and review of facility policy, the facility failed to ensure physician ordered medications were available for administration. This affected two residents (#26 and #80) of five (#26, #71, #80, #89, and #93) residents reviewed for accurate medical records. The Facility census was 92.
- D
Ensure that residents are free from significant medication errors.
Inspectors wroteBased on review of facility medical record, review, staff interview, and review of facility policy, the facility failed to ensure that residents were free of significant mediation errors. This affected three residents (#26, #89, and #93) of five residents (#26, #71, #80, #89, and #93) reviewed for accurate medical records. The Facility census was 92.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, staff interview, medical record review, and review of facility policy, the facility failed to ensure gloves were worn while administering subcutaneous insulin. This affected one resident (#71) of five (#26, #71, #80, #89, and #93) reviewed for medication administration. The facility identified 24 residents (#3, #4, #7, #8, #9, #10, #17, #26, #28, #29, #32, #39, #42, #50, #61, #65, #67, #69, #70, #71, #73, #79, #89, and #93) who were prescribed insulin. The facility census was 92.
October 24, 2024Complaint inspection · 2 citations
- E
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Inspectors wroteBased on review of the medical record, staff interview, and policy review, the facility failed to ensure medications were administered per physician orders. Additionally, the facility failed to maintain controlled substance drug records. This affected four (#118. #24, #117, #84) of seven residents reviewed for medication administration. The facility census was 99.
- 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 review of the medical record, staff interview, and policy review, the facility failed to ensure a comprehensive care plan was timely completed. This affected one (#100) of three residents reviewed for care planning. The facility census was 99.
April 1, 2024Complaint inspection · 1 citation
- D
Provide special eating equipment and utensils for residents who need them and appropriate assistance.
Inspectors wroteBased on medical record review, observation, and staff interview, the facility failed to ensure residents were provided with assistive devices as ordered/care planned. This affected one (Resident #27) out of three residents reviewed for assistance with drinking. The facility census was 104.
March 6, 2024Complaint inspection · 1 citation
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on observation, medical record review, staff interview, and review of facility policy, the facility failed to ensure wound treatments were applied in accordance with physician orders and failed to ensure wound measurements were consistently and accurately maintained in the medical record. This affected one (#3) of three residents reviewed for pressure ulcer wound management and care. Facility census was 98.
November 30, 2023Standard inspection · 11 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 interview, and review of the facility policy, the facility failed to ensure proper hand hygiene was practiced during meal services. This directly affected five (#30, #93, #94, #100, and #307) residents and had the potential to affect all residents in the facility except one resident (#38) the facility stated did not receive food from the kitchen. The facility census was 99.
- D
Reasonably accommodate the needs and preferences of each resident.
Inspectors wroteBased on observation, resident interview, staff interview, and review of the manufacturer specifications, the facility failed to ensure residents were provided beds of the appropriate length. This affected one (Resident #101) of three reviewed for accommodation of needs. The facility census was 99. Findings Include: Review of Resident #101's medical record revealed an admission date of 10/18/23. Diagnoses included type II diabetes, hypertension, muscle weakness and encounter for orthopedic after care. Review of Resident #101's Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating Resident #101 was cognitively intact. Resident #101 was independent with eating and oral care. Resident #101 required assistance from staff with dressing and mobility. Resident #101 was dependent on staff for toileting and bathing. [...]
- 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 medical record review, staff interview, and review of the facility policy, the facility failed to ensure advanced directives were consistent within the medical record. This affected two (Residents #74 and #258) of two residents reviewed for advanced directives. The facility census was 99.
- 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, resident interview, staff interview, and review of the facility policy, the facility failed to notify the physician when a wound treatment was not completed. This affected one (Resident #257) of two residents reviewed for wounds. Additionally, the facility failed to notify the physician regarding ongoing complaints of elevated pain. This affected one (Resident #101) of one resident reviewed for pain. The facility census was 99.
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on review of the medical record, review of bathing documentation, staff interview, and policy review, the facility failed to ensure resident showers were completed as scheduled. This affected one (Resident #64) of two residents reviewed for choices. The facility census was 99.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on record review, resident interview, staff interview, and review of the facility policy, the facility failed to complete an initial wound assessment and failed to complete wound treatments as ordered for one (Resident #257) of two residents reviewed for wound care. The facility census was 99.
- 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 observations, staff interview, and facility policy review, the facility failed to appropriately check the placement of a Percutaneous Endoscopic Gastrostomy (PEG) tube prior to administering medications. This affected one (Resident #357) of three residents reviewed for PEG tube medication administration. The facility census was 99.
- D
Provide safe, appropriate pain management for a resident who requires such services.
Inspectors wroteBased on medical record review, observation, resident interview, staff interview, and review of the facility policy, the facility failed ensure pain interventions were in place for a resident. This affected one (Resident #101) of one resident reviewed for pain management. The facility census was 99.
- D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on medical record review, staff interview and review of facility policy, the facility failed to ensure controlled pain medication administration was accurately documented throughout the resident's medical record. This affected one (#101) of one resident reviewed for pain management. The facility census was 99.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, staff interview and policy review, the facility failed to wear appropriate Personal Protective Equipment (PPE) while providing direct care to a resident on Enhanced Barrier Precautions (EBP). This affected one (#357) of four residents reviewed for Transmission-Based Precautions (TBP). The facility census was 99.
- D
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Inspectors wroteBased on medical record review, staff interview, review of the Centers for Disease Control and Prevention (CDC) guidelines, and review of facility policy, the facility failed to ensure pneumococcal vaccines were administered per CDC guidelines. This affected three (#11, #62, #64) of five residents reviewed for pneumococcal vaccinations. The facility census was 99.
June 10, 2021Standard inspection · 8 citations
- E
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Inspectors wroteBased on observation and staff interview, the facility failed to ensure a homelike environment when residents were provided a meal in the dining room on a meal tray. This affected 13 (#18, #19, #34, #38, #53, #54, #56, #61, #64 #89, #91, #92, and #96) of 13 residents observed in the dementia unit. The facility census was 100.
- 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, medical record review, review of precautionary label and review of facility policies, the facility failed to ensure fall interventions were appropriately implemented as care planned and failed to ensure medications and laundry detergent were maintained in a safe manner on the locked dementia unit. This deficient practice affected one (#204) resident reviewed for fall interventions and had the potential to affect ten (#16, #17, #18, #19, #26, #34, #53, #61, #91, and #93) residents the facility identified as independently mobile and cognitively impaired on the locked dementia unit. The facility census was 100.
- D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteBased on observation, review of medical record, staff interview and review of facility policy, the facility failed to treat residents with dignity by hanging a sign with resident care needs above the resident's bed. This affected one (#100) of two residents reviewed for dignity. The facility census was 100.
- 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 observation, staff interview, and medical record review, the facility failed to ensure a baseline or comprehensive care plan was developed within 48 hours of admission for a resident admitted with a urinary catheter. This affected one (#208) of one residents reviewed with urinary catheters. The facility identified eight residents with urinary catheters. The census was 100.
- 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 medical record review, resident and staff interviews, and review of facility policy, the facility failed to ensure resident participation in care conferences. This affected one (#5) of two residents reviewed for care conference participation. The facility census was 100.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on medical record review, resident and staff interviews, the facility failed to provide ongoing assistance with positioning in bed as indicated in the nursing plan of care. This deficient practice affected one (#11) of three residents reviewed for positioning. The facility census was 100.
- 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 medical record review, resident and and staff interviews, the facility failed to provide ongoing restorative nursing services in accordance with physical therapy recommendations. This deficient practice affected one (#11) of 24 residents reviewed for range of motion and treatment. The facility census was 100.
- 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, staff interview, medical record review, and review of a facility policy, the facility failed to ensure a resident admitted with a urinary catheter had a physician order for use and failed to ensure care was provided for the urinary catheter. This affected one (#208) of one residents reviewed with urinary catheters. The facility identified eight residents with urinary catheters. The census was 100.
Fire safety inspections
11 fire safety citations on file: 7 on August 21, 2025, 2 on November 30, 2023, 2 on June 10, 2021.
Every fire safety citation11 citations
- F
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
K 321 · August 21, 2025 · Corrected (the home has a date of correction)
- F
Provide properly protected cooking facilities.
K 324 · August 21, 2025 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · August 21, 2025 · Corrected (the home has a date of correction)
- F
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · August 21, 2025 · Corrected (the home has a date of correction)
- F
Have proper medical gas storage and administration areas.
K 923 · August 21, 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 · August 21, 2025 · Corrected (the home has a date of correction)
- E
Ensure proper usage of power strips and extension cords.
K 920 · August 21, 2025 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · November 30, 2023 · 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 30, 2023 · 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 · June 10, 2021 · Corrected (the home has a date of correction)
- E
Have properly installed electrical wiring and gas equipment.
K 511 · June 10, 2021 · Corrected (the home has a date of correction)