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
0J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
25D
7E
5F
Potential for minimal harm
0A
0B
0C
April 23, 2026Complaint inspection · 7 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, dishwasher temp logs, manufacturer recommendations, interview, and policy review the facility failed to ensure the dishwasher temp was high enough for sanitation. This had the potential to affect all residents who reside in the facility. The facility census was 113.
- 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 record review, interview, and policy review, the facility failed to ensure code status forms were in the medical record. This affected one (#116) of three residents reviewed for code status. The facility census was 113.
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on medical record review, staff interview, and policy review, the facility failed to report an injury of unknown origin to the State Agency as required. This affected one (#84) resident out of three residents reviewed for incidents/accidents. The facility census was 113.
- D
Respond appropriately to all alleged violations.
Inspectors wroteBased on medical record review, staff interview, and policy review, the facility failed to investigate an injury of unknown origin. This affected one (#84) resident of the three residents reviewed for incidents/accidents. The facility census was 113.
- 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 skin issues. This affected one (#68) of four residents reviewed for wounds. The facility census was 113.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on medical record reviews, staff interviews, and policy reviews, the facility failed to ensure comprehensive skin evaluations were completed upon admission for Resident #35 and failed to ensure wound care was completed as per physician orders for Resident #117. This affected two (#35 and #117) residents out of the three residents reviewed for skin breakdown. The facility census was 113.
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on medical record review, staff and resident interviews, and policy review, the facility failed to provide care/services to prevent a fall. This affected one (#84) resident out of three residents reviewed for falls. The facility census was 113.
July 1, 2025Standard inspection · 17 citations
- F
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
Inspectors wroteBased on review of Quality Assurance and Performance Improvement (QAPI) sign in sheets, staff interview and policy review, the facility failed to ensure the Medical Director attended QAPI meetings quarterly, as required. This had the potential to affect all 80 residents residing in the facility. The facility census was 80.
- E
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
Inspectors wroteBased on medical record review, staff interview and review of the Medscapes (online resource for healthcare professionals) indications for medication use, the facility failed to ensure residents were not ordered psychotropic medications without an appropriate indication for use and further failed to ensure residents were monitored for the use of psychotropic medications. This affected three (#43, #71, and #76) of six residents reviewed for unnecessary medications. The facility census was 80.
- E
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on observations, staff interviews and review of facility policy, the facility failed to ensure foods were labeled, dated, and stored in a manner to ensure food safety. This had the potential to affect all residents residing in the facility, except for one (#9) resident identified as receiving no food from the kitchen. The facility census was 80.
- E
Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse.
Inspectors wroteBased on medical record review, review of Binding Arbitration Agreements, resident interview, staff interview and policy review, the facility failed to ensure residents were able to understand and comprehend the terms of a Binding Arbitration Agreement before entering into one. This affected five (#27, #31, #60, #64, and #84) of six residents reviewed for arbitration agreements. The facility census was 80.
- E
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Inspectors wroteBased on medical record review, staff interview, and review of the Centers for Disease Control and Prevention (CDC) guidance, the facility failed to ensure residents were offered or provided the COVID-19 vaccination. This affected four residents (#28, #33, #47, #50) of five residents reviewed for immunizations. The facility census was 80.
- D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteBased on observation, staff interview, medical record review and review of facility policy, the facility failed to maintain resident dignity by ensuring catheter collection bags were covered in common areas. This affected two (#45 and #70) of three residents reviewed for catheter care. The facility census was 80.
- 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 medical record review, staff interview, and policy review the facility failed to ensure comprehensive care plans were developed to address resident care needs. This affected one (#53) of six residents reviewed for care plans. The facility census was 80.
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on observation, resident and staff interview, medical record review, review of bathing documentation and review of facility policy, the facility failed to ensure dependent residents received timely and adequate staff assistance with personal hygiene. This affected one (#32) of two residents reviewed for activities of daily living (ADLs). The facility census was 80.
- D
Provide activities to meet all resident's needs.
Inspectors wroteBased on resident and staff interview, medical record review, and review of activities documentation, the facility failed to ensure activities were offered to all residents. This affected one (#342) of one resident reviewed for activities. The facility census was 80.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wrote2. Review of medical record for Resident #53 revealed an admission date of 07/31/24 with diagnosis including, but not limited to, obstructive sleep apnea (difficulty breathing when sleeping). Review of current physician orders revealed an order dated 02/19/25 to schedule a sleep study for Resident #53. Further review of Resident #53's medical record revealed no evidence a sleep study was scheduled or completed. Review of a nursing progress note dated 06/09/25 revealed the Certified Nurse Practitioner (CNP) called into the facility to give a new order for a sleep study. Per the resident, they used a continuous positive airway pressure (CPAP) at home and did not bring it to the facility due to it being broken. Interview on 06/29/25 at 10:22 A.M. with Resident #53 revealed that he was supposed to have a sleep study done but it had not happened. Interview on 06/30/25 at 11:04 A.M. [...]
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observation, medical record review, staff interview and review of facility policy, the facility failed to ensure oxygen tubing was changed routinely. This affected two (#50 and #78) of three residents reviewed for oxygen. In addition, the failed to monitor and document as needed oxygen use. This affected one (#32) of three residents reviewed for oxygen. The facility census was 80.
- D
Provide safe, appropriate pain management for a resident who requires such services.
Inspectors wroteBased on interview, medical record review, and policy review the facility failed to ensure parameters were in place for pain medication administration and ensure non-pharmacological interventions were implemented and descriptions of pain were documented with administration of pain medication. This affected one resident (#48) of two residents reviewed for pain. The facility census was 80.
- D
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Inspectors wroteBased on medical record review, staff interview, and review of facility policy, the facility failed to ensure pre and post dialysis evaluations were completed. This affected one (#15) of one resident identified as receiving dialysis. The facility census was 80.
- D
Ensure that the resident and his/her doctor meet face-to-face at all required visits.
Inspectors wroteBased on medical record review, staff interview and review of facility policy, the facility failed to ensure residents were seen by the physician as required. This affected one (#4) of one resident reviewed for physician visits. The facility census was 80.
- D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Inspectors wroteBased on medical record review and staff interview, the facility failed to ensure blood pressure medications were administered per physician order. This affected one (#75) of one resident reviewed for medication monitoring. The facility census was 80.
- D
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Inspectors wroteBased on medical record review, review of pharmacy recommendations, and staff interview, the facility failed to ensure the physician addressed pharmacy recommendations timely. This affected one (#76) of five residents reviewed for unnecessary medications. The facility census was 80.
- D
Implement a program that monitors antibiotic use.
Inspectors wroteBased on medical record review, review of urine culture results, staff interview and review of the facility policy, the facility failed to ensure urinary tract infections (UTIs) were treated appropriately. This affected one (#70) of two residents reviewed for UTIs. The facility census was 80.
May 12, 2025Complaint inspection · 2 citations
- E
Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
Inspectors wroteBased on observation, interview, record review, and facility policy review the facility failed to ensure the crash carts were inspected routinely. This had the potential to affect all 47 residents the facility identified to have a Full Code status. The facility census was 87.
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on observation, interview, and facility policy review, the facility failed to ensure fall interventions were in place. This affected one (#71) of three residents reviewed for falls. The facility census was 87.
November 26, 2024Complaint inspection · 1 citation
- 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, interview, and policy review, the facility failed to maintain the kitchen in a clean and sanitary manner. This had the potential to affect all residents who receive food and beverages from the kitchen in the facility. The facility census was 103.
May 30, 2024Complaint inspection · 1 citation
- F
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on observations, staff interview, and review of facility policy, the facility failed to ensure proper hand hygiene during lunch meal service. This had the potential to affect 113 residents who ate food served from the kitchen. The facility identified two (#21 and #107) residents who received no food from the kitchen. The facility census was 115.
September 22, 2022Standard inspection · 5 citations
- D
Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death.
Inspectors wroteBased on resident personal needs accounts (PNA) reviews and staff interviews, the facility failed to ensure Medicaid residents were provided notification to spend down when their account was reaching the Medicaid Resource Limit. This affected one (#65) out of five residents accounts reviewed. The facility census was 97.
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on medical record review, observations and resident and staff interview, the facility failed to ensure residents were provided with timely incontinent care. This affected two (#24 and #25) of four residents reviewed for activities of daily living. The facility census was 97.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on medical record review and staff interview, the facility failed to implement as needed laxatives when a resident was experiencing constipation. This affected one (#73) out of six residents reviewed during the annual survey. The facility census was 97.
- 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 medical record review, observation and staff interview the facility failed to provide the correct enteral feeding to a resident. This affected one (#90) out of one resident reviewed for enteral feeding. The total facility census was 97.
- D
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 medical record review, observations and staff interview the facility failed to provide therapeutic diets as ordered. This affected three (#53, #67, and #13) out of three residents reviewed for therapeutic diets. The facility census was 97.
September 26, 2019Standard inspection · 4 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, interview of facility staff, and review of facility policy, the facility failed to store and label food in an appropriate manner. This had the potential to affect all 115 residents residing in the facility.
- E
Ensure that residents are free from significant medication errors.
Inspectors wroteBased on the medical record review, observation, staff interview, review of manufacturer recommendations and review of the facility policy, the facility failed to ensure staff administered the proper dose of insulin, which results in a significant medication error. This affected one (Resident #57) of five residents observed for medication pass. This had the potential to affect 20 residents who received insulin via the Kwik Pen. The facility census was 115.
- E
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Inspectors wroteBased on observation, staff interview and review of facility policy, the facility failed to ensure staff were properly securing medication carts when left unattended. This had the potential to affect five cognitively impaired residents who reside on the 300-hall. The facility census was 115.
- 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 staff interviews, review of facility's admission packet and record review, the facility failed to issue a bed hold notification letter to a resident. This affected one (Resident #115) of one resident reviewed for hospitalization. The facility census was 115.
Fire safety inspections
21 fire safety citations on file: 7 on July 1, 2025, 4 on September 22, 2022, 10 on September 26, 2019.
Every fire safety citation21 citations
- F
Conduct risk assessment and an All-Hazards approach.
E 6 · July 1, 2025 · Corrected (the home has a date of correction)
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · July 1, 2025 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · July 1, 2025 · Corrected (the home has a date of correction)
- F
Install corridor and hallway doors that block smoke.
K 363 · July 1, 2025 · Corrected (the home has a date of correction)
- F
Have a battery powered remote alarm panel in a location accessible by operating personnel.
K 916 · July 1, 2025 · Corrected (the home has a date of correction)
- E
Have corridors or aisles that are unobstructed and are at least 8 feet in width.
K 232 · July 1, 2025 · Corrected (the home has a date of correction)
- E
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
K 761 · July 1, 2025 · Corrected (the home has a date of correction)
- E
Install an approved automatic sprinkler system.
K 351 · September 22, 2022 · Corrected (the home has a date of correction)
- E
Inspect, test, and maintain automatic sprinkler systems.
K 353 · September 22, 2022 · Corrected (the home has a date of correction)
- E
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · September 22, 2022 · Corrected (the home has a date of correction)
- E
Ensure electrical receptacles or cover plates have distinctive color or marking.
K 917 · September 22, 2022 · Corrected (the home has a date of correction)
- F
Install emergency lighting that can last at least 1 1/2 hours.
K 291 · September 26, 2019 · Corrected (the home has a date of correction)
- F
Properly select, install, inspect, or maintain portable fire extinguishes.
K 355 · September 26, 2019 · Corrected (the home has a date of correction)
- F
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · September 26, 2019 · Corrected (the home has a date of correction)
- F
Have simulated fire drills held at unexpected times.
K 712 · September 26, 2019 · Corrected (the home has a date of correction)
- F
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · September 26, 2019 · Corrected (the home has a date of correction)
- E
Install proper backup exit lighting.
K 281 · September 26, 2019 · Corrected (the home has a date of correction)
- E
Install an approved automatic sprinkler system.
K 351 · September 26, 2019 · Corrected (the home has a date of correction)
- E
Install corridor and hallway doors that block smoke.
K 363 · September 26, 2019 · Corrected (the home has a date of correction)
- E
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
K 761 · September 26, 2019 · Corrected (the home has a date of correction)
- E
Ensure proper usage of power strips and extension cords.
K 920 · September 26, 2019 · Corrected (the home has a date of correction)