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 43 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
1G
0H
0I
Potential for more than minimal harm
35D
7E
0F
Potential for minimal harm
0A
0B
0C
November 25, 2025Standard inspection · 12 citations
- E
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observations, interviews and record review, the facility failed to ensure that respiratory care and services, consistent with professional standards of practice, were provided for 5 Residents (#56, #82, #62, #73 and #2) out of sample of 30 residents. Specifically,1. For Resident #56, the facility failed to set oxygen as ordered by the physician.2. For Resident #82, the facility failed to clean the concentrator filter as ordered by the physician.3. For Resident #62, the facility failed to clean the concentrator filter.4. For Resident #73, the facility failed to clean the concentrator filter, keep the water bottle off the floor and keep an oxygen cannula clean.5. For Resident #2, the facility failed to clean the concentrator filter and keep an oxygen cannula clean.
- 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, record review and interview, the facility failed to ensure medications were labeled and stored in accordance with acceptable professional standards on three of three units. Specifically,1. The facility failed to ensure medications were labeled in accordance with acceptable professional standards, to include open dates on medications with shortened expiration dates in three medication carts on three of three units.2. The facility failed to secure and lock an unattended medication cart on the first-floor unit.
- 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 and interview, the faciliy failed to 1. provide appropriate hand hygiene after glove changes and 2. appropriately label and date items in the unit kitchenettes on 2 of 3 units.
- E
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observations and interview the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Specifically, 1. The facility failed to maintain Enhanced Barrier Precautions (EBP) while caring for a resident with a gastrostomy tube.
- D
Allow residents to self-administer drugs if determined clinically appropriate.
Inspectors wroteBased on observation, record review and interview the facility failed to assess two Residents (#10 and #18), out of a total sample of 30 residents, for the ability to self-administer medications and determine if it was clinically appropriate.
- D
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Inspectors wroteBased on observations, interviews, and record review, the facility failed to assess the use of an abdominal binder as a potential restraint for one Resident (#40) out of a total sample of 30 residents.
- D
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
Inspectors wroteBased on record reviews and interviews, the facility failed to ensure one Resident (#27) was free from unnecessary psychotropic medications by ensuring a reassessment of an as needed (PRN) dose of Haldol (an antipsychotic medication) after 14 days, out of a total sample of 30 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 record review and interview, the facility failed to develop a person- centered comprehensive care plan for one Resident (#53) out of a total sample of 30 residents. Specifically, for Resident #53, the facility failed to develop a person-centered comprehensive care plan for a pacemaker.
- D
Ensure services provided by the nursing facility meet professional standards of quality.
Inspectors wroteBased on observation, record review and interview, the facility failed to ensure one Resident (#40) received care in accordance with professional standards of practice, out of a total sample of 30 residents. Specifically, for Resident #40, the facility failed to ensure nursing completed a weekly skin assessment per the physician order.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on observation, record review and interview, the facility failed to provide treatment and care in accordance with professional standards of practice for one Resident (#40) who was assessed to be at high risk for developing pressure ulcers, out of a total sample of 30 residents. Specifically, for Resident #40, the facility failed to notify the provider of an open skin lesion of his/her left heel.
- 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, interviews and record review, the facility failed to ensure staff provided appropriate care and services for one Resident (#53) with a gastrostomy tube (a tube that is placed directly into the stomach through an abdominal incision for administration of nutrition, fluids, and medication), out of 30 sampled residents. Specifically, the facility failed to ensure that the head of the bed was elevated to prevent potential aspiration while receiving enteral feedings.
- D
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
Inspectors wroteBased on observations, record and interviews, the facility failed to provide behavioral health care services in a person-centered environment for one Resident # 88 out of a sample of 30 Residents. Specifically, the facility failed to implement psychiatric recommendations provided after the Resident expressed suicidal ideations.
February 24, 2025Complaint inspection · 1 citation
- G
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on records reviewed and interviews, for one of three sampled residents, (Resident #1), who required assistance from staff with personal hygiene, the Facility failed to ensure that during the provision of personal care that staff took necessary steps to maintain his/her safety to prevent an incident resulting in an injury, when on 01/22/25, a Certified Nurse Aide (CNA) used an electric curling iron to curl Resident #1's hair, he/she sustained a second-degree burn (partial thickness, involves both the outer (epidermis) and underlying layer (dermis) of skin, they cause pain, redness, swelling, and blistering) to the upper left side of his/her forehead, which required treatment. Findings Include: [...]
October 10, 2024Standard inspection · 13 citations
- E
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on observations, record review and interview, the facility failed to implement treatment orders recommended by the Wound Physician for three Residents (#74, #40 and #55) out of a total of 22 sampled Residents. Specifically: 1. For Resident #74, the facility failed to implement the Wound Physician's treatment order for offloading heels while in bed. 2. For Resident #40, the facility failed to implement the Wound Physician's treatment order for offloading heels while in bed. 3. For Resident #55, the facility failed to transcribe and consistently implement a treatment order for wound care to the coccyx as ordered by the Wound Physician.
- 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 and interview, the facility failed to ensure staff followed proper sanitation and food handling practices to prevent the outbreak of foodborne illness. Review of the facility policy titled, General Food Preparation and Handling, dated 2021, indicated the following: -Bare hands must never touch ready to eat raw food directly. Disposable gloves are single use item and must be discarded after each use. Employees must wash hands prior to putting gloves on and off after removing gloves. On 10/8/24 at 8:12 A.M., the following was observed on the third-floor unit during the breakfast meal: -The server changed gloves twice without washing his hands in between. -The server touched the serving utensils, plastic wrap, plates and toaster buttons potentially contaminating his gloves. [...]
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on record review, policy review and interviews, the facility failed to report allegations of abuse to the state agency within two hours as required for one Resident (#65) out of a total sample of 22 residents. Specifically, on 10/8/24 at 9:00 A.M., the Director of Nursing (DON) was made aware of Resident #65's allegations of abuse. The DON did not report to the state agency until 10/9/24 at 11:15 P.M., when the surveyor inquired about the follow up, more than 24 hours after becoming aware of the allegations.
- D
PASARR screening for Mental disorders or Intellectual Disabilities
Inspectors wroteBased on record review, policy review and interview, the facility failed to accurately complete a Level 1 Preadmission Screening and Resident Review (PASARR) screen to determine if a resident had an intellectual or developmental disability (ID or DD) and/or serious mental illness (SMI) and needed further evaluation for one Resident (#61), out of a total sample of 22 residents. Specifically, for Resident #61, the facility failed to accurately complete a Level 1 PASARR indicating that the Resident had a diagnosis of schizotypal disorder which is a SMI, resulting in a Level II PASARR evaluation not being completed as required.
- 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 observations, record review and interviews, the facility failed to ensure a comprehensive resident centered care plan was developed for one Resident (#63) out of a total sample of 22 Residents. Specifically, the facility failed to develop an individualized comprehensive resident centered care plan related to the monitoring and care of a pacemaker for Resident #63.
- D
Ensure services provided by the nursing facility meet professional standards of quality.
Inspectors wroteBased on observation, record review and interview, the facility failed to provide services that met professional standards of practice for one Resident #55 out of a sample of 22 residents. Specifically, for Resident #55 the facility failed to ensure nursing implemented Teds (compression) stockings according to the physician's orders.
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on observations, record review and interviews, the facility failed to provide assistance with Activities of Daily Living (ADLs) for dependent residents for one Resident (#1) out of a total sample of 22 residents. Specifically, the facility failed to provide assistance with weekly showers for Resident #1.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on observation, record review and interview the facility failed to ensure standards of quality of care were implemented for one Resident (#32), out of a total sample of 22 residents. Specifically, the facility failed to identify a skin injury on the Resident's left upper arm.
- D
Assist a resident in gaining access to vision and hearing services.
Inspectors wroteBased on observation, interview, record review, the facility failed to ensure a resident received proper treatment to maintain hearing and ensure assistive devices to maintain hearing and enhance communication were utilized for one Resident (#63), out of a total sample of 22 residents. Specifically, for Resident #63, the facility failed to consistently implement his/her hearing aids. Finding Included: Review of the facility policy titled, Hearing Impaired Resident, Care of, last revised 2/18, indicated the following: Policy: -Staff will assist hearing impaired residents to maintain effective communication with clinicians, caregivers, other residents, and visitors. -Staff will assist residents with care and maintenance of hearing devices. [...]
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observations, record review and interviews the facility failed to ensure a resident who required respiratory care (continuous oxygen) received care consistent with professional standard of practice for one Resident (#27) out of a total sample of 22 residents. Specifically, for Resident #27, the facility failed to follow the physician's order for supplemental oxygen.
- D
Provide care or services that was trauma informed and/or culturally competent.
Inspectors wroteBased on record review and interview, the facility failed to ensure a plan of care was developed for Trauma-Informed Care for one Resident (#16), who was admitted with the diagnosis of Post-Traumatic Stress Disorder (PTSD), out of a total sample of 22 residents.
- D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on observation, record review and interview the facility failed to maintain an accurate medical record for two Residents (#55) out of a total sample of 22 residents. Specifically, Nurses documented in the Treatment Administration Record (TAR) that Resident #55 wore teds stocking while in bed, contrary to direct observation of the teds stockings not being worn.
- D
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Inspectors wroteBased on record review and interviews, the facility failed to assess for eligibility, and offer pneumococcal vaccinations per the Centers for Disease Control and Prevention (CDC) recommendations for one Resident (#6) out of a total of five residents reviewed.
October 4, 2023Standard inspection · 17 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, record review and interview the facility failed to ensure food was handled in a manner to prevent the risk for potential foodborne illness in the kitchen and during the meal service on one of three resident care units. Specifically, 1) A Diet Aide #3 handled cups with her fingers inside the cup and eating utensils by the end that touches food and enters the mouth. 2) Diet Aide #1 and Diet Aide #2 touched ready to eat food directly with potentially contaminated gloves during meal service on the C unit. 3)Cook #1 and [NAME] #2 were observed preparing food without hair restraints. Review of the 2022 Food Code, U.S. Food and Drug Administration, Code of Federal Regulations Title 21, indicated the following: 110.10 Personnel. The plant management shall take all reasonable measures and precautions to ensure the following: [...]
- 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 interview the facility failed to provide a dignified dining experience for one Resident (#19) out of a total sample of 21 residents.
- D
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Inspectors wroteBased on observations, record review and interview the facility failed to ensure, for one Resident (#77), was free from the use of a restraint, out of a total sample of 21 residents.
- D
Assess the resident when there is a significant change in condition
Inspectors wroteBased on record review and interview, the facility failed to complete a Significant Change in Status Minimum Data Set (MDS) assessment for one Resident (#11) out of a total sample of 21 residents.
- D
Ensure services provided by the nursing facility meet professional standards of quality.
Inspectors wroteBased on record review, and interview, the facility failed to meet professional standards of quality for three Residents (#18, #1 and #55), out of a total sample of 21 residents. Specifically: 1. For Resident #18 the facility failed to ensure nursing implemented a physician's order for medications ordered to be administered with breakfast and supper (with meals). 2. For Resident #55 the facility failed to ensure an order was obtained for the use, including the proper setting, and plan for monitoring the setting and function of the air mattress in use. 3. For Resident #1 the facility failed to implement a physician's order for contact precautions.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on observation, interview, record review and policy review the facility failed to ensure quality care was provided for two Residents (#44 and #33) out of a total sample of 21 residents. Specifically: 1.) For Resident #44 the facility failed to ensure geri sleeves were placed on the resident, as ordered by the Physician, on all days of survey. 2.) For Resident #33 the facility failed to identify and investigate bruising.
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on observation, record review, and staff interviews, the facility failed to ensure measures were in place to address the risk for pressure ulcers for three Residents (#53, #2, and #19) out of 21 sampled residents. Specifically: 1. Wound physician recommendations were not addressed and transcribed resulting in a delay of treatment for a skin injury on the right heel for Resident #53. 2. The physician orders for management/prevention of a pressure ulcer for Residents #2, and #19 were not followed. 3. The physician orders for the application of a bunny boot and the air mattress pressure setting was not followed for Resident #19.
- 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, record review and interview, the facility failed to follow the plan of care for an indwelling urinary catheter/Foley (a flexible tube that passes through the urethra and into the bladder to drain urine) for one Resident (#19) out of a total sample of 21 Residents. Specifically, the facility staff failed to ensure the correct size indwelling urinary catheter was in place for Resident #19 as ordered by the physician.
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observation, record review, and interview the facility failed to develop and implement a plan of care and maintain oxygen equipment for 2 Residents (#61 and #25) out of 21 sampled residents. Specifically: 1) For Resident #61 the facility failed to ensure the oxygen concentrator filter was clean and free of dust build up. 2) For Resident #25 the facility failed to obtain a physician's order for the use of an oxygen concentrator, oxygen liter amount to be given, and ensure the oxygen concentrator filter was clean and free of dust build up.
- 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 record review, interview and observation, the facility failed to: assess for the use of an installed bed rail, obtain informed consent or a physician's order, for one Resident (#25) out of 21 sampled residents.
- 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 and interview, the facility failed to ensure a licensed Registered Nurse (RN) had the appropriate competency and skill set to provide the necessary care and treatment for one Resident (#19) with skin protocol in place out of total sample of 21 residents.
- 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 record review and staff interview, the facility failed to ensure that the pharmacy recommendations were addressed by the attending physician for one Resident (#53), out of 21 sampled residents.
- 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 records reviewed, policy review, and interviews, the facility failed to ensure that as needed (PRN) orders for psychotropic medications are limited to 14 days unless the prescribing practitioner documents a rational to extend the medication for two Residents (#18 and #84), in a total sample of 21 residents. Specifically, 1.) For Resident #18 the facility failed to ensure an as needed (PRN) alprazolam (psychotropic medication) had a stop date as required. 2.) For Resident #84 the facility failed to ensure an as needed (PRN) diazepam (psychotropic medication) had a stop date as required.
- 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, record review, and interview the facility failed to ensure: 1. medications were secured and stored for one Resident (#55) out of a total sample of 21 residents and 2. failed to ensure that insulin (vials/flex pen), and lancets were stored safely on one of three resident care units.
- D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on observations, record reviews and interviews, the facility failed to maintain accurate medical records for three Residents (#84, #19 and #44) out of a total sample of 21 Residents. Specifically, 1. For Resident #84 nursing failed to accurately update the physician's order for tube feedings. 2. For Resident #19 nursing failed to accurately document in the Treatment Administration Record (TAR) regarding bunny boots and the air mattress setting. 3. For Resident #44 nursing failed to accurately document in the TAR regarding geri sleeves.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, record review and interview the facility failed to adhere to standards of practice to prevent the spread of potential infection on two of three resident care units. Specifically, housekeeping staff failed to perform hand hygiene when exiting resident rooms, between glove changes, and wore potentially contaminated gloves in the hall when disposing of soiled items.
- D
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Inspectors wroteBased on record review, policy review, and interview the facility failed to ensure that residents were provided education on the pneumococcal vaccine, were assessed for the eligibility for the administration of a pneumococcal vaccine and that the medical record for 2 out of 5 residents had documentation of the administration of the pneumococcal vaccine.
Fire safety inspections
29 fire safety citations on file: 12 on November 25, 2025, 9 on October 10, 2024, 8 on October 4, 2023.
Every fire safety citation29 citations
- F
Keep aisles, corridors, and exits free of obstruction in case of emergency.
K 211 · November 25, 2025 · Corrected (the home has a date of correction)
- F
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 · November 25, 2025 · Corrected (the home has a date of correction)
- F
Install emergency lighting that can last at least 1 1/2 hours.
K 291 · November 25, 2025 · Corrected (the home has a date of correction)
- F
Have properly located and lighted "Exit" signs.
K 293 · November 25, 2025 · Corrected (the home has a date of correction)
- F
Provide properly protected cooking facilities.
K 324 · November 25, 2025 · Corrected (the home has a date of correction)
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · November 25, 2025 · Corrected (the home has a date of correction)
- F
Properly select, install, inspect, or maintain portable fire extinguishes.
K 355 · November 25, 2025 · Corrected (the home has a date of correction)
- F
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · November 25, 2025 · 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 25, 2025 · Corrected (the home has a date of correction)
- F
Have elevators that firefighters can control in the event of a fire.
K 531 · November 25, 2025 · Corrected (the home has a date of correction)
- F
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
K 914 · November 25, 2025 · Corrected (the home has a date of correction)
- F
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · November 25, 2025 · Corrected (the home has a date of correction)
- F
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · October 10, 2024 · Corrected (the home has a date of correction)
- F
Provide a written emergency evacuation plan.
K 711 · October 10, 2024 · Corrected (the home has a date of correction)
- E
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · October 10, 2024 · Corrected (the home has a date of correction)
- E
Properly provide smoke detection systems in areas open to corridors.
K 347 · October 10, 2024 · Corrected (the home has a date of correction)
- E
Inspect, test, and maintain automatic sprinkler systems.
K 353 · October 10, 2024 · Corrected (the home has a date of correction)
- E
Meet requirements for the installation and maintenance of electrical systems.
K 911 · October 10, 2024 · Corrected (the home has a date of correction)
- E
Ensure proper usage of power strips and extension cords.
K 920 · October 10, 2024 · Corrected (the home has a date of correction)
- D
Properly select, install, inspect, or maintain portable fire extinguishes.
K 355 · October 10, 2024 · Corrected (the home has a date of correction)
- D
Have simulated fire drills held at unexpected times.
K 712 · October 10, 2024 · Corrected (the home has a date of correction)
- F
Implement emergency and standby power systems.
E 41 · October 4, 2023 · Corrected (the home has a date of correction)
- F
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
K 225 · October 4, 2023 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · October 4, 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 · October 4, 2023 · Corrected (the home has a date of correction)
- F
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
K 761 · October 4, 2023 · Corrected (the home has a date of correction)
- F
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · October 4, 2023 · Corrected (the home has a date of correction)
- F
Have proper fire barriers, ventilation and signs for the transfilling of oxygen.
K 927 · October 4, 2023 · Corrected (the home has a date of correction)
- E
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · October 4, 2023 · Corrected (the home has a date of correction)