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 34 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
1J
0K
0L
Actual harm
4G
0H
0I
Potential for more than minimal harm
19D
6E
3F
Potential for minimal harm
0A
0B
1C
June 22, 2026Complaint inspection · 1 citation
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure that a resident did not develop an avoidable pressure injury from wearing an abdominal binder. This applies to 1 of 4 residents (R4) reviewed for Quality of Care/Treatment in a sample of 4.
April 17, 2026Complaint inspection · 1 citation
- G
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on observation, interview and record review the facility failed to provide interventions to prevent the development and worsening of skin breakdown. This failure resulted in two residents developing pressure ulcer (also known as a bedsore or pressure wound is an injury to the skin and the tissue below the skin that are due to pressure on the skin for an extended period). This applies to 2 residents, R1 and R2 reviewed for facility acquired pressure ulcers in a sample of 8.
February 24, 2026Complaint inspection · 1 citation
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on interview and record review the facility failed to provide 2 assists for a full mechanical lift transfer in accordance with their policy. This applies to 1 of 3 residents (R1) reviewed for full mechanical lift transfer in the sample of 5.
February 10, 2026Complaint inspection · 4 citations
- J
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 interview and record review, the facility failed to assess a resident after CNA (Certified Nurse Assistant) was unable to obtain resident's blood pressure or heart rate and failed to document resident's code status in the medical record. This failure resulted in an Immediate Jeopardy (IJ). The Immediate Jeopardy began on [DATE] around 6:30 AM when V33 (Agency RN) did not assess R18 after V35 (CNA/Certified Nurse Assistant) notified V33 that she was unable to obtain a blood pressure or heart rate on R18. Around 7:45 AM, V33 (Agency RN) found R18 unresponsive and left R18 to find V16 (RN/Registered Nurse). V16 said V33 told her she thought R18 expired and R18 was DNR (Do Not Resuscitate). Around 8:00AM, R18 was found unresponsive by V41 (Respiratory Therapist) and V3 (LPN/ Acting ADON/Assistant Director of Nursing) and CPR (Cardio-Pulmonary Resuscitation) was initiated. [...]
- G
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on interview and record review, the facility failed to assess and notify the provider of changes in a resident's condition after fall incident with injuries and pain for R2 and R6. This resulted in a delay of treatment for R2 and R6 for pain and a fracture from a fall incident. The facility failed to notify the provider of R4's change of condition that included vomiting blood and black tarry stools that resulted in the need for hospitalization and blood transfusions. This applies to 3 of 3 residents (R2, R4, and R6) reviewed for resident injury and improper nursing.
- G
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on interview and record review, the facility failed to implement fall precautions for a high fall risk resident admitted with a history of fall and left hip fracture. This failure resulted in R5's fall in the facility on 12/25/25, transfer to the hospital, and diagnosis of right hip fracture. This applies to 1 resident (R5) reviewed for falls with injury in a sample of 3.
- D
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
Inspectors wroteBased on observation, interview, and record review, the facility failed to provide mechanical soft diet as per physician orders. This applies to 1 of 3 residents (R11) reviewed for safe diet consistency in a sample of 23 residents. On 1/21/26 at 11:58 AM, R11 was observed in the dining room, being fed lunch by V28 (CNA/Certified Nurse Assistant). R11's plate had the following on it: sauteed broccoli, mandarin oranges, chicken salad sandwich, potato chips, and nectar thick root beer. R11's POS (Physician Order Sheet) shows an order dated 1/24/25: regular diet, mechanical soft texture, nectar/mildly thick liquid consistency. R11's Care Plan created 4/4/23 and last revised 2/3/25 states resident is at risk for alteration in nutrition/hydration status secondary to frequent propelling, coughing/choking episodes, increased lethargy, and need for feeding assistance. Interventions include: [...]
August 25, 2025Complaint inspection · 1 citation
- D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteBased on interview and record review, the facility failed to obtain consent prior to a wound procedure of a cognitively impaired resident. This failure resulted in the facility obtaining a wound biopsy without consent from R2's family. This applies to 1 of 1 (R2) resident reviewed for resident's rights.
June 13, 2025Standard inspection · 5 citations
- D
Allow residents to self-administer drugs if determined clinically appropriate.
Inspectors wroteBased on observation, interview, and record review, the facility failed to safely store resident medications and properly assess resident for self-administration of medications. This applies to 1 resident (R52) reviewed for self-administration of medications in a sample of 22.
- 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 record review, the facility failed to implement fall interventions for a high fall risk resident with history of fall. This applies to 1 resident (R21) reviewed for fall interventions in a sample of 22.
- 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 observations, interviews, and record reviews, the facility failed to ensure proper positioning of indwelling catheters. This applies to 2 of 2 residents (R58 & R68) who were reviewed for catheter care in a sample of 22.
- D
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to properly store medications for 2 out of 2 residents (R1 & R131) reviewed for medication storage in a sample of 22.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to provide proper hand hygiene while providing resident care for 3 out of 3 residents (R14, R36, and R235) reviewed for infection control in a sample of 22.
September 1, 2024Complaint inspection · 1 citation
- E
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on observation, interview, and record review, the facility failed to provide timely incontinent care to dependent residents. This applies to 5 of 5 residents (R1-R5) reviewed for activities of daily (ADL) care in a sample of 5. The Findings Include: 1. R1 was a [AGE] year-old male admitted on [DATE] and having severe cognitive impairment as per the MDS dated [DATE]. On 8/31/24 at 11:00 AM, V1 (Administrator) stated that she heard about the incident and that the ambulance people were complaining that R1 was not clean when they picked him up on 8/24/24 to the hospital. On 8/31/24 at 12:20 PM, V8 (R1's certified nursing assistant / CNA) stated, I heard that EMS (Emergency Medical Service) was complaining that R1 was not super clean at the time of pick up at around 1:45 PM on 8/24/24. I didn't see any bowel movement when EMS picked him up, and I was with another resident. [...]
July 18, 2024Standard inspection · 7 citations
- G
Provide safe, appropriate pain management for a resident who requires such services.
Inspectors wroteBased on observation, interview, and record review the facility failed to manage a resident's pain during bathing and wound care. This applies to 1 of 2 residents (R36) reviewed for pain management in the sample of 19. This failure resulted in R36 crying in pain during bed bath, wound treatment, and repositioning.
- E
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure carrots had smooth consistency for residents who required a pureed diet. This applies to 4 of 4 residents (R16, R20, R38, and R47) reviewed for dietary needs in the sample of 19.
- E
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview, and record review, the facility failed to follow standard infection control practices related to hand hygiene and gloving during provisions of ADL (activities of daily living) care and wound care. In addition, the facility failed to ensure that a urinary catheter bag was not placed on the floor. This applies 5 of the 19 residents (R26, R36, R39, R40, R53) reviewed for infection control in the sample of 19.
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on observation, interview, and record review, the facility failed to assist a resident that was assessed to require assistance with ADLs (Activities of Daily Living). This applies to 1 of 1 resident (R436) in the sample of 19.
- D
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Inspectors wroteBased on interview and record review, the facility failed to offer and administer the pneumonia vaccines to new and current residents residing in the facility. This applies to 3 of 6 residents (R29, R53, R286) reviewed for immunizations in the sample of 19.
- D
Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
Inspectors wroteBased on interview and record review, the facility failed to offer the Covid-19 vaccine to new and current residents residing in the facility. This applies to 2 of 6 residents (R286 and R437) reviewed for Covid-19 immunizations in the sample of 19.
- C
Honor the resident's right to organize and participate in resident/family groups in the facility.
Inspectors wroteBased on interview and record review, the facility failed to make residents aware of their right to organize and participate in residents' group/council meeting. This applies to all the 92 residents in the facility.
July 7, 2024Complaint inspection · 1 citation
- D
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Inspectors wroteBased on interview and record review the facility failed to resolve residents' concerns. This applies to 3 of 6 residents (R2, R4 and R5) reviewed for call light concerns in the sample of 8.
May 2, 2024Complaint inspection · 2 citations
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on observation, interview and record review the facility failed to provide timely incontinence care. This applies to 1 of 4 residents (R2) reviewed for incontinence.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on observation, interview and record review the facility failed to provide skin assessments for skin injuries. This applies to 3 of 4 residents (R1, R3 and R4) reviewed for skin conditions.
August 4, 2023Standard inspection · 10 citations
- F
Post nurse staffing information every day.
Inspectors wroteBased on observations and interviews, the facility failed to post the daily staffing. This effects all 87 residents in the facility.
- 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 record review, the facility failed to store, label, and discard food to prevent risk of foodborne illnesses. The facility failed to meet the cooked food temperature requirements to prevent the risk of foodborne illnesses. The facility also failed to fill out the temperature logs completely. This applies to 85 out 87 residents eating from the kitchen supply of food.
- F
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview, and record review, the facility failed to follow contact isolation precautions and perform hand hygiene during incontinent care and wound care. This applies to all 87 residents in the facility.
- E
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to provide a safe environment for 9 residents (R2, R11, R18, R21, R20 R24, R29, R58, R18, and R176) in a sample of 29.
- E
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observations and interviews, the facility failed to contain reusable nebulizer treatment, oxygen masks, oxygen nasal cannula's, and CPAP (Continuous Positive Airway Pressure) masks in a protective bag This applies to 5 residents (R7, R20, R24, R58, and R226) reviewed for respiratory care in a sample of 29.
- 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 observations, interviews, and record reviews, the facility failed to appropriately store medications and biologicals safely for 8 residents (R2, R13, R20, R24, R50, R55, R61, and R226) in a sample of 29. 1. On [DATE] at 11:09 AM during a tour of R50's room, R50's Nizoral medicated shampoo was observed on his bedside table, 2 tubes of Cortisone cream 2oz , 1 tube of INZO anti-fungal cream, 2 syringes with 0.9 % sodium were observed in his bedside table. R50's electronic medical record showed that his mental cognition is severely impaired. 2. On [DATE] at 11:09 AM during a tour of R2's room showed 1 tube of Zinc paste at the bedside table. R2's electronic record showed that his cognition is moderately impaired. 3. [...]
- D
Reasonably accommodate the needs and preferences of each resident.
Inspectors wroteBased on observations, interviews, and record reviews the facility failed to keep residents' call lights within reach. This applies to 2 residents R13 and R18 in a sample of 29.
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on observation, interview and record review the facility failed to provide incontinent care in a timely manner. This applies to 1 resident (R53) reviewed for incontinent care in the sample of 29. R53 was admitted to the facility on [DATE], per the admission face sheet. The current physician orders dated August 1, 2023, showed that R53 had diagnoses of fractured right and left femur, heart disease with failure, kidney disease, diabetes, morbid obesity, chronic lung disease, sleep apnea, depression, anxiety, myocardial infarction, constipation, overactive bladder, myocardial infarction, previous pressure on thoracic spine and neoplasm of colon and prostate. On August 1, 2023, at 9:15am foul odors were present just outside the conference room by the reception area. At 9:45am just a few doors down from the conference hall the foul odor was very strong. [...]
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on observation, interview, and record review, the facility failed to provide, administer, or notify the nurse practitioner of an unavailable weekly medication. The facility also failed to properly obtain a blood sample for a blood glucose monitor. This applies to 3 of 3 residents (R20, R24, R435) reviewed for quality of care in a sample of 27.
- D
Ensure that residents are free from significant medication errors.
Inspectors wroteBased on interview and record review, the facility failed to administer insulin as ordered and failed to notify the nurse practitioner of missed medication. This applies to 1 of 1 resident (R435) reviewed for significant medication errors in a sample of 27.
Fire safety inspections
21 fire safety citations on file: 10 on June 13, 2025, 7 on July 18, 2024, 4 on August 4, 2023.
Every fire safety citation21 citations
- F
Establish emergency prep training and testing.
E 36 · June 13, 2025 · Corrected (the home has a date of correction)
- F
Establish staff and initial training requirements.
E 37 · June 13, 2025 · Corrected (the home has a date of correction)
- F
Conduct testing and exercise requirements.
E 39 · June 13, 2025 · Corrected (the home has a date of correction)
- E
Keep aisles, corridors, and exits free of obstruction in case of emergency.
K 211 · June 13, 2025 · Corrected (the home has a date of correction)
- E
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
K 223 · June 13, 2025 · Corrected (the home has a date of correction)
- E
Install proper backup exit lighting.
K 281 · June 13, 2025 · Corrected (the home has a date of correction)
- E
Have properly located and lighted "Exit" signs.
K 293 · June 13, 2025 · 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 13, 2025 · Corrected (the home has a date of correction)
- E
Install an approved automatic sprinkler system.
K 351 · June 13, 2025 · Corrected (the home has a date of correction)
- E
Install corridor and hallway doors that block smoke.
K 363 · June 13, 2025 · Corrected (the home has a date of correction)
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · July 18, 2024 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · July 18, 2024 · 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 · July 18, 2024 · Corrected (the home has a date of correction)
- E
Provide properly protected cooking facilities.
K 324 · July 18, 2024 · Corrected (the home has a date of correction)
- E
Install corridor and hallway doors that block smoke.
K 363 · July 18, 2024 · Corrected (the home has a date of correction)
- E
Have proper medical gas storage and administration areas.
K 923 · July 18, 2024 · Corrected (the home has a date of correction)
- C
Have simulated fire drills held at unexpected times.
K 712 · July 18, 2024 · Corrected (the home has a date of correction)
- F
Keep aisles, corridors, and exits free of obstruction in case of emergency.
K 211 · August 4, 2023 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · August 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 · August 4, 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 · August 4, 2023 · Corrected (the home has a date of correction)