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 38 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
1G
0H
0I
Potential for more than minimal harm
28D
3E
5F
Potential for minimal harm
0A
1B
0C
June 4, 2026Standard inspection, Complaint inspection · 10 citations
- D
Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death.
Inspectors wroteRecord review of the resident trust fund accounts and quarterly financial statements and staff interview revealed the facility failed to timely notify residents and/or responsible parties of the need to spend down excess resources to maintain Medicaid eligibility for three (Resident's #4, #55, and #56) out of four residents reviewed for personal funds. Findings Include:1. Review of the record for Resident #4 revealed the resident was admitted on [DATE] and had [NAME] Medicaid coverage. Review of the quarterly trust account statement for the period 01/01/26 through 03/31/26 revealed the resident's account balance exceeded the Medicaid resource limit of $2,000.00 from 01/01/26 through 02/12/26. The resident's balance decreased to $1,108.47 on 02/12/26. [...]
- D
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
Inspectors wroteBased on medication regimen review, medical record review, staff interview, and facility policy, the facility failed to appropriately monitor adverse affects for psychiatric medications as ordered and failed to ensure a gradual dose reduction order was completed timely. This affected one resident (Resident #69) out of five reviewed for unnecessary medications.
- D
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Inspectors wroteBased on resident record reviews, observations, staff interviews, and review of facility policy, the facility failed to ensure adequate activities of daily living (ADL) care was provided for two residents (#77 and 87). This affected two residents out of five residents reviewed for activities of daily living. Findings Include: 1. Review of a resident record revealed that Resident #77 was admitted to the facility on [DATE] and had diagnoses that included cognitive communication deficit, need for assistance with personal care and vascular dementia. Review of Resident #77's admission photo revealed that he was clean shaven. Review of Resident #77's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed that he had a Brief Interview for Mental Status score of 03, indicative of severe cognitive impairment. [...]
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on observations, record review, interviews, and review of facility policy, the facility failed to ensure a physician-ordered pressure reducing mattress was functioning as intended for Resident #131 who had multiple pressure ulcers requiring pressure relieving interventions. This affected one (Resident #131) out of four residents reviewed for pressure ulcers. Findings Include:Review of the medical record for Resident #131 revealed an admission date of 05/22/26. Diagnoses included cognitive communication deficit, disorder of muscle, rhabdomyolysis, chronic pain syndrome, spinal stenosis of the lumbar region without neurogenic claudication, peripheral vascular disease, osteoarthritis, other specified disorders of bone density and structure, idiopathic scoliosis, and macular degeneration. [...]
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on observation, record review, interviews, and facility policy, the facility failed to ensure fall prevention interventions were implemented and maintained following a fall for two (Resident #07 and #84) out of two residents reviewed for falls. The facility census was 112. Findings Include: 1. Review of the medical record for Resident #07 revealed an admission date of 11/06/25 and re-entry date of 03/11/26. Diagnoses included Alzheimer's disease, fracture of neck of left femur with routine healing following surgical repair, type 2 diabetes mellitus with diabetic neuropathy, chronic kidney disease stage 3, and syncope and collapse. Review of the significant change Minimum Data Set assessment dated [DATE] revealed a Brief Interview for Mental Status score of 02 indicating severe cognitive impairment. [...]
- D
Provide enough food/fluids to maintain a resident's health.
Inspectors wroteBased on observation, record review, resident interview, staff interview, and facility policy, the facility failed to monitor and document fluid intake for Resident #08 who was on fluid restrictions. Additionally, the facility failed to monitor weights for Resident #01 with a significant weight loss. This affected two (Residents #01 and #08) out of three residents reviewed for nutrition. The facility census was 112. Findings Include: 1. Review of the medical record for Resident #08 revealed an admission date of 11/21/25. Diagnoses included congestive heart failure, chronic kidney disease stage 4, dependence on renal dialysis, chronic obstructive pulmonary disease, and type 2 diabetes mellitus. Review of the care plan dated 11/23/25 revealed interventions for fluid management related to congestive heart failure, chronic kidney disease, and dialysis dependence. [...]
- D
Provide safe, appropriate pain management for a resident who requires such services.
Inspectors wroteBased on review of resident records, interviews and review of facility policy, the facility failed to ensure appropriate pain management medications were administered per professional standards of practice, when parameters were not in place for as needed pain medications, including opioids, for two residents. This affected two residents (#21 and #101) of three residents reviewed for pain management.
- 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, resident interview, and staff interview, the facility failed to properly store medications. This affected two residents (#16 and #122) out of 28 residents in the survey sample. Findings Include: 1. Review of the medical record for Resident #131 revealed an admission date of 11/07/25. Diagnoses included type two diabetes mellitus without complications, essential (primary) hypertension, peripheral vascular disease, and acute kidney failure. Review of the quarterly Minimum Data Set assessment dated [DATE] revealed a Brief Interview for Mental Status score of 14 indicating intact cognition. The assessment indicated the resident required extensive assistance with activities of daily living and medication administration. Review of physician orders revealed an active order for Losartan Potassium 100 milligrams by mouth daily for hypertension. [...]
- D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on record review, interview, and facility policy review, the facility failed to ensure complete documentation of urinary output tracking as ordered by the physician. This affected one resident (#02) out of two reviewed for catheters. The facility identified nine residents with catheters. Additionally, the facility failed to ensure complete documentation regarding regular cleaning of a residents continuous positive airway pressure (CPAP) machine. This affected one resident (#101) of one resident reviewed for respiratory care. The facility census was 112. Findings Include: 1. Review of the medical record for Resident #02 revealed a re-admission date of 01/24/26 with diagnoses of but not limited to chronic kidney disease, obstructive and reflux uropathy, acute kidney failure, anemia. [...]
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview, and review of Centers for Disease Control (CDC) guidance, the facility failed to ensure glucometers were sanitized/disinfected between resident use. This affected one resident (#05) and had the potential to affect four residents the facility identified as residents who utilized the facility glucometer. Findings Include: Review of the medical record for Resident #69 revealed the resident was originally admitted on [DATE] with the diagnosis of diabetes type two. Review of Resident #69's physician orders revealed an order for Humalog insulin 100 units per milliliter per sliding scale (a specific dose of insulin per the residents blood glucose reading). Review of the medical record for Resident #05 revealed the resident was admitted on [DATE] with the diagnosis of diabetes mellitus. Observation on 06/04/26 at 11:15 A.M. [...]
July 9, 2025Complaint inspection · 1 citation
- 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 review of resident records, staff interviews, and review of facility policy, the facility failed to provide documented evidence of good faith efforts to notify a former resident of an active urinary tract infection. This affected one former resident (Former Resident #115) out of four residents reviewed for urinary tract infections. The facility census was 113 residents.
June 10, 2025Complaint inspection · 1 citation
- G
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteTHIS IS AN INCIDENCE OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on medical record review, review of facility incident report, resident and staff interview, and facility policy review, the facility failed to ensure a resident was safely transferred by a mechanical lift. This resulted in Actual Harm on 05/27/25 when one staff attempted to transfer Resident #103 from the wheelchair to the bed with the mechanical lift and the strap to the lift pad tore and Resident #103 dropped to the floor. Resident #103 was observed by staff to have one missing tooth, and one tooth was broken in half at the time of the incident. Resident #103 was sent to the hospital and returned to the facility with no other injuries noted. The resident has a follow up appointment with the emergency dentist. [...]
April 1, 2025Complaint 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, record review, and staff interviews, the facility failed to store, prepare, distribute, and serve foods in accordance with professional standards for food service safety. This had the potential to affect all residents in the facility except one (Resident #34) who was ordered nothing by mouth (NPO) and didn't receive food from the kitchen. The facility census was 111.
November 24, 2024Standard inspection · 17 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 and staff interview, the facility failed to ensure the kitchen was maintained in a clean and sanitary manner. This had the potential to affect all residents who received food from the kitchen. The facility identified one resident (#60) who consumed nothing by mouth. The facility census was 108.
- F
Provide and implement an infection prevention and control program.
Inspectors wroteBased on record reviews, staff interview, review of the Centers for Disease Control and Prevention, and review of the facility policy, the facility failed to ensure the Water Management Program was timely and appropriately implemented to prevent the spread of Legionella. This had the potential to affect all 108 residents residing in the facility.
- E
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on observation, interview, and medical record review, the facility failed to ensure nail care was provided for dependent residents. This affected four residents (#75, #91, #95, #104) of six residents reviewed for activities of daily living (ADL). The facility census was 108.
- E
Provide activities to meet all resident's needs.
Inspectors wroteBased on interview and record review, the facility failed to ensure there were sufficient activities in the memory care unit especially in the evening and weekend. This affected four residents (#75, #91, #95, and #99) of four residents reviewed for activities and had the potential to affect all 25 residents residing in the memory care unit. The facility census was 108.
- D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure resident dignity was maintained during dining experiences. This affected two residents (#35 and #103) observed for dining during the annual survey. The facility census was 108.
- 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 record review and interview, the facility failed to provide residents with a bed hold notification prior to hospital stay. This affected two (Residents #15 and #39) of four residents reviewed for notification of bed hold. The facility census was 108.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure Thrombo-Embolic Deterrent (TED) hose were applied as ordered by the physician. This affected one resident (#57) of the eight residents reviewed for skin conditions during the annual survey. Additionally, the facility failed to timely collect urine and treat a urinary tract infection (UTI) for Resident #86. This affected one resident (#86) of one reviewed for UTI. The facility census was 108.
- D
Assist a resident in gaining access to vision and hearing services.
Inspectors wroteBased on observations, resident and staff interviews, medical record review, and facility policy review, the facility failed to ensure staff assisted one resident (#13) with the placement of bilateral hearing aids daily as ordered. This affected one resident (#13) of one reviewed for hearing services. The facility census was 108.
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on observations, interviews, record reviews, and review of facility policy, the facility failed to ensure pressure ulcer prevention interventions were in place per the plan of care, failed to ensure pressure ulcers were comprehensively evaluated upon admission, and failed to ensure staff were educated on the appropriate settings for Low Air Loss (LAL) mattresses. This affected two residents (#43 and 362) out of the five residents reviewed for pressure ulcers during the annual survey. The facility census was 108.
- 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 observations, interviews, and record reviews, the facility failed to ensure care and services to prevent the development or worsening of contractures were timely and appropriately implemented. This affected two residents (#43 and #91) out of two residents reviewed for limited range of motion during the annual survey. The facility census was 108.
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on observations, interviews, record reviews, and review of facility policy, the facility failed to ensure fall interventions were in place per the plan of care. This affected one resident (#57) of the four residents reviewed for falls during the annual survey. The facility census was 108.
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on medical record review, resident interview, and staff interview, the facility failed to complete timely follow up to obtain sleep study results for one resident (Resident #13). This affected one (Resident #13) of four residents reviewed for respiratory care. The facility census was 108.
- D
Provide care or services that was trauma informed and/or culturally competent.
Inspectors wroteBased on record review and staff interview, the facility failed to ensure a resident with Post Traumatic Stress Disorder (PTSD) was appropriately assessed to identify the cause of the resident's PTSD and minimize triggers and/or re-traumatization. This affected one (#46) of three resident identified by the facility as having PTSD/trauma. The facility census was 108.
- D
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Inspectors wroteBased on staff interview and medical record review, the facility failed to ensure Resident #69's blood pressure was monitored as ordered. This affected one (#69) of five residents reviewed for unnecessary medications. The facility census was 108.
- 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 observation,staff interview, and review of medical record, the facility failed to ensure Resident #29 was served his meal as physician ordered. This affected one resident (#29) of 25 residents in the memory care unit. The facility census was 108.
- D
Provide special eating equipment and utensils for residents who need them and appropriate assistance.
Inspectors wroteBased on observations, interviews, record reviews, and review of facility policy, the facility failed to ensure resident received appropriate set up assistance and adaptive equipment during meals necessary to maintain adequate nutrition. This affected one resident (#43) out of the five residents reviewed for nutrition during the annual survey. The facility census was 108.
- B
Ensure each resident receives an accurate assessment.
Inspectors wroteBased on observation, interview, and record review, the facility failed to accurately complete Minimum Data Set (MDS) assessments for residents. This affected six residents (#1, #22, #69, #91, #95, #99) of six residents reviewed for MDS accuracy. The facility census was 108.
November 14, 2023Complaint inspection · 2 citations
- F
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Inspectors wroteBased on observation and interview, the facility failed to provide a safe and sanitary environment for residents who use the facility shower rooms. This had the potential to affect all 118 residents in the facility.
- D
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Inspectors wroteBased on record review, facility reported incident review, and interviews, the facility failed to ensure residents remained free from staff to resident abuse and resident to resident altercations. This affected three residents (#144, #158, and #214) of 13 residents reviewed for abuse. The facility census was 118.
May 5, 2022Standard inspection · 6 citations
- F
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
Inspectors wroteBased on facility document review and staff interview, the facility failed to fully participate in Quality Assurance and Assessment (QAA) committee activities. This had the potential to affect 85 of 85 residents in the facility. Findings Include: Review of facility QAA meeting sign in sheets, dated March 2021 to March 2022, revealed the only meeting that the facility medical director attended was in April 2021. Review of facility Medical Director Monthly Reports, dated January 2022, October 2021, and July 2021, revealed hand written notes that indicated the QAA meeting minutes were reviewed with the medical director. [...]
- 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 interview, and facility policy review, the facility failed to properly store/date food in the main kitchen. This had the potential to affect 82 of 85 residents who receive food from the facility kitchen (Residents #8, #16, and #19 receive no food by mouth). The census was 85. Findings Include: Observations on 05/02/22 from 8:38 A.M. to 8:47 A.M. revealed the following items were found in the walk in freezer as opened and undated/improperly dated: opened bag of country friend steak that had a delivery date of 01/05/22 on the opened box, but no date on the bag of steak that was opened, and bags of chicken patties, breadsticks, green peas, and chicken tenders were opened and undated as to when they were opened or should be used by. Observations on 05/02/22 from 8:50 A.M. to 8:55 A.M. [...]
- D
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Inspectors wroteBased on observation, resident and facility staff interview the facility failed to maintain a safe home like environment. This had the potential to affect three residents (#133, #15 and #68) of 24 residents reviewed. The total facility census was 85. Findings Include: During initial observation of rooms on the secured hallway on 05/02/22 at 9:40 A.M. it was observed Resident #133's room had 10 floor tiles that were gouged through the top layer of the tile. The wall at the head of the resident's bed was damaged with the top layer of the drywall removed exposing the inner surface of the drywall. At this time, observation of Resident #15's room revealed the wall, the resident's bed was against, had multiple divots in the drywall. During an interview and observation of Resident #68's room on 05/02/22 at 10:29 A.M. it was revealed the cold water side of the sink did not work. [...]
- 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 resident record review, resident interview, staff interview and facility policy review, the facility failed to provide a resident the opportunity to participate in a plan of care meeting. This affected one Resident (#4) of one resident reviewed for care planning. The facility census was 85. Findings Include: On 05/02/22 at 1:12 P.M., an interview with Resident #4 was conducted. Resident #4 stated she was concerned about a wound that was bothering her on her head and a loose tooth causing discomfort in her mouth. Resident #4 further stated she did not remember talking to the staff about her concerns. She also stated she had not been asked to participate in a plan of care meeting to discuss those concerns. [...]
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on record review, and facility staff interview the facility failed to ensure a resident who had discontinuation of hospice services had timely monitoring and evaluation of anti-seizure medication. This affected one resident (#38) of one resident reviewed for change of condition. The total facility census was 85. Findings Include: Review of Resident #38's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses that include but are not limited to unspecified dementia adult failure to thrive, seizures, unstable angina, repeated falls. hypertension and trans ischemic attack. [...]
- D
Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care.
Inspectors wroteBased on record review, and facility staff interview the facility failed to ensure a physician was directing the care of a resident. This affected one resident (#38) of one reviewed for change of condition. The total facility census was 85. Findings Include: Review of Resident #38's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses that include but are not limited to unspecified dementia adult failure to thrive, seizures, unstable angina, repeated falls, hypertension, and trans ischemic attack. Review of significant change Minimum Data Set, dated [DATE] revealed the resident is not able to complete the brief interview of mental status score, resident had no behaviors, delusions, hallucinations, rejection of care but had one instance of wandering during the review period. [...]
Fire safety inspections
21 fire safety citations on file: 2 on June 4, 2026, 1 on November 18, 2025, 2 on December 17, 2024, 7 on November 24, 2024, 9 on May 5, 2022.
Every fire safety citation21 citations
- 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 · June 4, 2026 · Corrected (the home has a date of correction)
- E
Inspect, test, and maintain automatic sprinkler systems.
K 353 · June 4, 2026 · Corrected (the home has a date of correction)
- F
Provide a written emergency evacuation plan.
K 711 · November 18, 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 · December 17, 2024 · Corrected (the home has a date of correction)
- F
Provide a written emergency evacuation plan.
K 711 · December 17, 2024 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · November 24, 2024 · Corrected (the home has a date of correction)
- F
Have simulated fire drills held at unexpected times.
K 712 · November 24, 2024 · Corrected (the home has a date of correction)
- F
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
K 741 · November 24, 2024 · 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 · November 24, 2024 · Corrected (the home has a date of correction)
- E
Construct fire resistant interior walls.
K 331 · November 24, 2024 · Corrected (the home has a date of correction)
- E
Properly select, install, inspect, or maintain portable fire extinguishes.
K 355 · November 24, 2024 · Corrected (the home has a date of correction)
- E
Install properly constructed and protected linen or trash chutes.
K 541 · November 24, 2024 · Corrected (the home has a date of correction)
- F
Install emergency lighting that can last at least 1 1/2 hours.
K 291 · May 5, 2022 · Corrected (the home has a date of correction)
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · May 5, 2022 · Corrected (the home has a date of correction)
- F
Have simulated fire drills held at unexpected times.
K 712 · May 5, 2022 · 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 · May 5, 2022 · Corrected (the home has a date of correction)
- F
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · May 5, 2022 · Corrected (the home has a date of correction)
- E
Keep aisles, corridors, and exits free of obstruction in case of emergency.
K 211 · May 5, 2022 · 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 · May 5, 2022 · Corrected (the home has a date of correction)
- E
Inspect, test, and maintain automatic sprinkler systems.
K 353 · May 5, 2022 · Corrected (the home has a date of correction)
- E
Properly select, install, inspect, or maintain portable fire extinguishes.
K 355 · May 5, 2022 · Corrected (the home has a date of correction)