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 27 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
2G
0H
0I
Potential for more than minimal harm
20D
5E
0F
Potential for minimal harm
0A
0B
0C
June 25, 2026Standard inspection, Complaint inspection · 18 citations
- G
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on observation, interview, and record review, the facility did not ensure each resident with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing. Specifically, for 1 out of 40 sampled residents, the facility did not implement pressure ulcer interventions to prevent infection and new ulcers from developing. This will be cited at a harm level. Resident identifier: 3.
- E
Allow residents to self-administer drugs if determined clinically appropriate.
Inspectors wroteBased on observation, interview, and record review, the facility did not ensure that the resident right to self-administer medications was clinically appropriate and safe. Specifically for 4 out of 40 sampled residents, residents were observed to have medications in their rooms and were not evaluated to determine if they were safe to self-administer medications. Resident identifiers: 8, 22, 35, and 78.
- E
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, interview, and record review, the facility did not ensure each resident who entered the facility with an indwelling catheter or subsequently received one was assessed for removal of the catheter as soon as possible unless the resident's clinical condition demonstrates that catheterization was necessary. Specifically, for 3 out of 40 sampled residents, the facility did not discontinue residents' Foley catheters when there were no indications for use. Additionally, facility staff were not trained on the use of a PureWick for a resident and the PureWick tubing was observed draped over the head of the bed and not able to down drain. Resident identifiers: 3, 46, and 98.
- E
Keep complete, dated laboratory records in the resident's record.
Inspectors wroteBased on interview and record review, the facility did not file in the resident's clinical record the laboratory reports that were dated and contained the name and address of the testing laboratory. Specifically, for 3 out of 40 sampled residents, laboratory results were not located in the medical record. Resident identifiers: 4, 46, and 99.
- 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, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. Specifically, food items in the refrigerator and freezer were undated and opened to air. Additionally, food items in resident refrigerators were undated and/or expired.
- D
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
Inspectors wroteBased on interview and record review, the facility did not ensure that each resident who was given a psychotropic drug had adequate monitoring of that drug. Specifically, for 1 out of 40 sampled residents, a resident receiving an antidepressant did not receive a gradual dose reduction (GDR) in two separate quarters (with at least one month between the attempts), unless clinically contraindicated. Resident identifier: 35.
- D
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Inspectors wroteBased on interview and record review, the facility did not implement written policies and procedures on prohibiting and preventing abuse and investigating any such allegations. Specifically, for 1 out of 40 sampled residents, staff were aware of allegations of roughness during care but did not escalate the allegation up the chain of command to be investigated as a possible allegation of abuse. Resident identifier: 46.
- D
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Inspectors wroteBased on interview and record review it was determined that the facility did not document in the resident's medical record the information that was provided to the receiving provider which must include a minimum of the practitioner responsible for the care of the resident; the resident representative contact information; advanced directive information; comprehensive care plan; a copy of the resident discharge summary; and all necessary information to ensure a safe and effective transition of care. Specifically, for 2 out of 40 sampled residents, the facility did not document in the resident's medical record the information conveyed to the receiving provider when the resident was transferred to the Emergency Room. Resident identifiers: 18 and 54.
- D
Ensure services provided by the nursing facility meet professional standards of quality.
Inspectors wroteBased on observation, interview, and record review, the facility did not ensure that the services provided met professional standards of quality. Specifically, for 1 out of 40 sampled residents, a resident's tube feeding was labeled with an incorrect formula, an incorrect administration rate, and was not labeled with the initials of the nurse who initiated the infusion. Furthermore, additional tube feedings were missing required labeling information. Resident identifier: 3.
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on interview and record review, the facility did not ensure that a resident who was unable to carry out activities of daily living (ADLs) received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. Specifically, for 1 out of 40 sampled residents, a resident did not receive bathing assistance per their schedule. Resident identifier 46.
- 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, for 2 out of 40 sampled residents, the facility did not ensure each resident received adequate supervision and assistance devices to prevent accidents. Specifically, a resident left the facility and called his daughter to report he was lost and a week later another resident, who needed to be supervised during a Leave of Absence, left the facility. Resident identifiers: 29 and 110.
- D
Provide safe, appropriate pain management for a resident who requires such services.
Inspectors wroteBased on interview and record review, the facility did not ensure that pain management was provided to residents who required such services, consistent with professional standards of practice, the person-centered care plan and the residents' goals and preferences. Specifically, for 1 out of 40 sampled residents, a resident reported that his Tramadol dose was frequently administered late and it impacted his pain control. Resident identifier: 54.
- D
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Inspectors wroteBased on observation, interview, and record review, the facility must ensure that residents who required dialysis received such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences. Specifically, for 1 out of 40 sampled residents, a resident receiving dialysis had incomplete communication notes. Resident identifier: 4.
- D
Ensure that residents are free from significant medication errors.
Inspectors wroteBased on interview and record review, the facility did not ensure residents were free of any significant medication errors. Specifically, for 1 out of 40 sampled residents, a resident taking a phosphate binder was not administered the medication with meals. Resident identifier: 4.
- 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 and interview, the facility did not ensure that all drugs and biologicals were stored in compartments under proper temperature controls. Specifically, observations were made of multiple medications stored in a refrigerator that had a registered temperature of 24 degrees Fahrenheit (F). Resident identifiers: 5, 41, 46, and 73.
- D
Keep signed and dated reports of x-rays and other diagnostic services in the residents record.
Inspectors wroteBased on interview and record review, the facility did not file in the resident's medical record signed and dated reports of radiological services. Specifically, for 1 out of 40 sample residents, a resident's Electrocardiogram (EKG) report was not located in the medical record. Resident identifier: 99.
- D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on observation and interview, the facility did not keep confidential all information contained in the resident medical records and safeguard against unauthorized access. Specifically, observations were made of the licensed nurse leaving the computer unattended and open to resident medical records and leaving the report sheet with resident health information unattended and visible on the medication cart.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe and sanitary environment. Specifically, for 2 out of 40 sampled residents, personal protective equipment (PPE) was not worn for high contact care for residents on Enhanced Barrier Precautions (EBP). Resident identifiers: 3 and 15.
January 5, 2026Complaint inspection · 3 citations
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on interview and record review, it was determined for 1 out of 8 sampled residents, the facility did not ensure that all residents received the treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choice. Specifically, a resident was not provided wound vac supplies in a timely manner. Resident identifier: 2.
- D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Inspectors wroteBased on interview and record review it was determined, for 2 out of 8 sampled residents, the facility did not provide routine and emergency drugs and biologicals to its residents. Specifically, residents were not provided multiple medications due to them being out of stock and unavailable from the pharmacy. Resident identifiers: 2 and 8.
- D
Ensure that residents are free from significant medication errors.
Inspectors wroteBased on interview and record review, the facility did not ensure residents were free of any significant medication errors. Specifically, 1 out of 8 sampled residents did not receive their intravenous (IV) antibiotics every 8 hours as ordered by the hospital. Resident identifier: 2.
April 29, 2024Standard inspection · 4 citations
- 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 and interview, the facility did not label all drugs and biological's used in the facility in accordance with currently accepted professional principles, and include appropriate accessory instructions and the expiration date when applicable. Specifically, an insulin pen and a vial of Lidocaine were not labeled with an open date and were open and available for use. In addition, narcotics were repackaged into the narcotic cards.
- 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 ensure that the resident environment remained as free of accident hazards as was possible and each resident received adequate supervision and assistance devices to prevent accidents. Specifically, for 1 out of 26 sampled residents, a resident that was dependent on staff and required maximum assistance for bed mobility and toilet use had a brief change performed by one Certified Nursing Assistant (CNA), rolled out of the bed, and received contusions and suffered emotional distress. Resident identifier: 41.
- D
Provide safe, appropriate pain management for a resident who requires such services.
Inspectors wroteBased on observation, interview, and record the review, the facility did not ensure that pain management was provided to residents who required such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences. Specifically, for 1 out of 26 sampled residents, a resident that was observed and verbally expressed their pain was not provided pain medication in a timely manner. Resident identifier: 41.
- D
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
Inspectors wroteBased on interview and record review, the facility failed to ensure that each resident received the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. Specifically, for 1 out of 26 sampled residents, behavioral health services were not provided to a resident who was assessed to need them. Resident identifier: 29.
January 3, 2024Complaint inspection · 2 citations
- G
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on interview and record review, it was determined for 1 of 5 sampled residents, that the facility failed to ensure residents received treatment and care in accordance with professional standards of practice, the comprehensive assessment, the comprehensive person-centered care plan, and the resident's preferences. Specifically, a resident with multiple co-morbidities who had a change in condition, was hospitalized after failure to identify the change in condition in a timely manner. The deficient practice for resident 1 was found to have occurred at a harm level. Resident identifier: 1.
- 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 interview and record review, it was determined that for 1 of 5 sampled residents that the facility did not notify the facility's physician or resident representative of a significant change in a resident's physical, mental, or psychosocial status. Specifically, the facility did not inform a resident's physician of the resident's change in mental status prior to sending her out for a hemodialysis appointment. Upon arrival to the appointment, the hemodialysis center then sent the resident out to the hospital due to her altered mental status. Resident Identifier:
July 11, 2022Standard inspection · 0 citations
Fire safety inspections
13 fire safety citations on file: 1 on June 25, 2026, 8 on April 29, 2024, 4 on July 11, 2022.
Every fire safety citation13 citations
- F
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
K 321 · June 25, 2026 · Corrected (the home has a date of correction)
- F
Meet other general requirements.
K 200 · April 29, 2024 · Corrected (the home has a date of correction)
- F
Install properly constructed and protected linen or trash chutes.
K 541 · April 29, 2024 · Corrected (the home has a date of correction)
- F
Have simulated fire drills held at unexpected times.
K 712 · April 29, 2024 · Corrected (the home has a date of correction)
- F
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · April 29, 2024 · Corrected (the home has a date of correction)
- D
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 · April 29, 2024 · Corrected (the home has a date of correction)
- D
Install emergency lighting that can last at least 1 1/2 hours.
K 291 · April 29, 2024 · Corrected (the home has a date of correction)
- D
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
K 321 · April 29, 2024 · Corrected (the home has a date of correction)
- D
Properly select, install, inspect, or maintain portable fire extinguishes.
K 355 · April 29, 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 11, 2022 · Corrected (the home has a date of correction)
- D
Keep aisles, corridors, and exits free of obstruction in case of emergency.
K 211 · July 11, 2022 · Corrected (the home has a date of correction)
- D
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · July 11, 2022 · Corrected (the home has a date of correction)
- D
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · July 11, 2022 · Corrected (the home has a date of correction)