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 44 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
32D
12E
0F
Potential for minimal harm
0A
0B
0C
July 10, 2026Complaint inspection · 6 citations
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on interview and record review, it was determined the facility failed to report an allegation of verbal abuse within two hours to the State Agency for 1 of 4 sampled residents (#14) reviewed for abuse. This placed residents at risk for ongoing verbal abuse.
- D
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Inspectors wroteBased on interview and record review it was determined the facility failed to fully develop a baseline care plan related to falls within 48 hours for 1 of 3 sampled residents (#13) reviewed for care plans. This placed residents at risk for falls.
- 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 interview and record review it was determined the facility failed to implement care plan interventions for 1 of 3 sampled residents (#6) reviewed for ADLs. This placed residents at risk for not receiving showers.
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on interview and record review it was determined the facility failed to provide showers or bed baths for 1 of 3 sampled residents (# 11) reviewed for ADLs. This placed residents at risk for not receiving adequate assistance with ADLs.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on interview and record review it was determined the facility failed to follow physician orders for 3 of 4 sampled residents (#s 2, 4, and 13) reviewed for medications. This placed residents at risk for medication errors.
- D
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Inspectors wroteBased on observation, interview and record review, it was determined the facility failed to provide meals according to preferences and according to recommendations made by a clinician for 1 of 3 sampled residents (#12) reviewed for food preferences. This placed residents at risk for weight loss.
February 24, 2026Complaint inspection · 1 citation
- D
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Inspectors wroteBased on observation, interview and record review it was determined the facility failed to provide transportation for dialysis treatments for 1 of 3 sampled residents (#1) reviewed for dialysis care. This placed residents at risk for not receiving their dialysis services according to their schedules.
November 20, 2025Complaint inspection · 4 citations
- E
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, interview and record review it was determined the facility failed to ensure licensed nursing staff had the necessary competencies to care for residents with feeding tubes for 1 of 1 licensed staff (#25) reviewed for tube feedings. This placed residents at risk for incorrect tube feed and water flush administration.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on interview and record review it was determined the facility failed to follow physician orders for 1 of 3 sampled residents (#1) reviewed for physician orders. This placed residents at risk for adverse health consequences.
- 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 observation, interview and record review it was determined the facility failed to provide necessary care and services for tube feeding nutrition for 1 of 2 sampled residents (#1) reviewed for tube feedings. This placed residents at risk for dehydration and declining nutritional status.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview and record review it was determined the facility failed to adhere to Enhance Barrier Precautions related to feeding tubes for 1 of 2 sampled residents (#1) reviewed for infection control. This placed residents at risk for infection.
June 6, 2025Standard inspection, Complaint inspection · 10 citations
- E
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 observation, interview and record review it was determined the facility failed to ensure a system was in place to receive and resolve resident and/or resident representative grievances for 1 of 1 sampled facility reviewed for Resident Council. This placed residents at risk for unreported and unresolved grievances.
- E
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Inspectors wroteBased on interview and record review it was determined the facility failed to complete a comprehensive assessment for 4 of 8 sampled resident (#s 3, 254, 355 and 404) who were reviewed for accidents, ADLs, pain and food. This placed residents at risk for unidentified care needs.
- 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 it was determined the facility failed to properly store food and failed to maintain sanitary conditions in 1 of 1 kitchen and 1 of 3 unit refrigerators. This placed residents at risk for food borne illness and contaminated food.
- 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 it was determined the facility failed to respect resident rights for 1 of 1 sampled resident (#8) reviewed for personal property. This placed residents at risk for diminished quality of life.
- D
Allow residents to self-administer drugs if determined clinically appropriate.
Inspectors wroteBased on observation, interview and record review it was determined the facility failed to ensure residents were assessed for safe self-administration of medications for 1 of 1 sampled resident (#44) reviewed for self-administration of medications. This placed residents at risk for unsafe medication administration and adverse medication side effects.
- 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 and interview it was determined the facility failed to provide maintenance to maintain a safe, comfortable and homelike environment for 1 of 1 facility reviewed for physical environment. This placed residents at risk for an unsafe and unkempt interior building.
- D
Ensure each resident receives an accurate assessment.
Inspectors wroteBased on record review and interview it was determined the facility failed to complete MDS assessments which reflected accurate mental health diagnoses for 1 of 5 sampled residents (#45) reviewed for medications. This placed residents at risk for inaccurate assessment and care.
- D
Ensure services provided by the nursing facility meet professional standards of quality.
Inspectors wroteBased on interview and record review it was determined the facility failed to ensure Staff 17 (Former Agency LPN) adhered to professional standards for medication management and licensed nurse oversight of assigned residents. This placed residents at risk for adverse side effects of medication and unmet medical needs.
- 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, it was determined the facility failed to implement fall interventions to reduce hazards and risks for 1 of 3 sampled resident (#3) reviewed for accidents. This placed residents at risk for injury.
- E
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on interview and record review it was determined the facility failed to ensure Staff 17 (Former Agency LPN) adhered to medication administration and treatment management for 7 of 7 sampled residents (#s 5, 17, 21, 27, 31, 36, and 155) reviewed for failure to follow physician orders. This placed residents at risk for adverse side effects and unmet medical needs.
April 11, 2024Complaint inspection · 2 citations
- D
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Inspectors wroteBased on observation, interview and record review it was determined the facility failed to ensure residents were free from sexual abuse for 1 of 3 sampled residents (#202) reviewed for abuse. This placed residents at risk for abuse.
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on interview and record review it was determined the facility failed to timely report allegations of abuse to the State Survey Agency for 2 of 3 sampled residents (#s 201 and 202) reviewed for abuse. This placed residents at risk for delayed and incomplete investigations.
February 23, 2024Standard inspection, Complaint inspection · 11 citations
- E
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 and interview it was determined the facility failed to maintain a homelike environment for 1 of 1 facility reviewed for environment. This placed residents at risk for living in an unkempt environment.
- E
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Inspectors wroteBased on interview and record review it was determined the facility failed to ensure timely call light responses on 2 of 2 sampled units and for 1 of 3 sampled residents (#15) reviewed for sufficient staffing. This placed residents at risk for delayed and unmet needs.
- E
Observe each nurse aide's job performance and give regular training.
Inspectors wroteBased on interview and record review it was determined the facility failed to ensure CNAs received annual performance reviews for 5 of 5 randomly selected CNA staff (#s 7, 13, 28, 29 and 30) reviewed for staffing. This placed residents at risk for lack of care by competent staff.
- 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, interview, and record review it was determined the facility failed to ensure medications were secured, maintain and log appropriate medication storage temperatures and ensure proper labeling of biologicals for 3 of 3 floors reviewed for safe medication storage. This placed residents at risk for receiving medications with reduced efficacy and access to potentially harmful medications.
- 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 it was determined the facility failed to prepare and serve food in a safe and sanitary environment for 1 of 1 kitchen observed for food service. This placed residents at risk for foodborne illness.
- 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 observation, interview and record review it was determined the facility failed to provide a restorative program to maintain or improve ROM for 1 of 2 sampled residents (#14) reviewed for ROM. This placed residents at risk for decline in ROM.
- 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 it was determined the facility failed to assess for care plan effectiveness, identify and implement new fall interventions or provide adequate supervision needed to prevent falls for 1 of 3 sampled residents (#36) reviewed for falls. This placed residents at risk for avoidable falls.
- D
Ensure medication error rates are not 5 percent or greater.
Inspectors wroteBased on observation, interview and record review it was determined the facility failed to maintain a medication error rate of less than 5%. There were 2 errors with 35 opportunities resulting in an 5.71% medication error rate. This placed residents at risk for adverse drug reactions.
- D
Ensure that residents are fully informed and understand their health status, care and treatments.
Inspectors wroteBased on interview and record review it was determined the facility failed to ensure consent was obtained prior to administering psychotropic medications to residents for 1 of 5 sampled residents (#305) reviewed for unnecessary medications. This placed residents at risk for being uninformed about their medications.
- 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 the facility failed to notify the physician and the resident's responsible party of a change of condition for 1 of 1 sampled resident (#153) reviewed for change of condition. This placed residents at risk for delayed treatment and uniformed responsible parties.
- D
Protect each resident from the wrongful use of the resident's belongings or money.
Inspectors wroteBased on interview and record review it was determined the facility failed to properly secure controlled medications for 1 of 1 sampled resident (#11) reviewed for misappropriation. This placed residents at risk for loss of medications.
November 18, 2022Standard inspection · 10 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 and interview it was determined the facility failed to store food in a sanitary manner and ensure dietary staff wore facial hair restraints for 1 of 1 kitchen staff serving all residents within the facility and 1 of 1 steam carts. This placed residents at risk for food borne illness and contaminated food.
- E
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview and record review it was determined the facility failed to ensure a common-use glucometer (a device used to obtain blood glucose levels) was appropriately disinfected between uses for 3 of 3 sampled residents (#s 10, 24 and 29) reviewed for CBG monitoring. This placed residents at risk for bloodborne infections.
- D
Reasonably accommodate the needs and preferences of each resident.
Inspectors wroteBased on observation and interview it was determined the facility failed to ensure residents received reasonable accommodation of needs for 1 of 1 sampled resident (#10) reviewed for accommodation of needs. This placed residents at risk for not meeting resident's individualized needs.
- D
Keep residents' personal and medical records private and confidential.
Inspectors wroteBased on observation and interview it was determined the facility failed to ensure resident privacy was provided for 1 of 1 sampled resident (#10) reviewed for dignity. This placed residents at risk for lack of privacy.
- D
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Inspectors wroteBased on observation, interview and record review it was determined the facility failed to ensure residents were free from physical restraints for 1 of 1 sampled resident (#15) reviewed for restraints. This placed residents at risk for being physically restrained.
- D
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Inspectors wroteBased on interview and record review it was determined the facility failed to comprehensively assess restraints for 1 of 1 sampled resident (#15) reviewed for physical restraints. This placed residents at risk for unassessed physical restraints.
- 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 it was determined the facility failed to provide nail care for 1 of 3 sampled residents (#17) reviewed for ADL care. This placed residents at risk for unmet care needs.
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on observation, interview and record review it was determined the facility failed to implement interventions to prevent pressure ulcers and skin breakdown for 1 of 1 sampled resident (#17) reviewed for positioning. This placed residents at risk for the development of pressure ulcers and skin breakdown.
- D
Provide appropriate foot care.
Inspectors wroteBased on observation, interview and record review it was determined the facility failed to provide routine diabetic foot care for 1 of 1 sampled resident (#17) reviewed for foot care. This placed residents at risk for infection and pain.
- 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 it was determined the facility failed to ensure safety interventions were in place to prevent elopement for 1 of 2 sampled residents (#23) reviewed for elopement. This put residents at risk for potentially avoidable accidents.
Fire safety inspections
18 fire safety citations on file: 2 on November 26, 2025, 3 on June 6, 2025, 1 on July 17, 2024, 8 on February 23, 2024, 4 on November 18, 2022.
Every fire safety citation18 citations
- F
Establish emergency prep training and testing.
E 36 · November 26, 2025 · Corrected (the home has a date of correction)
- F
Have simulated fire drills held at unexpected times.
K 712 · November 26, 2025 · Corrected (the home has a date of correction)
- F
Develop Emergency Preparedness policies and procedures.
E 13 · June 6, 2025 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · June 6, 2025 · Corrected (the home has a date of correction)
- F
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · June 6, 2025 · Corrected (the home has a date of correction)
- D
Meet other general requirements that are deficient.
K 500 · July 17, 2024 · Past noncompliance: already fixed when inspectors found it
- F
Meet requirements for sections of health care facilities separated by fire resistive construction.
K 131 · February 23, 2024 · Corrected (the home has a date of correction)
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · February 23, 2024 · Corrected (the home has a date of correction)
- F
Have simulated fire drills held at unexpected times.
K 712 · February 23, 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 · February 23, 2024 · Corrected (the home has a date of correction)
- D
Ensure that suites are correctly sub-divided by noncombustible or limited-combustible construction.
K 255 · February 23, 2024 · Corrected (the home has a date of correction)
- D
Inspect, test, and maintain automatic sprinkler systems.
K 353 · February 23, 2024 · Corrected (the home has a date of correction)
- D
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
K 761 · February 23, 2024 · Corrected (the home has a date of correction)
- D
Ensure proper usage of power strips and extension cords.
K 920 · February 23, 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 · November 18, 2022 · Corrected (the home has a date of correction)
- E
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
K 761 · November 18, 2022 · Corrected (the home has a date of correction)
- D
Install noncombustible or limited-combustible interior walls.
K 163 · November 18, 2022 · Corrected (the home has a date of correction)
- D
Provide properly protected cooking facilities.
K 324 · November 18, 2022 · Corrected (the home has a date of correction)