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 58 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
1G
0H
0I
Potential for more than minimal harm
44D
9E
1F
Potential for minimal harm
0A
2B
1C
June 17, 2026Complaint inspection · 1 citation
- G
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on clinical record review, review of facility documentation, review of facility policy, and staff interviews for 1 of 3 sampled residents (Resident #30) reviewed for accidents, the facility failed to ensure that a resident who required physical assistance with toileting received the necessary hands on supervision/support to prevent a fall. This failure resulted in the resident falling and sustaining an injury that required staples.
March 2, 2026Complaint inspection · 2 citations
- 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 resident record review, facility documentation review, and staff interviews for one of three residents (Resident #1) reviewed for accidents, the facility failed to develop new fall interventions timely following a fall.
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on record review, facility documentation review and staff interviews for one of three residents (Resident #1) reviewed for accidents, the facility failed to provide supervision for a resident with dementia and known risk of falls to prevent a fall with injury.
January 15, 2026Complaint inspection · 1 citation
- D
Ensure services provided by the nursing facility meet professional standards of quality.
Inspectors wroteBased on record review, facility documentation review, and staff interviews for one of three residents (Resident #2) reviewed for abuse, the facility failed ensure staff did not move a resident after a fall resulting in resident complaint of pain.
July 28, 2025Complaint inspection · 3 citations
- D
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Inspectors wroteBased on record review, facility documentation, facility policy review, and staff interviews for one of three residents (Resident #1) reviewed for accidents, the facility failed to ensure a comprehensive care plan was developed to include a resident's transfer status.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on record review, facility documentation review, and staff interviews for one of three residents (Resident #1) reviewed for accidents, the facility failed to ensure a resident diagnosed with diabetes had routine monitoring of hemoglobin A1C blood glucose levels.
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on record review, facility documentation review, facility policy review, and staff interviews for one of three residents (Resident #1) reviewed for accidents, the facility failed to ensure the resident was transferred in accordance with facility policy during a mechanical lift resulting in a resident fall.
December 20, 2024Complaint inspection · 4 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 clinical record review, facility documentation, and staff interviews for two of three sampled residents (Resident #1 and #2) reviewed for abuse, the facility failed to ensure Resident #1 and Resident #2 were free from mistreatment.
- D
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Inspectors wroteBased on facility record review for abuse, the facility failed to ensure the facility policy directed abuse education for student nurse aides prior to placement on a resident unit.
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on clinical record review, facility documentation, and staff interviews for three sampled residents (Resident #1, 2 and 3) reviewed for abuse, the facility failed to ensure allegations of mistreatment were reported timely.
- D
Develop, implement, and/or maintain an effective training program for all new and existing staff members.
Inspectors wroteBased on facility documentation and staff interviews for staff education review, the facility failed to ensure students providing resident care were provided abuse education timely.
October 2, 2024Complaint inspection · 1 citation
- D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on review of the clinical record, facility documentation, facility policy, and interviews for one (1) of three (3) residents (Resident #1) reviewed for accidents, the facility failed to ensure the clinical record was complete and accurate to include a fall intervention after the resident had a fall.
August 6, 2024Standard inspection, Complaint inspection · 18 citations
- F
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observations, clinical record reviews, facility documentation review, and interviews for 4 of 4 residents (Resident #11, #86, #117 and #137) reviewed for infection control, the facility failed to ensure that infection control practices related to glucometer cleaning and disinfection in between resident and the facility failed to ensure personal protective equipment (PPE) carts were available outside every resident room who required the use of PPE, evidence of infection surveillance, evidence of annual review of the Intravenous and Infection Control Policy books, evidence facility water management plan and for 1 of 3 residents evaluated for pressure ulcers (Resident #24), the facility failed to ensure staff used appropriate personal protective equipment (PPE) when performing dressing changes and for 1 of 6 sampled residents (Resident #25) reviewed for infection control, the [...]
- E
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Inspectors wroteBased on clinical record reviews, facility documentation, facility policy and interviews for 3 of 40 sampled residents (Resident #25, Resident #227 and Resident #228) reviewed for advanced directives, the facility failed ensure a resident's code status was complete and accurate for a newly admitted /readmitted resident.
- E
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 clinical record reviews, observations and interviews for 2 of 3 residents reviewed for respiratory infection (Residents #91 and #276) the facility failed to ensure the care plan was revised to reflect the resident status requiring transmission-based precautions and 1 of 1 resident (#117) reviewed for Activities of Daily Living, the facility failed to ensure the residents care plan reflected the bathing preference of the resident.
- 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 interviews and review of facility documentation, the facility failed to ensure staff received ongoing education for Intravenous (IV) Therapy and perform competency evaluations to ensure staff remained competent to provide IV therapy.
- E
Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.
Inspectors wroteBased on the tour of the kitchen, observations and staff interview, the facility failed to ensure dinner and breakfast were served within the 14-hour gap.
- E
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on the tour of the kitchen, observations, facility documentation, review of policy and staff interviews, the facility failed to ensure the dietary department consistently labeled food to reflect their age or shelf life and failed to ensure the nourishment fridge and snacks cabinets on each unit were adequately stocked.
- E
Implement a program that monitors antibiotic use.
Inspectors wroteBased on review of the facility Infection Control program, review of facility document, facility policy and staff interview, the facility failed to ensure an Antibiotic Stewardship Program was in place and available for review.
- 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 clinical record review, facility documentation, facility policy and interviews for 1 of 3 sampled residents (Resident # 226) reviewed for change in condition, the facility failed ensure the physician was notified of a resident change in condition in a timely manner.
- 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 clinical record review, facility documentation, facility policy and interviews for 1of 3 sampled residents (Resident #35) reviewed for dignity, the facility failed to follow up with a resident reported concerns in a timely manner.
- D
Respond appropriately to all alleged violations.
Inspectors wroteBased on record review and staff interview for one of three residents (Resident #227) reviewed for abuse, the facility failed to ensure an alleged staff member was removed from the schedule after an allegation of mistreatment.
- D
Prepare residents for a safe transfer or discharge from the nursing home.
Inspectors wroteBased on clinical record review, facility documentation review, facility policy review, and interviews for one of three residents (Resident #176) reviewed for discharge planning, the facility failed to ensure Durable Medical Equipment (DME) was ordered timely for a planned discharge.
- D
Assess the resident when there is a significant change in condition
Inspectors wroteBased on clinical record review, facility documentation, and interviews for 1 of 3 residents (Resident #109) reviewed for change in condition, the facility failed to complete a Significant Change Status Assessment (SCSA) MDS assessment when the resident was admitted to hospice.
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on clinical record review and interviews for 1 of 3 residents ( Resident #117) reviewed for Activities of Daily Living, the facility failed to ensure a resident received a shower on per plan of care.
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on observations, review of the clinical record and facility policy and interviews for 1 of 4 residents (Resident #426) reviewed for pressure ulcers, the facility failed to follow physicians order regarding pressure reliving device.
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on observations, record reviews, review of facility documentation, review of policy and staff interviews for 2 of 4 residents reviewed for accidents for( Resident # 22), the facility failed to implement intervention to prevent future falls and for (Resident #47), the facility failed to ensure adequate supervision of a resident who left a nursing unit unauthorized .
- D
Provide enough food/fluids to maintain a resident's health.
Inspectors wroteBased on clinical record reviews, facility documentation, facility policy and interviews for 1 of 3 sampled residents (Resident #35) reviewed for nutrition, the facility failed to confirm weight loss according to policy.
- 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 and staff interview for one of three residents (Resident #227) reviewed for abuse the facility failed to ensure the clinical record was complete and accurate to include an RN assessment after an allegation of mistreatment.
- C
Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.
Inspectors wroteBased on observations, review of Resident Rights and interviews, the facility failed to ensure state inspection results were readily accessible to residents.
April 24, 2024Complaint 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 clinical record reviews, facility documentation, facility policies and interviews for one of three sampled residents (Resident #1) who were reviewed for a fall, a facility staff member failed to report a fall to the licensed staff when the resident had reported the unwitnessed fall so an assessment could be conducted to determine if the resident had sustained an injury or struck their head.
February 27, 2024Complaint inspection · 4 citations
- 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 the clinical record, facility documentation, facility policy, and interviews for one (1) of three (3) residents, (Resident #1), reviewed for a change in condition, the facility failed to ensure a change in condition it was reported timely to the physician timely and failed to report a change in condition to a responsible party.
- D
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Inspectors wroteBased on review of the clinical record, facility documentation, facility policy, and interviews for one (1) of three (3)residents, (Resident #2) reviewed for abuse, the facility failed to ensure the resident was free from physical abuse.
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on review of the clinical record, facility documentation, facility policy, and interviews for one (1) of three (3) Residents, (Resident #1), reviewed for abuse, the facility failed to report an allegation of abuse to the state agency within the required time frame.
- D
Respond appropriately to all alleged violations.
Inspectors wroteBased on review of the clinical record, facility documentation, facility policy, and interviews for one (1) of three (3)residents, (Resident #1) reviewed for abuse, the facility failed to conduct a complete and thorough investigation for an allegation of abuse.
November 9, 2023Complaint inspection · 1 citation
- E
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on clinical record reviews, facility documentation, facility policy and interviews for one of three sampled residents (Resident #1) who were reviewed for wound care, the facility failed to ensure a resident with a declining wound was seen at a wound center as recommended by the Advanced Practice Registered Nurse (APRN) and the clinical record failed to reflect documentation the attending physician or APRN assessed the wound.
March 9, 2022Standard inspection · 15 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, review of facility documentation, review of facility policy, and interviews the facility failed to ensure the environment was maintained in a homelike manner.
- E
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Inspectors wroteBased on review of the clinical record, facility documentation, facility policy, and interviews for 5 residents (Resident #54, 122, 162, 272, and 274) reviewed for immunizations, the facility failed to obtain and document consent or declination and administer the Prevnar 13 and Pneumococcal 23 vaccinations.
- D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteBased on clinical record reviews, review of facility documentation, facility policies and interviews for one of four sampled residents (Residents #97) who were reviewed for an allegation of mistreatment, the facility failed to ensure the resident was treated in a manner that maintained the resident's dignity and respect.
- 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 observation, review of the clinical record, facility documentation, facility policy, and interviews for 1 of 5 residents (Resident #162) reviewed for notification of change, the facility failed to ensure the physician and family were notified of a weight loss.
- D
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Inspectors wroteBased on review of the clinical record, facility documentation, facility policy, and interviews for 1 resident (Resident #128) reviewed for abuse, the facility failed to ensure Resident #128 was free from abuse by Resident #39.
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on clinical record reviews, review of facility documentation, facility policies and interviews for one of four sampled residents (Residents #97) who were reviewed for an allegation of mistreatment, the facility failed to report the results of the investigation within five (5) working days to the state agency.
- D
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Inspectors wroteBased on review of the clinical record, facility documentation, facility policy, and interviews for 1 (Resident #67) reviewed for Preadmission Screening and Resident Review (PASARR), the facility failed to ensure recommendations for a re-evaluation were requested in accordance with established timeframes.
- 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 observation, review of the clinical record, facility documentation, facility policy, and interviews for 1 of 2 Residents (Resident #271) reviewed for dialysis, the facility failed to ensure a baseline care plan for dialysis management.
- 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 review of the clinical record, facility documentation and interviews for 1of 4 residents (Residents #97) who were reviewed for an allegation of mistreatment, the facility failed to review and revise the plan of care to address an incident between a staff member and the resident, and for 2 residents (Resident #39 and 128) reviewed for falls and resident to resident abuse, the facility failed revise the care plan following repeated falls and failed to ensure the care plan was revised for a resident who was the victim of physical abuse.
- D
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 observation, review of the clinical record, facility documentation, facility policy, and interviews for 2 residents (Resident # 54 and #122) reviewed for Cardio-pulmonary resuscitation (CPR), the facility failed to ensure facility staff had immediately documented discussions with the resident or resident representative, the resident's wishes with regard to CPR or DNR, upon admission including, as appropriate, a resident's wish to refuse CPR.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on review of the clinical record, facility documentation, facility policy, and interviews for 1 of 5 residents (Resident #97) reviewed for unnecessary medications, the facility failed to ensure recommendations were responded to for a resident requiring psychiatric services.
- D
Provide enough food/fluids to maintain a resident's health.
Inspectors wroteBased on observation, review of the clinical record, facility documentation, facility policy, and interviews for 1 of 2 residents (Resident #162) reviewed for nutrition, the facility failed to monitor weights and implement dietary recommendations.
- D
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Inspectors wroteBased on observations, review of the clinical record, facility documentation, facility policy and interviews for 1 of 2 residents (Resident #106), reviewed for dialysis the facility failed to monitor the dialysis access site (Arterio-Venous (AV) fistula) for a thrill/bruit and failed to ensure that the resident was assess for signs and symptoms of infection and bleeding.
- 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, review of facility policy, and interviews, for 4 of 6 medication carts, the facility failed to maintain medication carts in a clean and sanitary manner and failed to ensure a medication cart was secured and in a designated area.
- D
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on observation, review of facility documentation, facility policy, and interviews the facility failed to ensure the kitchen was maintained in a clean and sanitary manner and failed to ensure food items were covered and dated according to policy.
August 9, 2019Standard inspection · 7 citations
- D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteBased on a review of the clinical record, review of facility documentation, review of facility policies and procedures, and interviews for one of three residents (Resident #83) reviewed for mistreatment, the facility failed to treat the resident in a dignified manner.
- D
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Inspectors wroteBased on observations, clinical record review, review of facility documentation, review of facility policy, and interviews for one of two sampled residents reviewed for choices (Resident #55), the facility failed to ensure Resident #55's preference related to getting out of bed was followed.
- D
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Inspectors wroteBased on clinical records reviewed, review of facility documentation, review of facility policy, and interviews for one of three residents (Resident #145) reviewed for abuse, the facility failed to keep the resident free from abuse.
- D
Respond appropriately to all alleged violations.
Inspectors wroteBased on review of the clinical records, facility documentation, facility policies and procedures, and interviews for one of three residents (Resident #41) reviewed for abuse, the facility failed to complete a thorough investigation of a bruise of unknown origin in accordance to facility policy.
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on observations, clinical record review, review of facility documentation, and interviews for one sampled residents reviewed for special needs during dining (Resident #83), the facility failed to ensure supervision during a meal.
- B
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Inspectors wroteBased on clinical record review, review of facility documentation, review of facility policy, and interviews for one sampled resident reviewed for resident assessment (Resident #2), the facility failed to ensure an Minimum Data Set (MDS) was transmitted as required per Federal regulations.
- B
Ensure each resident receives an accurate assessment.
Inspectors wroteBased on clinical record review and staff interview for the one of one sampled resident reviewed for bowel and bladder function (Resident #140) and for one of five sampled residents (Resident #172) reviewed for Preadmission Screening and Resident Review (PASRR), the facility failed to correctly code the MDS.
Fire safety inspections
22 fire safety citations on file: 9 on August 6, 2024, 10 on March 9, 2022, 3 on August 9, 2019.
Every fire safety citation22 citations
- D
Conduct risk assessment and an All-Hazards approach.
E 6 · August 6, 2024 · Corrected (the home has a date of correction)
- D
Establish policies and procedures including evacuation.
E 20 · August 6, 2024 · Corrected (the home has a date of correction)
- D
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 · August 6, 2024 · Corrected (the home has a date of correction)
- D
Have exits that are accessible at all times.
K 271 · August 6, 2024 · Corrected (the home has a date of correction)
- D
Have an alternate power supply for its alarm system.
K 344 · August 6, 2024 · Corrected (the home has a date of correction)
- D
Properly select, install, inspect, or maintain portable fire extinguishes.
K 355 · August 6, 2024 · Corrected (the home has a date of correction)
- D
Install corridor and hallway doors that block smoke.
K 363 · August 6, 2024 · Corrected (the home has a date of correction)
- D
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · August 6, 2024 · Corrected (the home has a date of correction)
- D
Provide a written emergency evacuation plan.
K 711 · August 6, 2024 · 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 · March 9, 2022 · Corrected (the home has a date of correction)
- E
Have an alternate power supply for its alarm system.
K 344 · March 9, 2022 · Corrected (the home has a date of correction)
- D
Establish policies and procedures including evacuation.
E 20 · March 9, 2022 · Corrected (the home has a date of correction)
- D
Keep aisles, corridors, and exits free of obstruction in case of emergency.
K 211 · March 9, 2022 · Corrected (the home has a date of correction)
- D
Install a fire alarm system that can be heard throughout the facility.
K 341 · March 9, 2022 · Corrected (the home has a date of correction)
- D
Meet other general requirements that are deficient.
K 500 · March 9, 2022 · Corrected (the home has a date of correction)
- D
Install properly constructed and protected linen or trash chutes.
K 541 · March 9, 2022 · Corrected (the home has a date of correction)
- D
Provide a written emergency evacuation plan.
K 711 · March 9, 2022 · Corrected (the home has a date of correction)
- D
Have simulated fire drills held at unexpected times.
K 712 · March 9, 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 · March 9, 2022 · Corrected (the home has a date of correction)
- D
Provide properly protected cooking facilities.
K 324 · August 9, 2019 · Corrected (the home has a date of correction)
- D
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
K 521 · August 9, 2019 · Corrected (the home has a date of correction)
- D
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
K 914 · August 9, 2019 · Corrected (the home has a date of correction)