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 35 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
1G
0H
0I
Potential for more than minimal harm
34D
0E
0F
Potential for minimal harm
0A
0B
0C
January 7, 2026Complaint inspection · 1 citation
- D
Protect each resident from separation (from other residents, his/her room, or confinement to his/her room).
Inspectors wroteBased on observations, interviews, record review and document review, the facility failed to ensure residents were not confined to a room and barricaded bed, for 2 of 6 sampled residents (Resident 2 and 3). The deficient practice resulted in residents being confined to bed without consent, placing the residents at risk of psychosocial harm, loss of dignity, and compromised resident rights.
August 29, 2025Standard inspection, Complaint inspection · 12 citations
- 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 observation, interview, and document review, the facility failed to ensure residents have a right to make choices about aspects of their life in the facility which were significant to the residents for 1 of 40 sampled residents (Resident 46) and 6 unsampled residents from the resident council interview. The deficient practice had the potential for the facility to not accommodate the residents' preferences and choices had the potential risk to cause psychosocial distress to the residents.
- D
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Inspectors wroteBased on interview, record review and document review, the facility failed to ensure a resident was kept safe from abuse for 1 of 40 sampled residents (Resident 166). The deficient practice had the potential for residents to experience emotional distress and physical harm.
- 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, interview, record review and document review, the facility failed to ensure a baseline care plan was developed for use of an abdominal binder for a resident who had a history of gastrostomy tube (G-tube) dislodgement for 1 of 40 sampled residents (Resident 12). The deficient practice had the potential to place the resident at risk for G-tube dislodgement.
- 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 observation, interview, record review, and document review, the facility failed to ensure the comprehensive care plan was revised to include identification of the need for oxygen therapy and corresponding interventions for 1 of 40 sampled residents (Resident 41). The deficient practice had the potential to result in unmet respiratory care needs, lack of staff guidance, and inadequate monitoring of oxygen therapy, which could compromise the resident's respiratory status.
- D
Ensure services provided by the nursing facility meet professional standards of quality.
Inspectors wroteBased on observation, interview, record review and document review, the facility failed to ensure professional standards of practice were adhered to for timely administration of medications and correct medication preparation and administration technique for medications given via the enteral route for 3 of 40 sampled residents (Residents 10, 15, and 12). The deficient practice had the potential to place residents at risk for adverse effects related to medication errors.
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on observation, interview, record review and document review, the facility failed to ensure a dependent resident was provided with nail care and hygiene to contracted hand for 1 of 40 sampled residents (Resident 12). The deficient practice had the potential to negatively impact residents' overall wellbeing.
- 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, record review and document review, the facility failed to ensure therapy recommendations for use of a palm guard for a resident with severe hand contracture were transcribed as an order and implemented for 1 of 40 sampled residents (Resident 12). The deficient practice had the potential to place the resident at risk for worsening contracture and pain.
- 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, interview, record review and document review, the facility failed to ensure medications were secured and not left at residents' bedside for 2 of 40 sampled residents (Residents 14 and 15). The deficient practice had the potential to place the residents at risk for adverse reactions to potential medication errors.
- 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, interview, and document review the facility failed to ensure foods were stored per recommended standards and ice machines were cleaned in 3 of 4 ice makers in the facility. This deficient practice posed a potential risk to safety and health standards which could lead to contamination and place residents at risk of foodborne illness.
- D
Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.
Inspectors wroteBased on interview and record review, the facility failed to ensure the facility assessment policy was reviewed and updated to reflect new guidance which included the active involvement of direct care staff, input from residents, resident representatives, family members and ensuring there were sufficient number of competent staff to meet the needs of each resident and failed to involve direct care staff in the development of the facility assessment. The deficient practice had the potential to result in an incomplete evaluation of resident population and facility resources, which could affect staffing decisions, training, and availability of services needed to meet resident needs.
- D
Have a plan that describes the process for conducting QAPI and QAA activities.
Inspectors wroteBased on interview and document review, the facility failed to ensure the facility had a Quality Assurance Performance Improvement (QAPI) plan. This deficient practice had the potential to negatively affect the outcomes of resident care and the quality of each resident's life.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview, and document review, the facility failed to maintain the laundry environment in a sanitary condition by allowing a non-operational dryer located in the clean area of the laundry to accumulate dust inside and on the exterior surfaces. The deficient practice had the potential to contaminate the clean linens and increase the risk of infection for residents.
January 30, 2025Complaint inspection · 2 citations
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on observation, interview, record review, and document review, the facility failed to ensure a medication was administered timely to 1 of 3 sampled residents (Resident #2). The deficient practice had a potential for the intended use of the medication to be insufficient or ineffective with a possible cause of harm to the resident.
- D
Provide safe, appropriate pain management for a resident who requires such services.
Inspectors wroteBased on observation, record review and interview, the facility failed to provide pain medication as requested, assess, and document resident pain level accurately according to physician's order for 1 of 1 unsampled residents (Resident 4). The deficient practice placed the resident at risk for ineffective and inadequate pain control.
September 11, 2024Standard inspection · 7 citations
- D
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Inspectors wroteBased on observation, interview, record review, and document review, the facility failed to complete a Preadmission Screening and Resident Review (PASARR) Level 2 evaluation for newly found changes or diagnosis for 4 of 32 sampled residents (Resident 115, 81, 139 and 119). The deficient practice had the potential to place residents at risk of not being evaluated for appropriate determination of necessary behavioral health services.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on observation, interview, record review and document review, the facility failed to ensure 1) the physician was notified of a high Vancomycin trough level (laboratory monitoring of Vancomycin to maintain therapeutic blood levels and prevent serious side effects) prior to administration of next dose and, 2) there was a physician order to hold Vancomycin when the nurse decided to not administer the medication during subsequent shift for a resident who was being treated for bacterial pneumonia for 1 of 32 sampled residents (Resident 143). The deficient practice placed the resident at risk for ineffective antibiotic therapy and serious side effects.
- D
Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services.
Inspectors wroteBased on observation, interviews, record review, and document review the facility failed to ensure care orders were entered and carried out for a colostomy (a surgical opening in the abdomen which provides a means for the collection of waste from the colon) in accordance with the resident care plan and facility policy for 1 of 32 sampled residents (Resident 69). The deficient practice had the potential for introducing infection and negative outcome of residents with a colostomy.
- 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, record review and document review, the facility failed to ensure gastrostomy (G-tube) care orders were entered and carried out in accordance with facility protocol for 1 of 32 sampled residents (Resident 79). The deficient practice placed the resident at risk for G-tube complications including but not limited to infection, malposition and discomfort.
- D
Ensure medication error rates are not 5 percent or greater.
Inspectors wroteBased on observation, interview, record review and document review, the facility failed to ensure it was free of a medication error rate of five percent (%) or greater for one unsampled resident (Resident 58) and 1 of 32 sampled residents (Resident 61). The deficient practice placed other residents at risk for medication errors.
- D
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Inspectors wroteBased on interviews, record review, and document review, the facility failed to provide documented evidence influenza and pneumococcal vaccine was provided for 2 of 5 sampled residents (Resident 115 and 81). The deficient practice had a potential to prevent ensuring residents have had the necessary vaccines in fighting off diseases.
- D
Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
Inspectors wroteBased on interviews, record review, and document review, the facility failed to provide documented evidence Corona Virus 19 (COVID 19) vaccine was provided for 2 of 5 sampled residents (Resident 115 and 81). The deficient practice had a potential to prevent ensuring residents have had the necessary vaccine in fighting off the specific viral disease.
March 29, 2024Complaint inspection · 2 citations
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on interview, record review, and document review, the facility failed to ensure verbal abuse or neglect allegation was reported to the abuse coordinator and state agency within the prescribed time for 2 of 7 sampled residents (Residents 1 and 2). The deficient practice could have the potential to put the residents at risk of further abuse or neglect, causing emotional distress and harm.
- D
Respond appropriately to all alleged violations.
Inspectors wroteBased on interviews, record reviews, and document reviews, the facility failed to ensure the allegations of verbal abuse and neglect were thoroughly investigated. The summary of the investigation, outcome or resolution, measures taken, and required documentation were not compiled and maintained for 2 of the 7 sampled residents (Residents 1 and 2). This deficient practice could potentially compromise the safety and well-being of the residents.
September 1, 2023Standard inspection, Complaint inspection · 11 citations
- G
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Inspectors wroteBased on interview and record review, the facility failed to ensure 1) a resident was kept safe from physical abuse for 1 of 31 sampled residents (Resident 159); 2) nursing staff followed up on physician orders and monitored a resident who experienced a change in condition for 1 of 31 sampled residents (Resident 309) ; and 3) incontinence care was provided to 2 of 31 sampled residents (Resident 1 and 84) for seven hours. The deficient practice had the potential for the residents to not receive adequate care.
- D
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Inspectors wroteBased on interview, record review, and document review the facility failed to ensure a Preadmission Screening and Resident Review (PASRR) level II referral was completed for 8 of 31 sampled residents (Resident 26, 64, 88, 74, 32, 7, 15, and 4). The deficient practice did not identify residents with a potential need for specialized services after a diagnosis of mental disorder (a clinically significant disturbance in an individual's cognition, emotional regulation, or behavior).
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on interview, record review, and document review, the facility failed to ensure medications were administered timely for 2 of 31 sampled residents (Resident 73 and 128). The deficient practice had the potential to impact treatment efficacy.
- D
Provide appropriate foot care.
Inspectors wroteBased on observation, interview, record review and document review. The facility failed to ensure podiatry follow up was completed for 1 of 31 sampled residents (Resident #61). Failure to identify the need for foot care could put the resident at risk of developing a wound or infection and a decrease of sense of well-being.
- 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 interview, record review and document review, the facility failed to ensure the restorative nursing services were provided per the therapy recommendations for 1 of 31 sampled residents (Resident 130). The deficient practice had the potential for the resident's further decline in physical functioning.
- D
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure an unused intravenous (IV) - lock (a thin, flexible tube placed in a vein in your hand or arm) was discontinued for 1 of 31 sampled residents (Resident #318). The deficient practice had the potential to be a portal of access for any microbial organism causing tissue infection at the insertion site.
- D
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Inspectors wroteBased on interview, record review and document review, the facility failed to ensure the Abnormal Involuntary Movement Scale was completed per the facility's policy (AIMS/a rating scale designed to measure involuntary movements known as tardive dyskinesia which could develop as a side-effect of an antipsychotic medication) for 2 of 31 sampled residents (Resident 77 and 84); and a consent for psychotropic medications was obtained for 2 of 31 sampled residents (Resident 84 and 32). The deficient practice had the potential to result in adverse consequences for the resident's health and well-being.
- 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, interview and document review the facility failed to ensure two multidose medications were labeled accordingly for 1 of 3 medication rooms. The failure to properly identify a discard date of a medication could result in administration of a sub-potent medication.
- 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, interview, and document review the facility failed to ensure the refrigerator in 1 of the 3 nourishment rooms was within the recommended temperature to keep cold foods cold. The deficient practice had the potential to impact the well-being of the residents through potential consumption of hazardous food items. On 08/30/2023 at approximately 8:05 AM, the refrigerator in the 200-hall nourishment room had an internal temperature of 48 degrees Fahrenheit. The Dietary Director confirmed the temperature. The refrigerator contained the following food items: - Three small apple sauce containers - Four milk cartons - Three medium sized plastic bags containing resident specific food items One apple sauce container was pulled from the refrigerator which had an internal temperature of 47 degrees Fahrenheit. The Dietary Director confirmed the temperature. [...]
- D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on interview, record review and document review, the facility failed to ensure the Record of Death and Mortician's Receipt form was completed for 1 of 3 sampled close records reviewed (Resident 157). The deficient practice had the potential for the facility failing to maintain an accurate and complete record to release the body of a deceased person to the appropriate entity and the resident's record of death. Resident 157 (R157) R157 was admitted on [DATE] and discharged on [DATE], with diagnoses including encounter for orthopedic aftercare following surgical amputation, burns involving less than 10% of body surface, and poisoning by unspecified narcotics, accidental (unintentional), initial encounter. [...]
- D
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Inspectors wroteBased on interview, record review and record review, the facility failed to ensure immunizations were provided and recorded for 5 of 6 sampled residents. (Resident #98, #8, #109, #148 and #139). The failure to administer vaccines poses a risk of a resident to contract communicable diseases.
Fire safety inspections
32 fire safety citations on file: 9 on August 29, 2025, 9 on September 11, 2024, 14 on September 1, 2023.
Every fire safety citation32 citations
- E
Include a process for Emergency Preparedness collaboration.
E 9 · August 29, 2025 · Corrected (the home has a date of correction)
- E
Provide emergency officials' contact information.
E 31 · August 29, 2025 · Corrected (the home has a date of correction)
- E
Have properly installed electrical wiring and gas equipment.
K 511 · August 29, 2025 · Corrected (the home has a date of correction)
- E
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
K 521 · August 29, 2025 · Past noncompliance: already fixed when inspectors found it
- D
Follow proper procedures when the fire alarm was out of service for more than 4 hours.
K 346 · August 29, 2025 · Corrected (the home has a date of correction)
- D
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
K 354 · August 29, 2025 · Corrected (the home has a date of correction)
- D
Properly select, install, inspect, or maintain portable fire extinguishes.
K 355 · August 29, 2025 · Corrected (the home has a date of correction)
- D
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
K 741 · August 29, 2025 · Corrected (the home has a date of correction)
- D
Have proper medical gas storage and administration areas.
K 923 · August 29, 2025 · Corrected (the home has a date of correction)
- F
Develop and maintain an Emergency Preparedness Program (EP).
E 4 · September 11, 2024 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · September 11, 2024 · 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 · September 11, 2024 · Corrected (the home has a date of correction)
- E
Establish policies and procedures including evacuation.
E 20 · September 11, 2024 · Corrected (the home has a date of correction)
- E
Establish policies and procedures for sheltering.
E 22 · September 11, 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 · September 11, 2024 · Corrected (the home has a date of correction)
- E
Have properly installed electrical wiring and gas equipment.
K 511 · September 11, 2024 · Corrected (the home has a date of correction)
- D
Install emergency lighting that can last at least 1 1/2 hours.
K 291 · September 11, 2024 · Corrected (the home has a date of correction)
- D
Ensure that testing and maintenance of electrical equipment is performed.
K 921 · September 11, 2024 · Corrected (the home has a date of correction)
- E
Develop and maintain an Emergency Preparedness Program (EP).
E 4 · September 1, 2023 · Corrected (the home has a date of correction)
- E
Address subsistence needs for staff and patients.
E 15 · September 1, 2023 · Corrected (the home has a date of correction)
- E
Implement emergency and standby power systems.
E 41 · September 1, 2023 · 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 · September 1, 2023 · Corrected (the home has a date of correction)
- E
Have properly located and lighted "Exit" signs.
K 293 · September 1, 2023 · Corrected (the home has a date of correction)
- E
Provide properly protected cooking facilities.
K 324 · September 1, 2023 · Corrected (the home has a date of correction)
- E
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · September 1, 2023 · Corrected (the home has a date of correction)
- E
Properly provide smoke detection systems in areas open to corridors.
K 347 · September 1, 2023 · Corrected (the home has a date of correction)
- E
Inspect, test, and maintain automatic sprinkler systems.
K 353 · September 1, 2023 · Corrected (the home has a date of correction)
- E
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
K 521 · September 1, 2023 · Corrected (the home has a date of correction)
- E
Have simulated fire drills held at unexpected times.
K 712 · September 1, 2023 · Corrected (the home has a date of correction)
- E
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
K 761 · September 1, 2023 · Corrected (the home has a date of correction)
- E
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · September 1, 2023 · Corrected (the home has a date of correction)
- E
Ensure that testing and maintenance of electrical equipment is performed.
K 921 · September 1, 2023 · Corrected (the home has a date of correction)