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 42 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
33D
9E
0F
Potential for minimal harm
0A
0B
0C
July 16, 2026Standard inspection · 12 citations
- E
Ensure each resident receives an accurate assessment.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure Minimum Data Set (MDS) assessments were complete and accurate for 8 of 15 residents, Residents #2, #3, #8, #9, #112, #73, #139, and #153, reviewed Minimum Data Set assessments.
- E
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on observation, interview and record review the facility failed to ensure wound care dressing changes were provided per physicians' orders for 4 of 7 residents, Resident #49, #58, #132, and #161 reviewed for skin conditions and failed to apply compression stockings per they physician order for 1 of 3 residents, Resident #150 reviewed for edema.
- 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 the facility failed to ensure medications were securely stored when unattended for 2 of 4 hallways.
- E
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on observation, interview, and record review the facility failed ensure residents' records were complete and accurate for 5 of 7 residents, Residents #49, #58, #132, #161, and #150, reviewed for documentation.
- D
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Inspectors wroteBased on interview and record review the facility failed to ensure a Preadmission Screening and Resident Review (PASRR) and Level II PASRR were completed when a mental illness was identified for 2 of 3 residents, Resident #2 and #136, review for PASRR screening.
- 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 the facility failed to develop and implement a comprehensive care plan for 1 of 3 residents, Resident #139, reviewed for behavioral management.
- 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 the facility failed to ensure the flushing of a gastric tube after the administration of a bolus feeding for 1of 4 residents, Resident #136, reviewed for enteral tube management.
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observation, interview, and record review the facility failed to ensure respiratory care for oxygen administration and/or humidification per physician orders for 2 of 6, Resident #48 and #147, and failed to obtain a physician order for the use of a continuous positive airway pressure machine for 1 of 3 residents, Resident #84, reviewed for respiratory services.
- D
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Inspectors wroteBased on interview and record review, the facility failed to ensure physician orders were followed related to the pharmacy Psychoactive Medication Use Recommendations for the monthly drug regimen review for 1 of 5 residents, Resident #49, reviewed for unnecessary medications.
- D
Provide timely, quality laboratory services/tests to meet the needs of residents.
Inspectors wroteBased on interview and record review the facility failed to ensure laboratory specimens as ordered by the physician were collected for 2 of 4 residents, Resident #3 and #48, reviewed for laboratory services.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview, and record review, the facility failed to prevent the possible spread of infection during wound care and the administration of gastrointestinal tube feeding.
- D
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Inspectors wroteBased on interview and record review the facility failed to ensure the residents' health record showed the residents either received the pneumococcal immunization for 1 of 5 residents, Resident #43 reviewed for immunization.
February 27, 2026Complaint inspection · 3 citations
- D
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Inspectors wroteBased on observation and interview, the facility failed to ensure Peripherally Inserted Central Catheter (PICC) dressing changes were performed in accordance with professional standards of practice for 1 of 5 residents, Resident #2, reviewed for intravenous therapy.
- 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 interview, the facility failed to ensure resident records were complete and accurately documented for wound care treatments 1 of 5 residents, Resident #1, reviewed for wound care.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview, and record review, the facility failed to prevent the possible spread of infection for not implementing enhanced barrier precautions for 1 of 3 residents, Resident #2, reviewed for intravenous therapy care.
February 20, 2025Standard inspection · 10 citations
- E
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Inspectors wroteBased on record review and interview the facility failed to provide a rationale when actions were not taken for pharmacy recommendations for 3 (Resident #7, #84, and #99) of 5 residents review for unnecessary medication.
- 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 the facility failed to ensure that residents were treated with dignity and respect and were free from physical restraint use when 1 resident had a splint on one hand and a nonskid sock covering the other hand for 1 resident (Resident #116) of 2 residents observed for positioning and mobility.
- D
Ensure each resident receives an accurate assessment.
Inspectors wroteBased on record review and interview, the facility failed to ensure accuracy of minimum data set assessments for 1 (Resident #4) of 6 residents reviewed for respiratory services and 1 (Resident #143) of 5 reviewed for unnecessary medications.
- 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 an interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for 1 (Resident #44) of 3 residents reviewed for urinary tract infections (UTI) , and for 1 resident (Resident #21) of 4 residents reviewed for mood and behaviors.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on interview and record review the facility failed to administer blood pressure medication following parameters for 2 (Resident #103 and 143) out of 8 residents reviewed for medication administration and failed to follow professional standards of practice during medication administration to 1 resident, Resident #456.
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observation, interview and record review, the facility staff failed to ensure that oxygen was administered consistent with professional standards of practice for two (Resident #8 and Resident #125) of 6 residents reviewed for respiratory care .
- D
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Inspectors wroteBased on interview and record review the facility failed to ensure residents' medications regimens were free of unnecessary antibiotic use based on adequate indications to reduce the risk of the developement of antibiotic resistant organisms for 1 (Resident #134) of 6 residents reviewed for unnecessary medications.
- 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 record review the facility failed to ensure the drugs and biologicals used in the facility were stored in accordance with currently accepted professional standards of practice when unsecured medications were observed in resident rooms for 1 out of 4 units reviewed for unattended medication.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to help prevent the transmission of communicable diseases and infection by failing to perform hand hygiene during medication administration for 4 (Residents #96 and #407) of 6 residents observed for medication administration, and failed to follow acceptable standards of care for storage of respiratory care equipment for 2 ( Resident #47 and Resident #143) of 6 residents reviewed for Respiratory care.
- D
Implement a program that monitors antibiotic use.
Inspectors wroteBased on interview and record review the facility failed to implement its antibiotic stewardship protocol when it failed to monitor the use of antibiotics to reduce the risk of development of antibiotic resistance for 1 (Resident # 134) of 3 residents reviewed for urinary tract infections.
November 7, 2024Complaint inspection · 1 citation
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview and review of policy and procedures, the facility failed to adhere to infection control practice standards during incontinence care for 2 out of 3 residents reviewed for incontinence care (Residents #5 and #6).
August 12, 2024Complaint inspection · 3 citations
- 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, interview and record review, the facility failed to provide a clean and homelike environment in 1 of 2 wings in the facility.
- 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 observation, record review, and interview, the facility failed to ensure comprehensive person-centered care plans were developed and implemented for 1 of 3 residents reviewed, Residents #5.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff used appropriate personal protective equipment while providing direct care to the residents on contact precautions to prevent the possible spread of infection and communicable diseases (Photographic evidence obtained).
November 3, 2023Standard inspection, Complaint inspection · 13 citations
- E
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Inspectors wroteBased on interview and record review, the facility failed to ensure the residents with newly evident or possible serious mental disorder, intellectual disability or related condition were referred to the appropriate state designated authority for 3 of 4 residents reviewed for mood and behaviors, Residents #53, #95, #142.
- E
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents received respiratory care services consistent with professional standards of practice for 4 of 6 residents reviewed for respiratory care, Residents #123, #231, #104 and #142.
- E
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Inspectors wrote2. Review of Resident #147's physician order dated 9/12/2022 reads, Liberal Renal diet, Regular Texture, Thin consistency. Review of Resident #147's physician order dated 9/12/2023 reads, Dialysis: Vitals Signs Pre Dialysis every day shift every Mon, Wed, Fri for Dialysis. Review of Resident #147's physician order dated 9/12/2023 reads, Dialysis: Vitals Signs Post Dialysis every evening shift every Mon [Monday], Wed [Wednesday], Fri [Friday] for Dialysis. Review of Resident #147's physician order dated 9/12/2022 reads, Dialysis: AV Fistula- Monitor for Signs & Symptoms of Infection every shift. Assess site for any change in skin condition. Report any noted redness, edema, or increased skin temperature to MD every shift. [...]
- E
Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the resident choices or preferences were followed.
- D
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Inspectors wrote2. Review of Resident #20's admission record revealed the resident was admitted to the facility on [DATE]. Review of Resident #20's medical records revealed the resident had a fall with injury on 10/3/2023. Resident #20 returned to the facility following a temporary absence for hospitalization on 10/9/2023 with a new diagnosis of fracture of left radius. Review of Resident #20's Minimum Data Set showed the resident's next assessment reference date of 10/16/2023 that was 18 days overdue. During an interview on 11/3/2023 at approximately 7:45 AM, the Director of Nursing stated, My expectation is that upon return to the facility, the assessment should be completed within 14 days. Review of the facility policy and procedure titled Resident Assessment Instrument (RAI) last reviewed on 3/30/2023 reads, Intent: [...]
- D
Ensure each resident receives an accurate assessment.
Inspectors wroteBased on record review and interview, the facility failed to ensure the assessments accurately reflected the resident's status at the time of assessment for 2 of 2 residents reviewed for hospice services, Residents #27 and #41, and 1 of 4 residents reviewed for discharge, Resident #179.
- 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, the facility failed to develop a person-centered care plan for 1 of 2 residents reviewed for hospice services, Resident #41, and 1 of 8 residents reviewed for nutrition, Resident #101.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents received treatment and care in accordance with professional standards for wound care for 1 of 3 residents reviewed for skin conditions, Resident #4.
- 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 record review and interview, the facility failed to ensure residents received restorative services as recommended by the physical therapist to increase range of motion and/or to prevent further decrease in range of motion for 1 of 3 residents reviewed for activities of daily living, Resident #161.
- D
Provide enough food/fluids to maintain a resident's health.
Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain appropriate parameters of nutritional status for 1 of 8 residents reviewed for nutrition, Resident #169.
- 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 record review, the facility failed to ensure medications were labeled in accordance with currently accepted professional principles in 1 of 3 medication rooms, and 1 of 4 medication carts.
- 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 record review, the facility failed to ensure food was stored in the kitchen cooler and in the stock/storage room areas in accordance with professional standards.
- 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, interview, and record review, the facility failed to ensure medical records were documented accurately for wound care treatments for 1 of 3 residents reviewed for skin conditions (Resident #4), and for 1 of 3 residents reviewed for turning and positioning and 1 of 4 residents reviewed for discharge (Resident #430).
Fire safety inspections
9 fire safety citations on file: 2 on July 16, 2026, 2 on February 20, 2025, 2 on August 13, 2024, 3 on November 3, 2023.
Every fire safety citation9 citations
- F
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · July 16, 2026 · deficient, provider has
- 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 · July 16, 2026 · deficient, provider has
- F
Install corridor and hallway doors that block smoke.
K 363 · February 20, 2025 · Corrected (the home has a date of correction)
- F
Have proper medical gas storage and administration areas.
K 923 · February 20, 2025 · Corrected (the home has a date of correction)
- D
Meet requirements for the use of electrical equipment.
K 919 · August 13, 2024 · Corrected (the home has a date of correction)
- D
Ensure that testing and maintenance of electrical equipment is performed.
K 921 · August 13, 2024 · Corrected (the home has a date of correction)
- E
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · November 3, 2023 · Corrected (the home has a date of correction)
- E
Inspect, test, and maintain automatic sprinkler systems.
K 353 · November 3, 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 · November 3, 2023 · Corrected (the home has a date of correction)