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 38 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
1J
0K
0L
Actual harm
1G
0H
0I
Potential for more than minimal harm
25D
10E
0F
Potential for minimal harm
0A
1B
0C
May 21, 2026Complaint inspection · 2 citations
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observation, record review, and staff interviews, the facility failed to obtain a physician's order for the initiation of oxygen therapy for 1 of 1 resident reviewed for respiratory services (Resident #1).
- D
Ensure that residents are free from significant medication errors.
Inspectors wroteBased on record review, observation, and resident, staff, Physician and Wound Physician interviews, the facility failed to administer two prescribed medications, ketoconazole 2% shampoo (an antifungal shampoo used to reduce scalp flaking, scaling, and itching) and fluocinonide 0.05% topical solution (a topical steroid used to relieve inflammation and itching) in accordance with the physician's orders. This failure occurred for 1 of 3 residents reviewed for significant medication errors (Resident #1).
January 20, 2026Complaint inspection · 1 citation
- D
Ensure that residents are free from significant medication errors.
Inspectors wroteBased on record reviews, and interviews with staff, Director of Nursing, Pharmacist, Administrator, and the Medical Director, facility failed to verify right patient before administering insulin, which resulted in an insulin injection being administered to a resident with the same last name without an insulin order for 1 of 1 resident reviewed for significant medication errors (Resident #19).
November 21, 2025Standard inspection, Complaint inspection · 17 citations
- E
Ensure services provided by the nursing facility meet professional standards of quality.
Inspectors wroteBased on observations, record review, staff interviews, Physician and Consulting Pharmacist interviews, the facility administered an expired medication that was stored in the medication cart to Resident #10 via enteral tube feeding for 9 days for a total of 18 doses. Resident #10 was sent to the Emergency Department and had no adverse outcome as a result of receiving this expired medication.
- E
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Inspectors wroteBased on observations, record review, resident and staff interviews, the Consultant Pharmacist, and the Medical Director interviews the facility failed to have effective safeguards and systems in place to prevent drug diversion of discontinued narcotic pain medication (Hydrocodone-Acetaminophen oral tablet 5-325 milligrams) which resulted in a total of 20 missing tablets. This occurred for 1 of 1 resident (Resident #3) reviewed for misappropriation of medications.
- 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 observations, record review, and staff interviews, the facility failed to 1) secure an unattended medication cart that was facing the hallway for 13 minutes during which time 3 staff members and a resident propelling himself in a wheelchair passed the unattended opened medication cart for 1 of 1 medication carts observed (400 hall medication cart), and 2) remove loose and unsecured pills (200 hall cart), label inhalation breathing medication vials with an open date and store the vials according to manufacturer guidelines (300 hall cart) for 2 of 4 medication carts and failed to discard expired over the counter (OTC) stock medication from 1 of 2 medication storage rooms (200 hall medication room) that were reviewed for medication storage.
- E
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observations, record review, and staff interviews the facility failed to 1.) implement the infection control policy and procedures for special contact and droplet precautions for a resident (Resident #68) who was positive for COVID 19. Nurse Aide # 9 was observed walking into Resident# 68's room without wearing gloves or a gown and moved the mechanical lift that was used to transfer Resident # 68 from her bed. Nurse Aide #9 rolled the mechanical lift into the hallway without cleaning it, placed it against the wall, and left the lift unattended. Nurse Aide # 9 went back into Resident #68's room without donning gloves and a gown and moved the bedside table, picked up Resident #68's water cup and handed it to the resident. [...]
- D
Reasonably accommodate the needs and preferences of each resident.
Inspectors wroteBased on observations, record review, and staff and resident interviews, the facility failed to honor a resident's right to make choices when a nurse aide (NA) turned off a resident's (Resident #21) air conditioning after she told them not to turn it off. This deficient practice occurred for 1 of 4 residents reviewed for choices.
- 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 record review, staff interviews, and Nurse Practitioner (NP) interview, the facility failed to notify the provider of significant weight gain for a resident with Congestive Heart Failure (CHF) and on diuretic medication (a medication that helps the body remove excess fluid) for 1 of 1 sampled resident reviewed for notification of change. (Resident #62)
- 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 record review and staff interviews, the facility failed to provide written grievance summaries for 2 out of 2 residents reviewed (Resident #10 and #62).
- D
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Inspectors wroteBased on observations, record review, and interviews with residents and staff, the facility failed to protect a resident's right to be free from neglect when two nurse aides (NA) on the 3:00 PM to 11:00 PM shift refused a dependent resident's (Resident #21) requests for transferring her to bed and incontinence care. Resident #21 was left sitting up in her electric wheelchair in her room that had a strong odor resembling bowel incontinence. When Resident #21's incontinence care was provided her brief was heavily soiled with a bowel movement that was caked and dried on her skin. Resident #21 was in a semi-private room, and she stated she was embarrassed and humiliated in front of her roommate by the NAs refusal of care. The deficient practice occurred for 1 of 4 residents reviewed for neglect.
- D
Assure that each resident’s assessment is updated at least once every 3 months.
Inspectors wroteBased on record review and staff interviews, the facility failed to complete quarterly Minimum Data Set (MDS) assessments within 14 days of the Assessment Reference Date (ARD-referring to the last day of the observation period for 2 of 22 residents sampled for assessments (Resident #17 and Resident #21).
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on observations, record review, and interviews with resident and staff, the facility failed to provide incontinence care to a dependent resident for 1 of 4 residents reviewed for activities of daily living (ADL) care (Resident #21).
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on observations, record review, staff interviews, the Registered Dietician, the Nurse Practitioner and the Physician interviews the facility failed to verify the accuracy of physician ordered weights for a resident (Resident #6) with congestive heart failure. This occurred for 1 of 1 resident (Resident #6) reviewed for quality of care. Based on observations, record review, staff interviews, the Registered Dietician, the Nurse Practitioner and the Physician interviews the facility failed to verify the accuracy of physician ordered weights for a resident (Resident #6) with congestive heart failure. This occurred for 1 of 1 resident reviewed for quality of care.
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on record review, staff interviews, and the Wound Care Physician's interview, the facility failed to complete initial wound assessments upon admission to include the wound descriptions with measurements and obtain wound care orders upon admission and when the wound vac (vacuum assisted closure (vac), negative pressure wound therapy that uses suction to aid in wound healing) was not available in the facility for a resident admitted with multiple pressure wounds and osteomyelitis (infection of the bone tissue) requiring intravenous and oral antibiotics. This occurred for 1 of 6 residents (Resident #86) reviewed for wound care.
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on observations, record review, and staff interviews the facility failed to provide care in a safe manner when Nurse Aide #8 provided incontinence care to a resident (Resident #39). This resulted in Resident #39 rolling off of the bed onto the floor sustaining a fracture to the first cervical vertebrae (C1) of the cervical spine. This occurred for 1 of 5 residents reviewed for accidents (Resident #39). Resident #39 was admitted to the facility on [DATE]. Her diagnoses included cerebral vascular accident (CVA), hemiplegia (paralysis or weakness on one side of the body), and dementia. A care plan dated 4/18/25 revealed Resident #39 required assistance with activities of daily living (ADLs) including bed mobility due to having limited mobility related to cerebral vascular accident (CVA) with hemiplegia. [...]
- D
Provide enough food/fluids to maintain a resident's health.
Inspectors wroteBased on record review, staff interviews, Nurse Practitioner (NP), and Registered Dietitian (RD) interviews, the facility failed to determine the accuracy of a weight when a resident had a significant weight gain of 26.8 pounds in 19 days and failed to communicate the significant weight gain to the Registered Dietitian for a nutritional assessment for 1 of 5 residents reviewed for nutrition (Resident #62).
- D
Observe each nurse aide's job performance and give regular training.
Inspectors wroteBased on record review and staff interviews, the facility failed to complete a performance review every 12 months for 1 of 1 nursing assistant (Nurse Aide #4) reviewed to ensure in-service education was designed to address the outcome of the performance review.
- D
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, staff interviews, and the Consultant Pharmacist's interview the facility failed to act on the Pharmacist's recommendation to remove a residents (Resident #3) discontinued narcotic pain medication (Hydrocodone- Acetaminophen 5-325 milligrams) from the medication cart. This resulted in 20 missing tablets. This occurred for 1 of 6 residents (Resident #3) reviewed for medication administration.
- D
Ensure that residents are free from significant medication errors.
Inspectors wroteBased on record review, staff interviews, the Pharmacy District Director, and the Wound Physician interviews, the facility failed to administer two intravenous (IV) antibiotics (Piperacillin Sodium Tazobactam - a broad-spectrum antibiotic used to treat moderate to severe bacterial infections and Vancomycin - an antibiotic used to treat severe infections) prescribed for the treatment of osteomyelitis (infection of the bone) following admission for a resident (Resident #86). This resulted in 4 missed doses of the Piperacillin and 4 missed doses of the Vancomycin. This occurred for 1 of 6 residents reviewed for medication administration. The hospital discharge instructions dated 3/15/25 revealed an order for Resident #86 for Piperacillin Sodium Tazobactam. Use 3.375 grams intravenously every 8 hours for osteomyelitis for 18 days. [...]
June 5, 2025Complaint inspection · 2 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 record review, and staff , Psychiatrist, Nurse Practitioner, and the Medical Director's interviews the facility failed to protect a residents right to be free from resident-to-resident abuse when Resident #1 hit and scratched Resident #2 on her left arm resulting in multiple areas of bruising and abrasions. This occurred for 1 of 4 residents reviewed for abuse (Resident #1).
- D
Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
Inspectors wroteBased on record review, and hospice staff and facility staff interviews, the facility failed to coordinate a plan of care with the Hospice provider and ensure required Hospice documentation was in the medical record for 1 of 1 resident (Resident #5) reviewed for Hospice care.
November 20, 2024Standard inspection, Complaint inspection · 9 citations
- E
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on observations, record review, and staff, Nurse Practitioner, and Consultant Pharmacist interviews the facility failed to 1.) follow a physicians order and apply an ace wrap to a residents left foot due to swelling sustained from a fall (Resident #17) and 2.) obtain a blood pressure prior to the administration of the antihypertensive medication Hydralazine 25 milligrams prescribed three times a day with parameters to hold the medication for systolic blood pressure less than 120 millimeters of mercury (Resident #5). This occurred for 2 of 2 residents reviewed for quality of care.
- E
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Inspectors wroteBased on observations, record review, staff, the Nurse Practitioner, and the Consultant Pharmacist interviews the facility failed to accurately transcribe an antihistamine order (Hydroxyzine 25 milligrams) prescribed as needed for itching. This resulted in the resident receiving the medication daily instead of as needed. The resident experienced no outcome from receiving the medication. This occurred for 1 of 5 residents (Resident #59) reviewed for medication administration.
- D
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Inspectors wroteBased on record review, and resident and staff interviews, the facility failed to protect a resident's right to be free from physical abuse. Resident #80 removed some of Resident #67's belongings from her room and when Resident #67 went to retrieve the belongings Resident #80 denied having them. Resident #80 then swung at Resident #67, and in response, Resident #67 punched Resident #80 in the forehead with a closed fist for 1 of 4 residents reviewed for abuse. Resident #80 was not injured.
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on record review, and resident, staff, Nurse Practitioner and Physician interviews, the facility failed to provide care safely to a dependent resident when Resident #46 fell off the bed during care on 7/30/24 and 9/20/24 resulting in minor injuries. This deficient practice affected 1 of 3 residents reviewed for falls.
- D
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 record review, resident, staff, Nurse Practitioner and Physician interviews, the facility failed to provide sufficient nursing staff to ensure the necessary supervision and assistance level was implemented in accordance with the resident's plan of care for the safe provision of activities of daily living care for a dependent resident. This deficient practice affected 1 of 3 residents reviewed for sufficient nursing staff.
- D
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Inspectors wroteBased on record review and staff interviews, the facility failed to provide 8 consecutive hours of Registered Nurse (RN) coverage on 5 of 60 days reviewed.
- D
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 staff and Consultant Pharmacist interviews the facility failed to act on the Pharmacist recommendations to clarify the dose of an antihypertensive medication (Hydralazine 25 milligrams) and to add blood pressure checks prior to administration. This occurred for 1 of 5 residents (Resident #5) reviewed for medication administration.
- D
Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
Inspectors wroteBased on record review and staff interviews, the facility failed to maintain communication and coordination of services provided by Hospice in the medical record for 1 of 1 resident reviewed for Hospice services (Resident #41).
- B
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 interviews the facility failed to maintain complete medical records in the area of medication administration. This occurred for 3 of 5 residents (Resident #36, Resident #38 and Resident #54) reviewed for medication administration.
May 31, 2024Complaint inspection · 1 citation
- J
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Inspectors wrote2) Resident #4 was admitted into the facility 12/7/2020 with diagnoses of unspecified dementia, unspecified severity, with psychotic disturbance, generalized anxiety disorder, depressive episodes, and acquired absence of right leg above knee. A review of Resident #4's quarterly Minimum Data Set, dated [DATE] indicated that he was moderately cognitively impaired, had no behaviors, and no rejection of care. A review Resident #4's comprehensive care plan revealed a focus created on 2/9/21 of resident/patient exhibits or has the potential to exhibit physical and verbal behaviors related to: unspecified dementia, unspecified severity, with psychotic disturbance. Interventions included evaluating the nature and circumstances (i.e., triggers) of physical behavior with resident and/or resident representative. [...]
November 16, 2023Standard inspection, Complaint inspection · 5 citations
- E
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on observation, record review and interviews of residents, family, resident representative, and staff, the facility failed to provide nail care for dependent residents (Resident #s 32, 41, 45, and 50) and failed to provide hair wash for dependent residents (Resident #s 13, 32, 41, and 45) for 5 of 6 residents reviewed for activities of daily living.
- E
Provide safe, appropriate pain management for a resident who requires such services.
Inspectors wroteBased on record review, staff, Pharmacy Manager, Nurse Practitioner, and the Medical Directors interviews the facility failed to provide pain management by a.) not administering an as needed dose of the opioid medication Oxycodone prescribed for pain to a resident (Resident #222) who experienced frequent pain and b.) not following up with the Pharmacy regarding the anticonvulsant medication Lyrica prescribed three times a day for pain which resulted in the resident not receiving 11 doses of the medication and having complaints of pain for 1 of 1 resident (Resident #222) reviewed for pain management.
- 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 observations, record review, and staff interviews the facility failed to record an opened date on multi dose oral inhalers and record an opened date on ophthalmic drops on 3 of 3 medication carts reviewed for medication storage.
- E
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Inspectors wroteBased on record review, observations and staff interviews the facility's Quality Assessment and Assurance (QAA) program failed to maintain implemented procedures and monitor interventions the committee put in place following the recertification and complaint investigation survey completed on 7/6/21. This was for a deficiency originally cited in the area of Label/Store Drugs and Biologicals (F761). The continued failure during two federal surveys of record shows a pattern of the facility's inability to sustain an effective QA program.
- D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Inspectors wroteBased on record review, staff, and the Pharmacy Managers interviews the facility failed to obtain a medication (Lyrica) prescribed for pain from the Pharmacy resulting in the resident not receiving 11 doses of the medication for 1 of 1 resident (Resident #222) reviewed for the provision of pharmacy services.
September 7, 2023Complaint inspection · 1 citation
- D
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Inspectors wroteBased on observations, record review, and staff interviews the facility failed to protect a resident ' s right to be free from abuse when a cognitively impaired resident (Resident #1) had a physical altercation with another cognitively impaired resident (Resident #2). Resident #1 punched Resident #2 in the face on 08/10/23. Resident #2 was assessed with redness to his face and a small abrasion to his nose and forehead; his emotional response was assessed as baseline (no change). This was for 1 of 2 residents reviewed for abuse.
Fire safety inspections
8 fire safety citations on file: 3 on November 21, 2025, 4 on November 20, 2024, 1 on November 16, 2023.
Every fire safety citation8 citations
- D
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
K 321 · November 21, 2025 · Corrected (the home has a date of correction)
- D
Inspect, test, and maintain automatic sprinkler systems.
K 353 · November 21, 2025 · Corrected (the home has a date of correction)
- D
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · November 21, 2025 · Corrected (the home has a date of correction)
- F
Have a battery powered remote alarm panel in a location accessible by operating personnel.
K 916 · November 20, 2024 · Corrected (the home has a date of correction)
- D
Inspect, test, and maintain automatic sprinkler systems.
K 353 · November 20, 2024 · Corrected (the home has a date of correction)
- D
Install corridor and hallway doors that block smoke.
K 363 · November 20, 2024 · Corrected (the home has a date of correction)
- D
Have proper medical gas storage and administration areas.
K 923 · November 20, 2024 · 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 · November 16, 2023 · Corrected (the home has a date of correction)