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 30 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
26D
4E
0F
Potential for minimal harm
0A
0B
0C
July 23, 2026Standard inspection · 6 citations
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on interview with staff, observation, and review of clinical records, the facility failed to implement a recommendation from the Registered Dietitian that was signed by the Primary Care Provider in a timely fashion and failed to follow a physician's order for two of 16 residents reviewed (Resident 80, 165).
- D
Provide safe, appropriate pain management for a resident who requires such services.
Inspectors wroteBased on interview, observation, and clinical record review, the facility failed to administer pain medication in accordance with physician's orders for 1 out of 8 residents reviewed (Resident 91).
- 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 a review of pharmacy consultants' monthly medication review (MMR), clinical records review, and staff interview, it was determined that the facility failed to act on the pharmacist's recommendations for one of five residents reviewed (Resident 59).
- D
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Inspectors wroteBased on a review of the facility's policy, clinical records review, observations, and staff interview, it was determined that the facility administered an as-needed anti-anxiety medication without appropriate indications and non-drug interventions and failed to monitor and report psychotropic side effects for two of five residents reviewed (Resident 8 and 225).
- 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 observations and staff interviews, it was determined that the facility failed to ensure medications were properly stored and labeled for one of the five medication carts observed (2 [NAME] back medication cart).
- 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 with staff and clinical record review, it was determined that the facility failed to maintain complete and accurate medical records related to treatments and observations for two of five residents reviewed (Resident 15, and Resident 217).
March 9, 2026Complaint inspection · 2 citations
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on review of the facility's policy, clinical records review, and staff interview, it was determined that the facility failed to accurately and comprehensively assess and timely provide a wound treatment for two of three residents, reviewed (Resident 1 and 2).
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observations, clinical records review, and staff interviews, it was determined that the facility failed to ensure infection control and prevention were implemented during a wound care treatment for two of the two residents reviewed (Resident 1 and 2).
August 26, 2025Standard inspection · 14 citations
- E
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on review of clinical records and shower schedules, as well as staff interviews, it was determined that the facility failed to ensure that residents were provided with showers as scheduled for two of 65 residents reviewed (Residents 13 and 144).
- E
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on review of facility policies and clinical record reviews, as well as staff interviews, it was determined that the facility failed to ensure that physician's orders regarding medication administration were followed for two of 65 residents reviewed (Residents 6, 30), and failed to address physician recommendations from an outside appointment for one of 65 residents reviewed (Resident 25).
- E
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on review of facility policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that the resident environment remained as free from accident hazards as possible by failing to complete an air mattress safety assessment to identify potential safety hazards for 11 of 65 residents reviewed (Residents 1, 5, 7, 10, 13, 14, 19, 111, and 143) and failed to ensure that each resident received assistance devices to prevent accidents during transport in a wheelchair for one of 65 residents reviewed (Resident 172). Findings Include: [...]
- E
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Inspectors wroteBased on review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to maintain accountability for controlled medications (drugs with the potential to be abused) for two of 65 residents reviewed (Resident 5 and 30).
- D
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Inspectors wroteBased on review of policies, clinical records and investigative reports, as well as observations and staff interviews, it was determined that the facility failed to ensure that residents were free from any physical restraints not required to treat the resident's medical symptoms for two of 65 residents reviewed (Residents 111, 172).
- D
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Inspectors wroteBased on review of the Resident Assessment Instrument User's Manual and clinical records, the Centers for Medicare & Medicaid Services (CMS) Minimum Data Set (MDS) validation report, as well as staff interviews, it was determined that the facility failed to ensure that the Care Area Assessment Process of comprehensive Minimum Data Set assessments and comprehensive assessments were completed in the required time frame for 9 of 65 residents reviewed (Residents 2, 3, 32, 35, 87, 99, 119, 122, 200).
- D
Assure that each resident’s assessment is updated at least once every 3 months.
Inspectors wroteBased on review of the Resident Assessment Instrument Manual and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that quarterly Minimum Data Set assessments were completed within the required time frame for 2 of 65 residents reviewed (Residents 25, 174).
- D
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Inspectors wroteBased on review of the Resident Assessment Instrument Manual and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that encoding/transmitting Minimum Data Set assessments were completed within the required time frame for 5 of 65 residents reviewed (Residents 15, 77, 147, 199, 200).
- D
Ensure each resident receives an accurate assessment.
Inspectors wroteBased on review of the Resident Assessment Instrument User's Manual and residents' clinical records, as well as staff interviews, it was determined that the facility failed to complete accurate Minimum Data Set assessments for four of 65 residents reviewed (Residents 9, 10, 34, and 111).
- 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 review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to develop and implement an individualized care plan for one of 65 residents reviewed (Resident 13).
- 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 facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that a resident's care plan was updated/revised to reflect the resident's specific care needs for two of 65 residents reviewed (Residents 5 and 13).
- D
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Inspectors wroteBased on review of policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that interventions were in place to prevent urinary tract infections for one of 65 residents reviewed (Resident 13) who had an indwelling urinary catheter.
- D
Ensure medication error rates are not 5 percent or greater.
Inspectors wroteBased on review of manufacturer's instructions and clinical records, as well as observations and staff interviews, it was determined that the facility failed to maintain a medication administration error rate of less than five percent.
- 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 review of manufacturer's instructions, as well as observations and staff interviews, it was determined that the facility failed to date an opened multidose vial of Aplisol tuberculin (TB) solution (used to test for tuberculosis infection) in one of two medication storage area refrigerators reviewed (1 Main) and failed to provide a separately-locked, permanently-affixed compartment in the refrigerator for the storage of controlled drugs (medications that have the potential to be abused) in two of two medication storage area refrigerators reviewed (1 main and 2 West).
August 28, 2024Standard inspection · 6 citations
- D
Not hire anyone with a finding of abuse, neglect, exploitation, or theft.
Inspectors wroteBased upon review of personnel records, it was determined the facility failed to obtain an FBI clearance for one of one employee reviewed (Employee E6).
- D
Respond appropriately to all alleged violations.
Inspectors wroteBased on review of the facility's policy, clinical records, and staff interviews, it was determined the facility failed to comprehensively investigate an unknown injury for one of the three residents reviewed (Resident 146).
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on clinical record review and staff interview, it was determined the facility failed to timely obtain a urine specimen for testing according to physician orders for one of 32 residents reviewed. (Resident 58)
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on review of clinical records, facility documentation, observations and staff interview it was determined the facility failed to provide care and services to prevent the development and/or worsening of pressure ulcer and promote healing for one of 31 residents sampled (Resident 103).
- D
Provide enough food/fluids to maintain a resident's health.
Inspectors wroteBased on facility policy, clinical record review, and staff interview, it was determined the facility failed to obtain and monitor weights for one of 12 residents reviewed for nutrition (Resident 83).
- 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 hospital records review, clinical records review, and staff interview, it was determined that the facility failed to ensure appropriate diagnosis for Antipsychotic medication and failed to attempt nonpharmacological intervention and appropriate indication for administration of as-needed anti-anxiety medication for one of five residents reviewed (Resident 73).
March 19, 2024Complaint inspection · 1 citation
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on clinical records review, and interviews with resident and staff interviews, it was determined that the facility failed to ensure an order for NPO (nothing per mouth) before a procedure was followed for one of the two residents reviewed (Resident R1).
January 17, 2024Complaint inspection · 1 citation
- D
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Inspectors wroteBased on observation and interviews, it was determined that the facility failed to maintain an environment that was safe and sanitary in three of 11 rooms observed on the 3rd Floor Unit (rooms [ROOM NUMBER])
Fire safety inspections
18 fire safety citations on file: 3 on July 23, 2026, 14 on August 26, 2025, 1 on August 28, 2024.
Every fire safety citation18 citations
- E
Keep aisles, corridors, and exits free of obstruction in case of emergency.
K 211 · July 23, 2026 · deficient, provider has
- E
Install emergency lighting that can last at least 1 1/2 hours.
K 291 · July 23, 2026 · deficient, provider has
- E
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
K 321 · July 23, 2026 · deficient, provider has
- F
Conduct risk assessment and an All-Hazards approach.
E 6 · August 26, 2025 · Corrected (the home has a date of correction)
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · August 26, 2025 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · August 26, 2025 · Corrected (the home has a date of correction)
- F
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · August 26, 2025 · Corrected (the home has a date of correction)
- E
Keep aisles, corridors, and exits free of obstruction in case of emergency.
K 211 · August 26, 2025 · 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 · August 26, 2025 · Corrected (the home has a date of correction)
- E
Have properly located and lighted "Exit" signs.
K 293 · August 26, 2025 · Corrected (the home has a date of correction)
- E
Provide properly protected cooking facilities.
K 324 · August 26, 2025 · Corrected (the home has a date of correction)
- E
Have a complete alarm system manually initiated and initiated by fire sprinkler system connection.
K 342 · August 26, 2025 · Corrected (the home has a date of correction)
- E
Have a fire alarm with audible and visual signals that transmits the alarm automatically to notify emergency forces in event of fire.
K 343 · August 26, 2025 · Corrected (the home has a date of correction)
- C
Develop and maintain an Emergency Preparedness Program (EP).
E 4 · August 26, 2025 · Corrected (the home has a date of correction)
- C
Develop Emergency Preparedness policies and procedures.
E 13 · August 26, 2025 · Corrected (the home has a date of correction)
- C
Meet other general requirements.
K 100 · August 26, 2025 · Corrected (the home has a date of correction)
- C
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
K 225 · August 26, 2025 · Corrected (the home has a date of correction)
- F
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · August 28, 2024 · Corrected (the home has a date of correction)