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 44 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
39D
3E
1F
Potential for minimal harm
0A
1B
0C
January 14, 2026Complaint inspection · 1 citation
- 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 interview, the facility failed to address and resolve a resident representative's grievances related to transportation and billing for 1 of 3 sampled residents (Resident #1).
October 2, 2025Standard inspection · 13 citations
- F
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on observation and staff interviews, the facility failed to keep food safety requirements in accordance with the professional standard of food service safety 2 visits to the main kitchen.
- E
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 observations, interviews and record reviews, the facility failed to initiate a care plan for advance directives for 5 of 5 sampled residents, Resident #10, Resident #27, Resident #60, Resident #72 and Resident #99; and failed to initiate care plans for 1 of 1 sampled resident reviewed for catheter, Resident #126.
- D
Reasonably accommodate the needs and preferences of each resident.
Inspectors wroteBased on observations, interviews, record review, and facility policy review, the facility failed to provide services with reasonable accommodation of resident needs and preferences for 3 of 27 sampled residents, (Resident #44, Resident #90, and Resident #104), whose call lights were not within their reach.
- 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, interviews, and record reviews, the facility failed to support the choices, activities, and schedules for 1 of 4 sampled residents reviewed for choices, Resident #8.
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on observation, interviews and record review, the facility failed to ensure that the resident environment remained free of accident hazards and failed to ensure that fall interventions were followed for 1 of 1 sampled resident reviewed for accidents, Resident #90.
- 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 observations, interviews, and record reviews, the facility failed to ensure tube feeding orders were followed as per the physicians' orders and failed to address a significant weight loss in a timely manner for 1 of 3 sampled residents reviewed for tube feeding (Resident #5).
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observation, interview and record review, the facility failed to provide respiratory care in a manner consistent with physician orders for 2 of 2 sampled residents (Residents #85 and #46) reviewed for respiratory and failed to assure resident care policies and procedures for respiratory care and services are developed affecting 1 of 3 tracheostomy residents (Resident #85.)
- D
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Inspectors wroteBased on observations, interviews, and record review, the facility failed to obtain dialysis communication sheets for 1 of 1 sampled resident reviewed for dialysis (Resident #117).
- D
Provide care or services that was trauma informed and/or culturally competent.
Inspectors wroteBased on record review and interview, the facility failed to identify triggers and implement care plans with triggers for residents with PTSD (Post Traumatic Stress Disorders) for 1 of 1 sampled resident, Resident #3. The fundings included:Record review revealed Resident #3 was admitted on [DATE] with diagnoses that included of the Psychosocial History and Assessment for Resident #3 dated 07/16/25 documented the following, resident has been diagnosed with PTSD. Is there a smell, sound, touch, taste, sight or other sensation that causes a flashback or trigger was answered yes. If yes, what causes flashbacks or triggers was answered being in situations where he feels anxiety. When asked what happens when the resident experiences a trigger was answered Increased anxiety. [...]
- 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 and interview, the facility failed to ensure adequate medication for 1 of 6 residents, Resident #39, reviewed for medication reconciliation.
- 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 record review, observation and interview, the facility failed to ensure medication were secured, for 1 of 27 sampled residents, Residents #99, reviewed for medications.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observations, interviews, and record review, the facility failed ensure they implemented an effective infection control program, as evidenced by failure to follow enhanced barrier precautions guidelines for 1 of 42 residents on enhanced barrier precautions, Resident #25.
- D
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Inspectors wroteBased on record review and interview, the facility failed to provide influenza and pneumococcal vaccines for 2 of 5 sampled residents, Resident #60 and Resident #126.
August 28, 2025Complaint inspection · 2 citations
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on observations, interviews and record review, the facility failed to ensure a physician order for a special study was scheduled and completed in a timely manner for 1 of 3 sampled resident reviewed, Resident #1.
- D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on observations, interviews and record review, the facility failed to maintain the residents' medical records that are accurately documented in accordance with accepted professional standards and practices for 1 of 3 sampled resident reviewed, Resident #1.
May 14, 2025Complaint inspection · 2 citations
- D
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Inspectors wroteBased on review of policy and procedure, observation, interview and record review, the facility failed to ensure it obtained a current physician order for an Intravenous (IV) dressing and IV site; and failed to change the Intravenous (IV) dressing to the right upper chest for 1 of 1 sampled resident observed, Resident #4.
- B
Post nurse staffing information every day.
Inspectors wroteBased on review of policy and procedure, observation and interview, the facility failed to ensure that it posted the current date for the Nurse Staffing Information for 2 of 5 posting areas observed.
May 31, 2024Standard inspection · 14 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 and interviews the facility failed to provide a safe, clean, comfortable, and homelike environment for 1 of 3 wings in the facility, [NAME] wing.
- D
Respond appropriately to all alleged violations.
Inspectors wroteBased on observations, interviews, and record review, the facility failed to properly document and thoroughly investigate an injury of unknown origin for 1 of 1 sampled resident reviewed for skin discoloration, Resident #120.
- 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 observations, interviews, and record review, the facility failed to initiate a comprehensive care plan for psychotropic medications with measurable objectives and interventions for 2 of 25 sampled residents, Resident #40 and Resident #63.
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on observation, record review and interview, the facility failed to ensure that residents receive wound care consistent with professional standards of practice for 1 of 1 sampled resident reviewed for wound care, Resident #48.
- 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 record review, observations, and interview, the facility failed to ensure staff followed proper indwelling (foley) catheter care consistent with accepted standards of practice; failed to insert the appropriate catheter size and failed to date the urinary drainage bag as per physician order for 1 of 1 sampled resident reviewed for urinary catheter care review during foley care provided for Resident #48.
- D
Provide enough food/fluids to maintain a resident's health.
Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to provide nutritional interventions in a timely manner for 1 of 3 sampled residents reviewed for nutrition, Resident #63.
- D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Inspectors wroteBased on observation, interviews and record review, the facility failed to ensure controlled substance medication reconciliations were accurate for 4 of 6 sampled residents reviewed during the controlled substance record review at the facility's west and south wings, for Residents #48, #82, #93 and #117; failed to obtain a physician's order for a psychotropic medication for Resident #93, reviewed for controlled substance use; failed to properly dispose of a controlled substance medication for Resident #117; failed to provide and document a scheduled medication as ordered for sampled Resident #83, as evidenced by it not being available; and failed to administer a scheduled medication to 1 of 3 residents observed for medicaiton administration, Resident #6.
- D
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Inspectors wroteBased on interviews and record review, the facility failed to adequately monitor residents' behaviors for those residents receiving psychotropic medications for 4 of 25 sampled residents, Residents #63, #40, #99 and #113.
- 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 interviews and record review, the facility failed to address physician ordered 'As Needed' (PRN) psychotropic medications that had 'no stop date' in a timely manner for 3 of 25 sampled residents, Residents #48, #82, and #99.
- 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, interviews, and record review, the facility failed to maintain medications and medication carts in a secure and sanitary manner for 2 of 3 medication carts observed during facility tours and medication administration opportunities; and failed to dispose of expired eyedrops as observed during medication storage tours.
- D
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Inspectors wroteBased on observations, interviews and record review, the facility failed to follow their menus to meet the nutritional needs of the residents for 1 of 2 observations completed in the main kitchen. This has the potential to affect 40 residents on a regular diet. The cnesus at the time of survey was 124 residents.
- D
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Inspectors wroteBased on observations, interviews, and record review, the facility failed to provide food choices and preferences for 3 of 25 sampled residents during dining observations, Resident #28, Resident #64, and Resident #110.
- D
Ensure each resident receives and the facility provides drinks consistent with resident needs and preferences and sufficient to maintain resident hydration.
Inspectors wroteBased on observations, interviews and record review, the facility failed to provide the correct fluid restriction for 1 of 1 sampled resident reviewed for dialysis, Resident #58.
- D
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on observations, interviews, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 2 observations conducted in the central kitchen.
May 4, 2023Standard inspection · 12 citations
- E
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Inspectors wroteBased on observation, interview, and record review, the facility failed to prepare an approved menu in advance and follow an approved menu to ensure the residents' nutritional needs are met for 109 facility residents in the facility, that included potentially 30 of 30 sampled residents.
- E
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 store, prepare, distribute and serve food in accordance with professional standards for food service safety that potentially affected 109 of the 113 facility residents and included 30 of 30 sampled residents.
- D
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Inspectors wroteBased on record review and interview, the facility failed to ensure that 2 of 3 sampled residents, Resident #36 & Resident #43, received the Notice of Medicare Non-Coverage (NOMNC) informing them of their rights to appeal termination of Medicare supported skilled services.
- 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 records review and interview, the facility failed to develop and implement a comprehensive person-centered care plan for activities that included measurable objectives and timeframes to meet the needs for 1 of 3 sampled residents, Resident #103, reviewed for psychosocial needs.
- D
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Inspectors wroteBased on observations, interviews, and records review, the facility failed to provide adaptive equipment to maintain, restore or improve the functional abilities of 2 of 4 sampled residents, Resident #45 and Resident #103, as evidenced by: no splint for Resident #103, and no weighted utensils and lip plate for Resident #45.
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased upon interview, record review, and observation, the facility failed to provide fingernail care for 2 of 2 sampled residents observed for Activities of Daily Living (ADLs), related to lack of fingernail care for Resident #103, and Resident #315.
- D
Provide activities to meet all resident's needs.
Inspectors wroteBased on observations, interviews, and records review, the facility failed to provide ongoing person-centered activities designed to meet the interest and the psychosocial well-being of 3 of 20 residents, Residents #35, #36 and #103, reviewed for activities.
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on observation, interview, and record review, the facility failed to adequate supervision and assistance to prevent smoking accidents, for 1 of 1 sampled resident, Resident #20.
- 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 interview, observation, and record review, the facility failed to perform catheter care using appropriate professional technique, for 1 of 1 sampled resident, Resident #315.
- 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 policy and procedure, observation and interview, the facility failed to ensure that it secured the resident's medications for 2 of 5 sampled medications carts observed, the North and South medication carts; failed to secure loose pills in one (1) of five (5) medications carts observed [NAME] medication cart; failed to discard expired wound care dressing in one (1) of three (3) treatment carts, [NAME] wing; and failed to discard expired Sunscreen lotion in Central Supply Room.
- D
Provide routine and 24-hour emergency dental care for each resident.
Inspectors wroteBased on observation and record review, the facility failed to provide ongoing dental services to 1 of 1 sampled resident, Resident #103.
- D
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Inspectors wroteBased on observation, record review, and interview, the facility failed to accommodate individual food preferences for 5 of 5 sampled residents, Residents' #10, #13, #40, #55, and #86.
Fire safety inspections
12 fire safety citations on file: 7 on October 2, 2025, 3 on May 31, 2024, 2 on May 4, 2023.
Every fire safety citation12 citations
- F
Establish policies and procedures for volunteers.
E 24 · October 2, 2025 · Corrected (the home has a date of correction)
- F
Provide emergency officials' contact information.
E 31 · October 2, 2025 · Corrected (the home has a date of correction)
- F
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 · October 2, 2025 · Corrected (the home has a date of correction)
- F
Provide properly protected cooking facilities.
K 324 · October 2, 2025 · Corrected (the home has a date of correction)
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · October 2, 2025 · Corrected (the home has a date of correction)
- F
Ensure that testing and maintenance of electrical equipment is performed.
K 921 · October 2, 2025 · Corrected (the home has a date of correction)
- E
Ensure electrical receptacles or cover plates have distinctive color or marking.
K 917 · October 2, 2025 · Corrected (the home has a date of correction)
- D
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · May 31, 2024 · Corrected (the home has a date of correction)
- D
Inspect, test, and maintain automatic sprinkler systems.
K 353 · May 31, 2024 · Corrected (the home has a date of correction)
- D
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · May 31, 2024 · Corrected (the home has a date of correction)
- D
Inspect, test, and maintain automatic sprinkler systems.
K 353 · May 4, 2023 · 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 · May 4, 2023 · Corrected (the home has a date of correction)