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 49 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
1J
0K
0L
Actual harm
2G
0H
0I
Potential for more than minimal harm
39D
6E
1F
Potential for minimal harm
0A
0B
0C
December 8, 2025Standard inspection · 7 citations
- E
Honor the resident's right to organize and participate in resident/family groups in the facility.
Inspectors wroteBased on interview and record review it was determined the facility failed to promptly respond to grievances and complaints from the resident council for three of four months reviewed. This placed residents at risk for a lack of resolution to voiced concerns.
- E
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 it was determined the facility failed to provide a clean and sanitary environment toilet/shower rooms for 3 of 4 communal resident bathrooms reviewed for homelike environment. This placed residents at risk for unsanitary conditions while using the communal toilet/shower rooms.
- D
Provide activities to meet all resident's needs.
Inspectors wroteBased on observation, interview and record review it was determined the facility failed to develop and implement a resident-centered activity program for 1 of 2 sampled residents (#42) reviewed for activities. This placed residents at risk for a diminished quality of life.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on observation, interview and record review it was determined the facility failed to follow physician orders for 1 of 6 residents (#14) reviewed for unnecessary medications. This placed residents at risk for decreased weight loss.
- 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 and record review it was determined the facility failed to provide appropriate treatment and services to prevent further decreases in range of motion for 1 of 1 sampled resident (#42) reviewed for position and mobility. This placed residents at risk for worsening contractures (a permanent tightening of the muscle, tendons and skin causing the joint to shorten and stiffen) and conditions.
- 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 it was determined the facility failed to ensure residents received adequate supervision and smoking materials were properly secured for 1 of 2 sampled residents (#73) reviewed for accidents. This placed residents at risk for accidents.
- 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 records review it was determined the facility failed to practice proper food safety techniques for 1 of 4 (#5) residents reviewed for food. The placed residents at risk for consumption of contaminated food.
August 7, 2025Complaint inspection · 1 citation
- D
Ensure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge.
Inspectors wroteBased on interview and record review it was determined the facility failed to ensure a safe discharge from the facility for 1 of 3 sampled residents (#5) reviewed for discharge. This placed residents at risk for an unsafe discharge.
April 16, 2025Complaint inspection · 1 citation
- 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 it was determined the facility failed to protect the resident's right to be free from physical abuse for 1 of 1 resident (#2) reviewed for physical abuse. This resulted in physical injury and prolonged pain which required increased pharmaceutical interventions.
April 9, 2025Complaint inspection · 2 citations
- 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 and record review it was determined the facility failed to accurately document wound assessments and dressing change refusals for 1 of 3 sampled residents (# 3) reviewed for accuracy of medical records. This placed residents at risk for inaccurate medical records and risk for injury and/or decreased ability for recovery.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview and record review it was determined the facility failed to follow infection control standards for 1 of 3 residents (# 2) sampled reviewed for infection control. This placed residents at risk for exposure and contraction of infectious diseases.
August 30, 2024Complaint 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 observation, interview and record review it was determined the facility failed to protect the resident's right to be free from sexual abuse by another resident for 1 of 1 sampled residents (#11) reviewed for sexual abuse. This placed residents at risk for psychological harm.
August 16, 2024Standard inspection, Complaint inspection · 14 citations
- F
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview, and record review it was determined the facility failed to follow infection control standards for 2 of 4 halls (East and Annex Halls), 1 of 1 dining room, and 2 of 4 sampled residents (#s 28 and 37) reviewed for dining and skin conditions. This placed residents at risk for exposure and contraction of infectious diseases.
- E
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 interview it was determined the facility failed to maintain a homelike environment for 3 of 4 halls reviewed for environment. This placed residents at risk for living in an unkempt environment.
- D
Allow resident to participate in the development and implementation of his or her person-centered plan of care.
Inspectors wroteBased on interview and record review it was determined the facility failed to involve residents/representatives in the care planning process for 2 of 2 sampled residents (#s 4 and 41) reviewed for care planning and dementia. This placed residents at risk for unmet needs.
- 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 interview and record review it was determined the facility failed to follow up on grievances for 1 of 1 resident (#309) reviewed for personal property. This placed residents at risk for unmet needs.
- D
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Inspectors wroteBased on interview and record review it was determined the facility failed to ensure the Office of the State Long Term Care Ombudsman was notified of resident hospitalizations for 1 of 1 sampled resident (# 56) reviewed for hospitalization. This placed residents at risk for lack of advocacy by the Ombudsman's office.
- D
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Inspectors wroteBased on interview and record review it was determined the facility failed to provide residents with a written notice of the facility's bed hold policy at the time of transfer to the hospital for 2 of 3 residents (#s 4 and 56 ) reviewed for hospitalization. This placed residents at risk for lack of knowledge regarding their choices and potential financial responsibilities.
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on observation, interview and record review it was determined the facility failed to provided nail care services to 1 of 1 resident (# 24) reviewed for ADL care. This placed residents at risk of unmet care needs.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on observation, interview and record review it was determined the facility failed to start antibiotic treatment timely or follow physician orders for 2 of 9 sampled residents (#s 4 and 28) reviewed for skin condition and unnecessary medications. This placed residents at risk for unmet needs.
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on interview and record review it was determined the facility failed to ensure necessary interventions were in place and followed to reduce the risk of falls and to thoroughly investigate the cause of a fall for 2 of 5 sampled residents (#s 37 and 360) reviewed for skin conditions and falls. This placed residents at risk for falls.
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on interview and record review it was determined the facility failed to follow physician orders and provide correct humidity administration for 1 of 1 sampled resident (#17) reviewed for respiratory care. This placed residents at risk for improper humidity administration.
- D
Employ or obtain outside professional resources to provide services in the nursing home when the facility does not employ a qualified professional to furnish a required service.
Inspectors wroteBased on interview and record review it was determined the facility failed to employ a Physical Therapist to provide therapy services to 1 of 1 resident (# 209) reviewed for therapy services. This placed residents at risk of a decline in function and/or a delayed recovery.
- 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 interview and record review it was determined the facility failed to have a plan in place to coordinate care and document hospice services for 1 of 1 sampled resident (#359) reviewed for hospice. This placed residents at risk for lack of coordination of care.
- D
Ensure each resident receives an accurate assessment.
Inspectors wroteBased on observation, interview and record review it was determined the facility failed to accurately assess residents for oxygen therapy and wounds for 2 of 6 sampled residents (#s 22 and 37) reviewed for respiratory care and skin conditions. This placed residents at risk for inaccurate assessments and unmet care needs.
- 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 and record review it was determined the facility failed to ensure care plans were revised to accurately reflect the needs of residents for 2 of 7 sampled residents (#s 22 and 28) reviewed for respiratory care and unnecessary medications. This placed residents at risk for unmet needs.
May 13, 2024Complaint inspection · 1 citation
- E
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 observation and interview it was determined the facility failed to have adequate staff available to meet resident care needs in a timely manner for 1 of 1 facility reviewed for staffing and call light response times. This placed residents at risk for delayed and unmet needs and lengthy call light response times.
February 7, 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 wroteBased on interview and record review it was determined the facility failed to implement policies and procedures for the prevention of sexual abuse for 2 of 2 sampled residents (#s 1 and 2) reviewed for abuse. This failure, determined to be an immediate jeopardy situation, placed residents at risk for sexual abuse when staff witnessed repeated nonconsensual sexual activity without putting interventions in place.
January 4, 2024Complaint inspection · 6 citations
- G
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on interview and record review it was determined the facility failed to ensure a resident was provided supervision and positioning assistance with eating and follow a resident's care plan related to bed mobility and bathing for 2 of 3 sampled residents (#s 5 and 11) reviewed for accidents. This resulted in Resident 5 aspirating while eating without supervision and positioning assistance.
- E
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Inspectors wroteBased on interview and record review it was determined the facility's quality assessment and performance improvement committee (QAPI) failed to systematically identify and correct deficiencies in the areas of reporting abuse, safe discharge and accident prevention. This placed residents at risk of abuse, accidents and injuries.
- 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 and record review it was determined the facility failed to ensure residents were free from abuse for 1 of 3 sampled residents (#1) reviewed for abuse. This placed residents at risk for abuse.
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on interview and record review it was determined the facility failed to timely report allegations of abuse for 2 of 3 sampled residents (#s 6 and 7) reviewed for abuse reporting. This placed residents at risk for abuse.
- D
Plan the resident's discharge to meet the resident's goals and needs.
Inspectors wroteBased on interview and record review it was determined the facility failed to ensure a safe discharge for 1 of 3 sampled residents (#13) reviewed for discharge. This placed residents at risk for accidents and lack of ADL care.
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on interview and record review it was determined the facility failed to ensure a resident was provided ADL care for 1 of 3 sampled residents (#4) reviewed for ADLs. This placed residents at risk for poor hygiene and pressure ulcers.
May 5, 2023Standard inspection · 15 citations
- E
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 observation, interview and record review it was determined the facility failed to ensure sufficient staffing to meet resident care needs in a timely manner for 4 of 6 residents (#s 6, 14, 18 and 25) reviewed for staffing concerns. This placed residents at risk for delayed and unmet care needs.
- D
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Inspectors wroteBased on interview and record review it was determined the facility failed to provide written information to residents concerning the right to formulate an advance directive for 3 of 3 sampled residents (#s 1, 44 and 99) reviewed for advance directives. This placed residents at risk for not having their health care decisions honored.
- D
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Inspectors wroteBased on interview and record review it was determined the facility failed to provide a Notice of Medicare Non-coverage for 2 of 3 sampled residents (#s 102 and 103) reviewed for beneficiary notification. This placed residents at risk for unknown financial liabilities.
- 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 and record review it was determined the facility failed to protect the resident's right to be free from verbal abuse by a resident for 1 of 1 sampled resident (#248) reviewed for abuse. This placed residents at risk for abuse.
- 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 is was determined the facility failed to ensure a resident's care plan reflected the needs of the resident for 1 of 2 sampled residents (#99) reviewed for ADLs. This placed residents at risk for pain and injury.
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on observation, interview and record review it was determined the facility failed to provide bed baths for 2 of 2 sampled residents (#s 6 and 99) reviewed for ADLs. This placed residents at risk for lack of hygiene.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on interview and record review it was determined the facility failed to ensure physician orders were followed for 2 of 6 sampled residents (#s 23 and 43) reviewed for unnecessary medications and amputation healing. This placed residents at risk for adverse medication consequences and inadequate amputation healing.
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on observation, interview and record review it was determined the facility failed to provide necessary services for pressure ulcer care for 1 of 1 sampled resident (#7) reviewed for pressure ulcers. This placed residents at risk for worsening pressure ulcers.
- D
Provide appropriate foot care.
Inspectors wroteBased on observation, interview and record review it was determined the facility failed to provide foot care for 1 of 2 sampled residents (#6) reviewed for ADLs. This placed residents at risk for increased foot problems.
- 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 and record review it was determined the facility failed to provide brace/splint devices to prevent further decrease in range of motion for 2 of 2 sampled residents (#s 14 and 27) reviewed for ROM. This placed residents at risk for worsening contractures.
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wrote1. Based on observation and interview it was determined the facility failed to ensure residents' environment was free from hazards for 1 of 1 facilities randomly observed. This placed residents at risk for injury and blood borne infection.
- D
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Inspectors wroteBased on observation, interview and record review it was determined the facility failed to conduct post dialysis assessments of resident's condition for 1 of 1 sampled resident (#31) reviewed for dialysis. This placed residents at risk for potential unmet care needs upon return from dialysis.
- 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 and record review it was determined the facility failed to ensure resident records were accurate for 2 of 3 sampled residents (#s 43 and 99) reviewed for bathing and skin conditions. This placed residents at risk for poor hygiene and improper amputation healing.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation and interview it was determined the facility failed to maintain respiratory care equipment in a sanitary manner and perform wound care in a sterile manner for 2 of 2 sampled residents (#s 29 and 99) reviewed for respiratory care. This placed residents at risk for infection.
- D
Make sure that a working call system is available in each resident's bathroom and bathing area.
Inspectors wroteBased on observation, interview and record review it was determined the facility failed to ensure residents' call lights were functional for 1 of 1 sampled resident (#27) reviewed for call light functioning concerns. This placed residents at risk for delayed assistance.
Fire safety inspections
5 fire safety citations on file: 2 on December 8, 2025, 2 on August 16, 2024, 1 on May 5, 2023.
Every fire safety citation5 citations
- F
Implement emergency and standby power systems.
E 41 · December 8, 2025 · Corrected (the home has a date of correction)
- D
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · December 8, 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 16, 2024 · Corrected (the home has a date of correction)
- D
Ensure proper usage of power strips and extension cords.
K 920 · August 16, 2024 · 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 · May 5, 2023 · Corrected (the home has a date of correction)