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 20 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
1G
0H
0I
Potential for more than minimal harm
15D
4E
0F
Potential for minimal harm
0A
0B
0C
December 11, 2025Standard inspection · 2 citations
- D
Ensure each resident receives an accurate assessment.
Inspectors wroteBased on clinical record review and staff interviews, it was determined that the facility failed to ensure that the resident assessment accurately reflected the resident's status for four of 21 residents reviewed (Resident 5, 14, 56, and 99). Findings Include:Review of Resident 5's clinical record revealed diagnoses that included hypertension (high blood pressure) and dysphagia (difficulty swallowing). Review of Resident 5's comprehensive care plan revealed a care plan for being at risk for elopement with an intervention for the resident to have door alarms on at all times, with an initiation date of July 15, 2025; and an intervention for a wander guard, with an initiation date of July 15, 2025. Further review of Resident 5's elopement care plan revealed an intervention for a chair alarm that was discontinued on June 25, 2025. [...]
- D
Observe each nurse aide's job performance and give regular training.
Inspectors wroteBased on facility document review and staff interviews, it was determined that the facility failed to complete a performance review for nurse aide staff at least once every 12 months for two of five employees reviewed (Employees 1 and 2). Findings Include: Review of select facility documentation revealed that Employee 1 was hired on July 13, 2021, and Employee 2 was hired on October 15, 2024. Review of Employee 1's most recent employee performance evaluation revealed that it was dated as being completed on December 8, 2025. Review of Employee 2's most recent employee performance evaluation revealed that it was dated as being completed on December 9, 2025. During an interview with the Nursing Home Administrator on December 11, 2025, at 11:22 AM, she stated that Employee 1's prior performance evaluation was completed on October 17, 2024. [...]
September 4, 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 facility policy review, clinical record review, and staff interviews, it was determined that the facility failed to provide and document sufficient preparation to residents to ensure a safe and orderly discharge from the facility; and failed to provide a discharge summary that included a post-discharge plan of care, including post-discharge services, for one of five discharged residents reviewed (Resident 1). Findings Include:Review of facility policy, titled Discharging the Resident, dated December 2016, revealed If the resident is being discharged home, ensure that resident and/or responsible party receive teaching and discharge instructions. Review of Resident 1's clinical record revealed diagnoses that included congestive heart failure (CHF-a chronic condition in which the heart doesn't pump blood as well as it should) and gastroesophageal reflux disease (GERD-acid reflux). [...]
December 5, 2024Standard inspection · 8 citations
- 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 facility policy review, clinical record reviews, facility document reviews, and staff interviews, it was determined that the facility failed to timely notify a resident's physician of an incident that had the potential to result in a negative outcome for one of 21 residents reviewed (Resident 44). Findings Include: Review of facility policy, titled Change in a Resident's Condition or Status, with a last review date of October 24, 2024, revealed, in part, facility shall promptly notify the resident, his or her Attending Physician, and representative (sponsor) of changes in the resident's medical/mental condition and/or status; and The nurse will notify the resident's Attending Physician or physician on call when there has been a(an): accident or incident involving the resident. [...]
- D
Ensure each resident receives an accurate assessment.
Inspectors wroteBased on clinical record review and staff interviews, it was determined that the facility failed to ensure that the resident assessment accurately reflected the resident's status for two of 21 residents reviewed (Residents 8 and 60). Findings Include: Review of Resident 8's clinical record revealed diagnoses that included hypertension (high blood pressure) and anxiety (a feeling of worry, nervousness, or unease). Review of Resident 8's clinical record revealed a physician's order for Oxygen via nasal cannula to maintain saturation above 91 as needed for shortness of breath, with an active date of November 6, 2024. Review of Resident 8's clinical record revealed Resident 8 was administered oxygen via nasal cannula on November 6, 7, 8, and 9, 2024. [...]
- 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 clinical record review and resident and staff interviews, it was determined that the facility failed to develop a comprehensive person-centered care plan to address the resident's medical, physical, mental, and psychosocial needs for three of 21 records reviewed (Residents 10, 60, and 75).
- 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 clinical record review and staff interviews, it was determined that the facility failed to ensure the care plan was reviewed and revised for three of 21 residents reviewed (Residents 1, 11, and 60). Findings Include: Review of Resident 1's clinical record revealed diagnoses that included epilepsy (a brain condition causing recurring seizures) and multiple sclerosis (a chronic autoimmune disease that affects the central nervous system). Review of Resident 1's care plan on December 2, 2024, revealed a care plan with a focus area of, Resident has an alteration in neurological function, with an intervention of IM (intramuscular) Ativan (benzodiazepine medication) as needed for seizure activity, with a date initiated of July 3, 2024. Review of Resident 1's physician orders on December 2, 2024, failed to reveal an order for Ativan for Resident 1. [...]
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on review of facility policy, clinical record review, observations, and staff interview, it was determined that the facility failed to provide respiratory care/oxygen services consistent with professional standards of practice for one of four residents reviewed (Resident 44).
- D
Provide special eating equipment and utensils for residents who need them and appropriate assistance.
Inspectors wroteBased on observations, policy review, clinical record review, and staff interview, it was determined that the facility failed to provide adaptive feeding devices for one of 21 residents reviewed (Resident 53).
- 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 and staff interview, it was determined that the facility failed to serve food in a sanitary manner during one of one tray line observations in the kitchen.
- D
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
Inspectors wroteBased on facility document review and staff interviews, it was determined that the facility failed to provide evidence that Quality Assurance Committee meetings were held at least quarterly for one of four quarters reviewed (First Quarter of 2024).
May 8, 2024Complaint inspection · 1 citation
- G
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on facility job description, clinical record review, review of facility investigation and documentation, and staff interviews, it was determined that the facility displayed past non-compliance in its failure to provide adequate supervision and assistive devices to prevent accidents, which resulted in harm, as evidenced by a scalp laceration and a leg injury for one of two residents reviewed (Resident 1).
January 10, 2024Standard inspection · 8 citations
- E
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 clinical record review and staff interview, it was determined that the facility failed to ensure residents received appropriate treatment and services to prevent urinary tract infections and complications related to the use of a foley catheter (small, flexible tube that can be inserted through the urethra and into the bladder, allowing urine to drain) for one of two residents reviewed for use of a catheter (Resident 42). Findings Include: Review of Resident 42's clinical record revealed diagnoses that included paraplegia (impairment in motor or sensory function of the lower extremities) and neuromuscular dysfunction of the bladder (urinary bladder problems due to disease or injury of the central nervous system or peripheral nerves involved in the control of urination). [...]
- E
Provide enough food/fluids to maintain a resident's health.
Inspectors wroteBased on clinical record review and staff interview, it was determined that the facility failed to ensure that assessed nutritional interventions were provided to maintain acceptable nutritional parameters for one of 19 residents reviewed (Resident 20).
- E
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 Food and Drug Administration (FDA) information review, facility policy review, clinical record review, and staff interviews, it was determined that the facility failed to ensure that residents were free of unnecessary psychotropic medications for one of five residents reviewed (Resident 35).
- E
Provide routine and 24-hour emergency dental care for each resident.
Inspectors wroteBased on observation, staff and resident interviews, grievance review, and record review, it was determined that the facility failed to offer and/or provide dental services for one of 19 resident records reviewed (Resident 16).
- D
Assess the resident when there is a significant change in condition
Inspectors wroteBased on clinical record review and staff interview, it was determined the facility failed to complete a comprehensive assessment after a significant change in condition of one of 19 residents reviewed (Resident 68).
- D
Ensure each resident receives an accurate assessment.
Inspectors wroteBased on clinical record review and staff interviews, it was determined that the facility failed to ensure that the resident assessment accurately reflected the resident's status for one of 19 residents reviewed (Resident 54).
- D
Ensure services provided by the nursing facility meet professional standards of quality.
Inspectors wroteBased on facility policy review, observation, clinical record review, and resident and staff interviews, it was determined that the facility failed to ensure care and services were provided in accordance with professional standards for one of 19 residents reviewed (Resident 53). Findings Include: Review of facility policy, titled IIA2: Medication Administration General Guidelines, undated, with a last review date of July 3, 2023, revealed, in part: 11) Residents are allowed to self-administer medications when specifically authorized by the attending physician and in accordance with procedures for self-administration of medications; 14) For residents not in their rooms or otherwise unavailable to receive medication on the pass, the MAR [medication administration record] is 'flagged' with appropriate tags. [...]
- 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 observations, clinical record review, and staff interviews, it was determined that the facility failed to ensure residents with limited mobility received appropriate services, equipment, and assistance to maintain or improve mobility for one of two residents reviewed for mobility (Resident 17). Findings Include: Review of Resident 17's clinical record revealed diagnoses that included Multiple Sclerosis (MS-a disease in which the immune system eats away at the protective covering of nerves) and contractures of the right and left hands and right and left elbows. Review of Resident 17's current physician orders revealed an order dated December 17, 2023, for bilateral elbow extension splints, on with AM care and off with PM care. [...]
Fire safety inspections
19 fire safety citations on file: 11 on December 11, 2025, 3 on December 5, 2024, 5 on January 10, 2024.
Every fire safety citation19 citations
- F
Install emergency lighting that can last at least 1 1/2 hours.
K 291 · December 11, 2025 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · December 11, 2025 · Corrected (the home has a date of correction)
- F
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
K 354 · December 11, 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 · December 11, 2025 · Corrected (the home has a date of correction)
- E
Keep aisles, corridors, and exits free of obstruction in case of emergency.
K 211 · December 11, 2025 · Corrected (the home has a date of correction)
- E
Install smoke barrier doors that can resist smoke for at least 20 minutes.
K 374 · December 11, 2025 · Corrected (the home has a date of correction)
- C
Develop and maintain an Emergency Preparedness Program (EP).
E 4 · December 11, 2025 · Corrected (the home has a date of correction)
- C
Meet other general requirements.
K 100 · December 11, 2025 · Corrected (the home has a date of correction)
- C
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · December 11, 2025 · Corrected (the home has a date of correction)
- C
Properly select, install, inspect, or maintain portable fire extinguishes.
K 355 · December 11, 2025 · Corrected (the home has a date of correction)
- C
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
K 914 · December 11, 2025 · Corrected (the home has a date of correction)
- 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 · December 5, 2024 · Corrected (the home has a date of correction)
- E
Install corridor and hallway doors that block smoke.
K 363 · December 5, 2024 · Corrected (the home has a date of correction)
- E
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · December 5, 2024 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · January 10, 2024 · Corrected (the home has a date of correction)
- 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 · January 10, 2024 · Corrected (the home has a date of correction)
- C
Install emergency lighting that can last at least 1 1/2 hours.
K 291 · January 10, 2024 · Corrected (the home has a date of correction)
- C
Provide properly protected cooking facilities.
K 324 · January 10, 2024 · Corrected (the home has a date of correction)
- C
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · January 10, 2024 · Corrected (the home has a date of correction)