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 34 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
1G
0H
0I
Potential for more than minimal harm
21D
7E
5F
Potential for minimal harm
0A
0B
0C
July 20, 2026Complaint inspection · 2 citations
- 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 observation, interview and record review, the facility failed to involve the resident representative in the development of the discharge plan for one of two residents (Resident 1) when Resident 1's Family Member (FM) 1, who was the healthcare decision maker, did not receive a written notice of the proposed discharge. This failure resulted in Resident 1's FM 1 to be uninvolved with the discharge planning process and was unable to appeal the Resident 1's discharge from the facility.
- D
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the resident was free from unnecessary medications (medications used in the presence of unwanted, unintended, or dangerous effects which indicate the dose should be reduced or discontinued) for one of three sampled residents (Resident 2). Resident 2 was administered Norco (also known as hydrocodone-acetaminophen) a controlled substance pain medication that causes dizziness and drowsiness), Lorazepam (also known as Ativan, a controlled substance medication that depresses the central nervous system [CNS] causing drowsiness, dizziness, weakness, and unsteadiness), and gabapentin (a medication used to treat nerve pain that causes extreme sleepiness, dizziness, and unsteadiness) in (one medication given along with either of the others) during the period of 12/11/23 to 12/15/23. [...]
February 10, 2026Complaint inspection · 2 citations
- E
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, the facility failed to protect three of three sampled residents (Resident 1, Resident 2, Resident 3) from aggressive and inappropriate sexual behaviors exhibited by Resident 4. Resident 4 inappropriately touched Residents 1, 2, and 3 on their thighs, scrotum and buttocks areas without their consent. Resident 4 threw hot coffee at Resident 2. This failure resulted in feelings of emotional distress, embarrassment, anger and a loss of personal security on Resident 1, 2 and 3.
- D
Respond appropriately to all alleged violations.
Inspectors wroteBased on interview and record review the facility failed to conduct a thorough investigation for an allegation of abuse involving two of four sampled residents (Resident 1, and Resident 4). Resident 1, a male resident alleged Resident 4 (female) touched him inappropriately and made sexual comments at him. This failure placed Resident 1 and other vulnerable residents at the facility to experience Resident 4's inappropriate sexual behaviors. Cross Reference F600.
October 20, 2025Standard inspection, Complaint inspection · 11 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, for four of four sampled residents (Resident 7, 90, 80, and 63) who were investigated for accidents, the facility failed to ensure adequate supervision and assistive device when: 1. Resident 7 fell out of bed when Certified Nursing Assistant (CNA) 3 looked away while changing Resident 7's brief. Resident 7 sustained multiple injuries that included, a hematoma (when blood collects outside a blood vessel) on the right cheek and around the right eye, intraparenchymal hemorrhage (bleeding that occurs within the brain tissue), and fractures of the left 10th and 11th ribs (when one of the bones in the rib cage cracks, usually as a result of a fall or an accident). Resident 7 was transferred to the hospital for further treatment. 2. Resident 90 fell out of bed while CNA 4 assisted with toileting hygiene. [...]
- D
Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
Inspectors wroteBased on interview and record review, the facility failed to protect belongings for one sampled resident (Resident 63), when his clothes and personal items were missing and were not accounted for. This failure had compromised the right of Resident 63 to retain personal possessions.
- 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, the facility failed to ensure residents were free from physical abuse when two of five sampled residents (Resident 3 and Resident 26) were involved in a physical altercation. This failure resulted in Resident 3 sustaining a skin tear on the left arm.
- D
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
Inspectors wroteBased interview and record review, for one of five sampled residents (Resident 2) reviewed for unnecessary medication use, the facility failed to ensure Resident 2 did not receive unnecessary psychotropic (also referred to as psychoactive medications, including antianxiety medications) medications when:-Lorazepam (antianxiety) was given for PRN (as needed) beyond 14 days.-Monitoring for behavioral manifestation for lorazepam use did not coincide with physician-ordered lorazepam PRN use. This failure had the potential to result in increased risk of adverse drug effects, such as dependence, sedation, confusion, and falls.
- D
PASARR screening for Mental disorders or Intellectual Disabilities
Inspectors wroteBased on interview and record review, for one of two sampled residents (Resident 6) who were reviewed for PASRR (Pre-admission Screening and Resident Review, required to determine if the resident needs specialized services for serious mental illness or mental retardation before admission to a Medicaid certified nursing facility) evaluation, the facility failed to coordinate PASRR Level II (a more in-depth evaluation for individuals identified by the Level I screen) determination after a positive PASRR I evaluation. This failure had the potential to result in Resident 6 receiving care that is not appropriate for their needs.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on observation, interview and record review, the facility failed to treat skin rash for one of five sampled residents (Resident 42) when nursing staff was not aware of Resident 42's skin rash. This failure resulted in Resident 42 having an untreated skin rash for unknown of length of time.
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observation, interview and record review, facility failed to provide the prescribed Bi-level positive airway pressure (BiPAP is a non-invasive ventilation machine that automatically adjusts the air pressure according to patient's requirement at a particular time) therapy as ordered for one of five sampled residents (Resident 8). This failure placed Resident 8 at risk for poor sleep quality, respiratory compromise and worsening chronic conditions.
- 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 interview and record review, the facility failed to schedule a registered nurse (RN) for eight consecutive hours a day, seven days a week for three days in January 2025. This failure had the potential to put residents at risk and not receive sufficient care. During a concurrent interview and record review on 10/3/25 at 9:20 a.m., with the Payroll Account Payable Coordinator (PAPC), PBJ (Payroll - Based Journal) Staffing Data Report [NAME] Report 171705D FY (Fiscal Year) Quarter 2 2025 (a method of staffing data from nursing facilities) January 1- March 31, dated 9/22/25 was reviewed. [...]
- 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, interview, and record review, the facility failed to ensure medications were available and provided to residents when: 1. Resident 78 did not receive Xarelto (a blood thinner) medication as ordered by the physician. 2. Two medication E-kits (Emergency kits) were opened and not replaced within 72 hours. These failures had the potential to put patients at risk for harm due to missed doses of medications including delayed treatment during emergency situations when medications are not available for use.
- 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 interview and record review, for one of five (Resident 2) sampled residents reviewed for unnecessary medication use, the facility failed to act on the Consultant Pharmacist's (CP) recommendations for monthly Medication Regimen Review (MRR, in-depth evaluation of a patient's complete list of medications by a pharmacist to ensure safety and effectiveness) for three consecutive months. This failure had the potential to result in unnecessary medication use.
- 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 observation, interview, and record review, the facility failed to ensure the safe storage and labeling of medications when:1. Three medications - Adult Gummies C, Extra strength D 3, and Magnesium Extra strength were observed at Resident 71's bedside.2. One over the counter (OTC) eye drop in the medication (med) cart 1 was not labeled with name. These failures had the potential for medication errors and unsafe use of medications and biologicals.
June 13, 2024Standard inspection · 3 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, interview and record review, the facility failed to store food in a safe and sanitary manner when: 1. Fresh lettuce stored inside the reach-in refrigerator was exposed and had no cover 2. A plastic container bin with single packs of graham crackers had no use by date or open dates Failure to store food in accordance with facility policy and/or professional standards had the potential to not meet food service safety standards and prevent food borne illnesses for 76 residents who received food from the kitchen out of a facility census of 76.
- E
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 interview and record review, the facility failed to ensure there was Registered Nurse (RN) coverage eight hours a day, seven days a week. This failure had the potential to endanger the health and safety of residents.
- 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 interview, and record review, the facility failed to provide the Restorative Nursing Assistant (RNA) services as ordered by the physician for two of 20 sampled residents reviewed for Range Of Motion (ROM) functions (Resident 2 and 69). This failure had the potential for decline in the resident's range of motion and mobility.
April 11, 2024Complaint inspection · 1 citation
- 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, the facility failed to ensure three of 78 sampled residents' (Resident 2, Resident 6, and Resident 8), call lights were within reach and easily accessible. This failure placed the Resident 2, Resident 6 and Resident 8 at risk of not being able to ask for assistance.
January 11, 2024Complaint inspection · 1 citation
- D
Ensure that residents are fully informed and understand their health status, care and treatments.
Inspectors wroteBased on interview and record review the facility failed to ensure one out of three residents (Resident 1) had written Informed Consent (a process in which a health care provider educates a patient about the risks, benefits, and alternatives of a given procedure or intervention to help them decide if they want to authorize the given procedure or intervention) before they were administered a psychoactive medication (a drug or other substance that affects how the brain works and causes changes in mood, awareness, thoughts, feelings, or behavior). This failure had the potential to cause Resident 1 to take a psychoactive medication without knowledge of the medication ' s risks, benefits, and alternatives. [...]
September 26, 2023Complaint inspection · 1 citation
- 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, the facility failed to ensure one of three sampled residents (Resident 1) received necessary care to maintain good grooming and personal hygiene when Resident 1 had long, sharp fingernails with brownish yellow matter underneath on both hands. This failure resulted in Resident 1 feeling helpless and placed her at risk for infections and hurting themselves with long fingernails.
May 20, 2022Standard inspection · 13 citations
- F
Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
Inspectors wroteBased on observation, interview, and facility document review, the facility failed to provide adequate oversight of the kitchen when multiple issues were identified with kitchen safety and sanitation; equipment was not maintained; food was not served so it was palatable and cooked to maintain nutritive value; and staff were not trained and competent for calibrating thermometers and cooking food to a safe temperature. These failures had the potential to result in food being served to residents in a safe and sanitary manner resulting in food borne illness; attract pests to the kitchen resulting in contamination of food, utensils, and equipment; and decrease the amount of food intake for residents resulting in nutritional related medical issues, for 71 residents who received food from the kitchen out of a facility census of 71.
- F
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure vegetables were palatable and cooked in a manner to conserve nutritive value for 71 residents who received food from the kitchen out of a facility census of 71. This failure had the potential for residents to not consume the amount of nutrients planned for the menu.
- 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, interview, and facility document review, the facility failed to ensure a safe and sanitary environment in the kitchen when: 1. Food was not frozen when stored in a reach-in freezer; 2. Two door screens were not intact and sealed properly to help prevent insects and rodents from entering the kitchen; 3. Cooking pans were in poor condition; 4. The ice machine was not stored in an area to help prevent contamination of the ice; 5. There were no air-gaps for the food preparation sink and the 2-compartment warewashing sink; 6. Staff did not practice appropriate hand hygiene; and 7. Soiled oven mitts came into contact with food. This failure had the potential to cause contamination of food resulting in food borne illness for 71 residents who received food from the kitchen out of a facility census of 71.
- F
Keep all essential equipment working safely.
Inspectors wroteBased on observation, interview, and facility document review, the facility failed to ensure a drainpipe from the 2-compartment kitchen sink was in good repair. This had the potential to attract pests resulting in contamination of food and utensils for 71 residents who received food from the kitchen out of a facility census of 71.
- 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 observation, interview, and record review, the facility did not ensure the comprehensive care plan for falls were updated and implemented for one of one sampled resident (Resident 67), when Resident 67 was identified as a high risk for falls and experienced multiple falls. This failure resulted in Resident 67 experiencing a fractured left femoral neck (hip bone), requiring a left hemiarthroplasty (hip replacement surgery) from the fall, and was transferred to the acute care hospital for treatment.
- E
Ensure medication error rates are not 5 percent or greater.
Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that its medication error rate was not five percent or greater. During the medication pass (med pass) observation, there were six medication errors observed out of 36 opportunities which resulted to a med pass error rate of 16.6 percent. This failure had the potential for Resident 54 not getting the full therapeutic benefit of the medications.
- E
Ensure that residents are free from significant medication errors.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of one sampled resident (Resident 54) was free of significant medication error, when Resident 54's oral medications were all crushed and administered together without a physician's order. This deficient practice had the potential for Resident 54 not receiving the full benefits of the 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 observation, interview and record review, facility failed to follow its policy and procedure on Oxygen Therapy when there was no date on the oxygen tubings of Resident 62. This deficient practice had the potential of delivering oxygen in an unsafe and unsanitary condition to resident.
- E
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Inspectors wroteBased on interview and record review, for two of five (Resident 26 and 34) sampled resident vaccination record, the facility failed to follow their immunization policy and procedure when the pneumococcal vaccine was not offered or documented for Resident 26 and 24 as recommended by the Advisory Committee on Immunizations Practices (ACIP, group of medical public health experts). This deficient practice had the potential to increase the risk for Resident 26 and 34 to acquire, transmit or experience complications from pneumococcal disease.
- D
Allow residents to self-administer drugs if determined clinically appropriate.
Inspectors wroteBased on observation, interview, and record review, the facility failed obtain a doctor's order and assess one of one resident (Resident 67) ability to self-administer medications when Resident 67 had a bottle of Sore Throat Oral Anesthetic Spray (medication to temporarily relieve sore throat pain) bottle at the bedside. This deficient practice had the potential to result in Resident 67 using the Sore Throat Oral Anesthetic Spray against safe dosing recommendations. It also had the potential to result in the use of the medication by other residents, who could potentially obtain Resident 67's medication from the bedside table where it was stored.
- 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 interview and record review, the facility failed to ensure one of one sampled resident's (Resident 27) preferences for showers were followed, when Resident 27's scheduled shower days were missed from April through May 2022. This failure resulted in Resident 27's request and preference for showers not being honored.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation and interview, the facility failed to follow infection control policies and procedures when the Infection Preventionist (IP) did not properly disinfect and store reusable ice bags. This deficient practive had the potential to place residents at risk for spread of infection and cross contamination.
- D
Ensure staff are vaccinated for COVID-19
Inspectors wroteBased on interview, record review, and document review, the facility failed to ensure one of four staff (Dietary Aide 1 [DA 1]) followed the COVID-19 (an infectious respiratory disease) vaccination policies and procedures when DA 1 did not complete COVID-19 vaccine series with a booster dose. This failure had the potential to result in the spread of COVID-19 infections to residents, staff, and visitors in the facility.
Fire safety inspections
34 fire safety citations on file: 8 on October 20, 2025, 14 on June 13, 2024, 12 on May 20, 2022.
Every fire safety citation34 citations
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · October 20, 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 · October 20, 2025 · Corrected (the home has a date of correction)
- E
Ensure proper usage of power strips and extension cords.
K 920 · October 20, 2025 · Corrected (the home has a date of correction)
- E
Ensure that testing and maintenance of electrical equipment is performed.
K 921 · October 20, 2025 · Corrected (the home has a date of correction)
- D
Provide properly protected cooking facilities.
K 324 · October 20, 2025 · Corrected (the home has a date of correction)
- D
Install corridor and hallway doors that block smoke.
K 363 · October 20, 2025 · 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 · October 20, 2025 · Corrected (the home has a date of correction)
- D
Meet requirements for the use of electrical equipment.
K 919 · October 20, 2025 · Corrected (the home has a date of correction)
- F
Properly install and monitor supervisory attachments on automatic sprinkler systems.
K 352 · June 13, 2024 · Corrected (the home has a date of correction)
- F
Provide a written emergency evacuation plan.
K 711 · June 13, 2024 · Corrected (the home has a date of correction)
- F
Have simulated fire drills held at unexpected times.
K 712 · June 13, 2024 · Corrected (the home has a date of correction)
- F
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · June 13, 2024 · Corrected (the home has a date of correction)
- E
Have properly located and lighted "Exit" signs.
K 293 · June 13, 2024 · Corrected (the home has a date of correction)
- E
Provide properly protected cooking facilities.
K 324 · June 13, 2024 · Corrected (the home has a date of correction)
- E
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · June 13, 2024 · Corrected (the home has a date of correction)
- E
Inspect, test, and maintain automatic sprinkler systems.
K 353 · June 13, 2024 · Corrected (the home has a date of correction)
- E
Properly select, install, inspect, or maintain portable fire extinguishes.
K 355 · June 13, 2024 · Corrected (the home has a date of correction)
- E
Install corridor and hallway doors that block smoke.
K 363 · June 13, 2024 · Corrected (the home has a date of correction)
- E
Ensure that testing and maintenance of electrical equipment is performed.
K 921 · June 13, 2024 · Corrected (the home has a date of correction)
- D
Use approved construction type or materials.
K 161 · June 13, 2024 · Corrected (the home has a date of correction)
- D
Install a fire alarm system that can be heard throughout the facility.
K 341 · June 13, 2024 · Corrected (the home has a date of correction)
- D
Have proper medical gas storage and administration areas.
K 923 · June 13, 2024 · Corrected (the home has a date of correction)
- E
Install corridor and hallway doors that block smoke.
K 363 · May 20, 2022 · Corrected (the home has a date of correction)
- D
Establish an Emergency Preparedness Program (EP).
E 1 · May 20, 2022 · Corrected (the home has a date of correction)
- D
Develop Emergency Preparedness policies and procedures.
E 13 · May 20, 2022 · Corrected (the home has a date of correction)
- D
Develop a communication plan.
E 29 · May 20, 2022 · Corrected (the home has a date of correction)
- D
Establish emergency prep training and testing.
E 36 · May 20, 2022 · Corrected (the home has a date of correction)
- D
Use approved construction type or materials.
K 161 · May 20, 2022 · Corrected (the home has a date of correction)
- D
Install a fire alarm system that can be heard throughout the facility.
K 341 · May 20, 2022 · Corrected (the home has a date of correction)
- D
Inspect, test, and maintain automatic sprinkler systems.
K 353 · May 20, 2022 · Corrected (the home has a date of correction)
- D
Properly select, install, inspect, or maintain portable fire extinguishes.
K 355 · May 20, 2022 · Corrected (the home has a date of correction)
- D
Have properly installed electrical wiring and gas equipment.
K 511 · May 20, 2022 · Corrected (the home has a date of correction)
- D
Have simulated fire drills held at unexpected times.
K 712 · May 20, 2022 · 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 20, 2022 · Corrected (the home has a date of correction)