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 43 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
1J
1K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
30D
4E
5F
Potential for minimal harm
0A
0B
2C
May 6, 2026Standard inspection · 11 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, record review and interview, the facility failed to ensure a sanitary kitchen was maintained related to proper chemical level in the dishwasher for 1 of 1 kitchen. (Main Kitchen) This had the potential to affect the 89 residents who received food from the kitchen.
- F
Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
Inspectors wroteBased on record review and interview, the facility failed to provide education of the benefits and risks of the COVID-19 vaccine and failed to offer the COVID-19 vaccine to the employees of the facility, which had the potential to affect all the residents who reside in the facility.
- 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, record review and interview, the facility failed to ensure medications and treatments were stored properly related to an expiration date torn off a medication, multi-use vial of medication undated, biological medication not destroyed timely and unlabled biologicals for 1 of 2 Medication Rooms and 2 of 3 Medication and Treatment Carts observed.
- D
Allow residents to self-administer drugs if determined clinically appropriate.
Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure residents were assessed to self-administer medications quarterly per the care plan for 1 of 1 resident reviewed for self-administration of medication. (Resident 1)
- 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 record review and interview, the facility failed to ensure care plans were implemented and in place for pain and hypotension for 2 of 20 resident's care plans reviewed. (Resident 5 and 7)
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on record review and interview, the facility failed to ensure residents received the necessary care and services related to medications not given as ordered and interventions and medications not provided for a resident with constipation for 1 of 5 residents reviewed for unnecessary medications and 1 of 1 resident reviewed for hospitalization. (Residents 16 and 6)
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure safety was maintained related to a lack of a smoking safety assessment for 1 of 5 residents reviewed for accidents. (Resident 74)
- 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 observation, record review, and interview, the facility failed to ensure urinary catheter care was completed and the catheter was kept off the floor for 2 of 2 residents reviewed for catheters. (Residents 1 and 32)
- D
Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services.
Inspectors wroteBased on record review and interview, the facility failed to ensure a resident with a colostomy (opening in the colon that lets stools pass from the body) received appropriate treatment and services related to a lack of documentation of completed colostomy bag changes and stoma care for 1 of 1 resident reviewed for ostomies. (Resident 1)
- D
Provide safe, appropriate pain management for a resident who requires such services.
Inspectors wroteBased on record review and interview, the facility failed to ensure pain medication and non-pharmacological interventions were administered as ordered for 1 of 3 residents reviewed for pain management. (Resident 33)
- D
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Inspectors wroteBased on record review and interview, the facility failed to ensure a resident's blood pressure was monitored for an as needed (prn) blood pressure medication for 1 of 5 residents reviewed for unnecessary medications. (Resident 5)
March 6, 2026Complaint inspection · 3 citations
- D
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
Inspectors wroteBased on record review and interview, the facility failed to ensure interventions were attempted prior to administering PRN (as needed) anti-anxiety medications and receiving an order for a routine anti-anxiety medication, for 1 of 3 residents reviewed for resident to resident abuse. (Resident F)
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on record review and interview, the facility failed to ensure a resident who required assistance for activities of daily living (ADL's), received bathing/showers at least twice a week, for 1 of 3 residents who require extensive to dependent assistance for ADL's. (Resident J)
- C
Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.
Inspectors wroteBased on record review and interview, the facility failed to implement the abuse policy and procedure for abuse training yearly for 2 of 5 staff members who have been employed at the facility for over four months. (LPN 1 and CNA 2)
July 16, 2025Complaint inspection · 8 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, record review, and interview, the facility failed to serve, store, and prepare food under sanitary conditions, related to opened food stored more than 72 hours, dirt/debris/food on the floors of the walk in cooler, dried storage area, and food preparation area, dirty shelves, food stored without opening dates and in dirty containers, dented cans, opened bags of cereal not re-sealed, and a staff member with uncovered open areas on his arm, for 1 of 1 kitchen.(Main Kitchen) This had the potential to affect 85 of 86 residents who reside in the facility.
- E
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 ensure grievances voiced by the residents were resolved or attempted to be resolved in a timely manner and failed to follow up on the resolution to ensure the grievances were resolved, for 8 of 11 residents interviewed for grievances. (Resident H, K, L, M, N,O, P, Q, and E)
- E
Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs.
Inspectors wroteBased on record review and interview, the facility failed to ensure residents were provided choices and the choices were honored for meals, for 9 of 11 residents interviewed. (Residents H, K, L, M, N, O, P, Q, and E)
- E
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Inspectors wroteBased on observation, record review and interview, the facility failed to serve 1 of 2 meals observed at an appetizing temperature, related to a supper meal served with temperatures of the food under 135 degrees. This had the potential to affect 71 residents who are on a regular diet with regular textured foods.
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on record review and interview, the facility failed to ensure treatments for pressure ulcers were completed as ordered by the physician for 1 of 3 residents reviewed for pressure ulcers. (Resident E)
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure a respiratory treatment was monitored for 1 of 3 residents reviewed for oxygen. (Resident B)
- D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on record review and interview, the facility failed to ensure a resident's record was accurate, related to an Agency LPN signing that a treatment had been completed when the treatment had not been completed, for 1 of 7 resident records reviewed. (Resident E and Agency LPN 2)
- D
Develop, implement, and/or maintain an effective training program for all new and existing staff members.
Inspectors wroteBased on record review and interview, the facility failed to ensure contracted staff training requirements were completed for Medication Administration for 3 of 6 Agency Staff reviewed for agency orientation. (Agency LPN 4, Agency LPN 5, and Agency LPN 6)
February 7, 2025Standard inspection, Complaint inspection · 6 citations
- D
Allow residents to self-administer drugs if determined clinically appropriate.
Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure residents had Physician's Orders for medications and an assessment to self-administer their own medications for 1 of 1 resident reviewed for self-administration of medication. (Resident 52)
- D
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Inspectors wroteBased on observation, record review and interview, the facility failed to ensure a resident's ADL (activities of daily living) functions were maintained related to walking the resident daily as care planned for 1 of 1 resident reviewed for rehabilitation and/or restorative care. (Resident 70)
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on observation, record review and interview, the facility failed to ensure residents received the necessary care and services related to a medication not resumed at the correct frequency for 1 of 1 residents reviewed for death (Resident B), lack of a treatment order for a dressing in place, and compression stockings not worn as ordered for 2 of 3 residents reviewed for non-pressure skin issues. (Residents D and C)
- 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, record review and interview, the facility failed to ensure a resident's range of motion (ROM) was maintained related to not following therapy recommendations for routine ROM exercises for 1 of 2 residents reviewed for limited ROM and/ or positioning. (Resident 21)
- D
Provide enough food/fluids to maintain a resident's health.
Inspectors wroteBased on record review and interview, the facility failed to monitor nutritional intake for meals for a resident with a history of weight loss for 1 of 3 residents reviewed for nutrition. (Resident 15)
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observation, record review and interview, the facility failed to ensure residents received the necessary respiratory care and treatments related to medications not initiated for a resident with COVID-19 for 1 of 2 residents reviewed for respiratory infections (Resident 70) and incorrect oxygen flow rates for 2 of 2 residents reviewed for oxygen. (Residents 10 and 65)
May 6, 2024Complaint inspection · 2 citations
- K
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
Inspectors wroteBased on observation, record review and interview, the facility failed to ensure ground meat was provided in accordance with the physician orders and failed to ensure specialized dietary instructions were provided to nursing staff for 6 of 6 residents on a memory care unit reviewed for a mechanically altered with ground meat diet. (Residents B, G, H, J, K, and L) This deficient practice resulted in a cognitively impaired resident with a history of food stuffing, ingesting the regular meat, the resident's airway becoming blocked, and the resident expired. (Resident B). The immediate jeopardy began on 4/16/24 when a cognitively impaired resident on the memory care unit with a history of stuffing food into her mouth and swallowing without chewing, was found unresponsive with sausage in her mouth and airway after the evening meal. [...]
- J
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on record review and interview, the facility failed to ensure adequate supervision was provided to prevent a cognitively-impaired resident on the Memory Care Unit with a history of food stuffing from ingesting and aspirating a large amount of unchewed food, for 1 of 3 residents reviewed for dining room supervision. This deficient practice resulted in the death of Resident B. The immediate jeopardy began on 4/16/24 when a cognitively impaired resident on the memory care unit with a history of stuffing food into her mouth and swallowing without chewing, was found unresponsive with sausage in her mouth and airway after the dinner meal. The resident had a care plan to be supervised during meals. [...]
February 23, 2024Standard inspection, Complaint inspection · 11 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 interview, the facility failed to ensure a sanitary kitchen, related to boxes of food stored on the freezer floor and clean dishes stored upright on a shelf, for 1 of 1 kitchens observed. (Main Kitchen). This had the potential to affect all 76 residents who received food from the kitchen.
- D
Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.
Inspectors wroteBased on record review and interview, the facility failed to ensure a resident and/or their responsible party were notified in writing related to a bed hold notice for 1 of 1 residents reviewed for hospitalization. (Resident 71).
- 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 observation, record review, and interview, the facility failed to develop and implement a care plan for a resident with a history of wandering into other resident's room, for 1 of 21 resident care plans reviewed. (Resident C)
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on record review and interview, the facility failed to ensure ADL (activities of daily living) care was provided to a dependent resident, related to showering as scheduled, for 1 of 3 residents reviewed for ADL care. (Resident 22)
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure residents received the necessary treatment and services, related to not holding a medication as ordered, for 1 of 1 residents reviewed for constipation, lack of Physician notification of a lab result, for 1 of 7 residents reviewed for accidents, and not assessing or monitoring skin discolorations, for 1 of 1 residents reviewed for non pressure skin conditions. (Residents 13, 67 and 27)
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure safety measures were in place to prevent accidents, related to fall precautions not implemented for a resident with a history of falls, for 1 of 3 residents reviewed for accidents. (Resident 64)
- 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 and interview, the facility failed to ensure staff monitored output from a foley catheter every shift per the care plan, for 1 of 1 residents reviewed for catheters. (Resident 22)
- D
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure continuous effective interventions were implemented to prevent known triggers for residents with dementia who were observed with physical behaviors and wandering behaviors, for 2 of 3 residents reviewed for dementia care. (Residents B and C)
- 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, record review, and interview, the facility failed to ensure medications were stored properly and with appropriate labeling, for 1 of 4 medication carts observed. (South Cart 1)
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure infection control guidelines were in place and implemented, related to not using hand hygiene in between glove changes during wound care, and touching resident items with gloved hands for 2 of 4 residents observed for pressure ulcers. (Residents 16 and 22)
- D
Implement a program that monitors antibiotic use.
Inspectors wroteBased on record review and interview, the facility failed to promote antibiotic stewardship by ensuring appropriate use of antibiotic therapy and reduce antibiotic resistance by only initiating therapy based on the McGeer Criteria for true infections, for 1 of 1 residents reviewed for respiratory care. (Resident 2)
September 28, 2023Complaint inspection · 2 citations
- F
Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.
Inspectors wroteBased on record review and interview, the facility failed to ensure there was sufficient qualified dietary staff available to cook meals. This had the potential to affect 66 residents who received meals from the kitchen. (Main Kitchen)
- C
Post nurse staffing information every day.
Inspectors wroteBased on observation and interview, the facility failed to have accurate and complete daily nurse staffing postings. This had the potential to affect all 67 residents residing in the facility.
Fire safety inspections
25 fire safety citations on file: 16 on May 6, 2026, 2 on February 7, 2025, 7 on February 23, 2024.
Every fire safety citation25 citations
- F
Develop and maintain an Emergency Preparedness Program (EP).
E 4 · May 6, 2026 · Corrected (the home has a date of correction)
- F
Develop Emergency Preparedness policies and procedures.
E 13 · May 6, 2026 · Corrected (the home has a date of correction)
- F
Develop a communication plan.
E 29 · May 6, 2026 · Corrected (the home has a date of correction)
- F
Conduct testing and exercise requirements.
E 39 · May 6, 2026 · Corrected (the home has a date of correction)
- F
Implement emergency and standby power systems.
E 41 · May 6, 2026 · Corrected (the home has a date of correction)
- F
Meet other general requirements that are deficient.
K 300 · May 6, 2026 · Corrected (the home has a date of correction)
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · May 6, 2026 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · May 6, 2026 · no revisit needed
- F
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · May 6, 2026 · Corrected (the home has a date of correction)
- F
Have proper fire barriers, ventilation and signs for the transfilling of oxygen.
K 927 · May 6, 2026 · Corrected (the home has a date of correction)
- E
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
K 223 · May 6, 2026 · Corrected (the home has a date of correction)
- E
Install proper backup exit lighting.
K 281 · May 6, 2026 · Corrected (the home has a date of correction)
- E
Install a fire alarm system that can be heard throughout the facility.
K 341 · May 6, 2026 · Corrected (the home has a date of correction)
- E
Properly select, install, inspect, or maintain portable fire extinguishes.
K 355 · May 6, 2026 · Corrected (the home has a date of correction)
- E
Ensure proper usage of power strips and extension cords.
K 920 · May 6, 2026 · Corrected (the home has a date of correction)
- D
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 · May 6, 2026 · Corrected (the home has a date of correction)
- E
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
K 741 · February 7, 2025 · Corrected (the home has a date of correction)
- C
Conduct testing and exercise requirements.
E 39 · February 7, 2025 · Corrected (the home has a date of correction)
- F
Meet other general requirements that are deficient.
K 300 · February 23, 2024 · Corrected (the home has a date of correction)
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · February 23, 2024 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · February 23, 2024 · Corrected (the home has a date of correction)
- E
Have exits that are accessible at all times.
K 271 · February 23, 2024 · Corrected (the home has a date of correction)
- E
Install corridor and hallway doors that block smoke.
K 363 · February 23, 2024 · Corrected (the home has a date of correction)
- E
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
K 761 · February 23, 2024 · Corrected (the home has a date of correction)
- E
Ensure proper usage of power strips and extension cords.
K 920 · February 23, 2024 · Corrected (the home has a date of correction)