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 37 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
1G
0H
0I
Potential for more than minimal harm
32D
3E
1F
Potential for minimal harm
0A
0B
0C
July 17, 2026Complaint inspection · 1 citation
- F
Employ staff that are licensed, certified, or registered in accordance with state laws.
Inspectors wroteBased on interview and document review, the facility failed to ensure a licensed practical nurse (LPN) maintained her current credentials for 1 (LPN #1) of 8 licensed nursing staff reviewed for current credentials. This deficient practice had the potential to affect all residents who currently resided in the facility.
April 22, 2026Complaint inspection · 2 citations
- G
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 medical record review and interviews, the facility staff failed to 1) ensure a resident was seen timely by the Urologist as ordered and 2) reassess and intervene for a resident with urinary catheter problems. This was evident for 1 (Resident #3) of 4 residents reviewed for urinary catheters during a complaint survey. This failure led to the hospitalization of Resident #3 with diagnosis to include urinary tract infection and acute kidney injury.
- D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on medical record review and interview, it was determined the facility failed to maintain complete and accurate medical records in accordance with accepted professional standards. This was evident for 2 (Residents #4, #3) of 9 residents reviewed during a complaint survey.
December 16, 2025Standard inspection, Complaint inspection · 14 citations
- E
Ensure each resident receives an accurate assessment.
Inspectors wroteBased on facility staff interviews and surveyor record reviews, it was determined that the facility failed to ensure that Minimum Data Set (MDS) assessments were coded accurately. This finding was found to be evident in 4 (Resident #1, #9, #33 and #103) out of 16 Residents reviewed for accuracy of assessments during the recertification/complaint survey.
- D
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Inspectors wroteBased on observations and facility staff interviews it was determined that the facility failed to have a safe/clean/comfortable/homelike environment for Residents. This finding was found to be evident in the following Resident rooms (room [ROOM NUMBER], 109, 111, 112 and 113) and the facility conference room during the recertification/complaint survey.
- 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 facility staff interviews and surveyor record reviews it was determined that the facility failed to develop and implement comprehensive care plans and follow care plan interventions for Residents. This finding was found to be evident for 3 (Resident #1, #29 and #41) out of 16 Residents reviewed for comprehensive care plans during the recertification/complaint survey.
- 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 facility staff interviews and surveyor record reviews, it was determined that the facility failed to update and revise a Resident's care plan. This finding was found to be evident for 1 (Resident #29) out of 6 Residents reviewed for revision of Resident's care plans during the recertification/complaint survey.
- D
Ensure services provided by the nursing facility meet professional standards of quality.
Inspectors wroteBased on observations, record review, review of facility policy, and interviews it was determined that the facility failed to utilize professional standards during medication administration. This was found evident in 2 (Resident #59 and #6) of 3 medications administrations on the recertification/complaint survey.
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on record review and interview, it was determined that the facility failed to provide necessary services to maintain good personal hygiene for dependent Residents. This was found evident in 1 (Resident #112) out of 1 residents reviewed for Activity of Daily Living (ADL) care during the recertification/complaint survey.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on record review, review of facility's policy, and interviews it was determined that the facility failed to identify and provide appropriate interventions for a resident's condition. This was found evident of 1 (Resident #112) out of 1 resident reviewed constipation/diarrhea during the recertification/complaint survey.
- D
Assist a resident in gaining access to vision and hearing services.
Inspectors wroteBased on observations and interviews it was determined that the facility failed to provide treatment/services to maintain hearing. This was found evident in 1 of 3 consults reviewed for Resident #59 on the recertification/complaint survey.
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observation, record review and interviews, it was determined that the facility failed to administer oxygen and maintain continuous positive airway pressure (CPAP) therapy in accordance with professional standards of practice. This was found to be evident for 2 (Residents #1, #58) out of 2 residents receiving oxygen and 1 (#1) out of 1 resident receiving CPAP therapy reviewed during the recertification/complaint survey.
- D
Provide safe, appropriate pain management for a resident who requires such services.
Inspectors wroteBased on medical record review and staff interview it was determined that the facility failed to provide pain management as prescribed. This was evident for 1 (Resident #109) of 1 resident reviewed for pain management during the recertification/complaint survey.
- D
Post nurse staffing information every day.
Inspectors wroteBased on observation, facility staff interview and surveyor record review it was determined that the facility failed to ensure that the posted nurse staffing information document displayed the required information. This finding was found to be evident in the review of sufficient and competent nurse staffing during the recertification/complaint survey.
- D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on surveyor record review, review of consultation notes and Resident and staff interviews, it was determined that the facility failed to maintain medical records in accordance with acceptable professional standards and practices by keeping complete and accurate documentation. This finding was found to be evident in 4 (Resident # 6, #33, #59, and #112) out of 41 Residents reviewed for identifiable information in the Resident medical records during the recertification/complaint survey.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, and interviews, it was determined that the facility failed to maintain practices to help prevent the transmission of infections. This was found evident on 2 (Resident #6 & #70) out of 2 observations of medication administration during the recertification/complaint survey.
- D
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Inspectors wroteBased on observations and interviews it was determined that the facility failed to provide a safe, functional, sanitary environment for a resident. This was found in 1 (Resident #59) of 26 Resident rooms reviewed in the initial sample during the recertification/complaint survey.
March 8, 2024Standard inspection · 12 citations
- E
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on the medical record review and staff interview it was determined the facility failed to keep complete and accurate medical records. This deficient practice was evident in 7 of 20 (#37, #42, #58, #5, #10, #77, #24) resident during the survey.
- D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteBased on observation and interview with facility staff, it was determined that the facility failed to maintain the dignity and privacy of a resident as evidenced by the resident's nephrostomy bags left uncovered while outside of their room. This was evident for 1 (Resident # 193) of 86 residents that were observed during the survey.
- D
Reasonably accommodate the needs and preferences of each resident.
Inspectors wroteBased on observation and interviews it was determined the facility staff failed to ensure that residents' call bells were in reach to request assistance. This deficient practice was evident in 2 of 8 (Resident #32 and Resident #58) residents assessed for call bell accommodations during the survey.
- D
Protect each resident from the wrongful use of the resident's belongings or money.
Inspectors wroteBased on observations and interviews with facility staff it was determined the facility failed to ensure that scheduled pain medications for a resident were not misappropriated. This was found to be evident during a medication drug storage review and narcotic review and reconciliation for 1 of 3 medication carts reviewed during the survey.
- 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 medical record review and interviews it was determined that the facility staff failed to generate a person-centered care plan for a resident who required assistance with dental care. This deficient practice was evident in 1(Resident #35) of 5 resident records reviewed for person centered care plans during the survey.
- 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 medical record review and interview it was determined that the facility staff failed to have quarterly care plan meetings. This deficient practiced was evidenced in 1 (#73) of 3 resident records reviewed for care plan meetings during the survey.
- D
Ensure services provided by the nursing facility meet professional standards of quality.
Inspectors wroteBased on a review of the medication administration audit record (MAAR) and interview with facility staff, it was determined the facility staff failed to document after administering medications to residents. This was evident for 1 (Residents #32) of 6 residents reviewed for timely medication administration.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on observations and interviews with facility staff it was determined the facility failed to: 1.) ensure that a resident (#5) received a scheduled dose of medication as ordered by the physician; 2.) ensure medications were signed off on the controlled drug receipt/disposition form after being administered to a resident (#10). This was evident during a medication drug storage review and narcotic review and reconciliation for 1 of 3 medication carts; and 3) administer scheduled medications to residents at the physician ordered time (Resident #32, Resident #23, Resident #42). This was evident for 3 (Residents #32, #23, #42) of 6 residents reviewed during a medication administration observation
- D
Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit.
Inspectors wroteBased on medical record review and staff interviews, it was determined the physician failed to evaluate a resident with a change in condition in a timely manner. This was evident for 1 of 6 sampled residents (Resident #24) during the survey.
- D
Ensure medication error rates are not 5 percent or greater.
Inspectors wroteBased on medication administration observation, medical record review and staff interview, it was determined that the facility staff failed to ensure a medication error rate of less than 5% during the medication observation facility task. This was evident for 5 of 27 medications administered during the observation which resulted in an error rate of 18.52%.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on medication administration observation and staff interview, it was determined that the facility staff failed to adhere to infection control practices and guidelines to prevent and control transmission of infectious agents during medication administration. This was evident for 2 of 27 medications administered during the medication administration observation.
- D
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Inspectors wroteBased on medical record review and interviews it was determined that the facility staff failed to offer and administer the pneumococcal vaccine to a resident. This deficient practice was evidenced in 1 (#40) in 5 resident records reviewed for immunizations during the survey.
April 29, 2019Standard inspection · 8 citations
- E
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on observation, it was determined that facility's food service employees failed to ensure that equipment was maintained and safe food handling practices were followed to reduce the risk of foodborne illness. This deficient practice has the potential to affect all residents.
- 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 medical record review and interview, the facility staff failed to honor a resident's choices (Resident #16). This was evident for 1 out of 40 residents reviewed during the survey process.
- D
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Inspectors wroteBased on surveyor observation during the initial tour of the facility it was determined that the facility staff failed to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior.
- 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 medical record review and staff interview it was determined that facility staff failed to notify a resident's representative in writing of a transfer to the hospital. This was evident for 3 of 40 residents (Resident #23, Resident #53, Resident #66) reviewed during survey investigation.
- 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 staff interview and medical record review it was determined that the facility failed to develop and implement comprehensive person-centered care plans with measurable goals. This was evident for 2 of 40 residents (Residents #37 and #53) reviewed during survey investigation.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on medical record review and staff interview it was determined the facility failed to follow the physician's orders for no weights, vitals or labs for a resident. This was evident for 1 of 40 residents (Resident #37) reviewed during the survey investigation.
- D
Provide enough food/fluids to maintain a resident's health.
Inspectors wroteBased on medical record review and interview, the facility staff failed to follow the recommendations of the dietitian. This was evident for 1 out of 40 residents (Resident #44) reviewed during the survey process.
- D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on medical record review and interview, it was determined the facility staff failed to maintain medical records in the most accurate form for a resident. This was evident for 1 of 40 residents (Resident #61) reviewed during the survey process.
Fire safety inspections
31 fire safety citations on file: 3 on December 16, 2025, 17 on March 8, 2024, 11 on April 29, 2019.
Every fire safety citation31 citations
- E
Install a fire alarm system that can be heard throughout the facility.
K 341 · December 16, 2025 · Corrected (the home has a date of correction)
- D
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 · December 16, 2025 · Corrected (the home has a date of correction)
- D
Meet requirements for the use of electrical equipment.
K 919 · December 16, 2025 · Corrected (the home has a date of correction)
- F
Develop and maintain an Emergency Preparedness Program (EP).
E 4 · March 8, 2024 · Corrected (the home has a date of correction)
- F
Provide properly protected cooking facilities.
K 324 · March 8, 2024 · Corrected (the home has a date of correction)
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · March 8, 2024 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · March 8, 2024 · Corrected (the home has a date of correction)
- F
Have simulated fire drills held at unexpected times.
K 712 · March 8, 2024 · Corrected (the home has a date of correction)
- F
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
K 761 · March 8, 2024 · Corrected (the home has a date of correction)
- F
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
K 914 · March 8, 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 · March 8, 2024 · Corrected (the home has a date of correction)
- E
Keep aisles, corridors, and exits free of obstruction in case of emergency.
K 211 · March 8, 2024 · Corrected (the home has a date of correction)
- E
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 · March 8, 2024 · 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 · March 8, 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 · March 8, 2024 · Corrected (the home has a date of correction)
- D
Install an approved automatic sprinkler system.
K 351 · March 8, 2024 · Corrected (the home has a date of correction)
- D
Properly select, install, inspect, or maintain portable fire extinguishes.
K 355 · March 8, 2024 · Corrected (the home has a date of correction)
- D
Provide a written emergency evacuation plan.
K 711 · March 8, 2024 · Corrected (the home has a date of correction)
- D
Have restrictions on the use of portable space heaters.
K 781 · March 8, 2024 · Corrected (the home has a date of correction)
- D
Have proper medical gas storage and administration areas.
K 923 · March 8, 2024 · Corrected (the home has a date of correction)
- F
Provide properly protected cooking facilities.
K 324 · April 29, 2019 · Corrected (the home has a date of correction)
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · April 29, 2019 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · April 29, 2019 · Corrected (the home has a date of correction)
- F
Meet other general requirements that are deficient.
K 500 · April 29, 2019 · Corrected (the home has a date of correction)
- F
Meet requirements for operating features, such as evacuation plans, fire drills, smoking regulations, draperies, decorations and the inspection, testing and maintenance of fire doors.
K 700 · April 29, 2019 · Corrected (the home has a date of correction)
- F
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
K 761 · April 29, 2019 · Corrected (the home has a date of correction)
- F
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · April 29, 2019 · Corrected (the home has a date of correction)
- E
Provide two separate exits in rooms of more than 1000 square feet.
K 253 · April 29, 2019 · Corrected (the home has a date of correction)
- E
Install an approved automatic sprinkler system.
K 351 · April 29, 2019 · Corrected (the home has a date of correction)
- D
Install proper backup exit lighting.
K 281 · April 29, 2019 · Corrected (the home has a date of correction)
- D
Install a fire alarm system that can be heard throughout the facility.
K 341 · April 29, 2019 · Corrected (the home has a date of correction)