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 27 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
1J
2K
0L
Actual harm
3G
0H
0I
Potential for more than minimal harm
19D
2E
0F
Potential for minimal harm
0A
0B
0C
July 21, 2026Complaint inspection · 1 citation
- D
Ensure that residents are free from significant medication errors.
Inspectors wroteBased on interview and record review, the facility failed to ensure newly ordered hospice comfort medications were promptly implemented and administered as ordered by the physician. Specifically, for 1 out of 11 sampled residents, staff failed to enter and administer newly ordered end-of-life pain and anxiety medications, resulting in multiple missed doses over a two-day period. The facility developed and implemented a correction action plan before the survey start date. The facility's correction action plan, which was developed and implemented by [DATE], included the following measures: individual education for Nurse 1, facility wide education on end-of-life care and entering physician orders, resident interview and record review to identify any other medication error concerns, daily medication error audits, and implementation of a triple-check process for entering in physician orders. [...]
February 12, 2026Standard inspection · 7 citations
- 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 that, for 1 out of 30 sampled residents, the facility failed to ensure that each resident's environment remained as free of accident hazards as possible, and received adequate supervision and assistance with devices to prevent accidents. Specifically, a resident who had significant dysphagia was coughing while eating with no staff supervision or assistance. Resident identifier: 122.
- D
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Inspectors wroteBased on observation, interview and record review the facility failed to ensure 1 out of 30 residents receiving a tube feeding received appropriate treatment and services to prevent complications. Specifically, observations revealed the tube feeding was not infusing at the rate prescribed by the provider. Resident identifier:
- D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Inspectors wroteBased on interview and record review, the facility did not provide routine and emergency drugs and biologicals to its residents. Specifically, for 1 out of 30 sampled residents, a resident who received medication for diabetes mellitus did not have those medications available from the pharmacy for administration. Resident identifier: 97.
- D
Provide or get specialized rehabilitative services as required for a resident.
Inspectors wroteBased on observation, interview, and record review, it was determined that, for 1 out of 30 sampled residents, the facility failed to provide the required specialized rehabilitation services, speech-language pathology. Specifically, one resident experienced a change in his eating abilities and speech therapy was not notified. Resident identifier: 122.
- 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, for 1 out of 30 sampled residents, that the facility did not maintain medical records on each resident that were complete; accurately documented; readily accessible; and systematically organized. Specifically, blood sugar results were not recorded in the medical record for a resident who was given unprescribed insulin. Resident identifiers: 126.
- D
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Inspectors wroteBased on interview, observation, and record review, the facility did not establish and implement written policies and procedures for feedback, data collections systems, and monitoring, including adverse event monitoring. Specifically, the facility did not implement policies to address the underlying cause of the problems or identify how corrective actions were taken and monitored in regard to feeding tubes. Resident identifier:
- D
Make sure that a working call system is available in each resident's bathroom and bathing area.
Inspectors wroteBased on observation and interview, the facility failed to ensure that an emergency call system was available and accessible in 5 out of 5 public and staff-accessible restrooms located in common areas used by residents. This failure created a risk that residents who utilized these restrooms would be unable to summon staff assistance in the event of an emergency or fall.
December 22, 2025Complaint 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 interview and record review it was determined, for 1 of 11 sampled residents, that the facility did not provide each resident adequate supervision to prevent accidents. Specifically, a resident was not provided two person assistance during a brief change, which led to a fall and subsequent fractures. This resulted in a finding of harm for resident 5. Resident identifiers: 5.
June 30, 2025Complaint inspection · 1 citation
- E
Provide and implement an infection prevention and control program.
Inspectors wroteBased on interview, observation, and record review, it was determined that the facility failed to adhere to its established infection prevention and control program. Specifically, a staff member was observed not to wash or sanitize their hands between resident rooms. On June 26, 2025 at 10:50 AM, the surveyor observed certified nursing assistant (CNA) 1. CNA 1 exited a resident's room designated by posted signage for enhanced barrier precautions. The displayed signage required hand hygiene upon entry and exit, as well as the use of gowns and gloves for high-contact resident care, including tasks such as dressing, bathing, transferring, linen changes, hygiene, and toileting assistance. CNA 1 was observed to be carrying a bag of garbage, which appeared to be soiled briefs or linens, and a water mug. [...]
January 11, 2024Standard inspection · 5 citations
- D
Allow residents to self-administer drugs if determined clinically appropriate.
Inspectors wroteBased on observation, interview, record review, and facility policy review, it was determined the facility failed to assess 1 (Resident #74) of 10 sampled residents to ensure the resident was safe to self-administer inhaled medications.
- 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, interview, record review, and policy review, it was determined the facility failed to develop a care plan for 1 (Resident #80) of 7 sampled residents who were dependent on respiratory ventilators.
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on observation, interview, record review, and policy review, the facility failed to provide nail care for 2 (Resident #76 and Resident #98) of 10 residents who were dependent on staff for personal hygiene.
- D
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Inspectors wroteBased on observation, interview, record review, and policy review, the facility failed to ensure 1 (Resident #91) of 10 residents receiving tube feeding received appropriate treatment and services to prevent complications. Specifically, observations revealed the tube feeding formula bottle for Resident #91 was not dated or timed when it was initiated to ensure the formula was not administered beyond 24 hours.
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observation, interview, record review, and policy review, the facility failed to obtain a physician order for 1 (Resident #30) of 3 sampled residents receiving supplemental oxygen administration.
November 8, 2023Complaint 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 observation, interview, and record review, it was determined, the facility failed to ensure that the resident environment remained as free of accident hazards as was possible and each resident received adequate supervision and assistance devices to prevent accidents. Specifically, for 1 out of 3 sampled residents, a resident that was a quadriplegic received second degree burns on his body after being served hot water by a Certified Nursing Assistant (CNA) and the resident was not supervised while drinking the hot water. Resident identifier: 1.
October 26, 2023Complaint inspection · 3 citations
- K
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, for 1 of 9 sampled residents, that the facility failed to protect residents form abuse. Specifically, a resident was sexually abused without ongoing interventions to prevent further abuse. Additionally, the facility had prior knowledge of the alleged perpetrators behaviors and the facility failed to provide protection for the resident thereby allowing ongoing access and abuse of the resident by the alleged perpetrator. This requirement was determine to be out of compliance at the severity level of immediate jeopardy. Due to the ongoing access to resident 1, by the alleged perpetrator, the scope of the noncompliance is determined to be a pattern. Resident identifier: 1. [...]
- K
Respond appropriately to all alleged violations.
Inspectors wroteBased on observation, interview and record review it was determined, for 1 of 9 sampled residents, that the facility failed to protect residents form abuse. Specifically, a staff member had an allegation of sexual abuse toward resident 1 that was not thoroughly investigated in July 2022. An additional allegation of sexual abuse of resident 1 was made against the same staff member in September 2023 that substantiated abuse. Additionally, the facility had prior knowledge of the alleged perpetrators behaviors and the facility failed to provide protection for the resident thereby allowing ongoing access to the resident by the alleged perpetrator. This was found to have occurred at an immediate jeopardy (IJ) level. Resident identifier: 1. [...]
- J
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on confidential and non-confidential interviews with administrative staff, therapy staff, licensed and unlicensed nursing staff, and record review, it was determined, for 1 of 9 sampled residents, the facility failed to ensure that all suspected or alleged violations involving abuse were reported immediately to the administrator and other officials in accordance with State law through established procedures. Specifically, when interviewed by surveyors, multiple staff reported observing Certified Occupational Therapy Assistant (COTA) 1 interacting with resident 1 in a suspicious manner and did not report their concerns, thereby, allowing COTA 1 ongoing access to resident 1. The facility's noncompliance relative to identifing and reporting abuse was determined to be at the severity level of immediate jeopardy. [...]
May 23, 2022Standard inspection · 8 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 did not ensure each resident received adequate supervision and services to prevent accidents. Specifically, for 1 out of 34 sampled residents, one resident sustained a skin tear to his face after falling off the bed during wound care. Resident identifier: 75.
- E
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Inspectors wroteBased on observation and interview, it was determined, the facility did not ensure each resident received and the facility provided, food and drink that was palatable, attractive, and at a safe and appetizing temperature. Specifically, several residents complained of cold meals, and on two separate meal observations the temperature of the food meant to be hot was served cold. Resident identifiers: 46, 85, and 252.
- 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 did not ensure that residents who were unable to carry out activities of daily living (ADL) received the necessary services to maintain good grooming and personal hygiene. Specifically, for 2 out of 34 sampled residents, residents were not provided assistance with showers. Resident identifiers: 58 and 152.
- D
Provide safe, appropriate pain management for a resident who requires such services.
Inspectors wroteBased on interview and record the review, it was determined, the facility did not ensure that pain management was provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences. Specifically, for 1 out of 34 sampled residents, a resident that had chronic pain was admitted to the facility with half the dose of a fentanyl patch than had been received at home. The same resident complained of pain and was unable to get a change in pain relief . Resident identifier: 152.
- D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Inspectors wroteBased on interview and record review, it was determined, that the facility did not provide routine and emergency drugs and biologicals to its residents. Specifically, for 1 out of 34 sampled residents, a residents medications were not administered as ordered by the physician due to the medications not being available by the pharmacy. Resident identifier: 81.
- 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 on interview and record review, it was determined, the facility did not ensure any irregularities reported by a pharmacist to the attending physician, the facility's Medical Director (MD), and Director of Nursing (DON), were acted upon. Specifically, for 2 out of 34 sampled residents, the facility did not implement recommendations, which were made on the Pharmacist Consultation Report and approved by the resident's physician. Resident identifiers: 49 and 92.
- D
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 interview and record review, it was determined, the facility did not ensure that a resident who used psychotropic drugs was not given these drugs unless the medication was necessary to treat a specific condition as diagnosed and documented in the clinical record. Residents who use psychotropic drugs receive gradual dose reductions (GDR), and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs. Specifically, for 1 out of 34 sampled residents, a resident did not receive a GDR on a benzodiazepine medication for anxiety that was initiated on 12/13/20. Resident identifier: 81.
- D
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, that the facility did not ensure that the Quality Assessment and Assurance (QAA) committee developed and implemented appropriate plans of action to correct identified quality deficiencies. Specifically, the facility was found to be in non-compliance with F689 which were cited within the facility's 2018 and 2019 recertification survey.
Fire safety inspections
29 fire safety citations on file: 11 on February 12, 2026, 11 on January 11, 2024, 7 on May 23, 2022.
Every fire safety citation29 citations
- F
Keep aisles, corridors, and exits free of obstruction in case of emergency.
K 211 · February 12, 2026 · Corrected (the home has a date of correction)
- F
Ensure gas and vacuum systems are inspected and tested as part of a maintenance program.
K 908 · February 12, 2026 · Corrected (the home has a date of correction)
- F
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · February 12, 2026 · Corrected (the home has a date of correction)
- F
Have proper medical gas storage and administration areas.
K 923 · February 12, 2026 · Corrected (the home has a date of correction)
- E
Have corridors or aisles that are unobstructed and are at least 8 feet in width.
K 232 · February 12, 2026 · Corrected (the home has a date of correction)
- E
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · February 12, 2026 · Corrected (the home has a date of correction)
- D
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
K 321 · February 12, 2026 · Corrected (the home has a date of correction)
- D
Provide properly protected cooking facilities.
K 324 · February 12, 2026 · Corrected (the home has a date of correction)
- D
Have properly installed electrical wiring and gas equipment.
K 511 · February 12, 2026 · Corrected (the home has a date of correction)
- D
Have restrictions on the use of portable space heaters.
K 781 · February 12, 2026 · Corrected (the home has a date of correction)
- D
Ensure proper usage of power strips and extension cords.
K 920 · February 12, 2026 · Corrected (the home has a date of correction)
- F
Develop and maintain an Emergency Preparedness Program (EP).
E 4 · January 11, 2024 · Corrected (the home has a date of correction)
- F
Conduct testing and exercise requirements.
E 39 · January 11, 2024 · Corrected (the home has a date of correction)
- F
Have restrictions on the use of portable space heaters.
K 781 · January 11, 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 · January 11, 2024 · Corrected (the home has a date of correction)
- F
Ensure that testing and maintenance of electrical equipment is performed.
K 921 · January 11, 2024 · 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 · January 11, 2024 · Corrected (the home has a date of correction)
- D
Install emergency lighting that can last at least 1 1/2 hours.
K 291 · January 11, 2024 · Corrected (the home has a date of correction)
- D
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 11, 2024 · Corrected (the home has a date of correction)
- D
Properly select, install, inspect, or maintain portable fire extinguishes.
K 355 · January 11, 2024 · Corrected (the home has a date of correction)
- D
Have simulated fire drills held at unexpected times.
K 712 · January 11, 2024 · Corrected (the home has a date of correction)
- D
Ensure proper usage of power strips and extension cords.
K 920 · January 11, 2024 · Corrected (the home has a date of correction)
- E
Establish an Emergency Preparedness Program (EP).
E 1 · May 23, 2022 · Corrected (the home has a date of correction)
- D
Install emergency lighting that can last at least 1 1/2 hours.
K 291 · May 23, 2022 · Corrected (the home has a date of correction)
- D
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
K 321 · May 23, 2022 · Corrected (the home has a date of correction)
- D
Inspect, test, and maintain automatic sprinkler systems.
K 353 · May 23, 2022 · Corrected (the home has a date of correction)
- D
Have properly installed electrical wiring and gas equipment.
K 511 · May 23, 2022 · Corrected (the home has a date of correction)
- D
Have simulated fire drills held at unexpected times.
K 712 · May 23, 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 23, 2022 · Corrected (the home has a date of correction)