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 36 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
20D
14E
2F
Potential for minimal harm
0A
0B
0C
February 23, 2026Complaint inspection · 2 citations
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on interview and record review, the facility failed to ensure blood pressure parameters for a resident (Resident B) were followed, as ordered by the physician, for 1 of 3 residents reviewed for quality of care. Findings Include:The clinical record for Resident B was reviewed on 2/23/26 at 10:45 a.m. The resident's diagnosis included, but was not limited to, hypotension (low blood pressure) The physician's order, dated 2/6/26, indicated the resident was to receive Midodrine HCl (hydrochloride) 2.5 mg (milligrams) three times a day at 8:00 a.m.,12:00 p.m., and 4:00 p.m. for hypotension. The medication was to be held if the resident's systolic blood pressure (top number measuring the pressure in arteries when the heart contracts) was above 130. [...]
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observation, interview and record review, the facility failed to ensure respiratory assessments and respiratory care equipment were in place for a resident (Resident B) who received breathing treatments for 1 of 3 residents reviewed for respiratory care.
November 13, 2025Complaint inspection · 1 citation
- E
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Inspectors wroteBased on observation, record review, and interview the facility failed to ensure the hot water temperatures were between 100 and 120 degrees. This deficient practice had the potential to affect 82 of 82 residents living in the facility.
September 8, 2025Complaint inspection · 1 citation
- D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Inspectors wroteBased on record review and interview, the facility failed to document medication administration for 1 of 5 residents reviewed for pharmacy services. (Resident B)
June 2, 2025Complaint inspection · 1 citation
- D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Inspectors wroteBased on record review and interview, the facility failed to ensure an intravenous ( IV) antibiotic was given in a timely manner for 2 of 3 residents reviewed for pharmacy services. (Residents 2 and 4)
May 8, 2025Standard inspection, Complaint inspection · 5 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, record review, and interview, the facility failed to ensure the food was disposed of once expired, the vents were cleaned and repaired, the refrigerator thermostat and drip pan under the stove top were repaired. This had the potential to affect 93 of 95 residents who consume meals from the facility.
- D
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Inspectors wroteBased on record review and interview, the facility failed to ensure the Physician was notified when long acting insulin was held and when blood pressure, cardiac and blood thinner medications were refused for 1 of 3 residents reviewed for notification. (Resident 49)
- 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 a resident received treatment and care in a timely manner for 1 of 5 residents reviewed for quality of care. (Resident 243) Findings Include: The record for Resident 243 was reviewed on 5/5/25 at 11:17 a.m. The resident's diagnoses included, but were not limited to, type 2 diabetes mellitus with diabetic peripheral angiopathy without gangrene, and sepsis due to methicillin susceptible staphylococcus aureus, and hyperglycemia. The physician's order, dated 4/9/25, indicated the resident was to receive Lispro 100 units per mg before meals for diabeties. The staff were to administer the rsident's insulin based on a sliding scale. The staff were to notifiy the physician if the resident's blood surgar level was less the 70 or grater than 400. If the resident's blood sugar level was 151 to 200 staff were to administer 2 units; [...]
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on observation, interview and record review the facility failed to ensure interventions and treatments were completed for 1 of 4 residents reviewed for pressure ulcers. (Resident 53).
- 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 sufficient information related to a resident's blood sugar was rechecked; and physician notification and verbal orders were documented in the resident's clinical record for 1 of 21 residents reviewed for Documentation. (Resident 243)
January 28, 2025Complaint inspection · 3 citations
- 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, the facility failed to ensure narcotic medications were not signed out prior to administration times for 7 of 11 residents reviewed for medication storage. (Resident E, Resident M, Resident N, Resident R, Resident S, Resident T and Resident U)
- E
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, the facility failed to ensure medication administration records reflected the administration of narcotic medications for 4 of 11 residents reviewed for medical records. (Resident M, Resident N, Resident O and Resident V)
- 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, interview and record review, the facility failed to ensure Indwelling catheter care orders were implemented for 1 of 3 residents reviewed for Indwelling catheters. (Resident M)
December 20, 2024Complaint inspection · 3 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 interview and record review, the facility failed to ensure the anti-psychotic medication was documented as administered (Resident G) and failed to ensure resident's (Resident C and Resident E) medication administration records reflected the administration of narcotic medication for 3 of 5 residents reviewed for medical records.
- D
Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder.
Inspectors wroteBased on interview and record review, the facility failed to ensure behaviors were care planned and monitored for 3 of 4 residents reviewed for behavior management. (Residents B, D, and G)
- D
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Inspectors wroteBased on observation, interview and record review, the facility failed to ensure affective interventions were in place for a resident with increased sexually inappropriate behaviors for 1 of 8 residents reviewed for dementia care. (Resident C)
August 29, 2024Complaint inspection · 1 citation
- 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, the facility failed to ensure fall interventions were in place for 1 of 3 residents reviewed for accident hazards. (Resident C)
May 16, 2024Standard inspection, Complaint inspection · 6 citations
- E
Reasonably accommodate the needs and preferences of each resident.
Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure the resident's call lights were within reach for 10 of 108 residents observed for call light placement. (Residents 20, 77, 256, 60, 47, 91, 11, 38, 46 and 94)
- E
Honor the resident's right to organize and participate in resident/family groups in the facility.
Inspectors wroteBased on interview and record review, the facility failed ensure Administration was taking resident concerns seriously or being visible to the residents for 11 of 13 Resident Council meetings (3/23, 4/23, 5/23, 6/23, 7/23, 9/23, 10/23, 1/24, 3/24. 4/24, and 5/24). This deficient practice had the potential to affect 108 of 108 residents currently residing in the facility.
- E
Ensure that nurse aides who have worked more than 4 months, are trained and competent; and nurse aides who have worked less than 4 months are enrolled in appropriate training.
Inspectors wroteBased on record review and interview, the facility failed to ensure the CNAs (Certified Nurse Aides) tested for their licensure, prior to 120 days after of employment and worked past the 120 days for 6 of 33 CNAs reviewed. (CNAs 13, 14, 16, 15, 19, and 17)
- E
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Inspectors wroteBased on observation and interview, the facility failed to ensure meals were at appropriate temperatures and palatable for residents, during 3 of 3 meal test trays. This had the potential to affect 106 of 108 residents who ate meals at the facility. (100, 400, and 200 Hall Test Trays)
- 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 and interview, the facility failed to ensure the kitchen was cleaned and in good repair 2 of 2 observations. This had the potential to affect 106 of 108 residents who consumed meals at the facility.
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on interview and record review, the facility failed to identify a resident's right heel pressure ulcer prior to the wound being first identified as an open blister, no longer holding fluid for 1 of 3 residents reviewed for pressure ulcers. (Resident 8)
March 3, 2023Standard inspection · 13 citations
- F
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure adequate staffing which contributed to the lack of resident care, the distribution of fluids, and supervision. This deficient practice had the potential to affect 104 of 104 residents residing in the facility.
- F
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Inspectors wroteBased on observation and interview, the facility failed to ensure meals were healthy and appetizing for residents, during 1 of 2 meal test trays. This had the potential to affect all 104 residents who ate meals at the facility.
- E
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 observation and interview, the facility failed to ensure residents' rooms were clean and free of debris for 4 of 5 random observations of the facility environment and for 5 of 104 residents that reside in the facility. (Residents 81, 105, 67, 20, and 33)
- E
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 the residents' rooms were free of hazards related to multiple medications, including controlled substances, were found on the bedroom floors in 5 of 61 resident rooms. (Residents 15, 32, 86, 20, and 97)
- 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 and interview, the facility failed to ensure the kitchen equipment was cleaned and in good repair, and food was stored properly in the dry goods room and refrigerator. This had the potential to affect all 104 residents who consumed meals at the facility.
- E
Perform COVID19 testing on residents and staff.
Inspectors wroteBased on record review and interview, the facility failed to ensure the residents were COVID-19 tested in accordance with their policy for 6 of 12 residents reviewed for COVID testing. (Residents 80, 76, 89, 70, 87 and 92).
- 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, record review, and interview, the facility failed to protect the resident's right to be free from physical abuse by another resident for 3 of 4 residents reviewed for abuse. (Residents B, H, and J)
- D
Protect each resident from the wrongful use of the resident's belongings or money.
Inspectors wroteBased on record review, interview, and observation, the facility failed to ensure misappropriation of a resident's property had not occurred, related to a missing narcotic card for 1 of 3 residents reviewed for misappropriation. (Resident 71)
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on record review and interview, the facility failed to ensure preventative interventions were implemented for 3 of 4 residents reviewed for pressure ulcers. (Residents E, O, and F)
- 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 provide proper perineal and catheter care for 2 of 3 residents reviewed for bowel and bladder. (Residents M and D)
- D
Provide enough food/fluids to maintain a resident's health.
Inspectors wroteBased on observations, record review, and interview, the facility failed to ensure residents were monitored for weight loss and provided with assistance for eating for 3 of 6 residents reviewed for nutrition (Residents 89, 59, and 70)
- D
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
Inspectors wroteBased on record review and interview, the facility failed to ensure appropriate interventions were implemented to prevent recurrent resident to resident aggressive behaviors for 1 of 3 residents reviewed for behaviors. (Resident 45)
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure appropriate Infection Control practices related to transmission-based precautions (TBP) were implemented related to Aerosol-Generating Procedures (AGP's) for 2 of 2 random observations of care. (Resident 87)
Fire safety inspections
46 fire safety citations on file: 16 on May 8, 2025, 17 on May 16, 2024, 13 on March 3, 2023.
Every fire safety citation46 citations
- F
Install emergency lighting that can last at least 1 1/2 hours.
K 291 · May 8, 2025 · Corrected (the home has a date of correction)
- F
Have properly located and lighted "Exit" signs.
K 293 · May 8, 2025 · Corrected (the home has a date of correction)
- F
Meet other general requirements that are deficient.
K 300 · May 8, 2025 · Corrected (the home has a date of correction)
- F
Follow proper procedures when the fire alarm was out of service for more than 4 hours.
K 346 · May 8, 2025 · Corrected (the home has a date of correction)
- F
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
K 354 · May 8, 2025 · Corrected (the home has a date of correction)
- F
Install smoke barrier doors that can resist smoke for at least 20 minutes.
K 374 · May 8, 2025 · Corrected (the home has a date of correction)
- F
Provide a written emergency evacuation plan.
K 711 · May 8, 2025 · 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 · May 8, 2025 · Corrected (the home has a date of correction)
- F
Ensure that testing and maintenance of electrical equipment is performed.
K 921 · May 8, 2025 · 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 · May 8, 2025 · Corrected (the home has a date of correction)
- E
Install proper backup exit lighting.
K 281 · May 8, 2025 · Corrected (the home has a date of correction)
- E
Inspect, test, and maintain automatic sprinkler systems.
K 353 · May 8, 2025 · Corrected (the home has a date of correction)
- E
Provide properly sized and located linen or trash receptacles.
K 754 · May 8, 2025 · Corrected (the home has a date of correction)
- E
Have proper medical gas storage and administration areas.
K 923 · May 8, 2025 · Corrected (the home has a date of correction)
- C
Implement emergency and standby power systems.
E 41 · May 8, 2025 · Corrected (the home has a date of correction)
- C
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · May 8, 2025 · Corrected (the home has a date of correction)
- F
Address subsistence needs for staff and patients.
E 15 · May 16, 2024 · Corrected (the home has a date of correction)
- F
Establish procedures for tracking staff and patients during an emergency.
E 18 · May 16, 2024 · Corrected (the home has a date of correction)
- F
Implement emergency and standby power systems.
E 41 · May 16, 2024 · Corrected (the home has a date of correction)
- F
Meet other general requirements that are deficient.
K 300 · May 16, 2024 · Corrected (the home has a date of correction)
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · May 16, 2024 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · May 16, 2024 · Corrected (the home has a date of correction)
- F
Have simulated fire drills held at unexpected times.
K 712 · May 16, 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 · May 16, 2024 · Corrected (the home has a date of correction)
- E
Meet other general requirements.
K 100 · May 16, 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 · May 16, 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 · May 16, 2024 · Corrected (the home has a date of correction)
- E
Construct fire resistant interior walls.
K 331 · May 16, 2024 · Corrected (the home has a date of correction)
- E
Properly select, install, inspect, or maintain portable fire extinguishes.
K 355 · May 16, 2024 · Corrected (the home has a date of correction)
- E
Install corridor and hallway doors that block smoke.
K 363 · May 16, 2024 · Corrected (the home has a date of correction)
- E
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · May 16, 2024 · Corrected (the home has a date of correction)
- E
Have properly installed electrical wiring and gas equipment.
K 511 · May 16, 2024 · Corrected (the home has a date of correction)
- E
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
K 761 · May 16, 2024 · Corrected (the home has a date of correction)
- F
Install smoke barrier doors that can resist smoke for at least 20 minutes.
K 374 · March 3, 2023 · Corrected (the home has a date of correction)
- F
Have simulated fire drills held at unexpected times.
K 712 · March 3, 2023 · Corrected (the home has a date of correction)
- F
Provide properly sized and located linen or trash receptacles.
K 754 · March 3, 2023 · Corrected (the home has a date of correction)
- E
Keep aisles, corridors, and exits free of obstruction in case of emergency.
K 211 · March 3, 2023 · 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 3, 2023 · Corrected (the home has a date of correction)
- E
Have properly located and lighted "Exit" signs.
K 293 · March 3, 2023 · Corrected (the home has a date of correction)
- E
Provide properly protected cooking facilities.
K 324 · March 3, 2023 · Corrected (the home has a date of correction)
- E
Inspect, test, and maintain automatic sprinkler systems.
K 353 · March 3, 2023 · Corrected (the home has a date of correction)
- E
Install corridor and hallway doors that block smoke.
K 363 · March 3, 2023 · 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 · March 3, 2023 · Corrected (the home has a date of correction)
- E
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
K 761 · March 3, 2023 · Corrected (the home has a date of correction)
- D
Have properly installed electrical wiring and gas equipment.
K 511 · March 3, 2023 · Corrected (the home has a date of correction)
- D
Ensure proper usage of power strips and extension cords.
K 920 · March 3, 2023 · Corrected (the home has a date of correction)