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 46 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
3G
0H
0I
Potential for more than minimal harm
35D
7E
1F
Potential for minimal harm
0A
0B
0C
May 22, 2026Complaint inspection · 8 citations
- G
Ensure that residents are free from significant medication errors.
Inspectors wroteBased on clinical record review, staff interviews, facility document review, and policy review the facility failed to ensure that a resident was free of significant medication errors for 1 of 4 residents reviewed (Resident #1). On 4/1/26, staff failed to remove the plastic backing off of a Fentanyl (a powerful synthetic opioid) patch for which resulted in Resident #1 not receiving any medication through the patch and experiencing more pain and required an increase in the use of liquid morphine (a powerful, naturally occurring opioid analgesic derived from the opium poppy, primarily used to treat moderate to severe acute or chronic pain) medication until 4/3/26 when a new Fentanyl patch was replaced. The facility reported a census of 46 residents.
- D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteBased on clinical record review, policy and procedure review, resident and staff interviews the facility failed to treat a resident with respect and dignity in a manner that promotes maintenance or enhancement of his or her quality of life for 1 out of 4 residents reviewed. (Resident #4). The facility identified a census of 46 residents.
- 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 clinical record review, staff interview, and policy review, the facility failed to notify the physician of a pain patch that was not activated for 48 hours for 1 of 1 resident reviewed (Residents #1). The facility reported a census of 46 residents.
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on clinical record review, staff interview and review of policy and procedures, the facility failed to ensure all alleged violations of abuse involving mistreatment, neglect, and injuries of unknown source were reported to the Department of Inspection and Appeals and Licensing (DIAL) within 2 hours for 2 of 3 resident reviewed. (Resident #2 and Resident #9). The facility reported a census of 46 residents.
- D
Respond appropriately to all alleged violations.
Inspectors wroteBased on clinical record review, policy review, and staff interviews, the facility failed to investigate injuries of unknown injury for 2 of 3 residents reviewed (Resident #2 and Resident #9). Resident #2 had a bruise on the right wrist and Resident #9 had a bruise underneath the left eye. The facility reported a census of 46 residents.
- D
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 resident and staff interviews, call light logs and the facility policy/procedure, the facility staff failed to answer resident call lights in a timely manner (no longer than 15 minutes) for 3 of 4 residents reviewed (Resident #4, #5 and Resident #11). The facility identified a census of 46 residents.
- 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 clinical record review, facility investigation review, staff interview and facility policy review, the facility failed to properly destroy Resident #1's narcotic (pain) medication per facility policy/procedure. The facility identified a census of 46 residents.
- D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on clinical record review, staff interviews, and policy review the facility failed to maintain an accurate and complete resident clinical records for residents that had injuries of unknown origin for 2 of 3 residents reviewed (Resident #2 and Resident #9). The facility reported a census of 46 residents.
December 15, 2025Complaint inspection · 1 citation
- D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteBased on Electronic Health Record (EHR) review, resident interviews, family interviews, staff interviews and policy review the facility failed to provide dignity and respect when a nurse yelled at a resident about being outside of the facility and smoking on the sidewalk to 1 of 3 residents reviewed (Resident #1). The facility reported a census of 52 residents.
October 8, 2025Complaint inspection · 1 citation
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on clinical record review, family interview, resident interview, staff interview, and policy review the facility failed to assist residents with activities of daily living by not offering an opportunity to bathe for 2 of 3 residents reviewed (Resident #1,and #3). The facility reported a census of 56 residents.
June 26, 2025Standard inspection, Complaint inspection · 7 citations
- 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 clinical record review, family interview, staff interview, and policy review the facility failed to ensure 1 of 5 residents personal property was protected from loss or theft (Resident #14). The facility reported a census of 49 residents.
- D
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Inspectors wroteBased on document review, staff interviews, and the facility policy review, the facility failed to implement the abuse and neglect policy by not completing background checks prior to staff employment for 1 out of 5 staff reviewed. The facility reported a census of 49 residents.
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on electronic health record review, resident interview, personnel file review, facility policy review, and staff interview the facility failed to investigate and report alleged violations related to mistreatment to officials including the State Survey Agency in an appropriate time frame for 1 of 1 residents (Resident #37). The facility reported a census of 49 residents.
- D
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Inspectors wroteBased on clinical record review and staff interview, the facility failed to refer 2 residents with a negative Level I result for the Pre-admission Screening and Resident Review (PASRR), who were later identified with newly evident or possible serious mental disorder, intellectual disability, or other related condition, to the appropriate state-designated authority for Level II PASRR evaluation and determination for 2 out of 2 residents reviewed for PASRR requirements (Resident #16, #20). The facility reported a census of 49 residents.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on record review, resident and staff interviews, the facility failed to provide quality of nursing care by leaving a resident on a bed pan for an extensive period of time without a call light and not documenting the event for 1 of 1 residents reviewed (Resident #37). The facility reported a census of 49 residents.
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wrote2. Review of Resident #8's MDS dated [DATE] revealed a BIMS score of 13 indicating intact cognition. The MDS further revealed Resident #8 utilizes oxygen therapy. Review of Resident #8's EHR page titled, Physician's orders revealed an order for oxygen 1 Liters Per Minute (LPM) per nasal cannula at night while sleeping. Interview 6/23/25 at 1:02 PM with Resident #8 revealed that she just puts the oxygen on, and is unsure how often the tubing is changed. Observation 6/23/25 at 1:02 PM oxygen tubing was noted to be dated 4/16/25, and humidification bottle was noted to be dated 4/23/25. Interview 6/24/25 at 10:37 AM with Staff A RN (Registered Nurse) revealed she works here every other weekend with an agency, and oxygen tubing is to be changed weekly on Wednesdays. Staff A then revealed that there is a book that shows oxygen tubing is to be changed weekly on Wednesday nights. [...]
- D
Provide and implement an infection prevention and control program.
Inspectors wrote2. Review of Resident #9's MDS dated [DATE] revealed an admission date to the facility from a short-term general hospital stay 5/13/24. The MDS further revealed Resident #9 utilizes an indwelling catheter. Review of Resident #9's EHR page titled, Clinical Physician ' s Orders revealed an order for coudé (a type of urinary catheter with a curved or bent tip) catheter for infection control with a date of 4/22/25. Observation 6/25/25 at 11:06 AM Staff D Certified Nursing Assistant (CNA) brought Resident #9 into the bedroom to empty Resident #9's catheter drainage bag. Staff D then donned a gown and gloves with no hand hygiene. Staff D then obtained a urine graduate and placed it on a barrier on the floor. Staff D then drained the drainage bag without cleaning the drainage port of the drainage bag. After the drainage bag was emptied Staff D cleansed the drainage port with an alcohol wipe. [...]
October 22, 2024Complaint inspection · 2 citations
- E
Ensure services provided by the nursing facility meet professional standards of quality.
Inspectors wroteBased on record review, facility investigative file, staff interviews, resident interviews and facility policy review the facility failed to ensure staff followed professional standards while administering medications for 4 of 4 residents reviewed (Resident #3, #4, #5, and #6). The facility reported a census of 45 residents.
- D
Protect each resident from the wrongful use of the resident's belongings or money.
Inspectors wroteBased on observations, record review, facility camera footage review, staff interviews, resident interviews and facility policy review the facility failed to ensure 1 of 3 residents (Resident #1) was free from financial exploitation. The facility reported a census of 45 residents.
August 11, 2024Standard inspection · 10 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, staff interview, and policy review, the facility failed to maintain sanitary practices by failing to prevent cross-contamination while serving food. The facility reported a census of 49 residents.
- E
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Inspectors wroteBased on observations, menu review, and staff interviews, the facility failed to properly prepare and serve the appropriate portions of pureed diets for 3 of 3 residents and minced and moist diets for 7 of 7 residents. The facility reported a census of 49.
- E
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on observations, staff interviews, and policy review, the facility failed to properly protect resident information from unauthorized access. The facility reported a census of 49 residents.
- E
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, facility policy and staff interview, the facility failed to provide proper hand hygiene during toileting and urinary catheter care for 2 of 2 residents (Resident #1, Resident #35) observed. The facility also failed to perform hand hygiene between feeding two (2) residents. The facility reported a total census of 49 residents.
- D
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Inspectors wroteBased on clinical record review, resident interview and facility policy review, the facility failed to complete a bed hold notice with the resident or resident's responsible person when residents transferred out of the facility for 1 of 2 residents reviewed (Residents #12). The facility reported a census of 49 residents.
- D
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Inspectors wroteBased on clinical record review, staff interview, and policy review the facility failed to complete a Pre-admission Screening and Resident Review (PASRR) for 1 of 2 residents (Resident #20), who was diagnosed with new mental disorder diagnoses since admission to the facility. The facility reported a census of 49 residents.
- 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, clinical record review, staff interviews, and policy review, the facility failed to develop a resident-centered comprehensive care plan for 3 of 3 residents reviewed (Resident #5, #18, and #39). The facility reported a census of 49 residents.
- 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 clinical record review, resident interview, policy review and staff interview the facility failed to revise and update a care plan to include current transfer needs for 3 out of 4 residents reviewed (Resident #24, Resident #42, and Resident #16). The facility reported a census of 49 residents. Findings Included: 1. The Minimum Data Set (MDS) assessment dated 611/24 for Resident #24 documented diagnoses of pain in the left knee, muscle weakness and heart failure. The MDS showed a Brief Interview for Mental Status (BIMS) score of 15 which indicated no cognitive impairment. The Progress Notes for Resident #24 showed the following: a. On 8/6/24 at 3:08 PM Resident #24 returned back to the facility after a procedure. Resident #24 reported having pain down her left leg. b. On 8/7/24 at 6:47 PM Resident #24 required a total lift to transfer to the wheelchair. [...]
- D
Ensure services provided by the nursing facility meet professional standards of quality.
Inspectors wroteBased on observations, clinical record review, and policy review the facility failed to ensure physician's orders were followed for 1 of 1 resident (Resident #46) reviewed. The facility identified a census of 49 residents.
- 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 observation, clinical record review, staff interviews, and policy review, the facility failed to identify target behaviors for psychotropic mediation use for 2 of 3 residents reviewed ( Resident #18 & #39). The facility reported a census of 49 residents.
May 15, 2024Complaint inspection · 2 citations
- D
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 observations, electronic health record (EHR) review, document review, resident interviews, and staff interviews the facility failed to provide nursing staff to assure residents safety by not responding to call lights in a timely manner for 2 of 5 resident reviewed (Resident #9 and #10). The facility reported a census of 52 residents.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observations, clinical record review, policy review, and staff interviews the facility failed to provide appropriate infection prevention practices when completing blood sugar monitoring for 3 of 3 residents reviewed (Resident #4, #5, and #6). The facility reported a census of 52 residents.
June 6, 2023Standard inspection · 15 citations
- G
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on facility record review, hospital record review, resident, and staff interviews, the facility failed to investigate a change in condition for three of three residents reviewed (Residents #22, #25, and #42). Two of the residents had a sudden increase of pain (Residents #22 and #25). Resident #22 walked independently in the facility and experienced a bout of dizziness causing her to fall on 5/13/23. At the time of the fall, Resident #22 denied pain but started to report pain later that evening and requested pain medication. Resident #22 did not use any as needed medication until after her fall on 5/13/23. Resident #22 received no evaluation by a provider until 5/17/23. During the hospital stay, the staff determined Resident #22 had multiple compression fractures in her back. Resident #22 received treatment to one of the compression fractures involving an invasive procedure. [...]
- G
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on interviews, emergency room, hospital and facility record review, the facility failed to provide adequate nursing supervision to prevent injuries for 3 of 4 residents reviewed (Residents #22, #25, and #33) for falls. In addition, the facility failed to complete neurological assessments for 1 of 4 residents (Resident #22) reviewed for falls. Despite the facility documenting that Resident #25 had difficulties with standing with her transfers using the mechanical standing lift, no one adjusted the transfer technique to ensure her safety with transfers. Due to the staff continuing to transfer Resident #25 with an unsafe technique, she fell out of the standing lift resulting in a compression fracture in her back. [...]
- E
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Inspectors wroteBased on review of the facility schedule and staff interviews, the facility failed to have a Registered Nurse (RN) on duty for 8 hours a day, 7 days per week. The facility reported a census of 49 residents.
- E
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Inspectors wroteBased on observations interviews and record review the facility failed to destroy and have an accurate account for discontinued narcotic medications for 2 of 2 residents reviewed (Residents #25 and #101). Resident #25 and Resident #101 had their narcotic medications discontinued but the pills remained in the medication storage room and the medication cart.
- E
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Inspectors wroteBased on observations, resident, and staff interviews the facility failed to serve hot food to residents in their rooms. The facility reported a census of 48 residents.
- D
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Inspectors wroteBased on clinical record review and staff interviews, the facility failed to ensure resident's current code status was available for 1 out of 16 residents reviewed (Resident #201).
- 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 clinical record review, staff interview, and policy review the facility failed to notify the family for a significant change in condition for 1 of 16 residents reviewed (Residents #42) for pressure ulcers.
- D
Protect each resident from the wrongful use of the resident's belongings or money.
Inspectors wroteBased on observation, interviews, and chart review the facility failed to prevent the mishandling of a resident's narcotic medications for 1 of 4 residents reviewed (Resident #38).
- D
Respond appropriately to all alleged violations.
Inspectors wroteBased on facility record review, hospital record review, resident, and staff interviews, the facility failed to investigate the sudden increase of pain for a resident who received scheduled pain medication for chronic pain who used a standing lift for transfers for one of one resident reveiwed (Resident #25). Despite reports that Resident #25 had difficulty standing with the standing mechanical lift, the facility did not investigate the concern. Without investigation of the concern, the staff continued to transfer Resident #25 with the standing mechanical lift. After a change in condition, the facility sent Resident #25 to the hospital who discovered a compression fracture.
- 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 record review, facility policy review, resident, and staff interviews the facility failed to revise and update the Care Plan to address the increased needs of Activities of Daily Living (ADLs) for 1 of 1 residents reviewed (Resident #25).
- D
Ensure services provided by the nursing facility meet professional standards of quality.
Inspectors wroteBased on clinical record review, staff interviews, and policy review, the facility failed to provide care and services according to accepted standards of clinical practice for 2 of 16 residents reviewed (Residents #45 and #33). The facility failed to obtain weights as ordered by the physician for Resident #45. In addition, the facility failed to document the administration of medications, blood sugars, and bed time (HS) snacks for a diabetic resident.
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on observations, staff interviews, facility record review, and policy review the facility failed to ensure residents received the necessary interventions and care consistent with professional standards of practice to prevent deterioration of a wound, heal a stage 2 pressure ulcer, and prevent the development of new ulcers for 2 of 2 residents reviewed (Residents #251 and #24). The MDS (Minimum Data Set) assessment identifies the definition of pressure ulcers: Stage I is an intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have a visible blanching; in dark skin tones it may appear with persistent blue or purple hues. Stage II is partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough (dead tissue, usually cream or yellow in color). [...]
- D
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Inspectors wroteBased on clinical record review, staff interview and policy review the facility failed to complete dialysis assessments before and after outpatient hemodialysis treatments for 1 of 1 resident reviewed (Resident #42).
- D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on clinical record review and staff interviews, the facility failed to have a complete and accurate medical record for 2 of 16 residents reviewed (Residents #45 and #251). After Resident #45 fell, their clinical record lacked a progress note related to the incident. During incontinence cares, the facility staff observed open areas to Resident #251. After reporting the concerns to the nurse, the clinical record lacked documentation of his open areas.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observations, clinical record review, staff interviews, and policy review, the facility failed to provide a safe and sanitary environment to help prevent the development and transmission of communicable diseases and infections. The facility failed to follow hand hygiene and gloving practices consistent with accepted standards of practice for 1 of 2 residents reviewed (Resident #45) while providing catheter care.
Fire safety inspections
17 fire safety citations on file: 1 on June 26, 2025, 9 on August 11, 2024, 7 on June 6, 2023.
Every fire safety citation17 citations
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · June 26, 2025 · Corrected (the home has a date of correction)
- F
Develop and maintain an Emergency Preparedness Program (EP).
E 4 · August 11, 2024 · Corrected (the home has a date of correction)
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · August 11, 2024 · Corrected (the home has a date of correction)
- F
Provide a written emergency evacuation plan.
K 711 · August 11, 2024 · Corrected (the home has a date of correction)
- F
Have simulated fire drills held at unexpected times.
K 712 · August 11, 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 · August 11, 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 · August 11, 2024 · Corrected (the home has a date of correction)
- D
Inspect, test, and maintain automatic sprinkler systems.
K 353 · August 11, 2024 · Corrected (the home has a date of correction)
- D
Have an externally vented heating system.
K 522 · August 11, 2024 · Corrected (the home has a date of correction)
- D
Have proper medical gas storage and administration areas.
K 923 · August 11, 2024 · Corrected (the home has a date of correction)
- F
Conduct testing and exercise requirements.
E 39 · June 6, 2023 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · June 6, 2023 · Corrected (the home has a date of correction)
- F
Have simulated fire drills held at unexpected times.
K 712 · June 6, 2023 · 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 · June 6, 2023 · Corrected (the home has a date of correction)
- E
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
K 362 · June 6, 2023 · Corrected (the home has a date of correction)
- E
Ensure proper usage of power strips and extension cords.
K 920 · June 6, 2023 · Corrected (the home has a date of correction)
- D
Have properly installed electrical wiring and gas equipment.
K 511 · June 6, 2023 · Corrected (the home has a date of correction)