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 40 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
39D
1E
0F
Potential for minimal harm
0A
0B
0C
June 3, 2026Complaint inspection · 2 citations
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on record review and interview, the facility failed to ensure residents were administered insulin and accuchecks (blood sugar testing) were completed as ordered for 2 of 3 residents reviewed for medications and accuchecks. (Residents C and D)
- D
Ensure medication error rates are not 5 percent or greater.
Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure a medication error rate of less than 5% for 1 of 3 residents observed during medication pass. Two errors were observed during 33 opportunities for errors during medication administration. This resulted in a medication error rate of 6.06%. (Resident G)
December 9, 2025Standard inspection · 6 citations
- D
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Inspectors wroteBased on observation, record review and interview, the facility failed to develop and implement a care plan related to the use of a Continuous Passive Motion (CPM) machine for 1 of 2 residents reviewed for rehab and restorative. (Resident 64)
- 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 compression glove was in place per the physician's order, there was adequate monitoring of use of the compression glove and medications were available and administered as ordered for 1 of 1 resident reviewed for edema and for 1 of 21 records reviewed. (Resident 58)
- D
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Inspectors wroteBased on observation, record review and interview, the facility failed to obtain Physician Orders and coordinate care between departments related to the use of a Continuous Passive Motion (CPM) machine for 1 of 2 residents reviewed for rehab and restorative care. (Resident 64)
- D
Provide safe, appropriate pain management for a resident who requires such services.
Inspectors wroteBased on observation, record review and interview, the facility failed to ensure a resident was assessed and treated for pain prior to wound care for 1 of 2 residents reviewed for pressure ulcers. (Resident 71)
- D
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medication was labeled correctly, a bag of normal saline (NS) 0.9% was not expired, and a tube of zinc paste was stored to prevent cross-contamination for 1 of 4 medication carts and 1 of 2 medication rooms. (Healthcare 1)
- D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on observation, record review and interview, the facility failed to ensure resident records were accurate related to documentation of an air mattress in place and intravenous (IV) flushes for 2 of 21 records reviewed. (Residents 71 and 61)
July 1, 2025Complaint inspection · 1 citation
- D
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Inspectors wroteBased on record review and interview, the facility failed to ensure prn (as needed) medications were administered with documentation for an indication for use for 1 of 3 residents reviewed for hospice. (Resident C)
February 18, 2025Complaint inspection · 2 citations
- D
Not require residents to give up Medicare or Medicaid benefits, or pay privately as a condition of admission; and must tell residents what care they do not provide.
Inspectors wroteBased on record review and interview, the facility failed to implement the admission policy, related to an admission Agreement not explained and signed by a resident who had been admitted into the facility for 1 of 1 resident reviewed for admission Agreement implementation. (Resident D)
- D
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Inspectors wroteBased on record review and interview, the facility failed to ensure a resident received blood sugar monitoring to determine if insulin was required (sliding scale) for 1 of 3 residents reviewed for unnecessary medications. (Resident B)
September 10, 2024Standard inspection · 11 citations
- 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 observation, record review, and interview, the facility failed to ensure a resident's preferences were honored related to allowing the resident to leave their room while in contact isolation for 1 of 1 resident reviewed for choices. (Resident 261)
- 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 record review and interview, the facility failed to ensure staff were knowledgeable regarding the residents' code status for 3 of 5 residents reviewed for advanced directives. (Residents 160, 50, and 261)
- D
Ensure each resident receives an accurate assessment.
Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure the comprehensive assessment was accurate related to dental status for 1 of 17 residents whose comprehensive assessments were reviewed. (Resident 6)
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure dependent residents received at least 2 baths a week and had their hair washed at least weekly for 2 of 4 residents reviewed for activities of daily living. (Residents 41 and 158)
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure surgical bandages were changed as ordered by the physician for 1 of 2 resident reviewed for skin conditions non-pressure. (Resident 41)
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure a resident with a pressure ulcer had interventions in place related to not floating their heels when in bed for 1 of 3 residents reviewed for pressure ulcers. (Resident 31)
- 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, record review, and interview, the facility failed to ensure a peg tube (a tube inserted into the stomach for nutrition) was cleaned on a daily basis and according to facility policy for 1 of 2 residents reviewed for peg tubes. (Resident 41)
- D
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure a resident's PICC (peripherally inserted central catheter) line had Physician's Orders for the care and monitoring of a PICC line for 1 of 1 residents reviewed for PICC lines. (Resident 31)
- 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 record review and interview, the failed to ensure a PRN (as needed) psychotropic medication was not ordered longer than 14 days for 1 of 5 residents reviewed for unnecessary medications. (Resident 25)
- D
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Inspectors wroteBased on observation, record review, and interview, the facility failed to store medicated creams and loose pills properly for 1 of 1 resident and 1 of 2 medication carts observed during medication storage. (Resident 41 and Health Care 2 medication cart)
- 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 observation, record review, and interview, the facility failed to ensure the resident's environment was clean and sanitary related to an uncontained bed pan for 1 of 3 units. (Health Care Center 2)
February 20, 2024Complaint inspection · 6 citations
- E
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure infection control guidelines were in place and implemented, related to cleaning of reusable equipment and hand hygiene after direct resident contact and glove removal, for random observations of infection control. (Residents P, D, R and S)
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure bandages were changed and treatments were completed as ordered by the Physician for a diabetic ulcer and a non pressure ulcer, for 1 of 3 residents reviewed for skin conditions. (Resident P)
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure a resident with pressure ulcers received the necessary care and treatment to promote healing, related to treatments not completed as ordered, and bandages not secure and in place as ordered, for 1 of 3 residents reviewed for pressure ulcers. (Resident O)
- 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, record review, and interview, the facility failed to ensure gastrostomy enteral feedings were infusing at the correct time, tubing was changed at least every 24 hours, stoma sites were cleaned as ordered, and medications were administered per facility policy, for 3 of 3 residents reviewed for peg tubes (a tube inserted into the stomach for nutrition). (Residents L, D, and M)
- D
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Inspectors wroteBased on record review and interview, the facility failed to manage medications appropriately, related to not administering antibiotic and pain medication as ordered by the Physician, for 2 of 3 residents reviewed for infections and 1 of 3 residents reviewed for pain medications. (Residents B, P and L)
- 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 clinical records were complete, related to the determination to discontinue 15 minute checks for a resident who was observed in his room with an unlit cigarette, for 1 of 3 residents reviewed for supervision. (Resident K)
September 19, 2023Complaint inspection · 1 citation
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure a Physician's Order was in place for a resident who received oxygen for 1 of 3 residents reviewed for oxygen. (Resident G)
August 11, 2023Standard inspection · 11 citations
- D
Allow residents to self-administer drugs if determined clinically appropriate.
Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure residents had Physician's Orders for medications and an assessment to self-administer their own medications for 1 of 1 residents reviewed for self-administration of medication. (Resident 41)
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure dependent residents received assistance with ADLs (activities of daily living) related to bathing, nail care, shaving, and clean clothing and linens for 2 of 4 residents reviewed for ADLs. (Residents 110 and 37)
- 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 fall follow-ups and neurological checks were initiated and/or completed following a fall for 1 of 3 residents reviewed for falls. (Resident 213)
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on record review and interview, the facility failed to ensure a resident with pressure ulcers received the necessary treatment and services to promote healing, related to treatments not completed as ordered and treatment orders not updated timely for 2 of 2 residents reviewed for pressure ulcers. (Residents 49 and 212)
- D
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a contracture was identified, treated, and monitored, and splints were applied as ordered for 2 of 4 residents reviewed for range of motion (ROM). (Residents 37 and 212).
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure oxygen was being administered at the correct flow rate for 1 of 1 residents reviewed for oxygen. (Resident 24)
- D
Ensure that residents are free from significant medication errors.
Inspectors wroteBased on record review and interview, the facility failed to ensure residents were free of significant medication errors related to timing of insulin administration for 1 of 1 residents reviewed for insulin. (Resident 18)
- D
Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.
Inspectors wroteBased on record review and interview, the facility failed to ensure specimens for laboratory testing were collected as ordered by the Physician for 1 of 1 residents reviewed for laboratory services (Resident 49).
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure infection control guidelines were in place and implemented, including those to prevent and/or contain COVID-19, related to improper cleaning of reusable equipment, improper hand hygiene between glove use, and improper disposal of a lancet for 1 of 6 residents observed during medication pass (Resident 45, LPN 1).
- D
Implement a program that monitors antibiotic use.
Inspectors wroteBased on record review and interview, the facility failed to promote antibiotic stewardship by ensuring the appropriate use of antibiotic therapy to reduce antibiotic resistance related to a practitioner prescribing antibiotics for wounds without being cultured for 1 of 2 residents reviewed for pressure ulcers. (Resident 49).
- 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 observation and interview, the facility failed to ensure the residents' environment was clean and in good repair related to urine odor and ripped carpet on 2 of 3 units. (Healthcare 2 Unit and TCU Unit)
Fire safety inspections
21 fire safety citations on file: 15 on December 9, 2025, 6 on August 11, 2023.
Every fire safety citation21 citations
- F
Implement emergency and standby power systems.
E 41 · December 9, 2025 · Corrected (the home has a date of correction)
- F
Install an approved automatic sprinkler system.
K 351 · December 9, 2025 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · December 9, 2025 · Corrected (the home has a date of correction)
- F
Meet other general requirements that are deficient.
K 500 · December 9, 2025 · Corrected (the home has a date of correction)
- F
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · December 9, 2025 · Corrected (the home has a date of correction)
- F
Ensure proper usage of power strips and extension cords.
K 920 · December 9, 2025 · Corrected (the home has a date of correction)
- F
Ensure that testing and maintenance of electrical equipment is performed.
K 921 · December 9, 2025 · Corrected (the home has a date of correction)
- F
Have proper fire barriers, ventilation and signs for the transfilling of oxygen.
K 927 · December 9, 2025 · 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 · December 9, 2025 · Corrected (the home has a date of correction)
- E
Provide properly protected cooking facilities.
K 324 · December 9, 2025 · Corrected (the home has a date of correction)
- E
Have properly installed electrical wiring and gas equipment.
K 511 · December 9, 2025 · 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 · December 9, 2025 · Corrected (the home has a date of correction)
- E
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
K 761 · December 9, 2025 · Corrected (the home has a date of correction)
- D
Keep aisles, corridors, and exits free of obstruction in case of emergency.
K 211 · December 9, 2025 · Corrected (the home has a date of correction)
- D
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · December 9, 2025 · Corrected (the home has a date of correction)
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · August 11, 2023 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · August 11, 2023 · Corrected (the home has a date of correction)
- E
Meet other general requirements.
K 100 · August 11, 2023 · Corrected (the home has a date of correction)
- E
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
K 225 · August 11, 2023 · Corrected (the home has a date of correction)
- E
Ensure proper usage of power strips and extension cords.
K 920 · August 11, 2023 · Corrected (the home has a date of correction)
- C
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · August 11, 2023 · deficient, provider has