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
0G
0H
0I
Potential for more than minimal harm
25D
19E
0F
Potential for minimal harm
0A
2B
0C
July 31, 2026Complaint inspection · 2 citations
- D
Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs.
Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure residents' meals were served according to their nutritional needs, special dietary needs, and preferences for 4 (Resident #R4, Resident #R5, Resident #R6, Resident #R7) of 6 residents investigated for dietary services.
- D
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, interviews, and record review, the facility failed to serve the dietician approved pureed menu for 1 of 2 meals observed for staff following the correct menu. This deficient practice was identified for 2 (Resident #R4, Resident #R8) of the 5 residents who had orders for a pureed diet.
March 12, 2026Complaint inspection · 3 citations
- 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 interviews and record review, the facility failed to ensure a residents responsible party was immediately notified of a fall for 1 (Resident #1) of 4 sampled residents reviewed for falls.
- 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 interviews and record reviews, the facility failed to ensure a resident's care plan to prevent falls included an individualized resident-centered intervention for 2 (Resident #1, Resident #2) of 4 sampled residents reviewed for falls.
- D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on interviews and record review, the facility failed to document a resident's newly identified wound in the resident's clinical record for 1 (Resident #6) of 3 sampled residents reviewed for pressure ulcers
December 4, 2025Complaint inspection · 1 citation
- D
Protect each resident from the wrongful use of the resident's belongings or money.
Inspectors wroteBased on interviews and record reviews, the facility failed to ensure residents were free from financial misappropriation for 1 (Resident #2) of 3 sampled residents investigated for abuse.
June 10, 2025Standard inspection · 7 citations
- E
Honor the resident's right to manage his or her financial affairs.
Inspectors wroteBased on interviews and record review, the facility failed to ensure that funds were available for resident use for 1 (Resident #23) of 1 (Resident #23) sampled residents reviewed for personal funds.
- E
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to: 1. Ensure staff donned personal protective equipment (PPE) prior to providing wound care services to residents on Enhanced Barrier Precautions (EBP) (Resident #31); 2. Ensure staff performed hand hygiene before and after administering medications (Resident #89, Resident #91, Resident #97); and, 3. Ensure staff performed hand hygiene before and after feeding residents (S6Activity Director). [...]
- D
Allow residents to self-administer drugs if determined clinically appropriate.
Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to assess a resident for self-administration of medications for 2 (Resident #40, Resident #108) of 29 (Resident #8, Resident #16, Resident #20, Resident #23, Resident #24, Resident #26, Resident #31, Resident #38, Resident #39, Resident #40, Resident #48, Resident #53, Resident #57, Resident #60, Resident #65, Resident #73, Resident #79, Resident #83, Resident #84, Resident #94, Resident #100, Resident #103, Resident #108, Resident #110, Resident #111, Resident #112, Resident #113, Resident #164, Resident #215) sampled residents observed for medications available at the bedside.
- D
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Inspectors wroteBased on observations and interview, the facility failed to ensure bathrooms were clean and sanitary for 2 (Room C, Room D) of 2 (Room C, Room D) bathrooms observed for environment requirements.
- 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 interviews and record review, the facility failed to accurately update a resident's care plan for 2 (Resident #8, Resident #57) of 2 (Resident #8, Resident #57) sampled residents reviewed for accuracy of care plans.
- D
Make sure that a working call system is available in each resident's bathroom and bathing area.
Inspectors wroteBased on observations, interviews and record review the facility failed to ensure call lights were available for resident use for 2 (Resident #20, Resident #53) of 2 (Resident #20, Resident #53) sampled residents investigated for call bell availability.
- D
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Inspectors wroteBased on observations and interview, the facility failed to maintain a functional environment by failing to ensure a water facet was functional in1 (Room B) of 1 (Room B) rooms observed for a functional environment.
February 26, 2025Complaint inspection · 3 citations
- E
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 observations, interviews, and record reviews, the facility failed to ensure: 1. A resident's indwelling catheter tubing and bag were changed monthly as ordered (Resident #3); and, 2. Indwelling urinary catheter tubing and collection bags were not on the floor (Resident #3, Resident #R4). This deficient practice was identified for 2 (Resident #3, Resident #R4) of 2 (Resident #3, Resident #R4) sampled residents investigated for urinary catheter care and Urinary Tract Infections (UTI).
- E
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Inspectors wroteBased on interviews and record reviews, the facility failed to ensure controlled drugs were accurately reconciled for 4 (Medication Cart a, Medication Cart b, Medication Cart c, Medication Cart d) of 4 (Medication Cart a, Medication Cart b, Medication Cart c, Medication Cart d) medication carts reviewed for the reconciliation documentation of controlled substances.
- 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 observations and interviews, the facility failed to ensure eight opened insulin (a medication that lowers blood glucose) multi-dose vials were dated when opened and/or discarded as required for 3 (Medication Cart a, Medication Cart b, Medication Cart c) of 4 (Medication Cart a, Medication Cart b, Medication Cart c, Medication Cart d) medication carts observed.
June 5, 2024Standard inspection · 6 citations
- E
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 record reviews, observations and interviews, the facility failed to: 1. ensure a resident's water, used for jejunostomy tube (J-tube is a soft, plastic tube placed through the skin of the abdomen into the midsection of the small intestine. The tube delivers food and medicine) flushes, was labeled properly; and, 2. ensure a resident's feeding syringe was labeled, dated and clean. This deficient practice was identified for 1 (Resident #72) of 3 (Resident #57, Resident #64, and Resident 72) sampled residents investigated for enteral feeding.
- D
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Inspectors wroteBased on record reviews and interviews, the facility failed to ensure a resident received specialized psychological service recommendations for 1 (Resident #65) of 1 (Resident #65) sampled residents reviewed for PASRR (Preadmission Screening and Resident Review).
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on record reviews, interviews and observations, the facility failed to ensure a resident's oxygen equipment was dated and stored in a sanitary manner when not in use for 1 (Resident #92) of 1 (Resident #92) sampled residents reviewed for respiratory care.
- 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 reviews and interviews, the facility failed to ensure a physician was notified of a pharmacist recommendation for 2 (Resident #8 and Resident #94) of 5 (Resident #8, Resident #19, Resident #74, Resident #89, and Resident #94) sampled residents reviewed for unnecessary medications.
- 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 reviews and interviews, the facility failed to have accurate documentation for the route of medication administration for 2 (Resident #64 and Resident #72) of 3 (Resident #57, Resident #64, and Resident 72) sampled residents investigated for enteral feeding.
- D
Make sure that a working call system is available in each resident's bathroom and bathing area.
Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a functional call bell was available for 1 (Resident #77) of the 4 (Resident #23, Resident #47, Resident #72, and Resident #77) investigated for environmental issues.
May 8, 2024Complaint inspection · 1 citation
- E
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on record reviews and interviews, the facility failed to ensure a resident that required two plus person assistance with transfers was transferred with at least two persons and the facility failed to prevent a resident fall for 1(Resident #1) of 3 (Resident #1, Resident #2 and Resident #3) sampled residents reviewed for accidents hazards.
April 4, 2024Complaint inspection · 1 citation
- E
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on interviews and record review, the facility failed to report and investigate an allegation of physical abuse to the State agency for 1 (Resident #3) of 5 (Resident #1, Resident #2, Resident #3, Resident #4, and Resident #5) sampled residents investigated for abuse.
December 19, 2023Complaint inspection · 2 citations
- D
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Inspectors wroteBased on interview and record review, the facility failed to ensure staff implemented their Policy & Procedure for abuse for 1(Resident #3) of 3 (Resident #1, Resident #2, and Resident #3) sampled residents reviewed for abuse.
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on record reviews and interviews, the facility failed to ensure an allegation of physical abuse was reported immediately, but not later than 2 hours after the incident was discovered to the State Survey Agency for 1 (Resident #1) of 3 (Resident #1, Resident #2 and Resident #3 ) sampled residents reviewed for abuse.
August 14, 2023Standard inspection · 20 citations
- E
Keep residents' personal and medical records private and confidential.
Inspectors wroteBased on record review, observation, and interview, the facility failed to ensure residents were provided with privacy during care for 3 (Resident #30, Resident #43 and Resident #313) of 22 (Resident #10, Resident #29, Resident #53, Resident #45, Resident #97, Resident #48, Resident #42, Resident #264, Resident #43, Resident #24, Resident #313, Resident #106, Resident #1, Resident #101, Resident #89, Resident #17, Resident #91, Resident #74, Resident #30, Resident #18, Resident #73, and Resident #49) sampled residents observed for privacy.
- 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, record review, and interview, the facility failed to: 1. Ensure dining room tables were in good repair for 7 of 27 tables present in the dining room; 2. Ensure the residents' bathrooms had soap present in the soap dispensers for 4 (Resident #1, Resident #18, Resident #30, and Resident #101) of 7 (Resident #1, Resident #17, Resident #18, Resident #24, Resident #30, Resident #101, and Resident #313) sampled resident rooms observed for environmental concerns; 3. Ensure the residents' bathrooms had paper towels in the dispensers for 2 (Resident #18 and Resident #30) of 7 (Resident #1, Resident #17, Resident #18, Resident #24, Resident #30, Resident #101, and Resident #313) sampled resident rooms observed for environmental concerns; 4. [...]
- E
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on record review and interview, the facility failed to ensure allegations of physical abuse were reported within 2 hours of the allegation being made for 3 (Resident # 45, Resident #49, and Resident #263) of 5 (Resident #10, Resident # 45, Resident #49, Resident #101 and Resident #263) sampled residents reviewed for abuse.
- E
Respond appropriately to all alleged violations.
Inspectors wroteBased on record review and interview the facility failed to: 1. Thoroughly investigate a resident's allegations of abuse and/or neglect for 3 (Resident # 45, Resident #49, and Resident #263) of 5 (Resident #10, Resident # 45, Resident #49, Resident #101 and Resident #263) sampled residents reviewed for abuse; and, 2. Protect residents from the potential of further abuse during the investigation process for 2 (Resident # 45 and Resident #49) of 5 (Resident #10, Resident # 45, Resident #49, Resident #101 and Resident #263) sampled residents reviewed for abuse.
- E
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 record review and interview, the facility failed to review and revise the residents' care plan after completion of quarterly review assessment for 2 (Resident #18 and Resident #91) of 24 sampled residents.
- E
Provide safe, appropriate pain management for a resident who requires such services.
Inspectors wroteBased on record review, observation, and interview, the facility failed to accurately assess and document the presence of pain for 2 (Resident #17 and Resident #101) of 2 (Resident #17 and Resident #101) residents reviewed for pain.
- E
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Inspectors wroteBased on record review and interview, the facility failed to ensure communication with a resident's dialysis facility for 1 (Resident #48) of 1 (Resident #48) sampled residents reviewed for dialysis.
- E
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Inspectors wroteBased on record review and interview, the facility failed to ensure Certified Nursing Assistants (CNA's) had completed annual competencies as required for 5 (S4CNA, S31CNA, S33CNA, S37CNA, and S38CNA)of 6 (S4CNA, S13CNA, S31CNA, S33CNA, S37CNA, and S38CNA) CNAs reviewed for annual competencies. Review of S4CNA's personnel file revealed, in part, the last annual competency documented was 07/28/2022. Review of S31CNA's personnel file revealed, in part, the last annual competency documented was 07/26/2022. Review of S33CNA Supervisor's personnel file revealed, in part, the last annual competency documented was 07/28/2022. Review of S37CNA's personnel file revealed, in part, the last annual competency documented was 07/28/2022. Review of S38CNA's personnel file revealed, in part, the last annual competency documented was 07/28/2022. [...]
- E
Observe each nurse aide's job performance and give regular training.
Inspectors wroteBased on record review and interview, the facility failed to complete annual performance evaluations for certified nursing assistants (CNA) for 6 (S4CNA, S13CNA, S31CNA, S33CNA, S37CNA, and S38CNA) of 6 (S4CNA, S13CNA, S31CNA, S33CNA, S37CNA, and S38CNA) CNA personnel files reviewed.
- E
Post nurse staffing information every day.
Inspectors wroteBased on observation and interview, the facility failed to post the required nurse staffing information on a daily basis.
- E
Provide and implement an infection prevention and control program.
Inspectors wroteBased on record review and interview, the facility failed to implement the facility's policy for the prevention of Legionella Disease.
- D
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Inspectors wroteBased on record review, observations, and interviews, the facility failed to implement their abuse policies and procedures to prevent resident abuse, neglect, exploitation and misappropriation of property by failing to ensure unlicensed staff who worked in the facility had a completed criminal background on file prior to providing care to residents for 2 (S6Agency Certified Nursing Assistant and S7Agency Certified Nursing Assistant) of 2 unlicensed contract staff personnel files reviewed.
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on record review, observation, and interview, the facility failed to ensure a new interventions were implemented following a resident's fall to prevent future falls for 1 (Resident #42) of 4 (Resident #42, Resident #106, Resident #264, and Resident #313) sampled residents reviewed for accident hazards.
- 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 record review, observation, and interview, the facility failed to ensure a resident's indwelling urinary catheter was secured for 1 (Resident #313) of 1 sampled residents reviewed for urinary catheter or urinary tract infection.
- D
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Inspectors wroteBased on record review, observation, and interview, the facility failed to administer intravenous (medication administered directly into the vein) medications per professional standards and physician's orders for 1 (Resident #264) of 1 (Resident #264) sampled residents investigated for intravenous medication administration.
- 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 record reviews, observations, and interviews, the facility failed to ensure medications were locked and not available for use at a resident's bedside for 1 (Resident #264) of 22 (Resident #10, Resident #29, Resident #53, Resident #45, Resident #97, Resident #48, Resident #42, Resident #264, Resident #43, Resident #24, Resident #313, Resident #106, Resident #1, Resident #101, Resident #89, Resident #17, Resident #91, Resident #74, Resident #30, Resident #18, Resident #73, and Resident #49) sampled residents observed for medications left at the bedside.
- D
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on observations and interviews the facility failed to: 1. Failed to discard expired milk in 1 of 1 nourishment refrigerators. 2. Failed to ensure Orange and cranberry juice were stored at a proper temperature to prevent food borne illness.
- D
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
Inspectors wroteBased on record review, and interview, the facility failed to ensure Quality Assurance and Performance Improvement (QAPI) committee meetings were held quarterly.
- B
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Inspectors wroteBased on record review and interview, the facility failed to ensure Minimum Data Set (MDS) assessments were transmitted to Centers for Medicare and Medicaid Services (CMS) within 14 days of the completion date for 6 (Resident #19, Resident #56, Resident #58, Resident #73, Resident #85, and Resident #96) of 6 (Resident #19, Resident #56, Resident #58, Resident #73, Resident #85, and Resident #96) residents reviewed for Resident Assessment.
- B
Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
Inspectors wroteBased on record review and interviews, the facility failed to electronically submit accurate payroll information for direct care staffing as required.
Fire safety inspections
8 fire safety citations on file: 1 on June 10, 2025, 4 on June 5, 2024, 3 on August 14, 2023.
Every fire safety citation8 citations
- D
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · June 10, 2025 · Corrected (the home has a date of correction)
- D
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 · June 5, 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 · June 5, 2024 · Corrected (the home has a date of correction)
- D
Inspect, test, and maintain automatic sprinkler systems.
K 353 · June 5, 2024 · Corrected (the home has a date of correction)
- D
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · June 5, 2024 · Corrected (the home has a date of correction)
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · August 14, 2023 · Corrected (the home has a date of correction)
- D
Meet other general requirements.
K 100 · August 14, 2023 · 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 · August 14, 2023 · Corrected (the home has a date of correction)