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 47 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
1J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
43D
1E
2F
Potential for minimal harm
0A
0B
0C
March 19, 2026Complaint inspection · 1 citation
- F
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 building was maintained in a sanitary and homelike environment. This had the potential to affect all residents residing in the facility. The facility census was 93.
December 9, 2025Complaint inspection · 2 citations
- D
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Inspectors wroteBased on record review, interview, policy review, and facility investigation report review, the facility failed to ensure residents were free from verbal abuse. This affected two (#12 and #22) of six residents reviewed. The facility census was 89.
- D
Respond appropriately to all alleged violations.
Inspectors wroteBased on record review, interview, policy review, and facility investigation report review, the facility failed to ensure allegations of abuse were thoroughly investigated. This affected one (#22) of two residents reviewed for abuse. The facility census was 89.
May 28, 2025Standard inspection, Complaint inspection · 17 citations
- E
Provide and implement an infection prevention and control program.
Inspectors wroteBased on record review, review of the facility's infection control tracking logs, observation, interview, and policy review, the facility failed to ensure all infections that occurred in the facility was included on their monthly infection control tracking log, trends/ patterns were identified by the infection preventionist when they occurred, and a resident with wounds was placed on enhanced barrier precautions as required. This affected one resident (#14) of five residents reviewed for unnecessary medications, one resident (#22) of four residents reviewed for pressure ulcers, and had the potential to affect all other residents residing in the facility. The facility's census was 84.
- D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wrote2 a.) On 05/18/25 11:58 A.M., an observation during the lunch meal service for the residents eating in their rooms on Unit 2 noted Certified Nursing Assistant (CNA) #187 to be feeding Resident #36, while the resident was in her bed. CNA #187 was standing at the side of the bed while feeding the resident. She was not noted to be sitting in a chair at the bedside to provide the resident with a dignified dining experience. 2 b.) On 05/18/25 at 12:00 P.M., an observation during the lunch meal service for the residents eating in their rooms on Unit 2 noted CNA #500 to be feeding Resident #57, while the resident was in her bed. CNA #500 was standing at the side of the bed while feeding the resident. She was not noted to be sitting in a chair at the bedside to provide the resident with a dignified dining experience. [...]
- D
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Inspectors wroteBased on review of self-reported incident (SRI), review of the facility's investigation, interviews, and policy review the facility failed to prevent resident neglect. This affected one resident (#73) of one resident reviewed for abuse.
- D
PASARR screening for Mental disorders or Intellectual Disabilities
Inspectors wroteBased on interview and medical record review the facility failed to ensure Preadmission Screening and Resident Review (PASARR) was completed accurately on admission. This affected one resident (#78) of one resident reviewed for PASARR. The facility census was 84.
- 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 record review, observation, interview, and policy review, the facility failed to ensure dental services were provided to Resident #32 and pressure ulcer prevention interventions were implemented for Resident #64 as per the plan of care. This affected three residents (Resident #32 and #64) of 27 residents reviewed for care plans.
- 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 observation, record review, interview, and policy review, the facility failed to ensure care conferences were completed timely following a resident's significant change Minimum Data Set (MDS) assessment and care plans were revised in the areas of dental status and to reflect a resident's reported non-compliance with non-pressure skin impairment interventions. This affected one resident (#32) of two residents reviewed for care conferences and two residents (#7 and #16) of 22 residents reviewed for care plans.
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on observation, interview and record review the facility failed to provide timely incontinence care for a resident and failed to provide timely nail care for a resident. This affected two residents (#2 and #14) of seven residents reviewed for activities of daily living.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on observations, medical record review, staff interview, and policy review, the facility failed to comprehensively assess and provide treatment to skin integrity concerns. This affected one resident (#73) of two reviewed for non-pressure skin impairments. The facility census was 84.
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on record review, observation, staff interview, and policy review, the facility failed to ensure skin prevention interventions were implemented for residents at risk for or having had pressure ulcers and also failed to ensure a resident's pressure ulcer was comprehensively assessed weekly to monitor for wound healing. This affected three residents (#16, #64, and #73) of four residents reviewed for pressure ulcers.
- 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 staff interviews, the facility failed to provide timely contracture management. This affected one resident (#56) of one resident reviewed for contractures. Facility census was 84.
- D
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Inspectors wroteBased on record review, staff interview, and policy review, the facility failed to ensure there was consistent communication between the facility and the dialysis center on the days a resident went out for hemodialysis treatments. This affected one resident (#62) of one resident reviewed for dialysis.
- D
Provide care or services that was trauma informed and/or culturally competent.
Inspectors wroteBased on record review and staff interview, the facility failed to provide services to prevent Resident #78 from experiencing triggers related to post traumatic stress disorder (PTSD). This affected one resident (#78) of one resident reviewed for PTSD. The facility census was 84.
- D
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
Inspectors wroteBased on record review, staff interview, review of a drug reference resource, and policy review, the facility failed to ensure a resident received a short acting anti-anxiety medication in accordance with their physician's orders to adequately manage anxiety. This affected one resident (#48) of five residents reviewed for behavioral-emotional care.
- D
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Inspectors wroteBased on medical record review, review of pharmacy recommendation, and interviews the facility failed to implement pharmacy recommendation and physician orders. This affected one resident (#14) of five residents reviewed for unnecessary medication review.
- 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 facility policy review, the facility failed to ensure insulin pens were dated when opened. This affected three residents (#26, #49 and #192) of three residents reviewed for insulin use.
- D
Provide or obtain dental services for each resident.
Inspectors wroteBased on record review, review of the facility's contracted dental company's visit list, resident interview, and staff interview, the facility failed to ensure a resident, who consented to receive dental services while in the facility, received those services to replace a broken lower denture plate. This affected one resident (#32) of three residents reviewed for dental services.
- D
Implement a program that monitors antibiotic use.
Inspectors wroteBased on review of the facility's infection control log, staff interview, and policy review, the facility failed to ensure residents were not treated with antibiotics for urinary tract infections, unless the residents met criteria for treatment. This affected two residents (#63 and #91), who were noted on the monthly infection control logs for the past three months to receive antibiotics without meeting criteria for treatment.
January 30, 2025Complaint inspection · 4 citations
- D
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Inspectors wroteBased on record review, review of the facility's related investigation, observation, staff interview, employee file review, and policy review, the facility failed to ensure a resident was free from staff to resident sexual abuse and another resident was free from neglect when the resident was left on a bed pan for fourteen (14) hours. This affected two residents (#44 and #46) of four residents reviewed for abuse/ neglect.
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on record review, review of the facility's related investigation, observation, staff interview, review of employee files, and policy review, the facility failed to ensure allegations of staff to resident sexual abuse and resident neglect were reported to the State survey agency as required. This affected two residents (#44 and #46) of four residents reviewed for abuse/ neglect.
- D
Respond appropriately to all alleged violations.
Inspectors wroteBased on record review, review of the facility's related investigation, staff interview, and policy review, the facility failed to ensure an allegation of sexually inappropriate behavior between a resident and a staff member was recognized as possible sexual abuse and investigated as required. This affected one resident (#44) of four residents reviewed for abuse/ neglect.
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteTHE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY Based on record review, review of the facility's related investigation, observation, staff interview, and policy review, the facility failed to ensure a resident who entered the facility without any skin breakdown received the care and services to prevent an avoidable pressure ulcer from developing. This affected one resident (#46) of two residents reviewed for pressure ulcers.
September 9, 2024Complaint inspection · 1 citation
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on medical record review, review of the shower/bathing schedule, review of shower sheets, review of concern log, interviews, and policy review the facility failed to ensure dependent residents received showers per preference. This affected three residents (#17, #52, and #70) of four residents reviewed for showers.
April 26, 2024Standard inspection · 9 citations
- J
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteTHE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on record review, review of the facility incident and accident log and corresponding investigation, review of the Facility Assessment, review of the Elopement Risk Assessment Policy and Procedure and staff, family and resident interviews, the facility failed to provide adequate supervision to Resident #74, who was actively exit seeking, cognitively impaired (with a Brief Interview Memory Score of six indicating severe cognitive impairment), identified as an elopement risk and resided on the secured unit, to prevent the resident from exiting the secured unit and the facility unsupervised. This resulted in Immediate Jeopardy and the potential for serious, life-threatening harm, injuries and/or death on 03/14/24 at approximately 5:50 P.M. [...]
- D
Reasonably accommodate the needs and preferences of each resident.
Inspectors wroteBased on observation, medical record review, electronic mail (email) communication review, interviews, and review of the facility policy, the facility failed to reasonably accommodate the request of Resident #72's family/responsible party to install an electronic monitoring device (camera of choice) in Resident #72's room. This affected one resident (#72) of five residents reviewed for unnecessary medication use. The facility census was 85.
- D
Keep residents' personal and medical records private and confidential.
Inspectors wroteBased on observation, interview, and policy review, the facility failed to ensure Resident #16's medical record was maintained in a secure and confidential manner. This affected one (Resident #16) of one resident reviewed for confidentiality of medical records. The facility census was 85.
- D
Respond appropriately to all alleged violations.
Inspectors wroteBased on record review, facility investigation review, interview and policy review the facility failed to ensure a thorough investigation was completed regarding a resident elopement. This affected one resident (Resident #74) of two residents reviewed for accidents. The facility census was 85.
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on record review, review of shower schedules, observation, resident interview, staff interview, and policy review, the facility failed to ensure residents, who were dependent on staff for personal care, were provided the assistance they required for showers and nail care. This affected three (Resident #26, #41, and #236) of five residents received for activities of daily living (ADL).
- D
Assist a resident in gaining access to vision and hearing services.
Inspectors wroteBased on record review, review of audiology visit reports, resident interview, and staff interview, the facility failed to ensure a resident was seen by an audiologist as requested by the resident and/ or her resident representative. This affected one (Resident #26) of two residents reviewed for ancillary services. The facility census was 85.
- D
Provide appropriate foot care.
Inspectors wroteBased on observation, record review, interview, and policy review, the facility failed to ensure residents received routine, preventative foot care. This affected one resident (#2) of two residents reviewed for ancillary services. The facility census was 85.
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observation, record review, resident and staff interviews, review of the facility policy, and review of manufacture instructions, the facility failed to ensure Resident #8's continuous positive airway pressure (CPAP) mask was properly cleaned. This affected one (Resident #8) out of three residents reviewed for respiratory care. The facility census was 85.
- 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, pharmacy review, and interview the facility failed to ensure physician orders were implemented after a pharmacy recommendation and failed to provide rationale for extending as needed psychotropic medication beyond 14 days. This affected one resident (Resident #62) of five residents reviewed for unnecessary medications. The facility census was 85.
December 19, 2023Complaint inspection · 2 citations
- D
Protect each resident from the wrongful use of the resident's belongings or money.
Inspectors wroteBased on record review, review of a self- reported incident (SRI), facility policy review, and interview, the facility failed to ensure resident medications were not misappropriated by facility staff. This affected one resident (#13) of four residents reviewed for abuse. The facility census was 82.
- 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 utilize the starter box from the pharmacy to administer the correct medication to a resident when their medication was not able to be located. This affected one resident (#13) of one resident reviewed for medications. The facility census was 82.
October 3, 2023Complaint inspection · 1 citation
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observation, interview, record review and policy review the facility failed to provide oxygen as ordered by the physician. This affected two Residents (#2 and #26) of three reviewed for oxygen. The facility census was 86.
September 27, 2022Standard 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, facility policy and procedure review and interview the facility failed to ensure cold foods were held and served at appropriate temperatures. This had the potential to affect all 78 residents residing in the facility.
- D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteBased on observation, open and closed record review, interview, resident handbook review and facility policy and procedure review the facility failed to ensure residents were provided the opportunity to exercise their right to smoke according to the facility smoking policy and failed to ensure new admissions were notified of the facility new smoking procedures upon admission. This affected two residents (#12 and #284) of two residents reviewed for smoking. The facility identified seven residents who smoke. The census was 78.
- 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 record review and interview the facility failed to revise a comprehensive person-centered care plan following a fall for Resident #38. This affected one resident (#38) of three residents reviewed for falls.
- 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 Resident #59, who required staff assistance with activity of daily living (ADL) care received timely and adequate assistance with nail care to maintain good hygiene/grooming. This affected one resident (#59) of three residents reviewed for ADL care.
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on observation, record review, facility policy and procedure review and interview, the facility failed to ensure a pressure ulcer treatment was provided as ordered for Resident #50. This affected one resident (#50) of two residents reviewed for pressure ulcers.
- 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 ensure Resident #51, who had a limitation in range of motion/contracture to the left hand was provided a hand roll as ordered by the physician. This affected one resident (#51) of one resident reviewed for range of motion.
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on closed record review, facility investigation review, facility policy and procedure review and interview the facility failed to provide adequate and appropriate supervision/interventions to prevent resident elopements and failed to ensure comprehensive elopement investigations were completed to potentially prevent reoccurrence. This affected two residents (#82 and #285) of two residents reviewed for elopement.
- 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, facility policy and procedure review and interview the facility failed to provide appropriate care in a manner to decrease the risk of Resident #78 developing a urinary tract infection. This affected one resident (#78) of one resident observed for incontinence care.
- D
Implement a program that monitors antibiotic use.
Inspectors wroteBased on record review, facility policy and procedure review and interview the facility failed to ensure Resident #9 did not receive an antibiotic without an adequate indication for use and meeting criteria for the treatment of a urinary tract infection (UTI). This affected one resident (#9) of five residents reviewed for unnecessary medication use.
- D
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Inspectors wroteBased on record review, facility policy and procedure review and interview, the facility failed to develop and implement a comprehensive and individualized immunization program to ensure influenza and/or pneumococcal immunizations were provided to Resident #68 and Resident #231 when indicated. This affected two residents (#68 and #231) of six residents reviewed for influenza and pneumococcal immunizations.
Fire safety inspections
5 fire safety citations on file: 2 on May 28, 2025, 2 on April 26, 2024, 1 on September 27, 2022.
Every fire safety citation5 citations
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · May 28, 2025 · Corrected (the home has a date of correction)
- F
Have simulated fire drills held at unexpected times.
K 712 · May 28, 2025 · Corrected (the home has a date of correction)
- E
Install an approved automatic sprinkler system.
K 351 · April 26, 2024 · Corrected (the home has a date of correction)
- E
Ensure proper usage of power strips and extension cords.
K 920 · April 26, 2024 · Corrected (the home has a date of correction)
- E
Have proper medical gas storage and administration areas.
K 923 · September 27, 2022 · Corrected (the home has a date of correction)