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 50 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
3J
0K
0L
Actual harm
1G
0H
0I
Potential for more than minimal harm
36D
8E
1F
Potential for minimal harm
0A
0B
1C
June 17, 2026Standard inspection · 5 citations
- F
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview and document review the facility failed to keep linen carts covered that were in the communal hallways. The facility also failed to offer hand hygiene to the residents prior to meal service. Lastly the facility failed to identify and investigate a foodborne pathogen that was diagnosed in a resident. This had the potential to affect all residents in the facility.
- D
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
Inspectors wroteBased on interview and document review, the facility failed to have a new order and a face-to-face provider visit every 14 days performed prior to renewing an as needed antipsychotic medication. This affected 1 of 5 (R34) residents reviewed for unnecessary medications.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure the use of thromboembolism-deterrent stockings (TEDs) as ordered for edema care. This affected 1 of 1 (R45) resident reviewed for edema.
- D
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Inspectors wroteBased on observation, interview and document review, the facility failed to provide monitoring to a dialysis site following a dialysis treatment for 1 of 1 resident (R9) reviewed for dialysis care.
- C
Post nurse staffing information every day.
Inspectors wroteBased on observation, interview, and document review the facility failed to ensure daily staffing data was posted over the weekend. This deficient practice had the potential to affect any resident, family member, or visitor who wished to view the posting.
June 4, 2026Complaint inspection · 1 citation
- J
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on interview, and document review the facility failed to reduce the risk of falls for 1 of 3 residents (R1) reviewed when R1 was care planned to use two staff for transfers with a mechanical lift and nursing assistant (NA)-A attempted a mechanical lift transfer with one staff, R1 fell from the sling onto the floor sustaining a left femur fracture, head laceration and injury to left toes. The immediate jeopardy began on [DATE] when NA-A attempted a mechanical lift transfer with one staff, R1 fell from the sling onto the floor sustaining a left femur fracture, head laceration, and injury to left toes. R1 was care planned to use two staff for transfers with a mechanical lift and was identified on [DATE]. The administrator and director of nursing (DON) were notified of the IJ on [DATE] at 2:48 p.m. [...]
December 19, 2025Complaint inspection · 1 citation
- E
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Inspectors wroteBased on interview and document review the facility failed to ensure controlled substances were accurately reconciled to prevent loss and diversion for 6 of 6 residents (R1, R2, R3, R4, R5, R6,) reviewed for narcotic diversion. A report to the State Agency (SA) dated 11/25/25, indicated a police report identified medications were found in possession of a former employee of the facility. The report identified the following medications and empty packages. Prescribed to R1:Hydrocodone/acetaminophen 5 milligrams (mg) -325mg, total prescribed 18. Prescribed to R2:Clonazepam 0.5 mg empty, total prescribed 29. Prescribed to R3:Gabapentin 100 mg, containing 4 tablets, total prescribed 30. Prescribed to R4:Lorazepam 1mg, total prescribed 30. Prescribed to R5:Oxycodone 5 mg empty, total prescribed 28. Oxycodone 5 mg empty, total prescribed 8. [...]
March 27, 2025Standard inspection, Complaint inspection · 13 citations
- E
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on interview, and document review the facility failed to notify the provider as ordered for a weight increase of 3 pounds (lb.) or more in 24 hours for 1of 2 residents (R27). The facility also failed to follow fluid restrictions as ordered for 2 of 2 residents (R27, R28). The facility also failed to address elevated blood glucose levels for 1 of 1 resident (R16). The facility also failed to have a resident assessed for usage of a walker for 1 of 1 resident (R12) reviewed for provider orders.
- E
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on observation, interview, and document review, the facility failed to maintain proper food storage temperature in a unit refrigerator containing resident food. Furthermore, the facility failed to ensure refrigerated food items were properly labeled and dated. This deficient practices had the potential to affect all residents and visitors using unit refigerators to store food.
- E
Provide and implement an infection prevention and control program.
Inspectors wroteBased observation, interview and record review the facility failed to ensure nebulizer equipment was properly washed, dried and stored for 2 of 2 residents (R29, R14); that equipment for tube feeding tube flushes was properly dated, rinsed, dried and stored for 1 of 1 residents (R16); and the facility failed to ensure proper PICC line cap placement occured for 1 of 1 resident (R200) who were reviewed for infection prevention and control.
- D
Allow residents to self-administer drugs if determined clinically appropriate.
Inspectors wroteBased on observation, interview, and document review facility failed to perform a self-administration of medication assessment and obtain provider order to have medication left in room for 2 of 2 (R13 and R29) residents reviewed for self-administration of medication. R13's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated R13 had intact cognition. Diagnoses included heart failure, hypertension and renal insufficiency. During an observation of R13's room on 3/24/25 at 3:17 p.m., a box with a tube of diclofenac cream was noted on the shelf to the right of the bed. During an interview on 3/24/25 at 3:17 p.m., R13 stated the staff utilize the diclofenac cream on her back and just leave it on the shelf so it would be available when they needed it. [...]
- 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 interview and document review, the facility failed to ensure advanced directives for emergency care and treatment were accurately reflected in all areas of the medical chart to ensure resident wishes would be implemented correctly in an emergent situation for 1 of 16 residents (R200) reviewed for advanced directives.
- D
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Inspectors wroteBased on interview and document review, the facility failed to provide the Skilled Nursing Facility Advanced Beneficiary Notice (SNFABN; CMS-10055) to 1 of 3 residents (R54) reviewed whose Medicare Part A coverage ended while in the facility.
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on interview and document review the facility failed to perform prescribed dressing changes to a pressure ulcer as ordered for 1 of 3 residents (R27) reviewed for pressure ulcers.
- D
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Inspectors wroteBased on interview and record review, the facility failed to consistently monitor dialysis access site for 1 of 1 resident (R27) reviewed for dialysis care.
- D
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 observation, interview, and record review the facility failed to ensure licensed staff were educated and competent in the administration of intravenous medications (IV) and/or the management and care of peripherally inserted central catheters (PICC) [a long thin tube inserted into a vein on the inside of the upper arm that extends into a larger vein leading to the heart for medication, blood, and nutrition administration] for 1 of 1 residents (R200) reviewed for PICC line care and management. This deficient practice had the potential to impact all residents at the facility who had IV/PICC access and/or received medications through IV/PICC access.
- D
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Inspectors wroteBased on interview and document review the facility failed to make sure pharmacy recommendations were addressed timely for 2 of 5 residents (R28, R33) reviewed for unnecessary medications.
- D
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Inspectors wroteBased on interview and document review the facility failed to have an appropriate diagnosis for use of medication for 1 of 5 residents (R28) reviewed for unnecessary medications.
- 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 interview and document review the facility failed to have an appropriate diagnosis for use of an antipsychotic for 1 of 5 residents (R28) reviewed for unnecessary medications. In addition, the facility failed to complete orthostatic blood pressure (series of blood pressures taken while lying, sitting, and standing) monitoring for an antipsychotic medication for 1 of 1 residents (R33).
- 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 document review the facility failed to ensure medications were properly labeled with direction for use for 1 of 1 resident (R13).
December 4, 2024Complaint inspection · 1 citation
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on observation, interviews, and documentation review the facility failed to properly provide maintenance to maintain bed wheel locks to prevent bed from moving during transfers for 1 of 3 residents (R2) resident reviewed for falls.
June 20, 2024Complaint inspection · 2 citations
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on interview and document review, the facility failed to ensure physician orders to obtain a Basic Metabolic Panel (BMP), and Urine Analysis (UA)/Urine Culture (UC) with susceptibility and sensitivity, timely for 1 of 3 residents (R1) reviewed, who was diagnosed with a urinary tract infection (UTI)
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on observation, interview and document review, the facility failed to provide adequate supervision for 1 of 3 residents (R1) reviewed, who was cognitively impaired and able to leave the building without staff's knowledge into the courtyard which resulted in a fall and being able to exit the secured area. In addition, the facility failed to implement fall interventions for 1 of 3 residents (R1), who was at high risk for falls.
April 5, 2024Complaint inspection · 2 citations
- D
Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
Inspectors wroteBased on interview and document review, the facility failed to ensure discharge summary requirements were met, which included a recapitulation of resident's stay (a concise summary of the resident's stay and course of treatment in the facility) and a final summary of the resident's status at discharge, as well as communicating resident's condition upon discharge with receiving the facility for 1 of 1 residents (R1) reviewed.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on interview and document review, the facility failed to ensure injuries following a fall were monitored for healing for 1 of 3 residents (R1) reviewed.
March 22, 2024Complaint inspection · 2 citations
- J
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 interview and document review the facility failed to provide the physician ordered textured diet for 1 of 3 residents (R1) who subsequently choked and required the Heimlich Maneuver. This was an Immediate Jeopardy (IJ) for R1 who required hospitalization following the choking incident where she was determined to have aspirated and required mechanically assisted ventilation. The IJ began on 3/9/24, at approximately 6:30 p.m. when R1 was found by nursing assistant (NA)-A in the common area of the unit observed as pale, lips blue and unable to speak. R1 was administered the Heimlich Maneuver, suction and was sent to the hospital where she subsequently required mechanically assisted ventilation. The IJ was identified on 3/22/24, and the administrator was notified of the IJ on 3/22/24, at 1:00 p.m. [...]
- D
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Inspectors wroteBased on interview and document review the facility failed to ensure 1 of 1 residents (R1) was re-assessed for supervision with eating following a diet change order.
March 7, 2024Complaint inspection · 1 citation
- G
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on observation, interview and document review the facility failed to ensure an environment free from hazards. This resulted in actual harm to R1 who sustained a second degree burn when his knee rested against the baseboard heater and he was unable to move his knee or call for help. The deficient practice was corrected prior to the start of the survey and was therefore issued at past noncompliance.
January 11, 2024Standard inspection · 17 citations
- E
Give residents a notice of rights, rules, services and charges.
Inspectors wroteBased on interview and document review, the facility failed to ensure the resident [NAME] of Rights were provided in writing and ongoing for residents of the facility for 5 of 5 residents (R7, R15, R26, R43, R50) interviewed during resident meeting. This deficient practice had the potential to affect all 54 residents residing in the facility.
- E
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Inspectors wroteBased on interview and document review, the facility failed to have a process to assess, offer and provide the most recent Centers for Disease Control (CDC) education regarding the potential risks and benefits of the pneumococcal vaccine for 4 of 5 residents (R7, R13, R14, R24) reviewed for immunizations. This had the potential to affect all residents who were eligible for the pneumococcal booster.
- E
Keep all essential equipment working safely.
Inspectors wroteBased on observation, interview, and document review the facility failed to ensure preventative maintenance and weight calibration was conducted on three scales. This had the opportunity to affect 29 residents at the facility who are routinely weighed with these scales.
- D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure clothing (other than a hospital type gown) was offered or provided for 1 of 3 residents (R205) reviewed for dignity. In addition, the facility failed to ensure bathing was offered or provided for 1 of 3 residents (R5) reviewed for dignity. The facility also failed to ensure a Medicare notification of non-coverage for therapy was delivered in a private and dignified manor for 1 of 3 residents (R42) reviewed for resident rights.
- D
Allow residents to self-administer drugs if determined clinically appropriate.
Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure self-administration of medications were assessed for safety and care planned accordingly to reduce the risk of an adverse event for 1 of 1 residents R31 reviewed for self-administration of medication.
- D
Reasonably accommodate the needs and preferences of each resident.
Inspectors wroteBased on observation, interview, and document review the facility failed to ensure 1 of 1 resident (R23) had access to their call light.
- D
Ensure each resident receives an accurate assessment.
Inspectors wroteBased on observation, interview and document review, the facility failed to correctly code Minimum Data Set (MDS) Section L. Oral/Dental Status to ensure dental issues were addressed in the plan of care for 1 of 1 resident (R12) reviewed for MDS accuracy.
- 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, interview and document review, the facility failed to provide quarterly care conferences for 1 of 4 residents (R17) reviewed for care planning.
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on observation, interview and document review, the facility failed to ensure routine bathing was offered or provided to promote good hygiene for 1 of 5 residents (R5) reviewed for activities of daily living (ADLs) and who was dependent on staff for their cares.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on observation, interview and document review, the facility failed to appropriately position 1 of 3 residents (R24) reviewed for pressure ulcers.
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on observation, interview and document review, the facility failed to follow care plan interventions for 1 of 2 residents (R33) reviewed for smoking.
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure tracheostomy cares were followed for 1 of 1 resident (R31) reviewed for tracheostomy (an opening in the trachea [windpipe] from the outside to allow air and oxygen to reach the lungs) care. In addition, the facility failed to ensure oxygen use parameters were followed and oxygen tubing was changed in a timely manner for 1 of 2 residents (R31) reviewed for respiratory care.
- D
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Inspectors wroteBased on observation, interview, and document review the facility failed to ensure dialysis assessments and treatments were completed as ordered and documented per policy for 2 of 2 residents (R43 and R12) reviewed for dialysis care.
- D
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Inspectors wroteBased on interview and document review, the facility failed to ensure the consultant pharmacist recommendations were addressed for 1 of 5 residents (R31) reviewed for unnecessary medications.
- 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 and interview, the facility failed to ensure medications were dated when opened in 3 of 3 med carts reviewed for medication storage. This had the opportunity to affect five residents (R51, R46, R14, R35, R6).
- D
Provide routine and 24-hour emergency dental care for each resident.
Inspectors wroteBased on interview, observation, and document review, the facility failed to coordinate necessary dental services for 1 of 1 resident (R12) reviewed for dental services.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure proper hand hygiene and glove use practices were maintained for 1 of 3 residents (R24) observed during wound care.
December 1, 2023Complaint inspection · 2 citations
- E
Respond appropriately to all alleged violations.
Inspectors wroteBased on interview and document review, the facility failed to protect facility residents from potential abuse when they allowed an alleged perpetrator (AP) (licensed practical nurse (LPN)-A) to work after an allegation of misappropriation of resident property (drug diversion). This had the potential to affect all seven residents who resided on Wing 3, who were ordered opioid (narcotic/pain) medication(s).
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on interview and document review, the facility failed to report allegations of misappropriation of resident property to the State Agency (SA) within 24 hours of the allegation for 1 of 3 residents (R1) reviewed for drug diversion.
October 13, 2023Complaint inspection · 3 citations
- J
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on interview and document review the facility failed to maintain resident safety when a resident (R1) who was assessed to be at risk for elopement verbalized his intent to leave the facility, left without staff knowledge and was returned to the facility by two strangers. Further, R1 was allowed to discharge home against medical advice from the facility even though he had been assessed to have cognitive impairment and admitted due to recurrent falls. This resulted in an immediate Jeopardy (IJ) situation for R1. The IJ began on 9/30/23, when R1 left the facility without staff knowledge. R1 was found by two strangers on a highly-trafficked four lane highway with a cut on his nose. Additionally, within two hours of R1' s return to the facility, R1 wanted to return home. [...]
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on interview and document review the facility failed to report an elopement to state agency (SA) for 1 of 1 residents (R1) who eloped from the facility without staff knowledge.
- D
Respond appropriately to all alleged violations.
Inspectors wroteBased on interview and document review the facility failed to thoroughly investigate an elopement for 1 of 1 residents (R1) who left the facility without staff knowledge and was found by two strangers on the highway.
Fire safety inspections
15 fire safety citations on file: 5 on June 17, 2026, 7 on March 27, 2025, 3 on January 11, 2024.
Every fire safety citation15 citations
- F
Install properly constructed and protected linen or trash chutes.
K 541 · June 17, 2026 · Corrected (the home has a date of correction)
- F
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · June 17, 2026 · Corrected (the home has a date of correction)
- E
Ensure proper usage of power strips and extension cords.
K 920 · June 17, 2026 · 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 · June 17, 2026 · Corrected (the home has a date of correction)
- D
Inspect, test, and maintain automatic sprinkler systems.
K 353 · June 17, 2026 · Corrected (the home has a date of correction)
- F
Have simulated fire drills held at unexpected times.
K 712 · March 27, 2025 · Corrected (the home has a date of correction)
- F
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
K 761 · March 27, 2025 · Corrected (the home has a date of correction)
- E
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
K 321 · March 27, 2025 · Corrected (the home has a date of correction)
- E
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · March 27, 2025 · 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 · March 27, 2025 · Corrected (the home has a date of correction)
- D
Install corridor and hallway doors that block smoke.
K 363 · March 27, 2025 · Corrected (the home has a date of correction)
- D
Ensure proper usage of power strips and extension cords.
K 920 · March 27, 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 · January 11, 2024 · Corrected (the home has a date of correction)
- D
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · January 11, 2024 · Corrected (the home has a date of correction)
- D
Install smoke barrier doors that can resist smoke for at least 20 minutes.
K 374 · January 11, 2024 · Corrected (the home has a date of correction)