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 37 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
1G
0H
0I
Potential for more than minimal harm
29D
6E
1F
Potential for minimal harm
0A
0B
0C
March 27, 2026Standard inspection · 7 citations
- D
Ensure that residents are fully informed and understand their health status, care and treatments.
Inspectors wroteBased on clinical record review, observation, and resident and staff interviews, it was determined the facility failed to ensure one of 17 residents reviewed (Resident 8) was fully informed of, and participated in decision-making regarding, a restriction preventing the resident from using the bathroom connected to the bedroom.
- 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 review of clinical records, facility policy, admission documentation, and staff interview, it was determined the facility failed to provide and maintain required written admission information and documentation for one of 17 residents reviewed (Resident 63).
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on a review of clinical records, select facility policy, and staff interview, it was determined the facility failed to ensure licensed nurses accurately administered prescribed medication consistent with professional standards of practice for one of five residents sampled for unnecessary medications (Resident 1).
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observations, review of clinical records, select facility policy review, and staff interview it was determined the facility failed to consistently ensure the provision of respiratory care and supplemental oxygen in accordance with physician orders and facility policy for one resident out of 17 residents reviewed. (Resident 65)
- D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Inspectors wroteBased on clinical record review, select policy review, and staff and resident interview, it was determined the facility failed to ensure the timely acquisition and availability of prescribed medications for one of 20 residents reviewed (Resident 7).
- 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 observation, resident interview, staff interview, and review of facility practices, it was determined the facility failed to ensure effective management and execution of the duties and responsibilities of the food and nutrition services department to provide timely meal service for three of 17 residents reviewed (Residents 66, 23, and 8).
- D
Provide or get specialized rehabilitative services as required for a resident.
Inspectors wroteBased on observations, clinical record review, select facility policy review, and staff and family interviews, it was determined that the facility failed to provide and ensure implementation of specialized rehabilitative services in accordance with professional standards of practice for positioning assessment, intervention, care planning, and staff training for 1 of 17 residents reviewed (Resident 12).
December 1, 2025Complaint inspection · 1 citation
- D
Respond appropriately to all alleged violations.
Inspectors wroteBased on a review of select facility policy, facility investigative reports, clinical records, and staff interviews, it was determined the facility failed to ensure a complete and accurate investigation was conducted into an allegation of misappropriation of medication for one of ten sampled residents (Resident 1).
May 30, 2025Standard inspection · 6 citations
- G
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on review of clinical records, facility policies, documentation provided by the facility, and staff interviews, it was determined the facility failed to consistently provide adequate supervision and implement appropriate, individualized fall prevention interventions based on assessed needs to ensure the safety of one of 18 sampled residents (Resident 50), resulting in multiple unwitnessed falls and significant injury, including a traumatic subdural hemorrhage and multiple fractures of the arm.
- 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, a review of facility-provided documents, and employee interviews, it was determined the facility failed to maintain acceptable practices for the storage and service of food to prevent the potential for contamination, including rodent activity, which increased the risk of food-borne illness in multiple areas of the kitchen.
- E
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Inspectors wroteBased on observations, a review of facility-provided documents, and resident and employee interviews, it was determined the facility failed to maintain an effective pest control program, including observations made on one of the three nursing units (Grey Unit- bedrooms of Residents 4, 23, and 39), experiences reported by one resident out of 18 sampled (Resident 23), and experiences reported by two residents during a group interview (Residents 27 and 28).
- D
Ensure that residents are fully informed and understand their health status, care and treatments.
Inspectors wroteBased on clinical record review, observation, and staff interviews, it was determined the facility failed to ensure that one resident out of 18 sampled (Resident 26) was afforded the right to participate in care and treatment decisions, to be fully informed of treatment, and to make choices about preferred treatment options.
- 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 review of clinical records, select facility policy, and staff interview, it was determined the facility failed to consistently provide restorative nursing services as planned to maintain mobility for one resident (Resident 53) out of 13 residents sampled.
- 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, review of select facility policy and clinical records, and staff interviews, it was determined the facility failed to adhere to acceptable storage and labeling for multi-dose medications in one of two medication carts observed (Teal Hall).
September 20, 2024Complaint inspection · 6 citations
- E
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on a review of facility investigative documentation, clinical records, and staff interviews it was determined the facility failed to provide nursing services consistent with professional standards of quality to ensure that licensed nurses promptly assessed and evaluated a resident after a significant medication error occurred to assure the resident received necessary care and services timely for one resident (Resident 1) and failed to implement physician's orders for wound treatments for two residents (Resident 3 and 4) out of 12 sampled.
- 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 review of clinical records, and staff interview, it was determined that the facility failed to timely notify the physician and the resident's responsible party of medication error for one resident out of 12 sampled (Resident 1).
- 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 a review of clinical records, a facility investigative report, nurse competencies and staff interview, it was determined the facility failed to to ensure that licensed nursing staff possessed the skills and competencies necessary to assure administration of medications accurately and safely for one resident out of 12 sampled (Residents 1).
- D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Inspectors wroteBased on a review of pharmacy documentation, clinical records and staff interviews it was determined the facility failed to implement procedures to assure timely acquiring and administration of medications to one of 12 sampled residents (Resident 4).
- D
Ensure that residents are free from significant medication errors.
Inspectors wroteBased on review of resident clinical records, select facility policy, facility investigative reports, and staff interview it was revealed the facility failed to assure that one of 12 residents reviewed were free of significant medication errors (Resident 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 review of clinical records and staff interview, it was determined the facility failed to maintain accurate and complete clinical records, according to professional standards of practice for one of 12 sampled residents (Resident 1).
July 31, 2024Standard inspection · 10 citations
- E
Provide safe, appropriate pain management for a resident who requires such services.
Inspectors wroteBased on a review of clinical records and select facility policy review and staff interview, it was determined that the facility failed to timely respond to a resident's increased level of pain and provide an effective pain management to alleviate pain for one resident of 13 residents sampled (Resident 52).
- 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 observation and staff interview, it was determined that the facility failed to maintain a safe, sanitary, and orderly environment in the resident's main dining room area.
- D
Protect each resident from the wrongful use of the resident's belongings or money.
Inspectors wroteBased on a review of clinical records, select facility policy and investigative reports and staff interview, it was determined that the facility failed to implement procedures to identify and prevent potential misappropriation of resident property, medications, for one resident out of 13 sampled (Resident 49).
- D
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Inspectors wroteBased on observation, clinical record review and staff interview, it was determined that the facility failed to timely develop and implement a person-centered care plan to meet one resident's current needs for two of 13 sampled resident (Resident 26). Findings including: Clinical record review revealed that Resident 26 was admitted to the facility on [DATE], with diagnoses to include dementia. [...]
- D
Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
Inspectors wroteBased on clinical record review and staff interview, it was determined that the facility failed to complete a discharge summary, which included a recapitulation of the resident's stay, the course of illness, corresponding treatment, discharge instructions, and a post-discharge care plan for one of three discharged resident records reviewed (Resident 23).
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on review of clinical records and staff interview it was determined that the facility failed to provide nursing services consistent with professional standards of quality by failing to ensure that licensed nurses accurately administered prescribed medication to one of 13 sampled residents (Resident 13).
- 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 clinical record and select facility policy review and staff interview, it was determined that the facility failed to clinically justify the use of a foley (indwelling) catheter for two of 4 sampled residents with catheters (Resident 7 and 24).
- D
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Inspectors wroteBased on a review of clinical records and staff interview, it was determined that the facility failed to develop and implement an effective individualized person-centered plan to address a resident's dementia-related behavioral symptoms for one out of 13 residents reviewed (Resident 29).
- 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 review clinical records and staff interviews, it was determined that the facility failed to ensure that a resident was free from unnecessary psychoactive drugs by failing to ensure the presence of clinical rationale for the continued use of an as needed psychotropic medication for one of five residents reviewed (Resident 29).
- D
Provide or obtain dental services for each resident.
Inspectors wroteBased on review of clinical records and staff interview, it was determined that the facility failed to follow-up with required dental services for one Medicaid payor source out of 13 residents sampled. (Resident 37).
April 16, 2024Complaint inspection · 3 citations
- F
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Inspectors wroteBased on observations and interviews with resident sand staff, it was determined that the facility failed to maintain an effective pest control program.
- 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 and staff interview, it was determined that the facility failed to maintain acceptable practices for the storage and service of food to prevent the potential for contamination and microbial growth in food, which increased the risk of food-borne illness.
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on observation, clinical record review and staff interview, it was determined that the facility failed to maintain an environment free of potential accident hazards to the extent possible on one of three resident hallways (Rooms 9-16).
November 14, 2023Complaint inspection · 4 citations
- E
Ensure that residents are free from significant medication errors.
Inspectors wroteBased on a review of clinical records and select facility reports and staff interview it was determined that the facility failed to assure that one resident out of six sampled was free from a significant medication error. (Resident 2).
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on a review of clinical records, information submitted by the facility and the facility's abuse prohibition policy and staff interviews, it was revealed the facility failed to timely report an injury of unknown origin, a fractured arm, and the results of the facility's completed investigation into possible resident abuse or neglect within 5 working days of the incident to the State Survey agency for one of four residents reviewed (Resident 2).
- D
Respond appropriately to all alleged violations.
Inspectors wroteBased on a review of the facility's abuse prohibition policy and procedures, facility provided documentation, and clinical records and interviews with staff it was determined that the facility failed to timely and thoroughly investigate an injury of unknown source to rule out abuse, neglect or mistreatment for one of the four residents sampled (Resident 2).
- 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 a review of clinical records, select facility reports and employee personnel files, and resident and staff interviews it was determined that the facility failed to assure that licensed and professional nursing staff possessed the necessary skills and competencies to accurately perform medication administration as prescribed to one resident out of four sampled (Resident 1).
Fire safety inspections
12 fire safety citations on file: 5 on March 27, 2026, 4 on May 30, 2025, 3 on July 31, 2024.
Every fire safety citation12 citations
- E
Inspect, test, and maintain automatic sprinkler systems.
K 353 · March 27, 2026 · Corrected (the home has a date of correction)
- E
Properly select, install, inspect, or maintain portable fire extinguishes.
K 355 · March 27, 2026 · Corrected (the home has a date of correction)
- E
Install corridor and hallway doors that block smoke.
K 363 · March 27, 2026 · 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 · March 27, 2026 · Corrected (the home has a date of correction)
- C
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · March 27, 2026 · Corrected (the home has a date of correction)
- E
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · May 30, 2025 · Corrected (the home has a date of correction)
- E
Inspect, test, and maintain automatic sprinkler systems.
K 353 · May 30, 2025 · Corrected (the home has a date of correction)
- E
Install corridor and hallway doors that block smoke.
K 363 · May 30, 2025 · Corrected (the home has a date of correction)
- E
Have simulated fire drills held at unexpected times.
K 712 · May 30, 2025 · Corrected (the home has a date of correction)
- E
Keep aisles, corridors, and exits free of obstruction in case of emergency.
K 211 · July 31, 2024 · 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 · July 31, 2024 · Corrected (the home has a date of correction)
- E
Inspect, test, and maintain automatic sprinkler systems.
K 353 · July 31, 2024 · Corrected (the home has a date of correction)