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 36 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
5G
0H
0I
Potential for more than minimal harm
18D
12E
1F
Potential for minimal harm
0A
0B
0C
July 16, 2026Complaint inspection · 3 citations
- E
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Inspectors wroteBased on observation, record review, and interviews, the facility failed to maintain an effective controlled substance reconciliation system, which included reconciling Resident (R) 1's narcotic medication upon delivery.
- D
Protect each resident from the wrongful use of the resident's belongings or money.
Inspectors wroteBased on observation, record review, and interviews, the facility failed to prevent misappropriation of a narcotic medication for Resident (R) 1.
- D
Ensure that residents are free from significant medication errors.
Inspectors wroteBased on record review and interviews, the facility failed to prevent a significant medication error when on 06/27/26 at approximately 08:30 AM, Certified Medication Aide (CMA) R administered unknown medications to Resident (R) 2 without verifying she had the correct resident.
April 1, 2026Complaint inspection · 1 citation
- G
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on observation, interview, and record review, the facility failed to provide follow-up care and services for Resident (R) 1's fractured wrist when staff failed to make an appointment and take her to a surgeon as ordered by the physician. This resulted in a non-removable device existing for longer than intended without physician oversight, which caused a Stage 3(full-thickness pressure injury extending through the skin into the tissue below) pressure ulcer on R1's thumb. Findings Included:- R1's Electronic Medical Record (EMR) revealed the following diagnoses: [...]
June 17, 2025Complaint inspection · 1 citation
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteThe facility reported a census of 68 residents. The sample included four residents, with four reviewed for accidents and supervision. Based on observations, interviews, and record review, the facility failed to provide adequate supervision for Resident (R) 1 resulting in an elopement from the facility. This deficient practice placed R1 at risk for preventable accidents and injuries.
December 11, 2024Standard inspection · 14 citations
- E
Provide activities to meet all resident's needs.
Inspectors wroteThe facility identified a census of 63 residents. The sample included 18 residents. Based on observation, record review, and interviews, the facility failed to provide consistent weekend activities on Saturdays to promote socialization. This deficient practice placed the affected residents at risk for decreased psychosocial well-being, boredom, and isolation.
- E
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteThe facility had a census of 63 residents. The sample included 18 residents with eight reviewed for accidents. Based on observation, record review and interview the facility failed to secure electrical panels and cleaning chemicals in a safe, locked area, and out of reach of the ten cognitively impaired, independently mobile residents. The facility additionally failed to provide adequate supervision for Resident (R) 33 and follow R43's care-planned fall interventions related to her wheelchair placement. This placed the affected residents at risk for preventable accidents and injuries. Findings Included: - On 12/09/24 at 07:05 AM, a walk-through of the Cedar View halls was completed with the following observations: An inspection of an unsecured housekeeping closet in the 580's hallway revealed numerous heavy-duty 3M brand cleaning products on the wall. [...]
- E
Observe each nurse aide's job performance and give regular training.
Inspectors wroteThe facility identified a census of 63 residents. The sample included 18 residents and five Certified Nurse Aides (CNA) were reviewed for yearly performance evaluations and the associated in-service training. Based on record review and interview, the facility failed to ensure one of the five CNA staff reviewed had yearly performance evaluations completed. This placed the residents at risk for inadequate care.
- E
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteThe facility identified a census of 63 residents with one kitchen and three dining rooms. Based on observation, record review, and interviews, the facility failed to follow sanitary dietary standards related to maintaining a sanitary service environment for food storage and meal service. These deficient practices placed the affected residents at risk related to food-borne illnesses and food safety concerns. Findings Included: - On 12/09/24 at 07:21 AM, an inspection of the dining room for Cedar View revealed dirty plates stored on the table next to the kitchenette's serving window from the previous evening's meal service. The table contained a stack of domed plate covers stored in an upward position. Inspection of the condiment shelf in the dining room to the right of the service window revealed a large, uncovered container of instant food thickener with no lid on the top shelf. [...]
- E
Provide and implement an infection prevention and control program.
Inspectors wroteThe facility identified a census of 63 residents. The facility identified eight residents on Enhanced Barrier Precautions (EBP-infection control interventions designed to reduce transmission of resistant organisms that employ targeted gown and glove use during high contact care). Based on record review, observations, and interviews, the facility failed to develop and implement a system to alert staff and visitors of EBP needs and additionally failed to complete hand hygiene during wound care and to ensure the sanitary storage of oxygen therapy equipment. These deficient practices placed the residents at risk for infectious diseases.
- E
Ensure that staff members are educated on resident rights and facility responsibilities to properly care for its residents.
Inspectors wroteThe facility identified a census of 63 residents. Based on record review and interviews, the facility failed to ensure agency staff received the required resident rights training. This placed the residents at risk for impaired care and decreased quality of life.
- E
Include as part of its infection prevention and control program, mandatory training that includes written standards, policies, and procedures for the program.
Inspectors wroteThe facility identified a census of 63 residents. Based on record review and interviews, the facility failed to ensure agency staff received the required infection control training. This placed the residents at risk for impaired care and decreased quality of life.
- D
Reasonably accommodate the needs and preferences of each resident.
Inspectors wroteThe facility had a census of 63 residents. The sample included 18 residents with two reviewed for accommodation of needs related to assistive devices. Based on observation, record review, and interview the facility failed to utilize and ensure the appropriate use of foot pedals during wheelchair transports for Resident (R) 1, R41, and R47. This placed the residents at risk for preventable accidents and injuries. Findings Included: - On 12/09/24 at 07:30 AM, R1 (resident with upper and lower extremity impairments) was wheeled out of his room to the medication cart by the nurse's station. R1's foot pedals were not in place as staff pushed him down the hall. At 07:35 AM, staff applied his foot pedals and wheeled him to breakfast. [...]
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteThe facility identified a census of 63 residents. The sample included 18 residents with four residents reviewed for activities of daily living (ADL) care. Based on observation, record review, and interviews, the facility failed to ensure staff assisted Resident (R) 4 with grooming. This deficient practice placed R4 at risk for impaired dignity and a further decline in ADL. Finding Included: - R4's Diagnosis section within the Electronic Medical Record (EMR) noted diagnoses of ischemia (decreased supply of oxygenated blood to a body part), heart disease (the heart does not pump as well as it should), myocardial infarction (heart attack), hypertension (high blood pressure), cognitive decline, kidney disease stage four (severe damage to the kidneys and a significant decline in function), and obesity (excessive body fat). [...]
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteThe facility identified a census of 63 residents. The sample included 18 residents with two residents reviewed for treatment and services to prevent and heal pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, because of pressure, or pressure in combination with shear and/or friction). Based on observation, record review, and interviews, the facility failed to ensure Resident (R)32's low air-loss mattress was set at the appropriate weight for pressure reduction. This placed R32 at increased risk for pressure ulcer development and delayed healing. Findings Included: [...]
- D
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
Inspectors wroteThe facility identified a census of 63 residents. The sample included 18 residents with eight residents reviewed for accidents. Based on observation, record review, and interviews, the facility failed to ensure that Resident (R) 33 had a safety assessment for the use of side rails that acknowledged the risks when used with a low air-loss mattress. This deficient practice placed R33 at risk for uninformed decisions and impaired safety related to the risks associated with the use of side rails. Findings Included: [...]
- 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 wroteThe facility identified a census of 63 residents. The sample included 18 residents with five residents reviewed for unnecessary medications. Based on observation, record review, and interviews, the facility failed to ensure Resident (R) 41 had a Centers for Medicare and Medicaid (CMS) approved indication or the required physician-documented rationale including risk versus benefits and nonpharmocologcal attempts prior to the use of the antipsychotic (a class of medications used to treat major mental conditions that cause a break from reality) medication Zyprexa. This placed R41 at risk for unnecessary medication administration and possible adverse side effects.
- D
Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
Inspectors wroteThe facility identified a census of 63 residents. The sample included 18 residents with two residents reviewed for hospice. Based on observation, record review, and interviews, the facility failed to ensure coordinated care and services provided by the facility with the care and services provided by hospice for Resident (R) 43 and R38. This placed the residents at risk for inadequate end-of-life care. Finding Included: [...]
- D
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Inspectors wroteThe facility identified a census of 63 residents. The sample included 18 residents with five residents reviewed for influenza (a contagious respiratory illness that infects the nose, throat, and sometimes the lungs) and pneumococcal (a disease that refers to a range of illnesses that affect various parts of the body and are caused by infection) immunizations. Based on record review and interviews the facility failed to ensure Resident (R) 51 received the pneumococcal vaccine after consenting to the vaccination. This deficient practice placed R51 at risk for acquiring, transmitting, or experiencing complications from the pneumococcal disease.
September 12, 2024Complaint inspection · 1 citation
- G
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteThe facility identified a census of 60 residents. The sample included three residents reviewed for accidents. Based on record review, interviews, and observations, the facility failed to ensure Resident (R)1 remained free from avoidable accident hazards when staff failed to provide safe transfers using the required number of staff and the required equipment per the resident's plan of care. Subsequently, R1 sustained fractures to both her ankles/lower legs. This deficient practice also placed R1 at risk for increased pain and impaired well-being.
February 1, 2024Complaint inspection · 1 citation
- G
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteThe facility identified a census of 62 residents. The sample included three residents reviewed for accidents. Based on record review, interview, and observation, the facility failed to provide an environment free from safety hazards when staff left Resident (R) 1 in a mechanical recliner, with the footrest raised, without assessing R1's ability to lower the footrest. On 01/10/24 R1 attempted to get out of the recliner by climbing over the footrest and fell. As a result, R1 sustained a fractured sternum (breastbone) and left fourth rib. This also placed R1 at risk for pain, decreased mobility, and impaired quality of life.
November 27, 2023Complaint inspection · 2 citations
- G
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Inspectors wroteThe facility identified a census of 62 residents. The sample included three residents. Based on observations, record review, and interviews, the facility failed to ensure Resident (R) 1 remained free from abuse when Certified Nurse Aide (CNA) M struck R1 on her arm after R1 had physical behaviors towards her. This deficient practice resulted in impaired psychosocial well-being and placed R1 at risk for continued abuse.
- D
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Inspectors wroteThe facility identified a census of 62 residents. The sample included three residents with one reviewed for dementia (progressive mental disorder characterized by failing memory, confusion) care. Based on observations, record review, and interviews, the facility failed to provide dementia care and services for Resident (R) 1 when the facility failed to ensure CNA M followed care-planned interventions in response to R1's dementia related behaviors. This deficient practice created an environment that affected R1's ability to maintain her highest practicable level for physical, mental, and psychosocial well-being and placed the resident at risk for ongoing abuse (See F600).
July 26, 2023Standard inspection · 9 citations
- G
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteThe facility identified a census of 63 residents. The sample included 16 residents with five residents reviewed for falls. Based on observation, interview, and record review the facility failed to respond to falls, assess, and identify injury, and apply standards of care for fall follow up for Resident (R)28. On 07/02/23 at 01:30 AM R28, who had severe cognitive impairment, had an unwitnessed fall in her room. Licensed Nurse (LN) K found R28 on the floor at which time R28 stated she was trying to get to her recliner. LN K assessed the resident and noted an abrasion to the left shoulder. R28 complained of left hip pain at that time. LN K assisted R28 to the recliner but failed to notify R28's physician and representative of the incident. [...]
- E
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteThe facility had a census of 63 residents. The sample included 13 residents with five residents reviewed for accidents and/or hazards. Based on observation, record review, and interview the facility failed to secure chemicals in a safe, locked area, and out of reach of the eleven cognitively impaired, independently mobile residents. The facility additionally failed to follow care planned interventions for Residents(R)10 and R36 resulting in non-injury falls for both residents. This deficient practice placed the residents at risk for preventable injuries and accidents. Findings Included: - On 07/24/23 at 07:05AM an inspection of the facility revealed an unsecured room labelled Trash in the southwest hall. The room contained six spray cans of cleaning Spot Remover, room deodorizer, and dry crystal floor cleaner stored on a shelf next to the door. [...]
- E
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteThe facility identified a census of 63 residents with one kitchen. Based on observation, record review, and interviews, the facility failed to maintain sanitary dietary standards related to storage of food and kitchenware. This deficient practice placed the residents at risk related to food borne illnesses and food safety concerns.
- E
Provide and implement an infection prevention and control program.
Inspectors wroteThe facility identified a census of 63 residents. Based on observation, record review, and interviews, the facility failed to ensure proper infection control standards were followed related to hand hygiene, soiled linen, and trash storage. This deficient practice placed the residents at risk for complications related to infectious diseases.
- 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 wroteThe facility identified a census of 63 residents. The sample included 13 residents reviewed for care plans. Based on observation, record review, and interview the facility failed to revise Residents (R)10 and R36's care plans related to the level of staff assistance needed during cares provided by staff. This deficient practice placed the residents at risk for preventable falls and injuries to uncommunicated or unmet care needs. Findings Included: [...]
- 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 wroteThe facility identified a census of 63 residents the sample included 16 residents with five sampled residents reviewed for unnecessary medications. Based on observation, record review and interview, the facility failed to ensure the Consultant Pharmacist (CP) identified and reported Resident (R)36's Zyprexa (antipsychotic-a class of medications used to treat psychosis and other mental emotional conditions) medication had an appropriate indication for use, or the required physician documentation. This deficient practice placed R36 at risk of unnecessary medication administration and possible adverse side effects.
- 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 wroteThe facility identified a census of 63 residents. The sample included 16 residents with five sampled for unnecessary medications. Based on observation, record review and interview, the facility failed to ensure Resident (R)36 and R44 had an appropriate indication for use, or the required physician documentation, for their anti-psychotic (a class of medications used to treat psychosis and other mental emotional conditions) medications. This deficient practice placed these residents at risk of unnecessary medication administration and possible adverse side effects.
- D
Ensure medication error rates are not 5 percent or greater.
Inspectors wroteThe facility identified a census of 63 residents. Six residents were observed for medication administration. Based on observation, record review and interview, the facility failed to ensure a medication administration error rate of five percent (%) or less when medication administration observations revealed an error rate of 33.33 %.
- 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 wroteThe facility identified a census of 63 residents, two medication rooms, and four medication carts. Based on observation, record review, and interview, the facility failed to properly date one insulin pen (a hormone which regulates blood sugar) for Resident (R) 32 when the pen was opened for use. This deficient practice left the resident being administered the insulin at risk for adverse effects or less effective insulin administration.
December 30, 2021Standard inspection · 4 citations
- F
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteThe facility had a census of 58 residents. The sample included 18 residents. Based on observation, record review, and observation, the facility failed to store, prepare, and serve food under sanitary conditions for 58 residents who reside in the facility and receive meals from the facility kitchen placing the residents at risk for food borne illness.
- 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 wroteThe facility had a census of 58 residents. The sample included 18 residents. Based on observation, interview and record review the facility failed to ensure expired medications were removed from use in one of two medication rooms and one of four medication carts. This placed the affected residents at risk for decreased or ineffective therapeutic medication effects.
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteThe facility had a census of 58 residents. The sample included 18 residents with which two reviewed for bathing. Based on observation, record review, and interview, the facility failed to provide Resident (R) 14 bathing assistance twice a week, placing the resident at risk for poor hygiene and decreased self-esteem.
- 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 wroteThe facility had a census of 58 residents. The sample included 18 residents with five reviewed for unnecessary medications. Based on observation, record review, and interview, the facility failed to ensure Resident (R) 14's as needed Ativan (an antianxiety medication) has a stop date as required, placing the resident at risk for adverse side effects related to psychotropic ( altering mood or mind) medication use.
Fire safety inspections
30 fire safety citations on file: 1 on April 6, 2026, 14 on December 11, 2024, 6 on July 26, 2023, 9 on December 30, 2021.
Every fire safety citation30 citations
- F
Have an alternate power supply for its alarm system.
K 344 · April 6, 2026 · Corrected (the home has a date of correction)
- F
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 · December 11, 2024 · Corrected (the home has a date of correction)
- F
Install emergency lighting that can last at least 1 1/2 hours.
K 291 · December 11, 2024 · Corrected (the home has a date of correction)
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · December 11, 2024 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · December 11, 2024 · Corrected (the home has a date of correction)
- F
Have simulated fire drills held at unexpected times.
K 712 · December 11, 2024 · Corrected (the home has a date of correction)
- F
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
K 914 · December 11, 2024 · Corrected (the home has a date of correction)
- F
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · December 11, 2024 · Waiver
- E
Use approved construction type or materials.
K 161 · December 11, 2024 · Corrected (the home has a date of correction)
- E
Meet other general requirements.
K 200 · December 11, 2024 · Corrected (the home has a date of correction)
- E
Provide large enough exits.
K 231 · December 11, 2024 · Corrected (the home has a date of correction)
- E
Properly select, install, inspect, or maintain portable fire extinguishes.
K 355 · December 11, 2024 · Corrected (the home has a date of correction)
- E
Install corridor and hallway doors that block smoke.
K 363 · December 11, 2024 · Corrected (the home has a date of correction)
- E
Install smoke barrier doors that can resist smoke for at least 20 minutes.
K 374 · December 11, 2024 · Corrected (the home has a date of correction)
- E
Have properly installed electrical wiring and gas equipment.
K 511 · December 11, 2024 · Corrected (the home has a date of correction)
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · July 26, 2023 · Corrected (the home has a date of correction)
- F
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
K 761 · July 26, 2023 · Corrected (the home has a date of correction)
- E
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 · July 26, 2023 · Corrected (the home has a date of correction)
- E
Inspect, test, and maintain automatic sprinkler systems.
K 353 · July 26, 2023 · Corrected (the home has a date of correction)
- E
Install corridor and hallway doors that block smoke.
K 363 · July 26, 2023 · Corrected (the home has a date of correction)
- E
Have properly installed electrical wiring and gas equipment.
K 511 · July 26, 2023 · Corrected (the home has a date of correction)
- F
Use approved construction type or materials.
K 161 · December 30, 2021 · Corrected (the home has a date of correction)
- F
Install an approved automatic sprinkler system.
K 351 · December 30, 2021 · Corrected (the home has a date of correction)
- F
Have simulated fire drills held at unexpected times.
K 712 · December 30, 2021 · 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 · December 30, 2021 · Corrected (the home has a date of correction)
- E
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · December 30, 2021 · Corrected (the home has a date of correction)
- E
Have properly installed electrical wiring and gas equipment.
K 511 · December 30, 2021 · Corrected (the home has a date of correction)
- E
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
K 761 · December 30, 2021 · Waiver
- 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 · December 30, 2021 · Corrected (the home has a date of correction)
- D
Meet other general requirements that are deficient.
K 500 · December 30, 2021 · Corrected (the home has a date of correction)