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 35 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
1G
0H
0I
Potential for more than minimal harm
23D
7E
2F
Potential for minimal harm
0A
0B
2C
July 15, 2026Complaint inspection · 1 citation
- G
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Inspectors wroteBased on a review of select facility policies and procedures, clinical record review, personnel record review, and staff interview, it was determined that the facility failed to protect a resident's right to be free from neglect by staff that resulted in actual harm with a serious injury of a fractured finger for one of six residents reviewed (Resident 1). This deficiency is cited as past noncompliance.
April 10, 2026Standard inspection · 11 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 and staff interview, it was determined that the facility failed to store food items in a safe and sanitary manner and maintain equipment in a sanitary condition, in the main kitchen of the facility and a resident pantry area on two of seven nursing units (Nursing Units 300 and 700).
- E
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 wroteBased on a review of select facility policies and procedures, clinical record review, observation, and resident and staff interview, it was determined that the facility failed to assess all potential risk areas for entrapment for five of six residents reviewed for accident hazards (Residents 2, 7, 12, 14, and 97).
- 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 clinical record review and staff interview it was determined that the facility failed to ensure that active physician orders incorporated resident wishes related to end-of-life care for two of four residents reviewed for advanced directives concerns (Residents 7 and 56).
- D
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Inspectors wroteBased on review of select facility policies and procedures, clinical record review, and staff interview, it was determined that the facility failed to thoroughly investigate and report to the appropriate agencies an allegation of resident-to-resident physical abuse for one of 26 records reviewed (Resident 128).
- D
Ensure each resident receives an accurate assessment.
Inspectors wroteBased on clinical record review and resident and staff interview, it was determined that the facility failed to ensure assessments accurately reflected a resident's status for two of 26 residents reviewed (Residents 40 and 139). Findings Review of a quarterly MDS (Minimum Data Set, an assessment completed at specific intervals to determine resident care needs) dated October 26, 2025, revealed staff assessed Resident 40 as having no impairments of her lower extremities. Review of Resident 40's next quarterly MDS dated [DATE], staff assessed Resident 40 as having bilateral impairment to her lower extremities. Interview with Employee 4 (LPNAC) on April 10, 2026, at 10:55 AM revealed that Resident 40 did not have a decline in her range of motion. Employee 4 confirmed Resident 40's functional limitation in her range of motion was coded in error on the MDS dated [DATE]. [...]
- 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 clinical record review, observation, and resident and staff interview, it was determined that the facility failed to develop, revise, and ensure resident/resident representative participation in care plan decisions for four of 26 residents reviewed (Residents 11, 12, 82, and 139)
- D
Assist a resident in gaining access to vision and hearing services.
Inspectors wroteBased on clinical record review and resident and staff interview it was determined that the facility failed to implement treatment and assistive devices to maintain vision and hearing abilities for two of two residents reviewed for vision and hearing concerns (Residents 56 and 139).
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on clinical record review, observation, and staff interview, it was determined that the facility failed to ensure an environment free from the potential spread of infection related to indwelling catheter equipment for one of two residents reviewed for catheter concerns (Resident 11), respiratory equipment for one of two residents reviewed for respiratory concerns (Resident 139), and laundry processing in the facility's main laundry facilities.
- D
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Inspectors wroteBased on a review of select facility policies and procedures, clinical record review, and staff interview, it was determined that the facility failed to maintain policies and procedures that each resident is offered a pneumococcal immunization per current Centers for Disease Control (CDC) guidelines; and failed to ensure that the resident's medical record included required documentation related to pneumococcal immunizations for one of five residents reviewed for immunization concerns (Resident 14).
- C
Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.
Inspectors wroteBased on observation and staff interview, it was determined that the facility failed to ensure the results of the most recent surveys were posted in a place readily accessible to residents, family members, and legal representatives in one of one area reviewed (main lobby).
- C
Dispose of garbage and refuse properly.
Inspectors wroteBased on observation and staff interview, it was determined that the facility failed to properly contain and dispose of garbage at the observed facility trash dumpster.
January 29, 2026Complaint inspection · 1 citation
- 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 closed clinical record review, review of facility documentation, and staff interview, it was determined that the facility failed to immediately notify a resident's representative of a change in a resident's condition for one out of three residents reviewed (Resident CR1).
May 23, 2025Standard inspection · 8 citations
- E
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on a review of select facility policies and procedures, clinical record review, and staff and resident interview it was determined that the facility failed to ensure the highest practicable care for three of 35 residents reviewed (Residents 40, 230, and 94).
- E
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 wroteBased on review of select facility policies, observation, clinical record review, and staff and resident interview, it was determined that the facility failed to assess for the risk of side rail entrapment for 6 of 7 residents reviewed for accident hazards (Residents 14, 44, 85, 102, 113, and 230).
- D
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
Inspectors wroteBased on clinical record review and staff interview, it was determined that the facility failed to ensure a resident's medication regime was free from potentially unnecessary medications for two of five residents reviewed (Residents 72 and 86).
- 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 clinical record review and staff interview, it was determined that the facility failed to revise the comprehensive care plan for one of 35 residents reviewed (Resident 11).
- 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 select facility policies and procedures, facility documentation, clinical record review, employee personnel record information, and staff interview, it was determined that the facility failed to ensure that nursing staff possessed the specific competencies and skill sets related to obtaining verbal or telephone physician orders for one of one employee reviewed (Employee 3; Resident 40).
- D
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Inspectors wroteBased on clinical record review and staff interview, it was determined that the facility failed to develop and implement an individualized person-centered care plan to address dementia and cognitive loss displayed by two of four residents reviewed (Residents 86 and 89).
- D
Provide or obtain dental services for each resident.
Inspectors wroteBased on a review of select facility policies and procedures, clinical record review, and family and staff interview, it was determined that the facility failed to obtain routine dental services for one of three residents reviewed for dental concerns (Resident 67).
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on a review of select facility policies and procedures, observation, and staff interview, it was determined that the facility failed to ensure an environment free from the potential spread of infection on one of six residents reviewed for infection control (Resident 83).
June 20, 2024Standard inspection · 12 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 and staff interview, it was determined that the facility failed to store food in accordance with professional standards for food service safety and sanitation in the facility's main kitchen and three of seven nursing units (100, 300, 800).
- E
Ensure medication error rates are not 5 percent or greater.
Inspectors wroteBased on observation, clinical record review, review of select facility policies and procedures, and staff interview, it was determined that the facility failed to ensure a medication error rate below five percent (Residents 29 and 82).
- E
Have policies and procedures ensuring the administrator's responsibilities for facility closure are completed successfully.
Inspectors wroteBased on a review of facility policies and procedures and staff interview, it was determined that the facility failed to have a policy and procedure in place to address facility closure or termination of the facility's Medicare and/or Medicaid Provider Agreement.
- E
Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
Inspectors wroteBased on a review of select facility policies and procedures, clinical record review, and staff and resident interview, it was determined that the facility failed to ensure the administration of a COVID-19 immunization for four of five residents reviewed for immunization concerns (Residents 11, 109, 118, and 119).
- D
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Inspectors wroteBased on clinical record review, review of facility documents, and staff interview, it was determined that the facility failed to ensure a resident was free from neglect resulting in injury for one of two residents reviewed (Resident 26).
- D
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Inspectors wroteBased on review of select facility policies, clinical record review, and staff interview, it was determined that the facility failed to develop and implement an abuse prohibition policy to ensure a complete and thorough investigation of an incident involving the potential for neglect for one of 27 residents reviewed (Residents 79).
- 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 clinical record review and staff interview, it was determined that the facility failed to develop and implement a comprehensive person-centered care plan to maintain the highest practicable care for three of 27 residents reviewed (Residents 11, 116, and 119). Findings Include: Clinical record review for Resident 116 revealed that the facility admitted her on December 8, 2023, with a diagnosis of a prolapsed vaginal vault (the top of the vagina folds into the lower vagina) after a hysterectomy (a surgical procedure to remove the uterus). Clinical record review for Resident 116 revealed consultation reports dated March 13, 2024, and June 11, 2024, that indicated she was seen by a gynecology physician to have her pessary (a device that is inserted into the vagina to prevent or control a prolapse of the vaginal vault, bladder, or uterus) checked. [...]
- D
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Inspectors wroteBased on clinical record review and staff interview, it was determined that the facility failed to identify and assess a resident's decline in activities of daily living (ADL) for two of two residents reviewed for an ADL decline (Residents 10 and 118).
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on clinical record review and staff interview, it was determined that the facility failed to provide the highest practicable care regarding physician ordered weights and feeding interventions for two of 27 residents (Residents 36 and 89).
- D
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Inspectors wroteBased on clinical record review and staff interview, it was determined that the facility failed to ensure each resident's medication regimen was free of adverse medication reactions for one of five residents reviewed for unnecessary medications (Resident 50).
- 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 clinical record review and staff interview, it was determined that the facility failed to ensure a resident's medication regime was free from potentially unnecessary medications for one of five residents reviewed (Resident 89).
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, review of a medication pass observation report, review of select facility policies and procedures, and staff interview, it was determined that the facility failed prevent the potential spread of infection during medication administration on 1 of 7 nursing units (600 hall, Resident 29).
June 5, 2024Complaint inspection · 1 citation
- E
Protect each resident from the wrongful use of the resident's belongings or money.
Inspectors wroteBased on clinical record review, review of facility documents, and staff interview, it was determined that the facility failed to thoroughly investigate and notify the appropriate agencies of an identified incident of potential resident misappropriation of property (medication) for two of five residents reviewed (Residents 4 and 5).
November 14, 2023Complaint inspection · 1 citation
- 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 employee competencies and interviews with staff, it was determined that the facility failed to ensure that nursing staff completed competencies and skill sets necessary to care for residents' needs for three of nine employees (Employees 1, 2, and 3; Residents 1, 2, and 3).
Fire safety inspections
10 fire safety citations on file: 4 on April 10, 2026, 2 on May 23, 2025, 4 on June 20, 2024.
Every fire safety citation10 citations
- E
Use approved construction type or materials.
K 161 · April 10, 2026 · Corrected (the home has a date of correction)
- E
Keep aisles, corridors, and exits free of obstruction in case of emergency.
K 211 · April 10, 2026 · 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 · April 10, 2026 · Corrected (the home has a date of correction)
- E
Inspect, test, and maintain automatic sprinkler systems.
K 353 · April 10, 2026 · Corrected (the home has a date of correction)
- E
Use approved construction type or materials.
K 161 · May 23, 2025 · Corrected (the home has a date of correction)
- E
Inspect, test, and maintain automatic sprinkler systems.
K 353 · May 23, 2025 · Corrected (the home has a date of correction)
- E
Keep aisles, corridors, and exits free of obstruction in case of emergency.
K 211 · June 20, 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 · June 20, 2024 · 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 20, 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 · June 20, 2024 · Corrected (the home has a date of correction)