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 24 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
22D
1E
0F
Potential for minimal harm
0A
0B
1C
July 20, 2026Complaint inspection · 2 citations
- 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 record review, interviews, and review of facility policy, the facility failed to ensure the physician was notified of medications not being administered as ordered. This affected one (Resident #21) of nine residents reviewed. The facility census was 73. Findings Include: Review of the medical record for Resident #21 was admitted on [DATE] with diagnoses including dementia, restlessness and agitation, depression, anxiety disorder and neurocognitive disorder. Review of the most recent quarterly Minimum Data Set (MDS) 3.0 assessment revealed the resident had severely impaired cognition. The MDS assessment revealed Resident #21 was short tempered and easily annoyed with behaviors occurring daily. [...]
- D
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Inspectors wroteBased on closed record review, staff interview, family interview, provider interview, and policy review, the facility failed to ensure a resident was provided with accurate information regarding home care access for a discharge. This affected one resident (Resident # 84) of four residents reviewed for discharge. The facility census was 73.
August 4, 2025Standard inspection · 7 citations
- D
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Inspectors wroteBased on medical record review, beneficiary notice review, policy review and interview, the facility failed to ensure residents were informed of what type of skilled services were being terminated. This affected three residents (#2, #20 and #83) of three residents reviewed for beneficiary notifications.
- D
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Inspectors wroteBased on record review, review of email correspondence to the local Ombudsman, and staff interview, the facility failed to ensure the State Ombudsman was notified of a resident's discharge from the facility. This affected one resident (#81) of three residents reviewed for discharge.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on record review, observations, and interviews, the facility failed to attempt new interventions for skin conditions (non-pressure related) and behaviors for Resident #42. This affected one resident (#42) of two residents reviewed for skin conditions. Additionally, the facility failed to ensure residents were positioned appropriately in their wheelchair. This affected one resident (#45) of one resident reviewed for positioning. The facility census was 69.
- 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 record review the facility failed to provide a safe environment for a resident left unattended with medications. This affected one resident (#28) of 69 residents residing in the facility. The facility census was 69. Findings Include: Medical record review revealed Resident #28 was admitted on [DATE] with diagnoses including rheumatoid arthritis, anxiety disorder, chronic pain and cerebral infarction without residual deficits. Review of the electronic Order Summary Report dated 07/31/25 revealed no evidence the resident was capable to self-administer medications. There was also no physician order for Resident #28's medications could be left at bedside unsupervised by the nurse. On 07/31/25 at 7:45 A.M., the surveyor observed Licensed Practical Nurse (LPN) #130 at the medication cart in the 400 hallway preparing medications. [...]
- 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 record review, policy review, and staff interview, the facility failed to ensure the physician addressed all the recommendations made by the facility's consulting pharmacist for irregularities that were identified during their monthly medication regimen review. This affected two residents (#3 and #8) of five residents reviewed for unnecessary medications.
- D
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Inspectors wroteBased on record review, interview, and policy review the facility failed to follow physician ordered parameters for medication administration. This affected two residents (#3, #5) of five residents reviewed for medication regimens. Findings Include:1. Review of Resident #3's medical record revealed he was admitted to the facility on [DATE]. His diagnoses included Parkinson's disease, adult onset diabetes mellitus, malignant neoplasm of the colon, schizo-affective disorder of the bipolar type, and mild intellectual disabilities. Review of Resident #3's physician's orders revealed the resident had an order to receive Hydrocodone- Acetaminophen (Norco) 5-325 milligrams (mg) by mouth (po) every six hours prn for pain rating 5-10. That order originated on 07/18/25. [...]
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, medical record review, policy review and interview, the facility failed to maintain adequate infection control practices during the administration of medications. This affected two residents (#35 and #51) of three residents observed for medication administration.
May 29, 2024Standard inspection · 5 citations
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to evaluate and treat a resident's skin condition. This affected one of one resident (#31) reviewed for non pressure skin impairment. The facility census was 71.
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on observations, staff interview, resident interview, and record review, the facility failed to ensure each resident received adequate supervision to prevent accidents. This affected one of one residents reviewed for falls (#12). The facility census was 71.
- D
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Inspectors wroteBased on interviews and record review, the facility failed to monitor a dialysis site per the resident centered care plan. This affected one resident (#26) of one resident reviewed who was receiving dialysis. The facility census was 71.
- D
Provide care or services that was trauma informed and/or culturally competent.
Inspectors wroteBased on interview and record review, the facility failed to ensure residents with Post Traumatic Stress Disorder (PTSD) were appropriately evaluated to identify the cause of the resident's PTSD and minimize triggers and/or re-traumatization. This affected two residents (#23 and #24) of two residents identified by the facility as having PTSD/trauma. The facility census was 71.
- D
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 record review, the facility failed to administer medication as ordered for Resident #26 after dialysis treatments. This affected one resident (#26) of one resident reviewed for dialysis. The facility census was 71.
January 24, 2023Standard inspection · 10 citations
- E
Provide enough food/fluids to maintain a resident's health.
Inspectors wroteBased on medical record review, resident interview, staff interview, and facility policy review, the facility failed to adequately monitor resident nutritional status and health. This affected four (Residents #7, #39, #41, and #59) of five residents reviewed for nutrition. The census was 71. Findings Include: 1. Record review revealed Resident #7 was admitted to the facility on [DATE]. Her diagnoses were acute of chronic right heart failure, atrial fibrillation, generalized edema, low back pain, disorder of bone density, constipation, enterococcus as the cause of diseases, urinary tract infection, and hypertension. Review of her Minimum Data Set (MDS) assessment, dated 10/02/22, revealed she was cognitively intact. Review of Resident #7 weights revealed the following weights and dates in which significant change occurred: [...]
- D
Honor the resident's right to manage his or her financial affairs.
Inspectors wroteBased on record review, review of resident fund management services authorization agreement form, interviews, and policy review the facility failed to obtain written authorization to manage residents' funds. This affected two (Resident #33 and #35) of six residents reviewed for personal funds.
- D
Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death.
Inspectors wroteBased on record review, resident fund review, interview, and policy review the facility failed to ensure residents received spend down notifications timely and reimbursed funds timely after death. This affected one (Resident #35) of five residents reviewed for personal funds and one (Resident #74) of two residents reviewed for closer of account.
- D
Ensure residents have reasonable access to and privacy in their use of communication methods.
Inspectors wroteBased on Resident medical and financial record review, resident interview, resident family interview, and staff interview, the facility failed to allow residents to receive all mail without it being unopened. This affected one (Resident #33) of one resident reviewed for opened mail. The census was 71. Findings Include: Resident #33 was admitted to the facility on [DATE]. His diagnoses included heart and kidney failure. Review of his Minimum Data Set (MDS) assessment revealed he was cognitively intact. Review of Resident #33 financial records revealed he had an opened personal funds account with the facility. There were multiple entries per month of funds that were being added, via checks that were deposited by the facility into this account. There were between two and four checks per month added to this financial account; [...]
- 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 medical record review, review of hospital records, interview, and policy review the facility failed to ensure a resident was involved in advance directive decisions. This affected one (Resident #225) of two residents reviewed for advance directives.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on observation, medical record review, and staff interview, the facility failed to ensure a resident's back brace (ordered to be in place at all times when out of bed) was implemented. This affected one (Resident #19) of the 24 residents reviewed for orders being implemented. The facility census was 71.
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on record review, observation, interviews, and policy review the facility failed to ensure respiratory equipment was maintained to prevent infection. This affected two (Resident #1 and #59) of two reviewed for respiratory.
- D
Implement a program that monitors antibiotic use.
Inspectors wrote2. Review of the medical record for Resident #46 revealed an initial admission date of 06/29/20 and re-admission [DATE]. Diagnoses included dementia without behavioral disturbances, carcinoma in situ of prostate, squamous cell carcinoma of skin of right ear and external auricular canal, acquired absence of part of head and neck, and psoriasis. Review of the plan of care dated 09/15/22 revealed Resident #46 had an alteration in skin integrity as evidenced by open lesion present at right ear with a cancer lesion 2nd squamous cell carcinoma. Resident picks at skin at times. Interventions included to assess area for size, color, drainage as needed, and complete skin care. Review of the plan of care, (no date noted) revealed Resident #46 was at risk for infection related to cancer lesion to right ear and resident has a habit of picking at area. [...]
- D
Perform COVID19 testing on residents and staff.
Inspectors wroteBased on review of COVID-19 testing records, staff interview, and facility policy review, the facility failed to ensure employees who tested positive for COVID-19 had a negative COVID test within 48 hours of returning to work when returning in seven days. This affected three of three employees who tested positive for COVID-19 in the past 50 days and had the potential to affect 71 of 71 residents residing in the facility.
- C
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Inspectors wroteBased on staff personnel record review, staff interview, and facility handbook review, the facility failed to complete reference checks for newly hired staff in a timely manner. This had the potential to affect 71 of 71 residents. Findings Include: Review of Registered Nurse (RN) #109 personnel file revealed she was hired by the facility on 06/13/22. Her reference checks were completed on 06/16/22 and 06/17/22. Review of State Tested Nursing Aide (STNA) #198 personnel file revealed she was hired by the facility on 09/16/22. Her reference checks were completed on 09/13/22 and 09/21/22, which one was after her hire date. Review of Human Resource (HR) Director #110 personnel file revealed she was hired by the facility on 01/24/22. She had three hand written notes on the back of her application in which it appeared that reference checks were completed/attempted. [...]
Fire safety inspections
16 fire safety citations on file: 6 on August 4, 2025, 6 on May 29, 2024, 4 on January 24, 2023.
Every fire safety citation16 citations
- F
Develop and maintain an Emergency Preparedness Program (EP).
E 4 · August 4, 2025 · Corrected (the home has a date of correction)
- F
Conduct testing and exercise requirements.
E 39 · August 4, 2025 · Corrected (the home has a date of correction)
- F
Provide properly protected cooking facilities.
K 324 · August 4, 2025 · Corrected (the home has a date of correction)
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · August 4, 2025 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · August 4, 2025 · Corrected (the home has a date of correction)
- E
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · August 4, 2025 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · May 29, 2024 · Waiver
- E
Have corridors or aisles that are unobstructed and are at least 8 feet in width.
K 232 · May 29, 2024 · Corrected (the home has a date of correction)
- E
Install an approved automatic sprinkler system.
K 351 · May 29, 2024 · Corrected (the home has a date of correction)
- E
Install corridor and hallway doors that block smoke.
K 363 · May 29, 2024 · Corrected (the home has a date of correction)
- E
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · May 29, 2024 · Corrected (the home has a date of correction)
- E
Have proper medical gas storage and administration areas.
K 923 · May 29, 2024 · Corrected (the home has a date of correction)
- F
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
K 521 · January 24, 2023 · Corrected (the home has a date of correction)
- E
Have exits that are accessible at all times.
K 271 · January 24, 2023 · Corrected (the home has a date of correction)
- E
Install an approved automatic sprinkler system.
K 351 · January 24, 2023 · Corrected (the home has a date of correction)
- E
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · January 24, 2023 · Corrected (the home has a date of correction)