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 34 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
25D
4E
0F
Potential for minimal harm
0A
4B
1C
March 17, 2026Standard inspection · 6 citations
- E
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 interviews, review of the medical record, facility documentation, observations, and facility policy for 3 of 3 residents (Resident #7, Resident #14 and Resident #20) reviewed for urinary tract infections, the facility failed to ensure the Advanced Practice Registered Nurse (APRN) was notified when a medication was unavailable and therefore not administered.
- E
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on review of the clinical record, facility policy, and interviews for 1 of 4 residents (Resident #3) reviewed for hospitalization, the facility failed to perform fingerstick glucose levels for a diabetic resident as indicated by the providers note and for 3 of 3 residents (Resident #7, Resident #14 and Resident #20) reviewed for urinary tract infections, the facility failed to ensure medications were administered per physician's orders. Additionally, for 1 of 3 residents (Resident #65) reviewed for non-pressure skin conditions, the facility failed to identify a change in wound status.
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on interviews, observations, clinical record review, and review of facility policy for the only sampled resident reviewed for respiratory care (Resident #37), the facility failed to ensure a safe environment for a resident on continuous oxygen by allowing the resident (Resident #37) to self-administer a petroleum-based ointment into the nose without physician orders, proper assessment, or staff interventions. Staff failed to recognize and act on posted safety signage (Oxygen in use-no petroleum lotions), did not remove the flammable material from the room, and did not educate the resident on the danger of using petroleum products with oxygen therapy.
- D
Provide special eating equipment and utensils for residents who need them and appropriate assistance.
Inspectors wroteBased on observations, interviews, review of the clinical record, and facility policy for the only resident reviewed for nutrition (Resident #62), the facility failed to provide adaptive equipment per the physician's order for a resident with dysphagia.
- B
PASARR screening for Mental disorders or Intellectual Disabilities
Inspectors wroteBased on review of the clinical record, facility documentation, interview, and facility policy for 2 of 5 residents (Resident #31 and Resident #32) reviewed for Preadmission Screening and Resident Review (PASRR), the facility failed to ensure that a redetermination was submitted to the appropriate state agency when a short-term approval expired.
- B
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on interviews, review of the medical record, facility documentation, observations, and facility policy for 3 of 3 residents (Resident #7, Resident #14 and Resident #20) reviewed for urinary tract infections, the facility failed to ensure the Medication Administration Record (MAR) related to medication administration contained accurate documentation.
January 29, 2026Complaint inspection · 1 citation
- D
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Inspectors wroteBased on review of the clinical record, facility documentation, facility policies, and interviews, for one (1) of four (4) residents reviewed for abuse (Resident #2), the facility failed to ensure Resident #2 was free from physical abuse when the resident, who was dependent on staff for bed mobility and transfers, was discovered with multiple injuries of unknown origin including a lip laceration, forehead abrasion with swelling, and bruising to the back of the right hand and wrist, and later indicated a staff member struck him/her.
February 26, 2025Complaint inspection · 1 citation
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on clinical record review, facility documentation review, facility policy review, and interviews for one of three residents (Resident #2) reviewed for medication administration, the facility failed to ensure medication orders were transcribed accurately and failed to ensure the resident was free from medication errors.
January 8, 2025Complaint inspection · 1 citation
- D
Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy.
Inspectors wroteBased on clinical record reviews, facility documentation, facility policy and interviews for one (1) of three (3) sampled residents (Resident #1) who had exhibited an inappropriate behavioral symptom and was transferred to the hospital for an evaluation, the facility failed to re-admit the resident after the hospital psychiatric physicians identified Resident #1 was not a risk of harm to self or others.
November 21, 2024Complaint 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 clinical record review, interviews and facility documentation for one (1) of three (3) residents (Resident #1) reviewed for a change in condition, the facility failed to report a change of condition to the physician timely.
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on clinical record review, facility documentation, and interviews for one (1) of three (3) residents reviewed for an injury of unknown origin (Resident #5), the facility failed to ensure that the resident remained free from injury during a Hoyer lift transfer.
May 16, 2024Standard inspection · 10 citations
- E
Provide appropriate foot care.
Inspectors wroteBased on observations, review of the clinical record, facility policy, and interviews for 1 of 2 residents (Resident #67) reviewed for Activities of Daily Living (ADL's), the facility failed to provide podiatry services to a long-term resident.
- 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 the clinical record, facility policy, and interviews for 1 of 6 residents (Resident #62) reviewed for nutrition, the facility failed to notify the provider when weights were not obtained per the physician's order.
- 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 review of the clinical record, facility policy, and interviews for the only sampled resident (Resident #67) reviewed for an allegation of mistreatment, the facility failed to develop a comprehensive care plan indicating refusal of care, inappropriate behaviors, and accusations towards staff.
- 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 review of the clinical record, facility documentation, facility policy, and interviews for 2 of 2 residents (Resident #53 and Resident #67) reviewed for bowel and bladder, for Resident #53, the facility failed to assess bowel and bladder continence status and failed to implement a plan to restore continence and for Resident #67 the facility failed to ensure the resident maintained bowel and bladder function.
- D
Provide enough food/fluids to maintain a resident's health.
Inspectors wroteBased on review of the clinical record, interviews, and review of facility policy for two of six residents (Resident #14 and Resident #62) reviewed for nutrition, for Resident #14, the facility failed to ensure a significant weight change was identified in a timely manner, and for Resident #62, the facility failed to obtain weights per the physician's orders.
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observations, review of the clinical record, facility policy, and interview for 1 of 2 residents (Resident #13) reviewed for oxygen, the facility failed to follow the physician's oxygen order.
- 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 of the clinical record, facility policy and interviews for the only sampled resident (Resident #67) reviewed for mistreatment, the facility failed to monitor and document targeted behaviors per the physician's order.
- 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 facility documentation, facility policy, and interviews for 1 of 2 medication rooms reviewed for medication storage and labeling, the facility failed to ensure drugs and biologicals were kept under proper temperature controls.
- C
Provide and implement an infection prevention and control program.
Inspectors wroteBased on interviews, observation of the laundry area, and facility policy, the facility failed to ensure a clean environment in the drying and folding areas.
- B
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Inspectors wroteBased on review of the clinical record and interview for 1 of 5 sampled residents, (Resident #11) reviewed for PASRR, the facility failed to refer the resident to the appropriate state-designated authority for a level II evaluation following a new psychiatric diagnosis.
April 3, 2024Complaint inspection · 1 citation
- 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 reviews, facility documentation, and interviews for one of three sampled residents (Resident #1) who developed a urinary tract infection, the facility failed to ensure urinary lab testing per the MD orders.
March 14, 2024Complaint 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 review of the clinical record, facility documentation, facility policy, and interviews for one (1) of three (3) residents, (Resident #1), reviewed for a change in condition, the facility failed to ensure the physician was notified when a resident was not provided with laboratory services and failed to ensure the physician and responsible party were notified when a resident refused to have blood drawn from the laboratory.
- D
Provide timely, quality laboratory services/tests to meet the needs of residents.
Inspectors wroteBased on review of the clinical record, facility documentation, facility policy, and interviews for one (1) of three (3) residents (Resident #1) reviewed for laboratory services, the facility failed to ensure resident had blood work completed in accordance with physician orders.
November 1, 2023Complaint inspection · 3 citations
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on clinical record reviews, facility documentation, facility policy and interviews for one (1) of three (3) residents, (Resident #1), who were reviewed accidents, the facility failed to ensure an injury of unknown origin was reported to the overseeing state agency within required time frames for a resident later identified to have sustained an injury.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on clinical record reviews, facility documentation, facility policy and interviews for one (1) of three (3) residents, (Resident #1), who was reviewed for accidents, the facility failed to ensure the nurse was notified following a compliant of pain for a resident who was later diagnosed with an injury.
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on clinical record reviews, facility documentation, facility policy and interviews for one (1) of three (3) residents, (Resident #2), who was reviewed for accidents, the facility failed to ensure a resident requiring assistance with locomotion using a wheelchair was provided leg rests.
January 28, 2022Standard inspection · 7 citations
- E
Provide appropriate foot care.
Inspectors wroteBased on observation, review of the clinical record, facility documentation, facility policy, and interviews for 1 resident (Resident #30) reviewed for foot care, the facility failed to provide podiatry services. Resident #30 was admitted to the facility on [DATE] with diagnoses that included a progressive nerve disease, muscle weakness, and essential hypertension. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #30 was without cognitive impairment and required physical assistance with bed mobility and personal care. The Resident Care Plan (RCP) dated 12/6/21 identified Resident #30 was a long-term resident and had an activity of daily living deficit. Interventions included to provide maximal assistance with bed mobility at least 4 times a shift. [...]
- D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteBased on observation, review of facility policy, and interviews for 1 resident (Resident #11) reviewed for an indwelling catheter the facility failed to ensure the resident's urine drainage bag was covered/not visible.
- 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 review of the clinical record, facility documentation, facility policy, and interviews for 3 of 7 residents (Resident #11, Resident #79 and Resident #179) reviewed for Advanced Directives, the facility failed to ensure a physician order was present that reflected the wishes of the resident or resident representative.
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on review of the clinical record, facility documentation, facility policy, and interviews for 1 resident (Resident #30) reviewed for mistreatment, the facility failed to ensure an allegation of physical mistreatment was reported to the State Agency prior to making the determination whether the allegation was credible.
- D
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Inspectors wroteBased on observation, review of the clinical record, facility documentation, facility policy, and interviews for 1 of 1 residents newly admitted to the facility (Resident #79), the facility failed to ensure the Interim Care Plan was completed within 48 hours of admission.
- 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 observation, review of the clinical record, facility documentation, facility policy, and interviews for 1 resident (Resident #11) reviewed for catheters, the facility failed to ensure the urinary tubing and drainage bag was below the level of the bladder for drainage.
- B
PASARR screening for Mental disorders or Intellectual Disabilities
Inspectors wroteBased on observation, review of the clinical record, facility documentation, facility policy, and interviews for 1 resident (Resident #52) reviewed for Preadmission Screening and Resident Review (PASRR), the facility failed to ensure recommendations for a re-evaluation was requested in a timely manner.
Fire safety inspections
6 fire safety citations on file: 1 on March 17, 2026, 2 on May 16, 2024, 3 on January 28, 2022.
Every fire safety citation6 citations
- D
Have simulated fire drills held at unexpected times.
K 712 · March 17, 2026 · Corrected (the home has a date of correction)
- D
Inspect, test, and maintain automatic sprinkler systems.
K 353 · May 16, 2024 · Corrected (the home has a date of correction)
- D
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
K 761 · May 16, 2024 · Corrected (the home has a date of correction)
- D
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · January 28, 2022 · Corrected (the home has a date of correction)
- D
Install corridor and hallway doors that block smoke.
K 363 · January 28, 2022 · Corrected (the home has a date of correction)
- D
Have simulated fire drills held at unexpected times.
K 712 · January 28, 2022 · Corrected (the home has a date of correction)