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 33 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
1K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
12D
17E
1F
Potential for minimal harm
0A
2B
0C
May 7, 2026Standard inspection · 6 citations
- K
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on facility review of policy, manufacturer's instructions, clinical records, and staff interviews, the facility failed to notify physicians of elevated or decreased Capillary Blood Glucose (CBG) levels, failed to assess residents for hyperglycemia (high blood glucose) and hypoglycemia (low blood sugar) resulting in immediate jeopardy for 7 of 36 residents (R3, R17, R64, R84, R116, R145, and R148).
- E
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 review of facility policy, observation and resident and staff interviews, it was determined that the facility failed to provide a safe, clean, comfortable, and homelike environment for two of four nursing units as required (TCU 1st. floor, and ARU1).
- E
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 observations and resident and staff interviews, it was determined that the facility failed to ensure that nursing staff possessed the specific competencies and skill sets related to the use of ACE wraps (elastic bandages) for 11 of 14 residents (Resident R16, R32, R50, R62, R74, R97, R117, R123, R130, R147, and R174).
- E
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Inspectors wroteBased on review of job descriptions, clinical records, and staff interviews, it was determined that the Nursing Home Administrator (NHA) and the Director of Nursing (DON) failed to effectively manage the facility to ensure provider notification of resident changes in condition. This failure resulted in immediate jeopardy for seven of 36 residents (R3, R17, R64, R84, R116, R145, and R148).
- E
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on the review of facility policy, observations, clinical records, and staff interviews, it was determined that the facility failed to maintain clinical records that were complete and accurate for three of eight residents (Residents R13, R48 and R75).
- E
Have a plan that describes the process for conducting QAPI and QAA activities.
Inspectors wroteBased on review of the clinical records, staff interviews, facility documents, and the results of the current survey, it was determined that the facility's Quality Assurance Performance Improvement (QAPI) committee failed to implement a good faith attempt to correct quality deficiencies and make certain that plans to improve the delivery of care and services effectively for seven of 36 residents (Resident R3, R17, 64, R84, R116, R145, and R148).
September 5, 2025Complaint inspection · 1 citation
- D
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 and staff interview, it was determined that the facility failed to provide adequate supervision to avoid injuries for one of three residents (Resident R1).
May 16, 2025Standard inspection · 5 citations
- E
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Inspectors wroteBased on a review of facility policy and documents, information provided by the State Ombudsman Office, clinical record reviews, and staff interviews, it was determined that the facility failed to ensure that the resident and/or their representative received written notice of the facility bed-hold policy at the time of transfer for four of six residents reviewed for hospitalization (Resident R6, R89, R123, and R138) and failed to notify the State Ombudsman Office of resident transfers and discharges for two years (11/2023 through 12/2023, 1/2024 through 12/2024, and 1/2025 through 4/2025) as required. Findings Include: Review of federal regulation §483.15(d) Notice of Bed-Hold Policy, indicated: -Facilities must provide written information about these policies to residents prior to and upon transfer for such absences. [...]
- E
Ensure each resident receives an accurate assessment.
Inspectors wroteBased on a review of Resident Assessment Instrument (RAI) User's Manual, clinical records, and staff interviews, it was determined that the facility failed to ensure that Minimum Data Set ( MDS - periodic assessment of resident care needs) assessments accurately reflected the resident's status for two of eight residents (Resident R30 and R50).
- 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 wroteBased on review of facility policy, observations, and staff interview, it was determined that the facility failed to make certain that medications were properly stored and/or disposed of in two of three medication rooms (First and Second floor medication rooms) and two of five medication carts (MedBridge A-hall, MedBridge B-hall).
- 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 facility policy, clinical records, and staff interview, it was determined that the facility failed to notify resident representatives of a transfer to the hospital for one of five residents (Resident R89).
- 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 appropriate treatment and care for one of four residents (Resident R21)
February 20, 2025Complaint inspection · 1 citation
- 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 review of facility policy, observations, and staff interview, it was determined that the facility failed to make certain that medications were properly secured in one of two medication carts (Second-floor medication cart for rooms 220-231).
December 12, 2024Complaint inspection · 3 citations
- 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 wroteBased on review of facility policy, observations, and staff interviews it was determined that the facility failed to properly secure medication in one medication refrigerator (Family Conference room), and one of three medication carts observed (ARU 1 nursing unit).
- D
Allow residents to self-administer drugs if determined clinically appropriate.
Inspectors wroteBased on a review of facility policy, resident interview, observations, and staff interview it was determined the facility failed to assess the clinical appropriateness of medication self-administration for two of 14 residents (Resident R1 and R2).
- D
Respond appropriately to all alleged violations.
Inspectors wroteBased on review of facility policy, clinical record review and staff interview, it was determined that the facility failed to fully investigate an incident to eliminate possible abuse or neglect for one of seven residents (Resident R3).
September 9, 2024Complaint inspection · 2 citations
- F
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 review of facility policy, observations, and staff interview, it was determined that the facility failed to make certain that medications were properly stored and/or disposed of in three of three medication carts (Medbridge B-hall, Medbridge A-hall, and the TCU-1 medication carts).
- E
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Inspectors wroteBased on review of facility policy, resident observations, resident and staff interviews, and grievance review, it was determined that the facility failed to have sufficient nursing staff to provide nursing and related services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of seven of 12 residents (Residents R1, R2, R3, R4, R5, R6, and R7). Findings Include: Review of the facility policy Activity of Daily Living (ADLs) dated 1/30/24, indicated the center must provide the necessary care and services to ensure that a resident's activities of daily living (ADL) abilities are maintained. Activities of daily living include hygiene care and will be recorded in the medical record. During an interview on 9/8/24, at 1:58 p.m. Resident R1, when asked if she felt the facility maintained sufficient staff, stated, No. [...]
June 13, 2024Complaint inspection · 2 citations
- D
Protect each resident from separation (from other residents, his/her room, or confinement to his/her room).
Inspectors wroteBased on clinical record review, observation and resident and staff interviews, it was revealed that the facility failed to prevent involuntary seclusion for two of 10 residents reviewed (Resident R1, and R2).
- D
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Inspectors wroteBased on review of facility policy, clinical record review, facility documentation, and staff interview, it was determined that the facility failed to ensure two of 10 residents observed (Resident R1, and R2) were free from physical restraints by being pushed up to a table with a wheelchair blocking the side exit.
May 9, 2024Standard inspection, Complaint inspection · 9 citations
- E
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 facility policy, clinical record review, and resident and staff interviews, it was determined that the facility failed to protect residents from staff initiated verbal abuse for two of nine residents (Resident R74 and R156).
- E
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Inspectors wroteBased on review of the Resident Assessment Instrument User's Manual, clinical records, and staff interview, it was determined that the facility failed to make certain that comprehensive Minimum Data Set (MDS- periodic assessment of care needs) assessments were completed in the required time frame for 12 of 16 residents (Resident R104, R120, R262, R263, R264, R265, R320, R321, R322, R362, R363, and R364).
- E
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Inspectors wroteBased on review of facility policy, clinical record reviews and interviews with staff, it was determined that the facility failed to establish a baseline care plan within 48 hours of admission/readmission for three of twelve residents (Resident R61, R72 and R324).
- E
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on review of facility policy and clinical record review and resident and staff interviews, it was determined that the facility failed to make certain that showers were consistently provided for three of six residents (Resident R74, R85, and R124, R328).
- E
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Inspectors wroteBased on review of facility policies and documents, resident observations, resident and staff interviews, and resident care records, it was determined that the facility failed to have sufficient nursing staff to provide nursing and related services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of nine of 32 residents (Resident R74, R85, R124, R128, and R328) and four of nine group residents (R401, R402, R403, and R404). Findings Include: Review of the facility policy Activity of Daily Living (ADLs) dated 1/30/24, indicated the center must provide the necessary care and services to ensure that a resident ' s activities of daily living (ADL) abilities are maintained. Activities of daily living include hygiene care and will be recorded in the medical record. During an interview on 5/6/24, at 1:10 p.m. [...]
- D
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Inspectors wroteBased on review of the Long-Term Care Resident Assessment Instrument User's Manual, clinical records, and staff interview, it was determined that the facility failed to transmit Minimum Data Set's (MDS -periodic assessment of care needs) to the required electronic system within the mandated time frame for one of 16 residents reviewed (Resident R20).
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on review of facility policy, clinical record review, and staff interview, it was determined that the facility failed to provide prescribed treatment and services related to the care of pressure ulcers for one of four residents (Resident R128).
- B
Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.
Inspectors wroteBased on review of facility policy, training records, and staff interview, it was determined that the facility failed to provide training on Quality Assurance and Performance Improvement (QAPI) for four of ten staff members (Employees E2, E3, E4, and E5).
- B
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
Inspectors wroteBased on review of facility policy, staff education records, and staff interviews, it was determined that the facility failed to conduct at least 12 hours of in-service education, within 12 months of their hire date anniversary, for nurse aides as required for two of five nurse aides (Nurse Aide (NA)Employees E2 and E3).
April 8, 2024Complaint inspection · 1 citation
- E
Ensure the facility is licensed under applicable State and local law and operates and provides services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards.
Inspectors wroteBased on a review of facility documents it was determined that the facility failed to ensure sufficient nursing staff to comply with state laws regarding mandated minimum staffing requirements.
December 19, 2023Complaint inspection · 2 citations
- D
Reasonably accommodate the needs and preferences of each resident.
Inspectors wroteBased on review of facility policy, observations, resident council group meeting minutes, resident and staff interview it was determined that the facility failed to answer call bells in a timely manner for six of six residents observed and failed to have an ample linen supply at the staffs immediate disposal (Residents R1, R2, R3, R4, R5, and R6).
- D
Honor the resident's right to organize and participate in resident/family groups in the facility.
Inspectors wroteBased on review of facility policy, resident council minutes, group and staff interviews it was determined that the facility failed to respond to resident concerns and grievances identified during resident council minutes for two of two months (October through November 2023).
October 5, 2023Complaint inspection · 1 citation
- E
Keep all essential equipment working safely.
Inspectors wroteBased on review of facility documentation, and staff interviews it was determined that the facility failed to keep essential equipment in working order from July 2023 till October 2023.
Fire safety inspections
4 fire safety citations on file: 1 on May 7, 2026, 1 on May 16, 2025, 2 on May 9, 2024.
Every fire safety citation4 citations
- E
Install smoke barrier doors that can resist smoke for at least 20 minutes.
K 374 · May 7, 2026 · Corrected (the home has a date of correction)
- E
Install smoke barrier doors that can resist smoke for at least 20 minutes.
K 374 · May 16, 2025 · Corrected (the home has a date of correction)
- D
Provide properly protected cooking facilities.
K 324 · May 9, 2024 · Corrected (the home has a date of correction)
- D
Ensure proper usage of power strips and extension cords.
K 920 · May 9, 2024 · Corrected (the home has a date of correction)