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 52 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
3J
0K
0L
Actual harm
2G
0H
0I
Potential for more than minimal harm
32D
9E
3F
Potential for minimal harm
0A
1B
2C
January 13, 2026Standard inspection, Complaint inspection · 12 citations
- E
Ensure that residents are free from significant medication errors.
Inspectors wroteBased on record review and staff, Pharmacist, Medical Director and Physician interviews, the facility failed to clarify and resolve a discrepancy with an order for carvedilol (medication in the class of alpha and beta blockers used to treat conditions affecting the heart and blood vessels) which resulted in a significant medication error for 1 of 5 residents reviewed for unnecessary medications (Resident #7).
- E
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on record review and staff interviews, the facility failed to have a complete and accurate Treatment Administration Record (TAR) and failed to have a complete and accurate Medication Administration Record (MAR) for 4 of 19 residents reviewed for medical record accuracy (Resident #76, Resident #36, Resident #54, and Resident #51).
- E
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observations, record review and staff and Nurse Practitioner (NP) interviews, the facility failed to: 1.) to follow their infection control practices and procedures for Contact Precautions when Nurse Aide (NA) #1 entered resident's room under contact precautions without wearing a gown or gloves to pick up a meal tray 2.) follow their infection control practices and procedures for Enhanced Barrier Precautions (EBP) during high contact care for a resident with a chronic wound when NA #2 provided a bed bath without wearing a gown and when NA #2 left dirty linens on the floor of the resident's room instead of placing them in a bag and later picked them up and held them against her body. [...]
- D
Ensure that residents are fully informed and understand their health status, care and treatments.
Inspectors wroteBased on record review, staff and Nurse Practitioner (NP) interview, the facility failed to obtain consent and inform the resident's Responsible Party (RP) of the risks and benefits of psychotropic medications prior to initiation or the treatment alternatives available. The deficient practice was identified for 1 of 5 residents reviewed for unnecessary medications (Resident #54).
- 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, and Medical Director, Nurse Practitioner (NP), staff and Responsible Party (RP) interviews, the facility failed to notify the physician/medical provider when an ordered medication was unavailable for administration (Resident #51) and failed to notify the resident's RP when a deep tissue pressure injury (DTI) developed on his right heel (Resident #78) for 2 of 3 residents reviewed for notification of changes (Resident #51 and Resident #78).
- D
Protect each resident from the wrongful use of the resident's belongings or money.
Inspectors wroteBased on record review and staff interviews, the facility failed to protect the residents' right to be free from misappropriation of money from their personal funds' accounts for 3 of 4 residents reviewed for misappropriation of property (Residents #51, #8, and #37).
- D
Ensure each resident receives an accurate assessment.
Inspectors wroteBased on record review and staff interviews, the facility failed to accurately code the Minimum Data Set (MDS) assessment in the area of medications for 1 of 5 residents reviewed for medication administration (Resident #51).
- D
Ensure services provided by the nursing facility meet professional standards of quality.
Inspectors wroteBased on record review and resident, staff, Medical Director and Nurse Practitioner (NP) interviews the facility failed to administer medication as ordered by the physician for 1 of 5 residents reviewed for medication administration (Resident #51).
- 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 and staff, Pharmacist, Medical Director, Nurse Practitioner and Physician interviews, the facility failed to ensure the attending physician was informed of the pharmacy recommendation to clarify a physician's order for carvedilol (medication in the class of alpha and beta blockers used to treat conditions affecting the heart and blood vessels) for 1 of 5 residents reviewed for unnecessary medications (Resident #7).
- 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 observations and staff interviews, the facility failed to keep medications in a locked treatment cart for 1 of 2 treatment carts observed (Treatment Cart #1).
- D
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Inspectors wroteBased on record review and staff interview, the facility failed to ensure a consent was documented prior to administering the Influenza vaccination for 1 of 5 residents reviewed for vaccination status (Resident #80).
- C
Ensure residents have reasonable access to and privacy in their use of communication methods.
Inspectors wroteBased on interviews with residents and staff, the facility failed to ensure residents' right to receive mail delivered on Saturdays. This had the potential to affect 67 of 67 residents in the facility.
November 14, 2025Complaint inspection · 2 citations
- D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteBased on record review, staff interviews, and resident interviews, the facility failed to act in a dignified manner toward (Resident #1) and within hearing distance of (Resident #3) for 2 of 3 residents reviewed for dignity (Resident #1 and Resident #3).
- D
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Inspectors wroteBased on record reviews, staff interviews, and a resident interview, the facility failed to protect a resident's right to be free from resident-to-resident physical abuse when Resident #3 struck Resident #4, resulting in a bruise to the right side of the face. This occurred for 1 of 3 residents reviewed for abuse (Resident #4).
May 28, 2025Complaint inspection · 5 citations
- F
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, record review and staff interview, the facility failed to: a.) follow their infection control practices and procedures for Enhanced Barrier Precautions (EBP) during high contact care for a resident with a chronic wound when Nurse #1 and Nurse Aide (NA) #1 provided wound care without wearing gowns for 2 of 2 staff observed for infection control (Nurse #1 and NA #1) and b.) to implement their policy for EPB for the current 41 of 61 residents that required the precautions due to chronic wounds or indwelling medical devices.
- F
Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
Inspectors wroteBased on record review and staff interviews, the facility failed to designate a qualified Infection Preventionist who was certified in infection prevention and control, to be responsible for the facility's Infection Control and Prevention Program. This had the potential to affect 72 of 72 residents in the facility.
- E
Include as part of its infection prevention and control program, mandatory training that includes written standards, policies, and procedures for the program.
Inspectors wroteBased on observation, record review, and staff interview, the facility failed to have an effective system in place to train nurses and nurse aides (NAs) and verify their competency with infection control policies for Enhanced Barrier Precautions (EBP). The Assistant Director of Nursing (ADON)/Infection Preventionist (IP) who was responsible for training staff on infection control practices and procedures was unaware that residents with chronic wounds and indwelling medical devices required EBP with high contact care. Nurse #1 and NA #1 failed to follow the infection control policy by providing wound care for a resident with chronic wounds without wearing gowns. The facility had 41 residents that required EBP due to chronic wounds or indwelling medical devices. [...]
- D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteBased on record review, and resident and staff interviews, the facility failed to maintain a resident's dignity when a resident wore a nightgown and no makeup to an outside appointment making the resident feel angry and unimportant for 1 of 1 resident (Resident # 4) reviewed for dignity and respect.
- D
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Inspectors wroteBased on record review and staff interviews, the facility failed to maintain evidence of grievance investigation and decisions for 3 of 3 residents reviewed for grievances (Resident #1, Resident #2 and Resident #3).
May 6, 2025Complaint 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 wroteBased on record review, staff interview, and family interview, the facility failed to protect the resident's right to be free from abuse for one (Resident #1) of three residents reviewed for physical abuse. Resident #1, a severely cognitively impaired resident, was hit with a belt by a family member resulting in three whip-like marks on her left upper thigh and abdomen. A reasonable person would be traumatized by being hit with a belt.
- G
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Inspectors wroteBased on record review, and staff and family interviews, the facility failed to immediately identify abuse and respond to intervene to protect a resident from physical abuse. Facility staff delayed intervention when Resident #1, a severely cognitively impaired resident, was hit with a belt by a family member resulting in three whip-like marks on her left upper thigh and abdomen and a visit to the emergency room. The facility also failed to notify the state agency within two hours of physical abuse that occurred in the facility. This occurred for 1 (Resident #1) of 3 residents reviewed for adherence to abuse policies and procedures during physical abuse investigations.
April 10, 2025Complaint inspection · 1 citation
- D
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Inspectors wroteBased on record review, and staff and Medical Director interviews, the facility failed to implement their policy for abuse, neglect, and misappropriation of property in the areas of reporting and investigating when Nurse #2 and Nurse #3 reported to the Unit Manager, Assistant Director of Nursing, and Director of Nursing allegations that Resident #1's liquid morphine appeared to be tampered with and Nurse #1 appeared impaired. These allegations were not reported to the State Agency, law enforcement, or Adult Protective Services (APS) and were not thoroughly investigated. This deficient practice affected 1 of 4 residents (Resident #1) reviewed for misappropriation of property and placed all facility residents who were ordered narcotic medication at risk of misappropriation of property.
November 26, 2024Complaint inspection · 2 citations
- J
Ensure that residents are free from significant medication errors.
Inspectors wroteBased on observation, record review, resident interview, staff interview, nurse practitioner interview, physician interview, pharmacist, and psychiatry nurse practitioner interview the facility failed to administer 6 doses of a required antipsychotic medication for one (Resident #11) of one resident reviewed for significant medication errors. Resident #11 had an acute psychotic event after missing 6 doses of his antipsychotic medication resulting in a fall with a broken shoulder and hip that required surgical repair, acute blood loss and acute pain. Resident #11 has been bedbound since the incident.
- J
Provide timely, quality laboratory services/tests to meet the needs of residents.
Inspectors wroteBased on observation, record review, resident interview, staff interview, nurse practitioner interview, physician interview, pharmacist interview, and psychiatry nurse practitioner interview the facility failed to obtain laboratory tests as ordered and provide laboratory results to the pharmacy as required for antipsychotic medication monitoring for one (Resident #11) of one resident reviewed for laboratory services. Resident #11 had an acute psychotic event after laboratory results were not obtained and faxed to the pharmacy for the renewal of his antipsychotic medication. Resident #11 suffered a fall with a broken shoulder and hip that required surgical repair, acute blood loss and acute pain. Resident #11 has been bedbound since the incident. Abrupt withdrawal from the medication can cause rebound psychosis (sudden return of psychotic symptoms).
October 15, 2024Standard inspection, Complaint inspection · 13 citations
- J
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Inspectors wroteBased on record review, observations, and interviews with resident, staff and the Physician, the facility failed to protect the residents' right to be free from resident to resident abuse for 3 of 5 residents reviewed for abuse (Resident #222, Resident #61, and Resident #41). On 10/19/23 Resident #2, a male resident, entered Resident #222's room (a female resident) and punched her in her legs multiple times with a closed fist as she was sitting on her bed. On 6/22/24 Resident #2 punched Resident #61 (a female resident) in the face multiple times with a closed fist at the nurse's station due to the belief that she was cheating on him. Resident #222 and Resident #61 were vulnerable and were unable to protect themselves. The physical abuse had a high likelihood of resulting in serious physical and psychosocial harm. [...]
- F
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Inspectors wroteBased on record review and staff interviews, the facility failed to provide a Registered Nurse (RN) for 8 consecutive hours per day, 7 days per week for 9 of 163 days reviewed.
- D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteBased on observation, record review, and staff and resident interviews, the facility failed to treat a resident in a dignified manner when staff referred to a resident who needed assistance with eating as a feeder for 1 of 3 residents reviewed for dignity (Resident #64). This caused Resident #64 to feel like an animal.
- D
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Inspectors wroteBased on observations, record review and resident and staff interviews the facility failed to ensure a sufficient number of clean mechanical lift pads were available to allow a resident to get out of bed in accordance with his preference (Resident #65) and failed to allow a resident who was assessed as a safe independent smoker to smoke in accordance with her preference (Resident #41). This was for 2 of 3 residents reviewed for self-determination.
- D
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Inspectors wroteBased on record review and staff interviews, the facility failed to provide a complete CMS-10055 (Centers for Medicare and Medicaid Services) Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNF ABN) by omitting the estimated cost for 1 of 3 residents reviewed for beneficiary notices (Resident #49).
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on record review, staff and resident interviews the facility failed to submit a 5-day investigation report (Resident #172) and an initial 24 hour and 5-day investigation report to the State Agency and report to Adult Protective Services (APS) and local law enforcement after allegations of misappropriation of property (Resident #3). This was for 2 of 6 residents reviewed for misappropriation.
- D
Ensure each resident receives an accurate assessment.
Inspectors wroteBased on record review and staff interviews, the facility failed to code cognition, mood, and behavior for 1 of 24 residents reviewed for MDS accuracy (Resident #66).
- 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 record review, and resident and staff interviews the facility failed to develop a comprehensive care plan that included the use of a mechanical lift device for transfers for 1 of 24 residents (Resident #65) whose comprehensive care plans were reviewed.
- 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 record review, Physician, staff and resident interviews, the facility failed to update care plan interventions (Resident # 2) and invite residents to care plan meetings (Resident # 43 and Resident #11) for 3 of 5 residents reviewed for care planning.
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on observation, record review and staff interviews, the facility failed to prevent a cognitively impaired resident from exiting the facility without staff knowledge for 1 of 8 residents reviewed for accidents (Resident #2). Resident #2 exited the building through a back door and was found by a staff member sitting outside in his wheelchair facing the door.
- D
Provide medically-related social services to help each resident achieve the highest possible quality of life.
Inspectors wroteBased on record review, resident and staff interviews, the facility failed to ensure a Resident #322 was driven to her physician's office in time to attend an 11:00 AM medical appointment. Resident #322 arrived one- and one-half hours late and the physician was unable to see her. The appointment had to be rescheduled for the following week. This deficient practice affected 1 of 1 sampled resident reviewed for medically related social services (Resident # 322).
- 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, and staff interviews, the facility failed to label and date an opened vial of influenza vaccine stored in the medication room refrigerator for 1 of 1 medication storage rooms reviewed.
- D
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Inspectors wroteBased on record review, staff, and physician interviews the facility failed to provide a pneumococcal vaccine to a resident with a signed consent form to receive the vaccine. This was for 1 of 5 residents reviewed for immunizations (Resident #61).
August 6, 2024Complaint inspection · 1 citation
- B
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on staff interviews, Wound Care Physician interview, and record review the facility failed to accurately document treatments on a resident's Treatment Administration Record (TAR) for 1 of 3 residents reviewed for pressure ulcer care. (Resident #1)
August 10, 2023Standard inspection · 14 citations
- E
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Inspectors wroteBased on record review, resident interview, and staff interview, the facility failed to allow residents who were assessed to be safe smokers the ability to smoke independently per their individual preference for 2 of 8 residents (Resident # 38, and #41) reviewed for preferences.
- E
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Inspectors wroteBased on observations, record review and staff and physician interviews, the facility failed to obtain post dialysis vital signs as ordered by the physician for 1 of 1 resident reviewed for dialysis (Resident #33).
- 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 observation and staff interviews the facility failed to date opened insulin for 2 of 3 (Hall 200 and Hall 300) medication carts reviewed for medication storage.
- E
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Inspectors wroteBased on observations, record review and resident, staff and physician interviews the facility's Quality Assessment and Assurance (QAA) Committee failed to maintain implemented procedures and monitor the interventions that the committee put into place following the 9/2/20 focused infection control and complaint investigation survey, the 5/19/22 recertification and complaint investigation survey, the 10/19/22 complaint investigation survey, and the 3/8/23 complaint investigation survey. [...]
- E
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, record review, and staff interviews the facility failed to have a staff member stay out of work following testing positive for COVID-19 per the facility's return to work criteria, and the facility failed to don personal protective equipment (PPE) for 2 of 3 residents reviewed for isolation precautions (Resident #31 and Resident #48).
- D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteBased on observation, record review, and staff interviews the facility failed to avoid the use of the term 'feeder' to refer to a resident who needed assistance with meals for 1 of 1 dining observation (Resident #22). The reasonable person concept was applied as individuals have the expectation of being treated with dignity and would not want to be labeled 'feeders'.
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on observations, record review, resident and staff interviews, the facility failed to provide showers, bed baths, or nail care for 2 of 5 dependent residents reviewed for activities of daily living (Resident #33 & Resident #16).
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on record review, resident, staff, and Physician interviews, the facility failed to provide a resident (Resident #58) medications after returning from the hospital. This occurred for 1 of 1 resident reviewed.
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on observation, record review, resident, staff, and Physician interviews, the facility failed to follow a physician order for a pressure ulcer dressing change for 1 of 2 residents reviewed for pressure ulcers (Resident #39).
- D
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Inspectors wroteBased on record review and staff interviews, the facility failed to schedule a Registered Nurse (RN) for at least 8 consecutive hours a day for 2 days of 19 days (6-11-23 and 7-8-23) reviewed for staffing.
- D
Provide medically-related social services to help each resident achieve the highest possible quality of life.
Inspectors wroteBased on record review, staff and physician interviews, the facility failed to schedule an appointment for a mammogram as ordered by the physician for 1 of 1 resident (Resident #19) reviewed for medically related social services.
- D
Ensure that residents are free from significant medication errors.
Inspectors wroteBased on record review, resident, staff, and Physician interview the facility failed to prevent a significant medication error by failing to administer a prescribed antibiotic for 2 of 2 residents (Resident #39 and Resident #58) reviewed for medication errors.
- D
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Inspectors wroteBased on record review and staff interviews the facility failed to offer the Pneumococcal 15-valent Conjugate Vaccine (PCV 15) or Pneumococcal 20-valent Conjugate Vaccine (PCV 20) in accordance with nationally recognized standards for 1 of 5 residents reviewed for immunizations (Resident #31).
- C
Post nurse staffing information every day.
Inspectors wroteBased on record review and staff interviews the facility failed to post accurate nurse staffing information for 19 of 92 days reviewed for daily posted staffing.
Fire safety inspections
12 fire safety citations on file: 6 on January 13, 2026, 2 on October 15, 2024, 4 on August 10, 2023.
Every fire safety citation12 citations
- F
Develop and maintain an Emergency Preparedness Program (EP).
E 4 · January 13, 2026 · Corrected (the home has a date of correction)
- F
Install corridor and hallway doors that block smoke.
K 363 · January 13, 2026 · 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 13, 2026 · Corrected (the home has a date of correction)
- E
Have properly installed electrical wiring and gas equipment.
K 511 · January 13, 2026 · Corrected (the home has a date of correction)
- D
Provide properly protected cooking facilities.
K 324 · January 13, 2026 · Corrected (the home has a date of correction)
- D
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · January 13, 2026 · Corrected (the home has a date of correction)
- D
Keep aisles, corridors, and exits free of obstruction in case of emergency.
K 211 · October 15, 2024 · Corrected (the home has a date of correction)
- D
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · October 15, 2024 · Corrected (the home has a date of correction)
- D
Satisfy building requirements after a repair, renovation, modification, or change of user/occupancy.
K 111 · August 10, 2023 · Corrected (the home has a date of correction)
- D
Have properly installed electrical wiring and gas equipment.
K 511 · August 10, 2023 · Corrected (the home has a date of correction)
- D
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · August 10, 2023 · Corrected (the home has a date of correction)
- D
Have proper medical gas storage and administration areas.
K 923 · August 10, 2023 · Corrected (the home has a date of correction)