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 39 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
1J
0K
0L
Actual harm
1G
0H
0I
Potential for more than minimal harm
30D
6E
1F
Potential for minimal harm
0A
0B
0C
July 8, 2026Complaint 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 staff interviews, clinical record review, and review of facility policy and procedure, the facility failed to ensure adequate assessment, monitoring, and supervision to prevent elopement for one (Resident #7) of the four sampled residents. The deficient practice could result in injury to residents. [...]
May 15, 2026Standard inspection, Complaint inspection · 8 citations
- 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 resident and staff interviews, facility documentation and policy review, the facility failed to ensure the services of a Registered Nurse (RN) for at least 8 consecutive hours a day, 7 days a week. The census was 100 residents. The deficient practice could result in residents not receiving appropriate care and treatment that they need.
- E
Provide and implement an infection prevention and control program.
Inspectors wroteNumber of residents sampled: Number of residents cited: Based on observations, staff interviews, and facility policy review, the facility failed to ensure proper hand hygiene was conducted during medication administration. The deficient practice could result in contaminated medications being administered to residents along with medication contamination, and potential infection .
- D
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Inspectors wroteBased on staff interviews, review of clinical record and policy review, the facility failed to protect the rights of 2 of 21 residents sampled (#70, #37) to be free from physical abuse between residents. The universe was 100 residents. The deficient practice could result in resident injury, psychological, or behavioral harm as well as continued resident to resident abuse.
- D
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Inspectors wroteBased on clinical record review, facility documentation, staff interviews, and policy review, the facility failed to implement their abuse policy involving an allegation of abuse with 2 of 21 residents (#70 and #37). The universe was 100 residents. The deficient practice could result in the appropriate State Agencies not being notified and allegations of abuse not being thoroughly investigated.
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on clinical record review, staff interviews, facility documentation, and policy review, the facility failed to implement its policy to ensure that an allegation of abuse for 2 out of 21 residents (#70, #37) was reported to all applicable state agencies. The universe was 100 residents. The deficient practice could result in further allegations of neglect not being reported.
- D
Respond appropriately to all alleged violations.
Inspectors wroteBased on clinical records, review of facility documentation, staff interviews and review of policy and procedure facility failed to ensure an allegation of abuse for 2 of 21 residents (#70, #37) was fully investigated. The universe was 100 residents. The deficient practice could result in allegations of abuse not being thoroughly investigated and abuse occurring in the facility.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteNumber of residents sampled: Number of residents cited: Based on a review of clinical records, staff and resident interviews, and facility policies and procedures, the facility failed to ensure that pain medication for one (Resident # 111) of the five sampled residents was administered in accordance with physician orders. This deficient practice had the potential to result in either overmedication or undermedication of the resident.
- D
Make sure that a working call system is available in each resident's bathroom and bathing area.
Inspectors wroteBased on observation, staff interviews, facility documents, and policy, the facility failed to ensure a call system was operational for 1 out of 20 residents sampled (# 5). The universe was 100 residents. The deficient practice could place residents' safety at risk.
February 18, 2026Complaint inspection · 1 citation
- D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Inspectors wroteBased on record review, staff interviews, facility documentation, and policy review, the facility failed to ensure controlled medications were recorded, stored, and reconciled accurately for one of three sampled residents (#1). The deficient practice could result in the inability to ensure the safe and effective use of medication. Findings Include:Resident #1 was initially admitted on [DATE], and re-admitted on [DATE], with a diagnosis that included Senile degeneration of the brain, dementia, cellulitis of the toe, nutritional deficiency, psychotic disturbance, anxiety, Pneumonia, and chronic pain. The individual Resident Controlled Substances record dated March 4, 2025, for Resident #1 revealed that Morphine Sulfate was received in an amount of 30 mL (milliliter). It further identified that the dosage to be given to the resident was 0.25mL by mouth. [...]
January 5, 2026Complaint inspection · 1 citation
- D
Ensure that residents are free from significant medication errors.
Inspectors wroteBased on clinical record review, interviews, and review of policies, the facility failed to ensure one resident (#61), did not receive medication prescribed to another resident (#71). The deficient practice could result in complications and adverse medication side effects.
December 17, 2025Complaint 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 clinical record review, facility documentation, and staff interviews, the facility failed to ensure that residents are free from abuse from another resident (Residents #1 and #3). The deficient practice could lead to additional resident-to-resident altercations, thereby creating an unsafe environment.
November 19, 2025Complaint 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 observation, interviews, review of records, and review of facility policy and procedures, the facility failed to ensure that two sampled residents (#88 and #71) were not physically abused by residents (#76 and #84). The sample size was 6. The deficient practice could lead to physical and psychosocial harm to residents. Findings Include:-Regarding residents #88 and #76Resident #88 was admitted to the facility on [DATE] with diagnoses including: unspecified dementia, with other behavioral disturbance, and insomnia. An admission minimum data set (MDS) assessment dated [DATE] revealed the resident had a brief interview for mental status (BIMS) score of 7, indicating severe cognitive impairment. Review of the care plan for resident #88 reveals a focus starting on July 16, 2025, for exhibiting behaviors of pacing in common areas, wandering, invading others personal space. [...]
April 28, 2025Complaint 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 observation, interviews, review of records, and review of facility policy and procedure, the facility failed to ensure a resident (#6) was not abused by another resident (#3). The deficient practice could lead to physical and psychosocial harm to residents. Regarding Resident #6: Resident #6 was re-admitted to the facility on [DATE], with diagnoses that included senile degeneration of brain, paroxysmal atrial fibrillation, hypertension, chronic obstructive pulmonary disease, and type 2 diabetes mellitus. A quarterly minimum data set (MDS) assessment dated [DATE], revealed the resident had a brief interview for mental status (BIMS) score of 4, indicating severe cognitive impairment. A progress note dated April 18, 2025, revealed at 7:45 AM, the nurse was notified by certified nursing assistants (CNAs) that another resident hit Resident #6 in the right arm during breakfast. [...]
March 27, 2025Complaint inspection · 2 citations
- 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 reviews, facility documentation, observation, staff interviews and policy review, the facility failed to ensure that one resident (#41) was free from physical abuse by a resident (#37). The deficient practice could result in further incidents of resident to resident abuse and could lead to injury.
- 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 reviews, staff interviews, and review of facility documentation and policy, the facility failed to evaluate and implement effective care plan interventions related to falls for one resident (#11). The deficient practice resulted in the resident experiencing multiple falls in the facility, and could result in other residents failing to receive effective fall-prevention measures.
March 3, 2025Complaint 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 clinical record review, facility documentation, observation, staff interviews, and policy review, the facility failed to ensure that two residents (#25 and #20) were free from physical abuse. The deficient practice could result in further incidents of resident to resident abuse and lead to injury.
February 20, 2025Complaint inspection · 1 citation
- E
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, facility documentation, and staff interviews, the facility failed to ensure eight residents (#1, #2, #3, #4, #5, #6, #7 and #8) were provided adequate supervision to prevent resident abuse. The deficient practice could result in residents being at risk for abuse.
January 31, 2025Standard inspection, Complaint inspection · 8 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 observations, clinical record review, staff interviews and facility policy, the facility failed to ensure that 7 residents were not abused (72, 76, 92, 42, 67, 54, 32 and 19). The deficient practice could result in physical and emotional harm to residents.
- E
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on observations, staff interviews, facility process and procedures, the facility failed to ensure that dishes and utensils were cleaned using professional standards of practice for sanitary conditions. The deficient practice could result in residents becoming ill.
- D
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Inspectors wroteBased on observation, record review, interviews, and facility policy, the facility failed to ensure that monitoring and evaluation of physical restraints are completed for the continued use of physical restraints for one resident (Resident #36). The deficient practice could lead to increased isolation and/or other psychosocial harm.
- D
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Inspectors wroteBased on clinical record review, staff interviews, and facility policy review, the facility failed to ensure a copy of the notice of one of one discharges for one resident (# 101 ) to a representative of the Office of the State Long-Term Care Ombudsman. The failure may result in residents not having the advocacy and support from the State Long-Term Ombudsman during the discharge process.
- 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 observations, clinical record review, staff interviews and facility policy, the facility failed to ensure that residents care plans were revised as needed for 3 residents (#72, #76, and #45).
- 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, staff interviews, and review of facility policy and procedure, the facility failed to ensure that one of one sampled residents (#304) was safe to self-adminster medication. The deficient practice could result in a medication overdose. Findings Include: Resident #304 was initially admitted on [DATE] with a diagnosis of dementia, type 2 diabetes, and dysphagia. Review of physician orders revealed active orders for the following medications: Bisacodyl 10mg Polyethylene glycol 3350 power solution Melatonin 3 mg tab Docusate sodium 100mg cap Quetiapine 25 mg tablet Acetaminophen 325 mg tab Diclofenac sodium 1 percent topical cream A in progress admission Assessment Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 13, which indicated intact cognition. [...]
- D
Provide or get specialized rehabilitative services as required for a resident.
Inspectors wroteBased on observations, clinical record review, staff interviews and facility policy, the facility failed to ensure that resident #45 received specialized services to meet therapeutic needs.
- D
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Inspectors wroteBased on interviews, record review, facility document review, and facility policy review, the facility failed to ensure that one resident (#66) was offered pneumococcal vaccine. The deficient practice could pose the risk of the residents contracting pneumonia and its associated complications.
January 6, 2025Complaint 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 observations, record review, interviews, and review of facility documentation and policy, the facility failed to ensure two residents (#2, and #3) were not abused by one resident (#1). The deficient practice could lead to physical harm, mental anguish, and psychosocial harm to a resident.
December 3, 2024Complaint 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 clinical record review, interviews, facility surveillance footage, the State Agency (SA) complaint tracking system, and policy review, the facility failed to ensure resident #3 was free from abuse from resident #4. The deficient practice could result in further resident abuse.
October 25, 2024Complaint inspection · 2 citations
- J
Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
Inspectors wroteBased on record reviews, staff interviews and reviews of facility policies and procedures, the facility failed to ensure that basic life support, including CPR (cardio-pulmonary resuscitation) in accordance to the advance directives for one resident (#1). The deficient practice resulted in actual harm to the resident and has the potential to result in advance directives not being followed for additional residents. As a result, the condition of Immediate Jeopardy (IJ) and Substandard Quality of Care was identified.
- 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, staff interviews, facility documentation, policy and procedure, the facility failed to ensure the care plan was implemented related to the need for repositioning for one resident's (#2). The deficient practice could result in residents not receiving the services as outlined in their care plan.
September 26, 2024Complaint inspection · 1 citation
- E
Provide and implement an infection prevention and control program.
Inspectors wroteBased on review of the facility's infection control program documentation, staff interviews, personnel files, and facility policy and procedures, the facility failed to implement a COVID-19 screening and consistent testing program during a COVID-19 breakout. The deficient practice could result in residents becoming ill.
July 30, 2024Complaint inspection · 1 citation
- D
Ensure services provided by the nursing facility meet professional standards of quality.
Inspectors wroteBased on clinical record review, interviews, and review of facility documentation, the facility failed to ensure the physician was notified of a change in condition for one resident (#1). The deficient practice could result in resident not receiving continuity and coordination of needed care.
June 27, 2024Complaint inspection · 2 citations
- 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, staff and resident interviews, facility documentation, policies and procedures, the facility failed to protect the rights of one resident (#525) to be free from abuse from visitors/family member. The deficient practice could result in further abuse of residents and appropriate action not taken.
- D
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Inspectors wroteBased on clinical record review, staff interviews, review of facility documentation, policy and procedures the facility failed to implement their policy on abuse and resident protection for one resident (#525). The deficient practice could result in abuse continuing and not being prevented.
May 15, 2024Complaint 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 wroteRegarding residents #6 and #116 (September 21, 2022) -Resident #6 was admitted to the facility on [DATE], with diagnoses that included dementia with agitation, Alzheimer's disease, major depressive disorder, repeated falls, and dysphagia-oral phase. A review of resident #6's care plan dated January 20, 2020, revealed that the resident exhibited behaviors that included verbal aggression toward staff and other residents, physical aggression toward staff, verbalizing hallucinations, and excessive crying related to dementia. A review of resident #6's Minimum Data Set (MDS) dated [DATE], revealed a BIMS score of 6 that indicated the resident had severe cognitive impairment. [...]
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on clinical record review, staff interviews, and review of facility policies, the facility failed to ensure oxygen was administered as ordered by the physician for one of 3 sampled residents (#13). The deficient practice could result in residents not receiving adequate oxygen to prevent hypoxia.
November 30, 2023Complaint inspection · 2 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 clinical record review, staff interviews, facility documentation, policies and procedures, the facility failed to ensure that nine residents (#5, #15, #35, #40, #50, #65, #20, #80, and #25) were free from abuse of another. The deficient practice could result in other residents being abused.
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on closed record review, staff interviews, review of facility documentation, policy and procedures, the facility failed to report allegations of abuse for two residents in a within the required timeframe (#5 and #15). The deficient practice could result in abuse allegations not being reported.
March 16, 2023Standard inspection · 1 citation
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on observation, interview, record review and policy and procedure, the facility failed to ensure that one resident (#41) who was dependent on staff for activities of daily living (ADL) such as grooming and hygiene, received the necessary services to maintain good hygiene. The facility census was 108, and the sample was 22. The risk of not cleaning/trimming nails could result in harboring of bacteria that can contribute to the spread of infections.
Fire safety inspections
20 fire safety citations on file: 6 on May 15, 2026, 7 on January 31, 2025, 7 on March 16, 2023.
Every fire safety citation20 citations
- F
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
K 222 · May 15, 2026 · Corrected (the home has a date of correction)
- F
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 · May 15, 2026 · Corrected (the home has a date of correction)
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · May 15, 2026 · Corrected (the home has a date of correction)
- F
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · May 15, 2026 · Corrected (the home has a date of correction)
- E
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · May 15, 2026 · Corrected (the home has a date of correction)
- E
Have proper medical gas storage and administration areas.
K 923 · May 15, 2026 · Corrected (the home has a date of correction)
- E
Install emergency lighting that can last at least 1 1/2 hours.
K 291 · January 31, 2025 · Corrected (the home has a date of correction)
- E
Inspect, test, and maintain automatic sprinkler systems.
K 353 · January 31, 2025 · Corrected (the home has a date of correction)
- E
Install corridor and hallway doors that block smoke.
K 363 · January 31, 2025 · Corrected (the home has a date of correction)
- E
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · January 31, 2025 · Corrected (the home has a date of correction)
- E
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
K 521 · January 31, 2025 · Corrected (the home has a date of correction)
- E
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
K 914 · January 31, 2025 · Corrected (the home has a date of correction)
- E
Ensure that testing and maintenance of electrical equipment is performed.
K 921 · January 31, 2025 · Corrected (the home has a date of correction)
- F
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · March 16, 2023 · Corrected (the home has a date of correction)
- E
Conduct testing and exercise requirements.
E 39 · March 16, 2023 · Corrected (the home has a date of correction)
- E
Provide properly protected cooking facilities.
K 324 · March 16, 2023 · Corrected (the home has a date of correction)
- E
Install a fire alarm system that can be heard throughout the facility.
K 341 · March 16, 2023 · Corrected (the home has a date of correction)
- E
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
K 521 · March 16, 2023 · Corrected (the home has a date of correction)
- D
Inspect, test, and maintain automatic sprinkler systems.
K 353 · March 16, 2023 · Corrected (the home has a date of correction)
- D
Install corridor and hallway doors that block smoke.
K 363 · March 16, 2023 · Corrected (the home has a date of correction)