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
0K
0L
Actual harm
1G
0H
0I
Potential for more than minimal harm
20D
8E
0F
Potential for minimal harm
0A
4B
0C
January 7, 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 clinical record reviews, review of facility documentation, facility policies, and interviews for one (1) of three (3) sampled residents (Resident #1) who were reviewed for accidents, the facility failed to ensure facility staff provided adequate supervision to prevent Resident #1 from exiting the facility unattended.
March 5, 2025Complaint inspection · 1 citation
- D
Provide enough food/fluids to maintain a resident's health.
Inspectors wroteBased on review of clinical records, interviews, and review of facility documentation and policies for one (1) of three (3) residents reviewed for fluid status, the facility failed to complete dehydration evaluations in accordance with facility policy and failed to notify the provider with the results of a dehydration evaluation timely.
February 8, 2025Standard inspection · 6 citations
- G
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on record review and interviews for one of three sampled residents (Resident #42) reviewed for accidents, the facility failed to ensure the resident was free from injury resulting from an instant hot pack.
- E
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Inspectors wroteBased on observations, review of facility documentation, review of facility policy/procedures and interviews, the facility failed to establish a system of records of receipt and disposition of all controlled medications in sufficient detail to enable an accurate reconciliation and failed to have a system in place to keep an accurate accounting of controlled medications.
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observations, review of the clinical record, review of facility policy/procedures and interviews for one of two sampled residents (Resident #252) reviewed for respiratory care, the facility failed to ensure a physician order was in place for a resident who required oxygen therapy.
- 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, review of facility policy/procedures and interviews, the facility failed to ensure the medication administration cart was appropriately secured during the medication administration pass while not within the line of sight of the nurse.
- D
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Inspectors wroteBased on review of clinical records, review of facility policy, review of facility documentation, and interviews for two of five sampled residents (Resident #4 and Resident #5), reviewed for immunizations, the facility failed to ensure that the pneumococcal vaccine was administered as requested by the resident upon admission.
- B
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on review of the clinical record, review of facility policy/procedures and interviews for 1 of 5 sampled residents (Resident #18) reviewed for unnecessary medication, the facility failed to ensure monthly pharmacy medication regimen review recommendations were part of the clinical record.
July 3, 2024Complaint inspection · 1 citation
- 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 review of the clinical record, facility documentation, facility policy, and interviews for one (1) of three (3) residents (Resident #1) reviewed for grievances, the facility failed to initiate a grievance concern for a missing item.
May 24, 2024Complaint 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, and interviews for one of three residents (Resident #2) reviewed for medication errors, the facility failed to ensure medication was administered in accordance with physician orders and failed to ensure the resident received the correct dose of a cancer treatment medication.
October 4, 2022Standard inspection · 17 citations
- 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 observation, review of facility documentation and interviews, the facility failed to ensure the environment was maintained in a clean, sanitary, and homelike manner.
- E
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on, review of the clinical record, facility documentation, facility policy, and interviews for 1 resident (Resident # 30) reviewed for pressure ulcers, the facility failed to ensure consistent conduct weekly wound monitoring for a resident with a pressure ulcer.
- 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 observation, review of facility documentation, facility assessment, and interviews, the facility failed to ensure that staffing levels were adequate for (44) residents on 2 units in accordance with the plan of care.
- 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 review of facility documentation, facility assessment, and interviews, the facility failed to ensure nursing staff possess the competencies and skill sets necessary to provide nursing and related services to meet the residents' needs safely and in a manner that promotes each resident's rights, physical, mental, and psychosocial well-being.
- 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 observations, review of facility policy, and interviews for 1 of 2 medication storage room, the facility failed to maintain the medication storage room in a clean manner and for 1 of 2 narcotic refrigerator, the facility failed to ensure the narcotic refrigerator freezer was free from build-up ice, and for 1 of 2 medications carts, the facility failed to maintain the medication cart in a clean and sanitary manner, and the facility failed to secure a medication following a specialized services appointment.
- 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 of the kitchen, review facility documentation, facility policy, and interviews, the facility failed to ensure a clean and sanitary kitchen.
- E
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observations, facility policy review and interviews for infection control, the facility failed to follow infection control guideline regarding discarding soiled gloves and failed to ensure isolation gowns were readily available for adherence to proper Personal Protective Equipment (PPE) use.
- D
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Inspectors wroteBased on observation, review of the clinical record, facility documentation, facility policy, and interviews for 1 sampled resident reviewed for misappropriation (Resident #15), the facility failed to implement the written policies and procedures for abuse to thoroughly investigate an allegation of misappropriation.
- D
Respond appropriately to all alleged violations.
Inspectors wroteBased on observation, review of the clinical record, facility documentation, facility policy, and interviews for sampled resident reviewed for misappropriation (Resident #15), the facility failed to implement the written policies and procedures for abuse to thoroughly investigate an allegation of misappropriation to prevent further abuse.
- 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 clinical record review, review of facility documentation, review of policy and staff interview for one sampled resident (Resident # 20) reviewed for falls, the facility failed to revise the care plan timely to provide further falls and for.
- D
Ensure services provided by the nursing facility meet professional standards of quality.
Inspectors wroteBased on clinical record review, facility documentation, facility policy, and interviews for 1 resident (Resident # 20) reviewed for medication administration, the facility failed to ensure medications were administered according to professional standards and within facility policy.
- 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 1 of 2 residents (Resident #20) reviewed for falls, the failed to ensure neurological testing was completed for a resident who sustained an unwitnessed fall and for one resident (Resident #30) reviewed for skin condition(s), the facility failed to ensure consistent weekly wound monitoring for a resident with non-pressure related wounds and failed to follow recommendations from a specialty service or hospital for a resident with a non-pressure related wound and for 1 sample resident (Resident # 41) reviewed for death, the facility failed to ensure that there was a written physician's order of RN May Pronounce Death when a resident death was anticipated.
- D
Provide enough food/fluids to maintain a resident's health.
Inspectors wroteBase clinical record reviews, facility policy review and interviews for 1 sample resident (Resident # 241) reviewed for hydration, the facility failed to monitor and record Intake and Output (I&O) according to the facility policy and for 1 sample resident (Resident # 9) reviewed for edema, the facility failed to monitor the resident weight according to the physician order.
- D
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Inspectors wroteBased on observation, review of the clinical record, facility documentation, facility policy, and interviews for 1 sampled resident (Resident#26) reviewed for specialized treatment, the facility failed to ensure the resident's communication form to the specialized center was complete and the facility failed to ensure the licensed staff consistently reviewed the communication form after the resident received specialized services and the facility failed to ensure consistent monitoring and documentation of Intake and Output for a resident on fluid restriction who received specialized treatment and the facility failed to ensure a medication receive during specialized treatment was secure in the medication storage room or medication cart and the facility failed to obtain a physician's order for a resident receiving specialized treatment.
- D
Observe each nurse aide's job performance and give regular training.
Inspectors wroteBased on review of facility documentation, facility policy and interview, the facility failed to ensure mandatory annual training for all staff was completed for 2 Nurse Aides (NA #2 and NA #3).
- 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 clinical record review and interview for two of five residents reviewed for Unnecessary Medication for (Resident # 20), the facility failed to consistently monitor the resident's blood pressure according to facility policy and procedure and for (Resident # 241), the facility failed to address the pharmacy recommendation in a timely manner in accordance to facility practice.
- D
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Inspectors wroteBased on observation, review of the clinical record, facility documentation, facility policy, and interviews for 2 of 5 residents (Resident # 6 and Resident #29) reviewed for Pneumococcal immunization, the facility failed to develop a method to track and / or monitor immunization status, screen for eligibility and provide for Pneumococcal vaccination as ordered.
December 12, 2019Standard inspection · 6 citations
- 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 review of the clinical record, facility documentation, facility policy and procedures and interviews for one of three residents reviewed for skin integrity (Resident #15), the facility failed to develop skin interventions on the Baseline Resident Care Plan.
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on review of the clinical record, facility documentation, facility policy and interviews for one of three sampled residents reviewed for skin integrity (Resident #15), the facility failed to implement preventative skin recommendations and failed to complete a weekly body audit.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interviews and review of facility policy, for one of one resident observed for wound care (Resident #23), the facility failed to follow infection control practices during a wound treatment and for one of fifteen bathrooms observed, the facility failed to ensure personal care items were stored in a safe and sanitary manner.
- B
Ensure each resident receives an accurate assessment.
Inspectors wroteBased on review of the clinical record, interviews and review of the Resident Assessment Instrument (RAI) Manual for 1 of 2 sampled residents (Resident #11) reviewed for Preadmission Screening and Resident Review (PASRR) and for 1 of 1 sampled residents reviewed for smoking (Resident #20), the facility failed to ensure the Minimum Data Set (MDS) was coded accurately.
- B
Observe each nurse aide's job performance and give regular training.
Inspectors wroteBased on review of facility documentation and interviews for one of three employee files reviewed (Nurse Aide #2), the facility failed to ensure a Nurse Aide (NA) performance evaluation was completed annually.
- B
Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.
Inspectors wroteBased on review of facility documentation and interviews, for one of three sampled Nurse Aides (NA) reviewed for abuse prohibition inservicing (NA #2), the facility failed to ensure annual training for abuse prohibition was completed.
Fire safety inspections
5 fire safety citations on file: 2 on February 8, 2025, 1 on October 4, 2022, 2 on December 12, 2019.
Every fire safety citation5 citations
- D
Provide properly protected cooking facilities.
K 324 · February 8, 2025 · Corrected (the home has a date of correction)
- D
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · February 8, 2025 · Corrected (the home has a date of correction)
- D
Have exits that are accessible at all times.
K 271 · October 4, 2022 · Corrected (the home has a date of correction)
- E
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
K 761 · December 12, 2019 · Corrected (the home has a date of correction)
- D
Keep aisles, corridors, and exits free of obstruction in case of emergency.
K 211 · December 12, 2019 · Corrected (the home has a date of correction)