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 32 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
2G
0H
0I
Potential for more than minimal harm
26D
2E
2F
Potential for minimal harm
0A
0B
0C
April 8, 2026Standard inspection, Complaint inspection · 14 citations
- G
Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
Inspectors wroteBased on record review, hospital/emergency department documentation, facility policy review, and staff interviews, the facility failed to ensure staff verified Resident #2's documented allergy (to the COVID-19 vaccine) prior to administering the vaccine. The facility also failed to provide timely clinical assessment and medical intervention after the vaccine was administered. This affected one resident (Resident #2) of five residents reviewed for vaccinations. On 11/07/25 at 12:10 P.M., staff administered a COVID 19 vaccination to Resident #2 despite the vaccine being listed as an allergy in the resident's medical record. No immediate assessment or monitoring was completed following administration of the contraindicated vaccine. [...]
- F
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview, record review and review of the facility policy, the facility failed to follow their legionella water management plan and practice appropriate hand hygiene during medication administration and wound care. This affected two residents (Residents #8 and #100) observed for infection control and had the potential to affect all 79 residents in the facility.
- E
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on record review, review of Self-Reported Incident (SRI), and interview the facility failed to notify the Board of Nursing of a licensed nurse's failure to perform their job duties. This affected 24 residents (Resident #6, #12, #15, #17, #24, #36, #39, #43, #52, #54, #56, #57, #59, #61, #66, #70, #82, #87, #88, #104, #105, #106, #107, #108) who resided on the second floor of the facility. The facility census was 79.
- D
Reasonably accommodate the needs and preferences of each resident.
Inspectors wroteBased on observation, interview, record review, and policy review the facility failed to ensure the call light was within reach for one resident (Resident #9). This affected one of eight residents reviewed for call lights.
- D
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Inspectors wroteBased on closed record review and interview, the facility failed to ensure Resident #94's discharge summary was signed, verifying receipt of discharge instructions. This affected one resident (Resident #94) of three reviewed for discharge process. Review of the closed medical record for Resident #94 revealed an admission date of 09/20/25 and a discharge date of 10/04/25. Diagnoses included foreign body in respiratory track, dysphagia, hypertension and anxiety. Review of the discharge Minimum Data Set 3.0 dated 10/04/26 revealed he was cognitively intact and required set-up to moderate assistance with activities of daily living. Review of the Discharge summary dated [DATE] revealed no evidence the resident or family member signed the discharge summary acknowledging wound care instructions as the form indicated a signature should be obtained. Interview on 04/01/26 at 10:13 A.M. [...]
- 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 observation, record review and interview the facility failed to ensure Resident #8's care plan was revised to indicate an accurate right buttock wound classification and failed to ensure Resident #50's care plan included individualized interventions to address her diagnosis of gastroesophageal reflux disease This affected one resident (Resident #8) out of three residents reviewed for pressure ulcers and one resident (Resident #50) out of four residents reviewed for medication administration. The facility census was 79.
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on interview and record review the facility failed to provide showers according to resident preferences. This affected two residents (Resident #9 and Resident #35) out of four residents sampled for activities of daily living.
- D
Provide activities to meet all resident's needs.
Inspectors wroteBased on interview, record review, and policy review the facility failed to provide individualized activities to meet Resident #9's interests. This affected one resident (Resident #9) out of one resident reviewed for activities.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on record review and interview the facility failed to ensure treatment was in place to properly manage Resident #98's diabetic needs. This affected one resident (Resident #98) out of two residents reviewed for insulin administration. The facility census was 79.
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observation, interview, record review, and policy review the facility failed to ensure oxygen equipment was changed per physician order and stored appropriately. This affected two residents (Resident #35 and Resident #49) of two residents reviewed for respiratory care. The census was 79.
- D
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Inspectors wroteBased on interview, record review, and policy review the facility failed to ensure Resident #2 was assessed upon return to the facility after dialysis. This affected one resident (Resident #2) out of one reviewed for dialysis.
- 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, interview and review of the facility policy, the facility failed to ensure pharmacy recommendations were addressed in a timely manner. This affected three residents (#6, #12 and #66) of five residents reviewed for unnecessary medications. Facility census was 79.
- D
Ensure medication error rates are not 5 percent or greater.
Inspectors wroteBased on observation, record review and interview the facility failed to ensure the medication error rate was less than five percent (%). This affected two (Resident #6, #50) out of four residents observed for medication administration. The facility had three errors out of 28 opportunities for a medication error rate of 10.7%.The facility census was 79.
- D
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 interview the facility failed to ensure accurate and complete documentation in Resident #50's clinical record. This affected one (Resident #50) out of four residents observed for medication administration. The facility census was 79.
June 24, 2025Complaint inspection · 5 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, observation, interview and facility policy review, the facility did not ensure Foley catheter drainage bags were covered in a dignified manner. This affected one (Resident #66) out of three residents reviewed for dignity and had the potential to affect two additional (Residents #29 and #38) identified by the facility as having a Foley catheter. The facility census was 77.
- 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, interview and facility policy review, the facility failed to make the appropriate notifications when Resident #79 removed his Foley catheter. This affected one (Resident #79) of three reviewed for dignity concerns. The facility census was 77.
- D
Protect each resident from the wrongful use of the resident's belongings or money.
Inspectors wroteTHE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on record review, self-reported incident (SRI) review, interview and facility policy review, the facility failed to ensure misappropriation of medications for Resident #80. This affected one (Resident #80) of three reviewed for abuse and had the potential to affect all 77 residents residing in the facility.
- D
Respond appropriately to all alleged violations.
Inspectors wroteTHE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on record review, self-reported incident (SRI) review, facility investigation review, interview and facility policy review, the facility failed to ensure residents were free from potential abuse by failing to immediately suspend a staff member after an allegation of staff-to-resident abuse. This affected one (Resident #63) of three residents reviewed for abuse and had the potential to affect all 77 residents in the facility.
- 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, interview and facility policy review, the facility failed to ensure fall interventions were in place and falls were thoroughly investigated. This affected two (Residents #40 and #66) of three residents reviewed for falls. The facility census was 77.
September 19, 2024Standard inspection · 3 citations
- 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 record review, interview and facility policy review, the facility failed to ensure advance directive orders were consistent across electronic and paper medical records. This affected two residents (#5 and #29) out of 24 resident records reviewed. Facility census was 84.
- D
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Inspectors wroteBased on observations, review of the medical record, interview with staff, and review of facility policy the facility failed to release a restraint every two hours as ordered for Resident #22. This affected one resident ( Resident #22) of one resident reviewed for restraints. The facility census was 84.
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased observation, interview, record review and review of the facility policy, the facility failed to ensure fall interventions were in place per the plan of care. This affected two residents (#22 and #29) of four residents reviewed for falls. Facility census was 84.
December 4, 2023Complaint inspection · 2 citations
- G
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on closed record review, hospital record review, facility policy review and interview the facility failed to provide adequate supervision and assistance to prevent a fall with injury for Resident #80. Following the fall, the facility failed to complete a comprehensive assessment, provide ongoing monitoring and physician notification to ensure the resident received timely medical treatment. Actual Harm occurred on 11/25/23 at 5:45 P.M. when Resident #80, who was cognitively impaired, at high risk for falls and with a history of recent falls, sustained a fall from the wheelchair in the lounge area following dinner, resulting in a left hip fracture. At the time of the fall, the facility identified the resident had wanted to go to bed and attempted to stand from the wheelchair independently (no staff were with the resident at the time of the incident). [...]
- 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 closed record review and interview the facility failed to ensure timely family and physician notification following a fall with injury for Resident #80. This affected one resident (#80) of four residents reviewed for falls. The census was 76.
November 22, 2023Complaint inspection · 5 citations
- D
Let each resident or the resident's legal representative access or purchase copies of all the resident's records.
Inspectors wroteBased on record review and interview, the facility failed to ensure Resident #80's family members were provided the proper procedure and documents necessary to access the resident's medical records from the facility. This finding affected one (Resident #80) of three residents reviewed for medical records.
- 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 interview, the facility failed to notify Resident #80's family/power-of-attorney (POA) of a change in the resident's health condition in a timely manner. This finding affected one (Resident #80) of three residents reviewed for changes in condition.
- 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 record review and interview, the facility failed to notify Resident #80 and/or the representative of the resident's discharge to the hospital in a timely manner. This finding affected one (Resident #80) of three residents reviewed for discharges.
- D
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Inspectors wroteBased on record review and interview, the facility failed to notify Resident #80 and/or the representative of a bedhold notice at the time of the discharge to the hospital. This finding affected one (Resident #80) of three residents reviewed for discharges.
- 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, record review and interview, the facility failed to ensure Resident #60 was provided timely incontinence care. This finding affected one (Resident #60) of three residents reviewed for incontinence care.
June 2, 2022Standard inspection · 3 citations
- F
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on observations, interview and record review, the facility failed to ensure the kitchen was clean and sanitary. This had the potential to affect 72 residents who received meals from the kitchen, as one resident (#28) did not eat by mouth. The facility census was 73.
- E
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
Inspectors wroteBased on observation, interview and record review, the facility failed to serve pureed food at a smooth, proper consistency. This affected ten residents (#2, #9, #22, #32, #33, #40, #55, #59, #60 and #73) of ten residents who received a pureed diet as ordered by the physician. The facility census was 73.
- D
Provide special eating equipment and utensils for residents who need them and appropriate assistance.
Inspectors wroteBased on observation, medical record review, and staff interviews, the facility failed to ensure residents were provided with adaptive equipment for drinking to maintain independence. This affected two (Resident's #18 and #66) of two residents (Resident's #18 and #66) who received adaptive equipment for drinking. The facility census was 54.
Fire safety inspections
19 fire safety citations on file: 6 on April 8, 2026, 8 on September 19, 2024, 5 on June 2, 2022.
Every fire safety citation19 citations
- F
Use approved construction type or materials.
K 161 · April 8, 2026 · Corrected (the home has a date of correction)
- F
Install emergency lighting that can last at least 1 1/2 hours.
K 291 · April 8, 2026 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · April 8, 2026 · Corrected (the home has a date of correction)
- F
Have properly installed electrical wiring and gas equipment.
K 511 · April 8, 2026 · Corrected (the home has a date of correction)
- F
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
K 761 · April 8, 2026 · Corrected (the home has a date of correction)
- E
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
K 321 · April 8, 2026 · Corrected (the home has a date of correction)
- F
Follow proper procedures when the fire alarm was out of service for more than 4 hours.
K 346 · September 19, 2024 · Corrected (the home has a date of correction)
- F
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · September 19, 2024 · Corrected (the home has a date of correction)
- F
Install smoke barrier doors that can resist smoke for at least 20 minutes.
K 374 · September 19, 2024 · Corrected (the home has a date of correction)
- F
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
K 761 · September 19, 2024 · Corrected (the home has a date of correction)
- F
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · September 19, 2024 · Corrected (the home has a date of correction)
- E
Have properly installed electrical wiring and gas equipment.
K 511 · September 19, 2024 · 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 · September 19, 2024 · Corrected (the home has a date of correction)
- E
Have restrictions on the use of portable space heaters.
K 781 · September 19, 2024 · Corrected (the home has a date of correction)
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · June 2, 2022 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · June 2, 2022 · Corrected (the home has a date of correction)
- F
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · June 2, 2022 · Corrected (the home has a date of correction)
- E
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 · June 2, 2022 · Corrected (the home has a date of correction)
- E
Install corridor and hallway doors that block smoke.
K 363 · June 2, 2022 · Corrected (the home has a date of correction)