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 37 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
3J
0K
0L
Actual harm
4G
0H
0I
Potential for more than minimal harm
14D
14E
2F
Potential for minimal harm
0A
0B
0C
January 29, 2026Complaint inspection · 1 citation
- E
Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death.
Inspectors wroteBased on interview, and record review, the facility failed to refund any and all monies due to the resident's representative within 30 days of the resident's date of death /discharge from the facility for 1 of 3 residents reviewed for discharge, of a total sample of 3 residents, (#1).
December 19, 2025Complaint inspection · 5 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 interview, and record review, the facility failed to protect the resident's right to be free from neglect by not providing necessary care and services for a totally dependent resident and failed to assess, recognize and intervene for changes in condition for 1 of 3 residents reviewed for neglect, out of a total sample of 15 residents, (#2). This failure contributed to the resident being found unresponsive and exhibiting physical signs consistent with having been deceased for some time prior to discovery. On [DATE] just after midnight, resident #2 was found unresponsive and staff initiated cardio-pulmonary resuscitation (CPR). The resident was transferred to the hospital by Emergency Medical Services (EMS). The EMS and hospital records noted resident #2 was very rigid with stiff extremities and core body temperature of 90.7 degrees Fahrenheit. [...]
- J
Respond appropriately to all alleged violations.
Inspectors wroteBased on record review, and interview, the facility failed to investigate allegation of neglect to ensure staff recognized change in resident condition and provided timely interventions for 1 out of 15 residents reviewed for advanced directives, (#2). On [DATE] after midnight, resident #2 was found unresponsive and staff initiated CPR. The resident was transferred to the hospital by Emergency Medical Services (EMS). The EMS and hospital records noted resident #2 was very rigid with stiff extremities and core body temperature of 90.7 degrees Fahrenheit. The records indicated the resident displayed signs and symptoms of rigor mortis indicating the resident had been deceased for some time, before staff had identified the resident to be unresponsive and initiated CPR. [...]
- J
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on interview and record review, the facility failed to provide care and services in accordance with the resident's care plan, the resident's choice and as per professional standards of practice for 1 of 6 residents reviewed for quality of care, out of a total sample of 15 residents, (#2). This failure contributed to the resident being found unresponsive and exhibiting physical signs consistent with having been deceased for some time prior to discovery. On [DATE] just after midnight, resident #2 was found unresponsive and staff initiated cardio-pulmonary resuscitation (CPR). The resident was transferred to the hospital by Emergency Medical Services (EMS). The EMS and hospital records noted resident #2 was very rigid with stiff extremities and core body temperature of 90.7 degrees Fahrenheit. [...]
- E
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Inspectors wroteBased on interview and record review, the facility failed to conduct a Quality Assurance and Performance Improvement (QAPI) meeting when allegations of neglect and concerns were identified related to the death of resident #2.
- E
Have a Compliance and Ethics Program.
Inspectors wroteBased on interview and record review, the facility failed to ensure all staff adhered to ethical practices and professional standards by providing inconsistent and misleading statements related to a resident's death in the facility, failed to provide high-level personnel oversight to ensure adherence to ethical standards, and failed to develop effective lines of communication to encourage immediate reporting of violations without fear of retaliation. These failures contributed to the inadequate investigation of resident #2's death.
October 16, 2025Complaint inspection · 5 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 observation, interview and record review, the facility neglected to identify and implement appropriate fall prevention interventions for a resident with a high risk for falls who also received a combination of high-risk medications, resulting in the resident experiencing a fall with injury. This failure resulted in actual harm to 1 of 4 residents reviewed for Quality of Care, (#1).
- G
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement appropriate interventions to include provision of adequate supervision to mitigate the prevention of fall with injury for 1 of 4 residents reviewed for Quality of Care, (#1). The facility's failure to increase supervision for a resident with a history of repeated falls who also received high-risk medications resulted in actual harm.
- E
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Inspectors wroteBased on interview and record review, the facility failed to maintain an effective Quality Assurance and Performance Improvement (QAPI)/Quality Assessment and Assurance (QAA) program by not identifying and addressing repeated deficiencies and by not ensuring complete monitoring documentation for corrective action plans. The deficient practice resulted in a pattern of unresolved quality concerns and had the potential to affect more than a limited number of residents by not ensuring consistent monitoring and follow-up of identified problems.
- E
Have a Compliance and Ethics Program.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the Director of Nursing (DON) adhered to ethical expectations and professional standards by backdating evaluations with incorrect documentation; lacked evidence of education or competency training for the role, and readily available employee program access.
- D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on interview and record review, the facility failed to maintain accurate and complete medical records for 1 of 4 residents reviewed for Quality of Care, (#1). Specifically, the Director of Nursing (DON) incorrectly documented and backdated resident records, resulting in inaccurate information in the clinical record and the Minimum Data Set (MDS) Coordinator inaccurately recorded fall histories. This deficient practice had the potential to affect all residents by compromising the accuracy and integrity of resident medical information used to make care decisions.
July 18, 2025Standard inspection · 6 citations
- E
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Inspectors wroteThe facility failed to ensure food was served to residents was palatable and served at appetizing temperatures for 2 of the approximately 18 residents who received meal trays from the satellite kitchen and ate in their room, of a total sample of 26 residents.
- E
Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse.
Inspectors wroteBased on interview, and record review, the facility failed to ensure the binding arbitration agreement explicitly granted the resident or their representative the right to rescind the agreement within 30 calendar days of signing it, failed to include that the signer was allowed to communicate with federal, state, or local officials, health department employees, and a representative Ombudsman, and failed to include evidence that the signer acknowledged they understood the agreement for 9 of 9 residents who signed binding arbitration agreements, of a total sample of 26 residents.
- E
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Inspectors wroteBased on interview, and record review, the facility failed to ensure the Quality Assessment & Assurance (QAA) / Quality Assurance and Performance Improvement (QAPI) committee conducted performance improvement activities to ensure prior improvement measures were sustained.
- E
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a system for tracking and monitoring infections for 3 out of 5 residents, (#13, #22, #35) reviewed for transmission-based precautions; and failed to identify and implement a system to prevent the spread of communicable diseases by not encouraging and providing hand hygiene for 16 of 16 residents reviewed for dining at the facility, of a total sample of 26 residents.
- D
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Inspectors wroteBased on interview, and record review, the facility failed to provide the appropriate notices of financial liability for 2 of 3 residents reviewed for Skilled Nursing Facility (SNF) Beneficiary Protection Notification, of a total sample of 26 residents, (#06 and #09).
- D
Help the resident make transportation arrangements to and from radiology services.
Inspectors wroteBased on interview, and record review, the facility failed to make transportation arrangements for a resident to a specialty medical care appointment, for 1 of 1 residents reviewed for transportation, of a total sample of 26 residents, (#8).
February 15, 2025Complaint inspection · 6 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 observation, interview, and record review, the facility neglected to provide necessary care and services to prevent falls and a fall-related injury and ensure appropriate post-fall monitoring and evaluation, for 1 of 4 residents reviewed for fall risk, of a total sample of 8 residents, (#4); and failed to maintain effective processes to educate staff and offer adequate supervision to meet the needs of all residents at risk for falls. The facility's failure to appropriately monitor residents with cognitive and/or physical impairments resulted in actual harm for resident #4, and placed all residents who required increased supervision at risk for injury. Resident #4, a physically and cognitively impaired resident, received blood thinner medication and had a history of repeated falls. [...]
- G
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on interview, and record review, the facility failed to provide adequate supervision to prevent falls and fall-related injury for 1 of 4 residents reviewed for fall risk, of a total sample of 8 residents, (#4). The facility's failure to appropriately monitor residents with cognitive and/or physical impairments resulted in actual harm for resident #4, and placed all residents who required increased supervision at risk for injury. Resident #4, a physically and cognitively impaired resident, received blood thinner medication and had a history of repeated falls. On 12/22/24, the Certified Nursing Assistant (CNA) assigned to supervise residents in the fall prevention program in the activity room left the residents unattended, and resident #4 fell from her wheelchair to the floor. [...]
- F
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, interview, and record review, the facility failed to maintain sufficient staff to provide adequate supervision and meet care needs to ensure the safety and well-being, according to the plans of care, for all residents of the facility.
- 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 interview, and record review, the facility failed to promptly notify the physician of an unwitnessed fall for a resident at high risk for bleeding, for 1 of 4 residents reviewed for fall risk, of a total sample of 8 residents, (#4).
- D
Respond appropriately to all alleged violations.
Inspectors wroteBased on interview, and record review, the facility failed to implement its abuse and neglect prohibition policy and procedures related to conducting a thorough investigation of a fall with injury to rule out neglect, determine if reporting was necessary, and ensure the safety of 1 of 4 residents reviewed for fall risk, of a total sample of 8 residents, (#4).
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on observation, interview, and record review, the facility failed to provide adequate assistance with activities of living (ADL) care related to fingernail care, oral care, and dressing for 3 of 4 residents reviewed for ADL care, of a total sample of 8 residents, (#1, #2, and #5).
January 23, 2025Complaint inspection · 1 citation
- E
Ensure residents have reasonable access to and privacy in their use of communication methods.
Inspectors wroteBased on interview, and record review, the facility failed to provide reasonable access to the use of a telephone and internet, including a place in the facility where calls could be made in private for 3 residents sampled for resident rights, of a total sample of 31 residents, (#1, #2, and #3).
September 19, 2024Standard inspection · 5 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 observation, and interview, the facility failed to ensure dry food items in the main pantry were properly stored by keeping track of expiration dates to prevent food-borne illnesses and failed to maintain a clean and sanitary environment in the unit refrigerator where resident's foods and bedtime snacks were kept. This noncompliance had the ability to affect 30 of 30 residents in the facility, who were able to eat.
- D
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Inspectors wroteBased on observation, interview, and record review, the facility failed to request a Preadmission Screening and Resident Review (PASARR) Level I Screen with a new mental disorder diagnosis for 2 of 3 residents reviewed for PASARR, of a total sample of 30 residents, (#24, and #14).
- D
PASARR screening for Mental disorders or Intellectual Disabilities
Inspectors wroteBased on interview and record review, the facility failed to request a Preadmission Screening and Resident Review (PASARR) level I and level II evaluation for 1 of 3 residents reviewed for PASARR, of a total sample of 30 residents, (#25). Review of the medical record revealed resident #25 was admitted on [DATE] from the hospital. Her diagnoses included vascular dementia, Alzheimer's disease, major depressive disorder and generalized anxiety disorder. Resident #25's admission Minimum Data Set (MDS) with an assessment reference date of 7/31/24 revealed the resident was admitted to the facility with Alzheimer's dementia, anxiety disorder and psychotic disorder (other than schizophrenia) and she received antipsychotic and antidepressant medications. [...]
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observation, interview, and record review, the facility failed to obtain physician orders before administering oxygen therapy, and failed to maintain oxygen flow rates as ordered by the physician for 2 of 3 residents reviewed for respiratory care, of a total sample of 30 residents, (#12 & #29).
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview, and record review, facility staff failed to change gloves and perform hand hygiene, before moving from a contaminated-body site to a clean-body site during wound care, consistent with professional standards of practice, for 1 of 1 resident reviewed for pressure ulcers, of a total sample of 30 residents, (#25).
June 13, 2024Complaint inspection · 4 citations
- D
Allow residents to self-administer drugs if determined clinically appropriate.
Inspectors wroteBased on observation, interview, and record review, the facility failed to promote the right to self-administer medication for 1 of 4 residents reviewed for medication administration, out of a total sample of 4 residents, (#3).
- 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 observation, interview, and record review, the facility failed to honor the right to choose the type and frequency of baths for 1 of 4 residents reviewed for activities of daily living (ADLs), out of a total sample of 4 residents, (#3).
- D
Provide enough food/fluids to maintain a resident's health.
Inspectors wroteBased on interview and record review, the facility failed to implement interventions to ensure the optimal nutritional status for 1 of 1 resident reviewed for assisted nutrition and hydration via tube feeding, out of a total sample of 4 residents, (#1).
- D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Inspectors wroteBased on interview and record review, the facility failed to provide pharmaceutical services to ensure the accuracy of acquisition and administration of anti-seizure medication for 1 of 4 residents reviewed for medication administration, out of a total sample of 4 resident, (#1).
September 28, 2023Standard inspection · 4 citations
- E
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents received prescribed enteral formula feedings via gastrostomy tube as ordered for 1 of 25 residents, (#26).
- E
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on observation and interview, the facility failed to distribute and serve food under sanitary conditions.
- E
Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse.
Inspectors wroteBased on interview and record review, the facility failed to ensure that the binding arbitration agreement explicitly granted the resident or their representative the right to rescind the contract within 30 calendar days of signing it for 3 of 3 residents reviewed for arbitration agreements, (#35, #236 and #535).
- E
Provide and implement an infection prevention and control program.
Inspectors wroteBased on record review and interview, the facility failed to have measures in place to prevent the growth of Legionella and other waterborne pathogens to ensure the health and safety of all 37 residents residing in the facility.
Fire safety inspections
8 fire safety citations on file: 5 on March 26, 2026, 1 on September 19, 2024, 2 on September 28, 2023.
Every fire safety citation8 citations
- F
Develop and maintain an Emergency Preparedness Program (EP).
E 4 · March 26, 2026 · Corrected (the home has a date of correction)
- F
Address subsistence needs for staff and patients.
E 15 · March 26, 2026 · Corrected (the home has a date of correction)
- F
Meet other general requirements.
K 100 · March 26, 2026 · Corrected (the home has a date of correction)
- F
Meet requirements for the installation and maintenance of electrical systems.
K 911 · March 26, 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 · March 26, 2026 · Corrected (the home has a date of correction)
- D
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
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 · September 28, 2023 · Corrected (the home has a date of correction)
- E
Inspect, test, and maintain automatic sprinkler systems.
K 353 · September 28, 2023 · Corrected (the home has a date of correction)