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 30 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
4J
0K
0L
Actual harm
1G
0H
0I
Potential for more than minimal harm
18D
7E
0F
Potential for minimal harm
0A
0B
0C
April 9, 2026Standard inspection · 6 citations
- E
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 observation, interview, and record review, the facility failed to have a person-centered care plan developed and implemented to meet each resident's preferences and goals, and address the resident's medical, physical, mental, and psychosocial needs for three of (52, 67, and 73) eight residents reviewed for care plans. The facility failed to ensure Resident # 67's initial care plan was completed upon admission to reflect Resident #67's need for treatments, such as TPN-Total Parental Nutrition (a method of delivering essential nutrients-carbohydrates, proteins, fats, electrolytes, vitamins, and minerals-directly into the bloodstream via a central vein catheter, bypassing the digestive system. [...]
- 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, interview, record review, the facility failed to ensure storage of medications used in the facility in accordance with currently accepted professional principles and included the appropriate expiration dates to preserve their integrity for the stored medications, and to store medications properly to prevent deterioration for two medications carts out of four and two nursing carts out of 4 reviewed for medications storage. The facility failed to ensure that the MC-D (hall 200) did not have 1 medication bottle that was undated in the drawer. The facility failed to ensure that the MC-D (hall 200) did not have 7 medication bottles that were labeled incorrectly. The facility failed to ensure that the MC-D (hall 200) did not have 1 white round TAB inside of unlabeled medication cup. [...]
- E
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 (Resident #41 and Resident #48) of 7 residents reviewed for infection control. The facility failed to ensure MA D performed hand hygiene before and after administering medications to Resident #55 and Resident #48. The facility failed to ensure LVN B performed hand hygiene before going to Resident #55 room. These failures could place residents at risk for cross contamination and the spread of infection.
- 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 interview, and record review, the facility failed to ensure all residents had the right to formulate an advance directive for 2 (Resident #52 and Resident #73) of 10 residents reviewed for advance directives. 1. The facility failed to ensure Resident #52's advanced directives were clearly identified, documented in the resident's electronic medical record, and on the residents' care plan.2. The facility failed to ensure Resident #73's advanced directives were clearly identified, documented in the resident's electronic medical record, and on the residents' care plan. This failure could place residents at risk of not having their end-of-life wishes honored and having incomplete records.
- D
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Inspectors wroteBased on interview and record review, the facility failed to ensure that each resident's drug regimen was free from unnecessary drugs for one of 10 residents, (Residents #67), reviewed for unnecessary medications. The facility failed to ensure Resident #67 had an indication/diagnosis for an antibiotic ordered. Resident #67 was receiving Ciprofloxacin HCl Tablet 500 MG without appropriate diagnoses. This failure could place residents at risk of not receiving the appropriate interventions, monitoring, and follow-ups. [...]
- 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 ensure its residents were free of any significant medication errors for 1 (Resident #55) of 3 residents observed and reviewed for medications administration. The facility failed to ensure that MA D did not inaccurately chart two refused medications as administered to Resident # 55. These failures placed the residents at risk of harm or not receiving desired outcomes from medications not administered according to physician's orders and manufacturer's specifications.
December 3, 2025Complaint inspection · 2 citations
- D
Keep residents' personal and medical records private and confidential.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that each resident has a right to secure and confidential personal and clinical records for one (Resident #2) out of 16 residents LVN B was providing care for on 12/03/2024. A. Resident #2's personal health information was left on the unlocked computer screen at the nursing station by LVN B. This failure could result in Resident #2's personal information being exposed to unauthorized individuals. This problem had the potential to affect all 16 residents in care of LVN B on 12/3/2025.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observations, interviews and record review, the facility failed to provide a safe and sanitary environment to prevent the development and transmission of communicable diseases and infections for 2 (Resident #1, Resident #2) of 7 residents reviewed for infection control. 1. The facility failed to properly use EBP personal protective equipment during wound care for Resident #1 and Resident #2.2. The facility failed to follow hand hygiene procedure during direct care for Resident #1. This failure could place residents at risk for infection transmission, sepsis, and hospitalization.
February 14, 2025Standard inspection · 6 citations
- E
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Inspectors wroteBased on observation, interview, and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for two of two medication rooms (second floor and third floor medication rooms) reviewed for pharmacy services. The facility failed to ensure the second and third floor medication rooms did not contain expired supplies. These failures could place residents at risk of receiving inadequate treatments or results or ingesting medications for which they were not prescribed.
- D
Ensure that residents are fully informed and understand their health status, care and treatments.
Inspectors wroteBased on record review and interview, the facility failed to ensure that the resident has the right to be informed of, and participate in, his or her treatment, including the right to be informed in advance of the risks and benefits of proposed care, of treatment and treatment alternatives or treatment options and to choose the alternative or option he or she prefers for 2 (Residents #8 and #10) of 6 residents reviewed for unnecessary medications. 1. The facility failed to obtain signed consent prior to administering psychotropic medication Depakote for Resident #8. 2. The facility failed to obtain signed consent prior to administering psychotropic medications Trazodone, Depakote, and Seroquel for Resident #10. [...]
- D
Reasonably accommodate the needs and preferences of each resident.
Inspectors wroteBased on observation, interview and record review the facility failed to ensure residents received services in the facility with reasonable accommodation of resident needs for 1 of 8 residents (Resident #24) who were observed for call light placement. The facility failed to ensure the call light was within reach for Resident #24. This deficient practice could affect any resident and keep them from calling for help as needed.
- 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, interview, and record review, the facility failed to ensure all drugs and biologicals used in the facility were stored and labeled in accordance with currently accepted professional principles for 1 of 1 medication rooms ( third floor medication room) and one of four medication carts (third floor Hall E medication aide cart) assessed for drug storage and labeling, as evidenced by: The facility failed to ensure all medications located inside the third floor Hall E medication aide cart were properly labeled. These failures could place residents at risk of receiving inadequate treatments or results or ingesting medications for which they were not prescribed.
- D
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on observations and record review, the facility failed to store food in accordance with professional standards for food service safety. 1. The facility failed to maintain refrigerated storage area free of contaminants and store food off flooring. 2. The facility failed to discard food items that were beyond labeled use-by date. 3. The facility failed to label food items with use-by date and date items were opened. 4. The facility failed to ensure items in the freezer were covered. These failures could place residents at risk for food contamination and foodborne illness.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observations, interview, and record review, the facility failed to maintain an infection prevention control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 of 4 residents (Resident#40 and Resident #10) reviewed for infection control related to isolation precautions. 1. The facility failed to ensure isolation precaution signage and personal protective equipment (PPE) were in place for Resident #40 who had been identified as requiring enhanced barrier precautions (EBP). 2. The facility failed to ensure CNA A utilized isolation precautions, including PPE and hand hygiene, for Resident #10, who had been identified as requiring contact precautions. These failures could result in the spread of infection to other residents and staff.
October 14, 2024Complaint inspection · 1 citation
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on interviews and record reviews, the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for one (Resident #1) of four residents reviewed for falls. The facility failed to conduct neurological assessments on Resident #1 per facility protocol after Resident #1 returned from the hospital the same day of her unwitnessed fall at the facility. This failure could place residents at risk of a change in condition and not receiving proper treatment and care in a timely manner.
May 1, 2024Complaint inspection · 1 citation
- J
Plan the resident's discharge to meet the resident's goals and needs.
Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement an effective discharge planning process that focused on the resident's discharge goals, the preparation of residents to be active partners and effectively transition them to post-discharge care, and the reduction of factors leading to preventable readmissions for one (Resident #1) of three residents reviewed for discharges. The facility failed to have a wheelchair and assistant services set up upon Resident #1's discharge to her apartment. She was unable to transfer herself and was found by EMS over 24 hours later laying in the same spot without access to food or water. This failure resulted in an identification of an Immediate Jeopardy (IJ) on 04/29/24 at 2:00 PM and an IJ template was provided to the ADM. [...]
January 26, 2024Standard inspection, Complaint inspection · 11 citations
- J
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 ensure the resident environment remained as free of accident hazards as is possible and that each resident received adequate supervision to prevent accidents for 1 (Resident #11) of 6 residents reviewed for accidents. The facility failed to ensure that the water used to prepare hot beverages for residents was maintained at a temperature appropriate to prevent scalding and burns. Water temperatures were taken on 01/24/24 from the coffee machine hot water Bunn dispenser the water temperature was 188 degrees Fahrenheit. On 09/12/23, Resident #11 spilled hot tea on herself, and she sustained a second degree burn to her right hip, which required wound care. An Immediate Jeopardy was identified on 01/25/24 at 11:50 AM. [...]
- 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, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen; specifically, the facility failed to ensure dishware were appropriately sanitized. The facility failed to ensure the dishwasher reached minimum wash and rinse temperatures of 140 degrees to wash and 180 degrees or final rinse. This failure could place residents at risk for food contamination and food borne illness.
- E
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observations and interviews the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 3 of 9 sharps containers, and 1 of 6 staff (CNA D) reviewed for infection control. 1. The facility failed to monitor sharps containers to prevent them from being over filled. 2. The facility failed to ensure CNA D disinfected the blood pressure cuff in between blood pressure checks for Residents #32, #34, #42 and #45. These findings could result in residents being exposed to infections and bloodborne pathogens.
- E
Provide bedrooms that don't allow residents to see each other when privacy is needed.
Inspectors wroteBased on observation and interview, the facility failed to equip rooms to assure full visual privacy for each resident in 5 of 16 rooms reviewed for privacy. The facility failed to install curtains to ensure the residents in the A bed would have full visual privacy when needed. This failure could cause the resident to be exposed to anyone entering the room during cares.
- D
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Inspectors wroteBased on observation, interview, and record review, the facility failed to implement written policies to prevent abuse, neglect, and exploitation for 1 of 6 (Resident #11) residents reviewed for neglect. Resident #11 sustained a second degree burn after spilling hot tea on herself which required wound care from 09/13/23-11/29/23 and the facility failed to report the incident to the State Survey Agency. This failure could place the resident at risk for unreported allegations of abuse, neglect, and injuries of unknown origin.
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on interview and record review the facility failed to ensure all alleged violations involving abuse, neglect, exploitation or mistreatment, which included injuries of unknown source and misappropriation of resident property, were reported immediately, but no later than 2 hours after the allegation was made, if the events that caused the allegation involved abuse or resulted in serious bodily injury, or not later than 24 hours if the events that caused the allegation did not involve abuse and did not result in serious bodily injury, to the administrator of the facility and to other officials, which included the state survey agency, in accordance with State law through established procedures for 1 of 6 residents (Resident #11) reviewed for abuse and neglect. [...]
- 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 interview and record review, the facility failed to develop a baseline care plan within 48 hours of admission for 2 of 6 residents (Resident #4 and Resident #209) reviewed for baseline care plans. The facility failed to ensure Residents #4 and Resident #209 had a baseline care plan, or conversely a comprehensive care plan, within 48 hours of admission. These failures could place the residents at risk of not having their needs and preferences met.
- D
Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident who enters the facility with a colostomy receive such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences for 1 of 1 resident (Resident #209) reviewed for colostomies. The facility failed to have physician orders and a care plan for Resident #209's colostomy. These findings place resident at risk of complications related to a colostomy.
- D
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 a resident who was fed by enteral means received appropriate treatment and services to restore, if possible, oral eating skills and to prevent complications of enteral feeding which included but not limited to aspiration, pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities and nasal-pharyngeal ulcers for one of four residents (Resident #221) reviewed for feeding tubes. The facility failed to follow physician's orders to change Resident #221's enteral feeding bag and tubing every 24 hours to provide with her 20 hours of feeding. This failure could place residents at risk for a decline in health or adverse effects due to inappropriate management of enteral feeding care.
- D
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents received parenteral fluids administered consistent with professional standards of practice and in accordance with physician orders for 1 of 2 resident (Resident #156) reviewed for peripheral intravenous care. The facility failed to ensure Resident #156's PICC line dressing was dated on 01/20/24. This failure placed residents at risk of developing an infection.
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that a resident who needs respiratory care was provided such care, consistent with professional standards of practice for 1 of 3 residents (Resident #4) reviewed for oxygen. 1. The facility failed to have physician orders for oxygen use. 2. The facility failed to ensure Resident #4's concentrator and nasal cannula was with changed out on a weekly basis. This failure could place residents who received oxygen therapy at risk for inadequate or inappropriate amounts of oxygen delivery and possible infection.
December 29, 2023Complaint inspection · 2 citations
- 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 ensure that residents received treatment and care in accordance with professional standards of practice for one 1 (Resident #1) of 6 residents reviewed for quality of care. The facility failed to follow physician orders for Resident #1 to monitor blood pressure and blood sugars after a medication error was discovered and resident had to be sent to the emergency department. An Immediate Jeopardy (IJ) existed from [DATE] - [DATE]. The IJ was determined to be at past noncompliance as the facility had implemented actions that corrected the noncompliance prior to the beginning of the investigation. These failures placed the resident at risk of not receiving adequate care and services, and decreased quality of life. [...]
- J
Ensure that residents are free from significant medication errors.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were free of significant medications errors for one of five residents (Resident #1) reviewed for any significant medication errors, in that: The facility gave Resident #1 medications belonging to another patient on 12/3/2023 and 12/4/2023 resulting in Resident #1 blood sugar dropping and being transferred to the emergency department. An Immediate Jeopardy (IJ) existed from 12/03/23 - 12/05/23. The IJ was determined to be at past noncompliance as the facility had implemented actions that corrected the noncompliance prior to the beginning of the investigation. This failure placed residents at risk of experiencing non-therapeutic side effects from medications which could cause injury and/or death.
November 5, 2023Complaint inspection · 1 citation
- 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 has failed to ensure the resident environment remained as free of accident hazards as possible and the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 of 3 residents (Residents #1) reviewed for accidents and supervision. Facility staff failed to ensure Resident #1's wheelchair was in the locked position during a transfer, causing a fall on 8/28/23 which resulted in fractures to the pubic bone and femur. The noncompliance was identified as PNC. The noncompliance began on 8/29/23 and ended on 9/3/23. The facility had corrected the noncompliance before the survey began. This failure could place residents at risk of injury from accidents and hazards.
Fire safety inspections
11 fire safety citations on file: 1 on April 9, 2026, 3 on February 14, 2025, 7 on January 26, 2024.
Every fire safety citation11 citations
- D
Inspect, test, and maintain automatic sprinkler systems.
K 353 · April 9, 2026 · Corrected (the home has a date of correction)
- F
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · February 14, 2025 · Corrected (the home has a date of correction)
- E
Have properly located and lighted "Exit" signs.
K 293 · February 14, 2025 · Corrected (the home has a date of correction)
- E
Inspect, test, and maintain automatic sprinkler systems.
K 353 · February 14, 2025 · Corrected (the home has a date of correction)
- F
Meet requirements for sections of health care facilities separated by fire resistive construction.
K 131 · January 26, 2024 · Corrected (the home has a date of correction)
- F
Have an enclosure around a vertical opening shaft.
K 311 · January 26, 2024 · Corrected (the home has a date of correction)
- F
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · January 26, 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 · January 26, 2024 · Corrected (the home has a date of correction)
- E
Keep aisles, corridors, and exits free of obstruction in case of emergency.
K 211 · January 26, 2024 · Corrected (the home has a date of correction)
- D
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 · January 26, 2024 · Corrected (the home has a date of correction)
- C
Have proper medical gas storage and administration areas.
K 923 · January 26, 2024 · Corrected (the home has a date of correction)