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 31 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
1J
2K
0L
Actual harm
3G
0H
0I
Potential for more than minimal harm
21D
4E
0F
Potential for minimal harm
0A
0B
0C
July 10, 2026Standard inspection · 7 citations
- E
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Inspectors wroteBased on interview and record review, the facility failed to ensure residents had the right to, and the facility promoted and facilitated resident self-determination through support of resident choice for 3 of 9 confidential residents. The facility failed to allow residents' right to choose to sign out of the facility independently. The facility failed to allow residents' right to choose to sit outside on the front patio without supervision. This failure placed residents at risk of decreased quality of life and loss of dignity.
- 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 to ensure the accurate acquiring, receiving, dispensing, and administering of medications, to meet the needs of residents for 2 of 23 residents (Resident # 10, Resident #115) reviewed for pharmaceutical services. The facility failed to provide Resident #115 with his as needed Cyclobenzaprine used to treat his muscle spasms on 7/6/2026. The facility failed to administer Resident #10's IV antibiotic as ordered on 07/08/2026. These failures placed residents at risk for pain, worsening symptoms, and discomfort.
- 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 and record review the facility failed to ensure drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles and safe and secure storage of all medication for 1 of 3 medication carts (100 hall cart) and 1 of 2 medication storage rooms (500 hall storage room) inspected for medication labeling and storage. The facility failed to remove three non-administered antibiotic prescriptions dated [DATE] from the 100 Hall medication cart for Resident #133 and Resident #134. The facility failed to ensure promethazine suppositories stored in the 500 Hall medication storage room were appropriately labeled. These failures placed residents at risk for medication errors, administration of improperly identified medications, and compromised medication safety.
- D
Ensure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge.
Inspectors wroteBased on interview and record reviews, the facility failed to develop and implement an effective discharge planning process that focused on the resident's discharge goals for 1 (Resident #76) of 5 residents reviewed for transfer/discharge. The facility failed to ensure that the WCN did not initiate the discharge process with Resident #76. The facility failed to ensure the discharge planner initiated discharge with Resident # 76. These failures placed residents at risk of not having an advocate who can inform them of their options, rights, and the added protection from being inappropriately transferred or discharged .
- D
PASARR screening for Mental disorders or Intellectual Disabilities
Inspectors wroteBased on observation, interview and record review the facility failed to ensure a level II pre-admission screen and resident review (PASRR) was completed for 1 of 23 residents (Resident #115) reviewed for PASRR screening. The facility failed to correct Resident #115's PASRR screening level 1 to indicate he had a mental illness so he could receive a level II PASRR evaluation. This failure placed the residents at risk for inappropriate placement and missed specialized services.
- 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 observations, interviews and record reviews, the facility failed to provide effective and person-centered care for 1 (Resident #142) out of 8 residents sampled for quality of careThe facility failed to ensure physician orders, dietary orders, and therapy services related to Resident #142's diagnosis of dysphasia and the need of therapeutic diet mechanical soft was included in base line care plan This failure could place residents at risk of aspiration or choking and decline in quality of life.
- 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 interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that included measurable objectives and timeframes to meet the resident's medical, nursing, and mental and psychosocial needs identified in the comprehensive assessment for 1 of 23 residents (Resident #69) reviewed for comprehensive person-centered care plans. The facility failed to develop a care plan addressing Resident #69's risk for skin breakdown. Resident #69 had dry, peeling skin on the buttocks that had resulted in a superficial pink area. This failure placed residents at risk for further skin breakdown, worsening skin impairment, pain, and infection
March 25, 2026Complaint inspection · 3 citations
- D
Keep residents' personal and medical records private and confidential.
Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents had the right to personal privacy for 2 (Resident #1 and Resident #2) of 7 residents review for personal privacy. CNA A failed to cover Resident #1 and Resident #2 body when she left the room on 03/25/26 to get assistance. This failure could place residents at risk of feeling uncomfortable or embarrassed.
- 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, interview, and record review the facility failed to ensure that a resident who is continent of bladder and bowel on admission receives services and assistance to maintain continence for 1 (Resident #4) of 7 residents observed for incontinent care. Resident #4's brief was heavily soiled in urine along with clothing on 03/20/26. This failure placed residents at risk for unwanted skin breakdown.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview and record review the facility failed to establish and maintain, and infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable disease and infections for 2 of 7 (Resident #3, Resident #4) reviewed for infection control. CNA A failed to change Resident #4's brief every 2 hours. Resident #4 brief was observed being heavily soiled in urine and resident clothing was soiled on 03/20/25. CNA B and CNA C failed to wear full PPE when providing incontinent care for Resident #3. CNA B used hand sanitizer to disinfect Resident #3's bedside table. CNA B took linen from another resident's room to Resident #3's room to provide incontinent care. CNA B and CNA C cleaned Resident #3 back and forward instead of front to back during incontinent care. [...]
February 26, 2026Complaint inspection · 4 citations
- G
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 interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that included measurable objectives and time frames to meet a resident's medical, nursing, mental, and psychosocial needs that were identified in the comprehensive assessment for one (Resident #1) of six residents reviewed for care plans. The facility failed to specify in the care plan whether Resident #1 would be a 1-person or 2-person assist for bed mobility. Resident #1 sustained a fall out of her bed on 1/6/26 when CNA A attempted to provide a 1-person assist during incontinent care. Resident #1 sustained a comminuted, mildly impacted, intra-articular fracture of the distal left femur and returned to the facility with a leg immobilizer. [...]
- 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 ensure the residents environment remained as free of accident hazards as is possible and ensure each resident received adequate supervision for one (Resident #1) of six residents reviewed for accidents and hazards. The facility failed to prevent Resident #1 from having a witnessed fall on 1/6/26 while CNA A provided incontinent care. Resident #1 sustained a comminuted, mildly impacted, intra-articular fracture of the distal femur. These failures could place residents at risk for harm, pain, and injury.
- 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, interview, and record review the facility failed to ensure residents had the right to a safe, clean, comfortable, and homelike environment including but not limited to receiving treatment and supports for daily living safely for 4 of 6 resident rooms in the 100 hall (Resident #2, Resident #3, Resident #4 and Resident #5) reviewed for environment. The facility failed to ensure Resident #2, Resident #3, Resident #4 and Resident #5's rooms were thoroughly cleaned and sanitized. This deficient practice could place residents at risk of living in an unclean and unsanitary environment which could lead to a decreased quality of life.
- 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 resident medical records were kept in accordance with accepted professional standards and practices, the facility must maintain medical records on each resident that are complete and accurately documented for one of six residents (Resident #1) reviewed for clinical records. The facility failed to ensure Resident #1's Medication Administration Record (MAR) reflected the administration of Tylenol (medication to treat pain) was accurately documented on 1/8/26. This failure could place residents at risk of not receiving the care and services needed due to inaccurate or incomplete clinical records.
December 23, 2025Complaint inspection · 1 citation
- D
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Inspectors wroteBased on observation, interviews, and record review, the facility failed to incorporate recommendations from a PASRR evaluation report into a resident's assessment, care planning, and transition of care for 1 (Resident #1) of 5 residents reviewed for PASRR services. The facility failed to submit a complete and accurate request for NFSS in the LTC online portal within 20 days after the IDT meeting .This failure could place residents who were PASRR positive at risk of not getting the PASRR services for a better quality of life and could lead to a decline in health. Record review of Resident #1's face sheet dated 12/23/25 revealed a [AGE] year-old female, admitted to the facility on [DATE]. [...]
May 15, 2025Standard inspection, Complaint inspection · 2 citations
- D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Inspectors wroteBased on observations, interviews and record reviews, 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 one (Resident #21) of 23 residents reviewed for pharmacy services. The facility failed to ensure MA A administered the medication Sevelamer Carbonate (a Phosphate binding medication to control Phosphorus levels for hemodialysis patients) with a meal to Resident #21 as ordered by the resident's physician. This failure to provide medications as ordered could lead to residents not receiving the care they require to reach their highest physical, mental and emotional wellbeing.
- 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, interviews, 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 reviewed for food procurement. 1. The facility failed to ensure foods were dated as opened after usage. 2. The facility failed to ensure that dietary staff did not leave a disposable plastic cup to scoop the cornmeal out of the container. These failures could place residents at risk of cross-contamination and foodborne illness.
April 3, 2025Complaint inspection · 1 citation
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation , interview and record review the facility failed to establish and 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 one of three residents (Resident #1) reviewed for infection control. Unknown A and Unknown B failed to use proper PPE for Enhanced Barrier resident (Resident #1). The facility failed to ensure Unknown A and Unknown B wore appropriate PPE when entering Resident #1s' room on 03/13/2025 who was on Enhanced Barrier precautions while they performed direct care. These failures could place residents at risk for spread of infection.
January 10, 2025Complaint inspection · 2 citations
- G
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on interview, and record review the facility failed to provide care consistent with professional standards of practice promoting healing and prevent new pressure ulcers from developing for 1(Resident#1) of 5 residents reviewed for pressure ulcers. The facility failed to ensure that no new pressure wounds were acquired at the facility. Resident #1 acquired a Stage 3 sacral wound. The facility failed to implement new interventions when the sacral wound was not healing, increasing in size and requiring debridement for necrotic tissue. The facility failed to ensure offloading and timely incontinent care was provided for Resident#1's sacral wound . This failure place residents at risk for wounds, infection, and pain. Findings Included: [...]
- 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 interview and record review, the facility failed to ensure care plans were reviewed and revised by the interdisciplinary team after each assessment for 1 of 5 (Resident #1) residents reviewed for care plan timeliness and accuracy in that: The facility failed to ensure Resident #1's care plan accurately addressed his facility acquired sacral wound and MASD (moisture associated skin damage) to his groin. This failure could affect residents by placing them at risk of not having accurate assessments, which could compromise their plan of care.
March 14, 2024Standard inspection, Complaint inspection · 4 citations
- D
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 1 resident (CR # 212) of 6 residents reviewed for physician's orders received treatment and care in accordance with professional standards of practice . -CR #212 had an order dated 03/08/2024 for a treatment for his left heel and for heel protectors to be applied. -The facility did not transfer the order to the eTAR, resulting in the resident not receiving the treatments for three days. The deficient practice could place residents at risk for additional skin breakdown.
- 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, including procedures that assured the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals to meet the needs of each resident and failed to establish a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation for 1 of 1 resident (Residents #90) reviewed for pharmacy services. The facility failed to ensure RN D administered Lorazepam (a controlled medication that treats anxiety) to Resident #90 in accordance with physician orders. [...]
- D
Dispose of garbage and refuse properly.
Inspectors wroteBased on observation, interview and record review, the facility failed to dispose of garbage and refuse properly for 1 of 2 dumpster reviewed for garbage disposal. -The facility failed to ensure the dumpster lid were secured. This failure could place residents at risk of infection for exposure to germs and diseases carried by rodents from improperly disposed garbage.
- 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 clinical records for 2 residents (CR #212 and Resident # 90) of 4 residents reviewed for clinical records were maintained in accordance with accepted professional standards and practices, were complete, and accurately documented. -CR #212 had a treatment order for staff to clean the resident's left heel and apply skin prep, then heel protectors and the treatment order was not transcribed to CR #212's eTAR. -The administration of a PRN anxiety medication to Resident #90 by not documenting Lorazepam .05mg tabs in the eMAR The deficient practice could place residents CR #212 at risk for additional skin breakdown and Resident #90 at risk for having inaccurate records and inadequate care.
February 1, 2024Complaint inspection · 1 citation
- K
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents who entered the facility without pressure ulcers did not develop pressure ulcers and a resident having pressure ulcers received care and treatment consistent with professional standards of practice to promote healing and prevent further development of skin breakdown or pressure ulcers for 1 (CR #1) of 6 residents reviewed for pressure ulcers. -The facility failed to prevent the development of CR #1's Stage IV facility acquired sacrum pressure wound and left heel deep tissue injury resulting in debridement and hospitalization. Resident was diagnosed with sepsis due to MRSA, Sacral osteomyelitis and sacral pressure ulcer. -The facility failed to timely intervene when CR#1's Stage IV Pressure ulcer continued to get worse and did not send him to the local hospital and only suggested hospice. [...]
September 29, 2023Complaint inspection · 6 citations
- K
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 interview and record review, the facility failed to provide basic life support, including cardiopulmonary resuscitation (CPR) for 1 (CR#1) of 12 residents reviewed for advanced directives. 1. The facility failed to immediately initiate CPR on 8/31/23 at about 7:20 AM when CR#1 was found unresponsive. 2. The facility failed to immediately contact EMS when CR#1 was found unresponsive between 7:00 AM and 7:20 AM. EMS was called at about 7:32 AM. (12-32-minute delay). 3. The facility failed to ensure CPR was performed on a cardiac board once initiated by staff. A cardiac board is used in the administration of cardiopulmonary resuscitation (CPR) by creating a flat, rigid surface to use under the person in need of care. An Immediate Jeopardy (IJ) situation was identified on 09/09/23. The IJ template was provided to the facility on [DATE] at 6:25 PM. [...]
- J
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 interviews and record reviews the facility failed to ensure that licensed nurses have the specific competencies and skill sets necessary to care for residents' needs, as identified through resident assessments, and described in the plan of care for 2 of 21 nurses (LVN A and LVN G) reviewed for competencies and skill sets for assessments. 1. The facility failed to ensure LVN A immediately and properly assessed CR#1 after the resident's change in condition was identified by CNA B as reported to be acting abnormally. 2. The facility failed to immediately and properly assess CR#1 after an additional change in condition was identified by CNA B as reported to appear pale and not look good. 3. The facility failed to assess and monitor CR#1 for approximately 10 hours after a change in condition was identified. 4. The facility failed to complete competency checks for LVN A and LVN G. 5. [...]
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteF609 Based on interview and record review, the facility failed to ensure all alleged violations involving injury of unknown origin, abuse, neglect, or misappropriation of resident property were reported immediately, but not later than 24 hours after the allegation was made, to the administrator of the facility and to other officials (including to the State Agency) for 2 (CR#2 and CR#4) of 12 residents reviewed for injury of unknown origin. The facility failed to immediately report within 24 hours CR#2's injury of unknown origin when he had increased pain and was diagnosed with a torn rotator cuff on 7/18/23. The facility failed to immediately report within 24 hours CR#4's, who had glaucoma and was cognitively impaired, ingesting shampoo from an unlabeled medication cup while CNA gave him a shower.
- D
Respond appropriately to all alleged violations.
Inspectors wroteBased on investigation and record review the facility failed to thoroughly investigate injury of unknown origin for 2(CR#2 and CR#4) of 12 residents reviewed for thorough investigations. CR#2 had an injury of unknown origin and the facility did not thoroughly investigate after he had increased pain and was diagnosed with a torn rotator cuff on 7/18/23. The facility failed to have evidence to demonstrate a thorough investigation after CR#4, who was cognitively impaired, ingested shampoo from a medicine cup while receiving a shower. These failures placed residents at risk of further injury, pain and potential exposure to abuse and neglect.
- 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 interview, and record review, the facility failed to provide treatment and care in accordance with the comprehensive person-centered care plan and in accordance with professional standards of practice for 1 resident (CR#2) of 12 residents reviewed for quality of care. The facility failed update CR #2's comprehensive care plan after CR#2 was diagnosed with torn rotator cuff. This failure placed residents at risk of not receiving needed care and services to meet the resident's physical, mental, and psychosocial needs.
- D
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 ensure each resident receives adequate supervision to prevent accidents for 1 (CR#4) of 12 residents reviewed for accidents, hazards, and supervision. The facility failed to adequately supervise CR#4 while giving him a shower using shampoo in an unlabeled medication cup. The facility failed to contact the physician after CR#4 drank shampoo The facility failed to contact poison control after drinking shampoo
Fire safety inspections
5 fire safety citations on file: 1 on July 10, 2026, 2 on May 15, 2025, 2 on March 14, 2024.
Every fire safety citation5 citations
- D
Install corridor and hallway doors that block smoke.
K 363 · July 10, 2026 · Corrected (the home has a date of correction)
- F
Have properly installed electrical wiring and gas equipment.
K 511 · May 15, 2025 · Corrected (the home has a date of correction)
- E
Have a fire alarm with audible and visual signals that transmits the alarm automatically to notify emergency forces in event of fire.
K 343 · May 15, 2025 · Corrected (the home has a date of correction)
- E
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · March 14, 2024 · Corrected (the home has a date of correction)
- D
Properly select, install, inspect, or maintain portable fire extinguishes.
K 355 · March 14, 2024 · Corrected (the home has a date of correction)