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 26 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
1K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
16D
9E
0F
Potential for minimal harm
0A
0B
0C
July 14, 2026Complaint inspection · 2 citations
- E
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 resident environment remained as free of accident hazards as was possible and each resident received adequate supervision and assistance devices to prevent accidents for 1 of 4 residents (Resident #3) reviewed for use of mechanical lifts. The facility failed to ensure mechanical lifts were always operated by two staff members during transfer of residents for Resident #3 on 04/17/2026 (by CNA A) and 06/14/2026 (by CNA B). This failure placed residents at risk of injury.
- D
Reasonably accommodate the needs and preferences of each resident.
Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the resident's right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for 2 of 8 residents (Residents #1 and 2) reviewed for access to their call system. The facility failed to ensure Resident #1 and Resident #2's call button was in reach when they were alone in their rooms on 07/14/2026. This failure could residents at risk of not having their care needs met.
April 8, 2026Complaint inspection · 1 citation
- D
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, interviews, and record review the facility failed to have sufficient nursing staff to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident and determined by considering the number, acuity, and diagnoses of the facility's resident population with accordance for 2 (03/30/2026 and 03/31/2026) of 31 days reviewed for sufficient staffing. The facility failed to provide sufficient CNAs on 03/30/2026 and 03/31/2026 leaving the secured unit without a CNA on the overnight shift of 10 p.m. to 6 a.m., leaving residents without proper supervision and care. This failure could place residents at risk of inadequate supervision and an unsafe environment which could lead to falls, serious harm and injury, exacerbations of disease processes, and abuse and neglect.
August 7, 2025Standard inspection · 7 citations
- E
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 residents had the right to request, refuse, and/or discontinue treatment, to participate in experimental research, and to formulate advance directives for 3 of 10 residents (Resident #1, #4 and #65) reviewed for advance directives. The facility failed to ensure that Resident #1's out of hospital DNR was uploaded to the electronic health record and the care plan was updated. The facility failed to ensure that Resident #4's out of hospital DNR was signed by the physician and uploaded to the electronic health record on [DATE]. The facility failed to ensure that Resident #65's out of hospital DNR was signed by the physician and uploaded to the electronic health record on [DATE]. These failures could place residents at-risk of having their wishes dishonored, and of having CPR performed against their wishes.
- 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 for 1 of 1 kitchen and 1 of 1 nourishment room reviewed for food and nutrition services. 1) The facility failed to properly seal food product bags in the walk-in freezer to prevent exposure to air. 2) The facility failed to label and date food items in the walk-in freezer, and the nourishment refrigerator. 3) The facility failed to maintain the proper temperature of the refrigerator in the nourishment room. This failure could have placed residents at risk for food contamination and foodborne illness.
- E
Have policies on smoking.
Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure it formulated, adopted, and enforced policies regarding smoking, smoking areas, and smoking safety for 3 of 5 residents (Residents #5, Resident #20, and Resident #78) reviewed for smoking. The facility failed to keep Residents #5, Resident #20, and Resident #78's cigarettes and lighters in a safe place per their policy. This failure placed all residents at risk for serious injury, harm, and/or death due to possible fire or smoking inside the building. Findings Included: Resident #5 Record review of Resident #5's Face sheet dated 08/06/2025 reflected a [AGE] year-old male who was admitted to the facility on [DATE]. [...]
- 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 observation, interview and record review, the facility failed to develop and implement a comprehensive person-centered care that included measurable objectives and timeframes to meet the residents' medical, nursing, and mental and psychological needs that are identified in the comprehensive assessment for 2 of 10 residents (Residents #1 and #7).1. The facility failed to ensure the care plan was updated when Resident #7's code status was changed from full code to DNR on [DATE].2. The facility failed to ensure the care plan was updated when Resident #1's code status was changed from full code to DNR on [DATE]. This failure could place residents at-risk of having their wishes dishonored, and of having CPR performed against their wishes.
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on interview and record review, the facility failed to ensure residents received necessary treatment and services, consistent with professional standards of practice to promote wound healing and to prevent new pressure ulcers from developing for one of two residents (Resident #4) reviewed for pressure injuries. The facility failed to ensure wound care was performed as ordered by the wound care doctor for Resident #4. Resident #4 missed 6 wound care treatments in July 2025 and August 2025. This failure could place residents at risk of improper wound management, the development of new pressure injuries, deterioration in existing pressure injuries, infection, and pain.
- 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 review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) (for Resident #8) to meet the needs of each resident for 1 of 1 medication storage room and 1 of 3 (hall 1 nurses' medication cart) medications cart reviewed for pharmacy services. The facility failed to ensure expired medications were removed from the medication storage room and the hall 1 nurses' medication cart on 08/07/2025. The facility failed to ensure that the narcotic count sheet accurately reflected the amount of Resident #8's phenobarbital (a controlled medication used in the treatment of seizures) stored in the hall 5 nurses' medication cart. [...]
- D
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure drugs and biologicals were stored and labeled in accordance with currently accepted professional principles for 1 of 3 (hall 1 nurse's medication cart) Nurse's medication carts reviewed. 1. The facility failed to ensure the nurses' medication cart for hall 1 was secured by a lock when it was left unattended by LVN G on 08/07/2025. These failures could place residents at risk of illness or injury due to missing medication or if unattended medication were consumed.
July 17, 2025Complaint inspection · 1 citation
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that residents received 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 three residents reviewed for quality of care. The facility failed to complete an accurate skin assessment on Resident #1 on 07/17/25 which did not include multiple red small scratches underneath both of her eyes. This failure could place residents at risk of skin integrity issues not being addressed, infection, and hospitalization.
June 5, 2025Complaint inspection · 2 citations
- E
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 that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours if the alleged violation involved abuse or neglect resulted in bodily injury, to other officials (including the State Agency) for 4 of 6 residents (Resident #1, Resident #2, Resident #3 and Resident #4) reviewed for abuse and neglect. 1. The facility failed to report to the State Agency an incident that involved Resident #1 on 05/25/2025 within the allotted timeframe. 2. The facility failed to report to the State Agency an incident that involved Resident #2 and Resident #3 on 04/06/2025. 3. [...]
- D
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 ensure the residents had the right to be free from physical abuse and neglect for two (Resident #1 and Resident #3) of five residents reviewed for abuse and neglect. 1. The facility failed to ensure Resident #1 was not physically abused by FM on 05/25/2025 when FM hit Resident #1 after Resident #1 became agitated and hit the FM. 2. The facility failed to protect Resident #3 from physical abuse by Resident #2. Resident #3 wandered into Resident #2's room and was hit by Resident #2 after Resident #2 stated I'm going to hit you. These failures placed residents at risk of abuse, neglect, trauma, and psychosocial harm.
March 4, 2025Complaint inspection · 1 citation
- 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 based on the comprehensive assessment of a resident, that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for one of three residents (Resident #1) reviewed for quality of care. The facility failed to ensure Resident #1 had a physician's order for suctioning, and order for monitoring for secretions, or an order for when to replace the suction machine's cannister and tubing. This deficient practice could place residents at risk of aspiration, aspiration pneumonia, or hospitalization. Findings Included: [...]
August 31, 2024Complaint inspection · 1 citation
- K
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on interview and record review, the facility failed to ensure residents received necessary treatment and services, consistent with professional standards of practice to promote wound healing and to prevent new pressure ulcers from developing for one (Resident #1) of three residents reviewed for pressure injuries. The facility failed to reinstate Resident #1's wound treatment orders after she was readmitted from the hospital on [DATE] until 07/16/24. Her wounds worsened and a new pressure injury was acquired during that timeframe. These failures resulted in an identification of an Immediate Jeopardy (IJ) on 08/30/24 at 1:44 PM. While the IJ was removed on 08/31/24 at 12:55 PM, the facility remained at a level of actual no actual harm at a scope of pattern that was not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems. [...]
July 11, 2024Standard inspection · 5 citations
- E
Keep residents' personal and medical records private and confidential.
Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure resident rights for personal privacy for 4 of 6 residents (Resident # 6, Resident # 14, Resident #20, and Resident # 43) residents reviewed for personal privacy. The facility failed to knock on Resident #6, #14, #20, and #43's room when going into the residents' rooms. The deficient practice could affect all residents right to privacy in the facility and cause the resident to feel like their privacy was being invaded or the facility was not their home.
- E
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observations, interviews, and record review, the facility failed to maintain an infection and prevention control program that included, at a minimum, a system for preventing and controlling infections for 4 of 6 residents (Residents #10, Resident #60, Resident#131, and Resident #39) reviewed for the usage of wrist blood pressure monitor. LVN C and LVN D did not clean and disinfect the wrist blood pressure monitor while using it on Resident #10, Resident # 39, Resident #60, and Resident #131. This failure could place the residents at the facility at risk of transmission of disease and infection.
- D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteBased on observations, interviews, and record review, the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promoted maintenance or enhancement of his or her quality of life for 1 of 20 (Resident #15) residents reviewed for dining services in 1 of 1 dining room. The facility failed to promote Resident #15's dignity while dining when staff did not serve the resident their lunch tray at the same time as other residents at the same table for lunch on 07/09/2024. This failure could affect all residents who were eat in the dining room, by contributing to poor self-esteem, and unmet needs.
- D
Reasonably accommodate the needs and preferences of each resident.
Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure residents received services in the facility with reasonable accommodations of resident's needs and preferences except when to do so would endanger the health and safety of the resident or other residents for 1 of 5 residents (Resident #47) reviewed for resident rights. The facility failed to ensure Resident #47's call light was within reach on 07/11/24. This failure could place residents at risk of needs not being met.
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure that one resident (Resident #57) out of five residents reviewed for activities of daily living received care and services for nail care. The facility failed to ensure that Resident #57's fingernails and/or toenails were cleaned and trimmed. This failure placed residents at risk for not receiving adequate care and services to prevent infection, injury, and diminished quality of life.
April 12, 2024Complaint inspection · 1 citation
- D
Provide or get specialized rehabilitative services as required for a resident.
Inspectors wroteBased on observation, interview and record review the facility failed to provide specialized rehabilitative services such as but not limited to physical therapy, speech-language pathology, occupational therapy, respiratory therapy, and rehabilitative services for mental illness and intellectual disability of services of a lesser intensity, for two of four residents (Resident #1 and Resident #2) reviewed for specialized rehabilitative services, in that: The facility failed to: - Ensure Resident #1 received PT and OT as ordered. - Ensure Resident #2 was evaluated for PT, OT, or ST upon admission as ordered in her admission clinical records. This failure could place residents at risk of decline or decrease in their physical capabilities.
May 25, 2023Standard inspection · 5 citations
- E
Ensure each resident receives an accurate assessment.
Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that each resident receives an accurate assessment, reflective of the resident's status at the time of the assessment for 4 of 18 (resident # 8, # 24, # 45, and #55,) residents reviewed for accuracy of assessment. -The facility failed to ensure that for Residents # 8, # 24, # 45, and #55, the MDS assessment correctly noted the resident's lack of natural teeth, tooth fragments, and/or dentures. -The facility failed to accurately assess Resident #24 for his mental illness (qualifying diagnoses) on his annual MDS assessment. These failures could place residents at risk for not receiving care and services to meet their needs.
- 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 reviewed for food preparation and storage in that: -One of one commercial can opener was not kept clean and in a sanitary condition. -The facility failed to ensure expired food items were removed from the walk-in cooler. -All food items in walk in cooler were properly sealed, labeled and dated with expiration date. These failures could affect residents who ate food from the facility kitchen and place them at risk of food borne illness and disease.
- 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 coordinate assessments with the (PASARR) program under Medicaid in subpart C to the maximum extent practicable to avoid duplicative testing and effort. in that -The facility failed to update the PASRR Level 1 forms for Resident #24 after a diagnoses of mental illness This failure could place residents requiring PASRR services at risk of not having their special needs assessed and met by the facility.
- 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 ensure a resident who was unable to carry out activities of daily living (ADLs) received the necessary services to maintain nutrition, grooming and personal and oral hygiene for 1of 5 residents (Resident #45) reviewed for ADLs. The facility failed to ensure Resident #45 was provided personal grooming (shower and shaving) by facility staff. This failure could place residents at risk for discomfort, and dignity issues.
- D
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Inspectors wroteBased on observation, interview, and record review the facility failed to ensure psychotropic medications were not given unless the medication was necessary to treat a specific condition as diagnosed and documented in the clinical record for 1 of 18 residents reviewed for unnecessary medications. (Resident #55) The facility failed to have an appropriate diagnosis or adequate indication for the use of Resident #55's Seroquel (antipsychotic medication used to treat certain mental/mood disorders such as schizophrenia, and bipolar disorder). This failure could place residents at risk of receiving unnecessary psychotropic medications with possible medication side effects, adverse consequences, decreased quality of life and dependence on unnecessary medications.
Fire safety inspections
12 fire safety citations on file: 5 on August 7, 2025, 4 on July 11, 2024, 3 on May 25, 2023.
Every fire safety citation12 citations
- F
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · August 7, 2025 · Corrected (the home has a date of correction)
- F
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · August 7, 2025 · Corrected (the home has a date of correction)
- D
Have simulated fire drills held at unexpected times.
K 712 · August 7, 2025 · Corrected (the home has a date of correction)
- C
Keep aisles, corridors, and exits free of obstruction in case of emergency.
K 211 · August 7, 2025 · no revisit needed
- C
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
K 521 · August 7, 2025 · no revisit needed
- F
Install a fire alarm system that can be heard throughout the facility.
K 341 · July 11, 2024 · Corrected (the home has a date of correction)
- E
Inspect, test, and maintain automatic sprinkler systems.
K 353 · July 11, 2024 · Corrected (the home has a date of correction)
- E
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
K 741 · July 11, 2024 · Corrected (the home has a date of correction)
- C
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
K 521 · July 11, 2024 · Corrected (the home has a date of correction)
- F
Provide properly protected cooking facilities.
K 324 · May 25, 2023 · Corrected (the home has a date of correction)
- C
Keep aisles, corridors, and exits free of obstruction in case of emergency.
K 211 · May 25, 2023 · Corrected (the home has a date of correction)
- C
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
K 521 · May 25, 2023 · Corrected (the home has a date of correction)