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
1J
0K
0L
Actual harm
1G
0H
0I
Potential for more than minimal harm
29D
6E
0F
Potential for minimal harm
0A
0B
0C
June 25, 2026Standard inspection, Complaint inspection · 10 citations
- E
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Inspectors wroteBased on interview and record review the facility failed to use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week, for 2 (03/01/2026 and 03/15/2026) of 90 days reviewed for RN hours, for the months January 1, 2026 through March 31, 2026. The facility failed to have RN coverage for 2 days on Sunday, 03/01/2026 and 03/15/2026. This failure could place residents at risk of harm by denying residents the advanced critical thinking skills a registered nurse could provide.
- 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 two of two nourishment rooms. 1. The facility failed to ensure refrigerator temperature logs were filled out correctly for nourishment room [ROOM NUMBER]. 2. The facility failed to ensure food items in nourishment room [ROOM NUMBER] were labeled and dated appropriately. 3. The facility failed to ensure that there were no personal items stored in the refrigerator in nourishment room [ROOM NUMBER]. 4. The facility failed to ensure that leftovers were discarded within 72 hours in nourishment room [ROOM NUMBER] refrigerator. These failures could place residents who consumed food from the kitchen at risk for food borne illness. [...]
- E
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observations, interviews, and record reviews, 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 4 Residents (Residents #122, #106, #92 and #12) of 11 residents reviewed for infection control practices during personal care:1. The facility staff were not following Isolation Precautions on wearing Personal Protective Equipment (PPE) when entering Resident #122's room.2. Resident #106 was not on EBP and/or isolation precautions for known contagious diseases. 3. Resident #92 was not on EBP and/or isolation precautions for known contagious diseases. [...]
- D
Keep residents' personal and medical records private and confidential.
Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the resident had a right to personal privacy including personal care for 1 staff (LVN A) providing care to 1 of 3 residents (Resident #19) reviewed for personal privacy, in that: LVN A did not closed Resident #19's privacy blinds during medication administration via feeding tube, leaving the resident in plain view of the outside parking lot area. The deficient practice could affect residents in the facility who received medication via mic-key-tube and could result in the resident being unnecessarily exposed and cause embarrassment.
- 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 and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care for 1 (Resident #122) of 8 residents reviewed for baseline care plans. The facility failed to include Resident #122's use of contact precautions in her baseline care plan. This failure could result in residents not receiving needed care and treatment. 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 observations, interviews, and record reviews, the facility failed to ensure that the comprehensive care plans were reviewed and revised by the interdisciplinary team after each assessment, for 3 residents (Resident #106, #92, and #12) of 8 residents whose care plans were reviewed for timing and revision.1. Resident #106's care plan did not indicate isolation precautions for known contagious diseases.2. Resident #92's care plan did not indicate isolation precautions for known contagious diseases until 06/24/26. 3. Resident #12's care plan did not indicate isolation precautions for known contagious diseases. These failures could affect residents in the facility by placing them at risk of not being provided with necessary care or services and not having personalized plans developed to address their specific needs.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for one resident (Resident #8) of 24 residents reviewed for quality of care. The facility failed to follow or revise the physician's orders for Resident #8's soft helmet to be on at all times, may remove for bathing. Resident #8 was not wearing his helmet, and it could not be found anywhere in his room. This deficient practice could affect residents who require care and monitoring, placing them at risk of not receiving the care and services they need.
- D
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 possible for 1 of 6 residents (Resident #121) reviewed for accidents and hazards: The facility failed to ensure a (diabetic) lancet was not left sitting on top of Resident #121's bedside table unattended. This failure could place residents at risk of access to or injury from a lancet.
- 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, is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals, and preferences for 1 of 4 residents (Resident #40) reviewed for respiratory care. The facility failed to ensure proper storage of Resident #40's nebulizer mask tubing when it was not kept in a plastic bag when not in use. This failure could place residents requiring oxygen at risk for respiratory infections due to the potential for microorganisms infiltrating their oxygen, nebulizer equipment and supplies causing a decline in physical health.
- D
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 establish a system of records of disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation, for four Resident (Resident #25) of 14 residents reviewed for controlled medication use, in that: Resident #25's Individual Resident's Controlled Substance Record did not accurately reflect Resident#25's Tramadol medication amount on hand. This failure could place all residents on the 500 hall at risk for medication overdose, medication under-dose, and ineffective therapeutic outcomes.
May 29, 2026Complaint inspection · 1 citation
- D
Provide enough food/fluids to maintain a resident's health.
Inspectors wroteBased on observation, interview and record reviews the facility failed to ensure a resident receives treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices, and maintains acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrates that this is not possible or the resident preferences indicate otherwise, for 2 (Resident #1 and Resident #2) of 7 residents, reviewed for nutritional status. The facility failed to ensure Resident #1 and Resident #2 were weighed weekly per physician's orders. This failure could place residents at risk for nutritional deficit, weight loss, skin breakdown, and overall decline in quality of life.
May 14, 2026Complaint inspection · 2 citations
- 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 used in the facility were stored in locked compartments under proper temperature controls and permit only authorized personnel to have access to the keys for 1 of 2 medication carts (400 hallway cart) reviewed for medication storage. The facility failed to ensure a medication named Normal Saline flush was not sitting on top the unattended 400 hall medication cart on 3/12/26 at 3:45 p.m. This failure could place all residents at risk of misuse of medication and decreased quality of life.
- D
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 1 of 3 residents (Resident #1) reviewed for infection control. 1. The facility failed to ensure CNA B and CNA C used the required personal protective equipment for Resident #1, who was on enhanced barrier precautions due to feeding tube during incontinent care on 05/13/26. 2. The facility failed to ensure CNA B performed hand hygiene while providing incontinent care to Resident #1 on 05/13/26 and failed to ensure CNA B and CNA C performed hand hygiene for at least 20 seconds. These failures could place the residents at risk of cross-contamination and development of infection.
March 19, 2026Complaint inspection · 1 citation
- 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 residents who needed respiratory care were provided such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences for 1 (Resident #1) of 3 residents reviewed for respiratory care. The facility failed to ensure Resident #1's oxygen was administered at the prescribed setting of 3 liters per minute on 3/19/2026 as ordered by the physician. This deficient practice could place residents at risk of developing respiratory complications and a decreased quality of care.
January 15, 2026Complaint 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 provide treatment and care in accordance with the comprehensive person-centered care plan and in accordance with professional standards of practice for 1 of 4 residents reviewed for quality of care (Resident #1). The facility failed to respond to Resident #1's call light to provide care for 1 hour and 45 minutes on 12/25/2025. This failure could place residents at risk for a delay in care and services.
November 20, 2025Complaint inspection · 1 citation
- D
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 failed to ensure each resident the right to be free from abuse for two residents (Resident #2 and Resident #3 ) of 6 residents reviewed for abuse. The facility failed to protect R #2 and R #3 from being hitting each other on 10/15/25 as they passed each other in the hallway. These failures have the potential to place residents at risk of serious injury and continued abuse. The Findings Include: [...]
July 16, 2025Complaint inspection · 2 citations
- J
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure adequate supervision was provided to prevent accidents for 1 of 4 residents (Resident #1) reviewed for supervision. CNA A did not follow 2-person assist as stated on Resident #1's care plan when providing incontinent care and repositioning on two separate occasions on [DATE] at around 12:00am and 1:00am. On [DATE] at 3:30am CNA A found Resident #1 on the floor. Resident #1 was sent to the hospital and later expired on [DATE]. An IJ was identified on [DATE]. The IJ template was provided to the facility on [DATE] at 3:51pm. While the IJ was removed on [DATE], the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with potential for more than minimal harm due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal. [...]
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on observation, interview and record review the facility failed to ensure all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property were reported immediately, but not later than 2 hours after the allegation was made, if the alleged violation involved abuse or resulted in serious bodily injury, to the administrator of the facility and to other officials (which included to the State Survey Agency) in accordance with State law through established procedures for 1 of 4 residents (Resident #1) reviewed for reporting injuries of unknown origin. [...]
April 24, 2025Standard inspection · 4 citations
- 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 each resident's needs, for one Resident (Resident #71), of twenty-four residents reviewed for call light access. Resident #71's call light was placed out of reach of Resident #71 while in bed. This failure could place residents on at risk for not being able to call for assistance from staff.
- D
Ensure each resident receives an accurate assessment.
Inspectors wroteBased on interviews, and record review the facility failed to ensure the assessment accurately reflected the resident's status for 1 (Resident #79) of 6 residents reviewed for accuracy of assessments. The facility failed to identify Resident #79 was receiving Dialysis on his Quarterly MDS assessment dated [DATE]. This failure could place residents at risk for receiving inadequate care and services based on inaccurate assessments.
- 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 residents who needed respiratory care were provided such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences for 1 of 5 (Resident #22) residents reviewed for respiratory care. The facility failed to ensure Resident #22's oxygen was administered at the correct setting of 2 liters per minute on 04/22/2025 as ordered by the physician. This deficient practice could place residents who receive respiratory care at an increased risk of developing respiratory complications and a decreased quality of care.
- 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 resident (Resident #37) of 1 observed for incontinent care, in that: CNA A did not use one wipe per swipe on the penile area during incontinent care on Resident #37. This failure could place residents at risk for infections and cross contamination.
March 20, 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 resident (Resident #1) of 1 observed for incontinent care, in that: CNA A did not use one wipe per swipe on the buttock area during incontinent care on Resident #1. This failure could place residents at risk for infections and cross contamination.
June 10, 2024Complaint inspection · 2 citations
- E
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 clinical records in accordance with accepted professional standards and practices that are complete and accurately documented for 2 of 4 Residents (Resident #2, Resident #3) reviewed for medical records accuracy, in that: 1. Resident #2's June 2024 Medication Administration Record documentation record was incomplete. Staff did not document or sign off on the administration of physician ordered insulin. 2. Resident #3's June 2024 Medication Administration Record documentation record was incomplete. Staff did not document or sign off on the administration of physician ordered insulin. This deficient practice could affect residents whose records are maintained by the facility and could place them at risk for errors in care, and treatment.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, record review, and interview, 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 3 of 6 Residents (Resident #2 and Resident #5 and Resident #6) that were reviewed for infection control and transmission-based precautions policies and practices, in that: 1. CNA C failed to don the appropriate PPE before he entered Resident #2's room. These failures could place residents at risk for infection through cross-contamination of pathogens and infectious diseases.
February 17, 2024Standard inspection · 8 citations
- G
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on interview, record review, and observation, the facility failed to ensure each resident received adequate supervision and assistive devices to prevent accidents for 1 of 6 resident (Resident #51) reviewed for accidents. The facility did not provide supervision to prevent Resident #51's from sustaining multiple falls in the facility. This failure could place residents with a history of falls at risk for additional falls and injuries.
- E
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview, and record review, the facility failed to establish 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 two residents (Resident #85 and Resident #91) of four residents observed for infection control issues, in that: 1. The CNA A and CNA B did not wash their hands for a minimum of 20 seconds while performing incontinent care on Resident #85. 2. The CNA D removed her dirty gloves and applied clean gloves without sanitizing hands between glove changes while performing incontinet care on Resident #91. These deficient practices could place residents at-risk for infection due to improper care practices.
- 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 that all alleged violations involving neglect, were reported immediately to the State Survey Agency, not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, for for 1 of 6 residents (Resident #39) reviewed for abuse/neglect. The facility did not report Resident #39's had an unwitnessed fall on 01/27/24. Resident #39's lying on the floor next to the toilet and her head in the bathroom shower. This failure could place all residents at increased risk for potential abuse to unreported allegations of abuse and neglect.
- 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 observations, interviews, and record reviews, the facility failed to ensure incontinent bladder residents received appropriate treatment and services to prevent urinary tract infections and restore continence to the extent possible for 1 of 6 residents (Resident #85) reviewed for quality of care, in that: The facility failed to ensure Resident #85's indwelling catheter was not pulled or tugged on during incontinent care that would cause pain or discomfort. This failure could place residents at risk for discomfort, urethral trauma (injury to the duct in which urine is transported out of the body from the bladder), and urinary tract infections due to improper care.
- 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 with professional standards of practice for 1 of 3 residents (Resident # 103) reviewed for quality of care in that: Resident #103's oxygen was administered at 2.5 Liters Per Minute instead of 3 Liters Per Minute via trach mask as ordered by physician. This failure could place residents who receive respiratory care at risk of developing respiratory complications and a decreased qualify of care.
- 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 record review and interviews, the facility failed to ensure residents were given psychotropic medications to treat specific diagnoses for 1 (Resident #22) of 5 Residents, reviewed for pharmacy services in that: The facility failed to ensure that Resident #22 did not receive an antipsychotic (Risperdal/risperidone) that was not necessary to treat Vascular Dementia. This failure could affect residents who received medications in the facility and put them at risk for adverse consequences such as impairment or decline in an individual's mental or physical condition or functional or psychosocial status.
- D
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 or food service safety for 1 of 1 kitchen reviewed for sanitation in that: 1. The facility failed to ensure equipment was clean and sanitized 2. The facility failed to maintain cleanliness of the floor in the kitchen These failures could place residents at risk of foodborne illnesses.
- 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 medical records were accurately documented, for one Resident (Resident #39) of six residents reviewed for accuracy of medical records. The facility failed to document Resident #39's falls in the Progress Notes. This failure could place all residents with falls at risk of not receiving adequate care and services.
February 9, 2024Complaint inspection · 1 citation
- E
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Inspectors wroteBased on interview and record review the facility failed to ensure residents who require dialysis receive such services, consistent with professional standards of practice, the comprehensive person -centered care plan, and the residents' goals and preferences, for 4 of 5 residents (R #2, R #3, R #4, R #5) reviewed for care plans, in that: The facility did not follow R #2, R #3, R #4, and R #5's care plans which indicated to obtain monthly labs from dialysis center and place in the resident's chart every day shift every 30 days. The facility failed to obtain the labs for the following months: September 2023-January 2024 for R #2, November 2020-November 2023 and January 2024 for R #3, July 2023 and August 2023 for R #4, January 2023-April 2023, and June 2023-December 2023 for R #5. [...]
January 12, 2024Complaint inspection · 2 citations
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that all alleged violations involving abuse, neglect, or mistreatment, including injuries of unknown source were reported immediately to the State Survey Agency, within two hours, if the events that cause the allegation involve abuse or result in serious injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury for 1 resident (Resident #1) of 3 residents reviewed for abuse/neglect, The facility did not report the allegation of resident abuse to the State Survey Agency within the allotted time frame for Resident #1 who had been administered CBD and THC oil by FM I. This failure could place all residents at increased risk for potential abuse due to unreported allegations of abuse and neglect.
- 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 review Resident #1's progress notes after NP C documented on progress notes on 12/20/23 that FM I was interested in administering CBD to Resident #1. This failure could place residents at risk of experiencing unmanaged pain, a decreased quality of life, and hospitalization.
September 15, 2023Complaint inspection · 1 citation
- D
Ensure services provided by the nursing facility meet professional standards of quality.
Inspectors wroteBased on observation, interview and record review, the facility failed to ensure services provided, met professional standard of quality for 1 (Resident #1) of 5 residents reviewed for professional standards. The facility failed to implement Resident #1's physician's order for treatment of her right arm blisters. This failure could place residents at risk of not receiving the care and services ordered by the physician and a decline in health status.
Fire safety inspections
7 fire safety citations on file: 2 on June 25, 2026, 4 on April 24, 2025, 1 on February 17, 2024.
Every fire safety citation7 citations
- F
Install smoke barrier doors that can resist smoke for at least 20 minutes.
K 374 · June 25, 2026 · Not yet corrected
- E
Inspect, test, and maintain automatic sprinkler systems.
K 353 · June 25, 2026 · Not yet corrected
- F
Have horizontal exits used in accordance with safety requirements.
K 226 · April 24, 2025 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · April 24, 2025 · Corrected (the home has a date of correction)
- F
Install smoke barrier doors that can resist smoke for at least 20 minutes.
K 374 · April 24, 2025 · Corrected (the home has a date of correction)
- F
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
K 761 · April 24, 2025 · Corrected (the home has a date of correction)
- E
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · February 17, 2024 · Corrected (the home has a date of correction)