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
0J
0K
0L
Actual harm
2G
0H
0I
Potential for more than minimal harm
20D
7E
1F
Potential for minimal harm
0A
0B
0C
April 1, 2026Complaint inspection · 3 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 observation, interview and record review, the facility failed to provide pharmaceutical services including procedures that assure the accurate acquiring, dispensing and administering of all drugs and biologicals to meet the needs of each resident for 1 of 3 (Resident #5) reviewed for pharmaceutical services.-The facility failed to ensure Resident #5's medications on 01/13/2026 were documented as given during the night shift. -Resident #5 did not receive pain medication on 03/05/2026 at 8:00p.m. per physician orders. This failure could cause residents to have unnecessary and avoidable pain. [...]
- 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.-The facility failed to ensure residents' lunch was served at a safe temperature on 3/31/2026. These failures could place residents who ate food from the kitchen at risk of foodborne illness and disease. In confidential interviews with residents in the facility, residents stated food was always cold when it arrived and they would prefer food to be warmer. Observation and interview with the Dietary Manager on 3/31/2026 at 12:30pm revealed, she took the temperature of the mixed vegetables consisting of peas and carrots which was 114.6F. The Dietary Manager brought a second bowl of mixed vegetables which she measured at 105.8F. [...]
- 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 #4) observed for infection control.-The facility failed to ensure CNA GG washed her hands or used hand sanitizer after doffing gloves during incontinent care observation on 3/31/26. These failures could place the residents at risk of cross-contamination and development of infection. [...]
July 9, 2025Standard inspection, Complaint inspection · 10 citations
- G
Provide safe, appropriate pain management for a resident who requires such services.
Inspectors wroteBased on observation, interview and record review the facility failed to ensure that pain management was provided to residents who required such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 1 of 6 Residents (Resident #20) whose records were reviewed for pain management. LVN H/Treatment Nurse, failed to ensure Resident #20 received a PRN pain medication prior to wound care. LVN H/Treatment Nurse failed to stop wound treatment when Resident #20 was grimacing and quizzing in pain on 7/8/25. [...]
- 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 of 3 residents (Resident #20 and Resident #74) observed for infection control. 1. The facility failed to ensure TX Nurse used the required PPE for Resident #20, who was on enhanced barrier precautions on 7/8/25. 2. The facility failed to ensure CNA RS used the required PPE for Resident #74, who was on enhanced barrier precautions. These failures could place the residents at risk of cross-contamination and development of infection.1. Record review of Resident #74's face sheet reflected an admission date of 01/17/25. [...]
- D
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Inspectors wroteBased on record review and interview, the facility failed to encode a resident's assessment within 7 days and complete and electronically transmit a resident's completed discharge MDS within 14 days for 2 ((Residents #36 and #67) of 2 residents reviewed for MDS transmittal.-Resident #36 passed away 3/8/2025 and Resident #67 passed away 4/11/2025 and their discharge MDS' were not encoded within 7 days after death and were not transmitted within 14 days after death. This failure could cause a resident's significant change such as their MDS to not be accurately reflected in their medical records. [...]
- 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 residents who were unable to carry out activities of daily living received necessary services to maintain grooming and personal hygiene for one (Resident #6) out of eight residents reviewed for ADLs. The facility failed to provide skin care to Resident #6 which resulted in patches and dry flaky skin from below the knee to her feet. These deficient practices could place residents at risk of skin breakdown and reduced feelings of self-worth. Record review of Resident #6's face sheet dated 07/08/25 revealed a [AGE] year-old female was admitted to the facility on [DATE] and readmitted on [DATE]. [...]
- 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 residents who were incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 1 of 3 residents (Resident #11) reviewed for incontinent care. 1. The facility failed to ensure CNA G cleaned Resident #11 properly during incontinent care on 7/8/25. This failure could place residents at risk for pain, infection and hospitalization. Record review of Resident #11's face sheet dated 7/7/25 reflected date of admission was 4/8/22 and re admitted on [DATE]. [...]
- 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 maintain medical records on each resident that are accurately documented in accordance with accepted professional standards and practices and must 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 1 (Resident #41) of 5 residents reviewed for accurate documentation and pharmaceutical services. -Resident #41 was documented as receiving his Invega suspension prefilled syringe for his bipolar disorder on 7/4/2025 when he did not receive the medication. The medication was not in the building. This failure could put residents at risk of not receiving the needed treatments they need to promote their mental and physical well-being. [...]
- D
Ensure medication error rates are not 5 percent or greater.
Inspectors wroteBased on observation, interview, and record review the facility failed to ensure its medication error rate was not 5 percent or greater for. There were 2 errors out of 29 opportunities, which resulted in a 6 percent error rate involving Resident #28 and Resident #39 observed for medication pass in that: -Medication Aide FF did not administer Resident #28 Tylenol ES as ordered by the Physician.-Medication Aide RR did not check Resident #39's blood pressure prior to administering blood pressure medication hydralazine 10 mg 2 tablets by mouth. These failures placed residents at risk for increase pain and decrease in quality of life. Resident #28Record review of Resident #28's face sheet dated 07/07/25 revealed an [AGE] year-old female admitted to the facility on [DATE]. [...]
- D
Ensure that residents are free from significant medication errors.
Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that its residents are free of any significant medication errors for 1(Resident #39) 7 residents reviewed for significant medication errors.-Medication Aide RR did not check Resident #39's blood pressure prior to administering blood pressure medication hydralazine 10 mg 2 tablets by mouth. This failure placed residents at risk for dangerous drop in blood pressure, organ damage, increase risk of falls, and hospitalization. Record review of Resident #39's face sheet dated 07/07/25 revealed an [AGE] year-old male admitted to the facility on [DATE] and again on 07/03/25. Resident's diagnoses included hypertension (high blood pressure) and urinary retention (difficulty urinating and completely emptying the bladder). [...]
- 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 for food service safety in the facility's only kitchen reviewed for food safety requirements and kitchen sanitation.-The facility failed to ensure foods stored in the walk-in cooler were labeled and dated.-The facility failed to ensure the kitchen back door was closed.-The facility failed to ensure the dry storage room floor did not have black build up on the floor and the walk-in-freezer did not have an accumulation of ice on the floor. These failures could place residents at risk of foodborne illness and food contamination. During an observation on 07/07/2025 between 8:21 a.m. [...]
- D
Have a policy regarding use and storage of foods brought to residents by family and other visitors.
Inspectors wroteBased on interview and record review, the facility failed to store foods brought to residents by family and other visitors to ensure safe and sanitary storage, handling, and consumption for 1 of 1 resident fridges in the facility.-There was unlabeled and undated food was stored in the residents' refrigerator.-The residents' refrigerator had items belonging to nursing staff. This failure has the potential to place all the residents at risk for consuming food that has not been handled in a safe and sanitary manner. Observation on 07/08/25 at 2: 40 p.m., revealed there were items in the resident refrigerator near the front lobby which contained staffs' personal food items including: [...]
April 3, 2025Complaint inspection · 1 citation
- E
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 assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of 1of 5 residents (CR#1). The facility failed to ensure that CR#1's Lorazepam was ordered, received, and dispensed when CR#1 was admitted to the facility. This failure could place the residents at risk of not receiving the intended therapeutic benefit of the medications, decreased quality of life and hospitalization.
May 31, 2024Standard inspection, Complaint inspection · 4 citations
- E
Ensure medication error rates are not 5 percent or greater.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the medication error rate was not 5 percent (5%) or greater for 3 of 30 opportunities resulting in a 10 percent medication error rate for 2 (Residents #11 and #67) of 6 residents observed for medication pass. Facility failed to ensure Resident #11 Sertraline dosage (Medication that works by increasing levels of a mood-enhancing chemical called serotonin in your brain: many people recover from depression and has fewer unwanted side effects than older antidepressants) was administered as per physician order. Facility failed to ensured Resident # 11 received Potassium Chloride as ordered. MA A initialed on MAR that Potassium Chloride was administered. Potassium Chloride ( ( medication use to prevent and treats low levels of potassium in your body. [...]
- E
Ensure that residents are free from significant medication errors.
Inspectors wroteBased on interview, and record review, the facility failed to ensure 1 of 6 residents (Resident #11) reviewed for medication administration were free of significant medication errors. Facility failed to administered Potassium Chloride Microencapsulated Crystals ER for 7 Days to Resident #11 This failure could place residents at risk of harm, injury, illness or hospitalization.
- E
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on observation and interview, the facility failed to 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 expired foods were discarded. 2. The facility failed to ensure foods were labeled and dated. 3. The Facility failed to ensure food is properly stored in designated areas at all times. These failures could place residents who ate food from the kitchen at risk of food borne illness and disease. Findings Included: Observation of the facility kitchen on 05/29/24 at 8:15 AM revealed the following. 1. A Plastic Container of Sliced American Cheese was dated 5/21/24 use by date 5/23/24 2. A Plastic Container of sliced Bologna had no label and was not dated. 3. A Plastic Container of sliced deli ham had no label and was not dated 4. [...]
- 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) to meet the needs of each resident for 1 of 6 residents reviewed for medications (Resident #67). The facility did not administer Resident #67's Divalproex Sodium (medication used to treat certain types of seizures, to treat manic episodes of bipolar disorder, and to prevent migraine headaches) as per pharmaceutical recommendation . These failures could place residents at risk of experiencing side effect of medications which could result in the exacerbation of their medical conditions and a decline in health status.
April 12, 2024Complaint inspection · 2 citations
- D
Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.
Inspectors wroteBased on interview and record review, the facility failed to ensure the discharge was documented in the resident's medical record and appropriate information was communicated to the receiving health care institution or provider for 1 (Resident #1) of 18 residents reviewed for discharge. The facility failed to have the resident's physician document their discharge and all other necessary information in the medical records. This failure could place residents at risk of not getting the necessary care and services in a new facility to meet their physical and psychological needs.
- D
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Inspectors wroteBased on interview and record review, the facility failed to send a copy of the discharge notice to the Office of the State Long-Term Care Ombudsman and failed to record the reasons for transfer or discharge in the resident's medical record for 1 (Resident #1) of 18 residents reviewed for discharge. The facility failed to notify the Ombudsman of Resident #1's discharge status after hospitalization. This failure could place residents at risk of being improperly discharged and not having access to available advocacy services, discharge/transfer options, and the appeal process.
March 17, 2023Standard inspection · 10 citations
- G
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on interviews, record reviews, and observations, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for one of three residents (Resident #1) reviewed for quality of care. - The facility failed to promptly identify skin redness to the peri area and buttocks, which had tiny openings on Resident #1, and failed to ensure interventions were implemented to treat and prevent skin deterioration. This failure could place residents at risk for a delay of care or treatment, pain, and suffering.
- F
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on observation, interview and record review the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety for the facility only kitchen, in that: The facility failed to ensure: One food item in the freezer was not secured in package. Several food items in the refrigerator were not secured in package. Several food items in the refrigerator were not labeled/had a use-by date. These failures have the potential to affect all residents who ate food from the facility's kitchen placing them at risk of foodborne illness.
- 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, which included procedures that assured the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals, for 3 of 4 medication carts (100-200 Hall Medication Nurses Cart and 300-400 Hall Nursing Cart,100 and 4 00 hall medication aide cart) reviewed for pharmacy services. - The facility failed to discard an expired medications located in the 300-400 Hall Medication Nurse Cart. - The facility failed to ensure accurate count of control medications in the locked box in 100 - 400 Hall Medication Aide Cart. - The facility failed to discard an expired medications and store medication in it's original packet located in the 100 and 200 hall nurse's medication cart. [...]
- E
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview, and record review, the facility did not maintain an infection prevention program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections for 7 of 8 Staff (Housekeeper F, LVN B, and CNA C, Treatment Nurse, Housekeeping supervisor, Laundry Aide E) reviewed for infection control. 1. The facility failed to ensure Laundry Aide E followed proper use of PPE and infection control procedure while picking dirty linen from 400 hall to 200 hall. 2. The facility failed to ensure Housekeeper F followed proper use of PPE and infection control procedure while picking up trash from residents' rooms in 400. 3. The facility failed to ensure proper infection procedure when clean linen was stored in 400 hall clean linen closet. 4. [...]
- D
Keep residents' personal and medical records private and confidential.
Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the residents' right to privacy during personal care for 2 of 3 residents (Resident #1 and Resident #175) reviewed for privacy in that: -The facility failed to ensure the Treatment Nurse and CNA C provided privacy during wound care for Resident #1. -The facility failed to ensure the Treatment Nurse and RA D provided privacy during wound care for Resident #175. These failures could place residents at risk of having their bodies exposed to the public, resulting in low self-esteem and a diminished quality of life.
- 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 residents who were unable to carry out activities of daily living received necessary services to maintain personal hygiene for two (Resident #1, and Resident #175) out of four residents reviewed for ADLs, in that: The facility failed to provide personal hygiene to Resident #1 and Resident #175, which resulted in Resident #1 toenails being overgrown and Resident # 175 feet being dry and having patches of dry skin. These deficient practices placed residents at risk of a decline in hygiene, at risk of skin breakdown, and reduced feelings of self-worth.
- 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 provide a safe, functional, sanitary and comfortable environment for residents, staff and the public for 1 of 3 residents (Resident #19) reviewed for environment. 1. The facility failed to monitor resident during smoke breaks. These failures could place residents at risk for accidental fire hazard. Findings Include: Record Review of Resident #19's Facesheet dated 03/16/23 revealed resident is a [AGE] year-old male who was admitted to the facility on [DATE]. [...]
- 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 a resident received appropriate treatment and services to prevent urinary tract infections for one (Resident #1) of 2 residents observed for indwelling urinary catheters. LVN B failed to provide appropriate care for Resident #1 during Foley catheter care. This failure could affect residents, who were incontinent or had a catheter, and placed them at risk for urinary tract infection, discomfort, skin breakdown and decreased quality of life.
- 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 that a resident fed by enteral means received the appropriate treatment and services to prevent complications of enteral feedings, for 1 (Resident #175) of 1 resident that was reviewed for feeding tubes, in that: -The facility failed to ensure LVN B appropriately verified placement and amount of fluid to be used for Resident #175 during medication administration and unclogging the feeding tube. This failure could place residents at risk for adverse reactions, inadequate therapy, and a decreased quality of life.
- 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 drugs and biologicals used in the facility were secured and stored properly for one of six medication carts (400 Hall Nurse Medication Cart) reviewed for drug storage. - LVN B failed to ensure 400 hall Nurse medication cart was locked when left unattended on 03/16/23. - LVN B failed to ensure a bottle of Aspirin was left on top of the 400 hall Nurse medication cart when left unattended. These failures could place residents at risk for possible drug diversions or accidental ingestion.
Fire safety inspections
12 fire safety citations on file: 3 on July 9, 2025, 4 on May 31, 2024, 5 on March 17, 2023.
Every fire safety citation12 citations
- E
Properly install and monitor supervisory attachments on automatic sprinkler systems.
K 352 · July 9, 2025 · 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 9, 2025 · Corrected (the home has a date of correction)
- D
Ensure proper usage of power strips and extension cords.
K 920 · July 9, 2025 · Corrected (the home has a date of correction)
- F
Properly install and monitor supervisory attachments on automatic sprinkler systems.
K 352 · May 31, 2024 · Corrected (the home has a date of correction)
- E
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
K 321 · May 31, 2024 · Corrected (the home has a date of correction)
- E
Provide properly protected cooking facilities.
K 324 · May 31, 2024 · Corrected (the home has a date of correction)
- E
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · May 31, 2024 · Corrected (the home has a date of correction)
- F
Properly install and monitor supervisory attachments on automatic sprinkler systems.
K 352 · March 17, 2023 · Corrected (the home has a date of correction)
- F
Have a battery powered remote alarm panel in a location accessible by operating personnel.
K 916 · March 17, 2023 · Corrected (the home has a date of correction)
- E
Install an approved automatic sprinkler system.
K 351 · March 17, 2023 · Corrected (the home has a date of correction)
- E
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · March 17, 2023 · Corrected (the home has a date of correction)
- C
Have simulated fire drills held at unexpected times.
K 712 · March 17, 2023 · Corrected (the home has a date of correction)