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 36 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
2G
0H
0I
Potential for more than minimal harm
29D
5E
0F
Potential for minimal harm
0A
0B
0C
July 10, 2026Complaint inspection · 1 citation
- 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 record review and interview, the facility failed to ensure a complete discharge plan for a resident with diabetes and a wound from the facility for 1 of 3 residents reviewed (Resident B).
March 19, 2026Complaint 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 ensure enhanced barrier precautions (EBP) (infection control measures requiring staff to wear gowns and gloves during high-contact care) were utilized during a dressing change for 1 of 5 residents reviewed for pressure ulcers (Resident D).
December 16, 2025Standard inspection · 5 citations
- D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteBased on observation, record review, and interview, the facility failed to meet resident's preferences for 1 of 5 residents reviewed (Resident 82).
- 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 effective communication with a hospice agency resulting in a delay in treatment for a resident who had a dislocated hip for 1 of 1 residents reviewed for hospice communication (Resident 94).
- D
Provide enough food/fluids to maintain a resident's health.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that a newly admitted resident, received meals prepared and served in accordance with the physician-ordered diet requirements, resulting in a significant weight loss of 6.38 percent within approximately 30 days for 1 of 4 residents reviewed for nutrition (Resident 151).
- 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 staff monitored a Gastrointestinal Tube (Gtube) (a feeding tube inserted through the belly directly into the stomach) feeding pump appropriately and ensured the resident received appropriate medications and positioning related to the Gtube for 1 of 1 residents reviewed for Gtube management (Resident 74).
- 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 and interviews, the facility failed to ensure all medications were stored and dated properly and all medication labels were fully intact displaying the entire prescription in medication carts for 2 of 4 medication carts reviewed for medication storage.
November 10, 2025Complaint inspection · 1 citation
- G
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the environment was free from the potential for accidents when a protective cap for a bedframe end-piece was missing which resulted in actual harm when a resident (Resident B) sustained an 18 centimeter (cm) long by 5 cm wide avulsion skin tear which required 6 sutures for 1 of 3 residents reviewed for accidents.
September 29, 2025Complaint inspection · 1 citation
- 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 (Resident D) with chronic Urinary Tract Infections (UTIs) and a nephrostomy tube (a thin, flexible tube inserted into the kidney to drain urine directly into a collection bag) had accurate medical orders and was receiving perineal care regularly for 1 of 1 residents reviewed for bowl and bladder concerns.
October 7, 2024Standard inspection · 8 citations
- E
Reasonably accommodate the needs and preferences of each resident.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure call lights were in reach for 4 of 8 residents reviewed for call lights (Resident 25, 50, 52, and 72).
- 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 and record review, the facility failed to ensure medications were labeled and dated for 3 of 3 medication carts reviewed for medications (Resident 47, 49, 56, 83, 86, 106, 112, and 278).
- D
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the physician was notified of a resident's, (Resident 102) change of condition after a fall when he experienced break through pain and a decline in his ability to perform activities of daily living for 1 of 1 residents reviewed for notification of change of condition.
- D
Ensure each resident receives an accurate assessment.
Inspectors wroteBased on interview and record review, the facility failed to ensure information reported on the Minimum Date Set (MDS) was accurate for 1 of 2 residents reviewed for MDS accuracy (Resident 61).
- 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 record review and interview, the facility failed to implement a care plan for the use of Seroquel (an antipsychotic) medication for 1 of 3 residents reviewed for care plans (Resident 43).
- 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 a resident, (Resident 102), who had diagnoses of dementia and an intellectual disability was adequately assessed for breakthrough pain and change of condition after a fall resulting in a delay of treatment for 1 of 2 residents reviewed for change of condition, and failed to ensure a resident with pain after a fall was sent to the hospital without delay after x-ray results confirmed a fracture for 1 of 2 residents reviewed for change of condition (Resident 40).
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure that medications were not left unsupervised in a resident's room for 1 of 1 random observation (Resident 49) and failed to implement fall prevention interventions for a resident (Resident 37) for 1 of 3 residents reviewed for falls.
- D
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Inspectors wroteBased on record review and interview, the facility failed to initiate a pharmacy recommendation for 1 of 5 residents reviewed for pharmacy requests (Resident 13).
August 1, 2024Complaint inspection · 6 citations
- G
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 interview and record review, the facility failed to ensure lab specimens were obtained immediately with symptoms of urinary tract infection and laboratory results were reviewed in a timely manner for a resident with an indwelling urinary catheter to prevent urinary tract infection for 1 of 3 residents reviewed for quality of care (Resident F). This deficient practice resulted in a delay of treatment and the resident developed urosepsis with acute kidney failure with a systemic inflammatory response syndrome (SIRS) and died.
- D
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Inspectors wroteBased on interview and record review, the facility failed to ensure a resident, (Resident E) received treatments and services in accordance with his guardian's wishes. This deficient practice had the potential to effect 1 of 3 residents reviewed for quality of care.
- D
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Inspectors wroteBased on interview and record review, the facility failed to ensure the family/representative for a resident, (Resident F) was notified of a change in condition related to an acute urinary tract infection (UTI) which resulted in urosepsis-associated acute kidney injury/failure, (SA-AKI) and had a systemic inflammatory response (SIRS) for 1 of 3 residents reviewed for quality of care.
- 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 record review and interview, the facility failed to update a skin care plan for a resident with skin breakdown for 1 of 3 residents reviewed for care plans (Resident D).
- 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 a resident's legal guardian participated and agreed to the changes in the resident's plan of care and treatment for 1 of 3 residents reviewed for quality of care (Resident E).
- D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on observations, record review, and interviews, the facility failed to document the results of glucometer (blood sugar) results for 1 of 3 residents reviewed for quality of care (Resident D).
June 18, 2024Complaint inspection · 1 citation
- 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 nail care was provided to a dependent resident for 1 of 3 residents reviewed for activities of daily living (ADL) (daily tasks related to resident care and hygiene) (Resident D).
January 19, 2024Complaint inspection · 3 citations
- 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 accurately promote continuity of care and communication within the resident's care plan, to maintain resident safety, and safeguard against adverse events for 1 of 1 resident reviewed for care plans (Resident C).
- D
Ensure that residents are free from significant medication errors.
Inspectors wroteBased on observation, interview, and record review the facility failed to prevent a significant medication error by not following the manufacture administration guidelines for 1 of 2 residents reviewed for medication administration (Resident C).
- D
Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs.
Inspectors wroteBased on observations, interview, and record review, the facility failed to implement a nothing by mouth (NPO) order for a resident with dietary restriction to ensure the resident was not given oral intake for 1 of 1 resident reviewed for gastric tube feedings (Resident C).
August 31, 2023Standard inspection · 9 citations
- E
Reasonably accommodate the needs and preferences of each resident.
Inspectors wroteBased on observation and interview, the facility failed to ensure resident's call lights were in reach for 5 of 24 residents reviewed for call lights. (Resident 9, 74, 31, 17, and 54)
- E
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 physician's orders for a Foley catheter (a flexible tube inserted through the urethra and into the bladder to drain urine) securement device was in place for a resident (Resident 126), failed to honor resident preferences to have a leg bag in place for two residents (Resident 126 and 21), and failed to ensure residents catheter tubing and drainage bags were positioned correctly for 5 residents (Residents 126, 21, 76, 41 and 94) for 5 of 7 residents reviewed for bowel & bladder.
- 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 ensure the three-compartment sink had sufficient chemicals to disinfection items washed, chef assistant (CA) had his moustache covered, and did not touch his eyeglasses while serving resident lunches and washed his hands correctly before returning to serve on the lunch line again. The facility failed to ensure a Certified Nursing Aide (CNA) while assisting a resident with did not contaminate her hands for 1 of 2 observed. (Resident 15)
- D
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Inspectors wroteBased on record review and interview, the facility failed to ensure a resident, (Resident 138) had the right for his physician to be notified of an alteration of his medication administration, when a blood pressure medication was withheld due to parameters that were not ordered for his medication, and the facility failed to ensure a resident, (Resident 115) had the right for his physician to be notified of elevated blood sugar levels, as ordered, for 2 of 3 residents reviewed for change of condition.
- 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 ensure a person-centered comprehensive care plan was initiated and implemented to prevent the worsening of contractures for 1 of 2 residents reviewed for mobility/range of motion/positioning (Resident 42).
- 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 a nebulizer mask was covered and nasal cannula (NC) tubing was observed disconnected from the oxygen concentrator for 2 for 8 residents observed. (Resident 29 and 69)
- D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Inspectors wroteBased on record review and interview, the facility failed to follow up with the pharmacy to ensure a resident (Resident 138) received medications as ordered by his physician for 1 of 6 residents reviewed for unnecessary medications.
- 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 insulin labels were consistent with the physician's orders (Residents 82 and 241) and to ensure an insulin opened date was legible (Resident 53) for 3 of 3 residents reviewed for insulin storage.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview and record review, the facility failed to ensure glucometers (device for measuring blood sugar) were cleaned according to the package instructions on the disinfecting wipe for 2 of 2 residents observed for glucometer cleaning. (Resident 82 and 241)
Fire safety inspections
10 fire safety citations on file: 6 on December 16, 2025, 2 on October 7, 2024, 2 on August 31, 2023.
Every fire safety citation10 citations
- F
Ensure that testing and maintenance of electrical equipment is performed.
K 921 · December 16, 2025 · Corrected (the home has a date of correction)
- E
Keep aisles, corridors, and exits free of obstruction in case of emergency.
K 211 · December 16, 2025 · Corrected (the home has a date of correction)
- C
Develop and maintain an Emergency Preparedness Program (EP).
E 4 · December 16, 2025 · Corrected (the home has a date of correction)
- C
Develop Emergency Preparedness policies and procedures.
E 13 · December 16, 2025 · Corrected (the home has a date of correction)
- C
Develop a communication plan.
E 29 · December 16, 2025 · Corrected (the home has a date of correction)
- C
Establish emergency prep training and testing.
E 36 · December 16, 2025 · Corrected (the home has a date of correction)
- E
Provide properly protected cooking facilities.
K 324 · October 7, 2024 · Corrected (the home has a date of correction)
- C
Provide a written emergency evacuation plan.
K 711 · October 7, 2024 · Corrected (the home has a date of correction)
- E
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
K 222 · August 31, 2023 · Corrected (the home has a date of correction)
- E
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
K 761 · August 31, 2023 · Corrected (the home has a date of correction)