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 22 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
13D
6E
0F
Potential for minimal harm
0A
0B
3C
March 17, 2026Standard inspection · 10 citations
- E
Keep residents' personal and medical records private and confidential.
Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure the resident's right to personal privacy during medical treatment and personal care and confidentiality of personal and medical records for four of twenty residents (Resident #1, #36, #69, and Resident #75) reviewed for privacy and confidentiality. The facility failed to ensure LVN E pulled the privacy curtain while connecting Resident #1's formula to his g-tube on 03/15/2026. The facility failed to ensure CNA J provided privacy while transferring Resident #36 on 03/16/2026. The facility failed to ensure LVN E closed, locked, or minimized her laptop monitor before leaving her cart, thus exposing Resident #69's medical information, on 03/15/2026. The facility failed to ensure RN D did not disclose Resident #75's treatment to her roommate and the roommate's family member on 03/16/2026. [...]
- 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 observations, interviews, and record review, the facility failed to ensure, in accordance with State and Federal laws, all drugs and biologicals were stored in locked compartments under proper temperature controls and permitted only authorized personnel to have access to the keys for five of eighteen residents (Residents #4, #17, #38, #51, and #67) reviewed for medication storage. 1. The facility failed to ensure an antifungal powder was not inside Resident #4's room and his medication was not left with him to take unattended on 03/15/2026.2. The facility failed to secure Resident #4's TUMS when it was left inside his room on 03/15/2026. 3. The facility failed to ensure an eyedrop was not inside Resident #17's room on 03/15/2026. 4. The facility failed to ensure an antifungal powder and a wound cleanser were not inside Resident #38's room on 03/15/2026. 5. [...]
- 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 the facility's one of one kitchen reviewed for food and nutrition services. The facility failed to ensure dietary staff properly labeled and dated stored food received by vendors. The facility failed to ensure the ice machine was thoroughly cleaned and/or sanitized. The facility failed to ensure the serving table had the appropriate amount of sanitizer in the container (red bucket) for sanitization. The facility failed to ensure the deep fryer was properly cleaned. The facility failed to ensure expired food in the refrigerator was discarded. These failures could place residents at risk of exposure to food contamination and illness.
- 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 observations, interviews, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for a resident for 1 of 6 residents (Resident #20) reviewed for care plan. The facility failed to ensure Resident #20's care plan reflected a plan of care for the resident's use of a Nebulizer. This failure could place the resident at risk of not receiving the necessary care and services.
- 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 provide appropriate treatment and services to prevent complications of enteral feeding for one of two residents (Resident #2) reviewed for feeding tube management. The facility failed to ensure LVN E flushed Resident #2's g-tube before administering the resident's bolus feeding on 03/15/2026. This failure could place residents with g-tubes at risk for tube displacement, clogging, aspiration, and discomfort.
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observations, interviews, and record reviews the facility failed to ensure that residents, who needed respiratory care, were provided care consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for one of six residents (Resident #20) reviewed for respiratory care. The facility failed to ensure Resident #20's Nebulizer mask was properly stored in a bag when not in use on 03/15/26. This failure could place the resident at risk for respiratory infection and not having their respiratory needs met.
- 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 assured the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals to meet the needs of each resident for one of eighteen residents (Resident #4) reviewed for pharmaceutical services. The facility failed to ensure Resident #4's medication was not left with the resident to take unattended on 03/15/2026. This failure could place residents at risk of not receiving medications as ordered, taking medications without a self-administration assessment, potential overdose, and adverse effect.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased 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 two of eighteen resident (Resident #1 and Resident #2) reviewed for infection control. 1. The facility failed to ensure LVN E performed hand hygiene and changed her gloves while preparing Resident #1's formula for g-tube on 03/15/2026. 2. The facility failed to ensure LVN E sanitized the tray she used between Resident #1 and Resident #2 during g-tube management on 03/15/2026. These failures could place residents at risk of cross-contamination and development of infections.
- D
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public for one of three direct care staff (RN D) reviewed for other environmental conditions. The facility failed to ensure that RN D did not leave a container of germicidal wipes on top of the nurse's cart unattended on 03/16/2026. This failure could prevent the residents from having an environment that was safe for the residents, staff, and public.
- C
Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.
Inspectors wroteBased on interview and record review, the facility failed to ensure 34 (Room numbers 2, 3, 4, 6, 7, 8, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37 and 39) out of 34 multiple-resident bedrooms, measured at least 80 square feet per resident. The facility failed to ensure multiple resident Room numbers 2, 3, 4, 6, 7, 8, 10, 18, 20, 24, 25, 26, 27, 28, 29, 30, 32, 33, 34, 35, 37 and 39 met the required minimum of 80 square feet per resident. The facility failed to ensure all resident rooms had the required minimum of 80 square feet per resident in rooms occupied by multiple residents. This failure could place residents who reside in these rooms at-risk for a limitation in their ability to move around the room and a decreased quality of life.
January 16, 2026Complaint 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 interview and record review, the facility failed to ensure the resident had the right to be free from abuse, neglect, misappropriation of resident property, and exploitation for one of one resident (Resident #1) reviewed for abuse and neglect. The facility failed to ensure Resident #1 was free from abuse when CNA A spoke to the resident in a rude, demeaning, and inappropriate manner, including making unnecessary and offensive comments. This failure could place residents at risk for emotional distress, verbal abuse, and violation of their rights. Record review of Resident #1's face sheet on 01/16/26, stated Resident #1 was a [AGE] year-old male who admitted to the facility on [DATE], with the following diagnoses: [...]
January 7, 2025Standard inspection, Complaint inspection · 3 citations
- E
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 residents' goals and preferences for 4 of twelve residents (Resident #20, Resident #27, Resident #36, and Resident #57) reviewed for Respiratory Care. 1. The facility failed to ensure Resident #20's nasal cannula (flexible tube used to deliver oxygen to the nose through two prongs) on her wheelchair was properly stored when not in use on 01/05/2025. 2. The facility failed to ensure Resident #27's nasal cannula at the back of the wheelchair was properly stored when not in use on 01/05/2025. 3. The facility failed to ensure Resident #36's nasal cannula at the back of the wheelchair was properly stored when not in use on 01/05/2025. 4. [...]
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased 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 #34) of eight residents reviewed for Infection Control. The facility failed to ensure CNA B changed her gloves and performed hand hygiene while providing incontinent care to Resident #34 on 01/05/2025. This failure could place residents at risk of cross-contamination and development of infections.
- C
Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.
Inspectors wroteBased on interview and record review, the facility failed to ensure 34 (Room numbers 2, 3, 4, 6, 7, 8, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37 and 39) out of 34 multiple-resident bedrooms, measured at least 80 square feet per resident. The facility failed to ensure multiple resident Room numbers 2, 3, 4, 6, 7, 8, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37 and 39 met the required minimum of 80 square feet per resident. This failure could place residents at risk of not having sufficient space.
October 19, 2023Standard inspection, Complaint inspection · 8 citations
- E
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Inspectors wroteBased on observations, interviews, and record reviews the facility failed to provide a safe, clean, comfortable, and homelike environment including but not limited to receiving treatment and supports for daily living safely for areas in the facility for 8 of 20 rooms (Room # 2, 13, 14, 15, 17, 18, 19, 20) observed for a safe, clean, comfortable, and homelike environment. The facility failed to ensure that resident rooms were cleaned and serviced in accordance with the facility's policy on Housekeeping Services. This deficient practice could place residents at risk of infections and living in an uncomfortable environment leading to a decreased quality of life.
- 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, interviews and record reviews the facility failed to ensure food was stored, prepared, distributed and served in accordance with professional standards for food service safety for the facility's only kitchen reviewed for kitchen sanitation. The facility failed to ensure kitchen equipment was clean and sanitary. This failure could place residents at risk for cross contamination and other illnesses.
- 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 immediately consult with the resident's physician when there was a significant change in the resident's physical, mental, or psychosocial status for 1 of 3 residents (Resident #64) reviewed for abuse. The facility failed to notify the facility physician/FNP following an allegation of abuse reported for Resident #64 on 09/22/23. This failure could place residents at risk for not having their allegations of abuse reported to the physician/FNP.
- D
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Inspectors wroteBased on interview and record review, the facility failed to develop and implement written policies and procedures that prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property and that establish policies and procedures to investigate any such allegations for 1 of 3 residents (Resident #64) reviewed for abuse and neglect. The facility did not follow their policy for Abuse and Neglect and thoroughly investigate when Resident #64 had an allegation of sexual abuse reported on 09/22/23. This failure could place residents at risk for not having their allegations of abuse and neglect investigated.
- D
Respond appropriately to all alleged violations.
Inspectors wroteBased on interview and record review, the facility failed to ensure all alleged violations of abuse and neglect were thoroughly investigated for 1 of 3 residents (Resident #64) reviewed for abuse and neglect. The facility did not thoroughly investigate when Resident #64 had an allegation of sexual abuse reported on 09/22/23. This failure could place residents at risk for not having their allegations of abuse and neglect investigated.
- D
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Inspectors wroteBased on interview and record review, the facility failed to refer all level II residents and all residents with newly evident or possible serious mental disorder, intellectual disability, or a related condition for level II resident review upon a significant change in status assessment for one (Resident #36) of three resident assessments reviewed for PASRR evaluations. 1. The facility did not complete a new PASRR Level 1 Screening for Resident #36 when he was diagnosed with PTSD on 06/21/23. These failures could affect residents with psychiatric diagnoses who may not be evaluated and receive needed PASRR services.
- 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 one (Resident #119) of three residents observed for infection control. CNA A failed to perform hand hygiene while providing incontinence care to Resident #119. This failure could place residents at risk for spread of infection through cross-contamination.
- C
Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.
Inspectors wroteBased on interview and record review, the facility failed to ensure 34 (Room number's 2, 3, 4, 6, 7, 8, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37 and 39) out of 34 multiple-resident bedrooms, measured at least 80 square feet per resident. The facility failed to ensure multiple resident Room number's 2, 3, 4, 6, 7, 8, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37 and 39 met the required minimum of 80 square feet per resident. This failure could place residents at risk of not having sufficient space.
Fire safety inspections
8 fire safety citations on file: 4 on March 17, 2026, 2 on January 7, 2025, 2 on October 19, 2023.
Every fire safety citation8 citations
- F
Use approved construction type or materials.
K 161 · March 17, 2026 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · March 17, 2026 · 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 · March 17, 2026 · Corrected (the home has a date of correction)
- C
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · March 17, 2026 · 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 · January 7, 2025 · 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 · January 7, 2025 · Corrected (the home has a date of correction)
- E
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · October 19, 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 · October 19, 2023 · Corrected (the home has a date of correction)