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 40 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
1G
0H
0I
Potential for more than minimal harm
20D
15E
1F
Potential for minimal harm
0A
3B
0C
April 12, 2026Standard inspection · 11 citations
- E
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one out of one sampled resident (Resident 9) was free from unnecessary physical restraint (any manual method, physical or mechanical device, material, or equipment attached to a patient's body that restricts freedom of movement or normal access to their body, which they cannot easily remove), by failing to 1. Justify medical indications for applying mittens (padded, glove-like medical device considered a form of physical restraint) on Resident 9. 2. Obtain a doctor's order prior to application of physical restraints on Resident 9. [...]
- E
Ensure each resident receives an accurate assessment.
Inspectors wroteBased on interview and record review, the facility failed to accurately code the Minimum Data Set (MDS - a resident assessment tool) to reflect the Level II (two) Preadmission Screening and Resident Review (PASRR - a federal assessment requirement to help ensure that individuals who have a mental disorder or intellectual disabilities are placed in facilities that can provide the appropriate care) for two of five sampled residents (Resident 2 and Resident 7) according to the facility's the facility's policy and procedures (P&P) titled, Minimum Data Set 3.0 Assessment Completion, Transmission and Validation, dated 1/2026. This deficient practice had the potential to incorrectly reflect the residents' plan of care and care and services received by the residents.
- E
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 implement the facility's policy and procedures (P&P) titled Enteral feeding- Safety Precautions dated 01/2026 for three of three sampled residents (Residents 4, 9, and 12), by failing to ensure: Resident 12 received the correct amount of gastrostomy tube (G-tube) feeding (a medical device inserted through the abdominal wall directly into the stomach to deliver nutrition, fluids, and medications, bypassing the mouth and esophagus [throat]). The facility nursing staff changed Residents 4 and 9 feeding tube every 24 hours. These deficient practices had the potential to cause infection and/or possible hospitalization, unintended weight loss manifested by malnutrition and dehydration, and the potential to result in severe nutrient deficiencies, weakened immunity, and electrolyte imbalances for the residents.
- 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 safe and sanitary food storage and preparation practices in the kitchen when:1. A container with fresh garlic gloves with use by date of 4/3/2026 was stored in the refrigerator past its use by date.2. Tuna salad with use by date of 4/8/2026 was stored in the refrigerator past its use by date.3. The dry storage room did not contain a dented can section. 4. An ice scoop did not have a date that the facility cleaned it or any documentation that the facility cleaned the ice scoop. These deficient practices had the potential to result in harmful bacteria growth and cross contamination (transfer of harmful bacteria from one place to another) that could lead to foodborne illness in 32 out of 35 residents who received food from the facility.
- D
Ensure that residents are fully informed and understand their health status, care and treatments.
Inspectors wroteBased on interview and record review, the facility failed to ensure facility verify informed consent (a principle in medical ethics and medical law that a patient should have sufficient information before making their own free decisions about their medical care) form was given to the physician prior to administering Ativan (a psychotropic medication [a substance that act on the central nervous system to affect brain function, resulting in changes to mood, perception, consciousness, and behavior] medication that is potentially life-threatening medication that treats psychosis) for one of five sampled residents (Resident 19). This deficient practice had the potential for Resident 19 to not be able to exercise his right to know what medications the facility is administering to the resident.
- D
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Inspectors wroteBased on interview and record review, the facility failed to ensure that a copy of the residents notice of transfer for medical reason was sent to the office of the Ombudsman (an advocate for residents of nursing homes, board and care centers, and assisted living facilities) as soon as practicable according to the facility's Policy & Procedure (P&P) titled Transfer and Discharge (Including AMA) dated 1/2026 for two of two sampled residents, (Resident 5 and Resident 38). This deficient practice resulted in the ombudsman's office not being aware of Residents 5 and 38's whereabouts for safety reasons during their emergency medical reason transfer to general acute care hospital (GACH).
- D
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Inspectors wroteBased on observation, interview and record review the facility failed to implement one of one sampled resident's (Resident 7) communication care plan interventions by not providing/applying Resident 7 his hearing aid (a device worn in or behind the ear designed to amplify sound for individuals who have difficulty hearing) daily according to the facility's policy and procedures titled, Care of Hearing Aid, dated 1/2026. Resident 7 had decreased hearing. This deficient practice had the potential to result in a delay in communication for Resident 7.
- D
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Inspectors wroteBased on observation, interview, and record review, the facility failed to develop a care plan (a document outlining a detailed approach to care customized to an individual resident's need) with measurable goals and interventions to address care and treatment of a resident with dementia (a progressive state of decline in mental abilities) for one of one sampled residents (Resident 19). This deficient practice had the potential to negatively affect the delivery of services.
- D
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Inspectors wroteBased on observation interview and record review, the facility failed to provide appropriate monitoring for the targeted behavior of Ativan (an anti-anxiety medication) for one of five sampled residents (Resident 19) according to the facility's policy and procedures titled, Behavior Assessment and Monitoring, dated 1/2026, indicated. This deficient practice had the potential to result in delayed provision of necessary care and services. Findings; A review of Resident 19's admission Record indicated the resident was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included anxiety disorder (a mental health condition with feeling of worry, anxiety, or fear interfering with one`s daily activities) and encephalopathy (brain damage that causes severe confusion and forgetfulness). [...]
- D
Dispose of garbage and refuse properly.
Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a safe, sanitary, compliant environment with properly maintained and disposed of garbage according to their facility's policy and procedures (P&P) tiled, Kitchen Garbage and Trash, dated 1/2026, when one of four trash bins in the kitchen did not have a lid on it. This deficient practice had the potential to attract insects and rodents in the kitchen.
- B
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 observation, interview, and record review the facility failed to ensure 18 of 21 resident rooms ( Rooms 1, 2, 3, 4, 5, 6, 7, 9, 10, 11, 14, 15, 16, 18, 19, 21, 23 and 25) met the are footage requirements of 80 square feet (sq ft) per resident. This deficient practice had the potential to result in inadequate space to provide safe nursing care and privacy for 31 Residents.
January 27, 2026Complaint inspection · 1 citation
- E
Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
Inspectors wroteBased on interview and record review the facility failed to employ an Infection Preventionist Nurse (IPN- a healthcare professional who works to prevent the spread of infections in healthcare facilities) at least part time, to oversee the infection prevention and control program outlined in the Facility Assessment Tool (the facility's self-evaluation of its resident population and identification of the resources needed to provide the necessary person-centered care and services the residents require) dated 1/8/2026. This deficient practice had the potential for a delay in implementing and practicing infection prevention and control measures that could lead to increased risk of infection for the residents in the facility.
December 15, 2025Complaint inspection · 1 citation
- 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 staff failed to assess and notify the physician immediately when the resident had a change of condition with severe weakness, unable to eat, and unable to speak on 12/11/2025 AM shift for one of three sampled residents (Resident 3). This failure resulted in Resident 3 declining further and requiring a transfer to General Acute Care Hospital (GACH) via 911 (a telephone number used to reach emergency medical, fire, and police services) for further evaluation and treatment. [...]
March 9, 2025Standard inspection · 17 citations
- F
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 observation, interview, and record review, the facility failed to ensure that a Registered Nurse (RN) worked onsite for at least 8 consecutive hours a day, seven days a week. This deficient practice had the potential for the facility's inability to manage and oversee nursing services provided to 31 residents including resident assessments, consulting with physicians, and administering intravenous fluids or medications.
- E
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Inspectors wroteBased on interview and record review, the facility failed to provide the Notice of Medicare Non-Coverage (NOMNC - notification of termination of covered care) at least two days prior to the last covered day for three of three selected residents (Residents 7, 11, and 18). This deficient practice had the potential to result in residents losing their right to appeal the decision of termination of covered care.
- 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 observation, interview, and record review, the facility failed to maintain a safe, clean, comfortable and home-life environment in three of seven residents' rooms (Rooms 1, 16 and 20). These deficient practices had the potential to negatively impact the quality of life and increased risk for physical discomfort for residents residing in the facility.
- E
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: 1. Ensure residents' notice of proposed transfer/discharge's notification was sent to the Office of the State Long-Term Care Ombudsman (public advocate) for four of 10 sampled residents, (Resident 35, 11, 19 and 30) 2. Ensure the documentation was completed and recorded the reasons for the transfer or discharge in the resident's medical record for Resident 35 These deficient practices denied the residents additional protections from being inappropriately discharged for and an incomplete documentation of the discharge process.
- E
Post nurse staffing information every day.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the actual nursing hours worked by licensed and unlicensed nursing staffing directly responsible for resident care per shift were posted for three of three sampled days (3/7/2025, 3/8/2025 and 3/9/2025). This deficient practice resulted in the actual staffing information not being readily accessible and available to residents and visitors and had the potential to cause inadequate staffing.
- 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 follow food safety, labeling, and kitchen sanitation policies and procedures. These deficient practices had the potential to result in compromised food qualities, harmful bacteria growth could lead to foodborne illness in medically compromised residents living in the facility.
- 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 ensure the medical record for four of five residents (Residents 11, 19, 27 and 30) was accurate and compete for: 1. Resident 27's Physician Orders for Life Sustaining Life (POLST- a portable medical order that communicates a patient's wishes for end-of-life care and treatment interventions, particularly during a medical emergency, and is intended for people with serious illnesses) and Advance Directive were filled out accurately, 2. Residents 11, 19 & 30's Notice of Proposed Transfer / Discharge form was signed by the residents or representative. This failure resulted in an inaccurate and incomplete forms in the medical record and had the potential to affect the delivery of care.
- E
Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
Inspectors wroteBased on interview and record review, the facility failed to ensure their Payroll Based Journal (PBJ - information of the provider's daily staffing hours for the appropriate care of the residents) complete and accurate data had been submitted to the Center for Medicare and Medicaid Services (CMS) for three of four required quarters (1st fiscal quarter: 10/2023 - 12/2023, 2nd fiscal quarter: 1/2024 - 3/31/2024, and 4th fiscal quarter: 7/2024 - 9/2024) in 2024. This deficient practice had the potential to place 41 facility residents (bed capacity) as risk for delay in care, treatment, and services necessary to maintain physical and emotional wellbeing.
- E
Keep all essential equipment working safely.
Inspectors wroteBased on observation and interview, the facility failed to ensure one of one Hoyer Lift (a mechanical device used to lift and/or transfer a person from place to place) was properly maintained for a safe and effective operation with safety regulations. This deficient practice has a potential to cause incidental accidents to the residents while using the equipment.
- 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 interview and record review the facility failed to create a care plan (a document outlining a detailed approach to care customized to an individual resident's need) for psychotropic (a medication that affects behavior, mood, thoughts, or perception) medication and the resident's anxiety for one of five residents (Resident 16). This deficient practice had the potential for Resident 16 to not receive the appropriate care and experience adverse (harmful) side effects which could result in injury.
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observation, interview, and record review, the facility failed to provide respiratory care services for one out of 23 sample residents (Resident 13) by failing to auscultate (listen to) lung sound after nebulized medication Albuterol/Ipratropium inhalation solution (aka Duoneb - a medication used to treat breathing problems) treatment per the physicians' order. This deficient practice had the potential for Resident 13 to not have effective respiratory therapy care.
- 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 ensure to label an open date of ipratropium-albuterol inhalation solution (used to prevent and treat difficulty breathing, wheezing, shortness of breath, coughing, and chest tightness) inhalation solution for one of five residents (Resident 13) that can expire once opened with an open date according to manufacturer guidelines. This deficient practice had the potential to compromise the therapeutic effectiveness of the stored medications and unintended complications related to the management of medications.
- 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 interview and record review, the facility failed to ensure facility verify informed consent (a principle in medical ethics and medical law that a patient should have sufficient information before making their own free decisions about their medical care) form was given to the physician prior to administering the psychotropic medication Seroquel (a potentially life-threatening medication that treats psychosis) for one of five sampled residents (Resident 16). This deficient practice had the potential for Resident 16 to not be able to exercise his right to know what medications the facility is administering to the resident.
- D
Ensure medication error rates are not 5 percent or greater.
Inspectors wroteBased on observation, interview, and record review the facility failed to maintain a medication error rate below 5% (percent-unit of measurement). This failure resulted in three medication errors observed for one of three sampled residents (Resident 27). There was a total of 28 medication opportunities out of which three were observed given incorrectly, which resulted in a medication error rate of 10.71%.
- D
Ensure that residents are free from significant medication errors.
Inspectors wroteBased on observation, interview, and record review the facility failed administer medications without error to one of five sampled residents (Resident 27). This failure resulted in three medications being crushed and administered together, which had the potential to result in therapeutic failure, and unpredictable chemical and physical interactions of the medications.
- D
Provide routine and 24-hour emergency dental care for each resident.
Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a routine dental visit to one of five residents (Resident 15). This failure had the potential to affect the resident's self-esteem and quality of life.
- B
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 observation, interview, and record review the facility failed to ensure 18 of 21 resident rooms (Rooms 1, 2, 3, 4, 5, 6, 7, 9, 10, 11, 14, 15, 16, 18, 19, 21, 23 and 25) met the are footage requirements of 80 square feet (sq ft) per resident. This deficient practice had the potential to result in inadequate space to provide safe nursing care and privacy for 31 Residents.
June 28, 2024Complaint 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 one of four sampled residents (Resident 1), who are at high risk of fracture (break in the bone) and who required maximum assistance with at least two-people assist during repositioning and perineal (involves washing the genital and rectal areas of the body) care was provided an environment to prevent accident, by failing to: 1. Properly reposition Resident 1 with at least two- three persons assist on 6/10/2024 during perineal care and utilizing according to Resident 1's plan of care dated 7/16/2023 2. Implement the facility's policy and procedures (P&P) titled, Refusal of Treatment to not force a resident on any medical treatment, to document detailed information relating to the refusal and to notify the supervisors if resident refuses care. 3. [...]
March 1, 2024Standard inspection · 8 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 ensure that a Registered Nurse (RN), worked onsite for at least 8 consecutive hours a day seven days a week. This deficient practice had the potential for the facility not to manage and oversee nursing services provided to 35 residents including resident assessments, consulting with physicians, and administering intravenous fluids or medications.
- 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 residents' medical records were updated to show accurate documentation that advance directives (written statement of a person's wishes regarding medical treatment made to ensure those wishes are carried out should the person be unable to communicate them to a doctor) were provided to the residents and/or responsible parties for two of five sampled residents (Resident 2 and Resident 10 ). This deficient practice violated the residents' and/or the representatives' right to be fully informed of the option to formulate their advance directives and had the potential to cause conflict with the residents' wishes regarding health care for Resident 2 and Resident 10.
- 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 immediately notify a physician regarding a left eye infection for one (1) of five (5) sample residents (Resident 8). This deficient practice could have resulted in a delay of care and treatment for Resident 8.
- D
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Inspectors wroteBased on interview and record review, the facility failed to ensure residents' Minimum Data Set (MDS- standardized assessment and care screening tool) assessments were transmitted to Centers for Medicare and Medicaid Services within 14 days after completion for four out of four sampled residents (Residents 2, 5, 27, and 33). This deficient practice resulted in 14 days delayed transmission of MDS assessments for Residents 2, 5, 27, and 33.
- 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 interview, and record review, the facility failed to develop and/or implement an individualized person-centered plan of care with measurable objectives, timeframe, and interventions for a left eye infection for one out five sampled residents (Resident 8). These deficient practices had the potential to negatively affect the delivery of necessary care and services for Resident 8.
- 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 received treatment and care in accordance with professional standards of practice for one (1) of five (5) sample residents (Resident 8) by: Failing to follow facility's policy on Resident Change of Condition for Resident 8's left eye infection. This deficient practice could have resulted in a delay of care and treatment for Resident 8.
- D
Implement a program that monitors antibiotic use.
Inspectors wroteBased on interview and record review, the facility failed to implement an antibiotic stewardship program (a coordinated program that promotes the appropriate use of drugs used to treat infections, including antibiotics), for antibiotic use protocol to ensure that residents received the right antibiotic for the right indication, dose, and duration for one of two sampled residents (Resident 22) in 1/2024. This deficient practice had the potential not to optimize the treatment of infections while reducing the adverse events associated with antibiotic use for Resident 22.
- B
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 observation, interview, and record review the facility failed to ensure 18 of 21 resident rooms (1, 2, 3, 4, 5,6,7,9,10,11,14,15,16,18,19,21,23 and 25) met the square footage requirement of 80 square feet (Sq. Ft.) per resident. This deficient practice had the potential to result in inadequate space for nursing care and privacy and safety of residents.
September 12, 2023Complaint inspection · 1 citation
- E
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview and record review the failed to ensure Licensed Vocational Nurse 1 (LVN 1) wore appropriate personal protective equipment (not limited gown, mask, gloves, eye protection) before entering a transmission based airborne precaution isolation (used to help stop the spread of germs from one person with known or suspected infection to another) room for three of three residents (Residents 1, 2, and 3) in accordance with the facility's policies and procedures titled, Infection prevention and control programs, Covid-19, and Personal Protective Equipment-Using gowns. Residents 1, 2, and 3 tested positive for COVID-19 (an acute disease caused by coronavirus characterized by fever and cough and is capable of progressing to severe symptoms and in some cases death). [...]
Fire safety inspections
17 fire safety citations on file: 6 on April 12, 2026, 9 on March 9, 2025, 2 on March 1, 2024.
Every fire safety citation17 citations
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · April 12, 2026 · Corrected (the home has a date of correction)
- F
Have simulated fire drills held at unexpected times.
K 712 · April 12, 2026 · Corrected (the home has a date of correction)
- D
Provide properly protected cooking facilities.
K 324 · April 12, 2026 · Corrected (the home has a date of correction)
- D
Inspect, test, and maintain automatic sprinkler systems.
K 353 · April 12, 2026 · Corrected (the home has a date of correction)
- D
Properly select, install, inspect, or maintain portable fire extinguishes.
K 355 · April 12, 2026 · Corrected (the home has a date of correction)
- D
Have proper medical gas storage and administration areas.
K 923 · April 12, 2026 · Corrected (the home has a date of correction)
- F
Install emergency lighting that can last at least 1 1/2 hours.
K 291 · March 9, 2025 · Corrected (the home has a date of correction)
- F
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · March 9, 2025 · Corrected (the home has a date of correction)
- E
Install an approved automatic sprinkler system.
K 351 · March 9, 2025 · Corrected (the home has a date of correction)
- E
Have properly installed electrical wiring and gas equipment.
K 511 · March 9, 2025 · Corrected (the home has a date of correction)
- D
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
K 321 · March 9, 2025 · Corrected (the home has a date of correction)
- D
Inspect, test, and maintain automatic sprinkler systems.
K 353 · March 9, 2025 · Corrected (the home has a date of correction)
- D
Ensure proper usage of power strips and extension cords.
K 920 · March 9, 2025 · Corrected (the home has a date of correction)
- D
Have proper medical gas storage and administration areas.
K 923 · March 9, 2025 · Corrected (the home has a date of correction)
- C
Establish policies and procedures including evacuation.
E 20 · March 9, 2025 · Corrected (the home has a date of correction)
- E
Construct fire resistant interior walls.
K 331 · March 1, 2024 · Corrected (the home has a date of correction)
- C
Provide emergency officials' contact information.
E 31 · March 1, 2024 · Corrected (the home has a date of correction)