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 23 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
1K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
11D
11E
0F
Potential for minimal harm
0A
0B
0C
June 2, 2026Complaint 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 provide the necessary services for residents who are unable to carry out activities of daily living to maintain good grooming and personal hygiene for 1 (Resident#1) of 4 residents reviewed for ADLs. The facility failed to ensure Resident#1 had her fingernails cleaned and trimmed on 06/02/26. This failure could place residents at risk for loss of dignity, risk for infections, and a decreased quality of life. A record review of Resident #1's quarterly MDS assessment dated [DATE] reflected Resident #1 was a [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE] with the diagnosis of: type 2 diabetes mellitus (elevated blood sugar), non-Alzheimer's dementia (brain disorders causing cognitive decline due to factors other than Alzheimer's), and stroke. [...]
March 19, 2026Standard inspection · 2 citations
- D
Provide enough food/fluids to maintain a resident's health.
Inspectors wroteBased on observations, interviews, and record review, the facility failed to maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrates that this is not possible or resident preferences indicate otherwise for 1 of 5 residents (Resident #73) reviewed for nutritional status. The facility failed to recognize, evaluate, and address timely interventions for Resident #73 when the Dietitian made the recommendation for it on 01/02/26. Resident #73 experienced weight loss of 7.07% (7.4 pounds) from 12/24/25 to 03/01/26. This failure could place residents at risk for improper care, weight loss, malnutrition, and overall health decline.
- 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 2 of 5 residents (Residents #2 and #31) reviewed for pharmacy services.1. LVN J failed to administer a Potassium Chloride Extended-Release tablet in the proper form, when she crushed the tablet, before administering it to Resident #2 through the resident's enteral feeding tube. 2. RN H failed to ensure Resident #31 received his morning dose of sodium chloride 1 gram when RN H prepared the medication and left it on the 100-hall medication cart. RN H did not return to administer the medication to Resident #31 when he came back to the room. [...]
November 19, 2025Complaint inspection · 1 citation
- D
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food that accommodates resident allergies, intolerances, and preference for 1 (Resident #2) of 1 resident reviewed for food preferences. The facility failed to ensure Resident #2 was given a substitute food item. This failure could place residents at risk of not eating their meals, further resulting in weight loss, and poor quality of life.
July 29, 2025Complaint inspection · 1 citation
- D
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Inspectors wroteBased on observation, interviews and record review, the facility failed to ensure residents received food that accommodate the allergies, intolerances, and preferences of 2 (Resident #1 and Resident #2) of 5 residents reviewed for food and nutrition services. 1. On 07/25/25 during dinner, the facility failed to accommodate the preference of Resident #1 when she was served a pork hotdog that caused her to become nauseous and vomit. 2. On 07/29/25 during lunch, the facility failed to accommodate the preference of Resident #2 when he was served beef tacos. The failure could affect residents who consumed food from the facility's kitchen by placing them at risk for allergic reactions, dissatisfaction, poor intake, weight loss, and decline in health.
January 13, 2025Standard inspection · 8 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 a resident who needs respiratory care was provided such care, consistent with professional standards of practice for 1 of 3 residents (Resident #47) reviewed for oxygen. The facility failed to have accurate physician orders for oxygen use for Resident #47. This failure could place residents who received oxygen therapy at risk for inadequate or inappropriate amounts of oxygen delivery and possible infection.
- E
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Inspectors wroteBased on interview and record review, the facility failed to ensure that residents who required dialysis received such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 1 of 2 residents (Resident #48) reviewed for dialysis. The facility failed to ensure dialysis communication forms were completed for Resident #48 before going for dialysis and after returning from dialysis treatment. This failure could place residents at risk of inadequate communication between the facility and dialysis center.
- 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 monitor and verify that the feeding tube is in the right location (e.g., stomach or small intestine, depending on the tube) before administering medications to prevent complications for 1 of 1 resident (Resident #92) reviewed for feeding tubes and for 1 of 2 refrigerators and 2 of 2 medication rooms reviewed for pharmacy procedures. 1. The facility failed to ensure LVN J checked for residual (the amount of liquid remaining in the stomach after an enteral feeding) before administering medication to Resident #92. This failure could place residents at risk for adverse effects due to inappropriate management of g-tube care. 2. [...]
- E
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure each resident's drug regimen was free of unnecessary medication for 1 of 5 residents (Resident #89) reviewed for adequate monitoring of unnecessary medication. The facility did not monitor Resident #89 for side-effects related to the use of the anti-anxiety medication Buspirone, hypnotic medication Zolpidem Tartrate, and the anti-psychotic medication Ingrezza. This failure could place the residents at risk for adverse consequences of medication.
- 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 to help prevent the development and transmission of communicable diseases and infections for 2 of 10 residents (Residents #7 and #9) reviewed for infection control. 1. The facility failed to ensure CNA M used Personal Protection Equipment during urinary catheter care performed for Resident #7 while on EBP precautions. 2. The facility failed to ensure RN C used Personal Protection Equipment during medication pass and providing care for Resident #9's tube feeding cite while on EBP precautions. These failures could place residents at risk for cross contamination and the spread of infection.
- 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 provide the necessary services to maintain good grooming for a resident who is unable to carry out activities of daily living for 1 of 3 residents (Resident #14) reviewed for ADL care. The facility failed to ensure Resident #14 received grooming assistance to remove unwanted facial hair. This failure could affect the residents who require assistance with care from facility staff by placing them at risk for social isolation, loss of dignity and self-worth.
- 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 interview and record review, the facility failed to ensure a resident with an indwelling urinary catheter received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 1 of 3 residents (Resident #9) reviewed for catheter care. The facility failed to follow physician orders for routine catheter care including cleaning for Resident #9. This failure could place residents with foley catheters at risk of urinary infection and improper catheter care.
- D
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure parenteral fluids were administered consistent with professional standards for 1 of 2 residents (Resident #64) reviewed for intravenous fluids. The facility failed to ensure the dressing on Resident #64's peripheral intravenous line (a short flexible tube inserted into a vein to administer fluids and medications) was dated and initialed. The failures could affect residents by placing them at risk for infections.
November 5, 2024Complaint 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 record reviews and interviews, 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 two (Resident #1 and Resident #2) of 2 residents, reviewed for pharmaceutical services, in that: Medications must be released to residents only on the written or verbal authorization of the attending physician. When a resident is transferred directly to another nursing facility or discharged to home, the resident's medications must be released to the new facility or to the resident or his family, respectively. The facility failed to provide the correct medications to Resident #1 upon discharge and failed to provide the correct medication to Resident #2 upon discharge. [...]
September 19, 2024Complaint inspection · 1 citation
- K
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a resident receives care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable for 1 of 2 residents (Resident # 1) reviewed for quality of care. The facility did not prevent the development of one facility-acquired Stage IV pressure injury on the right calf for Resident #1. An Immediate Jeopardy (IJ) was identified on 09/18/2024. The IJ Template was provided to the facility on [DATE] at 12:55PM. [...]
December 20, 2023Standard inspection, Complaint inspection · 8 citations
- E
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 are unable to carry out the activities of daily living received the necessary services to maintain personal hygiene for 3 of 6 residents (Resident #205, Resident #206, and Resident #209) reviewed for ADL care. The facility failed to ensure Resident #205 and #206 were provided regular showers. The facility failed to ensure Resident #209 was provided regular showers and personal hygiene based on the resident's preference. These failures could place residents at risk of not receiving personal care services and a decreased quality of life.
- E
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 that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 1 of 8 residents (Resident #355), reviewed for quality of care. 1. Facility failed to ensure an active order was followed for blood sugar monitoring for Resident # 355 from 12/12/23 to 12/19/23 as ordered by provider. 2. Facility failed to notify physician of an implanted continuous blood sugar monitoring medical device for Resident# 355. These failures could place residents at risk for inadequate care, inaccurate blood sugar results, infection at device site, and or bleeding.
- E
Provide enough food/fluids to maintain a resident's health.
Inspectors wroteBased on interview and record review, the facility failed to ensure residents were able to maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrated that it was not possible, or the resident preferences indicated otherwise for 2 of 10 residents (Resident #205 and Resident #301) reviewed for quality of care. 1. The facility failed to weigh Resident #205 and #301 at admission per facility policy and physician's orders. 2. The facility failed to ensure Resident #301 did not have an unplanned significant weight loss. 3. The facility failed to ensure the Dietitian assessed Resident #205 upon admission. These failures could place residents at risk for decrease nutritional and weight status and a decline in health.
- 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, distribute and served food in accordance with professional standards for food safety in the facility's only kitchen reviewed for food and nutrition services. The facility failed to dispose of food items 72 hours after opening date in the walk-in refrigerator of the facility's kitchen. These failures affected residents by placing them at risk for contamination and food-borne illness.
- 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 disease and infections for 4 (Residents #10, #47, #94, #355) of 8 residents reviewed for infection control. 1. Facility failed to ensure the Dietary Manager wore proper Personal Protective Equipment (PPE) (gown, face shield, gloves, and N-95/KN95 respirator mask) before entering Resident #94 and Resident # 355's room that was on Transmission Based Precaution (isolation due to communicable infectious disease). 2. [...]
- D
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Inspectors wroteBased on interviews and record reviews, the facility failed to preserve the resident right to make choices about aspects of his or her life in the facility that were significant to the resident for 1 of 6 (Resident #305) reviewed for Resident Rights. The facility failed to respect the rights of Resident #305 regarding choice of food and care. This failure placed residents at risk of their rights being disregarded and a diminished quality of life.
- 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 develoop and implement a comprehensive person-centered care plan that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 1 (Resident #355) of 8 residents reviewed for comprehensive care plans. Facility failed to complete a care plan for an implanted continuous blood sugar monitoring medical device for Resident# 355. This failure could place residents at risk for inadequate care, inaccurate blood sugar results, infection at device site, and or bleeding.
- 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, 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 one of ten residents (Resident #55) reviewed for pharmacy services. The facility failed to ensure Resident #55 did not have unsecured medication in her room on 12/18/23 and 12/19/23. This deficient practice could place residents at risk of not being monitored for their medications, adverse reactions, and drug diversion.
Fire safety inspections
7 fire safety citations on file: 1 on March 19, 2026, 4 on January 13, 2025, 2 on December 20, 2023.
Every fire safety citation7 citations
- F
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
K 521 · March 19, 2026 · Corrected (the home has a date of correction)
- F
Include a process for Emergency Preparedness collaboration.
E 9 · January 13, 2025 · Corrected (the home has a date of correction)
- F
Establish staff and initial training requirements.
E 37 · January 13, 2025 · Corrected (the home has a date of correction)
- F
Conduct testing and exercise requirements.
E 39 · January 13, 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 · January 13, 2025 · Corrected (the home has a date of correction)
- F
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
K 761 · December 20, 2023 · 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 · December 20, 2023 · Corrected (the home has a date of correction)