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 25 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
1J
3K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
15D
4E
2F
Potential for minimal harm
0A
0B
0C
July 8, 2026Complaint 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 failed to immediately inform the resident; consult with the resident's physician; and notify, consistent with his or her authority, the resident representative when there is to commence a new form of treatment for 1 of 5 residents (Resident #1) reviewed for resident rights. On 06/29/26, LVN B failed to notify Resident#1's legal representative about a new order for intravenous Vancomycin (glycopeptide antibiotic used to treat severe bacterial infections) to treat leukocytosis (an increase in the number of white blood cells in the bloodstream). This failure placed residents at risk of not making an informed decision about treatment, and risking side effects and allergic reactions.
May 10, 2026Complaint inspection · 1 citation
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observations, interviews, and record reviews, 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 2 (Resident #1 and Resident #2) of 6 residents observed for infection control. The facility failed to clean up blood on the door frame of Resident #1 and Resident #2 bathroom. This failure could place residents at risk for healthcare associated cross contamination and blood borne infections.
February 18, 2026Complaint inspection · 1 citation
- D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteBased on observations, interviews and record reviews, the facility failed to treat the residents with respect and dignity for 1 (Resident #1) of 3 residents reviewed. 1. The facility failed to place Resident #1's name on the nameplate outside her room. 2. CNA A failed to wear her name tag when she provided care to Resident #1 .This failure placed residents at risk of needs not being met and not having their rights and dignity respected. Findings Included:Record Review of Resident #1's admission Record revealed Resident #1 was a [AGE] year-old female admitted to the facility on [DATE] with a primary diagnosis of Acute and Chronic Respiratory Failure with Hypoxia (a life-threatening, sudden worsening of gas exchange in patients with pre-existing, long-term lung disease) Record Review of Resident#1's Care Plan revision date 03/20/2025 revealed; [...]
December 28, 2025Complaint 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 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 1 of 3 (Resident #1) reviewed for infection control. The facility failed to identify on the exterior of Resident #1's room that contact precautions were required before entering and did not provide the appropriate PPE at or near the door for Resident #1. This failure could place residents at risk of being infected by staff in contact with other residents with infections. Findings Included: [...]
December 4, 2025Complaint inspection · 1 citation
- E
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteBased on interviews and record reviews, the facility failed to ensure the resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility. A facility must protect and promote the rights of each resident. for 4 (Resident #1, Resident #2, Resident #3 and Anonymous Person) of 5 residents reviewed. The facility failed to protect and promote the rights of Resident #1, Resident #2, Resident #3 and Anonymous Person who wanted to continue to be able to sit in the front patio. This failure could place residents at risk of a diminished quality of life.
November 19, 2025Complaint inspection · 2 citations
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on interview and record review the facility failed to ensure that all alleged violations involving abuse were reported immediately, but not later than 2 hours after the allegation was made, if the events that caused the allegation involved abuse, to the administrator of the facility and to other officials including to the State Survey Agency where state law provides for jurisdiction in long-term care facilities in accordance with State law through established procedures for 2 of 2 residents (Residents #1 and #2), reviewed for abuse, neglect, and exploitation. The facility failed to report an incident of resident to resident abuse between Resident #1 and Resident #2 that occurred on 10/10/2025. This failure could place residents at risk of abuse, neglect and exploitation.
- 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 residents received treatment and care in accordance with professional standards of practice, and the comprehensive person-centered care plan for 1 of 4 residents (Resident #1) reviewed for quality of care. The facility failed to ensure Resident #1's weekly skin assessment was completed on 10/17/2025. This failure could place residents at risk of not identifying skin breakdown or injuries, and delayed treatment and monitoring.
September 9, 2025Complaint inspection · 2 citations
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on interviews and record review, the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported immediately, but not later than 2 hours if the alleged violation involved abuse or neglect and resulted in bodily injury, to other officials (including the state Agency) and the administrator of the facility for 1 of 1 resident reviewed for reporting abuse. CNA A failed to notify the ADM and DON about an accident/hazard regarding Resident #1 that happened on 08/27/25. This failure could place residents at risk for abuse and neglect.
- 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 ensure that each resident received adequate supervision for one (Resident #1) of three residents reviewed for supervision and ensured the environment remained free of accidents hazards. The facility failed to ensure CNA A appropriately transferred Resident #1 from the bed to the motorized wheelchair to ensure accidents did not occur. This failure could place residents at risk of being in an unsafe environment and at risk of accidents and injury.
August 19, 2025Standard inspection · 4 citations
- E
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 coordinate assessments with the pre-admission screening and resident review (PASRR) and refer all level II residents and all residents with possible serious mental disorder, intellectual disability, or a related condition for one (Resident #8) of one residents reviewed for PASRR screenings. The facility failed to ensure Resident #8's PASRR Level One screening accurately reflected their diagnosis of mental illness. This failure placed residents at risk of not receiving specialized therapy and equipment services they may benefit from.
- 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 1 (Resident #2) of 8 residents, and 1 of 1 laundry room reviewed for infection control in that: 1. ADON B did not wear PPE during wound care for Resident #2 who was on Enhanced Barrier Precautions for wounds. 2. The facility failed to prevent cross contamination of three racks of clean residents' clothing by placing the racks in front of two washing machines in the soiled area of the laundry room. 3. The Laundry Aide failed to keep the clean laundry folding table clean, when she placed her shoes on the table next to residents' clean clothing. [...]
- D
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 provide a safe, clean, comfortable, and homelike environment, for 3 of 18 residents (Resident #81, Resident #5, and Resident #18) reviewed for maintenance services. The facility failed to ensure Resident #81's ceiling tile was repaired and maintained around the air vent. The facility failed to ensure Resident #5's air vent was cleaned and free of debris. The facility failed to ensure a hole in the wall of Resident #18's room was repaired. The facility failed to ensure resident #18 had sufficient lighting in the bathroom. These failures could place residents at risk of living in an unclean, unsanitary, and accident-free environment which could lead to 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 medication was stored in locked compartments for 1 of 7 Medication Carts (Cart A) and 1 of 2 Treatment Carts (Cart B) reviewed for drug security. 1. A medication cart (Cart A) was left unlocked when not in use, unattended, and out of nurse's view while Resident #15 sat across from medication Cart A on 08/17/25. 2. A treatment cart (Cart B) was left unlocked when not in use and unattended on 08/17/25. These deficiencies could place residents at risk of medications loss, drug diversion, or harm due to accidental ingestion of unprescribed medications.
June 10, 2025Complaint 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 a resident who is unable to carry out activities of daily living receives showers to maintain grooming and personal hygiene for 1 (Resident #1) of 3 residents reviewed for ADL care. The facility did not provide showers or baths to Resident #1 as scheduled. This failure can affect residents by decreasing their quality of life.
April 7, 2025Complaint inspection · 1 citation
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents with pressure ulcers receive necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for 1 of 3 residents (Resident #1) reviewed for treatment of pressure ulcers. The facility failed to follow their Wound Care management protocol when they failed to refer Resident #1 to the Wound care consultant at the time of her re-admission to the facility when she was admitted with a sacral pressure ulcer. Resident #1 was readmitted on [DATE] and facility did not refer the resident to the Wound Care consultant until 03/25/25. The noncompliance was identified as Past Noncompliance (PNC). The noncompliance began on 03/17/25 and ended on 03/25/25. [...]
July 11, 2024Standard inspection · 1 citation
- F
Dispose of garbage and refuse properly.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the facility's only garbage storage dumpster, and surrounding area, was maintained in a sanitary condition to prevent the harborage and feeding of pest. 1. The facility failed to ensure the trash dumpster's door, located outside the facility's building, was closed., 2. The facility failed to ensure trash was not left outside of the dumpster on the ground. This failure could place residents at risk of contracting disease by attracting pest, disease carrying rodents, and having debris dangerous to residents.
April 9, 2024Complaint inspection · 1 citation
- E
Make sure that a working call system is available in each resident's bathroom and bathing area.
Inspectors wroteBased on observation, interview and record review, the facility failed to ensure resident rooms were adequately equipped to allow residents to call for staff assistance through a communication system which relays the call directly to a staff member or to a centralized staff work area for 7 residents (#1, #2, #3, #4, #5, #7, #8) of 8 residents reviewed for resident call system in that: The facility failed to ensure 7 out of 8 Resident's (#1, #2, #3, #4, #5, #7, #8) call buttons were accessible on 4/9/24 to residents on the secured unit. This failure could have placed 20 residents on the secured unit at risk of being unable to obtain assistance for activities of daily living or in the event of an emergency.
March 28, 2024Complaint inspection · 2 citations
- J
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 each resident received adequate supervision and assistance to prevent accidents for one of seven residents (Resident #2) reviewed for accidents and supervision . The facility failed to ensure Resident #2 was transferred by two staff, which resulted in a fall with fracture of her distal left Femur (a distal femur is a fracture of the thighbone that occurs just above the knee joint) on 01/19/24 . The noncompliance was identified as PNC. The IJ began on 01/19/24 and ended on 01/22/24. The facility had corrected the noncompliance before the survey began. This failure could place residents at risk for serious injury due to unsafe transfers.
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on observation, interview and record review the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported immediately, but not later than 2 hours after the allegation was made, if the events that caused the allegation involved abuse or resulted in serious bodily injury, or not later than 24 hours if the events that caused the allegation did not involve abuse and did not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures for 1 of 8 residents (Resident #2) reviewed for abuse and neglect. [...]
October 5, 2023Complaint inspection · 5 citations
- K
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Inspectors wroteBased on interviews and record reviews, the facility failed to ensure the resident has the right to be free from neglect for one (Resident #1) of 6 residents reviewed for neglect. The facility failed to provide necessary x-ray services in a timely manner and failed to follow up to get results in a timely manner for Resident #1. The facility failed to provide education and training for nursing staff on how to carry out carry out physician orders for x-rays and follow up on the results in a timely manner. The facility failed to follow their policies for laboratory, diagnostic and radiology services and physician orders. Resident #1 fell on 9/28/2023 at 2:00 PM and sustained an injury, the order for an x-ray was obtained on 9/28/2023 at 5pm. The x-ray was completed on 9/29/2023 at 1:15 PM (20 hours delay). The facility was notified of results at 8:00 PM on 9/29/2023. [...]
- K
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Inspectors wroteBased on interview and record review, the facility failed to have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care and considering acuity of the facility residents for 4 ( LVN A, LVN B, LVN C, and ADON) of 6 nurses reviewed for competency, in that : The facility failed to ensure: - LVN B carried out an x-ray for Resident #1. - RN C followed up with the x-ray order for Resident #1. - LVN A followed up with the x-ray order in timely manner and to get results for Resident #1. [...]
- K
Provide timely, approved x-ray services, or have an agreement with an approved provider to obtain them.
Inspectors wroteBased on interview and record review the facility failed to provide radiology or other diagnostic services to meet the needs of its residents in a timely manner for 1 (Resident #1) of 6 residents reviewed for radiology services. 1. The facility failed to ensure that an x-ray was completed in a timely manner for Resident #1 2. The facility failed to follow up to get Resident #1's x-ray results in a timely manner. Resident #1 had an unwitnessed fall on 9/28/23 at 2pm and sustained an injury, The order for an x-ray was obtained on 9/28/23 at 5pm. The x-ray was completed on 9/29/23 at 1:15pm (20 hours delay). The facility was aware of results on 9/29/23 at 8:00 PM. Resident #1 had a fracture to the right hip. Thirty hours after the fall with fracture, the resident was sent to the hospital for treatment. [...]
- D
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Inspectors wroteBased on interview and record review, the facility failed to implement their written policies and procedures that prohibit and prevent neglect of residents for one (Resident #1) of six residents reviewed for neglect. The facility failed to implement a policy and process for immediately investigating and reporting allegation of neglect related to facility's failure to obtain an x-ray and send Resident #1 to the hospital in a timely manner when facility became aware on 09/29/23 of Resident #1's delay in x-ray result. This deficient practice could place residents at risk for delayed treatment and neglect.
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on interview and record review the facility failed to ensure all alleged violations involving neglect were reported immediately, but not later than 2 hours after the allegations were made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, for one (Resident #1) of six residents reviewed for neglect. The facility failed to ensure an allegation of neglect related to facility's failure to obtain an x-ray and send Resident #1 to the hospital in a timely manner when facility became aware on 09/29/23 of Resident #1's delay in x-ray result. This deficient practice could place residents at risk for delayed treatment and neglect.
June 1, 2023Standard inspection · 1 citation
- 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 safety in the facility's only kitchen. The facility failed to ensure food items in the refrigerator, freezer and dry storage were dated, labeled and properly sealed. These failures could affect residents by placing them at risk for food-borne illness.
Fire safety inspections
17 fire safety citations on file: 3 on August 19, 2025, 9 on July 11, 2024, 5 on June 1, 2023.
Every fire safety citation17 citations
- F
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · August 19, 2025 · Corrected (the home has a date of correction)
- E
Have properly located and lighted "Exit" signs.
K 293 · August 19, 2025 · Corrected (the home has a date of correction)
- E
Install an approved automatic sprinkler system.
K 351 · August 19, 2025 · Corrected (the home has a date of correction)
- F
Conduct risk assessment and an All-Hazards approach.
E 6 · July 11, 2024 · Corrected (the home has a date of correction)
- F
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
K 321 · July 11, 2024 · Corrected (the home has a date of correction)
- F
Install an approved automatic sprinkler system.
K 351 · July 11, 2024 · Corrected (the home has a date of correction)
- F
Properly select, install, inspect, or maintain portable fire extinguishes.
K 355 · July 11, 2024 · 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 · July 11, 2024 · Corrected (the home has a date of correction)
- E
Install corridor and hallway doors that block smoke.
K 363 · July 11, 2024 · Corrected (the home has a date of correction)
- E
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · July 11, 2024 · Corrected (the home has a date of correction)
- E
Install smoke barrier doors that can resist smoke for at least 20 minutes.
K 374 · July 11, 2024 · Corrected (the home has a date of correction)
- D
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
K 223 · July 11, 2024 · Corrected (the home has a date of correction)
- F
Provide properly protected cooking facilities.
K 324 · June 1, 2023 · Corrected (the home has a date of correction)
- E
Keep aisles, corridors, and exits free of obstruction in case of emergency.
K 211 · June 1, 2023 · 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 · June 1, 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 · June 1, 2023 · Corrected (the home has a date of correction)
- E
Install corridor and hallway doors that block smoke.
K 363 · June 1, 2023 · Corrected (the home has a date of correction)