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 44 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
33D
7E
0F
Potential for minimal harm
0A
4B
0C
March 4, 2026Complaint inspection · 1 citation
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1), received treatment and care in accordance with professional standards of practice when facility nurses (in general) failed to monitor Resident 1's vital signs (objective, measurable, and essential physiological indicators, including temperature, pulse, respiration rate, blood pressure, oxygen saturation, and often pain) after Resident 1 experienced a change in condition on 2/28/2026 at 6:21 PM.This failure had the potential for Resident 1 to experience a decline in health and wellbeing. [...]
February 13, 2026Standard inspection · 14 citations
- E
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 develop and implement individualized and resident-centered care plans (CP) for two of two sampled residents (Residents 26 and 53). These deficient practices had the potential for Residents 26 and 53 to not receive appropriate care, treatment, and/or services related to their specific needs.
- E
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Inspectors wroteBased on observation and interview, the facility failed to ensure the kitchen handwashing sink was draining. This failure had the potential to result in overflow of wastewater and lead to contamination.
- 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 obtain written informed consent for one of five sampled residents (Resident 53) for the use of psychotropic (any medication capable of affecting the mind, emotion, and behavior) medication. This deficient practice had the potential for Resident 53 not receiving adequate information regarding psychotropic medications necessary to make an informed health care decision.
- D
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
Inspectors wroteBased on interview and record review, the facility failed to ensure the order for lorazepam (a medication used for anxiety- a feeling of fear, dread, or uneasiness) as needed (PRN) was limited to a 14-day duration for one of five sampled residents (Resident 5). This deficient practice had the potential to result in unnecessary or prolonged use of lorazepam that could lead to Resident 5 experiencing adverse effects (unwanted, uncomfortable, or dangerous effects of a drug) related to medication therapy.
- D
Assure that each resident’s assessment is updated at least once every 3 months.
Inspectors wroteBased on interview and record review, the facility failed to complete one of three sampled residents (Resident 41) quarterly Minimum Data Set (MDS, a resident assessment and care screening tool). This failure had the potential to result in not meeting the resident's care needs and/or identifying a change in the resident's physical and mental care needs.
- D
Ensure each resident receives an accurate assessment.
Inspectors wroteBased on interview and record review, the facility failed to ensure one of one sampled resident's (Resident 43), Minimum Data Set (MDS - a federally mandated resident assessment tool) dated 12/24/2025 accurately documented the resident's dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidneys have failed) treatment. This failure had the potential to result in delay of treatment and inaccurate plan of care and interventions for Resident 43.
- 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 ensure one of one sampled resident (Resident 43)'s care plan (CP) was revised to address 1,000 milliliters (ml- unit of measurement) fluid restriction. This failure had the potential to place Resident 43 at risk for fluid overload and other related complications.
- D
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the suprapubic catheter (a soft tube inserted directly into the bladder through a small incision to drain urine into a bag) bag was not touching the floor for one of two sampled residents (Resident 1). This deficient practice resulted in contamination of Resident 1's care equipment and placed the resident at risk of infection.
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observation, interview, and record review, the facility failed to administer continuous oxygen therapy (treatment that provides supplemental, or extra, oxygen) for one of one sampled resident (Resident 15) according to accepted standards of clinical practice and in accordance with the facility's policy and procedure (P&P) titled, Oxygen Administration. This deficient practice placed Resident 15 at risk for shortness of breath and/or hypoxia (low levels of oxygen in the body tissues) which could lead to serious complications.
- D
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure hemodialysis (HD - a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed) device access dressing was removed as ordered by the physician for one of one sampled resident (Resident 43). This deficient practice had the potential for Resident 43 to develop complications related to HD device access.
- 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 one of one sampled resident (Resident 19) was properly identified during Resident 19's medication administration. This failure had the potential to result in medication errors from Resident 19 receiving incorrect medications.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview, and record review, the facility failed to implement and follow infection prevention procedures to prevent the transmission of infectious organisms for one of four sampled residents (Resident 1) by failing to wear required personal protective equipment (PPE, equipment that protects people from injury or illness in hazardous environments) while providing care to Resident 1 who was on Enhanced Barrier Precaution (EBP, precautions that involve using a glove and gown during high-contact resident care activity for residents who are colonized or infected with multidrug-resistant organisms [MDRO, bacteria that is resistant to many types of antibiotics] and those at a higher risk of developing a MDRO, such as, residents with wounds or indwelling medical devices). [...]
- B
Post nurse staffing information every day.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staffing information on the Nurse Staffing Sheet (posted information that contains the facility's current resident census and total number and actual hours worked by licensed and unlicensed nursing staff) was posted in a prominent place readily accessible to residents and visitors. This deficient practice had the potential to mislead the residents and visitors that may affect the quality of nursing care provided to the residents.
- 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 provide a minimum of 80 square feet (sq. ft., unit of measurement) per resident area for eighteen (18) out of twenty-four (24) resident rooms (Rooms 101, 103, 104, 105, 106, 107, 108, 109, 110, 111, 112, 114, 115, 116, 117, 118, 119, and 122). This deficient practice had the potential to impact the ability to provide safe nursing care and privacy to the residents.
June 24, 2025Complaint inspection · 1 citation
- D
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of two sampled residents (Resident 1), received appropriate treatment to prevent further decrease in Resident 1's range of motion (ROM, the full movement potential of a joint or body part) in Resident 1's left shoulder. This failure resulted in Resident 1 experiencing pain and joint stiffness on Resident 1's left shouder due to a decrease in range of motion.
June 10, 2025Complaint inspection · 3 citations
- D
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Inspectors wroteBased on interview and record review, the facility failed to incorporate Assessments and Care Planning Goals and Objectives in the Care Plans that lead to the residents' highest obtainable level of independence for one of five residents (Resident 1). Resident 1's care plan did not include Resident 1's behavior of crawling on the floor. This failure result in no nursing interventions for Resident 1's behavior of crawling on the floor and placed Resident 1 at risk for not reaching Resident 1's highest obtainable level of independence.
- 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 implement its Policy and Procedure, titled Falls and Fall Risk, Managing, for one of five sampled residents (Resident 1) when: 1. Resident 1 was not assessed for injury whenever staff (in general) found Resident 1 on floor crawling on the floor mats (a padded cushion placed on the floor next to the bed to help reduce injuries from a fall) as indicated in Resident 1's fall risk care plan. 2. Resident 1's care plan did not include Resident 1's behavior of crawling on the floor. 3. Licensed Vocational Nurse (LVN) 1 did not document Resident 1's wander guard trial in Resident 1's medical record. This failure placed Resident 1 at risk for harm and injury.
- D
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 to implement its Policy and Procedure titled, Charting and Documentation, for one of five sampled residents (Resident 1) when: Licensed Vocational Nurse 1 (LVN 1) did not document Resident 1's wander guard trial in Resident 1's medical record. This failure result in incomplete documentation for Resident 1 and placed Resident 1's inter disciplinary team at risk for miscommunication regarding the Resident 1's condition and response to care. Cross Reference:
January 23, 2025Complaint inspection · 1 citation
- D
Provide timely, quality laboratory services/tests to meet the needs of residents.
Inspectors wroteBased on interview and record review, the facility failed to follow a physician's order to collect a stool sample for one of three sampled residents (Resident 1). This deficient practice had the potential for a delay of care and services to Resident 1.
December 20, 2024Standard inspection · 9 citations
- E
Reasonably accommodate the needs and preferences of each resident.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure call lights were within reach for three of three sampled residents (Residents 13, 17 and 35). These deficient practices had the potential for the residents not to receive necessary care or receive delayed services to meet the residents' needs that could result in a fall or injury.
- E
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
Inspectors wroteBased on observation, interview, and record review, the facility failed to implement its Policy and Procedure (P&P) on the use of side rails/bed rails (adjustable metal or rigid plastic bars attached to the bed) for three of three sampled residents (Residents 21, 33 and 48) by failing to: a. (1). Ensure appropriate alternative interventions were attempted before the installation of side rails for Resident 21. (2). Assess Resident 21 for risk of entrapment (an event in which a resident is caught, trapped, or entangled in the space in or about the bed rail) and obtained an informed consent to review the risks and benefits prior to installing bed rails. b. Ensure appropriate alternative interventions were attempted and did not meet the needs of Resident 33 before the installation of side rails. c. [...]
- 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 proper food handling practices by failing to ensure food items were dated when it was first opened in one of two facility refrigerators. This deficient practice had the potential risk for food borne illnesses (infections caused by ingesting contaminated food or beverages) to the residents.
- D
Ensure that residents are fully informed and understand their health status, care and treatments.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of one sampled resident (Resident 21) was informed in advance, of the risks and benefits of a psychoactive medication (a drug that changes brain function and results in alterations in perception, mood, consciousness, or behavior). This failure violated the residents' right to make an informed decision regarding the use of a psychoactive medication.
- D
Ensure each resident receives an accurate assessment.
Inspectors wroteBased on interview and record review, the facility failed to ensure the Minimum Data Set (MDS, a resident assessment tool) reflected an accurate assessment for one of one resident (Resident 51). This failure resulted in inaccurate reporting to the Centers for Medicare and Medicaid Services (CMS, a federal agency that administers the Medicare program and works with state governments to administer the Medicaid and health insurance portability standards) agency and had the potential for Resident 51 not to receive interventions to address the resident's specific care concerns.
- D
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 utilize bilateral landing mats as ordered, for one of three sampled residents (Resident 13) who had a history of falls. This deficient practice had the potential to result in serious consequences that may accompany a fall for Resident 13.
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observation, interview, and record review, the facility staff failed to ensure one of one sampled resident (Resident 40) received two liters of oxygen as needed according to physician's order and monitor the resident's oxygen usage in accordance with professional standards of practice. This deficient practice had the potential to cause complications associated with oxygen therapy for Resident 40.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a safe and sanitary environment to help prevent the development and transmission of communicable diseases for a resident on hemodialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed) with indwelling medical device placed on Enhanced Barrier Precautions (EBP, infection control measures used to prevent the spread of multidrug-resistant organisms [MDROs] in healthcare settings) for one of six sampled residents (Resident 44). This failure had the potential to expose Resident 44 to infection.
- 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 meet the 80 square feet (sq. ft., a unit area of measurement) per resident in multiple resident bedrooms requirement for 18 of 24 resident rooms (Rooms 101,103, 104, 105, 106, 107, 108, 109, 110, 111, 112, 114, 115, 116, 117, 118, 119 and 122) in the facility. This failure had the potential to affect residents' privacy and result in the residents not having adequate space for nursing care and emergency services.
December 22, 2023Standard inspection · 15 citations
- E
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 implement fall intervention to utilize bilateral landing mats for two of two sampled residents (Resident 15 and Resident 17) who had history of falls as indicated in residents care plan titled Fall Risk. These deficient practices had the potential to result in serious consequences like fractures (break in the bone) and bleeding that may accompany with falls.
- E
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observation, interview, and record review, the facility failed to administer oxygen therapy (treatment that provides supplemental oxygen) for three of three sampled residents (Residents 199, 149 and 8) according to standards of practice and with the facility's Policy and Procedure (P&P) titled, Oxygen Therapy. a. Resident 199 did not receive two liters of oxygen as ordered by the physician. b. Resident 149 received continuous oxygen therapy without a physician's order. c. Resident 8 received continuous oxygen therapy without a physician's order. These deficient practices placed Residents 199, 149 and 8 at risk for shortness of breath and/or hypoxia (low levels of oxygen in the body tissues) which can lead to serious complications.
- D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteBased on observation, interview, and record review, the facility failed to provide bilateral handsocks (a type of glove that covers the hands) for one of two sampled residents (Resident 8) in accordance with the physician's order. This deficient practice had the potential to affect Resident 1's self-esteem (self-worth) and psychosocial well-being.
- D
Reasonably accommodate the needs and preferences of each resident.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the call light (an alerting device for staff to assist a resident in need) was within reach for one of one sampled resident (Resident 42). This deficient practice had the potential to result in Resident 42 not receiving care and assistance in a timely manner.
- 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 to provide information of advance care planning (a process of communication between individuals and their healthcare agents to understand, reflect on, discuss, and plan for future healthcare decisions for a time when individuals are not able to make their own healthcare decisions.) for one of one sampled resident (Resident 42). This deficient practice had the potential for facility staff to provide treatment against the resident's will.
- 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 comfortable and home like environment for one of one sampled resident (Resident 42). This failure had the potential to result in Resident 42 not residing in a comfortable environment that could affect Resident 42's 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 interview and record review the facility failed to develop and implement an individualized a person-centered plan of care (details why a person is receiving care, assessed health or care needs, medical history, personal details, expected and aimed outcomes, and what care and support will be delivered, how, when and by whom) with measurable objectives and interventions to meet the residents' needs for one of one sampled resident (Resident 5) as indicated in the facility's Policy and Procedure, titled Care Plans, Comprehensive. This deficient practice had the potential for Resident 5 not to receive appropriate care, treatment and/or services.
- 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 observation, interview and record review the facility failed to revise a plan of care for one of one sampled resident (Resident 15), who sustained a fall from his bed on 9/25/2023 as indicated in the facility's policy Care Plans, Comprehensive. This deficient practice had the potential to place Resident 15 at risk for recurrent falls.
- 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 provide an effective communication method for one of one non-English speaking sampled resident (Resident 18). This failure had the potential for Resident 18 to not receive the necessary care and services due to the lack of effective communication aids.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on interview and record review, the facility failed to assign a designated staff to coordinate with hospice care (end of life care) for one of one sampled resident (Resident 42). This failure had the potential for Resident 42 to not receive individualized compassionate care that could affect Resident 42's quality of life.
- 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 follow the physician's order to set up Gastrostomy tube (G-tube, a tube that is placed directly into the stomach through an abdominal wall incision for administration of food, fluids, and medications) feeding of Fibersource HN (nutritionally complete tube feeding formula) via pump (a machine used to infuse nutrition formula through G-Tube to the stomach) for one of four sampled residents with tube feeding (Resident 28). This failure had the potential to result in weight loss and malnutrition for Resident 28 and could affect Resident 28's health condition.
- D
Observe each nurse aide's job performance and give regular training.
Inspectors wroteBased on interview and record review, the facility failed to complete a performance evaluation for at least once every 12 months for one of two sampled Certified Nursing Assistants 3 (CNA 3). This failure had the potential for the facility to not be aware of CNA 3's competency skills and techniques and miss the opportunity to provide the necessary in-service education specific to CNA 3's performance which could negatively affect the provision of care to residents.
- D
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Inspectors wroteBased on interview and record review, the facility failed to act upon the pharmacist's monthly medication regimen review (MRR, a thorough evaluation of the medication regimen of a resident, with the goal of promoting positive outcomes and minimizing adverse consequences associated with medication) recommendation to obtain an informed consent for the use of Venlafaxine (medication used to treat depression, anxiety disorder and panic disorder) for one of five sampled residents (Resident 38) on psychotropic medication (medication that affects brain activities associated with mental process and behavior). This failure had the potential to result in Resident 38 receiving an unnecessary medication and could prevent Resident 38 from maintaining the resident's highest practicable level of physical, mental, and psychosocial well-being.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the nasal cannula (NC, small flexible tube with two prongs that sit inside the nostrils to deliver supplemental oxygen) was labeled and dated, the tubing was not touching the floor, and the NC prongs were not touching the oxygen humidifier (device used to provide moistened oxygen) when not in use for one of three sampled residents (Resident 20) on oxygen therapy in accordance with the facility's policy and procedure titled, Oxygen Therapy. This deficient practice had the potential to result in an increased risk of spread of infection to the residents, staff, and other visitors in the facility.
- 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 meet the 80 square feet (sq. ft., a unit area of measurement) per resident in multiple resident bedrooms requirement for 18 of 24 resident rooms (Rooms 101, 103, 104, 105, 106, 107, 108, 109, 110, 111, 112, 114, 115, 116, 117, 118, 119 and 122) in the facility. This failure had the potential to affect residents' privacy and result in the residents not having adequate space for nursing care and emergency services.
Fire safety inspections
11 fire safety citations on file: 7 on February 13, 2026, 2 on December 20, 2024, 2 on December 22, 2023.
Every fire safety citation11 citations
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · February 13, 2026 · Corrected (the home has a date of correction)
- F
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · February 13, 2026 · Corrected (the home has a date of correction)
- E
Properly select, install, inspect, or maintain portable fire extinguishes.
K 355 · February 13, 2026 · 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 · February 13, 2026 · Corrected (the home has a date of correction)
- D
Have properly installed electrical wiring and gas equipment.
K 511 · February 13, 2026 · Corrected (the home has a date of correction)
- D
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
K 914 · February 13, 2026 · Corrected (the home has a date of correction)
- C
Establish procedures for tracking staff and patients during an emergency.
E 18 · February 13, 2026 · Corrected (the home has a date of correction)
- D
Provide properly protected cooking facilities.
K 324 · December 20, 2024 · Corrected (the home has a date of correction)
- D
Ensure proper usage of power strips and extension cords.
K 920 · December 20, 2024 · Corrected (the home has a date of correction)
- E
Implement emergency and standby power systems.
E 41 · December 22, 2023 · Corrected (the home has a date of correction)
- E
Ensure proper usage of power strips and extension cords.
K 920 · December 22, 2023 · Corrected (the home has a date of correction)