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 30 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
2J
2K
0L
Actual harm
1G
1H
0I
Potential for more than minimal harm
17D
6E
1F
Potential for minimal harm
0A
0B
0C
June 25, 2026Standard inspection · 4 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 observation, interview, and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident that described the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 3 of 10 (Resident #53, Resident # 74, Resident # 83) residents reviewed for care plans. -The facility failed to ensure the care plan for Resident #53 addressed the care needs of the resident with a colostomy regarding her specific stoma care and how often the site is to be changed and cleaned.-The facility failed to ensure the care plan for Resident # 74 and Resident # 83 address the care needs and refusals of the residents regarding nail care. This failure placed the residents at risk of not having their care needs met to maintain health status.
- D
Reasonably accommodate the needs and preferences of each resident.
Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure residents received services in the facility with reasonable accommodations of resident's needs and preferences except when to do so would endanger the health and safety of the resident or other residents for 1 of 5 residents (Resident #75) reviewed for resident rights. The facility failed to ensure Resident #75's call light was within reach on 06/23/26. This failure could place residents at risk of needs not being met.
- 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 observations, record reviews, and interviews, the facility failed to provide a safe, functional, sanitary and comfortable environment for residents for one(Resident #80) of 1 facility reviewed for ADL care. The facility failed to ensure Resident #80's shower chair did not have yellow-brown discoloration extending across the center of the seat surface and dark black substance near one of the seat drainage holes. The failure could place residents at risk of living in an unsafe, unsanitary, and uncomfortable environment.
- D
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to assure that menus are developed and prepared to meet resident choices including their nutritional, religious, cultural, and ethnic needs while using established national guidelines, for 1 of 3 meals observed. The facility failed to document the substitutions for the lunch menu on 06/23/26. These failures placed the residents at risk of decreased intake, dissatisfaction with their meals, and weight loss.
December 22, 2025Complaint inspection · 2 citations
- E
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 5 residents (Resident #2) reviewed for infection control practices. The facility failed to ensure Resident #2's soiled wash cloth was removed from the bedside table on 12/22/2025The facility failed to ensure Resident # 2's urinal bottle was emptied on 12/22/2025. This failure placed residents at risk of cross contamination.
- D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on observation, interview and record review the facility failed to ensure, in accordance with accepted professional standards and practices, medical records were maintained on each resident that were complete and accurately documented for 1 of 5 residents (Resident #1) for complete and accurate records. The facility failed to ensure Resident #1's nothing by mouth was documented in PCC for December 20th and December 21st on the 10:00 PM -6:00 AM shift. This failure could place residents at risk for the possibility of not verifying the needed care and services to meet their needs.
June 23, 2025Complaint inspection · 1 citation
- D
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Inspectors wroteBased on observation, interview, and record review the facility failed to submit a completed and accurate request for nursing facility specialized services in the LTC Online Portal within 20 business days from the IDT for 1 of 1 (Resident #1) resident reviewed for delinquent PASARR processes. The facility failed to ensure Resident #1 received the services recommended by the PASARR evaluation when they failed to submit a complete and accurate request for NFSS in the LTC online Portal within 20 business days from the IDT meeting. This failure caused a delay in her Medicaid Entitled Services including physical therapy and occupational therapy. This failure placed Resident #1 at risk of not achieving or maintaining her highest practicable level of physical functioning and could potentially result in increased disability.
April 17, 2025Standard inspection · 2 citations
- D
Reasonably accommodate the needs and preferences of each resident.
Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure residents received services in the facility with reasonable accommodations of resident's needs and preferences except when to do so would endanger the health and safety of the resident or other residents for 2 of 6 residents (Resident #7 and #34) reviewed for resident rights. The facility failed to ensure Resident's #7's and Resident #34's call lights were within reach on 04/15/25. This failure could place residents at risk of needs not being met.
- D
Ensure each resident receives an accurate assessment.
Inspectors wroteBased on interview and record review, the facility failed to conduct initially and periodically a comprehensive, accurate, standardized reproducible assessment of each resident's functional capacity for 1 of 6 residents (Resident #45) reviewed for comprehensive assessments. The facility failed to complete an accurate comprehensive assessment for Resident #45 due to MDS assessment reflected resident received insulin and injections. This failure could place residents at risk of not having their care and treatment needs assessed to ensure necessary care and services were provided.
July 29, 2024Complaint inspection · 4 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 interview and record review, the facility failed to ensure the residents had the right to be free from neglect for one (Resident #1) of five residents reviewed for neglect, in that: The facility failed to administer Resident #1's Levothyroxine (medication used to treat hypothyroidism) for an unknown period of time at the end of June 2024 and beginning of July 2024. This subsequently led to her TSH (Thyroid Stimulating Hormone) levels elevating to 28.62 (normal range is .450 - 5.330), resulting in a change of condition where she became fatigued, dizzy, and depressed. An Immediate Jeopardy (IJ) was identified on 07/24/24 at 4:50 PM. While the IJ was removed on 07/29/24 at 12:15 PM, the facility remained out of compliance at a severity level of no actual harm and at a scope of pattern due to the facility's need to evaluate the effectiveness of the corrective systems. [...]
- K
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Inspectors wroteBased on interview and record review, the facility failed to provide pharmaceutical services (including procedures that assured the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for one (Resident #1) of five residents reviewed for pharmacy services. The facility failed to administer Resident #1's Levothyroxine (medication used to treat hypothyroidism) for an unknown period of time at the end of June 2024 and beginning of July 2024. This subsequently led to her TSH (Thyroid Stimulating Hormone) levels elevating to 28.62 (normal range is .450 - 5.330), resulting in a change of condition where she became fatigued, dizzy, and depressed. An Immediate Jeopardy (IJ) was identified on 07/24/24 at 4:50 PM. [...]
- E
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 that a resident who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections to the extent possible for three (Resident #1, Resident #2, and Resident #3) of six residents reviewed for incontinent care. The facility failed to: 1. Change Resident #1's foley catheter after she was diagnosed with a UTI until six days later and failed to ensure the catheter bag was not continuously laying on the ground on 07/24/24. 2. Ensure Resident #2 was provided incontinent care after CNAs E and F removed her dirty brief and put on a clean one. 3. Ensure sanitary infection control practices were used when CNA G provided incontinent care to Resident #3. CNA G also failed to don PPE per EBP protocol as Resident #3 had an indwelling catheter. [...]
- E
Provide timely, quality laboratory services/tests to meet the needs of residents.
Inspectors wroteBased on observation, interview and record review, the facility failed to obtain laboratory services to meet the needs of its residents for one (Resident #2) of five residents reviewed for laboratory services. The facility failed to collect a urine specimen for a UA (urine analysis) for Resident #2 as ordered by the physician on 07/19/24 until 07/24/24 because they were out of UA specimen collection cups. Resident #2 was diagnosed with a UTI on 07/28/24 which required antibiotics for seven days. This failure could place residents with indwelling urinary catheters at risk of infection, renal failure, urinary tract infections, and pain. Findings Included: Review of Resident #2's undated face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses including type II diabetes, chronic kidney disease, age-related physical debility, and morbid obesity. [...]
July 3, 2024Complaint inspection · 2 citations
- H
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 one (Resident #1) of four residents reviewed for quality of care, in that: The facility failed: - To obtain orders for wound care after Resident #1 was found to have several round red areas to his upper bilateral buttocks on 06/30/24. On 07/03/24, one of the areas had opened, measuring 12 mm x 12 mm, causing him pain and a burning sensation for several days. [...]
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections, for one (Resident #2) of two residents observed for infection control practices. The facility failed to ensure staff (CNA E and CNA F) followed infection control practices while performing peri care on Resident #1. This failure placed residents at risk for cross contamination and the spread of infection.
May 14, 2024Complaint inspection · 1 citation
- J
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that residents who needed respiratory care received such care consistent with professional standards of practice for 2 of 6 residents (Residents #1 and Resident #2) reviewed for respiratory care. 1. The facility failed to ensure Resident #1 received weekly filter cleanings for her BiPAP machine (A BiPAP Machine is a respiratory machine used to provide positive airway pressure through a mask, worn while sleeping, to provide airway pressure during inhalation and exhalation to keep the user's throat open from collapsing.). 2. [...]
February 25, 2024Standard inspection, Complaint inspection · 12 citations
- J
Ensure that residents are free from significant medication errors.
Inspectors wroteBased on interview and record review the facility failed to ensure residents were free of significant medication errors for 1 of 6 residents (Resident #234) reviewed for medication errors. The facility failed to accurately transcribe amitriptyline 10mg by mouth at bedtime and instead transcribed amitriptyline 300mg by mouth twice daily. The facility administered 300mg of amitriptyline to Resident #234 which caused an overdose that sent the resident to the hospital with abnormal labs and cardiac arrhythmia. This failure could place residents at risk for complications and possible death. This failure resulted in an identification of an Immediate Jeopardy (IJ) On 2/21/2024 @ 5:25pm. [...]
- G
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on observation, interviews, and record review, the facility failed to ensure residents received quality care and quality treatment in accordance with professional standards of practice for 1 of 8 residents (Resident #25) reviewed for quality of care. The facility failed to apply an anti-fungal cream, per medical orders 2/14/2024 through 2/21/2024, which resulted in itching, intermittent burning, annoyance, and anger. This failure placed the residents at the facility at risk of having their needs not met.
- 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 service safety in 1 of 1 kitchen reviewed for dietary services. 1) Dietary staff failed to effectively reseal, label and date items in the walk-in refrigerator. 2) Dietary staff failed to effectively reseal, label and date items in the walk-in freezer. These failures could place residents at risk for food contamination and foodborne illness.
- E
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on observation, interviews, and record review, the facility failed to ensure residents who were unable to conduct activities of daily living received the necessary services to maintain acceptable grooming and personal hygiene for 2 of 8 residents (Resident #7 and Resident #40) reviewed for ADL Care. 1. The facility failed to provide Resident #7 with nail care, which resulted with some nails protruding past the fingertip, some nails gagged, and 8 of 10 digits had collection of dirt, stain, or debris under the nail on 02/20/2024. 2. The facility failed to provide Resident #40 with nail care, which resulted with nails protruding past the fingertip for all 10 digits. Resident's toenails on her left foot extended .5 an inch on two toes, which had begun to split and curl on 02/20/2024. [...]
- 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 they were adequately equipped to allow residents to call for staff assistance through a communication system which relayed the call directly to a staff member or to a centralized staff work area from each residents bedside and the toilet and bathing facilities for 3 of 8 residents (Resident #41, Resident #10 and Resident #51) reviewed for environment. 1. The facility failed to ensure Resident # 41's call light pull string, in the bathroom, was from free from entanglements and extended to its intended length and was reachable from lying on the floor. 2. The facility failed to ensure Resident # 10's call light pull string, in the bathroom, was from free from entanglements and extended to its intended length and was reachable from lying on the floor. 3. [...]
- D
Ensure each resident receives an accurate assessment.
Inspectors wroteBased on interviews, observations, and record review the facility failed to complete an assessment that accurately reflected the resident's status for 1 of 6 residents (Resident #44) whose records were reviewed for MDS accuracy, in that: The facility failed to ensure that Resident #44's admission MDS assessment dated [DATE] reflected tobacco use. These failures by the facility placed residents at risk of not receiving the care and services to meet their needs.
- D
PASARR screening for Mental disorders or Intellectual Disabilities
Inspectors wroteBased on record review, and interviews, the facility failed to ensure residents diagnosed as having a mental illness were screened and evaluated prior to admission by the local authority and receive care and services in the most integrated setting appropriate to their needs for 1 of 6 residents reviewed for PASRR screening. (Resident #18). The facility failed to correctly screen on admission [DATE]), and refer, Resident #18 who was diagnosed with mental illness to the appropriate state designated mental health or ID authority for evaluation. This failure placed residents at risk and could affect other residents with psychiatric diagnoses for not being assessed by the local authority and not receiving services to prevent declines.
- D
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Inspectors wroteBased on interviews and record reviews, the facility failed to develop and implement a baseline care plan for each resident within 48 hours of the resident's admission that included instructions for providing effective and person-centered care for the resident and met professional standards of quality care for 1 of 6 residents (Resident #228) reviewed for care plans, in that: The facility failed to develop and implement a baseline care plan within 48 hours of admission for Resident #228 . This deficient practice could place residents at risk of not having their immediate care needs met or not receiving continuity of care.
- 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 observations, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the residents' rights, which included measurable objectives and time limits to meet a resident's medical, nursing, and mental, and psychosocial needs for 2 of 6 residents (Residents #35 & #44) reviewed for care plans. Resident #35's comprehensive care plan dated 02/20/2024 did not address the resident's fentanyl patch. Resident #44's comprehensive care plan dated 01/26/24 did not address the resident's smoking. These deficient practices could place residents at risk for not receiving proper care and services due to inaccurate care plans.
- 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 who was incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 1 of 6 residents (Resident #228) reviewed for incontinent care. Facility failed to evaluate Resident #228 for removal of newly placed indwelling catheter or establish a rational for original placement to establish a need for an indwelling foley catheter upon admission. This deficient practice could place residents at risk by exposing them to care that could lead to infection, tissue breakdown, communicable diseases, and feelings of isolation related to poor hygiene.
- D
Provide medically-related social services to help each resident achieve the highest possible quality of life.
Inspectors wroteBased on observation, interview and record review the facility failed to provide medically-related social services to attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident.for 1 out of 6 residents (Resident # 234) reviewed for behaviors. The facility failed to provide appropriate behavioral health services and/or interventions to prevent or improve the depressive behaviors of Resident # 234. This deficient practice could place residents at risk for causing a delay in receiving appropriate services and a deterioration in the resident's psychosocial well-being.
- 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 based on a comprehensive assessment of a resident, residents who had not used psychotropic drugs were not given these drugs unless the medication was necessary to treat specific condition as diagnosed and documented in the clinical record for 1 of 6 residents (Resident #230) reviewed for unnecessary psychotropic medications. The facility failed to ensure Resident #230's prescribed Bupropion (an antidepressant) was administered to treat a specific diagnosis . This failure could place residents at risk for adverse consequences such as impairment or decline in an individual's mental or physical condition or functional or psychosocial status.
January 11, 2024Complaint inspection, Infection control · 2 citations
- D
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Inspectors wroteBased on interviews and record review, the facility failed to ensure resident's medical records included documentation that indicated the resident, or their RP, received education of the benefits, and potential side effects, of the influenza or pneumococcal immunization, receipt of the influenza or pneumococcal immunization, or residents did not receive the influenza or pneumococcal immunization due to medical contraindication, or refusal, for 2 of 5 residents (RES #2 and RES #4) who were reviewed for immunizations, in that:. 1. [...]
- D
Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
Inspectors wroteBased on interview and record reviews, the facility failed to implement their policy to ensure the resident's, or their RP, received education of the benefits and risks, or potential side effects of Covid-19 immunizations, receipt of Covid-19 immunizations, or the residents did not receive the Covid-19 immunizations, due to medical contraindication, or refusal, for 2 of 5 residents (RES #2 and RES #4) who were reviewed for immunizations. 1. The facility failed to document RES #2's medical records for having had received education, whether by self or with RP, of the benefits and risk, and potential side effects, of the Covid-19 immunization, receipt of the of the Covid-19 immunization, or having had not received the Covid-19 immunization due to medical contraindication or refusal. 2. [...]
Fire safety inspections
7 fire safety citations on file: 2 on June 25, 2026, 1 on April 17, 2025, 4 on February 25, 2024.
Every fire safety citation7 citations
- F
Conduct testing and exercise requirements.
E 39 · June 25, 2026 · Corrected (the home has a date of correction)
- F
Have a complete alarm system manually initiated and initiated by fire sprinkler system connection.
K 342 · June 25, 2026 · Corrected (the home has a date of correction)
- F
Install smoke barrier doors that can resist smoke for at least 20 minutes.
K 374 · April 17, 2025 · Corrected (the home has a date of correction)
- F
Install an approved automatic sprinkler system.
K 351 · February 25, 2024 · Corrected (the home has a date of correction)
- F
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
K 761 · February 25, 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 · February 25, 2024 · Corrected (the home has a date of correction)
- D
Properly install and monitor supervisory attachments on automatic sprinkler systems.
K 352 · February 25, 2024 · Corrected (the home has a date of correction)