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
5K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
15D
8E
0F
Potential for minimal harm
0A
0B
0C
July 23, 2026Complaint inspection · 1 citation
- D
Provide appropriate colostomy, urostomy, or ileostomy 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 colostomy, urostomy, or ileostomy services, received such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences for one of three residents (Resident #2) reviewed for quality of care. The facility failed to ensure adequate and consistent colostomy care was provided every 3 days. Resident #2 went 6 days without her colostomy bag being changed. This failure could place residents at risk of physical and mental health decline and could cause pain and further discomfort.
June 29, 2025Standard inspection, Complaint inspection · 7 citations
- J
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 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 and furnish services to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 2 of 11 residents (CR #1and Resident #34) reviewed for comprehensive care plans. The facility failed to care plan CR #1 for risk of elopement and document interventions prior to CR #1 eloping from the facility on 06/20/2025 around 4:45pm and did not know her whereabouts until 06/20/2025 around 8:40pm. [...]
- E
Assist a resident in gaining access to vision and hearing services.
Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that 1 (Resident #61) of 5 residents reviewed for hearing services, received proper treatment to maintain hearing capabilities. -The facility did not complete an Audiology (hearing) referral for Resident #61 who was hard of hearing until 06/27/25. -The facility failed to identify that Resident #61's hearing aids were not functioning properly when resident placed new batteries in hearing aids. This failure could place residents at risk for further decrease in communication, social engagement, and decrease in quality of life.
- E
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 properly store, label, and/or secure medications and biologicals for 1 of 4 medication carts (400 hall medication cart), in accordance with State and Federal laws, all drugs and were stored in locked compartments under proper temperature controls and permitted only authorized personnel to have access to for 1 of 14 residents reviewed for medication administration (Resident #67). The facility failed to ensure Resident #67 medication was not left unattended on [DATE], 600-hall medication cart had medication open not dated. This failure could place residents at risk to having access to unauthorized medication and/or lead to possible harm or drug diversion and receiving the appropriate medications and not reaching the intended therapeutic dose and possible exacerbation of health conditions.
- D
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Inspectors wroteBased on observation, interview, and record review, the facility failed to immediately consult with the resident's physician of a significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications) for 1 of 5 residents (Resident #34) reviewed for resident rights. -The facility failed in notifying Resident #34's physician on 06/24/25 right away when resident had a significant change in condition. Resident experienced a choking episode while eating his breakfast at 8:48AM on 06/24/25. This failure placed all residents in the facility who may experience a significant change in condition at risk for harm or injury if not reported to the physician in a timely manner. [...]
- D
Ensure medication error rates are not 5 percent or greater.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a medication error rate of less than 5 percent. There were 3 errors out of 37 opportunities, resulting in a 8 percent medication error involving for 1 of 14 residents (Resident #67) reviewed for medication errors. LVN J did not administer the full dose of carvedilol oral tablet 3.125 mg (carvedilol=medication used to help lower blood pressure and reduce the workload of the heart). Misoprostol oral tablet 100 mcg (misoprostol= medication used to protect the stomach against acid damage, and decreases the amount of acid produced by the stomach) and Famotidine oral tablet 40 mg (famotidine) (medication used to reduce the amount of acid produced in your stomach) as ordered by the Physician to Resident #67 on 6/24/25. [...]
- 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 2 (Residents #8 and #41) of 4 residents reviewed for infection control practices. -LVN A did not wipe his accu-check machine between after using it on Resident #8 and Resident #41 to check their blood glucose and did not store the accu-check machine properly to prevent infection on 06/24/2025. This failure could put residents at risk of a spread of infection and diseases due to not following infection control policies and procedures.
- J
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on observations , interview and record review the facility failed to ensure the resident environment remained as free of accident hazards as possible and that each resident received adequate supervision and assistance devices to prevent accidents for 2 out of 11 residents (CR#1 and Resident # 58) reviewed for adequate supervision and accident hazards. -CR #1 left the faciity on [DATE] around 5:45pm and the facility was not aware of CR #1's whereabouts until 06/20/2025 at 8:42pm when they received notice CR #1 was found walking on the road near the facility . This was determined to be an IJ on 6/26/25 for CR #1's elopement. The Administrator and DON were notified on 6/26/25 at 4:23pm. The DON and Administrator were provided with the IJ template on 6/26/25 at 4:27pm and a Plan of Removal was requested. [...]
June 3, 2025Complaint 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 observations, interviews and record reviews the facility failed to ensure 4 (CR#2, CR#3 R#1 and R#2) of 9 resident reviewed was free from abuse and neglect The facility failed to prevent neglect and failed to provide the required structures and processes in order to meet the needs of CR#2 when interventions were not implemented: WCD orders for changing bandages, turning, and repositioning, and getting CR#2 in the chair twice daily. As a result, CR#2 did not receive proper treatment to prevent wound deterioration and infection, which resulted in hospitalization with severe sepsis and required surgical wound debridement. An Immediate Jeopardy (IJ) was identified on 5.28.2025. The IJ template was provided to the facility on 5.28.2025 at 1:15p.m. [...]
- K
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Inspectors wroteBased on Interviews and record review the facility failed to implement the facility's abuse policy ensuring 1 (CR#3) of 9 residents was free from abuse reviewed for developing/implementing abuse policies. The facility failed to implement their abuse policy when CR #3 made an allegation of physical and verbal abuse. The allegation was not reported to the abuse coordinator or investigated and the alleged abuser had access to CR#3 after an allegation of abuse was made. An Immediate Jeopardy (IJ) was identified on 5.30.2025. The IJ template was provided to the Administrator and DON on 5.30.2025 at 1:27p.m. [...]
- K
Respond appropriately to all alleged violations.
Inspectors wroteBased on interviews and record review the facility failed to immediately investigation, report and protect 1 (CR#3) of 9 residents reviewed for abuse and neglect. The facility failed to immediately investigate, report, and protect CR#3 when he reported being stabbed in the arm with an insulin needle and scratched on the nose by LVN B. They facility failed to prevent further potential abuse when the facility failed to remove CR#3 from LVN B care after the report of abuse. An Immediate Jeopardy (IJ) was identified on 5.30.2025. The IJ template was provided to the Administrator and DON on 5.30.2025 at 1:27p.m. [...]
- K
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on interviews and record review the facility failed to ensure that 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; and a resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for 3 (CR2, R#1, R#2) of 9 residents reviewed for Treatment/Services to Prevent/Heal Pressure Ulcers in that: The facility failed to ensure CR #2's wound interventions were implemented: WCD orders for changing bandages, turning, and repositioning, and getting CR#2 in the chair twice daily. [...]
- K
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on, interviews and record review the facility failed to ensure resident environment remains as free of accident hazards as is possible; and each resident receives adequate supervision and assistance devices to prevent accidents for 1 of 9 residents (CR #1) reviewed for accidents and supervision, in that: The facility failed to ensure CR#1 was transferred properly per therapy assessments and instruction, by CNA B. CR#1, a bedbound resident, who was totally dependent on staff for care sustained an unexplained head injury and hip fracture in her room alone. The facility failed to ensure precautionary interventions in place for CR#1, who was a known fall risk. An Immediate Jeopardy (IJ) was identified on 5.22.2025. The IJ template was provided to the Administrator on 5.22.2025 at 1:07 p.m. [...]
May 16, 2024Standard inspection, Complaint inspection · 7 citations
- E
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Inspectors wroteBased on observations, interviews, and record review, 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 4 of 8 residents (Resident #68, Resident #18, Resident #25, and Resident #3) reviewed for pharmacy services. -LVN J and LVN C failed to ensure the narcotic count was correct during shift change for Resident #68, Resident #18, Resident #25, and Resident #3. - LVN J failed to document the administration of narcotic medications in a correct manner for Resident #68, Resident #18, Resident #25, and Resident #3. -Staff administered Tramadol 50 mg instead of Tramadol 37.5 mg - Acetaminophen 325 mg as ordered by the Physician to Resident #68 for an unknown period. [...]
- D
Reasonably accommodate the needs and preferences of each resident.
Inspectors wroteBased on interviews, observations, and record review, the facility failed to ensure residents were provided with a reasonable accommodation to access the ability to call for staff assistance through a communication system for one of twenty-four (Resident #79) reviewed for call system placement. -Resident #79's call light cord was wrapped around the call light base on the wall in an area inaccessible to the resident. This failure could place this resident or other residents at risk for not having their call light answered timely in an emergency and staff not being aware of an emergency situation for an extended period of time, injury, or death.
- D
PASARR screening for Mental disorders or Intellectual Disabilities
Inspectors wroteBased on interviews and record review, the facility failed to refer all residents with newly evident or possible serious mental disorders, intellectual disabilities, or a related conditions for level II resident review upon a significant change in status assessment for 1 of 18 residents (Resident #48) reviewed for PASARR evaluations. The facility failed to refer Resident #48 to the appropriate, State-designated authority when she was diagnosed with delusional disorder (firmly held false beliefs), mood disorder (psychiatric disorders that impact emotions), generalized anxiety disorder (over worry), psychosis (difficulty determining what is real or not), and bipolar disorder (mood disorder with ups and downs). This failure could place residents at risk for not receiving necessary PASARR mental health services, causing a possible decline in mental health.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 1 (Resident #35) of 18 residents reviewed for quality of care. -LVN M failed to document notification to NP B of Resident #35's blood sugar of 422 on 5/13/24, and failed to document and/or give 10u of Insulin that was ordered by NP B for Resident #35's blood sugar. This failure could place the resident at risk for high blood sugar, and possible hospitalization.
- 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 interviews and record review the facility failed to ensure a psychotropic drug that affects brain activities associated with mental processes and behavior is free from unnecessary drugs for one of five residents (Resident #79) reviewed for unnecessary drugs. -The facility failed to document a correct diagnosis, monitor its effectiveness, and side effects of Seroquel (antipsychotic medication) prescribed for Resident #79. This failure affected one resident and placed him at risk of receiving unnecessary medications.
- D
Ensure medication error rates are not 5 percent or greater.
Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure that the medication error rate was not five percent (%) or greater. The facility had a medication error rate of 11% based on 3 errors out of 27 opportunities, which involved 2 of 7 residents (Residents #2 and #59) reviewed for medication errors. -LVN N did not administer the full dose of Lacosamide (a medication used to prevent and control seizures) to Resident #59 until State Surveyor intervention. -MA V administered Sucralfate (a medication used to treat and prevent ulcers in the intestines) to Resident #2 at 9:06 a.m. instead of 6:30 a.m. as scheduled and did not administer Lexapro (a medication used to treat depression and anxiety) to Resident #2 as ordered by the Physician. These failures could place residents at risk of inadequate therapeutic outcomes.
- D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on interviews, observations, and record reviews, in accordance with accepted professional standards and practices, the facility failed to maintain medical records on each resident that were complete, accurately documented, readily accessible, and systematically organized for 2 (Resident #48 and Resident #63) of 18 residents reviewed for accurate medical records. -The facility failed to update Resident #48's oxygen order to PRN instead of continuous, when she no longer wore it. -The facility failed to order Resident #63's oxygen, when he was on it continuously. This failure could place residents at risk of receiving unnecessary oxygen or the wrong amount of oxygen.
September 7, 2023Complaint inspection, Infection control · 1 citation
- E
Provide and implement an infection prevention and control program.
Inspectors wroteBased on interview and record review the facility failed 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 residents (Resident #1) reviewed for infection control. -The facility failed to submit a completed PIR(#419917) to the SSA within 5 working days after CNA B tested positive for COVID-19 on 04/19/2023. -The facility failed to submit a completed PIR(#422526) to the SSA within 5 working days after Resident#1 tested positive for COVID-19 on 05/04/2023. -The facility failed to submit a completed PIR(#438333) to the SSA within 5 working days after CNA C tested positive for COVID-19 on 07/20/2023. [...]
March 16, 2023Standard inspection · 9 citations
- E
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on observation and interview, 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 four sharps containers (Shower rooms on Hall 200, 400,500, and 600) of 12 sharps containers observed for safe storage of sharps. The facility failed to monitor the sharps containers in the shower rooms on Halls 200, 400, 500 and 600 for fill levels and safe storage of contaminated sharps. These failures placed residents at risk of being exposed to contaminated sharps and possible bloodborne pathogens.
- E
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Inspectors wroteBased on interview and record review, the facility failed to use the service of an RN for at least eight consecutive hours a day, seven days a week in the facility for 20 of 30 days (12/04/22, 12/17/22, 12/18/22, 12/25/22, 01/21/23, 01/22/23, 01/28/23, 01/29/23, 02/04/23, 02/05/23, 02/11/23, 02/12/23, 02/18/23, 02/19/23, 02/25/23, 02/26/23, 03/04/23, 03/05/23, 03/11/23, and 03/12/23) reviewed during a look back period from 12/03/22 to 03/12/23. The facility failed to have RN coverage in the facility for eight consecutive hours on 12/04/22, 12/17/22, 12/18/22, 12/25/22, 01/21/23, 01/22/23, 01/28/23, 01/29/23, 02/04/23, 02/05/23, 02/11/23, 02/12/23, 02/18/23, 02/19/23, 02/25/23, 02/26/23, 03/04/23, 03/05/23, 03/11/23, and 03/12/23. This failure could place residents at risk for missed resident nursing assessments, interventions, care, and treatment.
- E
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Inspectors wroteBased on observations, interviews, and record reviews 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 four (Resident #63, Resident #9 and Resident #29, Resident #30) of 8 residents reviewed for medication administration and labeling and storage. 1. MA E left a cup of pills at the bedside of Resident #63 and MA M left a cup of pills at the bedside of Resident #30, failing to observe the resident take the pills. 2. The facility failed to monitor the MARs and narcotic logs for Hall 200 and Hall 500 hall for Residents #9 and #29 to ensure the narcotics were being administered. [...]
- E
Make sure that a working call system is available in each resident's bathroom and bathing area.
Inspectors wroteBased on observation and interviews the facility failed to adequately equip resident rooms 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 from each resident's bedside, toilet and bathing facilities for three (Residents # 43, #65, and #197) of 12 residents reviewed for call lights. The facility failed to provide a call light button, or an alternative, for Residents # 43, #65, and #197. These failures placed residents at risk of not receiving immediate care in the event of an emergency.
- D
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Inspectors wroteBased on interview and record review the facility failed to electronically transmit encoded, accurate, and complete MDS data to the CMS System, including a quarterly review and subset of items upon a resident's discharge for 4 (Residents #46, #84, #58, and #6) of 18 residents reviewed for MDS assessments. The facility failed to complete and transmit the discharge MDS assessment as required for Residents #46, #84, #58, and #6. This failure could place residents at risk of not having timely assessments to identify care needs.
- 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 necessary treatment and services to promote healing for 1 of 3 residents (Residents #31) reviewed for wounds. LVN G failed to follow-up with Resident #31's surgical wound dressing after being informed Resident #31's wound dressing came off. This failure could place residents at risk of severe pain, and lead to systemic infections causing harm for residents.
- 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 ensure residents fed by enteral means received the appropriate treatment and services to prevent complications of enteral feedings for three (Resident #83, Resident #81, and Resident #90) of seven residents reviewed for enteral nutrition, in that: 1. The facility failed to follow the physician orders for enteral feedings for Residents #83 and #81. 2. The facility failed to notify the physician of Resident #90's refusal for continuous feedings during the day and to obtain new orders to address the need for tube feeding at night if Resident #90 was not able to eat my mouth. This failure could affect residents receiving enteral nutrition and hydration by placing them at risk of health complications.
- D
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 in the facility's only kitchen for food service safety. Cook J failed to ensure foods were handled in a manner to prevent contamination (bare hand contact). This failure could place residents who eat from facility's only kitchen at increased risk of exposure to food-borne illnesses.
- D
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, interview, and record review, the facility failed to maintain a safe, functional, sanitary, and comfortable environment for 1 (room [ROOM NUMBER] ) of 15 rooms observed. The facility failed to maintain room [ROOM NUMBER] in a safe and sanitary condition. This failure could place residents at risk for decreased quality of life.
Fire safety inspections
4 fire safety citations on file: 1 on June 29, 2025, 2 on May 16, 2024, 1 on March 16, 2023.
Every fire safety citation4 citations
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · June 29, 2025 · Corrected (the home has a date of correction)
- F
Ensure precautions for handling oxygen cylinders and equipment are correctly followed.
K 929 · May 16, 2024 · Corrected (the home has a date of correction)
- E
Install corridor and hallway doors that block smoke.
K 363 · May 16, 2024 · Corrected (the home has a date of correction)
- E
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · March 16, 2023 · Corrected (the home has a date of correction)