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 28 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
1J
0K
0L
Actual harm
0G
1H
0I
Potential for more than minimal harm
21D
2E
2F
Potential for minimal harm
0A
0B
1C
May 20, 2026Complaint 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 interview and record review the facility failed to ensure the 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 (Resident #1) of 6 residents reviewed for accidents and hazards. The facility failed to ensure Resident #1 did not have access to a double-sided razor blade. Resident #1 used the razor blade to cut his left wrist, resulting in a 7 cm laceration on the inside of Resident #1's left wrist which required 23-26 stitches on the night of [DATE]. The noncompliance was identified as PNC. The IJ began on [DATE] and ended on [DATE]. The facility had corrected the noncompliance before the investigator entered the facility. This failure could place residents at risk of harm or death. [...]
- D
Ensure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge.
Inspectors wroteBased on interviews and record reviews the facility failed to establish and follow a written policy on permitting residents to return to the facility after they are hospitalized or placed on therapeutic leave for 1 (Resident #1) of 5 residents reviewed for transfer/discharge rights. The facility failed to allow Resident #1 to return to the facility after he was admitted to a short-term psychiatric hospital following an apparent suicide attempt. This failure could place residents at risk of feelings of instability/insecurity. [...]
March 26, 2026Standard inspection · 9 citations
- 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 ensure all residents had a right to a dignified existence for 1 of 24 residents (Resident #56) observed for dining room experience when the facility failed to: Ensure Resident #56 was treated with respect, dignity and consideration when she failed to receive her noon meal at the same time as her table mates. This failure could place residents at risk of feeling neglected or ignored and could negatively impact residents' quality of life.
- 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 and clean environment for 1 (Resident #59) of 17 residents reviewed for environment. -Resident #59 had soiled washcloths left in her room for 29 hours. This failure could place residents at risk for diminished quality of life due to the lack of a well-kept environment.
- D
Ensure each resident receives an accurate assessment.
Inspectors wroteBased on interview and record review the facility failed to ensure the assessment accurately reflected the resident's status for 2 (Resident #18 and Resident #71) of 18 residents reviewed for accuracy of assessment. The facility inaccurately coded Resident #18 as having a bipolar diagnosis when he did not have a bipolar diagnosis. This failure could place residents at risk of receiving unnecessary care/medication or not receiving necessary care/medication. [...]
- D
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 refer to the state designated authority all residents with newly evident or possible serious mental disorder, intellectual disability, or a related condition for level II resident review upon a significant change in status assessment for 1 (Resident #9) of 18 residents reviewed for PASRR.The facility failed to refer Resident #9 to the state designated authority for a PASRR Evaluation due to his diagnosis of Major Depressive Disorder Recurrent Severe. This failure could place residents at risk of not receiving necessary services or of being harmed by residents who have not been screened properly for placement in a nursing home setting. [...]
- D
PASARR screening for Mental disorders or Intellectual Disabilities
Inspectors wroteBased on interview and record review the facility failed to perform a preadmission screening for individuals with a mental disorder and individuals with intellectual disability for 1 (Resident #18) of 18 residents reviewed for preadmission screening. The facility failed to ensure an accurate PL1 for Resident #18 prior to her admission on [DATE]. She was coded as not having mental illness when she did have mental illness. This failure could place residents at risk of not receiving needed services. [...]
- D
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 required respiratory care were provided such care consistent with professional standards of practice for 1 (Resident #5) of 18 residents reviewed for respiratory care. Resident #5 did not have physician orders for oxygen therapy. This failure had the potential to affect residents by placing them at risk for respiratory compromise and associated complications, including shortness of breath, confusion, respiratory failure, infection, and exacerbation of their condition.
- D
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Inspectors wroteBased on observation, interview, and record review, the facility failed to prepare, and serve foods using methods to ensure palatability and flavor for 1 of 4 residents with a pureed diet (Resident #56) when they failed to: A. Ensure facility staff prepared pureed foods for meal service using standardized recipes, and nutritive methods to ensure palatability, flavor and meal satisfaction. These failures placed Reside1 of 4 residents who ate food that was pureed and served by the kitchen at risk of meal dissatisfaction and potential weight loss.
- 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, and serve food under sanitary conditions in 1of 1 kitchen when they failed to: Ensure facility staff wore hair restraints and beard guards while in the kitchen. These failures placed all residents who ate food served by the kitchen at risk of cross contamination and food-borne illness.
- 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 1 (Resident #65) of 17 residents observed for infection control. -Resident #65's oxygen nasal cannula was left on the floor for 23 hours. This deficient practice has the potential to affect residents by exposing them to the spread of infections, tissue breakdown, and feelings of isolation related to poor hygiene.
May 22, 2025Complaint inspection · 1 citation
- 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 establish a system of record of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation and determine that drug records were in order and that an account of all controlled drugs were maintained periodically reconciled for 1 of 18 residents (Resident #1) reviewed for pharmacy services. The facility failed to ensure Resident #1's OxyContin Oral Tablet ER 12-hour abuse-deterrent 10mg-28 count was accounted for at the time of receiving from the facility's Pharmacy on 05/02/2025. This failure could place residents at risk of not receiving medication therapy that would be effective for their treatment, resulting in the exacerbation of conditions and disease processes.
February 27, 2025Complaint inspection · 1 citation
- D
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 to include the accurate dispensing and administering of drugs to meet the needs for 1 of 7 residents (Resident #1) reviewed for physician orders. The facility failed to accurately enter physician orders for Lamotrigine (a medication that is used to treat epilepsy and bipolar disorder) for Resident #1. The deficient practice could affect residents in the facility resulting in not receiving needed care to maintain optimum health and placing them at risk for injury and/or deterioration in their condition.
January 15, 2025Standard inspection · 4 citations
- 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, and serve food under sanitary conditions in 1of 1 kitchens when they failed to: A. Ensure stored food was properly labeled and dated. B. Ensure hairnets were worn. C. Ensure frozen foods were properly stored according to the label. These failures could place residents who ate food served by the kitchen at risk of cross contamination and food-borne illness.
- 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, it was determined the facility failed to ensure drugs and biologicals were stored in locked compartments and labeled in accordance with currently accepted professional principles and include the appropriate accessory and cautionary instructions, and the expiration date when applicable on 3 of 3 medication carts and 1 of 2 medication rooms reviewed for medication storage. -LVN F left medications for Resident #4 unattended on top of her medication cart. -2C South medication cart contained 2 insulins for Resident #68 that were expired. Lantus and Humalog insulin both had open dates of 12/10/2024. -2C South Medication room refrigerator contained Acetaminophen 650mg suppositories for Resident #71 with an expiration date of 10/2024. -1C North Medication cart contained 1 loose pill identified as Benzonatate 100mg for Resident #45. [...]
- D
Provide care or services that was trauma informed and/or culturally competent.
Inspectors wroteBased on interviews and record review, the facility failed to ensure residents who were trauma survivors receive culturally competent, trauma-informed care in accordance with professional standards of practice and accounting for residents' experiences and preferences in order to eliminate or mitigate triggers that may cause re-traumatization of the resident for 1 of 18 residents (Resident #18) reviewed for trauma-informed care. The facility did not ensure Resident #18 had a trauma screening that identified possible triggers when Resident #18 had a history of trauma. These failures could put residents at an increased risk for severe psychological distress due to re-traumatization.
- 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 to help prevent the development and transmission of communication diseases and infections for 2 (Resident #11, and Resident #27) of 18 Residents in that: 1. The facility failed to ensure Resident #27's catheter bag and tubing were kept off the floor and below the level of his waist. 2. The facility failed to ensure CNA G performed hand hygiene and a glove change during incontinent care of Resident #11. 3. The facility failed to ensure CNA C performed hand hygiene and glove changes while performing catheter care for Resident #27 as well as cross contaminating Resident #27's belongings. [...]
February 6, 2024Complaint inspection · 1 citation
- 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 for food service safety in 1 of 1 kitchen observed. The facility failed to ensure that all staff were wearing proper protective hair restraints in the kitchen. This failure placed residents who ate food served by the kitchen at risk of food contamination caused by fallen hair.
November 20, 2023Standard inspection, Complaint inspection · 10 citations
- H
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on observation, interview and record review the facility failed to ensure a resident with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection, and prevent new ulcers from developing for 1 of 18 residents (Resident # 4) reviewed for pressure ulcers. The facility failed to prevent the development of one facility-acquired Stage III pressure injury for Resident #4. This failure could place residents at risk for worsening of an ulcer, infection, and a decreased quality of life.
- 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 the professional standards for food service safety for 1 of 1 kitchen reviewed for kitchen sanitation. 1. The facility failed to ensure foods were properly stored, labeled, and dated. 2. The facility failed to ensure general cleanliness was maintained in the kitchen. 3. The facility failed to ensure beard covers were worn. These failures could place residents who ate food served by the kitchen at risk of food-borne illness.
- 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 ensure drugs and biologicals were stored and labeled in accordance with currently accepted professional principles to include the appropriate accessory and cautionary instructions, and the expiration date when applicable on 2 of 3 medication carts (1BEast and 1BWest medication carts) and 1 of 3 (1BEast/1BWest Medication room) medication rooms in that: 1. 3 loose pills were found in the 1BEast medication cart. 2. 16 loose pills were found in the 1BWest medication cart. 3. Refrigerator in medication room, shared by 1BWest and 1Beast, had a temperature at 29 degrees. 4. 5 Medications discovered in E-kit for 1BEast and 1BWest were expired. These failures could result in residents not receiving an accurate dose of medication as well as not being maintained at their best therapeutic level.
- 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 ensure each resident has a right to a dignified existence and to treat each resident with respect and dignity for 1 (Resident #180) of 18 residents reviewed for resident's rights. The facility failed to keep Resident #180's catheter bag covered in a privacy bag. This failure could lead to residents at risk of experiencing feelings of shame and/or embarrassment as well as having their right to privacy violated.
- 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 observation, interview and record review, the facility failed to ensure all residents had the right to formulate an advanced directive for 1 (Resident #36) of 18 residents reviewed for advanced directives in that: Resident #36's DNR was signed on [DATE]. The chart header stated that resident was a Full Code. This failure could place residents at risk for not receiving healthcare as per their or their legal representatives wishes.
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteThe facility failed to ensure that all alleged violations including abuse, neglect, exploitation or mistreatment, which included 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 for 1 of 8 residents (Resident #31) reviewed for abuse and neglect. The facility failed to report an unwitnessed fall with injury for Resident #31. This failure could place residents at risk for physical and psychological harm, worsening injuries, and delay of care.
- 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 observation, interview, and record review the facility failed to develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care for 1 (Resident #52) of 18 residents reviewed for baseline care plans in that: Resident #52 was admitted to the facility with a gastrostomy tube (a medical device used to provide nutrition to people who cannot obtain nutrition by mouth, are unable to swallow safely, or need nutritional supplementation) and her baseline care plan did not mention the tube. This failure could place residents in danger of not receiving necessary care. Findings Included: [...]
- 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 maintain complete, accurate, readily accessible, and systemically organized medical records for 2 (Resident #36 and Resident #180) of 18 residents reviewed for medical records. 1. Resident #180 was admitted to the facility with a catheter and no physician's orders for catheter care. 2. Resident #36 was receiving antipsychotic injections bi-weekly outside of the facility and there was no documentation of said in his EHR. These failures could place residents at risk of not receiving appropriate care through inadequate documentation possibly resulting in deterioration in condition, exacerbation of disease process, overmedication, and increased risk of harm or injury.
- 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 programs 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 #180) of 18 residents reviewed for infection control in that: Resident #180's catheter bag and tubing were allowed to rest on the floor of his room. This failure could place residents at risk of infection.
- C
Post nurse staffing information every day.
Inspectors wroteBased on observation, interview, and record review the facility failed to post the following information on a daily basis: facility name, the current date, the total number and the actual hours worked by the following categories of licensed and unlicensed nursing staff directly responsible for resident care per shift--registered nurses, licensed practical nurses, or licensed vocational nurses (as defined under state law), certified nurse aides-and resident census for one of one facility reviewed for posted nurse staffing information. The facility failed to post nurse staffing data as required in that it did not include the current date on posting, posting was dated 11/06/2023. This failure could place residents and visitors at risk of not being informed regarding the current day's nurse staffing levels.
Fire safety inspections
10 fire safety citations on file: 5 on March 26, 2026, 2 on January 15, 2025, 3 on November 20, 2023.
Every fire safety citation10 citations
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · March 26, 2026 · Corrected (the home has a date of correction)
- E
Install an approved automatic sprinkler system.
K 351 · March 26, 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 · March 26, 2026 · Corrected (the home has a date of correction)
- D
Have properly installed electrical wiring and gas equipment.
K 511 · March 26, 2026 · Corrected (the home has a date of correction)
- D
Ensure precautions for handling oxygen cylinders and equipment are correctly followed.
K 929 · March 26, 2026 · Corrected (the home has a date of correction)
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · January 15, 2025 · Corrected (the home has a date of correction)
- E
Have elevators that firefighters can control in the event of a fire.
K 531 · January 15, 2025 · Corrected (the home has a date of correction)
- F
Install an approved automatic sprinkler system.
K 351 · November 20, 2023 · Corrected (the home has a date of correction)
- E
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 · November 20, 2023 · Corrected (the home has a date of correction)
- D
Provide properly protected cooking facilities.
K 324 · November 20, 2023 · Corrected (the home has a date of correction)