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 32 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
3J
0K
0L
Actual harm
1G
0H
0I
Potential for more than minimal harm
18D
7E
0F
Potential for minimal harm
0A
0B
3C
July 21, 2026Complaint inspection · 1 citation
- D
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Inspectors wroteBased on interviews and record review the facility failed to immediately inform the resident; consult with the resident's physician; and notify, consistent with his or her authority, the resident representative(s) when there is a significant change in the resident's physical status for one (Resident #1) of seven residents reviewed for resident rights. The facility failed to ensure LVN A notified the resident's responsible party/medical power of attorney within a reasonable time when Resident # 1's x-ray's result revealed she had bronchitis ( an inflammation of the tubes that carry air to the lungs). This failure could place residents at risk of not having their responsible party/medical power of attorney notified of changes, which could result in a delay in timely intervention and a decline in condition.
July 9, 2026Standard inspection · 5 citations
- E
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, functional, sanitary, and comfortable environment for resident rooms for 8 of 16 (Rooms #56, 61, 62, 63, 65, 29, 48 and 76) rooms reviewed for environmental concerns. Resident rooms #56, 61, 62, 63, and 65 had damaged window blinds. Resident rooms #48 and 76 had floors with dried glue embedded in the floor tile. Resident room [ROOM NUMBER] had ceiling damage over the resident bed. Resident room [ROOM NUMBER] had damaged window trim with a gap between the windowpane and wall. This failure could place residents at risk for diminished quality of life due to the lack of a well-kept environment.
- 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 a person-centered care plan for each resident, consistent with the resident rights that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs and described the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 4 of 21 (Resident #4, Resident #12, Resident #14, and Resident #67) residents reviewed for comprehensive person-centered care plans. The facility failed to develop a comprehensive care plan that included the code status for Resident #67. The facility failed to develop a comprehensive care plan that included the discharge goals for Resident #4, Resident #12, Resident #14, and Resident #67. [...]
- D
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Inspectors wroteBased on observation, interview and record review, the facility failed to ensure medications were secured on 1 of 6 (Station 2 Medication cart) medication carts reviewed for medication storage The facility failed to ensure the Station 2 medication cart was secured and locked. This failure could place the residents at risk for drug diversion.
- C
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 maintain all essential equipment in safe operating condition, for 1 of 1 handwash sink in the kitchen reviewed for food service in that: The facility failed to have a kitchen handwash sink operational with hot water. This failure could place residents at risk of foodborne illnesses.
- C
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 store, prepare, distribute, and serve food in accordance with professional standards for food service safety in one of one kitchen reviewed for food and nutrition services. 1. The facility failed to ensure the kitchen floor in the food preparation area was not soiled with food particles imbedded in the tile grout. This failure could place residents at risk for foodborne illness and a decline in health status.
June 2, 2026Complaint inspection · 3 citations
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on interview, record review, and observation the facility failed to follow and implement care plan interventions for 1 out of 1 resident (Resident # 1) for assistance with ADLs. The facility failed to provide extensive assist with 1 support person during meals for Resident #1's therapeutic puree diet as per Care Plan interventions due to Resident # 1 visual impairment. This failure places ADL dependent residents with the need of feeding assistance at risk of choking, aspiration and safety due to not following or implementing care plan intervention in place. [...]
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on record review, observation, and interview, the facility failed to ensure each resident receives adequate supervision and assistance devices to prevent accidents for 2 out 5 residents reviewed for quality of care (Resident # 1 and Resident # 2)The facility failed to have staff interventions in place for supervision for Resident #1 and Resident #2 resulting in physical aggression. This failure could place residents at risk of physical harm, and a decrease in safety due to the lack of staff supervision.
- 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 interviews, record review, and observation, the facility failed to ensure a safe, functional, sanitary environment for residents for 1 of 2 residents (Resident # 2) quality of care. The facility failed to maintain toilet in Resident # 2 bathroom was securely bolted for useThis failure can cause risks to residents health and safety by transfer assistance or independent use of toilet in resident's private bathroomFindings included:Record review of Resident # 2's admission record revealed a [AGE] year-old male, admitted [DATE] and readmitted [DATE], with diagnoses of Cerebral Infarction due to Thrombosis of Unspecified Cerebral Artery (a type of ischemic stroke. [...]
April 20, 2026Complaint inspection · 3 citations
- E
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Inspectors wroteBased on observation, interview, and record review, the facility failed to promote and facilitate resident self-determination through support of resident choice to including but not limited to the residents right to make choices about aspects of his or her life in the facility that are significant to the resident, healthcare and providers of healthcare services consistent with his or her interest, assessments, and plan of care and other applicable provisions of this part for 3 of 9 residents (Residents #1, #2 and #3) reviewed for resident rights. The facility failed to support Resident #3 choice to use Medical Transportation B for transportation to and from medical appointments. The facility failed to support Residents #1 and #2's choice to use Medical Transportation B for transportation to and from medical appointments when their family members requested it. [...]
- D
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Inspectors wroteBased on record review and interview, the facility failed to provide written notice as soon as practicable before transfer or discharge to resident and resident's representative and the reason for the move in writing and in a language and manner they understand and send a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman 1 of 2 resident (CR #10) reviewed for transfer and discharge rights.-The facility failed to provide a written notice of transfer to CR #10, CR #10's representative and the long-term care ombudsman as soon as practicable when CR #10 was transferred to another nursing facility on 3/5/26. This failure placed residents at risk of not receiving an advocate who can inform them of their options, rights, and the added protection from being inappropriately transferred or discharged .
- D
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Inspectors wroteBased on observation, interview, and record review, the facility failed to have sufficient nursing staff to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being, as determined by resident assessments and individual plans of care and considering the number, acuity and diagnoses of the facility's resident population for 1 of 3 nursing stations (Station 3) reviewed for sufficient staff. The facility failed to have sufficient staff to ensure staff were always present in the locked memory care unit that housed 14 residents with dementia. This failure could place residents at risk of decreased supervision, accidents, abuse and injuries.
March 15, 2026Complaint inspection · 2 citations
- J
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Inspectors wroteBased on observation, interview and record review the facility failed to ensure residents had the right to be free from abuse, neglect, misappropriation of resident property and exploitation for 2 of 8 residents (Resident #1 and #2) reviewed for abuse and neglect, in that; Resident #2 made repeated hateful remarks toward Resident #1 and struck Resident #1 with her wheelchair. Following the incident of being struck by Resident #2's wheelchair, Resident #1 reported increased right shoulder pain lasting approximately one week, exhibited tearfulness and avoidance behaviors, and remained in her room due to fear of encountering Resident #2. Resident #2 continued to be present in common areas for approximately three weeks after Resident #1 expressed fear and concern. An Immediate Jeopardy (IJ) situation was identified on 3/14/2026. [...]
- J
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Inspectors wroteBased on observation, interview and record review the facility failed to develop and implement written policies and procedures that to prohibited and prevented abuse, neglect, and exploitation of residents and misappropriation of resident property for 2 of 8 residents (Resident #1 and #2) reviewed for implementation of the abuse policy. The facility failed to implement its abuse policy by not investigating or reporting allegations of verbal and physical abuse to the facility's Abuse Coordinator after Resident #1 and her RP reported concerns of abuse by Resident #2 to LVN A and CNA A on the weekend of 2/21/2026. The facility failed to assess Resident #1 following the allegation of abuse in accordance with its abuse/neglect policy. Resident #1 subsequently reported shoulder/arm pain and exhibited signs of psychological distress related to the alleged abuse. [...]
November 18, 2025Complaint inspection · 9 citations
- E
Reasonably accommodate the needs and preferences of each resident.
Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for five (Resident #3, Resident #4, Resident #5, Resident #13, and Resident #14) of twenty-one residents reviewed for reasonable accommodation of needs. The facility failed to ensure the call light system in Resident #3, Resident #4, Resident #5, Resident #13 and Resident #14's rooms was in a position that was accessible to the resident on 11/17/2025. This failure could place the residents at risk of being unable to obtain assistance when needed and help in the event of an emergency.
- E
Provide and implement an infection prevention and control program.
Inspectors wroteBased 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 four (Resident #5, Resident #8, Resident #12, and Resident #13) of fifteen residents reviewed for infection control. 1. The facility failed to ensure CNA F and CNA G performed hand hygiene and changed their gloves during Resident #5's incontinent care on 11/17/2025.2. The facility failed to ensure LVN C wore a gown while administering Resident #8's medication via g-tube, who had an order for enhanced barrier protection, on 11/17/2025. 3. The facility failed to ensure CNA I performed hand hygiene during Resident #12's incontinent care on 11/17/2025.4. [...]
- 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 that the call light system was adequately equipped to allow residents to call for staff assistance through a communication system which relays the call directly to a staff member or to a centralized staff work area from toilet and bathing facilities for fourteen (Resident #4, #12, #15 #16, #17, #18, #19, #20, #21, #22, #23, #24, #25, and #26) of twenty-six residents reviewed for resident call system. 1. The facility failed to ensure the call light system in Resident #4's restroom was functioning on 11/17/2025. 2. The facility failed to ensure the call light system in Resident #15 and Resident #16's restroom was functioning on 11/17/2025. 3. The facility failed to ensure the call light system in Resident #17 and Resident #18's restroom was functioning on 11/17/2025. 4. [...]
- D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteBased on observations, interviews, and record review, the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promoted maintenance or enhancement of his or her quality of life for two (Resident #1 and Resident #2) of fifteen residents reviewed for dignity. 1. The facility failed to ensure CNA H did not stand while assisting Resident #1 with lunch on 11/17/2025. 2. The facility failed to provide a privacy bag for Resident #2s catheter bag (collects urine from the urinary bladder) on 11/17/2025. These failures could place the residents at risk of not having their right to a dignified existence maintained.
- D
Keep residents' personal and medical records private and confidential.
Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure the residents' right to personal privacy and confidentiality of his or her personal and medical records for two (Resident #6 and Resident #7) of residents reviewed for privacy and confidentiality. 1. The facility failed to ensure MA D did not leave Resident #6's medical information at the side of the medication cart unattended on 11/17/2025. 2. The facility failed to ensure MA E did not leave Resident #7's medical information on top of the medication cart unattended on 11/17/2025.
- 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, interviews and record reviews, the facility failed to provide a safe, sanitary, and homelike environment including but not limited to treatment and support for daily living safely when one of one sit-to-stand transfer chair was reviewed for environment. The facility failed to ensure the sit-to-stand transfer chair was thoroughly cleaned and sanitized. This deficient practice could place residents at risk of living in an unclean and unsanitary environment which could lead to a decreased 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 provide appropriate treatment and services to prevent complications of enteral feeding (delivery of food through feeding tube) for one (Resident #8) of one resident reviewed for feeding tube. The facility failed to ensure LVN C checked Resident #8's gastric residual (volume of liquid and food remaining in the stomach) before administering medications via g-tube on 11/17/2025. This failure could place residents with g-tubes at risk for aspiration.
- 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 a resident who needed respiratory care, including tracheostomy care and tracheal suctioning, was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for two (Resident #9 and Resident #10) of ten residents reviewed for respiratory care. 1. The facility failed to ensure Resident #9 's nasal cannula (flexible tube used to deliver oxygen to the nose through two prongs) was stored properly when not in use on 11/17/2025. 2. The facility failed to ensure Resident #10's breathing mask was stored properly when not in use on 11/17/2025. These failures could place residents at risk for respiratory infection and not having their respiratory needs met.
- D
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure the medications for two (Residents #6 and #11) of twelve residents were stored properly in locked compartments or provided a safe and secured storage with limited access. 1. The facility failed to ensure there were no nystatin powder (antifungal medication) and barrier ointment inside Resident #6's room on 11/17/2025. 2. The facility failed to ensure a tube of zinc oxide (cream used to treat skin irritations, diaper rash, and other skin conditions) was not left inside Resident #11's room on 11/17/2025. These failures could place the residents at risk of accidental overdose or misuse of medications.
August 30, 2025Complaint inspection · 1 citation
- E
Hire a qualified full-time social worker in a facility with more than 120 beds.
Inspectors wroteBased on interview and record review, the facility with more than 120 beds failed to employ a qualified social worker on a full-time basis, for 1 of 1 social services staff reviewed for qualifications of Social Worker. The facility failed to employ a full-time social worker from 6/25/25 to 8/30/25. This failure could place residents at risk of social service and psychosocial needs not being met.
June 27, 2025Complaint inspection · 1 citation
- G
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 residents were free from abuse for one (Resident # 1) of 6 residents reviewed for abuse. The Administrator emotionally and verbally abused Resident # 1 when she yelled at the resident and pointed her finger in Resident #1's face bringing Resident #1 to tears. The failure place residents at risk of further abuse and diminished self worth.
April 16, 2025Standard inspection, Complaint inspection · 2 citations
- 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 observations, interviews, and record review, the facility failed to ensure residents who were incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 1 of 3 resident (Resident #1) reviewed for incontinent care. -The facility failed to ensure CNA D properly cleaned Resident #1 during incontinent care. This failure could place residents at risk for urinary tract infections (UTI), skin breakdown, and a decreased quality of life.
- D
Ensure medication error rates are not 5 percent or greater.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the medication error rate was not 5 percent or greater. The facility had a medication error rate of 6% based on 2 errors for 31 opportunities. The errors effected 1 resident (Resident #8) of 4 residents reviewed for medication administration. -Two medications (Lactobacillus and D-Mannose Oral Capsule 500 mg) for Resident #8 were not dispensed or administered. The failure placed resident at risk for inadequate therapeutic outcomes and a decline in health.
February 29, 2024Standard inspection, Complaint inspection · 3 citations
- 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 a resident who was incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections for 1 of 2 residents (Resident #39) observed for urinary incontinence. The facility failed to ensure Resident #39's catheter tubing (tube inserted into the bladder for urine drainage) was over her leg and secured in place with a catheter anchor (a device attached to the leg to hold the catheter tubing in place) to prevent catheter movement. This failure placed residents with indwelling catheters at risk for increased infections, trauma, and hospitalization.
- D
Dispose of garbage and refuse properly.
Inspectors wroteBased on observation, interview, and record review, the facility failed to dispose of garbage and refuse properly for one of one waste receptacle observed for garbage disposal. The waste receptacle on the right had its top right lid opened when no one was disposing of trash. These failures could place residents at risk for exposure to germs and diseases carried by vermin and rodents.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 5 of 6 residents food trays reviewed for infection control practices, in that: 1. CNA C did not utilize appropriate hand hygiene during the food tray pass to Residents . These failures could place residents at risk of infection, transmission of communicable diseases and a decline in health.
January 26, 2024Complaint inspection · 1 citation
- C
Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.
Inspectors wroteBased on observation, interview, and record review, the facility failed to post in a place readily accessible to residents, and family members and legal representatives of residents, the results of the most recent survey of the facility for one of one facility. The facility failed to ensure the survey result from the previous recertification surveys were readily available to the residents and family. This failure could place residents, family members, and legal representatives at risk of not being informed of survey results.
December 16, 2023Complaint inspection · 1 citation
- J
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 and the residents' choices for 1 of 5 residents (CR# 1) reviewed for quality of care. The facility failed to immediately contact emergency services and transfer CR #1 to the hospital when she complained of pain to the head, and was on a prescribed anticoagulant medication, after an unwitnessed fall on 11/21/2023 at 9:25 pm. CR#1 was life flighted to the hospital after vomiting three times after the fall. An IJ was identified on 11/30/2023. The IJ template was provided to the facility on [DATE] at 1:59pm. While the IJ was removed on 12/1/2023 at 3:40pm, the facility remained out of compliance at a scope of isolated and a severity level of actual harm because the facility needs to measure the effectiveness of their plan. [...]
Fire safety inspections
22 fire safety citations on file: 10 on July 9, 2026, 6 on April 16, 2025, 6 on February 29, 2024.
Every fire safety citation22 citations
- F
Have properly installed electrical wiring and gas equipment.
K 511 · July 9, 2026 · Corrected (the home has a date of correction)
- F
Have simulated fire drills held at unexpected times.
K 712 · July 9, 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 · July 9, 2026 · Corrected (the home has a date of correction)
- E
Have properly located and lighted "Exit" signs.
K 293 · July 9, 2026 · Corrected (the home has a date of correction)
- E
Install an approved automatic sprinkler system.
K 351 · July 9, 2026 · Corrected (the home has a date of correction)
- E
Inspect, test, and maintain automatic sprinkler systems.
K 353 · July 9, 2026 · Corrected (the home has a date of correction)
- E
Install corridor and hallway doors that block smoke.
K 363 · July 9, 2026 · Corrected (the home has a date of correction)
- E
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
K 741 · July 9, 2026 · Corrected (the home has a date of correction)
- D
Ensure proper usage of power strips and extension cords.
K 920 · July 9, 2026 · Corrected (the home has a date of correction)
- C
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
K 521 · July 9, 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 · April 16, 2025 · Corrected (the home has a date of correction)
- E
Provide properly protected cooking facilities.
K 324 · April 16, 2025 · Corrected (the home has a date of correction)
- E
Properly select, install, inspect, or maintain portable fire extinguishes.
K 355 · April 16, 2025 · Corrected (the home has a date of correction)
- E
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · April 16, 2025 · Corrected (the home has a date of correction)
- E
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
K 741 · April 16, 2025 · Corrected (the home has a date of correction)
- E
Ensure precautions for handling oxygen cylinders and equipment are correctly followed.
K 929 · April 16, 2025 · Corrected (the home has a date of correction)
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · February 29, 2024 · Corrected (the home has a date of correction)
- F
Properly select, install, inspect, or maintain portable fire extinguishes.
K 355 · February 29, 2024 · Corrected (the home has a date of correction)
- E
Have properly located and lighted "Exit" signs.
K 293 · February 29, 2024 · Corrected (the home has a date of correction)
- E
Provide properly protected cooking facilities.
K 324 · February 29, 2024 · Corrected (the home has a date of correction)
- E
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · February 29, 2024 · Corrected (the home has a date of correction)
- C
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
K 521 · February 29, 2024 · Corrected (the home has a date of correction)