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
2J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
14D
9E
1F
Potential for minimal harm
0A
1B
1C
March 26, 2026Standard 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 observation, interview 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 3 of 9 residents (Resident #1, # 86 and #95) reviewed for pharmaceutical services. The facility failed to ensure Resident # 95 received Levothyroxine daily as prescribed by the physician. The facility failed to administer the correct dose of Metoprolol (an antihypertensive medication) as physician ordered to Resident #1 on 03/25/26. The facility failed to administer Clonidine (an antihypertensive medication) as physician ordered when Resident #86's systolic blood pressures were greater than 150 on 03/01/26, 03/02/26, 03/03/26, 03/04/26, 03/07/26, 03/17/26, 03/16/26, 03/17/26 and 03/20/26. [...]
- 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 observations, interviews and record review, the facility failed to ensure all drugs and biologicals were stored securely for one of nine residents (Resident #86) and one of three medication carts (200 Hall nurse medication cart) reviewed for medication storage. The facility failed to keep resident medications stored securely. Two large white oblong tablets were found in Resident #86's possession with no nursing staff present. The facility failed to lock the 200 Hall nurse medication cart and secure an IV medication that was left on top of the cart prior to walking away. These failures could affect residents receiving medications placing them at risk of receiving the wrong medication, adverse side effects and drug diversion.
- D
Ensure that residents are fully informed and understand their health status, care and treatments.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure each resident was fully informed in a language that he or she could understand of his or her total health status, including but not limited to, his or her medical condition for 2 (Resident #86 and #75) of 8 residents reviewed for resident rights. The facility failed to communicate effectively with Resident #86 whose primary language was Spanish, and Resident #75 whose primary language was Vietnamese. This failure could place residents who communicate in a foreign language at risk of unmet needs.
- D
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Inspectors wroteBased on interview and record review the facility failed to develop and implement a comprehensive 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 that were identified in the comprehensive assessment for 1 of 8 (Resident #9) residents reviewed for comprehensive assessments. The facility failed to ensure Resident #9's care plan addressed the resident's history of UTI (urinary tract infection) and interventions for UTI.These failures could place residents at risk of not having their individually assessed needs determined, monitored and met.
- 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 who were fed by enteral means received the appropriate treatment and services to prevent complications of enteral feeding for one (Resident #1) of 2 residents reviewed for enteral nutrition. LVN B failed to check for Gtube (gastrostomy tube) placement prior to administration of medications as per Physician orders and facility policy. This failure could place residents who receive medications or feedings via Gtube at risk of aspiration, pain and hospitalization.
- D
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
Inspectors wroteBased on observation, interview and record review, the facility failed to ensure bed rails were maintained and checked regularly to make sure they are installed correctly as rails may shift or loosen over time for 1 (Resident #14) of 10 residents reviewed for bed rails. The facility failed to ensure that Resident #14's bedrails were not loose. This failure could place residents at risk of injuries, entrapment or death.
- 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, interviews, and record review the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety reviewed for 1 of 5 (Dietary Manager) kitchen staff members. The facility failed to ensure food service staff wore appropriate hair nets while in the kitchen and food was being prepared. This failure had the potential to contaminate food and affect residents' health and safety.
November 24, 2025Complaint inspection · 5 citations
- E
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on observation, interviews and record review the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source were reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures for 1 of 1 facility and 2 of 10 staff (MA A and LVN A ) reviewed for misappropriation. [...]
- E
Respond appropriately to all alleged violations.
Inspectors wroteBased on observation, interview and record review the facility failed to ensure that all alleged violations involving abuse, neglect and injury of unknown origin, are thoroughly investigated and results reported of all investigations to the State Survey Agency, within 5 working days of the incident for 1 of 1 facility reviewed for misappropriation. [...]
- 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 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 and ensure it had a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable accurate reconciliation and that drug records were in order and an account of all controlled drugs was maintained and periodically reconciled for 1 of 10 staff (LVN A) for pharmacy services. - LVN A failed to maintain an accurate inventory of controlled substances when she failed to log into 80 controlled substances into the automated dispensing system on [DATE] which resulted in drug diversion. This failure could result in accurate controlled substance counts and drug diversion.
- 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 in accordance with State and Federal laws, all drugs and biologicals were stored in locked compartments under proper temperature controls and permitted only authorized personnel to have access to the keys for 1 of 10 staff (LVN A) reviewed for medication storage . - LVN A failed to ensure that controlled substances were stored behind a double lock when she left them unattended at the nursing station on [DATE] which resulted in 80 tabs of controlled medication stolen from the facility. This failure could place residents at risk of misappropriation of medications, adverse reactions to medications, overdose and hospitalization.
- C
Post nurse staffing information every day.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that the daily staffing was posted and readily accessible for review for 1 of 1 facility reviewed for required postings. - The facility failed to update the facility nursing postings on 10/14/25 and 10/21/25. This failure could affect residents, facility visitors, vendors, and emergency personnel by placing them at risk of not having access to information regarding daily nursing staffing in a timely manner. Findings Include: Observations on Tuesday, 10/14/25, at 08:21 AM and 10:14 AM revealed, the facility Direct Care Report posting on the top of the nursing station facing the front door that read Monday [DATE]. [...]
June 9, 2025Complaint inspection · 3 citations
- J
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 interview and record review, the facility failed to consult with the resident's physician when there was 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 4 residents (CR #1) when reviewed for quality of care. 1. The facility failed to notify CR#1's physician at 7 am when he had blurry vision, increased heart rate, shortness of breath, and his O2 levels dropped below baseline. 2. The first attempt at contact was made by text at 8:17 am but the NP did not respond until 9:30 am. CR#1 was transported to the hospital at 10am on 06/02/25, 3 hours after chief complaints of shortness of breath and unsuccessful interventions. An IJ was identified on 06/05/25. [...]
- 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 based on the comprehensive assessment of a resident, that resident received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices for 2 of 4 residents (CR #1, CR#2) reviewed for quality of care. 1. The facility failed to notify CR#1's physician at 7 am when he had blurry vision, increased heart rate, shortness of breath, and his O2 levels dropped below baseline. 2. The first attempt at contact was made by text at 8:17 am but the NP did not respond until 9:30 am. CR#1 was transported to the hospital at 10am on 06/02/25, 3 hours after chief complaints of shortness of breath and unsuccessful interventions. 3. The facility failed to notify the Doctor when CR#2 began to have open wounds to her lower legs, identified on 09/24/24. [...]
- E
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety for 40 of 106 residents reviewed for kitchen safety. 1. Dietary staff failed to ensure all perishable items were fresh before serving to residents. 2. During the lunch service on 06/09/25, Resident #1 took a sip of chocolate milk that had an expiration date of 05/19/25. This failure could place residents at risk of contracting a food borne illness.
December 12, 2024Standard inspection, Complaint inspection · 3 citations
- E
Ensure medication error rates are not 5 percent or greater.
Inspectors wroteBased on observation, interview, 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 6.9 % based on 2 errors out of 29 opportunities, which involved 2 of 8 residents (Resident #15 and Resident #96) reviewed for medication errors in that:. - LVN L failed to administered medication as ordered to Resident #96 by administering Multivitamins w/ Minerals instead of plain Multivitamins as ordered. - LVN M failed to administer medications as ordered to Resident #15 by administering eye drops with Tetrahydrozoline Hydrochloride 0.05% instead of eye drops with Carboxymethylcellulose Sodium as ordered. These failures could place residents receiving medication at risk of inadequate therapeutic outcomes. [...]
- D
PASARR screening for Mental disorders or Intellectual Disabilities
Inspectors wroteBased on interview and record review, the facility failed to ensure all Pre admission Screening and Resident Review (PASRR) Level I residents with mental illness were provided with a PASRR Level II assessment for 1 of 2 residents reviewed for a mental illness, intellectual disability or developmental disability. (Resident #64) Resident #64 was admitted to the facility with a pre-admission screening reflecting no indicators of a mental illness when the resident had a diagnosis of Bipolar Disorder. This failure could place residents with mental illness, intellectual disability or developmental disability at risk for not receiving needed care and services to meet their needs or decreased quality of life.
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure 1 of 2 residents (Resident #96) reviewed for pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing, in that: Resident #96 was observed to not be repositioned off of sacral wound for a span of 4 hours. This failure could place residents at risk for skin breakdown or failure for ulcers to heal.
November 16, 2023Standard inspection, Complaint inspection · 10 citations
- F
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 observation, interview and record review the facility failed to use the services of a registered nurse for at least 8 consecutive hours a day 7 days a week from 10/2/2023 to 10/7/2023, 10/9/2023 to 10/13/2023, 10/15/2023 to 10/31/2023 and 11/1/2023 to 11/16/2023. The facility had no DON from 9/29/2023 to 10/10/2023. These failures placed the residents at risk for not having decisions made that would have required an RN to make in the management of the resident's healthcare needs and in managing and monitoring of the direct care staff.
- E
Ensure each resident receives an accurate assessment.
Inspectors wroteBased on observation, interview and record review the facility failed to accurately assess each resident's status for 2 of 4 residents (Resident #52 and Resident #78) reviewed for assessment accuracy in that: - The facility failed to accurately assess and document Resident #78's use of hearing aids. - The facility failed to ensure Resident #52's MDS reflected the correct pain medication regimen. These failures could place residents at risk of not having accurate assessments, which could compromise their plan of care.
- E
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on observations, 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 1 of 8 residents (Resident #74) reviewed for quality of care. - The facility failed to properly assess Resident #74 when she returned to the facility with a dressing of approximately 5 X 5 inches located on her right chest under the collarbone from 11/07/23 to 11/14/23. This failure could place residents at risk of late identification of wounds and or worsening of current wounds as well as infection. Findings Included: Record review of Resident #74's Face Sheet dated 11/14/23 revealed, a [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included: [...]
- E
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Inspectors wroteBased on observation, record review and interviews, 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 1 of 8 residents (Resident#58) and 1 out of 4 Med Carts (400 Hall Nursing Cart) reviewed for pharmaceutical services. - The facility failed to ensure Resident #58's rapid-acting pre-prandial insulin (insulin that should be administered within 5-20 minutes before meals), NovoLog, was administered without regard to the facility scheduled or actual meal times. - The facility failed to ensure the 400 Hall nursing Cart did not contain expired liquid protein supplements. This failure could place residents at risk of not receiving the therapeutic benefit of medications, adverse reactions to medications and hospitalization. Findings Include: [...]
- 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, functional, sanitary, comfortable, and homelike environment for 1 of 8 Residents (Resident #78) reviewed for a safe, clean and homelike environment. - The facility failed to ensure Resident #38 had clean and unsoiled linens on his bed. This could place the residents at risk of decreased quality of like due to the lack of a well-kept environment.
- D
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Inspectors wroteBased on interview and record review, the facility failed to conduct a comprehensive assessment of a resident within 14 calendar days after admission for 1 of 21 residents (Resident #207) reviewed for comprehensive assessments, in that: - Resident #207 had no admission comprehensive assessment completed within 14 calendar days of admission. This failure may place residents at risk of not having all medical needs assessed and met.
- 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 observation, interview and record review the facility failed develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that include measurable objectives and timeframes to meet resident's medical, nursing and mental and psychosocial needs which were identified in the comprehensive assessment for 1 of 5 residents(Resident #78) reviewed for care plans. -The facility failed complete a comprehensive care plan that addressed Resident #78's use of hearing aids. This failure could place residents at risk of not having their needs met, decreased quality of life or injury.
- D
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Inspectors wroteBased on interview and record review the facility failed to ensure irregularities noted by the pharmacist were acted upon for 1 (Resident #26) of 5 residents reviewed for pharmacy review. The facility failed to ensure: - The pharmacist's Director of Nursing Report dated October 13,2023 reflected order for Aspirin capsule 81mg daily be updated for Resident #26. - The pharmacist's Director of Nursing Report dated October 13, 2023, recommended changing Lipitor from morning to bedtime for Resident #26. These failures could place residents at risk for having a change in condition and not having the desired therapeutic effect.
- 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 drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles, for 1 out of 4 medication carts ( 300 Hall Medication Aide Cart ) reviewed for medication storage. - The facility failed to ensure the 300 Hall Medication Aide Cart did not contain inappropriately labeled and in use protein supplements. These failures could place residents at risk of not receiving the therapeutic benefit of medications or adverse reactions to medications. Findings Included: In an observation and interview on 11/15/23 at 12:15 PM, inventory of the medication 300 Hall Medication Aide Cart with MA B revealed: - one open and in use bottle of Active Liquid Protein with no open date and manufacturers instructions to discard 3 months after opening. [...]
- B
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on interview, and record review the facility failed to maintain medical records on each resident that were complete and accurately documented, in accordance with accepted professional standards and practices, for 2 of 8 residents (CR #1 and CR #2) whose records were reviewed for accuracy and completeness. - The facility failed to maintain complete and accessible records of medication administration times for CR #1 and CR #2. These failures could place residents at risk of having incomplete or inaccurate records.
Fire safety inspections
5 fire safety citations on file: 1 on March 26, 2026, 3 on December 12, 2024, 1 on November 16, 2023.
Every fire safety citation5 citations
- E
Inspect, test, and maintain automatic sprinkler systems.
K 353 · March 26, 2026 · Corrected (the home has a date of correction)
- F
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · December 12, 2024 · Corrected (the home has a date of correction)
- F
Have properly installed electrical wiring and gas equipment.
K 511 · December 12, 2024 · Corrected (the home has a date of correction)
- D
Install an approved automatic sprinkler system.
K 351 · December 12, 2024 · Corrected (the home has a date of correction)
- E
Inspect, test, and maintain automatic sprinkler systems.
K 353 · November 16, 2023 · Corrected (the home has a date of correction)