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 20 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
13D
6E
0F
Potential for minimal harm
0A
1B
0C
July 13, 2026Complaint inspection · 2 citations
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on observations, interviews, and recorded reviews, the facility failed to ensure that residents received the necessary care and services to attain or maintain the highest practicable mental and psychosocial well-being consistent with the resident comprehensive assessment and plan of care for one resident (Resident#1) of 10 residents reviewed for quality of life. The facility failed to ensure Resident#1 received prompt assistance needed to maintain comfort ,dignity, and safety. This failure could put the residents at risk for unmet needs, falls, Incontinence, skin breakdown, and emotional distress.
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on observation and interviews, the facility failed to ensure the resident environment remained free of accident hazards as possible for 1 (200 hall) out of 3 hallways reviewed for quality of care. The facility failed to ensure that the mechanical lift on 200 hall was locked and secured when not in use. This failure could place residents at risk of falls and/or injuries. Findings Included: Observation on 07/13/26 at 10:17 am of the 200 hall revealed an unlocked and unsecured mechanical lift parked where residents were observed wheeling themselves up and down the hallway. During an interview on 07/13/26 at 10:25 am with CNA B revealed that mechanical lifts should always be locked and stored away from high traffic areas where residents could access them and get hurt. She stated she had been in-serviced on mechanical lifts to include storage. [...]
May 29, 2026Complaint inspection · 1 citation
- D
Respond appropriately to all alleged violations.
Inspectors wroteBased on interview and record review, the facility failed to have evidence that all allegations of abuse, neglect, exploitation, or mistreatment, were thoroughly investigated for 1 of 2 residents (Resident #4) reviewed for abuse and neglect. The facility did not thoroughly investigate an incident in which Resident #4 made a grievance that a staff member pinched her. This failure could place residents at risk for abuse/neglect and could lead to a diminished quality of life and psychosocial harm.
March 20, 2026Standard inspection · 5 citations
- E
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident who is unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 2 of 6 residents (Residents #23 and #63) reviewed for ADL care. The facility failed to answer Resident #23 and Resident #63 call lights in a timely manner. This failure could place residents at risk for complications associated with delayed care such as skin breakdown and dignity issues.
- E
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, in accordance with accepted professional standards and practices, the facility failed to maintain medical records on each resident that are complete; accurately documented; readily accessible; and systematically organized for 2 of 6 residents (Residents #25 and Resident #7) completed and accurate records. The facility failed to ensure Resident #7 and Resident # 25 had either a Full Code or a Do Not Resuscitate status listed in the electronic medical record making it unclear as to what the code status was. This failure placed residents at risk of not having their preferences and wishes honored in an emergency.
- D
Provide enough food/fluids to maintain a resident's health.
Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that a resident was offered a therapeutic diet when there was a nutritional problem and the health care provider ordered a therapeutic diet for one (Resident #65) of three residents reviewed for therapeutic diets. The facility failed to ensure Resident #65 was offered alternative menu items for a therapeutic diet when she did not like the meal and received ordered Boost (supplement shake) instead of Glucerna (supplement shake for diabetes). This failure placed residents at risk of weight loss, receiving the wrong supplement, and not having choices of alternate menu items.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observations, interviews, and record reviews 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 one (Resident #104) of five residents, reviewed for infection control. 1. The facility failed to ensure LVN K performed hand hygiene and changed his gloves after treating one wound and moving on to another wound on Resident #104. This failure placed residents at risk for healthcare associated cross contamination and infections.
- B
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
Inspectors wroteBased on interview and record review, the facility failed to maintain a quality assessment and assurance committee consisting at a minimum the required committee members for three (October 2025, November 2025 and December 2025 of four meetings reviewed for QAPI.1. The facility did not ensure the Infection Preventionist attended the December 2025 meeting.2. The facility did not ensure meeting occurred monthly as per their policy and did not conduct meetings for January 2026 and February 2026. These failures could place residents at risk for quality deficiencies being unidentified, infections, no appropriate plans of action developed and implemented, and no appropriate guidance developed.
December 12, 2024Standard inspection · 6 citations
- 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 observations, interviews, and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights for 1 of 4 residents reviewed for clinical records (Resident #30). The facility failed to ensure Resident #30's use of bed rails/grab bars was documented in their care plan. The facility's failure placed residents requiring care at risk of not having their individual needs met, not receiving necessary care and services, and a failure to ensure continuity of care.
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure each resident received adequate supervision for 1 of 2 residents (Resident #43) reviewed for accidents. The facility failed to safely transfer Resident #43 during a mechanical lift from the bed to the wheelchair. The facility failed to provide safe mechanical transfer by not ultilizing 2 staff members to perform the transfer. This failure could place residents at risk of accidents, injuries, 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 observations, interviews, and record review the facility failed to assess the risks and benefits of bed rails and grab bars with the resident or resident representative or obtain informed consent prior to installation for two (Resident #29 and Resident #54) of 4 resident rooms observed and reviewed for bed rails/enabler bars. The facility failed to have evidence of informed consent and assessment of the resident for risk of entrapment for bed rails or grab bars for Resident #29 and failed to have evidence of informed consent for bed rails or grab bars for Resident #54. This failure could affect residents who used bed rails/grab bars at risk of the resident not being assessed for bed rails or grab bars, resident/responsible party not being aware of the risks, and informed consent not being obtained from the resident or responsible party.
- 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 for 1 of 2 medication rooms (Med Room A) reviewed for pharmacy services. The facility failed to ensure Med Room A did not have expired insulin. This failure could place residents at risk of receiving expired medication and not having appropriate therapeutic effects.
- 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, 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 medication cart for 1 of 7 medication carts (Med Cart C) and 2 of 2 medication rooms (Med Room A and Med Room B) reviewed for storage of medication. 1. The facility failed to ensure drugs and biologicals were labeled. Med Room B had unlabeled and undated TB vaccine and food was stored next to medications in the fridge. 2. The facility failed to ensure Med Cart C was kept locked or under direct observation of authorized staff in an area where residents and family could access it outside Resident #209's room. [...]
- 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 and prevention control program, designed to provide a safe, sanitary, and comfortable environment, and help prevent the development and transmission of communicable disease and infection, for two residents (Resident #2 and Resident #7) of eight residents reviewed for infection control practices. CMA F failed to perform hand hygiene between residents while alternately feeding Resident #2 and Resident #7. This failure had the potential to result in the spread of infection.
February 23, 2024Complaint inspection · 3 citations
- 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 store all drugs and biologicals in locked compartments and permit only authorized personnel to have access for 2 of 4 (Medication Cart #1 and Medication Cart #2) medication carts reviewed for pharmacy services. Medication cart #1 was observed unlocked and unattended with 6 blister packs medication cards left on top unsupervised by MA P for 4 minutes. Medication cart #2 was observed outside resident room facing hallway where individuals passed, unlocked and unattended for 2 minutes by RN N. This failure could place residents at risk of having access to unauthorized medications and/or lead to possible harm or drug diversion.
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure that residents who needed respiratory care were provided with such care, consistent with professional standards of practice for 2 (Resident # 82 and Resident #83) of 3 residents reviewed for respiratory care, in that: The facility failed to ensure Resident #82 oxygen tubing and nasal cannula were kept off the floor and bagged when not in use. The facility failed to ensure Resident #83's oxygen tubing was being changed weekly as ordered based on the EMAR and interview with the resident. These failures could place residents that receive oxygen therapy at risk for inadequate care and respiratory infection.
- 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 provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public for 1 (Resident #82) of 3 residents reviewed for safe , clean, sanitary, and comfortable environment. The facility failed to ensure Resident #82's rooms were free of smeared oatmeal, hard colorful candies, blanket on the floor obstructing walk path for resident #83 with a history of falls. This failure could place residents at risk falls, injuries, and unsanitary care.
November 8, 2023Standard inspection · 3 citations
- E
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Inspectors wroteBased on record reviews and interviews, the facility failed to transmit MDS data for 3(Resident #64, 41, 26) of 5 residents reviewed for MDS transmission. The facility failed to transmit a Discharge MDS for Residents # 64, 41, and 26. This failure could place residents at risk of facility not providing complete and specific information for payment and quality of measure purposes.
- E
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Inspectors wroteBased on observation, interview and record review, the facility failed to develop a comprehensive person-centered care plan to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 6 (Resident #70, Resident #6, Resident # 7, Resident #10, Resident #43, and Resident #55) of 15 residents reviewed for comprehensive person-centered care plans. 1. The facility failed to develop a comprehensive person-centered care plan based on assessed needs to address the use of antidepressant, diuretic, and antibiotic medications for Resident #70. 2. The facility failed to develop a comprehensive person-centered care plan based on assessed needs to address the special diet and fluid restriction due to heart failure for Resident #6. 3. [...]
- E
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on observations, interviews, and record reviews the facility failed to properly store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed. The facility failed to ensure foods were sealed and/or labeled properly in refrigerators. The facility failed to ensure refrigerated foods were held at or below 41 degrees. These failures could place residents that eat out of the kitchen at risk for food borne illnesses.
Fire safety inspections
18 fire safety citations on file: 5 on March 20, 2026, 4 on December 12, 2024, 9 on November 8, 2023.
Every fire safety citation18 citations
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · March 20, 2026 · Corrected (the home has a date of correction)
- F
Ensure that building systems meet requirements determined by risk assessment procedures performed by qualified personnel.
K 901 · March 20, 2026 · Corrected (the home has a date of correction)
- E
Install proper backup exit lighting.
K 281 · March 20, 2026 · Corrected (the home has a date of correction)
- E
Have properly sized and located compartments to protect residents from smoke.
K 371 · March 20, 2026 · Corrected (the home has a date of correction)
- C
Conduct risk assessment and an All-Hazards approach.
E 6 · March 20, 2026 · 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)
- F
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · December 12, 2024 · Corrected (the home has a date of correction)
- E
Provide properly protected cooking facilities.
K 324 · December 12, 2024 · Corrected (the home has a date of correction)
- E
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
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
K 321 · November 8, 2023 · Corrected (the home has a date of correction)
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · November 8, 2023 · Corrected (the home has a date of correction)
- F
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · November 8, 2023 · Corrected (the home has a date of correction)
- E
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
K 222 · November 8, 2023 · Corrected (the home has a date of correction)
- E
Have exits that are accessible at all times.
K 271 · November 8, 2023 · Corrected (the home has a date of correction)
- E
Install corridor and hallway doors that block smoke.
K 363 · November 8, 2023 · Corrected (the home has a date of correction)
- E
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · November 8, 2023 · Corrected (the home has a date of correction)
- E
Have properly installed electrical wiring and gas equipment.
K 511 · November 8, 2023 · Corrected (the home has a date of correction)
- E
Have proper medical gas storage and administration areas.
K 923 · November 8, 2023 · Corrected (the home has a date of correction)