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 33 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
3J
0K
0L
Actual harm
1G
0H
0I
Potential for more than minimal harm
19D
10E
0F
Potential for minimal harm
0A
0B
0C
July 23, 2026Complaint inspection · 1 citation
- D
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Inspectors wroteBased on interview and record review, the facility failed to complete a thorough and accurate discharge summary for one of two residents (Resident #1) reviewed for discharge process. -The facility failed to initiate a formal discharge with appropriate documentation when Resident #1 went on therapeutic leave without medications or personal belongings from 06/14/26-06/24/26, which extended beyond Medicaid's bed-hold limit of 3 days. Resident #1 was readmitted to the facility on [DATE] after a hospital stay. This failure could place residents at risk of not receiving ongoing person-centered care, which could lead to worsening conditions or serious harm.
April 15, 2026Complaint inspection · 1 citation
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on interview and record review the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including 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, or not later than 24 hours if the events that caused the allegation did not involve abuse and did not result in serious bodily injury, to the administrator of the facility and to other officials, including to the State Survey Agency where state law provides for jurisdiction in long-term care facilities, in accordance with State law through established procedures for 1 of 4 residents (Resident #1) reviewed for reporting. [...]
February 20, 2026Standard inspection · 4 citations
- 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 review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food safety in the facility's only kitchen. 1. The facility failed to ensure the stand-by freezer food items were dated, labeled, and secured. 2. The facility failed to ensure the stand-by refrigerator food items were dated with the date opened or expiration date, labeled with the contents in the clear package or box, and secured and tightly sealed according to the facility policy. 3. The grease in the deep fryer was dirty with blackened grease and food particles around edges. These failures could place residents at risk for foodborne illness and foodborne intoxication.
- E
Dispose of garbage and refuse properly.
Inspectors wroteBased on observation and interview, the facility failed to dispose of garbage and refuse properly for 1 of 2 (Dumpster #1) dumpster sites. The facility failed to ensure the doors were completely shut on Dumpster #1. This failure could place residents at risk of an unsanitary environment and could attract pests, rodents and other animals.
- D
Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made.
Inspectors wroteBased on observation, interview and record review the facility failed to provide written notice, including the reason for the change, before the resident's room or roommate in the facility is changed for 1 of 5 (Resident #23) residents reviewed for room changes. The facility failed to notify Resident #23's RP of room changes on 11/25/25. This failure could place residents at risk for decreased quality of life being in a new environment.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice for 1 of 25 residents (Resident #23) reviewed for quality of care. The facility failed to complete a swallow study referral for Resident #23 when it was requested during a care plan meeting on 01/29/26. This failure could place all residents at risk of not being provided adequate care and treatment.
August 14, 2025Complaint 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 observation, interview, and record review, the facility failed to ensure that the resident environment remained as free of accident hazards as is possible and each resident received adequate supervision and assistive devices to prevent accidents for 1 of 8 residents (Resident #1) reviewed for supervision. The facility failed to ensure Resident #1, who had a history of wandering for which he wore a WanderGuard device, was provided with adequate supervision to prevent him from exiting the building on 07/23/25. The resident was observed outside the facility by a staff member, and he was found on the sidewalk near a street sign outside the facility. The noncompliance was identified as past non-compliance. The Immediate Jeopardy (IJ) began on 07/23/25 and ended on 07/24/25. The facility had corrected the noncompliance before the survey began. [...]
- E
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Inspectors wroteBased on observation, interview, and record review, the facility failed to incorporate the recommendations from the PASRR Level II determination and the PASRR evaluation report into a resident's assessment, care planning, and transitions of care for 2 of 4 residents reviewed (Residents #2 and #3) for PASRR assessments. The facility failed to submit a Nursing Facility Specialized Services (NFSS) form by the specific deadline for Resident #2 and Resident #3. The failure placed residents at risk of not receiving specialized services and equipment which could decrease their quality of life.
April 8, 2025Complaint inspection · 1 citation
- E
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
Inspectors wroteBased on interview and record review, the facility failed to provide behavioral health services to attain or maintain the highest practicable physical, mental, and psychosocial well-being for one (Resident #1) of four residents reviewed for behavioral health services. The facility failed to follow-up to ensure Resident #1 received a psychiatric consultation after a verbal order was received from the NP on 02/12/25. This failure could place residents at risk for not receiving behavioral health services and a decline in quality of life.
November 14, 2024Standard inspection, Complaint inspection · 12 citations
- G
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an effective pest control program to keep the facility free of pests for 2 of 6 halls (500 and 600) reviewed for pest control. The facility failed to prevent pests from entering the facility. On 10/21/24, Resident #162 was found in bed with fire ants on his body and he had been bit multiple times his torso, arms, and legs. This failure places residents at risk of serious physical harm from ant or other pest bites.
- E
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 incorporate the recommendations from the PASARR Level II determination and the PASARR evaluation report for 2 of 5 residents reviewed (Residents #15 and #80) for PASARR assessments. 1. The facility failed to submit a Nursing Facility Specialized Services (NFSS) form requested by the specific deadline for Resident #15. 2. The facility did not refer Resident #80 to the appropriate state-designated mental health authority for review when he received a new diagnosis of schizoaffective disorder. This failure could affect residents with psychiatric diagnoses who may not be evaluated and receive needed PASRR services.
- E
Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
Inspectors wroteBased on interview and record review, the facility failed to ensure a final summary of the resident's status at the time of the discharge was available for release to authorized persons and agencies, with consent of the resident or resident's representative for 1 of 3 residents (Resident #110) reviewed for discharge summary. The facility failed to complete a discharge summary after Resident #110 discharged from the facility on 08/24/24. This failure could place residents at risk for a lack of continued care and services.
- E
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 a resident who was fed by enteral means received appropriate treatment and services to prevent complications for 2 of 3 reviewed (Resident #44 and #84) for feeding tubes. 1. RN E failed to provide Resident #44 with two cartons of formula during bolus feeding as ordered by the physician. 2. The facility failed to follow physician's orders of providing Resident #84 with her 20 hours of feeding intake. This failure could place residents at risk for a decline in health or adverse effects due to inappropriate management of g-tube care or weight loss.
- E
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Inspectors wroteBased on interview and record review, the facility failed to ensure any drug regimen irregularities reported by the Pharmacist Consultant were acted upon, for 1 of 5 residents (Resident #80) reviewed for unnecessary medications, psychotropic medications, and medication regimen review. The facility's Pharmacist Consultant recommended a dose reduction for Resident #80's Olanzapine 10mg. The physician agreed to be reduced to 5 mg, but the medication continued to be administered at 10 mg to the resident. This failure could place residents on psychoactive medications at risk for possible adverse side effects, adverse consequences, and decreased quality of life.
- D
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Inspectors wroteBased on observation, interview, and record review, the facility failed to implement written policies and procedures that prohibit and prevent neglect and misappropriation for two of two incidents (Resident #162 and Resident #300) reviewed for reporting. 1. The facility failed to follow their policy to report to the State Survey Agency when Resident #162 was found in bed and had been bitten by fire ants. 2. The Administrator, who was the Abuse Prevention Coordinator, failed to follow their policy to report to the State Agency and initiate an investigation after being informed of a written allegation of misappropriation made by Resident #300's family member. This failure could place the residents in the facility at risk of continued abuse and neglect.
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure in response to allegations of abuse, neglect, exploitation, or mistreatment that all alleged violations involving abuse, neglect, exploitation or mistreatment were reported immediately 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 Stat Survey Agency in accordance with State law through established procedured for two of two incidents (Resident #162 and Resident #300) reviewed abuse, neglect, and misappropriation. 1. The facility failed to report to the State Survey Agency when Resident #162 was found in bed and had been bitten by fire ants. 2. [...]
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice for 2 of 5 residents (Resident #55 and Resident #10) reviewed for quality of care. 1. The facility failed to ensure LA Z did not pick Resident #55 up and place her in her wheelchair before a nurse was able to complete an assessment after she fell out of her wheelchair onto the hard-wood floor in the dining room on 11/12/24. Resident #55 was seen on the floor with a pool of blood around her head and was moaning in pain after she fell. The facility failed to ensure CNA Y did not remove Resident #55 from the dining room area after she had a fall from her wheelchair, before she could be assessed by a nurse, and while she was actively bleeding from her head. 2. [...]
- 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 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 3 residents (Resident #42) reviewed for pressure ulcers. The facility failed to ensure Resident #42 received wound care treatment and services for newly identified wound to the sacral area. This failure could affect the residents, who received pressure ulcer care, by placing them at risk of infections and worsening of pressure ulcers.
- 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 dispensing and administering of all drugs and biologicals to meet the needs of each resident for 1 of 3 residents (Resident #84) reviewed for pharmaceutical services. LVN O failed to follow physician orders for administering a Scopolamine Transdermal Patch, which was used to prevent nausea and vomiting, to Resident #84 on 11/12/24. This failure could put residents at risk of not receiving their medications as ordered.
- D
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that the menu was followed for the lunch meal on 11/13/24 for 1 of 2 reviewed (Resident #11) for food and nutrition services. The facility failed to ensure residents on a pureed diet were served pureed bread during the lunch meal on 11/13/24. This failure could place residents at risk for unwanted weight loss, hunger, unwanted weight gain, and metabolic imbalances.
- D
Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice for 1 of 2 residents (Resident #30) reviewed for hospice care. The facility failed to ensure Resident #30, who was receiving hospice services, had a physician order for hospice care. These problems could result in residents not receiving needed care as ordered by their physician. These problems had the potential to affect any resident receiving hospice care services.
May 29, 2024Complaint inspection · 2 citations
- D
Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.
Inspectors wroteBased on interview and record review the facility failed to permit each resident to remain in the facility, and not transfer or discharge the resident from the facility unless the discharge was necessary for the resident's welfare and the resident's needs could not be met in the facility for 1 (Resident #1) of 2 residents reviewed for discharge requirements. The facility failed to provide and document sufficient preparation to ensure safe and orderly discharge for Resident #1, when they claimed he was being sexually inappropriate with Resident #2. This failure could affect residents by placing them at risk of being discharged and not having access to available advocacy services, discharge/transfer options, and appeal processes.
- D
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Inspectors wroteBased on interview and record review, the facility failed to notify the resident, resident representative and send a copy to the Office of the State Long-Term Care Ombudsman, of the transfer or discharge and the reasons for the move in writing and in a language and manner they understood for one (Resident #1) of two residents reviewed for discharge. The facility failed to notify the Ombudsman of Resident #1's discharge. This failure could put residents at risk of being discharged and not having access to available advocacy services, discharge/transfer options, and appeal processes.
March 13, 2024Complaint 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 interviews and record reviews the facility failed to ensure residents were free from abuse and exploitation for 1 (Resident #1) of 5 residents reviewed for abuse, neglect, and exploitation. The facility failed to ensure Resident #1 was protected from sexual abuse by Resident #2, who had a history of being inappropriate with female residents. Resident #1 reported that Resident #2 came into her room on 02/23/24 at 3:00 AM and removed her brief and attempted to have non-consensual intercourse with the resident. An IJ was identified on 03/13/24. The IJ template was provided to the facility on [DATE] at 10:45 AM. While the IJ was removed on 03/13/24, the facility remained out of compliance at a scope of isolated and a severity level of potential for more than minimal harm because all staff had not been trained on documenting inappropriate behavior. [...]
- J
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Inspectors wroteBased on interviews and record reviews, the facility failed to develop and implement a comprehensive person-centered care plan for 1 (Resident #2) of 5 residents reviewed for care plans. The facility failed to ensure Resident #2's care plan included his behaviors and monitoring of his behaviors. An IJ was identified on 03/13/24. The IJ template was provided to the facility on [DATE] at 10:45 AM. While the IJ was removed on 3/13/24, the facility remained out of compliance at a scope of Isolated and a severity level of potential for more than minimal harm because all staff had not been trained on documenting inappropriate behavior. This failure could place residents at risk of inappropriate sexual behaviors from other residents.
October 12, 2023Standard inspection · 6 citations
- E
Provide activities to meet all resident's needs.
Inspectors wroteBased on observation, interview, and record review, the facility failed to provide an ongoing program of activities designed to meet the interests and the physical, mental, and psychosocial well-being of 5 of 33 residents reviewed for activities. The facility failed to ensure resident received activities during the weekdays and weekends. The failure placed residents at risk for a diminished quality of life, isolation, lack of stimulation, and a decline in mental status.
- 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 safety in the facility's only kitchen observed for kitchen sanitation. The facility failed to ensure food items were properly labeled, dated, and thawed in accordance with professional standards. These failures could place all residents, who receive food from the kitchen, at risk for food contamination and food-borne illness.
- D
Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
Inspectors wroteBased on interview and record review, the facility failed to ensure residents had the right to be treated with respect and dignity for 1 of 24 residents (Resident #37) reviewed for dignity. The facility failed to cover Resident #37's catheter bag that was visible from the hallway. This deficient practice could place residents at risk for psychosocial harm due to a diminished quality of life.
- D
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Inspectors wroteBased on interview and record review, the facility failed to ensure the prompt resolution of all grievances to include ensuring that all written grievance decisions include the date the grievance was received, a summary statement of the resident's grievance, the steps taken to investigate the grievance, a summary of the pertinent findings or conclusions regarding the resident's concerns, a statement as to whether the grievance was confirmed or not confirmed, any corrective action taken or to be taken by the facility as a result of the grievance, and the date the written decision was issued for 1 of 2 residents (Resident #23) reviewed for grievances. The facility failed to ensure Resident #23's grievance was documented and resolved when she reported her cell phone was misplaced or lost. [...]
- D
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents fed by enteral means received the appropriate treatment and services to prevent complications of enteral feedings for 1 of 1 resident (Resident #18) reviewed for enteral nutrition. The facility failed to follow Resident #18's physician orders for enteral feeding. These failures could affect residents receiving enteral nutrition/hydration and place them at risk of health complications and decline in health.
- 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, including procedures that assure the accurate acquiring, receiving, disposition, dispensing, and administering of all drugs and biologicals to meet the needs of each resident for 1 (Resident #14) of 2 residents reviewed for insulin administration. The facility failed to ensure LVN C did not administer Humalog Insulin after the physician order dated 10/03/23 indicated to discontinue Humalog Insulin. This failure placed one resident, who had a physician's order to discontinue Humalog Insulin, at risk for Hypoglycemia (low blood sugar) altered mental status and falls.
October 4, 2023Complaint inspection · 2 citations
- D
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 residents unable to carry out activities of daily living received the necessary services to maintain good personal hygiene for 3 (Residents #1, #2, and #3) of 7 residents reviewed for activities of daily living. The facility failed to ensure Residents #1, #2, and #3 received incontinence care according to professional standards of practice. This failure could place the residents at risk of skin breakdown and infections.
- 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 designed to provide a safe and sanitary environment to prevent the transmission of communicable diseases for 1 (Resident #1) of 7 residents reviewed for infection control. The facility failed to ensure CNA B followed the facility's infection control policy for hand hygiene while providing incontinence care for Resident #1. This failure could place residents at risk of developing or spreading infectious agents.
Fire safety inspections
10 fire safety citations on file: 3 on February 20, 2026, 3 on November 14, 2024, 4 on October 12, 2023.
Every fire safety citation10 citations
- F
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
K 521 · February 20, 2026 · 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 · February 20, 2026 · Corrected (the home has a date of correction)
- E
Have properly located and lighted "Exit" signs.
K 293 · February 20, 2026 · Corrected (the home has a date of correction)
- F
Provide properly protected cooking facilities.
K 324 · November 14, 2024 · 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 14, 2024 · Corrected (the home has a date of correction)
- E
Inspect, test, and maintain automatic sprinkler systems.
K 353 · November 14, 2024 · Corrected (the home has a date of correction)
- F
Provide properly protected cooking facilities.
K 324 · October 12, 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 · October 12, 2023 · Corrected (the home has a date of correction)
- E
Install smoke barrier doors that can resist smoke for at least 20 minutes.
K 374 · October 12, 2023 · Corrected (the home has a date of correction)
- D
Inspect, test, and maintain automatic sprinkler systems.
K 353 · October 12, 2023 · Corrected (the home has a date of correction)