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 30 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
16D
12E
0F
Potential for minimal harm
0A
0B
2C
July 16, 2026Standard inspection · 11 citations
- E
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Inspectors wroteBased on interviews, and record review, the facility failed to ensure that residents who require dialysis receive such service, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences, for 1 of 8 (Resident #2) residents reviewed for dialysis care. The facility failed to document Resident #2's post dialysis assessment in the medical record for 04/27/26, 06/23/26, 06/27/26, 07/02/26, 07/07/26, and 07/08/26. This failure could place residents at risk for untreated medical issues and diminished quality of care.
- E
Ensure medication error rates are not 5 percent or greater.
Inspectors wroteBased on observations, 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 25.93 % based on 7 errors out of 27 opportunities, which involved three residents (Resident #76, Resident#101 and Resident#39) of five reviewed for medication administration. [...]
- E
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 (Resident #42, Resident #61, Resident #78, Resident #81, and Resident #89) of 9 residents reviewed for infection control.1. LVN C failed to use appropriate infection control techniques while providing gastrostomy tube site care for Resident#89, by repeatedly wiping the gastrostomy stoma (opening) back and forth with the same moistened gauze during an observation of care on 07/15/2026 at 9:25 a.m.2. MA E and MA F failed to sanitize the blood pressure monitors on 07/14/26 while obtaining blood pressure on Resident #78, Resident # 81, Resident #61 and Resident #42. [...]
- D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteBased on observation, interviews, and record review, the facility failed to ensure the resident had a right to be treated with respect and dignity for 1 (Resident #25) of 5 residents reviewed for respect and dignity. The facility failed to ensure CNA A did not enter Resident #35's room, to answer their call light, without knocking and/or announcing themself prior to entry. This failure could place residents at risk of an invasion of their privacy.
- 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, interviews and record review, the facility failed to provide a safe, clean, comfortable, and homelike environment for 1 of 5 residents (Resident #17) reviewed for resident rights. The facility failed on 07/14/2026 at 10:36 AM and 12:29 PM to ensure that Resident #17 had clean bed linens, and the room was free from odors. These failures could place residents at risk for the potential to compromise the resident's dignity, comfort, skin integrity, and quality of life.
- D
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
Inspectors wroteBased on interview and record review, the facility failed to ensure PRN orders for psychotropic drugs were limited to 14 days unless the attending physician or prescribing practitioner believed, and documented, that it was appropriate for the PRN order to be extended beyond 14 days for 1 of 5 resident (Resident #17) reviewed for PRN psychotropic medications, in that:The facility failed to ensure Resident #17 did not have an PRN order for Ativan 0.5 mg after 14 days without a stop date or re-evaluation by the physician to evaluation if the medication was still needed. This failure could place residents at risk for receiving unnecessary psychotropic medications and could result in residents experiencing adverse drug reactions.
- 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, which 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 residents (Resident #2) reviewed for care plans. The facility failed to ensure Resident #2's comprehensive care plan addressed her dialysis needs and interventions were in place to ensure the ileostomy(surgical opening of the intestine to allow stool to pass without going through the colon or anus) bag was intact and secure before dialysis to prevent from being returned without treatment. This failure could place residents at risk of not having their individual medical and nursing needs being met.
- 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 who were unable to carry out activities of daily living received necessary services to maintain personal hygiene for 1 (Resident #100) of 5 residents reviewed for bathing. The facility failed to provide Resident #100 with a shower within her first few days of admission, and gave her a bed bath on 07/14/2026 despite Resident #100 preferring, and asking for a shower. This failure could place residents at risk of skin breakdown, infection, and/or mental dissatisfaction related to their self-worth.
- 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, interviews, and record review, the facility failed to store all drugs and biologicals in locked compartments under proper temperature controls for 1 of 2 (400 hall cart) medication carts reviewed for pharmacy services. RN B failed to ensure the 400-hall medication cart was locked and medications were secured and not accessible to other staff, residents, or visitors when not in use on 07/14/26. This failure could place residents at risk of having access to unauthorized medications and lead to an increased risk for drug diversion and possible harm.
- 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 have the results of the most recent survey of the facility posted in a place readily available to residents, family members, and legal representatives for 1 of 1 survey results books. The facility failed to ensure there was a survey binder posted in a place readily available to everyone which contained the results of the most recent health recertification survey or all surveys, certifications, and complaint/ incident investigations during the 3 preceding years and any plan of correction in effect with respect to the facility. This failure placed residents at risk of not having all the information necessary to make decisions about living at the facility.
- C
Post nurse staffing information every day.
Inspectors wroteBased on observation and interview, the facility failed to ensure nurse staffing data was posted daily and readily accessible to residents and visitors with all required information for 2 (07/15/2026 and 07/16/2026) of 3 days reviewed for nurse staffing posting. The facility failed to have nurse staffing information prominently posted in a manner that was accessible to residents and visitors on 07/15/2026 and 07/16/2026. This failure could place residents, families, or visitors at risk of not being informed of the census and number of staff working each day to provide care on all shifts.
July 6, 2026Complaint inspection · 2 citations
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that residents, who needed respiratory care, were provided such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 1 of 5 residents (Resident#1) reviewed for respiratory care. The facility failed to ensure the humidifier water bottle and oxygen cannula connected to the oxygen concentrator of Resident#1 were changed every Sunday as ordered by the physician. This failure could place residents at risk for respiratory infections through contamination.
- D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure, in accordance with accepted professional standards and practices, medical records were maintained on each resident that are complete, accurately documented, readily accessible; and systematically organized for 1 of 5 residents (Resident#1) reviewed for respiratory care. The facility failed to ensure RN B and LVN C did not document the changing of water bottle and oxygen cannula connected to the oxygen concentrator of Resident#1 as completed on 06/28/26 and 07/05/26 on the MAR, when it was not completed on those days. This failure placed residents at risk for not receiving scheduled medications and treatments. contamination.
May 14, 2025Standard inspection · 2 citations
- E
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteBased on observation, interview, and record review, the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life for 3 of 10 residents (Resident #71, Resident #191, and Resident #194) reviewed for rights. The facility failed to ensure PTA and RN A knocked on Resident #71, Resident #191, and Resident #194's doors when going into the residents' rooms. The deficient practice could place residents at risk of feeling like their privacy was being invaded or the facility was not their home.
- E
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 8 of 10 residents (Resident #10, Resident #32, Resident #35, Resident #76, Resident #52, Resident #22, Resident #15 and Resident #193) reviewed for infection control. 1. CNA A did not conduct hand hygiene between each resident when passing lunch trays on the 400 Hall to Residents #10, #35, #76, #52, #22, and #15. 2. During peri-care, CNA B did not sanitize her hands or change gloves when going from the front to the back for Resident #10. 3. RN A did not wear a gown for Enhanced Barrier Precautions when administering medications to Resident #193, who had an enteral feeding tube. 4. [...]
December 19, 2024Complaint inspection · 2 citations
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on interviews and record reviews, 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, are 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 for 1 (Resident #1) of 5 residents reviewed for incidents. The facility failed to report within 2 hours to the SA after Resident #1 alleged sexual abuse to her Hospice caretaker on 12/13/24, who subsequently notified the facility on 12/16/24. [...]
- 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 reviews, the facility failed to ensure that each resident receives adequate supervision and assistance devices to prevent accidents for 1 (Resident #2) of 5 residents reviewed for unwitnessed falls. The facility failed to adjust Resident #2's wheelchair brakes so they locked in place. On 12/19/24, Resident #2 went to the bathroom unsupervised and fell due to wheelchair brakes not properly locking, subsequently leading to soreness and pain. This failure could place residents at risk of falls, bruises, skin tears, fractures, and hospitalizations.
November 21, 2024Complaint inspection · 1 citation
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on interviews and record reviews, 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, are 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 for 1 (Resident #1) of 4 residents reviewed for incidents. The facility staff failed to inform the ADM of Resident #1's allegation of neglect from 10/19/24 until 10/22/24, subsequently making the ADM's report late to the SA. [...]
October 9, 2024Complaint inspection · 1 citation
- 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 ensure the resident has a right to a safe, clean, comfortable and homelike environment for 2 of 4 (Resident #1 and Resident #2) residents reviewed for environmental concerns. The facility failed to ensure that the Resident #1 and Resident #2's bedding, and Resident #1's air mattress were clean and free of dirt and dried food. These failures could place residents at risk of living in an unsafe, unsanitary, and uncomfortable environment.
June 6, 2024Complaint inspection · 1 citation
- 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 timetables to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for one (Resident #1) of five residents reviewed for care plans. The facility failed to ensure a care plan was developed to address Resident #1's psychiatric behaviors such as wandering, insomnia, aggitation, and anxiety. This failure could place residents at risk of not having their individualized needs met, a delay in services, and not receiving adequate care.
March 28, 2024Standard inspection · 10 citations
- E
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteBased on observation, interview, and record review, the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life for 4 of 6 (Resident #7, Resident #46, Resident #52 Resident #58, 139 and Resident #188) residents in 1 of 1 dining room. The facility failed to promote Resident #7, 46, 52, 58, 139 and 188's dignity while dining when staff did not serve the resident their lunch tray at the same time as other residents at the same table. This failure could affect all residents who were eat in the dining room, by contributing to poor self-esteem, and unmet needs.
- E
Honor the resident's right to manage his or her financial affairs.
Inspectors wroteBased on interview, and record review, the facility failed to manage the personal funds of the resident deposited with the facility for 3 (Resident #2, Resident #4, and Resident #20) of five residents reviewed for trust funds. The facility failed to ensure Resident #2, 4, and 20 had ready access to his personal funds on the weekends. This failure could place twenty-seven residents whose funds are managed by the facility of not receiving funds deposited with the facility and not having their rights and preferences honored. Findings Included: Interview on 03/27/2024 at 9:00 AM in the Resident Group Meeting revealed Resident #2, Resident #4, and Resident #20 did not have access to their funds on the weekend or after 5 pm. Resident #2 stated that the residents can only get their money when the business office manager was there. [...]
- E
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Inspectors wroteBased on observation, interview and record review, the facility failed to ensure all residents had the right to participate, discontinue or refuse to participate in experimental research for 4 of 4 residents (Resident #2, Resident #16, Resident #65 and Resident #67) reviewed for participation in experimental research. The facility failed to review and maintain in residents' chart signed consents for a sleep study for Residents #2, #16, #65, and #67 This failure placed residents at risk of not knowing how their personal information was used and being unaware of their right to refuse to participate in the study.
- E
Keep residents' personal and medical records private and confidential.
Inspectors wroteBased on observation, interview, and record review the facility failed to ensure resident rights for personal privacy for 7 of 7 residents (Resident # 4, Resident # 18, Resident #36, Resident # 44, Resident #50, Resident #65, Resident #68, and Resident #69) reviewed for personal privacy. The facility posted personal incontinent information on the inside of Resident #4, 36, 44,50,65, and 68's closet. The facility posted Resident #69's incontinent information on the outside of his bathroom door that was visible by anyone walking past the resident's room. The deficient practice could affect all residents in the facility who are incontinent and could result in the resident being humiliated and cause embarrassment to the residents.
- 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 and implement a comprehensive person-centered care plan for 6 of 8 residents (Resident #47, Resident #58, Resident #2, Resident #16, Resident #65, Resident #67) reviewed for comprehensive care plans. The facility failed to revise Resident #47's care plan to reflect interventions for her diagnosis of lymphedema. The facility failed to revise Resident #58's care plan to reflect interventions for her diagnosis of diabetes mellitus. The facility failed to revise Resident #2's, Resident #16's, Resident #65's, and Resident #67's care plan to reflect their participation in an experimental research study. These failures placed residents at risk of not having interventions in place to meet their needs.
- 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 all residents who were unable to carry out activities of daily living received the necessary services to maintain grooming and personal and oral hygiene for 3 of 8 (Resident #32, Resident #57 and Resident #58) residents reviewed for ADL's. The facility failed to ensure Resident #32 received nail care. The facility failed to ensure Resident #57 and Resident #58 received shaving care. These failures placed residents at risk of poor personal hygiene.
- E
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an Infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infection for 2 of 7 residents (Resident #85 and Resident #26) reviewed for infection control, in that: 1. The facility failed to ensure Resident #26 received peri-care by not following infection control techniques such as handwashing and changing gloves, and 2. The facility failed to place a barrier between Resident #85's left heel wound and her mattress while providing wound care. These deficient practices placed residents at risk for infections and diminished quality of life.
- D
Reasonably accommodate the needs and preferences of each resident.
Inspectors wroteBased on observation, interview and record review, the facility failed to accommodate the needs and preferences of five of 24 residents (Residents #4, Resident #22, Resident #41, Resident #55, and Resident #64) reviewed for accommodation of needs. The facility failed to place Residents #4, 22, 41,55, and 64's call-lights within reach. This failure affected five residents and placed an additional twenty-five residents who reside at the facility at risk of not having their needs and preferences met and a decreased quality of life.
- 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 all residents received treatment and care in accordance with professional standards of practice for 1 of 8 (Resident #47) residents reviewed for edema care. The facility failed to obtain orders and provide treatment for Resident #47's lymphedema. This failure could place residents at risk for untreated medical issues and diminished quality of care.
- D
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Inspectors wroteBased on observation, interview and record review, the facility failed to ensure all residents received food that accommodated the resident's preferences for 1 of 8 (Resident #58) residents reviewed for food preferences. The facility served Resident #58 food items she disliked as reflected on her meal ticket. This failure placed residents at risk of decreased appetite and oral intake.
Fire safety inspections
3 fire safety citations on file: 1 on May 14, 2025, 2 on March 28, 2024.
Every fire safety citation3 citations
- D
Install smoke barrier doors that can resist smoke for at least 20 minutes.
K 374 · May 14, 2025 · Corrected (the home has a date of correction)
- E
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · March 28, 2024 · Corrected (the home has a date of correction)
- D
Ensure proper usage of power strips and extension cords.
K 920 · March 28, 2024 · Corrected (the home has a date of correction)