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 26 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
2J
0K
0L
Actual harm
1G
0H
0I
Potential for more than minimal harm
9D
11E
2F
Potential for minimal harm
0A
0B
1C
June 18, 2026Complaint inspection · 1 citation
- D
Keep residents' personal and medical records private and confidential.
Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure the personal privacy during personal care for 1 (Resident #1) out of 1 residents reviewed for privacy.-The facility failed to ensure CNA M closed the door and/or the privacy curtain while providing incontinence care to Resident #1, on 6/17/26. This failure could place the residents at risk of not having their personal privacy maintained during personal care, and a decrease in dignity.
May 19, 2026Complaint inspection · 1 citation
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview, and record review the facility failed to establish and maintain an Infection Prevention and Control Program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections that includes written standards, policies, and procedures for the program for 2 (Resident #2, Resident #3) of 4 residents reviewed for infection control. 1. ADON B failed to perform proper hygiene when she touched the tube and button device for the G Tube for Resident #2. ADON B failed to wash her hands prior, failed to wear gloves, and failed to wash her hands after for a resident on enhanced barrier precautions. 2. ADON B failed to perform proper hygiene when she opened the brief for Resident #3. [...]
March 31, 2026Complaint inspection · 3 citations
- J
Provide safe, appropriate pain management for a resident who requires such services.
Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that pain management was provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 1 of 13 residents (Resident #2) reviewed for pain. - The Facility failed to ensure Resident #2's pain was assessed and treated prior to wound care treatments causing the resident to cry out when touched or moved. An immediate Jeopardy (IJ) was identified on 03/26/2026. The IJ template was provided to the facility on [DATE] at 5:22 PM. [...]
- 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 2 (Residents #3 and #4) of 6 residents reviewed for pharmaceutical services. The facility failed to ensure accurate administering of all drugs and biologicals to meet the needs of Resident #4, whomissed 2 doses of Lidocaine External Patch 4% on 03/25/26 and 03/26/26 resulting in resident being sore, was administered high dosages and low dosages of Tramadol and Resident #4 putting her at risk of overdose, and Resident #3 was administered insulin outside of her parameters which could cause her to go into hyper or hypoglycemia. MA C and LVN G failed to administer Resident #4's Lidocaine External Patch 4 % during the scheduled time. [...]
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interviews, and record reviews, 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 1 of 4 residents (Resident #2) reviewed for infection control, in that: -CNA J failed to wear PPE for EBP, when she provided incontinent care to Resident #2. These deficient practices could place residents at-risk for infection, sepsis, and hospitalization due to cross contamination.
June 27, 2025Complaint inspection · 1 citation
- E
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 have an established system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation and failed to determine that drug records were in order and that an account of all controlled drugs were maintained and periodically reconciled for 1 (CR #1) of 5 residents reviewed for pharmacy services. - The facility failed to document CR #1's ABH cream on her May 2025 MAR. - The facility failed to document CR #1's Morphine on her April 2025 MAR. - The facility failed to document CR #1's Morphine on her May 2025 MAR. These failures could place residents at risk for inaccurate administration of medication, over medication, or drug diversion.
May 8, 2025Standard inspection, Complaint inspection · 5 citations
- F
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 1 of 1 kitchen observed for kitchen sanitation. The facility failed to ensure the kitchen vents above the steam table was free from dripping condensation on 05/07/2025. This failure could have the potential to affect residents who ate food from the facility's kitchen placing them at risk of foodborne illness.
- F
Provide and implement an infection prevention and control program.
Inspectors wroteBased on interview and record review, the facility failed to establish and maintain an infection prevention and control program designed to help prevent the development and transmission of communicable diseases and infections for 1 of 1 facility reviewed for infection control. The facility failed to provide documentation regarding regular or periodic testing and monitoring of environmental control limts, such as PH levels, temperature levels and disinfectant levels according to their policy and procedure regarding their water management plan. This failure could place residents at risk of exposure to Legionnaires' disease (a serious type of lung infection caused by Legionella bacteria which can live in standing water within facility water systems).
- E
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Inspectors wroteBased on observations, interviews, and record review the facility failed to maintain an effective pest control program to remain free of pests on 1 of 1 kitchen. The facility failed on 05/08/2025 to ensure the dishwashing area was free from 1 roach observed. This failure could place residents at risk of food borne illnesses and unsanitary conditions in the kitchen which could result in a decline in health.
- 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, and included the appropriate professional principles, and included the appropriate accessory and cautionary instructions, and the expiration date when applicable for 1 of 6 medication carts (100 hall nursing cart) and 1 of 15 resident rooms (Resident #2)reviewed for drug labeling and storage. 1- The facility failed on 05/07/2025 to ensure prescribed medication, not belonging to Resident#2 be left bedside tray, unattended. 2. The facility failed to ensure on 05/07/2025 the following was not left on top of the 100 Hall Nursing Cart unattended: [...]
- E
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Inspectors wroteBased on observations and interviews, the facility failed to ensure the right to a safe, clean, comfortable and homelike environment for 3 of 4 resident bathrooms (room [ROOM NUMBER], 218 and 411) reviewed for environmental concerns in that: The facility failed to maintain a clean and homelike environment on 05/6/2025 as followed: -The toilet in room [ROOM NUMBER] was not kept clean and had a large yellow stain in the bowl. -The toilet seats in rooms [ROOM NUMBERS] had yellow stains. -The floors in the bathroom of room [ROOM NUMBER] were not in good condition. The floors were covered in black tread tape (tape that prevents slipping) that was peeling off and no longer intact. These failures could place residents at risk of a diminished quality of life due to exposure to an environment that is was unpleasant, unsanitary, and unsafe.
March 1, 2024Standard inspection, Complaint inspection · 6 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 the resident environment remained as free of accident hazards and each resident received adequate supervision to prevent accidents for 1 (CR #100) of 1 resident reviewed for adequate supervision. -The facility failed to provide adequate supervision and training of the staff when they incorrectly identified CR #100 as having left the facility with a family member on 05/22/2023 but later identified him as eloped on 05/23/2023. This failure placed residents living in the facility at risk of harm due to avoidable accidents by inadequately monitoring and documenting resident whereabouts, with the potential of the residents eloping from the facility while still requiring care and treatment. This noncompliance was identified as Past Non-Compliant. The IJ began on 5/22/23 and ended on 5/24/23. [...]
- E
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Inspectors wroteRecord review of Resident # 30's face sheet dated 02/29/24 revealed a [AGE] year-old female admitted to the facility on [DATE] re-admitted [DATE] with a diagnosis that included: [Dementia] a condition characterized by progressive or persistent loss of intellectual functioning, especially with impairment of memory. Cerebrovascular disease ( stroke), paraplegia ( inability to voluntarily move the lower parts of the body), muscle wasting and atrophy, (aphasia) is a disorder that affects how you communicate [ Depressive disorder] is a mood disorder that causes a persistent feeling of sadness and loss of interest. Record review of Resident # 30's Quarterly MDS dated [DATE], revealed Resident #30 had a BIMS score of 01, which indicated severe cognitive Impairment. [...]
- 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 8% based on 2 errors out of 25 opportunities, which involved 2 of 5 residents (Resident #36, and #75) reviewed for medication errors. 1.- MA B did not administer Turmeric capsule (a medication that helps the inflammation, metabolic syndrome, arthritis, hyperlipidemia, kidney) to Resident #75. 2.- LVN A poured (26mls) wrong dosage of Potassium Chloride 10mg/ml and was about to administered via GTube ( Gastrostomy tube) to Resident #36 . These failures could place residents at risk of inadequate therapeutic outcomes, increased negative side effects, and a decline in health.
- D
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 refer all level II residents and all residents with newly evident or possible serious mental disorder, intellectual disability, or a related condition for level II resident review upon a significant change in status assessment for 1 of 3 residents (Resident #13) reviewed for coordination of PASRR and assessments. The facility failed to request, submit and coordinate the PASRR assessment and screening in the Simple LTC portal to ensure therapeutic services (physical, speech and occupational) were completed for Resident #13 . This failure could place residents at risk of not receiving necessary care and services in accordance with individually assessed needs.
- 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 that include procedures to ensure accurate acquiring, receiving, dispensing, administering of all drugs and disposingof expired medications for 2 of 4 medication carts residents (Nurse's cart for 100 and 200 hall) reviewed for medication storage. -The facility failed to ensure the nurse's cart for 100 hall,s did not have expired Lemon Glycerin swab sticks expired date 10/2023. -The facility failed to ensure the nurse's cart for 300 halls did not have expired lubricating jelly expired date 09/2023. These failures could place the residents in the facility at risk for not receiving needed medications to maintain optimum health, resulting in deterioration in their condition.
- 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 control program designed to prevent the development and transmission of infections for 1 of 2 residents (Resident #30) reviewed for infection control. 1. CNA A failed to perform hand hygiene appropriately while providing incontinent care for Resident #30 by not changing gloves and washing hands . These failures could place residents at risk for transmission of diseases and organisms.
December 30, 2022Standard inspection · 9 citations
- G
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 receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 2 (Residents #40 and #75) of 7 residents reviewed for quality of care. The facility failed to prevent Residents #40 and #75 from developing MASD (Moisture Associated Skin Damage) causing them pain and emotional distress. These failures placed residents at risk of a diminished quality of care which lead to residents having severe pressure ulcers and severe moisure associated skin damage.
- E
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents who were incontinent received appropriate treatment and services to prevent urinary tract infections for 2 of 4 residents (Resident #30 and Resident #135) reviewed for catheter and incontinent care in that: The facility failed to ensure CNA T and the treatment nurse placed Resident # 30's Foley bag below the bladder during wound care. The facility failed to ensure WFM YY followed proper infection control procedures, and completely cleaned Resident #135, during incontinent care. These failures could affect residents, who were incontinent or had a catheter, and placed them at risk for urinary tract infection, discomfort, skin breakdown and decreased quality of life.
- 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 1 (Resident #16) of 6 residents reviewed for pharmacy services. RN E did not administer Humulin N insulin to Resident #16 as ordered by the physician. Resident #16 had medication at the bedside and did not have an order to self-administer medication. These failures could place residents at risk of not receiving the therapeutic outcomes, increased side effects, or a decline in health.
- 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 10% based on 3 errors out of 30 opportunities, which involved 3 of 6 residents (Resident #52, #65, and #66) reviewed for medication errors. - RN E did not administer Furosemide (a medication that helps the body get rid of extra water) to Resident #52. - LVN P administered expired Insulin aspart to Resident #65. - MA A administered four drops of Cyclosporine eye drops in each eye instead of one drop in each eye as directed by the physician for Resident #66. These failures could place residents at risk of inadequate therapeutic outcomes, increased negative side effects, and a decline in health.
- 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 in one of one kitchen reviewed for food service safety, in that: -Three dented cans were on the can rack located in the dry storage room. -1 box of chips were on the floor in the dry storage room. -4 plastic containers of potentially rotten or expired fruit was present in the walk-in cooler. This failure could place residents at risk for cross-contamination and foodborne illnesses.
- E
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview, and record review, the facility did not maintain an infection prevention program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections for 6 of 6 residents (Resident #10, #26, #29, #40, #75, and #135) reviewed for infection control. -CNA C failed to change gloves and wash or sanitize her hands when moving from a dirty area to a clean area when providing incontinent care to Resident #10. -CNA AA failed to change gloves and wash or sanitize her hands when moving from a dirty area to a clean area when providing incontinent care to Resident #29. -CNA BB failed to change gloves when providing wound care to Resident #26. [...]
- 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 that housekeeping and maintenance services maintained a sanitary, orderly, and comfortable interior for 1 (Resident #135) of 7 residents reviewed for environment. -Resident #135's restroom had a sewage odor causing the resident not to want to use the restroom to shower. This failure placed her at risk of a diminished quality of life leading to a variety of emotional and physical problems/issues.
- 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 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 1 (Resident #135) of 7 residents reviewed for ADLs. The facility failed to provide routine showers and timely incontinent care to Resident #135. These failures placed residents at risk of poor personal hygiene, skin problems, infection, and a diminished quality of life.
- C
Dispose of garbage and refuse properly.
Inspectors wroteBased on observation, interview and record review the facility failed to dispose of garbage and refuse properly for 1 of 1 dumpster reviewed for garbage disposal. -The facility failed to ensure the dumpster lids and doors were secured. This failure could result in providing harborage and breeding areas for insects, rodents and other pests which could infest the facility.
Fire safety inspections
9 fire safety citations on file: 5 on May 8, 2025, 2 on March 1, 2024, 2 on December 30, 2022.
Every fire safety citation9 citations
- E
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
K 321 · May 8, 2025 · Corrected (the home has a date of correction)
- E
Install an approved automatic sprinkler system.
K 351 · May 8, 2025 · Corrected (the home has a date of correction)
- E
Install corridor and hallway doors that block smoke.
K 363 · May 8, 2025 · Corrected (the home has a date of correction)
- E
Have proper medical gas storage and administration areas.
K 923 · May 8, 2025 · Corrected (the home has a date of correction)
- D
Properly select, install, inspect, or maintain portable fire extinguishes.
K 355 · May 8, 2025 · Corrected (the home has a date of correction)
- F
Have simulated fire drills held at unexpected times.
K 712 · March 1, 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 · March 1, 2024 · Corrected (the home has a date of correction)
- E
Provide properly protected cooking facilities.
K 324 · December 30, 2022 · Corrected (the home has a date of correction)
- E
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · December 30, 2022 · Corrected (the home has a date of correction)