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 25 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
1K
0L
Actual harm
1G
0H
0I
Potential for more than minimal harm
17D
6E
0F
Potential for minimal harm
0A
0B
0C
August 8, 2025Complaint inspection · 2 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 interview, and record review, the facility failed to develop and implement a care plan to meet the resident's needs for 1 of 3 residents (Resident #1) reviewed for care plans. The facility failed to ensure Resident #1's care plan accurately documented the resident's need for supervision when actively eating/drinking. These failures could place residents at risk of their needs not being met.
- D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on interview, and record review, the facility failed to maintain medical records, in accordance with accepted professional standards and practices, that were complete; and accurately documented for 1 of 3 residents (Resident #1) reviewed for documentation. The facility failed to ensure Resident #1's nurse progress notes accurately documented when the resident's vitals were taken. These failures could place residents at risk of their records not accurately documenting interventions, monitoring, and information provided to the interdisciplinary team.
July 11, 2025Standard inspection · 5 citations
- D
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Inspectors wroteBased on interview and record review, the facility failed to immediately inform the resident, consult with the resident's physician, and notify, consistent with his or her authority, the resident representatives when there was a significant change in resident's physical, mental, or psychosocial status for 1 of 2 residents (Resident #17) reviewed for physician notification of changes in condition. The facility failed to notify Resident #17's physician when his blood sugar levels were out of physician ordered parameters on 6/25/2025. This deficient practice could place residents at risk of not receiving adequate and timely intervention and a decline in condition.
- 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 that a resident who is fed by enteral means receives the appropriate treatment and services to prevent complications of enteral feeding for 1 of 1 resident (Resident #151) reviewed for enteral feeding: The facility failed to ensure Resident #151's medications were diluted before administering the medications into the resident's feeding tube, did not label the resident's feeding formula and water containers with the appropriate identifiers and did not discard the feeding containers after the feeding was completed. This deficient practice could place residents who received enteral nutrition and medications at increased risk of aspiration, infection, bloating discomfort, and not receiving the full benefit of the medications administered.
- 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 (Resident #17) of 3 residents reviewed for medications. The facility failed to stock an emergency supply of Lispro (fast-acting insulin) to maintain Resident #17's medical condition during a medication absence resulting in a blood sugar level of 386. This failure could place the residents at risk of not receiving therapeutic doses of their medication.
- D
Ensure that residents are free from significant medication errors.
Inspectors wroteBased on the interview and record review, the facility failed to ensure that 1 of 2 residents (Resident #17) reviewed for medication errors was free of any significant medication errors. The facility failed to administer Resident #17's insulin Lispro medication (a quick acting medication used to lower blood sugar) as prescribed. This deficient practice could place residents at risk of inadequate therapeutic outcomes, increased adverse side effects, and a decline in health.
- D
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on observation, 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 5 (memory unit) satellite kitchens. The facility failed to ensure dietary staff used facial hair restraints properly during plate preparation. This failure could place residents who received meals and/or snacks from the kitchen at risk for food borne illness.
March 17, 2025Complaint inspection · 3 citations
- E
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Inspectors wroteBased on observation, interview and record review, the facility failed to immediately consult with the resident's physician when there was a significant change in resident condition for 1 of 3 residents (Resident #1) reviewed for physician notification of changes in condition. The facility failed to notify Resident #1's physician when his blood sugar levels were out of physician ordered parameters on 3/07/2025, 3/10/2025, 3/13/2025 and 3/14/2025. This deficient practice could affect residents with a change of condition and result in not receiving adequate and timely intervention and a decline in condition.
- E
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on interviews and record review, the facility failed to maintain clinical records in accordance with accepted professional standards and practices that were complete and accurately documented for 1 of 3 residents (Resident #1) reviewed for accuracy of records, in that: 1. The facility failed to ensure Resident #1's 2:00 a.m. blood glucose readings were documented in his medical record on 2/24/2025, 2/27/2025, 3/02/2025, 3/03/2025, 3/04/2025 and 3/07/2025. 2. The facility failed to ensure Resident #1's hospital stay from 2/11/2025-2/17/2025 were uploaded into his medical record. These failures could put residents at risk of resident medical records containing incomplete and/orinaccurate information affecting care.
- 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 that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental needs that are identified in the comprehensive assessment, and describes services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 of 3 residents (Resident #1) reviewed for care plans. The facility failed to ensure Resident #1's care plan was individualized specifically for to meet the resdient's needs for the diagnosis of diabetes mellitus based on physician order. This deficient practice could place residents at risk for not receiving proper care and services due to incomplete care plans.
January 3, 2025Complaint inspection · 2 citations
- K
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on interviews and record reviews the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices, for 1 of 13 residents (Resident #1) reviewed for diabetic medical interventions. The facility failed to ensure Resident #1 had supporting orders for his diagnosis of diabetes mellitus upon admission to the facility from the hospital on [DATE] and led to Resident #1 not being assessed for daily blood sugar levels for the months of June 2024, August 2024, and September 2024, resulting on 10/18/2024, a hemoglobin A1C (HbA1c, a blood test that shows what your average blood sugar level was over the past two to three months) lab level of 9.9% (A1c normal level below 5.7; diabetes level = 6.5 or higher) and a finger stick blood sugar assessments of 300 at 06: [...]
- D
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 the facility did not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion for 1 of 8 residents (Resident #2) reviewed for abuse, neglect, and or exploitation. The facility failed to ensure residents were free from physical abuse on 09/30/2024, while Resident #2 was laying on her bed CNA H placed a pillow over Resident #2's face and stated, Pillow Therapy! The noncompliance was identified as PNC. The noncompliance began on 09/30/2024 and ended on 10/01/2024. The facility had corrected the noncompliance before the survey began. This failure could place residents at risk for harm by abuse.
May 10, 2024Standard inspection · 9 citations
- 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 each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental needs that are identified in the comprehensive assessment, and services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 3 of 8 residents (Resident #12, Resident #28, and Resident #44) reviewed for care plans. The facility failed to ensure Residents #12, #28 and #44 care plans reflected their need or placement on a secured memory care unit. This deficient practice places residents at risk for not receiving proper care and services due to inaccurate care plans.
- 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 that a resident who is fed by enteral means receives the appropriate treatment and services to prevent complications of enteral feeding for 1 of 1 resident (Resident #12) reviewed for enteral feeding tubes in that: LVN C did not check for residual volume prior to medication administration, did not flush the enteral feeding tube per physician's orders and administered the flush and medications with the syringe plunger instead of via gravity flow to Resident #12. These deficient practices could place residents receiving enteral nutrition and medications at increased risk of aspiration, infection, bloating discomfort, and not receiving the full benefit of the medications administered.
- E
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 maintain clinical records in accordance with accepted professional standards and practices that are complete and accurately documented for 4 of 8 residents (Residents #12, #28, #33, and #44) reviewed for accuracy of medical records. Facility failed to ensure Residents #12, #28, #33 and #44 had physician orders for admission to the locked memory care unit. This deficient practice could affect residents whose records are maintained by the facility and could place them at risk for errors in care and treatment.
- D
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 interview and record review, the facility failed to ensure residents' right to formulate an advance directive for 1 of 6 residents (Resident #10) reviewed for advanced directives, in that: The facility failed to ensure Resident #10's Out-of-Hospital Do Not Resuscitate (OOH DNR) was dated and had the physician's license number which made the document invalid. This failure could place residents at-risk of having their end of life wishes dishonored, and of having CPR performed against their wishes.
- D
Keep residents' personal and medical records private and confidential.
Inspectors wroteBased on observation, interview, and record review, the facility failed to respect the residents' right to confidentiality in his or her personal and medical records for 1 of 1 resident (Resident #14) reviewed for residents' rights, in that: The facility failed to ensure LVN E locked the Medication Cart Computer screen and left Resident #14's information exposed. This failure could place residents at risk of resident-identifiable information being accessed by unauthorized persons.
- D
Ensure each resident receives an accurate assessment.
Inspectors wroteBased on interview and record review, the facility failed to ensure assessments accurately reflected the resident's status for 1 of 7 Residents (Resident #54) whose MDS records were reviewed for accuracy. Resident #54's Quarterly MDS assessment dated [DATE] incorrectly documented the resident was discharged to a Short-term hospital. This failure could place residents at risk for inadequate care due to inaccurate assessments.
- 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 the resident environment remained as free of accident hazards as was possible for 2 of 8 residents (Resident #4 and Resident #28) reviewed for accidents and hazards in that: Facility failed to ensure Resident #4, and Resident #28 did not have disposable razors left on bathroom counters. This failure could place residents at risk of harm or injury and contribute to avoidable accidents.
- 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 all drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles and include the appropriate accessory and cautionary instructions and were stored in accordance with currently accepted professional principles for 2 of 7 medication carts (Household Treatment Cart and Household Medication Cart) reviewed for storage of drugs. 1. The facility failed to ensure the Household Treatment cart was locked and secured when it was left unattended. 2. The facility failed to ensure a change of direction label was used after the medication orders had changed for a medication package prescribed to Resident #46 in the Household Medication Cart. This deficient practice could place residents at risk of medication misuse and diversion.
- 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 for 2 of 7 residents (Resident #12 and #18) reviewed for infection control practices, in that: 1. LVN C did not sanitize or wash her hands between glove changes and turned off the water faucet after washing her hands which contaminated her hands prior to administering medications to Resident #12. 2. RN F used gloves from her pocket to administer a pain patch to Resident #18. These deficient practices could place residents who receive medications at risk of infection or a decline in health.
March 4, 2024Complaint inspection, Infection control · 1 citation
- G
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on observation, interview, and record review, the facility failed to provide the necessary treatment and services, based on the comprehensive assessment and consistent with professional standards of practice, to prevent development of pressure injuries for 1 of 15 (Resident #1) residents reviewed for wound care in that: 1. The facility failed to ensure prompt wound care when a new wound to Resident #1's left and right lower leg was discovered on 11/21/23. The Wound Care Nurse D was first notified of the wounds on 11/28/23. 2. While performing Resident #1's left heel and right lower extremity wound care on 2/27/24, Wound Care Nurse D did not perform Resident #1's wound care as ordered by the physician. This deficient practice could affect residents who receive wound care and place them at risk for delayed wound healing.
April 7, 2023Standard inspection · 3 citations
- E
Ensure medication error rates are not 5 percent or greater.
Inspectors wroteBased on observation, interview, and record review the facility failed to ensure their medication error rate was not 5 percent or greater and had a medication error rate of 38.46 percent with 26 medications administration opportunities observed with 10 errors for 1 of 5 residents (Resident #26) and 1 of 4 staff (LVN B) reviewed for medication administration in that: 1. [...]
- D
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 promote care for residents in a manner and in an environment that maintained or enhanced dignity and respect for 2 of 8 Residents (Resident #15 and Resident#25) reviewed for resident rights in that: 1. Resident #15's indwelling urinary catheter bag was not covered. 2. Resident #25's indwelling urinary catheter bag was not covered. These deficient practices could affect residents who had indwelling urinary catheters by contributing to poor self-esteem, lack of information, and unmet needs.
- 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 prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of infections for 1 of 24 residents (Residents #15) and 1 of 5 staff (LVN C) reviewed for infection control, in that: 1. LVN C did not sanitizer the scissors prior to cutting a bandage during wound care for Resident #15. 2. LVN C used the same paper towel to turn off the sink faucet and dry her hands prior to wound care for Resident #15. These deficient practices could place residents who receive wound care at-risk for infections.
Fire safety inspections
4 fire safety citations on file: 3 on July 11, 2025, 1 on April 7, 2023.
Every fire safety citation4 citations
- F
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · July 11, 2025 · Corrected (the home has a date of correction)
- D
Inspect, test, and maintain automatic sprinkler systems.
K 353 · July 11, 2025 · Corrected (the home has a date of correction)
- D
Have properly installed electrical wiring and gas equipment.
K 511 · July 11, 2025 · Corrected (the home has a date of correction)
- E
Meet requirements for operating features, such as evacuation plans, fire drills, smoking regulations, draperies, decorations and the inspection, testing and maintenance of fire doors.
K 700 · April 7, 2023 · Corrected (the home has a date of correction)