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 35 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
1J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
25D
9E
0F
Potential for minimal harm
0A
0B
0C
May 21, 2026Standard inspection · 14 citations
- E
Honor the resident's right to organize and participate in resident/family groups in the facility.
Inspectors wroteBased on observation, interview and record review, the facility failed to provide a private meeting space for the residents' monthly council meetings for 11 of 11 confidential residents reviewed for resident council. The facility failed to provide a private space for resident council meetings. This failure could place residents who attended the resident council meetings at risk of not being able to voice concerns due to lack of privacy. Observation and interview on 05/20/2026 at 11:30 a.m. during a confidential resident group meeting held in a private therapy gym, revealed the meeting was normally held in the upstairs dining room. There were no doors or solid walls that separated the dining room from the open nurses' station or the two hallways leading into the dining room. [...]
- E
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Inspectors wroteBased on observation, interview, and record review the facility failed to, in accordance with State and Federal laws, store all drugs and biologicals in locked compartments under proper temperature controls, and permitted only authorized personnel to have access to the keys for six of twenty residents (Residents #29, #44, #70, #74, #78, and #86) and one of three carts (Nurse Cart) reviewed for medication storage. 1. The facility failed to ensure that Resident #78's eye drops were not accessible to other residents on 05/19/2026. 2. The facility failed to ensure that Resident #70 analgesic topical gel was not inside his room on 05/19/2026. 3. The facility failed to ensure that Resident #86 did not have a tube of zinc oxide inside her room on 05/19/2026. 4. The facility failed to ensure that Resident #29 did not have a tube of zinc oxide inside his room on 05/19/2026. 5. [...]
- 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, interviews, and record reviews, the facility failed to ensure food was stored, prepared, distributed, and served in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for food and nutrition services. The facility failed to ensure all food items in the facility's kitchen were dated and discarded prior to their use-by date and were properly sealed. These failures could place residents at risk of food contamination and food-borne illness.
- 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 four of twenty residents (Residents #11, #46, #51,and #87) reviewed for infection control. 1. The facility failed to ensure LVN C performed hand hygiene when she suctioned, changed the tracheostomy's inner cannula, changed the g-tube's dressing, and changed Resident #11's feeding formula on 05/20/2026. 2. The facility failed to ensure CNA D wore a gown while changing Resident #46's linen, who had a midline IV (a thin tube inserted into the vein for delivery of medications) and pressure ulcer, on 05/19/2026. 3. [...]
- D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteBased on observations, interviews, and record review, the facility failed to treat each resident with respect, dignity, and care in a manner and environment that promoted maintenance or enhancement of his or her quality of life for one (Resident #87) of nineteen residents reviewed for dignity. The facility failed to treat Resident #87 with dignity and promote enhancement of their quality of life when the resident was not provided a privacy bag for her catheter bag on 05/20/2026. This failure could place the residents at risk of not having their right to a dignified existence maintained.
- D
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Inspectors wroteBased on interview and record review the facility failed to ensure residents had the right to be free from abuse, neglect, misappropriation of resident property, and exploitation for two of ten residents (Resident #54 and Resident #6) reviewed for abuse and neglect. The facility failed to ensure Resident #6 was free from abuse when Resident #54 hit him on 05/05/2026. This failure could place residents at risk of abuse and emotional stress.
- 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 were reported immediately, but not later than 2 hours after the allegation was made, if the events that caused the allegation involved abuse, 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 2 of 4 residents (Residents #54, and #6) reviewed for freedom from abuse, neglect, and exploitation. The facility failed to report an allegation of resident abuse for Resident #6 to the State Survey Agency within the allotted time frame of 2 hours, after being advised of the incident occurrence on 05/05/26 when Resident #54 admitted to striking Resident #6. [...]
- D
Respond appropriately to all alleged violations.
Inspectors wroteBased on interview and record review, the facility failed to have evidence that all allegations of abuse, neglect, exploitation, or mistreatment, were thoroughly investigated for 1 of 5 residents (Resident #6) reviewed for abuse and neglect. The facility was made aware of the incident on 05/05/2026 and did not investigate an allegation of abuse which Resident #6 was struck on the leg by Resident #54. This failure could place residents at risk for abuse/neglect and could lead to a diminished quality of life and psychosocial harm. Record review Resident #54's face sheet revealed a [AGE] year-old male who was admitted to the facility on [DATE]. His diagnosis included: Hemiplegia and Hemiparesis following nontraumatic subarachnoid. Hemorrhage affecting right dominant side. (a type of hemorrhagic stroke indicate damage to the brain. [...]
- 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 the residents' environment remained free of hazards as was possible for one of eighteen residents (Resident #87) and one direct care staff (LVN B) of three direct care staff reviewed for accident hazard. 1. The facility failed to ensure CNA E did not transfer Resident #87 using a Hoyer lift (a mechanical lift used to transfer an individual with limited mobility) by herself, and leave the resident suspended in the air via the Hoyer lift without supervision on 05/20/2026. 2. The facility failed to ensure LVN B did not leave a container of germicidal wipes (substance that destroys germs and microorganism) on top of her cart unattended on 05/20/2026. These failures could place residents at risk of injuries and exposure to toxic chemicals.
- D
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 observation, interview, and record review the facility failed to ensure residents who were incontinent of bladder received appropriate treatment and services to prevent urinary tract infection for two of five residents (Resident #3 and Resident #87) reviewed for incontinent care. 1. The facility failed to ensure Resident #3's catheter bag was off the floor on 05/19/2026. 2. The facility failed to ensure that CNA E did not place Resident #87's catheter bag on top of the resident's bed, rendering the catheter to not be below the bladder while changing the resident's clothing on 05/20/2026. 3. The facility failed to ensure Resident #87's catheter bag was off the floor on 05/20/2026. These failures could place the residents at risk for urinary tract infection.
- 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 provide appropriate treatment and services to prevent complications of enteral feeding for one of four residents (Resident #85) reviewed for feeding tube management. The facility failed to ensure LVN B checked Resident #85's gastric residual and g-tube placement before flushing and administering medications on 05/20/2026. This failure could place residents with g-tubes at risk for tube displacement, clogging, aspiration, and discomfort.
- 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 a resident who needed respiratory care was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for two of ten residents (Residents #46 and Resident #87) reviewed for respiratory care. 1. The facility failed to ensure Resident #46's nasal cannula was stored properly when not in use on 05/21/2026.2. The facility failed to ensure Resident #87's nasal cannula (flexible tube used to deliver oxygen to the nose through two prongs) was stored properly when not in use on 05/20/2026. These failures could place residents at risk for respiratory infection and not having their respiratory needs met.
- 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 one of ten residents (Resident #67) reviewed for pharmaceutical services. The facility failed to dispose of Resident #67's expired insulin on 05/21/2026. This failure could place residents at risk of not receiving the medication's full therapeutic benefits and not receiving medications as ordered resulting to adverse effects.
- 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, in accordance with accepted professional standards and practices, the facility failed to maintain medical records on each resident that are complete; accurately documented; readily accessible; and systematically organized for for 2 (Resident #20 and Resident #66) of 5 residents reviewed for Advanced Directives. The facility failed to ensure that Resident #20 and Resident #66's OOH-DNR (Out of Hospital-Do Not Resuscitate) were completed correctly with both signatures not meeting the criteria for a qualified witness, making the forms invalid. This failure could affect all residents who have implemented an Advanced Directive and established their choice not to be resuscitated at the risk of receiving CPR (Cardiopulmonary Resuscitation) against their wishes.
December 2, 2025Complaint inspection · 2 citations
- D
Keep residents' personal and medical records private and confidential.
Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure the resident had a right to confidentiality of his or her personal and medical records for one (Resident #1's) of ten residents reviewed for privacy and confidentiality. The facility failed to ensure ADON A did not leave Residents #1's medical information exposed and unattended on top of the nurse's station countertop on 12/02/2025. This failure could place the residents at risk of their medical information being accessed by unauthorized individuals.
- D
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Inspectors wroteBased on observations, interviews, and record review, the facility failed to store all drugs and biologicals in a locked cart or under direct observation of authorized staff in an area where residents could access it for one (Nurse Cart) of one cart reviewed for medication storage. The facility failed to ensure that LVN B locked the nurse cart before leaving it unattended on 12/02/2025. This failure could place the residents at risk of accessing/opening the cart causing accidental overdose, adverse reactions, or misuse of medications.
June 18, 2025Complaint inspection · 4 citations
- E
Reasonably accommodate the needs and preferences of each resident.
Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for three (Residents #1, #2, and #3) of ten residents reviewed for Reasonable Accommodation of Needs. The facility failed to ensure the call light systems in Residents #1, #2, and #3's rooms were in a position that was accessible to the resident on 06/18/2025. This failure could place the residents at risk of being unable to obtain assistance when needed and help in the event of an emergency.
- 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 a resident who needed respiratory care, including tracheostomy care and tracheal suctioning, was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 1 (Resident #6) of one residents reviewed for Respiratory Care. The facility failed to ensure Resident #6's breathing mask for his nebulizer (a medical device that turns liquid medicine into mist that could be inhaled through a face mask) was properly stored when not in use on 06/18/2025. This failure could place residents at risk for respiratory infection and not having their respiratory needs met.
- D
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure that drugs and biologicals were stored in locked compartments for two (Resident #4 and Resident #5) of two residents reviewed for Storage of Drugs and Biologicals. The facility failed to ensure that no medications were inside Resident #4 and Resident #5's room. This failure could place the residents at risk of overdose or misuse of medications.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased 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 one (Resident #5) of 1 resident reviewed for Infection Control. The facility failed to ensure CNA D performed hand hygiene and changed her gloves while providing incontinent care to Resident #5 on 06/18/2025. This failure could place residents at risk of cross-contamination and development of infections.
March 13, 2025Standard 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 interviews and record reviews, 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 timeframes to attain or maintain the resident's highest practicable mental and psychosocial well-being for 3 of 8 residents (Resident #2, #74, and #182) reviewed for Care Plans. 1. The facility failed to ensure Resident #2 was care planned for oxygen administration. 2. The facility failed to ensure Resident #74 was care planned for condom catheter and hospice care. 3. The facility failed to ensure Resident #182 was care planned to use the call light to alert staff. These failures could place residents at risk of not receiving the necessary care and services needed.
- E
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 a resident who needed respiratory care, including tracheostomy care and tracheal suctioning, was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 4 of 8 residents (Resident #2, #19, #39, and #67) reviewed for Respiratory Care. 1. The facility failed to ensure Resident #2 had an order for oxygen administration on 3/11/2025. 2. The facility failed to ensure Resident #19's mask for CPAP was stored properly on 3/11/2025. 3. The facility failed to ensure Resident #39's oxygen tubing was properly stored when not in use on 03/11/2025. 4. [...]
- 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, distributed, and serve food in accordance with professional standards for food service safety for the facility's only kitchen, reviewed for food and nutrition services. 1. The facility failed to ensure the ice scoop for the ice machine in the facility kitchen was cleaned and not stored inside the ice machine. 2. The facility failed to cover a large trash can stored in the kitchen area. 3. The facility failed to ensure kitchen cooking equipment was cleaned. 4. The facility failed to place a cover on top of the tea dispenser to avoid air borne contaminants. These failures could place residents at risk for cross contamination and other air-borne illnesses.
- D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteBased on observations, interviews, and record review, the facility failed to treat each resident with respect, dignity, and care in a manner and environment that promoted maintenance or enhancement of his or her quality of life for one (Resident #58) of nineteen residents reviewed for Dignity. The facility failed to ensure CNA C pulled the privacy bag all the way down on Resident #58's catheter bag (collects urine from the urinary bladder) so the catheter bag and its content would not be visible during lunchtime on 03/11/2025. This failure could place the residents at risk of not having their right to a dignified existence maintained.
- D
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Inspectors wroteBased on interviews and record reviews, the facility failed to ensure the timeliness of each resident's person-centered, comprehensive care plan, and to ensure that the comprehensive care plan is reviewed and revised by an interdisciplinary team for one of (Resident #19) eight residents reviewed for Revised Care Plans. The facility failed to complete a quarterly care plan for Resident #19. These failures placed residents at risk of needs not being met.
- 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 residents' environment remained free of accident hazards as was possible for 1of 6 residents (Resident #25) reviewed for accident prevention. The facility failed to ensure resident #25 had physician orders for the bolster pads that were applied to her mattress for fall prevention. This failure could prevent the resident from having an environment that was free and clear of accidents and hazards.
- D
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 observation, interview, and record review the facility failed to ensure residents who were incontinent of bladder received appropriate treatment and services to prevent urinary tract infection and to restore continence to the extent possible for one of (Resident #74) two residents reviewed for Catheter Care. The facility failed to ensure that Resident #74's external catheter (non-invasive to collect urine from the bladder such as a condom catheter) had an order on 03/11/2025. This failure could place residents at risk of needs for catheter care not met.
- D
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure that one (Probiotics) of one medication reviewed for Medication Storage was stored properly. 1. The facility failed to ensure MA F administered Resident #26's probiotics that was properly stored. 2. The facility failed to ensure LVN E administered Resident #46' probiotics that was properly stored. These failures could place the residents at risk of not receiving the full benefit of the medications or supplement.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased 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 one (Resident #34) of eight residents reviewed for Infection Control. The facility failed to ensure CNA B changed his gloves after touching the drainage tubing of Resident #72's Foley catheter (device that drains urine from the urinary bladder) during incontinent care on 03/11/2025. This failure could place residents at risk of cross-contamination and development of infections.
March 10, 2025Complaint inspection · 1 citation
- J
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on observations, interview, and record review, the facility failed to ensure resident received adequate supervision to prevent Resident #1's accidents from an elopement for (Resident #1) 1 of 6 residents reviewed for wandering, elopement, accidents, hazards, and supervision. On 01/26/2025, the facility failed to identify potential hazards and follow internal systems in place for Resident #1 to prevent her from exiting thru unlocked doors located in the dining area leading to a corridor land fire exit door which connected to a stairwell where she experienced an unwitnessed fall down the stairs and sustained multiple serious injuries that included right wrist and extensive facial fractures. A Past Non-Compliance Immediate Jeopardy (PNC IJ) was identified and presented to the Administrator and DON on 03/10/2025 at 3:30 PM. The noncompliance began on 01/26/2025 and ended on 02/02/2025. [...]
February 15, 2024Standard inspection, Complaint inspection · 5 citations
- E
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 residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for two (Resident #12 and Resident # 135) of three residents reviewed for wounds. 1) Resident #12's skin tear to her right forearm was not monitored after she received it on 02/06/24. 2) LVN E failed to treat Resident# 135's wounds on 02/11/24. This failure could place residents at risk for delays in treatment, developing infections and unidentified deterioration of their wounds.
- 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 notify, consistent with his or her authority, the resident representative(s) when there was an accident involving the resident which resulted in injury and had the potential for requiring physician intervention for one (Resident #12) of three residents reviewed for injuries. The facility failed to notify Resident #12's family after the resident was injured and sustained a skin tear to her right forearm that required ster-strips on 02/06/24. This failure could result in family members and resident representative's not receiving notification of resident injuries.
- 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 residents with pressure ulcers received the necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection, and prevent new ulcers from developing for 2 of 4 residents (Resident #135 and Resident #77) reviewed for pressure injury. 1. LVN E failed to treat Resident #135's and Resident #77's wounds on 02/11/24. 2. The WCN failed to ensure Resident #77's head wound was not exposed to infection and contamination when she laid the resident's head on his pillow after cleaning the wound. These failures could place residents at risk for deterioration of wound.
- 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 safety in the facility's only kitchen. The facility failed to ensure that food items past their expiration date were discarded. This failure could place residents at risk for food borne illness.
- 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 1 (Resident #3) of 8 residents reviewed for infection. 1. The facility failed to ensure CNA A performed hand hygiene during incontinence care for Resident #3. This failure could cause residents to suffer from infection.
Fire safety inspections
10 fire safety citations on file: 3 on May 21, 2026, 1 on March 13, 2025, 6 on February 15, 2024.
Every fire safety citation10 citations
- F
Have a fire alarm with audible and visual signals that transmits the alarm automatically to notify emergency forces in event of fire.
K 343 · May 21, 2026 · Corrected (the home has a date of correction)
- F
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · May 21, 2026 · Corrected (the home has a date of correction)
- D
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · May 21, 2026 · Corrected (the home has a date of correction)
- F
Ensure that building systems meet requirements determined by risk assessment procedures performed by qualified personnel.
K 901 · March 13, 2025 · Corrected (the home has a date of correction)
- F
Establish policies and procedures including evacuation.
E 20 · February 15, 2024 · Corrected (the home has a date of correction)
- F
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
K 761 · February 15, 2024 · Corrected (the home has a date of correction)
- E
Properly select, install, inspect, or maintain portable fire extinguishes.
K 355 · February 15, 2024 · Corrected (the home has a date of correction)
- E
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · February 15, 2024 · Corrected (the home has a date of correction)
- E
Have proper power supply for life support equipment.
K 915 · February 15, 2024 · Corrected (the home has a date of correction)
- D
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
K 321 · February 15, 2024 · Corrected (the home has a date of correction)