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
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
14D
5E
6F
Potential for minimal harm
0A
0B
0C
March 3, 2026Complaint inspection · 3 citations
- F
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure Licensed Practical Nurses (LPN) were board certified to administer intravenous (IV) infusion of medications for three residents (#1, #3, and #4) out of five residents sampled for medication administration.
- E
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observations, interviews, and record review, the facility failed: 1) to ensure proper PPE (personal protective equipment) was utilized for one resident (#5) on Enhanced Barrier Isolation, 2) to properly store a nebulizer for one resident (#3) receiving respiratory treatments, 3) to provide timely dressing changes for a Peripherally Inserted Central Catheter (PICC) for one resident (#3), and 4) to properly dispose of potentially contaminated personal protective equipment and linen for two residents (#3 and 5) out of five sampled residents for infection control.
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on observation, interviews, and record review, the facility failed to provide necessary treatment and services for pressure ulcers in a timely manner for one resident (#5) out of two residents sampled.
December 3, 2025Complaint inspection · 4 citations
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure adequate provision of care and services for activities of daily living, toileting services for two residents (#14 and #10) of sixteen sampled residents.
- 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, record review, and interview, the facility failed to ensure pharmacy services for timely procurement of pain medication for one (#14) resident and failed to ensure a system of accurate accounting of dispensed controlled substances for one (#14) resident of three residents reviewed for pain medications.
- D
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Inspectors wroteBased on observation, and interview, the facility failed to ensure a safe, sanitary, and comfortable homelike environment for 6 resident rooms (105, 110, 112, 205, 212, and 109) out of 16 rooms observed related to absent caulking around commodes, discoloration on commodes, unclean resident room and bathroom flooring, and discoloration on privacy curtain.
- D
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure an effective pest control program to maintain a pest free environment for two residents (#15 and #10) of sixteen sampled residents.
October 15, 2025Complaint inspection · 1 citation
- E
Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made.
Inspectors wroteBased on record review and interviews, the facility failed to document room change notifications for three residents (#2, #3, and #4) of three residents sampled.
July 21, 2025Complaint inspection · 1 citation
- 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 interviews and policy review, the facility did not ensure medications were stored and labeled appropriately in three medication carts (Split back, East front and [NAME] front) of three medication carts observed.
March 26, 2025Standard inspection · 6 citations
- F
Post nurse staffing information every day.
Inspectors wroteBased on observation and record review, the facility did not ensure up-to-date staffing information was posted on one day (3/24/25) of three days observed.
- F
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on observations and interviews, the facility did not follow professional standards for food service safety as evidenced by food not maintained for safe consumption and improper labeling and dating of food items in the main kitchen and dining room.
- E
PASARR screening for Mental disorders or Intellectual Disabilities
Inspectors wroteBased on record review, review of policy and procedures, and interviews, the facility failed to ensure a Level II Pre-admission Screening and Resident Review (PASRR) screening was completed for five residents (#48, #29, #6, #13, and #2) of 15 residents sampled.
- 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 observations, interviews, and policy review, the facility did not ensure a safe, clean, and homelike environment in two resident rooms (#201 and #214) of 32 rooms in the facility.
- 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 observations, record review, and interviews, the facility failed to develop an individualized plan of care to include goals and interventions for two residents (#11 and #9) of forty two residents sampled.
- D
Provide care or services that was trauma informed and/or culturally competent.
Inspectors wroteBased on observations, record review, and interviews, the facility failed to identify specific triggers related to post traumatic stress disorder (PTSD) and develop an individualized plan of care to prevent re-traumatization for one resident (#11) of one residents reviewed for PTSD.
January 5, 2023Standard inspection · 6 citations
- F
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 policy reviews, the facility failed to properly store and secure medications in two of three medication carts, one medication stock room, one of three medication refrigerators, and for one (Resident #208) of one resident reviewed.
- 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 observations and staff interviews, the facility failed to ensure a safe, clean, comfortable and homelike environment to include one of one main hall through ways (East unit), and one of one main dining rooms, during three of three days observed (1/3/2023, 1/4/2023, and 1/5/2023).
- 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 observations, record review, and interviews, the facility failed to ensure care planning with problem areas, goals, and interventions was developed for three (Residents #108, #3, and #10), of twenty residents related to contracture management, splint/bracing management, and PTSD/Trauma behavior management.
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on observations, interviews, and record review, the facility did not ensure activities of daily living (ADLs) related to showers and hair care were provided for one (Resident #17) of three residents reviewed.
- D
Provide medically-related social services to help each resident achieve the highest possible quality of life.
Inspectors wroteBased on observations, interviews, and record reviews, the facility did not ensure follow through on services related to a power wheelchair were conducted in a timely manner for one (Resident #3) of two sampled residents.
- D
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Inspectors wroteBased on interview and record reviews, the facility failed to ensure behavior monitoring was in place for one (Resident #10) of five residents on psychotropic medication reviewed for unnecessary medication.
July 15, 2021Standard inspection · 4 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 ensure sanitizer solution used to clean food and non-food contact surfaces in the kitchen, which serviced two of two hallways, was at manufacturing concentration levels of 200-400 parts per million (ppm) to ensure equipment was sanitized prior to storage.
- F
Have a plan that describes the process for conducting QAPI and QAA activities.
Inspectors wroteBased on observation, interview and record review, it was determined the facility failed to provide Quality Assurance and Performance Improvement (QAPI) practice that demonstrated identification, monitoring and implementation of an effective Action Plan to improve findings of deficient practice on the annual survey conducted 7/15/2021 regarding cleanliness and food safety in the kitchen.
- 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 observation, interview, and record review the facility failed to ensure resident areas were maintained in safe, clean, comfortable and homelike conditions related to wall bumpers at the base of the walls were not maintained in good repair and, a light fixture inside a resident's room directly over the head of the bed was not secured against the wall on two of two units.
- D
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Inspectors wroteBased on observations, interviews and record reviews, the facility failed to respond to a request for room change in a timely manner for one of two residents reviewed (Resident #31).
Fire safety inspections
21 fire safety citations on file: 9 on March 26, 2025, 5 on January 5, 2023, 7 on July 15, 2021.
Every fire safety citation21 citations
- F
Address subsistence needs for staff and patients.
E 15 · March 26, 2025 · 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 26, 2025 · Corrected (the home has a date of correction)
- D
Meet other general requirements.
K 200 · March 26, 2025 · Corrected (the home has a date of correction)
- D
Provide properly protected cooking facilities.
K 324 · March 26, 2025 · Corrected (the home has a date of correction)
- D
Have properly installed hallway dispensers for alcohol-based hand rub.
K 325 · March 26, 2025 · Corrected (the home has a date of correction)
- D
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · March 26, 2025 · Corrected (the home has a date of correction)
- D
Inspect, test, and maintain automatic sprinkler systems.
K 353 · March 26, 2025 · Corrected (the home has a date of correction)
- D
Have simulated fire drills held at unexpected times.
K 712 · March 26, 2025 · Corrected (the home has a date of correction)
- D
Ensure precautions for handling oxygen cylinders and equipment are correctly followed.
K 929 · March 26, 2025 · Corrected (the home has a date of correction)
- D
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · January 5, 2023 · Corrected (the home has a date of correction)
- D
Inspect, test, and maintain automatic sprinkler systems.
K 353 · January 5, 2023 · Corrected (the home has a date of correction)
- D
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
K 521 · January 5, 2023 · Corrected (the home has a date of correction)
- D
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
K 761 · January 5, 2023 · Corrected (the home has a date of correction)
- D
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · January 5, 2023 · Corrected (the home has a date of correction)
- D
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · July 15, 2021 · Corrected (the home has a date of correction)
- D
Inspect, test, and maintain automatic sprinkler systems.
K 353 · July 15, 2021 · Corrected (the home has a date of correction)
- D
Install corridor and hallway doors that block smoke.
K 363 · July 15, 2021 · Corrected (the home has a date of correction)
- D
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · July 15, 2021 · Corrected (the home has a date of correction)
- D
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
K 741 · July 15, 2021 · Corrected (the home has a date of correction)
- D
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · July 15, 2021 · Corrected (the home has a date of correction)
- D
Have proper medical gas storage and administration areas.
K 923 · July 15, 2021 · Corrected (the home has a date of correction)