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
0J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
19D
3E
2F
Potential for minimal harm
0A
2B
0C
June 17, 2026Complaint 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 observations and staff interview, it was determined that the facility failed to provide a safe, clean, and comfortable environment on one of two nursing units. (Unit B)
December 5, 2025Standard inspection · 6 citations
- 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, it was determined that the facility failed to maintain the environment in a clean, comfortable, and homelike manner on two of two nursing units. (A and B wing)
- D
Allow residents to self-administer drugs if determined clinically appropriate.
Inspectors wroteBased on facility policy review, clinical record review, observation, and resident and staff interview, it was determined that the facility failed to assess a resident's capability to self-administer medications for one of 14 sampled residents. (Resident 19)
- D
Ensure each resident receives an accurate assessment.
Inspectors wroteBased on clinical record review and staff interview, it was determined that the facility failed to ensure that the Minimum Data Set (MDS) assessment was completed to accurately reflect the current status of two of 14 sampled residents. (Residents 1 and 4)
- 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 clinical record review and staff interview, it was determined that the facility failed to develop a comprehensive care plan to meet each resident's needs as identified in the comprehensive assessment for one of 14 sampled residents. (Resident 1)
- 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 clinical record review, review of facility documentation, observation, and staff and resident interviews, it was determined that the facility failed to accommodate food preferences for one of 14 sampled residents. (Resident 54)
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on facility policy review, clinical record review, observation, and staff interview, it was determined that the facility failed to implement enhanced barrier precautions and use of personal protective equipment (PPE) to prevent the spread of infection for one of four sampled residents observed during medication administration. (Resident 4)
April 23, 2025Complaint inspection · 2 citations
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on clinical record review, observation, and staff interview, it was determined that the facility failed to ensure that physician's orders were implemented for one of eight sampled residents. (Resident 1)
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on clinical record review, observation, and interview, it was determined that the facility failed to provide interventions to prevent pressure ulcers for three of eight sampled residents. (Residents 1, 2, 3).
January 16, 2025Standard inspection · 9 citations
- E
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Inspectors wroteBased on facility policy review, employee file review, and staff interview, it was determined that the facility failed to initiate an employee criminal background check, verify professional license/registration, and/or ensure employees completed required abuse training in a timely manner for six of six newly hired employees. (Employees RN 1, RN 2, RN 3, NA 1, NA 2, DA 1)
- D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteBased on clinical record review and observation, it was determined that the facility failed to provide assistance with dining in a manner that promoted dignity for one of 16 sampled residents. (Resident 5)
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on facility policy review, clinical record review, review of facility documentation, and staff interview, it was determined that the facility failed to report an allegation of abuse to the Administrator and the State Survey Agency for one of 16 sampled residents. (Resident 16)
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on clinical record review, observation, and resident interview, it was determined that the facility failed to ensure that physician's orders were implemented for one of 16 sampled residents. (Resident 40)
- D
Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services.
Inspectors wroteBased on clinical record review, and family and staff interview, it was determined that the facility failed to provide ostomy (an opening of the bowel through the abdomen), care in accordance with the resident's care plan for one of one sampled resident who had an ostomy. (Resident 158)
- D
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Inspectors wroteBased on clinical record review and staff interview, it was determined that the facility failed to ensure that pharmacy recommendations were reviewed by the physician in a timely manner for one of 16 sampled residents. (Resident 41)
- D
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
Inspectors wroteBased on review of facility documents and staff interview, it was determined that the facility failed to conduct Quality Assessment and Assurance (QAA) meetings at least quarterly with all the required committee members for two of four quarterly meetings, the first and fourth, of 2024.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on facility policy review, clinical record review, and observation, it was determined that the facility failed to follow policies and procedures to prevent the spread of infection for two of 16 sampled residents. (Residents 27 and 35)
- B
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Inspectors wroteBased on clinical record review and staff interview, it was determined that the facility failed to notify the resident and the resident's representative(s) of transfer(s), including the reasons for the moves and Ombudsman information, in writing upon transfer from the facility for three of three sampled residents who were transferred to the hospital. (Resident 11, 13, 56)
August 10, 2024Complaint inspection · 1 citation
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on clinical record review and staff interview, it was determined that the facility failed to ensure that physician's orders were implemented for two of four sampled residents. (Residents 1, 2)
August 1, 2024Complaint inspection · 2 citations
- F
Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
Inspectors wroteBased on policy review and staff interview, it was determined that the facility did not have a qualified Infection Preventionist (IP) who had completed specialized training in infection prevention and control.
- E
Provide and implement an infection prevention and control program.
Inspectors wroteBased on facility policy review, clinical record review, observation, and staff interview, it was determined that the facility failed to follow policies and procedures to prevent the spread of infection on two of two nursing unit wings. (A Wing, B Wing)
March 14, 2024Complaint inspection · 1 citation
- B
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, it was determined that the facility failed to provide a clean, homelike, and comfortable environment on two of two nursing units. (A-wing and B-wing)
December 28, 2023Standard inspection · 3 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 clinical record review and staff interview, it was determined that the facility failed to develop a care plan and interventions to meet each resident's needs as identified in the comprehensive assessment for two of 13 sampled residents. (Residents 25, 154)
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on clinical record review, policy review, and staff interview, it was determined that the facility failed to ensure that physicians' orders or care plan interventions were implemented for two of 13 sampled residents. (Residents 36, 42)
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on policy review, observation, and staff interview, it was determined that the facility failed to administer medications in accordance with facility infection control policies on one of two nursing units. (A hall)
November 6, 2023Complaint inspection · 1 citation
- 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, review of facility documentation, and interview, it was determined that the facility failed to store food under sanitary conditions in the kitchen and on the nursing unit.
Fire safety inspections
18 fire safety citations on file: 9 on December 5, 2025, 3 on January 16, 2025, 6 on December 28, 2023.
Every fire safety citation18 citations
- F
Conduct risk assessment and an All-Hazards approach.
E 6 · December 5, 2025 · Corrected (the home has a date of correction)
- F
Provide a means of sharing information on occupancy/needs.
E 34 · December 5, 2025 · Corrected (the home has a date of correction)
- F
Establish emergency prep training and testing.
E 36 · December 5, 2025 · Corrected (the home has a date of correction)
- E
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
K 222 · December 5, 2025 · Corrected (the home has a date of correction)
- E
Meet requirements for the installation and maintenance of electrical systems.
K 911 · December 5, 2025 · Corrected (the home has a date of correction)
- C
Develop and maintain an Emergency Preparedness Program (EP).
E 4 · December 5, 2025 · Corrected (the home has a date of correction)
- C
Establish procedures for tracking staff and patients during an emergency.
E 18 · December 5, 2025 · Corrected (the home has a date of correction)
- C
Establish roles under a Waiver declared by secretary.
E 26 · December 5, 2025 · Corrected (the home has a date of correction)
- C
Provide family notifications of emergency plan.
E 35 · December 5, 2025 · Corrected (the home has a date of correction)
- E
Have properly located and lighted "Exit" signs.
K 293 · January 16, 2025 · Corrected (the home has a date of correction)
- E
Have power receptacles that are properly grounded.
K 912 · January 16, 2025 · Corrected (the home has a date of correction)
- E
Have proper medical gas storage and administration areas.
K 923 · January 16, 2025 · Corrected (the home has a date of correction)
- F
Conduct risk assessment and an All-Hazards approach.
E 6 · December 28, 2023 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · December 28, 2023 · Corrected (the home has a date of correction)
- E
Install emergency lighting that can last at least 1 1/2 hours.
K 291 · December 28, 2023 · Corrected (the home has a date of correction)
- E
Have proper medical gas storage and administration areas.
K 923 · December 28, 2023 · Corrected (the home has a date of correction)
- C
Develop and maintain an Emergency Preparedness Program (EP).
E 4 · December 28, 2023 · Corrected (the home has a date of correction)
- C
Provide family notifications of emergency plan.
E 35 · December 28, 2023 · Corrected (the home has a date of correction)