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 30 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
21D
8E
0F
Potential for minimal harm
0A
0B
1C
February 27, 2026Standard inspection · 10 citations
- 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 and staff interview, it was determined that the facility failed to store food items in a safe and sanitary manner and maintain equipment in a sanitary condition in the facility's main kitchen.
- E
Provide and implement an infection prevention and control program.
Inspectors wroteBased on clinical record review, observation, and resident and staff interview, it was determined that the facility failed to store indwelling urinary catheter equipment in a manner to prevent the potential for infection for one of one resident reviewed for catheter concerns (Resident 9).
- D
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
Inspectors wroteBased on clinical record review and staff interview it was determined that the facility failed to identify and monitor the medical symptoms that warranted the use of an antipsychotic medication and monitor for potential adverse consequences of antipsychotic medication use for one of five residents reviewed for potentially unnecessary medication (Resident 9).
- D
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Inspectors wroteBased on clinical record review, review of facility documentation, and staff interview it was determined that the facility failed to provide written notice of transfer to the resident representative for three of six residents reviewed (Residents 5, 9, and 12) and written notice of the facility bed-hold policy for two of six residents reviewed for hospitalization (Residents 9 and 12).
- 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 an assessment accurately reflected the resident's status for one of 18 residents reviewed (Resident 9).
- 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 and implement a comprehensive, person-centered, trauma-informed care plan to meet a resident's mental and psychosocial needs for one of 18 residents reviewed (Resident 9).
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on clinical record review, observation, and staff and family interview, it was determined that the facility failed to ensure assistance with activities of daily living for a dependent resident for one of one resident reviewed for activities of daily living concerns (Resident 66).
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on review of select facility policy and procedures, clinical record review, observation, and staff interview, it was determined that the facility failed to provide respiratory care for non-invasive ventilation consistent with professional standards of practice and develop a comprehensive and person-centered care plan for one of two residents reviewed (Resident 5) and maintain respiratory related equipment supplies in a safe and sanitary manor in two of two dining rooms observed (main dining room and restorative dining room).
- D
Provide safe, appropriate pain management for a resident who requires such services.
Inspectors wroteBased on clinical record review, review of facility documentation, and staff interview, it was determined that the facility failed to provide the highest practicable care regarding physician ordered pain medications and pain parameters for one of one resident reviewed for pain (Resident 3).
- D
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Inspectors wroteBased on a review of select facility policies and procedures, clinical record review, and staff interview, it was determined that the facility failed to ensure a resident received pneumococcal immunizations unless refused or clinically contraindicated for one of five residents reviewed for immunization concerns (Resident 12).
January 22, 2026Complaint inspection · 1 citation
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on closed clinical record review, review of select policies and procedures, and staff interview, it was determined that the facility failed to thoroughly investigate and report allegations of abuse and neglect for two of three residents reviewed (Residents CR1 and CR2).
March 21, 2025Standard inspection · 10 citations
- E
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Inspectors wroteBased on clinical record review and staff interview, it was determined that the facility failed to develop and implement individualized person-centered care plans to address dementia and cognitive loss displayed by three of three residents reviewed (Residents 18, 55, and 61).
- 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 and staff interview, it was determined that the facility failed to store food items in a safe and sanitary manner, maintain equipment in a sanitary condition, and prepare food items in accordance with professional standards in the facility's main kitchen.
- E
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
Inspectors wroteBased on review of employee education records and staff interview, it was determined that the facility failed to ensure that nurse aides received 12 hours of in-service training annually for three of three nurse aides reviewed (Employees 1, 2, and 3).
- D
Reasonably accommodate the needs and preferences of each resident.
Inspectors wroteBased on observation and resident and staff interview, it was determined that the facility failed to provide a reasonable accommodation of needs in response to call bell activations for one of two nursing units observed (Unit 2; Residents 14 and 57).
- 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 and staff interview, it was determined that the facility failed to provide adequate housekeeping and maintenance services to ensure a clean, safe, and orderly environment on one of two nursing units (Unit 3; Residents 51 and 73).
- D
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Inspectors wroteBased on clinical record review and staff interview, it was determined that the facility failed to ensure that the resident or resident representative received written notice of the facility bed hold policy at the time of transfer for two of five residents reviewed for hospitalizations (Residents 11 and 70).
- 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 on clinical record review, review of select facility policies and procedures, and staff interview, it was determined that the facility failed to provide appropriate treatment and services to promote bladder continence for one of one resident reviewed for incontinence (Resident 31).
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on clinical record review, observation, and staff interview, it was determined that the facility failed to store supplemental oxygen equipment per professional standards of practice for one of one resident reviewed (Resident 19).
- D
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
Inspectors wroteBased on observation, clinical record review, and staff interview, it was determined that the facility failed to assess for the risk of side rail entrapment for one of three residents reviewed for accident hazards (Resident 72).
- C
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 a resident and/or their responsible party in writing of a transfer to the hospital with the required information for four of five residents reviewed (Residents 11, 39, 48, and 70).
March 22, 2024Standard inspection · 9 citations
- E
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Inspectors wroteBased on clinical record review, review of select policies and procedures, and staff interview, it was determined that the facility failed to initiate their abuse policy and thoroughly investigate incidents to rule out the potential for abuse for one of two residents reviewed (Resident 64).
- E
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 provide the highest practicable care regarding bowel protocol medication administration for two of two residents reviewed (Residents 43 and 77) and regarding the use of a cardiac pacemaker for one of one resident reviewed with a pacemaker (Resident 26).
- 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 clinical record review, observation, and staff interview, it was determined that the facility failed to provide the appropriate physician ordered enteral nutrition for one of one resident reviewed for tube feeding concerns (Resident 27).
- 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 clinical record review and staff interview, it was determined that the facility failed to establish clear and consistent resident's wishes regarding advance directives for two of three residents reviewed (Residents 26 and 32).
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on observation, clinical record review, review of facility documentation, and staff and a resident's family interview, it was determined that the facility failed to implement interventions to prevent falls and/or injuries for one of seven residents reviewed for falls (Resident 57) and failed to prevent a potential accident hazard at the facility's main entrance.
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on clinical record review, observation, and staff interview, it was determined that the facility failed to administer supplemental oxygen as prescribed by the physician for one of one resident reviewed for oxygen concerns (Resident 27).
- D
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
Inspectors wroteBased on clinical record review and staff interview, it was determined that the facility failed to ensure necessary behavioral health treatments were initiated for one of one resident reviewed (Resident 64).
- D
Ensure medication error rates are not 5 percent or greater.
Inspectors wroteBased on observation, clinical record review, and staff interview, it was determined that the facility failed to ensure a medication error rate of less than five percent (Resident 45).
- D
Have a policy regarding use and storage of foods brought to residents by family and other visitors.
Inspectors wroteBased on review of select facility policies, observations, and staff and resident family interviews, it was determined that the facility failed to ensure safe and sanitary storage and handling of personal food products brought in from outside sources for one of two nursing units. (200 Nursing Unit, Resident 57). Findings Include: Review of Facility Policy: Foods Brought by Family/Visitors, last reviewed without changes on November 17, 2023, revealed that the facility will strive to balance resident choice and a homelike environment with the nutritional and safety needs of residents. Facility staff will discard perishable foods on or before the use by date. Nursing and/or food service staff will discard any food any foods prepared for the resident that show obvious signs of potential foodborne danger (for example, mold growth, foul odor, past due package expiration dates). [...]
Fire safety inspections
4 fire safety citations on file: 2 on February 27, 2026, 1 on March 21, 2025, 1 on March 22, 2024.
Every fire safety citation4 citations
- E
Have properly located and lighted "Exit" signs.
K 293 · February 27, 2026 · Corrected (the home has a date of correction)
- E
Install an approved automatic sprinkler system.
K 351 · February 27, 2026 · 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 · March 21, 2025 · Corrected (the home has a date of correction)
- 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 · March 22, 2024 · Corrected (the home has a date of correction)