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 36 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
2K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
23D
6E
5F
Potential for minimal harm
0A
0B
0C
April 22, 2026Standard inspection, Complaint inspection · 6 citations
- F
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 interviews, the facility failed to ensure a safe, comfortable, and homelike environment. This had the potential to affect all 91 residents in the facility.
- E
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 failed to ensure the food was prepared and stored in a safe and sanitary manner. This had the potential to affect all but two residents who the facility identified did not receive food from the kitchen. The facility census was 91.
- E
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, staff interviews, and review of facility policy, the facility failed to follow enhanced barrier precautions, and failed to ensure intravenous (IV) bags were properly secured and not on lying on a soiled surface. This affected one (Resident #3) of 14 residents reviewed for enhanced barrier precautions and had the potential to affect 34 residents identified by the facility on enhanced barrier precautions. The facility census was 91.
- D
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
Inspectors wroteBased on record review, staff interview, and review of the facility policy, the facility failed to ensure antipsychotic medications were used for an indicated diagnosis. This affected one, Resident (#73) out of five residents reviewed for unnecessary medications. The facility census was 91.
- D
Respond appropriately to all alleged violations.
Inspectors wroteBased on record review, resident and staff interviews, and review of the facility policy, the facility failed to investigate an allegation of verbal abuse. This affected one, Resident (#2) out of five residents reviewed for freedom from abuse, neglect, and misappropriation. The facility census was 91.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on record review, observation, and interviews, the facility failed to ensure a follow up appointment was scheduled in a timely manner for Resident #49. This affected one resident out of seven reviewed for wound care. The facility census was 91.
February 4, 2026Complaint inspection · 1 citation
- F
Provide and implement an infection prevention and control program.
Inspectors wroteBased on review of the facility's water management plan, staff interview, and review of the Centers for Disease Control and Prevention (CDC) Toolkit for Controlling Legionella in Common Sources of Exposure (Legionella Control Toolkit), the facility failed to have an adequate water management plan. This had the potential to affect all 93 residents residing in the facility. The census was 93.
March 6, 2025Standard inspection, Complaint inspection · 10 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 wrote4. Review of the medical record for Resident #59 revealed an admission date of 05/19/23, with diagnoses of major depressive disorder, post-traumatic stress disorder, panic disorder, schizophrenia, psychoactive substance abuse, anxiety, insomnia and unspecified mood disorder. Review of the care plan dated 10/27/23 revealed Resident #59 has diagnoses of anxiety with an intervention of maintaining a calm environment. Review of MDS assessment completed 01/17/25 revealed Resident #59 has a brief interview for mental status (BIMS) score of 15, indicating the resident is cognitively intact. Review of functional abilities section revealed the resident requires supervision or touching assistance with oral hygiene, toileting, and personal hygiene. [...]
- E
Provide and implement an infection prevention and control program.
Inspectors wroteBased on resident record review, observations, staff interviews, and review of policy, the facility did not have proper personal protective equipment in the laundry room to manage infectious material. Also, the facility did not follow proper isolation procedures for Resident #89. This had the potential to affect 87 residents of 89 residents in the facility. The facility identified two residents (#13 and #43) who did not have the facility launder their items. The facility census was 89.
- 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 medical record review, resident interview, staff interview, and facility document review, the facility failed to allow residents to refuse treatment without the threat of being discharged from the facility. This affected one (Resident #201) of two residents reviewed for dignity/rights. The census was 89.
- D
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Inspectors wroteBased on medical record review, staff interview and policy review, the facility failed to ensure all resident Pre-admission Screening and Resident Review (PASARR) documents were accurate to resident current conditions and diagnoses. This affected three (#3, #15, and #59) of four residents reviewed for PASARR documents. The census was 89.
- D
Notify the appropriate authorities when residents with MD or ID services has a significant change in condition.
Inspectors wroteBased on medical record review, staff interview and policy review, the facility failed to ensure all significant mental health changes were communicated to the state mental health agency. This affected three (#3, #15, and #59) of four residents reviewed for Pre-admission Screening and Resident Review (PASARR) documents. The census was 89.
- D
Provide enough food/fluids to maintain a resident's health.
Inspectors wroteBased on record review, staff interview, and policy review, the facility failed to ensure weekly weights were obtained per physician orders. This affected two (#77 and #92) of five reviewed for nutritional monitoring. The facility census was 96.
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on medical record review, review of hospital records and staff interviews, the facility failed to ensure a resident's respiratory needs were being met. This affected the one resident (#196) of one resident reviewed for oxygen use. The facility census was 89 residents.
- D
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Inspectors wroteBased on medical record review, observations, staff interviews and review of policy, the facility failed to ensure communication between the facility and dialysis vendor regarding dialysis treatments was on going for continuity of care. This affected one (#24) of one resident reviewed for dialysis. Seven residents currently receive dialysis treatments. The facility census was 89 residents.
- D
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Inspectors wroteBased on medical record review and staff interview, the facility failed to provide parameters for as needed pain medication. This affected one (#3) of five residents reviewed for unnecessary medications. The census was 89. Findings Include: Review of Resident #3's medical record revealed an admission on [DATE]. Her diagnoses included acute bronchitis, epileptic seizures, pulmonary embolism, post traumatic stress disorder, conversion disorder, phantom limb syndrome, bipolar disorder, unspecified protein calorie malnutrition, hypothyroidism, hypertension, other cervical disc degeneration, vitamin D deficiency, insomnia, atrial fibrillation, nonrheumatic mitral valve prolapse, muscle weakness, hypotension, repeated falls, pain, type II diabetes, depression, macular degeneration, hypermetropia, hyperlipidemia, anxiety disorder, acquired absence of right leg below knee, and epilepsy. [...]
- 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, medical record review, staff interviews, and policy review, the facility failed to secure and store medications appropriately. This affected one (#72) of 24 residents observed during the annual survey. The facility census was 89.
December 12, 2024Complaint inspection · 1 citation
- D
Respond appropriately to all alleged violations.
Inspectors wroteBased on record review, review of facility investigations, staff interviews, and facility policy and procedure, the facility failed to ensure allegations of abuse and misappropriation had thorough investigations and documentation of the investigation. This affected three residents (#86, #94, and #95) out of four residents reviewed for allegations of abuse and misappropriation. The facility census was 89.
November 21, 2024Complaint inspection · 2 citations
- F
Provide and implement an infection prevention and control program.
Inspectors wroteBased on interview, observation, record review and policy review, the facility failed to implement infection control procedures during a dressing change and while storing soiled laundry. This affected one (Resident #92) of three residents reviewed for wounds and had the potential to affect all residents residing in the facility. The facility census was 93.
- F
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, staff and resident interviews, review of plumbing invoices, and review of facility policy, the facility failed to maintain a safe, functional, and sanity environment in the shower room for the B hallway. This deficient practice had the potential to affect all residents residing in the facility. The facility census was 93. Findings Include: Review of the plumbing company invoice #143340436 dated 11/12/24 revealed plumbing company arrived at the customers property for a shower drain back up. After attempting to cable the shower drain, the blockage was removed and restored flow to the drain. Review of the plumbing company invoice #143544314 dated 11/13/24 revealed the facility was experiencing emergency flooding in the B hallway over the course of three days. [...]
October 29, 2024Complaint inspection · 4 citations
- K
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Inspectors wroteBased on medical record review, facility staff interviews, review of the fire investigation report, observation of facility video camera footage, review of the facility submitted Self-Reported Incident (SRI), and review of facility policy, the facility failed to ensure a resident was free from neglect when staff did not timely implement fire procedures when a mattress/bedding fire occurred in Resident #19's room. This resulted in Immediate Jeopardy and the potential for serious life-threatening harm, injuries, negative health outcomes and/or death when on 09/26/24 at 11:46 P.M. a fire occurred in Resident #19's room which ignited the resident's mattress/bedding on fire, activating the fire alarm and sprinkler system and facility staff did not attempt to immediately implement fire protocols to rescue, contain and/or extinguish the fire in Resident #19's room until 11:53 P.M. on 09/26/24. [...]
- K
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on medical record review, observations, facility staff interviews, resident interviews, family interviews, review of a fire drill report, review of emergency response reports, review of report of fire email communication, review of facility video camera footage, review of hospital records, review of the fire investigation report, and review of the facility policies for smoking and Oxygen Administration, the facility failed to ensure the residents environment remained as free from accident hazards as is possible when one resident (#19), who utilized oxygen therapy and who smoked cigarettes, possessed smoking materials, including cigarettes and a cigarette lighter, in her room. This resulted in Immediate Jeopardy and the potential for serious life-threatening harm, injuries, negative health outcomes and/or death when on 09/26/24 at 11:46 P.M. [...]
- E
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on medical record review, staff interviews, observation of facility video footage, review of the facility submitted Self-Reported Incident (SRI), and facility policy review, the facility failed to report an incident of potential neglect when the facility failed to timely implement fire protocol regarding rescuing residents, containing the fire and extinguishing and evacuating residents. This affected one Resident (#19) who had a fire in her room on 09/26/24 and had the potential to affect the other nine residents (Resident #11, #15, #16, #17, #18, #20, #21, #22, and #23) living in the same smoke compartment as Resident #19. The total facility census was 88.
- E
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Inspectors wroteBased on record reviews, staff interviews, review of facility camera footage, observation, review of a job description, review of the facility Self-Reported Incident (SRI), and facility policy review, the facility failed to be administered in a manner that enabled the facility to utilize available resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. This included failure to prevent neglect of residents by staff during a fire that occurred on 09/26/24, failure to ensure residents utilizing oxygen therapy were not able to possess lighters and smoking materials unsupervised, failure to timely and appropriately implement emergency procedures, when a fire occurred in Resident #19's room and ignited the resident's mattress/bedding on fire which ultimately activated the sprinkler system, including: [...]
August 16, 2024Complaint inspection · 1 citation
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on record review, observation, and interview, the facility failed to ensure fall interventions were in place. This affected one (Resident #22) of three residents reviewed for falls. The facility census was 94.
July 23, 2024Complaint inspection · 1 citation
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on medical record review, observation, staff interview and review of the facility policy the facility failed to maintain proper infection control measures during medication administration. This affected two (Residents #22) of four residents observed for medication administration. The facility also failed to implement enhanced barrier precautions (EBP) when appropriate. This one resident (Resident #28) of three residents reviewed for isolation precautions. The facility census was 95 residents.
June 21, 2024Complaint inspection · 2 citations
- F
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, record review, interview, and photographs, the facility was not maintained in a clean, homelike environment and was not in good repair. This affected all 87 residents residing in the facility. The census was 87.
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on record review, observation, policy review, and interview, the facility failed to assist one female resident with shaving her face. This affected one resident (#44) of three residents reviewed for activities of daily living (ADLs). The facility census was 87.
April 2, 2024Complaint inspection · 1 citation
- D
Ensure that residents are free from significant medication errors.
Inspectors wroteBased on medical record review, staff interview, and review of the facility policy, the facility failed to ensure medications were administered without significant errors. This affected one (Resident #96) of three residents reviewed for medications. The facility census was 91.
March 14, 2024Complaint inspection · 1 citation
- D
Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.
Inspectors wroteBased on medical record review and staff interview, the facility failed to ensure the contact information for the practitioner responsible for the care of the resident, resident representative information, advanced directives information, all special instructions or precautions for ongoing care and all other necessary information to ensure a safe and effective transition of care was communicated to the receiving health care institution or provider upon transfer/discharge. This affected three (Residents #90, #91, and #92) out of three residents reviewed for hospitalization. The facility census was 85.
November 7, 2023Complaint inspection · 4 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 medical record review and staff interview, the facility failed to ensure resident representatives were notified of medication changes. This affected one (Resident #1) out of three residents reviewed for medications. The census was 91.
- D
Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
Inspectors wroteBased on closed record review and staff interview, the facility failed to develop a recapitulation of a resident's stay when the resident had a planned discharge. This affected one (Resident #93) out of one sampled resident who had a planned discharge to the community. The census was 91.
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on medical record review, staff interview, and facility policy review, the facility failed to routinely assess pressure ulcers as well as ensure wound assessments included a description of the wound. This affected three (#48, #92, and #93) out of three residents reviewed for pressure ulcers. Additionally, the facility failed to initiate treatment for a pressure ulcer in a timely manner. This affected one (#92) out of three residents reviewed for pressure ulcers. The census was 91.
- D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Inspectors wroteBased on closed record review and staff interview, the facility failed to ensure there was a receipt of disposition for narcotic pain medication upon discharge from the facility. This affected one (Resident #93) out of one resident reviewed for planned discharge. The census was 91.
March 16, 2023Standard inspection · 2 citations
- 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 record review, interviews, and policy review, the facility failed to complete quarterly care conferences for residents. This affected two (Residents #16 and #18) of two residents reviewed for care plans. The facility census was 87.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on medical record review, resident interview, hospital staff interview, and staff interview, the facility failed to ensure a resident attended scheduled medical appointments. This affected one (Resident #71) of three residents reviewed for medical appointments. The census was 87.
Fire safety inspections
31 fire safety citations on file: 5 on April 22, 2026, 1 on February 4, 2026, 6 on March 6, 2025, 3 on January 13, 2025, 5 on November 19, 2024, 5 on October 29, 2024, 6 on March 16, 2023.
Every fire safety citation31 citations
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · April 22, 2026 · Corrected (the home has a date of correction)
- F
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · April 22, 2026 · Corrected (the home has a date of correction)
- F
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
K 521 · April 22, 2026 · Corrected (the home has a date of correction)
- E
Install an approved automatic sprinkler system.
K 351 · April 22, 2026 · Corrected (the home has a date of correction)
- E
Have properly installed electrical wiring and gas equipment.
K 511 · April 22, 2026 · Corrected (the home has a date of correction)
- E
Have restrictions on the use of portable space heaters.
K 781 · February 4, 2026 · Corrected (the home has a date of correction)
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · March 6, 2025 · Corrected (the home has a date of correction)
- F
Properly select, install, inspect, or maintain portable fire extinguishes.
K 355 · March 6, 2025 · Corrected (the home has a date of correction)
- F
Have restrictions on the use of portable space heaters.
K 781 · March 6, 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 · March 6, 2025 · Corrected (the home has a date of correction)
- E
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · March 6, 2025 · Corrected (the home has a date of correction)
- E
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
K 761 · March 6, 2025 · Corrected (the home has a date of correction)
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · January 13, 2025 · Corrected (the home has a date of correction)
- E
Keep aisles, corridors, and exits free of obstruction in case of emergency.
K 211 · January 13, 2025 · Corrected (the home has a date of correction)
- E
Install smoke barrier doors that can resist smoke for at least 20 minutes.
K 374 · January 13, 2025 · Corrected (the home has a date of correction)
- F
Install an approved automatic sprinkler system.
K 351 · November 19, 2024 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · November 19, 2024 · Corrected (the home has a date of correction)
- F
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
K 354 · November 19, 2024 · Corrected (the home has a date of correction)
- E
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
K 362 · November 19, 2024 · Corrected (the home has a date of correction)
- E
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
K 741 · November 19, 2024 · Corrected (the home has a date of correction)
- K
Provide a written emergency evacuation plan.
K 711 · October 29, 2024 · Corrected (the home has a date of correction)
- K
Ensure that sources of ignition are removed from patients receiving respiratory therapy.
K 925 · October 29, 2024 · Corrected (the home has a date of correction)
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · October 29, 2024 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · October 29, 2024 · Corrected (the home has a date of correction)
- F
Install smoke barrier doors that can resist smoke for at least 20 minutes.
K 374 · October 29, 2024 · Corrected (the home has a date of correction)
- F
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 · March 16, 2023 · Corrected (the home has a date of correction)
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · March 16, 2023 · Corrected (the home has a date of correction)
- F
Have proper power supply for life support equipment.
K 915 · March 16, 2023 · Waiver
- E
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · March 16, 2023 · Corrected (the home has a date of correction)
- E
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
K 741 · March 16, 2023 · Corrected (the home has a date of correction)
- D
Have power receptacles that are properly grounded.
K 912 · March 16, 2023 · Corrected (the home has a date of correction)