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 45 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
1G
0H
0I
Potential for more than minimal harm
35D
2E
7F
Potential for minimal harm
0A
0B
0C
July 23, 2026Standard inspection, Complaint inspection · 11 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, staff interview, and review of facility documents and policy, the facility failed to ensure food was stored and prepared under sanitary conditions. This had the potential to affect all residents in the facility with the exception of one facility-identified (Resident #61) who did not receive food from the facility kitchen. The facility census was 87 residents. Findings Include:1. Observation on 07/20/26 at 9:08 A.M. of the dry food storage area revealed there was a box of thickened hot chocolate mis with a use by date of 11/02/25 and a box of thickened coffee with a use by date of 02/15/26. Interview on 07/20/26 at 9:17 A.M. with [NAME] #272 verified thickened hot chocolate and thickened coffee were expired and should have been discarded. 2. Observation on 07/20/26 at 9:30 A.M. [...]
- F
Provide and implement an infection prevention and control program.
Inspectors wroteBased on record review, staff interview, and policy review, the facility failed to conduct adequate infection control surveillance. This had the potential to affect all of the residents residing in the facility. The facility census was 87 residents.
- E
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Inspectors wroteBased on medical record review, staff interview, and policy review, the facility failed to notify the Ombudsman of resident discharges and hospitalizations and did not provide bed hold notices. This affected four (Residents #3, #10, #92, and #95) of seven residents reviewed for discharge and hospitalizations. The facility census was 87 residents.
- E
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on medical record review, resident interview, staff interview, and policy review, the facility failed to ensure dependent residents received showers. This affected four (Residents #51, #1, #9, #65) of 18 residents reviewed for activities of daily living (ADLs). The facility census was 87 residents.
- D
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Inspectors wroteBased on medical record review and staff interview, the facility failed to provide Notice of Medicare Non-Coverage (NOMNC) when therapy services were completed and failed to provide Skilled Nursing Facility/Advance Beneficiary Notice of Non-coverage (SNF/ABN) notifications. This affected two (Residents #5 and #9) of three residents reviewed for NOMNC and SNF/ABN notices. The facility census was 87 residents.
- D
Ensure each resident receives an accurate assessment.
Inspectors wroteBased on medical record review, staff interview, and review of the facility policy, the facility failed to ensure resident assessments were accurate. This affected two (Residents #97 and #106) of 18 residents sampled. The facility census was 87 residents.
- D
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Inspectors wroteBased on medical record review, observation, resident interview, staff interview, and policy review, the facility failed to ensure baseline care plans were accurate. This affected one (Resident #51) of 18 residents sampled. The facility census was 87 residents. Review of the medical record for Resident #51 revealed an admission date of 05/28/26 with diagnoses including acute osteomyelitis right ankle and foot, type two diabetes, and urge incontinence. Review of the Minimum Data Set (MDS) assessment for Resident #51 dated 06/03/26 revealed the resident had intact cognition, was dependent on staff assistance with toileting, and had a urinary catheter. Review of the baseline care plan for Resident #51dated on 05/28/26 revealed the resident was incontinent of bladder but not indicate the presence of a urinary catheter or basic interventions for the resident's catheter. [...]
- 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 medical record review, staff interview, and review of the facility policy, the facility failed to ensure care conferences were conducted on a quarterly basis. This affected three residents (Residents #2, #6, and #67) of 18 residents sampled. The facility census was 87 residents.
- 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 medical record review, staff interview, and policy review, the facility failed to ensure catheter care orders were in place for residents requiring catheter care. This affected one (Resident #5) of two residents with catheters. The facility census was 87 residents.
- D
Ensure medication error rates are not 5 percent or greater.
Inspectors wroteBased on medical record review, observation, staff interview, and policy review, the facility failed to ensure a medication error rate below five percent (%). The medication error rate was 11.1 % based on 27 medication opportunities and three medication errors. This affected one (Resident #73) of three residents observed for medication administration. The facility census was 87 residents.
- 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, staff interview, and review of the facility policy, the facility failed to ensure residents' insulin was properly labeled. This affected two (Residents #54 and #30) of 21 facility-identified residents with orders for insulin. The facility census was 87 residents.
April 13, 2026Complaint 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 interview and record review, the facility failed to notify a resident's resident representative of a change in condition or an injury of unknown origin. This affected one (#24) resident out of three residents reviewed for notification of change in condition. The facility census was 80. [...]
- 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 an injury of unknown origin was reported to the state surveying agency. This affected one (#24) resident out of three residents reviewed for injury of unknown origins. The facility census was 80. Review of Resident #24's chart revealed Resident #24 admitted to the facility on [DATE] with unspecified dementia unspecified severity without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety, Type Two Diabetes Mellitus without complications, acute embolism and thrombosis of unspecified vein, cognitive communication deficit, muscle weakness, hyperlipidemia, altered mental status, dysphagia, other toxic encephalopathy, insomnia, essential hypertension, orthostatic hypertension, peripheral vascular disease, depression, unspecified urinary incontinence, full incontinence of feces and gastrostomy status. [...]
- D
Respond appropriately to all alleged violations.
Inspectors wroteBased on interview and record review, the facility failed to thoroughly investigate an injury of unknown origin. This affected one (#24) resident out of three residents reviewed for injury of unknown origins. The facility census was 80. Review of Resident #24's chart revealed Resident #24 admitted to the facility on [DATE] with unspecified dementia unspecified severity without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety, Type Two Diabetes Mellitus without complications, acute embolism and thrombosis of unspecified vein, cognitive communication deficit, muscle weakness, hyperlipidemia, altered mental status, dysphagia, other toxic encephalopathy, insomnia, essential hypertension, orthostatic hypertension, peripheral vascular disease, depression, unspecified urinary incontinence, full incontinence of feces and gastrostomy status. [...]
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on interview and record review, the facility failed to monitor a resident's swollen upper lip with dark purple discoloration as ordered by the Nurse Practitioner (NP). This affected one (#24) resident out of three residents reviewed for monitoring resident conditions. The facility census was 80. [...]
February 23, 2026Complaint inspection · 8 citations
- G
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on record review, review of hospital paperwork, staff interview, policy review and review of online medical resources, the facility failed to monitor and record resident bowel functioning. This resulted in Actual Harm for Resident #76 whose last documented bowel movement occurred on 11/19/25. Resident #76 was subsequently treated in the hospital for a fecal impaction on 01/25/26. This affected one (Resident #76) of three residents reviewed for hospitalization. The facility census was 78 residents.
- F
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Inspectors wroteBased on observation, review of the facility menu and dietary spreadsheets, and staff interview, the facility failed to ensure the menu was followed and portion sizes were served as planned on dietary spreadsheets. This had the potential to affect 76 residents in the facility. The facility identified two (Residents #49 and #50) who did not receive food from the kitchen. The facility census was 78 residents.
- F
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Inspectors wroteBased on observation, staff interview, resident interview, and policy review, the facility failed to ensure food was served at the appropriate temperature and was palatable. This had the potential to affect 76 of 78 residents in the facility. The facility identified two (Residents #49 and #50) who did not receive food from the kitchen. The facility census was 78 residents.
- 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, staff interview, and policy review, the facility failed to ensure staff wore hair restraints in the kitchen, failed to ensure staff washed their hands upon entering the kitchen and before handling food, and failed to ensure food was stored in a manner to protect against the potential spread of foodborne illness. This had the potential to affect 76 of 78 residents residing in the facility. The facility identified two (Residents #49 and #50) who did not receive food from the kitchen. The facility census was 78 residents.
- F
Keep all essential equipment working safely.
Inspectors wroteBased on observation, staff interview, and policy review, the facility failed to ensure kitchen staff had access to adequate handwashing facilities in the kitchen. This had the potential to affect 76 residents. The facility identified two (Residents #49 and #50) who did not receive food from the kitchen. The facility census was 78 residents.
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on medical record review, staff interview, observation, and policy review, the facility failed to ensure adequate care was provided to residents. This affected two (Residents #28 and #77) of four residents reviewed for activities of daily living (ADL) care. The facility census was 78 residents.
- D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on medical record review and staff interview, the facility failed to ensure medical records were accurate and updated. This affected three (Residents #76, #77, and #84) of four residents reviewed for documentation. The facility census was 78 residents.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on medical record review, observation, staff interview, and policy review the facility failed to ensure staff wore appropriate personal protection equipment (PPE) while providing care to residents in Enhanced Barriers Precautions (EBP). This affected one (Resident #71) and had the potential to affect 13 facility-identified residents with orders for OBP. The facility census was 78 residents.
January 27, 2025Complaint inspection · 4 citations
- D
Reasonably accommodate the needs and preferences of each resident.
Inspectors wroteBased on medical record review, staff interview, and observation, the facility failed to ensure the phones were answered during the nighttime hours. This affected one (Resident #45) of three residents reviewed for communication with the staff via telephone. This had the potential to affect all of the residents. The facility census was 73 residents.
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on medical record review, observation, and staff interview, the facility failed to ensure incontinence care was provided in a timely manner. This affected one (Resident #36) of three residents reviewed for incontinence care. The facility census was 73 residents.
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on medical record review, staff interview, and review of the facility policy, the facility failed to ensure staff provided the appropriate level of supervision during resident transfers using the sit to stand lift. This affected one (Resident #36) of three residents reviewed for falls. The facility census was 73 residents.
- 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 medical record review, observation, staff interview, resident interview, and review of the facility policy, the facility failed to ensure the temperature in resident rooms was satisfactory. This affected one (Resident #43) of three residents reviewed for the physical environment. The facility census was 73 residents.
November 18, 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 medical record review, and staff interview, the facility failed to use the proper lift for resident transfers. This affected one (Resident #10) of three residents reviewed for lift transfers. The facility census was 81 residents.
September 30, 2024Complaint inspection · 3 citations
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on medical record review, observations, and staff and resident interview, the facility failed to ensure a resident who was dependent on staff with transferring out of bed received timely assistance with activities of daily living (ADL). This affected one (Resident #3) of one resident reviewed for ADLs. The facility census was 87.
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on medical record review, observations, and family and staff interviews, the facility failed to ensure the residents who were at risk for developing pressure ulcer were turned and repositioned every two to three hours per their care plan interventions and failed to complete treatments to the right heel ordered by the physician at the hospital. This affected three (#10, #18, and #72) three residents reviewed for change of positioning. The facility census was 87.
- 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 medical record review, staff interview and policy review, the facility failed to ensure the resident's bladder scans were completed for a trial after the indwelling catheter was removed per hospital discharge orders. This affected one (#18) of one resident reviewed for bladder scanning. The facility census was 87.
May 16, 2024Complaint inspection · 3 citations
- D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Inspectors wroteBased on medical record review, staff interviews and policy review, the facility failed to ensure medications were administered via the physician ordered route. This affected one (#31) of five residents observed for medication administration observation. The facility census was 69.
- 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 medical record review, observations, staff interviews and policy review, the facility failed to ensure medications were securely stored. This affected two (#22 and #19) of five residents observed for medication administration. The facility census was 72.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on medical record review, staff interview, observations, policy review, review of manufacture's recommendations and review of the Centers of Disease Control website, the facility failed to disinfect a glucose monitoring device after usage with an appropriate disinfectant. This had the potential to affect two residents (#13 and #6) residing on the B unit of the second floor who share the glucose monitoring device. Additionally, the facility failed to ensure staff completed hand hygiene after removing wound dressing on resident in enhanced barrier precaution. This affected one (#34) out of three residents reviewed for infection control practices. The facility census was 72.
February 29, 2024Complaint inspection · 1 citation
- F
Provide and implement an infection prevention and control program.
Inspectors wroteBased on record review, staff interview, and policy review, the facility failed to have a comprehensive water management plan to prevent water contamination. This had the potential to affect all residents residing in the facility. The census was 70.
February 2, 2024Standard inspection, Complaint inspection · 10 citations
- D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteBased on observation, interview, and facility policy, the facility failed to treat a resident with dignity and respect. This affected one (Resident #28) of one reviewed for dignity and respect. The facility census was 72.
- D
Reasonably accommodate the needs and preferences of each resident.
Inspectors wroteBased on record review, observation, interview, and facility policy, facility failed to ensure a resident had access to their call light. This affected one (Resident #71) of three residents reviewed for call lights. The facility census was 72.
- 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 record review, staff interview, and policy review, the facility failed to ensure advance directives were documented appropriately. This affected one (#37) out of eight residents reviewed for advance directives. The census was 72.
- 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 an injury of unknown origin was reported to the state agency. This affected one (#51) of one resident reviewed for abuse. The facility census was 72.
- D
Respond appropriately to all alleged violations.
Inspectors wroteBased on interview and record review, the facility failed to ensure an injury of unknown origin was thoroughly investigated. This affected one (#51) out of one resident reviewed for abuse. The facility census was 72.
- 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 interview and record review, the facility failed to ensure resident care plans reflected the residents current status and behaviors. This affected one (#70) of one resident reviewed for care planning. The facility census was 72.
- D
Assist a resident in gaining access to vision and hearing services.
Inspectors wroteBased on medical record review, observation, and staff interview, the facility failed to ensure a resident had access to hearing aids. This affected one (Resident #43) of one resident reviewed for hearing. The facility census was 72.
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on record review, and staff interview, the facility failed to ensure residents received proper staff assistance with care to prevent falls. This affected one (#66) out of seven residents reviewed for accidents. The facility census was 72.
- 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 medical record, observation, interview, and facility policy, facility failed to provide timely incontinence care for two residents (#328 and #28) of four reviewed for incontinence care. Facility census was 72.
- 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 wroteReview of facility record, observation, interview, and facility policy, the facility failed to provide supervision when taking medication for one resident (#50) out of four residents reviewed for medication. Facility census was 72.
January 16, 2020Standard inspection · 0 citations
Fire safety inspections
25 fire safety citations on file: 7 on July 23, 2026, 3 on August 15, 2024, 10 on February 2, 2024, 5 on January 16, 2020.
Every fire safety citation25 citations
- F
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
K 321 · July 23, 2026 · deficient, provider has
- F
Install an approved automatic sprinkler system.
K 351 · July 23, 2026 · deficient, provider has
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · July 23, 2026 · deficient, provider has
- F
Install corridor and hallway doors that block smoke.
K 363 · July 23, 2026 · deficient, provider has
- F
Install properly constructed and protected linen or trash chutes.
K 541 · July 23, 2026 · deficient, provider has
- F
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · July 23, 2026 · deficient, provider has
- E
Provide properly protected cooking facilities.
K 324 · July 23, 2026 · deficient, provider has
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · August 15, 2024 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · August 15, 2024 · Corrected (the home has a date of correction)
- F
Have simulated fire drills held at unexpected times.
K 712 · August 15, 2024 · Corrected (the home has a date of correction)
- F
Conduct risk assessment and an All-Hazards approach.
E 6 · February 2, 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 · February 2, 2024 · Corrected (the home has a date of correction)
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · February 2, 2024 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · February 2, 2024 · 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 · February 2, 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 2, 2024 · Corrected (the home has a date of correction)
- E
Provide properly protected cooking facilities.
K 324 · February 2, 2024 · Corrected (the home has a date of correction)
- E
Install corridor and hallway doors that block smoke.
K 363 · February 2, 2024 · Corrected (the home has a date of correction)
- E
Have properly installed electrical wiring and gas equipment.
K 511 · February 2, 2024 · Corrected (the home has a date of correction)
- E
Have proper medical gas storage and administration areas.
K 923 · February 2, 2024 · Corrected (the home has a date of correction)
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · January 16, 2020 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · January 16, 2020 · Corrected (the home has a date of correction)
- F
Have properly installed electrical wiring and gas equipment.
K 511 · January 16, 2020 · Corrected (the home has a date of correction)
- E
Have exits that are accessible at all times.
K 271 · January 16, 2020 · Corrected (the home has a date of correction)
- E
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · January 16, 2020 · Corrected (the home has a date of correction)