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 24 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
20D
2E
2F
Potential for minimal harm
0A
0B
0C
June 11, 2026Standard inspection, Complaint inspection · 7 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, staff interview, and policy review, the facility failed to ensure safe temperatures were maintained and documented for resident personal refrigerators. This deficient practice affected four (#7, #37, #38, and #40) of four residents reviewed for personal refrigerators. The facility census was 54.
- D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteBased on observation, medical record review, resident and resident representative interview, staff interview, and review of posted meal times, the facility failed to serve meals in a manner to preserve resident dignity. This affected two (#45 and #10) of two residents directly observed during meals. The facility census was 54.
- 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, family representative interview, staff interview, and facility policy review, the facility failed to maintain the building in a safe, clean, and homelike manner. This affected two (#10 and #48) of 20 residents residing on the Memory Care Unit. The census was 54. Findings Include:Observation on 06/08/26 at 9:30 A.M. during tour of the Memory Care Unit dining room revealed, on the East wall, an air conditioning (AC) unit was installed in the wall under a window. Around the AC unit and along the wall near the floor there appeared to be three large black-green fuzzy spots on the wall. On the North wall, the wallpaper located next to the door leading into the kitchen area was torn and peeling off the wall in four spots. There appeared to be brown residue on the floor where the wall connected to the flooring under the torn wallpaper. [...]
- D
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Inspectors wroteBased on medical record review and staff interview, the facility failed to ensure a Pre-admission Screening and Resident Review (PASARR) was completed when a resident was diagnosed with a new serious mental illness. This deficient practice affected one (#7) of one residents reviewed for PASARR. The facility census was 54.
- 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, medical record review, staff interview, and policy review, the facility failed to ensure medications were not pre-prepared for administration. This affected three (#48, #52, and #55) of three residents observed with medications which were pre-prepared and not given immediately after preparation. The facility census was 54.
- D
Ensure medication error rates are not 5 percent or greater.
Inspectors wroteBased on observation, medical record review, staff interview, review of medication packaging, and policy review, the facility failed to ensure medications were administered as ordered resulting in a medication error rate greater than five (5) percent (%). A total of two (2) medication errors were observed out of 29 opportunities for a medication error rate of 6.9%. This affected two (#22 and #40) of four residents observed for medication administration. The facility census was 54.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on medical record review, observation, staff interview, and review of a facility sign, the facility failed to ensure staff followed required infection control practices related to care of residents on enhanced barrier precautions. This deficient practice affected one (#4) of four residents reviewed for infection control. The facility census was 54.
June 4, 2025Complaint inspection · 2 citations
- D
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Inspectors wroteTHE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NONCOMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on record review, review of facility Self-Reported Incident (SRI), staff interview and policy review, the facility failed to ensure residents were free from abuse and neglect. This affected one (#10) of three residents reviewed for abuse. The facility census was 64.
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteTHE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NONCOMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on record review, review of facility Self-Reported Incident (SRI), staff interview and policy review, the facility failed to ensure allegations of abuse and neglect were timely reported to the Administrator. This affected one (#10) of three residents reviewed for abuse. The facility census was 64.
March 14, 2025Complaint inspection · 1 citation
- D
Respond appropriately to all alleged violations.
Inspectors wroteBased on review of the facility's Self-Reported Incidents (SRI), facility investigation documentation, staff interview, and review of facility policy, the facility failed to ensure staff were immediately removed from the floor when allegations of staff to resident verbal abuse occurred. This affected one resident (#5) of four residents reviewed. The facility census was 65. Findings Include: Review of Resident #5's medical record revealed an admission date of 02/08/22 and a discharge date of 02/27/25. Diagnoses included major depressive disorder, altered mental status, type II diabetes, anxiety disorder, chronic pain, and insomnia. Review of Resident #5's Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 indicating Resident #5 was cognitively intact. Resident #5 required supervision with toilet use and personal hygiene. [...]
November 21, 2024Complaint inspection · 1 citation
- D
Protect each resident from the wrongful use of the resident's belongings or money.
Inspectors wroteTHE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NONCOMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on record review, review of a facility self-reported incident (SRI), staff interview, and review of the facility misappropriation policy, the facility failed to ensure a resident was free from misappropriation of medication. This affected one (Resident #01) out of three residents reviewed for misappropriation. The facility census was 64.
April 10, 2024Standard inspection, Complaint inspection · 8 citations
- E
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 interviews, the facility failed to ensure residents were free of potential hazards and accidents. This affected one (#60) resident and had the ability to affect 19 additional residents (#7, #8, #11, #14, #28, #29, #30, #34, #36, #39, #40, #41, #48, #50, #51, #53, #56, #58, and #59) in the memory unit who were cognitively impaired and independently mobile. The facility census was 64.
- D
Honor the resident's right to manage his or her financial affairs.
Inspectors wroteBased on medical record review, staff interview, and policy review, the facility failed to ensure a resident authorization form was in place for a resident with a personal fund account. This affected one (#15) of the six residents reviewed for personal fund accounts. The facility census was 64.
- 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, staff and resident interviews, revealed the facility failed to maintain a homelike environment in completing repairs. This affected one (#60) of 23 resident rooms observed. The facility census was 64.
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on observation of wound care, record review, resident interview, staff interview, and review of policy, the facility failed to ensure residents did not acquire pressure ulcers from medical devices in place. This affected one (#32) of three residents reviewed for pressure ulcers. The current census is 64.
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observation, record review, staff and resident interviews, interview with respiratory care provider, and policy review, the facility failed to ensure a resident's noninvasive ventilator such as bi-level positive airway pressure (BiPap), average volume-assured pressure support (AVAPS), or continuous positive airway pressure was administered as ordered. This affected one (#25) resident of four residents reviewed for noninvasive ventilators. The facility identified four residents had noninvasive ventilators. The facility census was 64.
- D
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Inspectors wroteBased on medical record review, staff interview, and review of policy, the facility failed to monitor blood pressure prior to the administer of medications as ordered. This affected for one (#24) of five residents observed for medication administration. The facility census was 64.
- D
Ensure that residents are free from significant medication errors.
Inspectors wroteBased on observation, staff interview and review of the product insert instructions, the facility failed to ensure insulin pen needles were primed after a new needle was applied. This affected one (#24) of two residents observed for insulin administration. The facility census was 64.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, staff interview, and review of policy, the facility failed to ensure personal protective equipment (PPE) was utilized during a procedure for one resident (#04) of two residents with Enhanced Barrier Protection (EBP) in place. The facility also failed to ensure staff performed proper hand hygiene when performing tracheostomy care for one (#04) resident out of the two residents reviewed for tracheostomy care. Furthermore, the facility failed to ensure a sanitary environment was provided during meal service. This directly affected one resident (#20) and had the possibility to affect five males (#13, #17, #20, #24, and #61) who eat in their rooms. The facility census was 64.
April 27, 2023Standard inspection · 5 citations
- F
Provide and implement an infection prevention and control program.
Inspectors wroteBased on medical record review, observation, staff interview, and review of facility policies, the facility staff failed to maintain contact precautions during wound care, and failed to have a Legionella water management program in place. This directly affected one (#165) of three residents reviewed for transmission based precautions and had the potential to affect all 58 residents residing in the facility. The census was 58.
- F
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 files, staff interview, and review of facility policy, the facility failed to ensure state tested nurse aides (STNAs) who worked the in the facility for more than one year received 12 hours of continuing education for the previous year, and failed to ensure STNAs received specific education related to providing care and services to residents on the special care unit. This affected eight (STNA #212, #213, #218, #226, #243, #244, #246, and #278) of eight employee files reviewed. The deficient practice had the potential to affect all 58 residents residing in the facility. The census was 58.
- D
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Inspectors wroteBased on medical record review, staff interviews, and policy review, the facility failed to comprehensively assess a resident's activity pursuits on admission. This affected one (#42) of the 16 residents reviewed for assessments. The facility census was 58.
- 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 and family and staff interview, the facility failed to conduct a quarterly care plan review meeting. This affected one (#37) of 16 residents reviewed for care planning meetings. The facility census was 58.
- 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, observation, staff interview, and policy review, the facility failed to provide adequate interventions and supervision to ensure a cognitively impaired resident did not elope from the facility. Additionally, the facility failed to conduct a thorough investigation to determine root cause analysis to identify potential hazards and resident-specific interventions to prevent further elopements. This affected one (#37) resident of seven residents reviewed on the secured memory care unit. The facility census was 58.
Fire safety inspections
33 fire safety citations on file: 10 on June 11, 2026, 10 on April 10, 2024, 3 on March 11, 2024, 10 on April 27, 2023.
Every fire safety citation33 citations
- F
Develop and maintain an Emergency Preparedness Program (EP).
E 4 · June 11, 2026 · Corrected (the home has a date of correction)
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · June 11, 2026 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · June 11, 2026 · Corrected (the home has a date of correction)
- F
Have simulated fire drills held at unexpected times.
K 712 · June 11, 2026 · 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 · June 11, 2026 · 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 · June 11, 2026 · Corrected (the home has a date of correction)
- E
Properly select, install, inspect, or maintain portable fire extinguishes.
K 355 · June 11, 2026 · Corrected (the home has a date of correction)
- E
Ensure that waiting areas, nurse’s stations, gift shops, and cooking facilities, open to the corridor are properly protected.
K 361 · June 11, 2026 · Corrected (the home has a date of correction)
- E
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · June 11, 2026 · Corrected (the home has a date of correction)
- E
Have properly installed electrical wiring and gas equipment.
K 511 · June 11, 2026 · Corrected (the home has a date of correction)
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · April 10, 2024 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · April 10, 2024 · Corrected (the home has a date of correction)
- F
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · April 10, 2024 · Corrected (the home has a date of correction)
- E
Keep aisles, corridors, and exits free of obstruction in case of emergency.
K 211 · April 10, 2024 · Corrected (the home has a date of correction)
- E
Install a fire alarm system that can be heard throughout the facility.
K 341 · April 10, 2024 · Corrected (the home has a date of correction)
- E
Install an approved automatic sprinkler system.
K 351 · April 10, 2024 · Corrected (the home has a date of correction)
- E
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · April 10, 2024 · Corrected (the home has a date of correction)
- C
Develop and maintain an Emergency Preparedness Program (EP).
E 4 · April 10, 2024 · deficient, provider has
- C
Conduct risk assessment and an All-Hazards approach.
E 6 · April 10, 2024 · deficient, provider has
- C
Establish emergency prep training and testing.
E 36 · April 10, 2024 · deficient, provider has
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · March 11, 2024 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · March 11, 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 · March 11, 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 · April 27, 2023 · Corrected (the home has a date of correction)
- F
Install a fire alarm system that can be heard throughout the facility.
K 341 · April 27, 2023 · Corrected (the home has a date of correction)
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · April 27, 2023 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · April 27, 2023 · 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 27, 2023 · Corrected (the home has a date of correction)
- F
Provide a written emergency evacuation plan.
K 711 · April 27, 2023 · Corrected (the home has a date of correction)
- F
Have simulated fire drills held at unexpected times.
K 712 · April 27, 2023 · Corrected (the home has a date of correction)
- F
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · April 27, 2023 · Corrected (the home has a date of correction)
- F
Have proper medical gas storage and administration areas.
K 923 · April 27, 2023 · Corrected (the home has a date of correction)
- E
Ensure proper usage of power strips and extension cords.
K 920 · April 27, 2023 · Corrected (the home has a date of correction)