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 21 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
13D
6E
0F
Potential for minimal harm
0A
0B
2C
June 9, 2026Complaint inspection · 2 citations
- E
Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit.
Inspectors wroteBased on review of facility policy, clinical records, and staff interview, it was determined that the facility failed to ensure that the attending physician documented required visits by writing, signing, and dating a physician progress note for each visit for six of six residents reviewed (Residents R4, R7, R8, R9, 10, and R11) and failed to ensure that the physician signs and dates all orders during each of his/her visits for one of size residents reviewed (Resident R11).
- E
Ensure that the resident and his/her doctor meet face-to-face at all required visits.
Inspectors wroteBased on review of facility policy, clinical records, and staff interview, it was determined that the facility failed to ensure the physician alternated required resident visits with the nurse practitioner or physician's assistant for four of six residents reviewed (Residents R4, R8, R9, and R10).
February 23, 2026Complaint inspection · 4 citations
- E
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteBased on review of facility policies, observations, and resident and staff interviews, it was determined that the facility failed to implement dignified feeding practices and to maintain resident dignity for seven of 18 residents interviewed (Residents R7, R8, R9, R15, R16, R24, and R25).
- E
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Inspectors wroteBased on a review of facility policy, clinical and facility records, and resident and staff interviews, it was determined that the facility failed to provide a shower/bath as resident preference for seven of 13 residents reviewed (Residents R8, R9, R19, R20, R21, R22, and R23).
- E
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 review of facility policies, facility records, observations, and resident and staff interviews, it was determined that the facility failed to ensure meals were prepared and served in accordance with planned menus and failed to note or update menu changes and notify residents of a change to the posted menu for five of 18 residents interviewed (Residents R7, R11, R16, R24 and R25).
- D
Keep all essential equipment working safely.
Inspectors wroteBased on review of facility policy, observations, and staff interview, it was determined the facility failed to properly maintain safe operation of essential equipment in the main kitchen and prevent excessive buildup of frost in the walk-in freezer.
December 11, 2025Standard inspection · 1 citation
- D
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on review of a facility policy, observations, and staff interview, it was determined that the facility failed to ensure that food was stored in accordance with standards for food safety in a resident pantry in two of four refrigerators reviewed (Rehab Unit and North Unit).
April 11, 2025Complaint inspection · 3 citations
- D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteBased on review of facility policies, observations, and resident and staff interviews, it was determined that the facility failed to implement dignified feeding practices and to maintain resident dignity and respect by serving meals in a timely manner to individuals seated at the same table for two of two dining areas observed (North and Haven).
- 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 review of facility policy and clinical record, and staff interviews, it was determined that the facility failed to notify the resident's physician and emergency contact timely regarding a change in condition for one of 13 residents reviewed (Resident R1).
- D
Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.
Inspectors wroteBased on observations, review of facility records, and resident and staff interviews, it was determined that the facility failed to provide sufficient staff to carry out the functions of the food and nutrition services in the kitchen.
November 22, 2024Standard inspection · 3 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 review of clinical records and facility policy and staff interviews, it was determined that the facility failed to notify the resident's representative of a change in condition and/or treatment for one of 24 residents reviewed (Resident R30).
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on review of facility policy and clinical records, observations, and staff and resident representative interviews, it was determined the facility failed to ensure that residents with indwelling catheters (a tube inserted into the bladder to facilitate urine drainage) receive proper care and services to help prevent infections for two of nine residents reviewed with indwelling catheters (Residents R19 and R79).
- C
Keep all essential equipment working safely.
Inspectors wroteBased on review of facility policy, observations, and staff interview, it was determined the facility failed to properly maintain safe operation of essential equipment in the main kitchen and prevent excessive build up of frost in the walk-in freezer.
July 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 observations, review of facility policy and clinical record, and staff and resident interviews, it was determined that the facility failed to safely transfer a resident using a mechanical lift for one of one residents reviewed (Resident R9).
December 12, 2023Standard inspection, Complaint inspection · 7 citations
- E
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Inspectors wroteBased on observations and staff and resident interviews, it was determined that the facility failed to serve food that was palatable for taste and temperature for four of four units.
- 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, and staff interview, it was determined that the facility failed to ensure that a safe, clean, comfortable homelike environment was maintained related to resident's wheelchair for one of four units observed (Rehabilitation Unit).
- 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 review of facility policy and clinical records, and staff interview it was determined that the facility failed to develop a comprehensive care plan for one of 24 residents reviewed (Resident R94).
- D
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Inspectors wroteBased on review of facility policy and clinical records, observations, and resident and staff interviews, it was determined that the facility failed to ensure that residents with limited range of motion received physician ordered treatment and services to prevent further decrease in range of motion for one of 24 residents reviewed (Resident R13).
- D
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Inspectors wroteBased on review of facility policy, clinical records, and staff interviews, it was determined that the facility failed to provide a clinical rationale for the continued use of a PRN (as needed) psychotropic (affecting the mind) medication beyond 14 days for one of 24 residents reviewed (Resident R64).
- D
Dispose of garbage and refuse properly.
Inspectors wroteBased on review of facility policy, observation and staff interview, it was determined that the facility failed to ensure that the garbage and refuse was disposed of properly for two of two dumpsters.
- C
Keep all essential equipment working safely.
Inspectors wroteBased on review of facility policy, observations, and staff interview, it was determined the facility failed to properly maintain safe operation of essential equipment in the main kitchen and failed to ensure safe operating equipment for two of eight food carts used to transport meals from the main kitchen to the individual units.
Fire safety inspections
8 fire safety citations on file: 2 on December 11, 2025, 3 on November 22, 2024, 3 on December 12, 2023.
Every fire safety citation8 citations
- E
Have exits that are accessible at all times.
K 271 · December 11, 2025 · Corrected (the home has a date of correction)
- E
Have proper medical gas storage and administration areas.
K 923 · December 11, 2025 · Corrected (the home has a date of correction)
- E
Keep aisles, corridors, and exits free of obstruction in case of emergency.
K 211 · November 22, 2024 · Corrected (the home has a date of correction)
- E
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · November 22, 2024 · Corrected (the home has a date of correction)
- D
Have properly located and lighted "Exit" signs.
K 293 · November 22, 2024 · Corrected (the home has a date of correction)
- E
Have restrictions on the use of highly flammable decorations.
K 753 · December 12, 2023 · Corrected (the home has a date of correction)
- D
Inspect, test, and maintain automatic sprinkler systems.
K 353 · December 12, 2023 · Corrected (the home has a date of correction)
- D
Properly select, install, inspect, or maintain portable fire extinguishes.
K 355 · December 12, 2023 · Corrected (the home has a date of correction)