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 10 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
6D
3E
1F
Potential for minimal harm
0A
0B
0C
January 9, 2026Standard inspection · 2 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 observations, staff interviews, and facility policy review, the facility failed to ensure foods stored in one of two nourishment refrigerators (South unit) were labeled, dated when opened, and not expired. This failure placed the residents on the South unit at risk for transmission of foodborne illness.
- D
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Inspectors wroteBased on record review, staff interviews, and facility policy review, the facility failed to ensure written notice to the resident or representative of the transfer to the hospital included a statement of the appeal rights, information on how to file an appeal, and appeals contact information for two of four residents (Resident (R) 91 and R79) reviewed for hospitalization in a sample of 23 residents. This failure created the potential for a lack of understanding of appeal rights should the resident not be permitted to return or disagree with the reason for transfer, potentially causing confusion or distress upon transfer.
September 5, 2025Complaint inspection · 5 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 observations and staff interviews, the facility failed to ensure a safe, functional, sanitary, comfortable environment in the clean linen room, the overflow Linen Room, the Biohazard Room, and the South Hall Medication Room were maintained in an clean, orderly, and sanitary manner.
- 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 wroteBased on observations, record review, staff interviews, and review of the facility policy titled, Routine Cleaning and Disinfection, the facility failed to ensure a safe, clean, comfortable, homelike environment in the North and South hallways, resident rooms for four of 24 sampled residents (Resident (R)3, R4, R20, and R5), resident shower rooms, resident equipment for five of 24 sampled Rs (R22, R25, R24, R15, and R21), and the main dining room were maintained in a safe, clean, comfortable and clutter-free manner to create a homelike environment.
- E
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 observations, staff interviews, record review, and facility policy review, the facility failed to ensure expired insulin pens and insulin vials were removed from two of four medication carts (South Hall long and South Hall short) reviewed. In addition, the facility failed to ensure two of two medication room refrigerators (North Hall and South Hall) were locked and the schedule II lock box (containing narcotics that have a high incidence of abuse) were affixed to shelving, as required. This failure had the potential of medication diversion to residents, staff or visitors, and residents receiving ineffective medications.
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on observations, record review, and resident and staff interviews, the facility failed to ensure staff provided nail care for one of four residents (Resident (R) 3) observed for the provision of ADL (activities of daily living) care out of a total sample of 24 residents resulting in dirty, long, and jagged nails.
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on observations, staff interviews, record review, and review of facility policy, the facility failed to supervise one of one (Resident (R)1) of 24 sampled residents at risk for elopement, resulting in R1 eloping from the facility. The failure had the potential to cause harm to R1 while out of the facility unaccompanied.
August 18, 2024Standard inspection · 3 citations
- D
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Inspectors wroteBased on staff interviews, record review, and review of the facility's policies titled, Resident Assessment-Coordination with PASARR Program, the facility failed to refer one of 29 residents (R) (R61) for a pre-admission screening and resident review (PASARR) Level II screening. The deficient practice had the potential to place R61 at risk for medical complications, unmet needs, and a diminished quality of life.
- 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 observations, resident and staff interviews, record review, and review of the facility policy titled, Comprehensive Care Plans, the facility failed to follow the care plan related to correctly administering the physician ordered rate of oxygen (O2) for two of 15 residents (R) (R41 and R47) receiving O2 therapy. Additionally, the facility failed to follow the care plan related to cleaning the O2 filter on the O2 concentrator (machine that converts room air into oxygen) per physician's orders for two of 15 residents (R32 and R61) receiving O2 therapy.
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observations, staff interviews, record review, and review of the facility policies titled, Oxygen Administration and Oxygen Concentrator, the facility failed to ensure respiratory equipment was maintained in a sanitary manner for two of 15 residents (R) (R32 and R61) receiving oxygen therapy. In addition, the facility failed to ensure oxygen (O2) was administered according to physician orders for two of 15 residents (R41 and R47) receiving oxygen therapy. The deficient practices could potentially place the resident at risk for medical complications, unmet needs, and a diminished quality of life.
October 21, 2022Standard inspection · 0 citations
Fire safety inspections
10 fire safety citations on file: 3 on January 9, 2026, 5 on August 18, 2024, 2 on October 21, 2022.
Every fire safety citation10 citations
- F
Install a fire alarm system that can be heard throughout the facility.
K 341 · January 9, 2026 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · January 9, 2026 · Corrected (the home has a date of correction)
- D
Ensure proper usage of power strips and extension cords.
K 920 · January 9, 2026 · Corrected (the home has a date of correction)
- E
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · August 18, 2024 · Corrected (the home has a date of correction)
- D
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
K 321 · August 18, 2024 · Corrected (the home has a date of correction)
- D
Inspect, test, and maintain automatic sprinkler systems.
K 353 · August 18, 2024 · Corrected (the home has a date of correction)
- D
Install properly constructed windows in hallway walls or doors.
K 364 · August 18, 2024 · 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 · August 18, 2024 · Corrected (the home has a date of correction)
- F
Keep aisles, corridors, and exits free of obstruction in case of emergency.
K 211 · October 21, 2022 · 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 21, 2022 · Corrected (the home has a date of correction)