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 27 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
1J
0K
0L
Actual harm
1G
0H
0I
Potential for more than minimal harm
24D
1E
0F
Potential for minimal harm
0A
0B
0C
April 9, 2026Standard inspection, Complaint inspection · 9 citations
- E
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
Inspectors wroteBased on observation, staff interview, review of recipe, and review of diet and nutrition manual the facility failed to serve pureed foods at a smooth consistency for safe swallowing. This had the potential to affect five (#3, #16, #20, #22, and #34) residents who the facility identified to require a pureed diet. The facility census was 44. Observation on 04/08/26 at 11:48 A.M. of the first pan of preprepared pureed ham revealed the pureed ham appeared chopped and was separated, not a smooth consistency. Observation of a test tray of the pureed ham revealed the pureed ham was not a smooth consistency. Interview on 04/08/26 at 11:50 A.M. with Dietary Manager #302 verified the first pan of pureed ham was not smooth. Observation on 04/08/26 at 11:55 A.M. [...]
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on medical record review, observation, resident interview, staff interview, review of self-reported incidents, and review of facility policy the facility failed to report incidents of potential misappropriation. This affected one (#27) of one residents reviewed for misappropriation. The facility census was 44. Review of the medical record revealed Resident #27 was admitted on [DATE]. Diagnoses included Type Two Diabetes Mellitus without complications, essential hypertension, hyperlipidemia, chronic kidney disease, anxiety disorder, and lymphedema. Review of the Minimum Data Set (MDS) assessment, dated on 02/04/26, revealed the resident was cognitively intact. Interview on 04/07/26 at 2:16 P.M. with Resident #27 revealed his smart phone was stolen a few months ago. Resident #27 stated he believed it was stolen, not lost as he always left it on his bedside table. [...]
- D
Respond appropriately to all alleged violations.
Inspectors wroteBased on medical record review, observation, resident interview, staff interview, and review of facility policy the facility failed to thoroughly investigate an allegation of misappropriation. This affected one (#27) of one resident reviewed for misappropriation. The facility census was 44. Review of the medical record revealed Resident #27 was admitted on [DATE]. Diagnoses included Type Two Diabetes Mellitus without complications, essential hypertension, hyperlipidemia, chronic kidney disease, anxiety disorder, and lymphedema. Review of the Minimum Data Set (MDS) assessment, dated 02/04/26, revealed the resident was cognitively intact. Interview on 04/07/26 at 2:16 P.M. with Resident #27 revealed his smart phone was stolen a few months ago. Resident #27 stated he believed it was stolen, not lost as he always left it on his bedside table. Resident #27 stated it was an iPhone 17. [...]
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on observation, medical record review, staff interview, and review of the facility policy, the facility failed to ensure dependent residents received timely facial grooming. This affected one (#3) of three residents reviewed for the provision of activities of daily living in a facility census of 44.
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on observation, medical record review, staff interview, and review of facility policy, the facility failed to ensure pressure relief interventions were provided to promote wound healing and prevent further deterioration. This affected one (#31) of two residents reviewed with pressure ulcers in a facility. The census of 44.
- 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 observation, medical record review, staff interview, and review of the facility policy, the facility failed to ensure timely incontinence care was provided to a dependent resident. This affected one, (#31) of two residents reviewed for incontinence care services in a facility census of 44.
- D
Provide enough food/fluids to maintain a resident's health.
Inspectors wroteBased on observation, medical record review, staff interview and facility policy the facility failed to ensure adequate fluid was provided to dependent resident. This affected one of one residents (#31) reviewed for hydration in a facility census of 44.
- D
Provide or obtain dental services for each resident.
Inspectors wroteBased on medical record review, observation, resident interview, staff interview, and review of facility policy the facility failed to ensure timely follow-up for dental concerns. This affected one (#27) of one resident reviewed for dental services. The facility census was 44. Review of the medical record revealed Resident #27 was admitted on [DATE]. Diagnoses included Type II Diabetes Mellitus without complications, essential hypertension, hyperlipidemia, chronic kidney disease, anxiety disorder, and lymphedema. Review of the Minimum Data Set (MDS) assessment, dated on 02/04/26, revealed the resident was cognitively intact and required set-up/clean-up assistance for oral hygiene. Resident #27 had obvious or likely cavity or broken natural teeth. The MDS assessment, dated 02/03/25, also identified obvious or likely cavity or broken natural teeth. [...]
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, medical record review, staff interview, and review of the facility policy, the facility failed to ensure Enhanced Barrier Precautions were followed as ordered by the physician. This affected one of two residents (#2) reviewed for implementation of Enhanced Barrier Precautions. The facility identified 14 current residents(#2, #7, #13, #20, #22, #24, #26, #29, #31, #32, #35, #43, #48, #50) placed in Enhanced Barrier Precautions.
January 18, 2023Standard inspection · 11 citations
- J
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, review of a Self-Reported Incident (SRI), staff interviews, review of the local police report, review of the facility investigation, review of email and policy review, the facility failed to ensure one resident (Resident #28) was free from physical abuse by facility staff. This resulted in Immediate Jeopardy and serious negative psychosocial harm, based on a reasonable person's response of fear and anxiety, for Resident #28, who has severe cognitive impairment, when Licensed Practical Nurse (LPN) #431 physically walked Resident #28 back a couple steps to a wall, held her against the wall with her right forearm, and placed her left hand on the resident's throat in response to behaviors Resident #28 was exhibiting, causing Resident #28 to start screaming and crying. This affected one (#28) of four residents (#10, #20, #28, and #30) reviewed for abuse. [...]
- G
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on staff interview, review of the medical records, review of hospital records, and review of the facility policy, the facility failed to implement fall interventions for one (#26). This resulted in Actual Harm when Resident #26's bed was not placed in the low position, the resident fell out of bed and suffered a dislocated left little finger. This affected one (Resident #26) of four residents reviewed for falls. Additionally, the facility failed to ensure post-fall assessments were completed and falls were tracked on the facility's incident log. This affected three (#26, #244, and #245) of four residents reviewed for falls. The facility census was 44.
- 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, staff interview and facility policy , the facility failed to follow physician orders to notify the physician when blood glucose readings were outside of specific parameters for two residents (#6, #246) and failed to notify the physician of urinalysis results for one (#243) resident. The facility census was 44.
- D
Respond appropriately to all alleged violations.
Inspectors wroteBased on medical record review, staff interview, review of the facility Self-Reported Incidents (SRIs), and review of facility policy, the facility failed to ensure allegation of one resident shoving another resident was investigated and reported to the State Survey Agency. This affected one (#28) of four residents reviewed for abuse. The facility census was 44.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on staff interview, record review, and review of the facility policy, the facility failed to complete neurological checks after unwitnessed falls and after a witnessed head injury. This affected three (#26, #244 and #245) of four residents reviewed for falls. The facility census was 44.
- D
Provide enough food/fluids to maintain a resident's health.
Inspectors wroteBased on observation, staff interview, review of meal tickets, and review of the medical record, the facility failed to implement weight loss supplements per physician order after a significant weight loss. This affected one (#26) of two residents reviewed for weight loss. The facility census was 44.
- D
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Inspectors wroteBased on medical record review, staff interview, and review of the facility policy, the facility failed to ensure the physician reviewed and responded to pharmacist recommendations. This affected one (#10) of five residents reviewed for unnecessary medications. The facility census was 44.
- D
Ensure that residents are free from significant medication errors.
Inspectors wroteBased on medical record review, staff interview, review of manufacturer instructions, review of meal times, and review of the facility policy, the facility failed to administer insulin in accordance with the manufacturer instructions for one (Resident #246) of three residents reviewed for insulin use. The facility census was 44.
- D
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Inspectors wroteAMENDED 02/13/23 Based on review of the facility Self-Reported Incidents (SRI), email communication, and staff interview, the facility failed to substantiate and accurately report the results of an investigation of staff to resident abuse to the State Survey Agency. This affected one (#230588) SRI out of six SRIs reviewed. The facility census was 44.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteAMENDED 02/14/23 Based on observation, staff interview and review of the facility policy, the facility failed to ensure infection control practices were adhered to during a dressing change. This affected one (#8) of one resident observed during a dressing change. The facility census was 44.
- D
Implement a program that monitors antibiotic use.
Inspectors wroteBased on medical record review, staff interview, review of the infection surveillance log, and review of facility policy, the facility failed to ensure residents receiving an ongoing prophylactic antibiotic had a reason for continued use. This affected one (Resident #294) of six residents reviewed for unnecessary medications. The facility census was 44.
December 21, 2021Standard inspection · 7 citations
- D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteBased on record review, observations, staff interview, and review of the facility's policy, the facility failed to ensure residents with indwelling catheters had their catheters managed in a dignified manner. This affected one (Resident #30) of the two residents the facility identified as having indwelling catheters. The facility census was 48.
- D
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Inspectors wroteBased on medical record review, review of the facility's policy, and staff interview, the facility failed to ensure residents and responsible parties were provided a notice of transfer upon transfer from the facility. This affected two (#13 and #51) of two residents reviewed for hospitalizations. The facility identified three residents transferred to the hospital in the past 90 days. The facility census was 48.
- D
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Inspectors wroteBased on medical record review, review of the facility's policy, and staff interview, the facility failed to ensure residents were provided with bed hold notices upon transfer from the facility. This affected one (#13) of two residents reviewed for hospitalizations. The facility identified three residents discharged to the hospital in the last 90 days. The facility census was 48.
- 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, resident interview, staff interview, and policy review, the facility failed to provide a copy of the baseline care plan to a resident and their representative. This affected one (Resident #251) of thirteen residents reviewed for care plans. The facility census was 48.
- D
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Inspectors wroteBased on medical record review, staff interview, and policy review, the facility failed to provide care and services to monitor a vascular access for a resident that received dialysis. This affected one (Resident #251) of one resident reviewed for dialysis. The facility identified one resident receiving dialysis in the facility.
- 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 administer medications as ordered by the physician with a medication error rate of less than five percent (%). There were three medications errors out of 26 opportunities resulting in a 11.5% medication error rate. This affected two (Resident #4 and #14) of four residents observed for medication administration. The facility census 48.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on record review, observation, staff interview, and policy review, the facility failed to administer eye drops using appropriate infection control practices. This affected one resident (#33) of two residents observed for eye drops. In addition, the facility failed to ensure residents with indwelling catheters had their catheters managed in a sanitary manner. This affected one (#30) of two residents the facility identified as having indwelling catheters. The facility census was 48.
Fire safety inspections
18 fire safety citations on file: 6 on April 9, 2026, 6 on January 18, 2023, 6 on December 21, 2021.
Every fire safety citation18 citations
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · April 9, 2026 · Corrected (the home has a date of correction)
- F
Follow proper procedures when the fire alarm was out of service for more than 4 hours.
K 346 · April 9, 2026 · 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 · April 9, 2026 · Corrected (the home has a date of correction)
- F
Provide a written emergency evacuation plan.
K 711 · April 9, 2026 · Corrected (the home has a date of correction)
- F
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
K 741 · April 9, 2026 · 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 9, 2026 · 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 · January 18, 2023 · Corrected (the home has a date of correction)
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · January 18, 2023 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · January 18, 2023 · Corrected (the home has a date of correction)
- F
Have simulated fire drills held at unexpected times.
K 712 · January 18, 2023 · Corrected (the home has a date of correction)
- F
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
K 741 · January 18, 2023 · Corrected (the home has a date of correction)
- E
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · January 18, 2023 · Corrected (the home has a date of correction)
- F
Develop and maintain an Emergency Preparedness Program (EP).
E 4 · December 21, 2021 · Corrected (the home has a date of correction)
- F
Conduct risk assessment and an All-Hazards approach.
E 6 · December 21, 2021 · Corrected (the home has a date of correction)
- F
Install an approved automatic sprinkler system.
K 351 · December 21, 2021 · Corrected (the home has a date of correction)
- E
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · December 21, 2021 · Corrected (the home has a date of correction)
- E
Install smoke barrier doors that can resist smoke for at least 20 minutes.
K 374 · December 21, 2021 · Corrected (the home has a date of correction)
- D
Ensure proper usage of power strips and extension cords.
K 920 · December 21, 2021 · Corrected (the home has a date of correction)