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 28 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
7E
1F
Potential for minimal harm
0A
0B
0C
June 30, 2026Complaint inspection · 2 citations
- 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 clinical record review, facility policy review, and staff and resident interviews, the facility failed to ensure that residents were able to choose sleeping and waking schedules per their preference for 4 residents (Resident #11, Resident #16, Resident #24 and Resident #25) when an intoxicated resident (Resident #8) frequently woke the residents during the night due his being loud and argumentative with staff. The facility reported a census of 71 residents.
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on observation, clinical record review, resident and staff interview, the facility failed to ensure resident safety by not storing smoking materials in a safe location for a resident using oxygen and ensuring a resident's feet are on the foot pedals during a wheelchair transport for 2 of 5 residents (Resident #6 and Resident #22) reviewed for safety. The facility reported a census of 71 residents.
April 6, 2026Standard inspection, Complaint inspection · 8 citations
- E
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observations, clinical record review, facility policy review, resident and staff interviews, the facility failed to implement the infection control practices of hand hygiene and use of Enhanced Barrier Precautions during wound care treatment and the cleaning of a g-tube insertion site for 4 of 6 residents (Resident #1, Resident #2, Resident #5, Resident #64, and Resident #) reviewed for infection control. The facility reported census of 68 residents.
- 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 clinical record review, policy review and staff interview the facility failed to maintain accurate Advance Directive decisions for 1 of 16 residents reviewed (Resident #43). The facility reported a census of 68.
- 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, facility policy review, and resident and staff interview and facility policy review the facility failed to maintain a homelike environment due broken wall tiles in the shower room, stained and crumbling ceiling tiles in a resident's room, window curtains unable to be completely closed to provide privacy, and maintaining mouse traps in timely manner. The facility reported a census of 68 residents.
- D
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Inspectors wroteBased on clinical record review, facility record review and staff interview, the facility failed to notify the the Long-Term Care Ombudsman of a discharge for 1 of 3 residents (Resident #77) reviewed. The facility reported a census of 68 residents.
- D
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Inspectors wroteBased on clinical record review, staff interview and the 2025 Resident Assessment Instrument (RAI) manual, the facility failed to transmit Minimum Data Set (MDS) Assessments within the Federal Guidelines timeframe for 1 of 24 residents (Resident #31) reviewed. The facility reported a census of 68.
- D
PASARR screening for Mental disorders or Intellectual Disabilities
Inspectors wroteBased on clinical record review, facility policy review and staff interview, the facility failed to accurately list known mental health diagnoses on a Pre-admission Screening and Resident Review for 1 of 2 residents reviewed (Resident #15) for Pre-admission Screening and Resident Reviews. The facility reported a census of 68 residents.
- 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 clinical record review, family representative interview, resident and staff interviews the facility failed to develop comprehensive Care Plans for 3 of 8 residents (Resident #1, Resident #19, and Resident #30) reviewed for Care Plans. The facility reported a census of 68 residents.
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on observations, clinical record review, resident and staff interviews, the facility failed to assist dependent residents with shaving, nail care and toothbrushing for 2 of 4 residents (Resident #6 and Resident #40) reviewed for activities of daily living. The facility reported a census of 68 residents.
October 2, 2025Complaint inspection · 1 citation
- D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteBased on clinical record review, facility policy review, family representative and staff interviews, the facility failed to treat each resident with dignity and respect when a staff member made a resident condition statement in the presence of a family member for 1 of 9 resident records reviewed (Resident #7). The facility reported a census of 64 residents.
June 25, 2025Complaint 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 observation, clinical record review, and staff interview, the facility failed to ensure a resident with a history of poly substance overuse smoked safety when under the influence for 1 of 1 (Resident #1) residents reviewed for smoking safety. The facility reported a census of 70 residents.
March 20, 2025Standard inspection · 4 citations
- F
Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
Inspectors wroteBased on the Center of Medicare and Medicaid Services (CMS) Payroll Based Journal (PBJ) Staffing Data Report (for October 1st to December 31, 2024) review, facility staffing assignments review and staff interview, the facility failed to submit accurate agency staffing data for the PBJ Staffing Data Report. The facility reported a census of 66 residents.
- 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, record review and staff interviews, the facility failed to label and date opened food items in the refrigerator, freezer and dry storage areas in an effort to prevent foodborne illness. The facility reported a census of 66 residents. Findings Include: During the initial kitchen tour with Staff G, [NAME] on 3/16/25 at 10:10 AM, observations included: a. In the cooler, apple sauce, cheese, cabbage, and ranch dressing observed open. No label present or open date indicated. b. In the ice freezer, breadsticks, biscuits and slider rolls observed open. No label present or open date indicated. c. In the 3-door freezer, waffle fries and breaded fish fillets observed open. No label present or open date indicated. d. In the 2-door freezer, two packages of vegetables observed open. No label present or open date indicated. e. [...]
- 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 observations, clinical record review, facility policy review and staff interviews, the facility failed to ensure urinary catheter bags and tubing placed off the floor to minimize the risk of urinary tract infections for 2 of 4 residents reviewed (Resident #37 and Resident #121) with indwelling catheters. The facility reported a census of 66 residents.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, record review and staff interviews, the facility failed to utilize proper infection control methods during the change of a resident's colostomy bag/wafer (Resident #2) for one of one residents reviewed with a colostomy and during wound care for one of three residents reviewed for wound care (Resident #37) and failed to initiate and follow precautions for one of four residents reviewed for Enhanced Barrier Precautions (Resident #121). The facility reported a census of 66 residents. 1. The Minimum Data Set (MDS) dated [DATE] for Resident #2 revealed a diagnosis of paraplegia identified a colostomy. The Brief Interview for Mental Status (BIMS) score was 15 that suggested an intact cognition. [...]
November 26, 2024Complaint inspection · 3 citations
- E
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteBased on observations, maintenance record review, resident and staff interviews the facility failed to provide dignified care to residents when the water temperature unpredictably changed from a comfortable temperature to a cold temperature for 6 of 6 resident reviewed for dignity. The facility reported a census of 66 residents.
- E
Keep all essential equipment working safely.
Inspectors wroteBased on observations, maintenance record review, and resident and staff interviews the facility failed to maintain essential equipment in acceptable operating condition to maintain water temperatures in resident showers between 110 degrees Fahrenheit (F) and 120 degrees F as required. The facility reported a census of 66 residents.
- D
Ensure services provided by the nursing facility meet professional standards of quality.
Inspectors wroteBased on observations, clinical record review, resident and staff interviews, the facility failed to follow physician orders for wound care and positioning for 1 of 3 resident records reviewed for wound care (Resident #2). The facility reported a census of 66 residents.
September 3, 2024Complaint inspection · 1 citation
- D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteBased on observation, clinical record review, resident and staff interviews the facility failed to treat residents with dignity and respect, in full regard of the resident's stated needs and right to refuse a shower, for 1 of 8 resident's reviewed (Resident #5). The facility reported a census of 67 residents.
May 23, 2024Standard inspection, Complaint inspection · 5 citations
- E
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Inspectors wroteBased on clinical record review, staff interviews and facility policy review the facility pharmacy failed to deliver medications ordered to the facility in a timely fashion for 4 out of 4 residents reviewed, (Resident #22, #30, #47, and #70). The facility reported a census of 70 residents.
- 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, policy review and staff interview the facility failed to maintain a sanitary kitchen, ensure the disinfectant solution was within proper test range, label food appropriately for storage, wear hair restraints appropriately and dispose of expired food items. The facility identified a census of 70 residents.
- D
Ensure services provided by the nursing facility meet professional standards of quality.
Inspectors wroteBased on observation, record review, resident and staff interview, the facility failed to obtain a physician order to obtain Lorazepam from the facility's Med Bank for one of six residents reviewed, (Resident #30). The facility reported a census of 70 residents.
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on observation, record review, resident and staff interview, the facility failed to follow the care plan and transfer the resident with the use of the stand lift for one of one resident reviewed, (Resident #55). The facility reported a census of 70 residents.
- D
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Inspectors wroteBased on observation, record review, policy review, and staff interview the facility failed to date feeding tube equipment, flush for patency with the correct water amount, and confirm correct settings on a feeding tube pump in order to follow physician orders for 1 of 1 resident reviewed, (Resident #4). The facility reported a census of 70 residents.
February 29, 2024Complaint inspection · 1 citation
- D
Ensure services provided by the nursing facility meet professional standards of quality.
Inspectors wroteBased on clinical record review, staff interviews and facility policy review, the facility failed to follow accepted practices for enteral (feeding tube formula bags) feeding supplies, and to follow a Physician's Order to continue clopidogrel (Plavix, the brand name of the medication. The medication purpose is to keep platelets from sticking together) for 1 of 3 residents in the sample (Resident #1). The facility reported a census of 66 residents. Findings Include: The Minimum Data Set (MDS) Assessment Tool, dated 2/14/24, listed diagnosis for Resident #1 included hemiplegia (one sided paralysis) following a stroke affecting the right dominant side, dysphagia (difficulty swallowing), and aphasia (difficulty with communication). The MDS listed the resident's Brief Interview for Mental Status (BIMS) score as 8 out of 15, indicating severely impaired cognition. [...]
February 19, 2024Complaint inspection · 2 citations
- 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 clinical record review, staff interviews and policy review the facility failed to notify the Resident Representative/Emergency Contact of a hospital transfer for 1 of 3 residents reviewed for transfers out of the facility (Resident #3). The facility reported a census of 72 residents. Findings Include: Review of the Minimum Data Set (MDS) assessment dated [DATE] for Resident #3 revealed the resident discharged to the hospital on 1/17/24. A readmission MDS dated [DATE] documented the resident re-admitted back to the facility The Care Plan initiated 4/5/23 documented Resident #3 with altered cardiovascular status, heart disease, congested heart failure and history of cerebral vascular accident (stroke). The Notice of Transfer Report to the Ombudsman for January 2024 identified resident #3 transferred for hospitalization on 1/17/2024. [...]
- D
Provide enough food/fluids to maintain a resident's health.
Inspectors wroteBased on clinical record review, staff and resident interviews, and Dietician Job Description review, the facility failed to ensure Registered Dietician (RD) involvement for consultation, education, Care Plan updates for nutritional interventions to address protein needs and nutritional deficits for promotion of chronic wound healing of 1 of 3 residents reviewed (Resident #1). In addition, the Dietician lacked participation of expectations in Quality Assurance and Performance Improvement (QAPI) meetings. The facility reported a census of 72. Findings Include: The Minimum Data Set (MDS) assessment dated [DATE] for resident #1 included diagnoses of paraplegia and malnutrition. The MDS revealed 3 pressure ulcers and coded for protein and/or calorie malnutrition, risk for malnutrition. [...]
Fire safety inspections
21 fire safety citations on file: 5 on April 6, 2026, 7 on March 20, 2025, 9 on May 23, 2024.
Every fire safety citation21 citations
- 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 6, 2026 · Corrected (the home has a date of correction)
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · April 6, 2026 · Corrected (the home has a date of correction)
- F
Have properly installed electrical wiring and gas equipment.
K 511 · April 6, 2026 · Corrected (the home has a date of correction)
- F
Have simulated fire drills held at unexpected times.
K 712 · April 6, 2026 · Corrected (the home has a date of correction)
- E
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · April 6, 2026 · Corrected (the home has a date of correction)
- F
Use approved construction type or materials.
K 161 · March 20, 2025 · Corrected (the home has a date of correction)
- F
Install emergency lighting that can last at least 1 1/2 hours.
K 291 · March 20, 2025 · Corrected (the home has a date of correction)
- F
Have properly located and lighted "Exit" signs.
K 293 · March 20, 2025 · Corrected (the home has a date of correction)
- F
Have simulated fire drills held at unexpected times.
K 712 · March 20, 2025 · Corrected (the home has a date of correction)
- F
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
K 914 · March 20, 2025 · Corrected (the home has a date of correction)
- F
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · March 20, 2025 · 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 · March 20, 2025 · Corrected (the home has a date of correction)
- F
Develop and maintain an Emergency Preparedness Program (EP).
E 4 · May 23, 2024 · Corrected (the home has a date of correction)
- F
Establish roles under a Waiver declared by secretary.
E 26 · May 23, 2024 · 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 · May 23, 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 · May 23, 2024 · Corrected (the home has a date of correction)
- F
Provide a written emergency evacuation plan.
K 711 · May 23, 2024 · Corrected (the home has a date of correction)
- F
Have simulated fire drills held at unexpected times.
K 712 · May 23, 2024 · 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 · May 23, 2024 · Corrected (the home has a date of correction)
- E
Properly provide smoke detection systems in areas open to corridors.
K 347 · May 23, 2024 · Corrected (the home has a date of correction)
- E
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · May 23, 2024 · Corrected (the home has a date of correction)