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 31 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
17D
2E
12F
Potential for minimal harm
0A
0B
0C
April 9, 2026Complaint 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 interview and record review the facility failed to ensure wheelchair foot pedals were in place to prevent resident injury for 1 (R4) of 3 residents reviewed for accidents in the sample of 8. This past non-compliance occurred between 3/24/2026 and 3/26/2026.
August 22, 2025Standard inspection · 5 citations
- F
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on observation, interview and record review, the facility failed to ensure food items were covered while stored in the refrigerator and scoops were removed from bulk food containers to decrease the risk of cross contamination. This failure has the potential to affect all 33 residents residing in the facility. Findings Include:On 8/18/25 at 10:00 AM during the initial tour of the kitchen, scoops with handles were found in a bulk container of brown sugar and in the food thickener. In addition during this same initial tour, a tray full of pitchers was observed in the refrigerator that were not labeled or covered with lids. V4 (Culinary Director) stated that he would have V3 (Culinary/Cook) find the lids to cover them. A food supply and storage policy with a revision date of January 2012, documents: Food and supply storage areas shall be maintained in a clean, safe and sanitary manner. [...]
- 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 observation, interview and record review, the facility failed to ensure pureed food was prepared in accordance with the recipes and to preserve nutritional value for 6 (R4, R5, R10, R21, R26 and R27) of 6 residents reviewed for puree diets in a sample of 27. The Findings Include:R4's Face Sheet documented an admission date of 8/22/2024. R4's current physician orders for August of 2025 document R4 is to receive a regular diet/pureed consistency. R5's Face Sheet documented an admission date of 3/31/22 and a readmission date of 6/24/24. R5's current physician orders for August of 2025 document R5 is to receive a regular diet/pureed consistency. R10's Face Sheet documented an admission date of 8/3/19. R10's current August 2025 physician orders document R10 is to receive a regular diet/puree consistency. R21's Face Sheet documented an admission date of 12/1/23. [...]
- D
PASARR screening for Mental disorders or Intellectual Disabilities
Inspectors wroteBased on interview and record review, the facility failed to ensure the referral and coordination of PASARR (Preadmission Screening and Resident Review) Level II Screening was completed for 1 (R4) of 1 resident reviewed for PASARR assessments in the sample of 27. Findings Include:R4's Resident Face Sheet documents an initial admission date to the facility of 08/22/2024 and included diagnoses of cerebral infarction, psychotic disorder, spastic hemiplegia affecting left non dominant side, essential hypertension, chronic obstructive pulmonary disease, major depressive disorder, gastro - esophageal reflux disease, anxiety disorder, hyperlipidemia, lymphedema, bipolar disorder, and pain in right knee. R4's Notice of PASRR Level 1 Screen Outcome was dated 07/21/2024, prior to admission, and documented Level 1 Negative, No Status Change. [...]
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on interview and record review, the facility failed to ensure timely assessment and treatment was provided for a resident with a urinary tract infection for 1 (R29) of 1 resident reviewed for necessary care and services in the sample of 27. Findings Include:R29's Face Sheet documented an initial admission date to the facility on [DATE] and included diagnoses of pulmonary disease, essential hypertension, gastro - esophageal reflux disease, hyperlipidemia, osteoarthritis of knee, gout, depression, hypothyroidism, and adjustment disorder with mixed anxiety and depressed mood. R29's Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 05, indicating R29 has severe cognitive impairment. R29's Progress Notes document the following: [...]
- 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 observation, interview, and record review, the facility failed to ensure restorative services were provided as ordered to maintain or improve range of motion for 1 (R4) of 1 resident reviewed for mobility in the sample of 27. The Findings Include: R4's Resident Face Sheet documented an initial admission date to the facility of 08/22/2024 and included diagnoses of cerebral infarction, psychotic disorder, spastic hemiplegia affecting left non dominant side, essential hypertension, chronic obstructive pulmonary disease, major depressive disorder, gastro - esophageal reflux disease, anxiety disorder, hyperlipidemia, lymphedema, bipolar disorder, and pain in right knee. [...]
February 21, 2025Complaint inspection · 1 citation
- F
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Inspectors wroteBased on interview and record review, the facility failed to provide 8 hours of daily Registered Nurse (RN) coverage. This failure has the potential to affect all 36 residents residing in the facility.
September 13, 2024Standard inspection · 7 citations
- F
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Inspectors wroteBased on interview and record review, the facility failed to provide adequate direct care staffing to meet resident's needs. This has the potential to affect all 32 residents living at the facility.
- F
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Inspectors wroteBased on interview and record review, the facility failed to provide 8 hours of daily Registered Nurse coverage. This failure has the potential to affect all 32 residents residing in the facility.
- F
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on observation, record review, and interview, the facility failed to store food and maintain the kitchen in safe and sanitary manner to prevent potential contamination. This has the potential to all 32 residents residing in the facility. Findings Include: On 9/10/24 at 9:45 AM, the initial kitchen tour was completed and the following concerns were noted: [...]
- D
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Inspectors wroteBased on interview and record review, the facility failed to ensure assessments were successfully transmitted within 14 days of completion for 1 (R32) of 12 residents reviewed for assessments in the sample of 41. Findings Include: R32's Face Sheet documented an admission date of 04/29/2024. Diagnoses include, but not limited to dementia, Alzheimer's disease, benign prostatic hyperplasia, and essential hypertension. On 09/11/2024 at 1:52 PM, V2 (Registered Nurse / Minimum Data Set Nurse) stated R32 had an admission assessment on 05/03/2024 and the discharge assessment was completed on 05/24/2024. V2 stated that she does not have to transmit the MDS because it was a private pay discharge. V2 stated that she did not transmit the assessment as it is not required to be. On 09/11/2024 at 2:55 PM, V1 (Administrator) stated that she is unfamiliar with the MDS not being transmitted. [...]
- 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 interview and record review the facility has failed to update comprehensive care plans for 2 of 12 residents (R15 and R21) reviewed for care plans in a sample of 41. The Findings Include: 1. R15's Face sheet documents an admission date of 2/9/21. R15's Face sheet includes the following diagnosis: major depressive disorder, cognitive communication deficit, depression, unspecified dementia, without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety, vascular dementia with agitation. R15's Current care plan documents a problem area of falls. The goal for this problem area is that resident will remain free from injury. The approach to this problem area include: [...]
- 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 and interview the facility failed to implement fall precautions by placing the call light within reach for 1 of 2 (R15) residents reviewed for falls in a sample of 41. Findings Include: R15's face sheet documents an admission date of 2/9/21. This same document includes the following diagnosis: muscle weakness, other abnormalities of gait and mobility, and vascular dementia. R15's care plan has a problem area category of falls that has a start date of 8/18/22 and an edited date of 8/27/24. The goal for this problem area with a long term goal target date of 11/29/24 is that the resident will remain free from injury. An approach to this problem area with a start date of 8/18/22 is to keep the call light in reach at all times. [...]
- 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 record review and interview the facility failed to ensure residents were free from unnecessary medications for 1 of 5 (R2) residents reviewed for unnecessary medications in a sample of 41. The Findings Include: R2's Face sheet documents an admit date of 9/6/23 and includes the following diagnosis: vascular dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. R2's current Physician Order Sheet documents an order for 1 mg (milligram) Risperadol with diagnosis: vascular dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety with a start date of 9/6/2023. [...]
May 17, 2024Complaint inspection · 1 citation
- F
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Inspectors wroteBased on interview and record review, the facility failed to provide adequate direct care staffing to meet resident's needs. This has the potential to affect all 37 residents living at the facility.
April 19, 2024Complaint inspection · 10 citations
- F
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Inspectors wroteBased on interview and record review, the facility failed to provide adequate direct care staffing to meet resident's needs. This has the potential to affect all 36 residents living at the facility.
- F
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Inspectors wroteBased on interview and record review, the facility failed to provide the services of a trained, competent Certified Nursing Assistant (CNA) on 3/31/24. This has the potential to affect all 36 residents living at the facility.
- F
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Inspectors wroteBased on interview and record review, the facility failed to provide the services of a full time Director of Nurses/DON. This has the potential to affect all 36 residents living at the facility.
- F
Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.
Inspectors wroteBased on interview and record review, the facility failed to provide sufficient kitchen staff to carry out nutrition services on 3/26/24. This has the ability to affect all 36 residents living at the facility.
- F
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on observation, interview, and record review, the facility failed to check the dish machine and surface cleaning agent for the correct proportion of a sanitizing agent, failed to maintain equipment, food contact surfaces and storage areas in a clean and sanitary manner, and failed to store foods to prevent potential contamination. This has the potential to affect all 36 residents living in the facility.
- 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 observation, interview, and record review, the facility failed to serve the appropriation portions for a lunch meal according to the menu spreadsheet for four (R3, R9, R13, R14) of eight residents reviewed for nutrition in the sample of 17.
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on interview and record review, the facility failed to provide twice weekly showers for 3 of 17 dependent residents (R4, R12, R13) reviewed for ADL (Activities of Daily Living) care in the sample of 17.
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on interview and record review, the facility failed to safely transfer a resident requiring the use of a mechanical lift for 1 of 4 residents (R13) reviewed for transfers in the sample of 17.
- D
Provide enough food/fluids to maintain a resident's health.
Inspectors wroteBased on observation, interview, and record review, the facility failed to provide nutritional supplements according to physician's orders for four (R3, R14, R15, R16) of four residents reviewed for nutrition in the sample of 17.
- D
Ensure that residents are free from significant medication errors.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents are free from significant medication errors for one of four residents (R7) reviewed for medication errors in the sample of 17.
February 29, 2024Complaint inspection · 1 citation
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on interview and record review, the facility failed to provide timely and thorough incontinence care for a dependent resident who requires assistance with toileting and hygiene for one of four residents (R1) reviewed for incontinence care in the sample of four.
July 21, 2023Standard inspection · 5 citations
- F
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Inspectors wroteBased on interview and record review, the facility failed to have a Registered Nurse (RN) for at least 8 consecutive hours, 7 days a week. This has the potential to affect all 38 residents who reside at this facility. This past non-compliance occurred between 1/14/23 and 5/20/23.
- D
Ensure each resident receives an accurate assessment.
Inspectors wroteBased on observation, interview, and record review the facility failed to correctly code restraint use for 1 (R11) of 2 residents reviewed for Minimum Data Set (MDS) restraint coding in the sample of 21. Findings Include: Review of R11's Minimum Data Set, dated [DATE] and documented as being a quarterly review assessment noted in section P0100 Physical Restraints, A. Bed Rail is documented as 1. Used less than daily. On 07/19/23 at 01:58 PM, R11 was observed lying in bed sleeping. No bed rails or other restraint devices of any kind were observed being utilized or in place on her bed. Review of R11's current and active Physician Orders documents no order for a bed rail or any other restraint use. On 07/20/23 at 11:24 AM, V4 (MDS / Care Plan Coordinator) acknowledges that R11's 6/20/23 MDS did have an error in coding, and R11 does not utilize a bed rail as a restraint. [...]
- D
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Inspectors wroteBased on interview and record review the facility failed to refer a resident for a Level II Preadmission Screening and Resident Review (PASARR) for 1 of 2 residents (R22) reviewed for PASARR's in the sample of 21. Findings Include: R22's PASARR, as provided by the facility, dated 11/1/19 documents no Developmental Disability or Mental Illness diagnoses during this evaluation, therefore not requiring a level II screening. Review of R22's Continuity of Care with a created date of July 20, 2023 documents active diagnosis of Delusional Disorders with an effective date of 05/27/2022. This same document also lists a diagnosis of Major depressive disorder, single episode, moderate with an effective date of 06/23/2023. No PASARR re-evaluation is documented as being completed after these diagnoses were added. [...]
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on interview, observation, and record review, the facility failed to provide the required supervision to prevent a fall for 1 of 7 residents (R31) reviewed for falls in the sample of 21.
- 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 interview and record review, the facility failed to ensure a residents medication regimen was free from unnecessary medications for one resident of five residents (R4) reviewed for unnecessary medications in the sample of 21.
Fire safety inspections
30 fire safety citations on file: 12 on August 22, 2025, 9 on September 13, 2024, 9 on July 21, 2023.
Every fire safety citation30 citations
- F
Have corridors or aisles that are unobstructed and are at least 8 feet in width.
K 232 · August 22, 2025 · deficient, provider has
- F
Have properly located and lighted "Exit" signs.
K 293 · August 22, 2025 · deficient, provider has
- F
Install a fire alarm system that can be heard throughout the facility.
K 341 · August 22, 2025 · deficient, provider has
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · August 22, 2025 · deficient, provider has
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · August 22, 2025 · deficient, provider has
- F
Have simulated fire drills held at unexpected times.
K 712 · August 22, 2025 · deficient, provider has
- F
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · August 22, 2025 · deficient, provider has
- E
Properly select, install, inspect, or maintain portable fire extinguishes.
K 355 · August 22, 2025 · deficient, provider has
- E
Install corridor and hallway doors that block smoke.
K 363 · August 22, 2025 · deficient, provider has
- 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 22, 2025 · deficient, provider has
- D
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · August 22, 2025 · deficient, provider has
- D
Meet requirements for the use of electrical equipment.
K 919 · August 22, 2025 · deficient, provider has
- F
Address subsistence needs for staff and patients.
E 15 · September 13, 2024 · Corrected (the home has a date of correction)
- F
Implement emergency and standby power systems.
E 41 · September 13, 2024 · Corrected (the home has a date of correction)
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · September 13, 2024 · Corrected (the home has a date of correction)
- F
Have simulated fire drills held at unexpected times.
K 712 · September 13, 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 · September 13, 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 · September 13, 2024 · Corrected (the home has a date of correction)
- E
Inspect, test, and maintain automatic sprinkler systems.
K 353 · September 13, 2024 · Corrected (the home has a date of correction)
- E
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
K 741 · September 13, 2024 · Corrected (the home has a date of correction)
- E
Ensure proper usage of power strips and extension cords.
K 920 · September 13, 2024 · Corrected (the home has a date of correction)
- F
Establish procedures for tracking staff and patients during an emergency.
E 18 · July 21, 2023 · Corrected (the home has a date of correction)
- F
Establish roles under a Waiver declared by secretary.
E 26 · July 21, 2023 · Corrected (the home has a date of correction)
- F
Implement emergency and standby power systems.
E 41 · July 21, 2023 · Corrected (the home has a date of correction)
- F
Have simulated fire drills held at unexpected times.
K 712 · July 21, 2023 · Corrected (the home has a date of correction)
- E
Have exits that are accessible at all times.
K 271 · July 21, 2023 · Corrected (the home has a date of correction)
- E
Install proper backup exit lighting.
K 281 · July 21, 2023 · Corrected (the home has a date of correction)
- E
Provide properly protected cooking facilities.
K 324 · July 21, 2023 · Corrected (the home has a date of correction)
- E
Inspect, test, and maintain automatic sprinkler systems.
K 353 · July 21, 2023 · Corrected (the home has a date of correction)
- E
Properly select, install, inspect, or maintain portable fire extinguishes.
K 355 · July 21, 2023 · Corrected (the home has a date of correction)