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 14 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
8D
3E
0F
Potential for minimal harm
0A
3B
0C
December 4, 2025Standard 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 review of facility policies, 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 one of two resident refrigerators (Nursing Unit Two); failed to label food brought into the facility with the resident's name and use by date in one of two resident refrigerators ( Nursing Unit Two); failed to maintain sanitary conditions in one of two resident refrigerators (Nursing Unit One); failed to maintain dishwashing machine water temperatures in accordance with manufacturer recommendations for food service safety for the kitchen dishwasher; and failed to prepare food items in accordance with professional standards in the facility's main kitchen.
- D
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
Inspectors wroteBased on review of facility employee in-service training records and staff interview, it was determined that the facility failed to assure that staff completed all the required mandatory trainings for the yearly 12 hour mandatory trainings for five of five Nurse Aide (NA) records reviewed.
September 18, 2025Complaint inspection · 1 citation
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on review of facility policies, clinical records, and shower schedules, and staff interviews, it was determined that the facility failed to ensure that residents were provided with showers as scheduled for one of 13 residents reviewed (Resident R1).
November 15, 2024Standard inspection · 3 citations
- D
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 review of facility policy, observation, and staff interview, it was determined that the facility failed to store Schedule II-V medications in a separately locked, permanently affixed compartment in one of two medication rooms reviewed (Unit 1 medication room).
- B
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 review of facility policy and clinical records, and staff interview, it was determined that the facility failed to send copies of notice of emergency transfer to the representative of the Office of State Long-Term Care (LTC) Ombudsman for four of four residents reviewed (Residents R18, R37, R56, and R88).
- B
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 review of facility policies and clinical records, and staff interview, it was determined that the facility failed to provide the resident and/or resident representative with a written notice of the facility bed-hold (explanation of how long a bed can be held during a leave of absence and the cost per day) upon or within twenty-four hours of transfer for four of four residents reviewed for hospitalizations (Residents R18, R37, R56, and R88).
March 21, 2024Complaint inspection · 1 citation
- D
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Inspectors wroteBased on a review of facility policy, facility grievances, and resident representative and staff interviews, it was determined that the facility failed to resolve a resident representative's grievance concerns related to care/treatment for one of 31 residents reviewed (Resident R1).
February 7, 2024Complaint inspection · 1 citation
- E
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on observations and staff interviews, it was determined that the facility failed to ensure a safe environment for residents residing on two of three units regarding a soiled utility room area (Unit 1 and Unit 2).
December 21, 2023Standard inspection, Complaint inspection · 6 citations
- E
Provide activities to meet all resident's needs.
Inspectors wroteBased on a review of facility policy, observations, and resident representative and staff interviews, it was determined that the facility failed to develop and implement a comprehensive activity program for one of three resident care units observed (Memory Care Unit Three).
- 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 review of facility policies, clinical records, and staff interview, it was determined that the facility failed to ensure urinary catheter (tube inserted into the bladder to drain urine) care was completed and urinary output was documented per physician orders for one of 20 residents reviewed (Resident R50).
- 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 and failed to provide evidence that non-pharmacological interventions (interventions attempted to calm a resident other than medication) were attempted prior to the administration of an as needed (PRN) psychotropic (mind altering) medication for one of five residents reviewed (Resident R41), and failed to ensure PRN orders for psychotropic medications be used only when the medication is necessary to treat a diagnosed specific condition for two of five residents reviewed related to psychotropic medication usage (Residents R76 and R85).
- D
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 review of facility policy, observations and staff interviews, it was determined that the facility failed to label multi-dose containers of insulin (medication to treat elevated blood sugar levels) and tuberculin solution (used to test for the disease tuberculosis) with the date they were opened in one of three medication carts (Long Cart 2).
- 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 facility policy, observations, and staff interview, it was determined that the facility failed to ensure food was stored and prepared in a safe and sanitary manner related to the walk-in freezer, dry storage area, cooking equipment, and fans in the dishwashing area for one of one main kitchens.
- B
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Inspectors wroteBased on review of facility policy and clinical records, and staff interview, it was determined that the facility failed to provide a written summary of the baseline care plan and order summary to the resident and resident representative for four of 20 residents reviewed (Residents R50, R41, R86, and R89).
Fire safety inspections
11 fire safety citations on file: 2 on December 4, 2025, 4 on November 15, 2024, 5 on December 21, 2023.
Every fire safety citation11 citations
- C
Establish emergency prep training and testing.
E 36 · December 4, 2025 · Corrected (the home has a date of correction)
- C
Inspect, test, and maintain automatic sprinkler systems.
K 353 · December 4, 2025 · Corrected (the home has a date of correction)
- F
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
K 521 · November 15, 2024 · Corrected (the home has a date of correction)
- E
Provide properly protected cooking facilities.
K 324 · November 15, 2024 · Corrected (the home has a date of correction)
- D
Have power receptacles that are properly grounded.
K 912 · November 15, 2024 · Corrected (the home has a date of correction)
- C
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · November 15, 2024 · Corrected (the home has a date of correction)
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · December 21, 2023 · Corrected (the home has a date of correction)
- F
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
K 761 · December 21, 2023 · 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 · December 21, 2023 · Corrected (the home has a date of correction)
- E
Inspect, test, and maintain automatic sprinkler systems.
K 353 · December 21, 2023 · Corrected (the home has a date of correction)
- C
Conduct testing and exercise requirements.
E 39 · December 21, 2023 · Corrected (the home has a date of correction)