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 17 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
11D
2E
4F
Potential for minimal harm
0A
0B
0C
March 25, 2026Standard inspection · 2 citations
- D
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Inspectors wroteBased on resident and staff interviews, record review, and review of the facility policy titled Abuse, Neglect and Exploitation and Misappropriation Prevention Program, the facility failed to protect one of 36 sampled residents (R) (R26) right to be free from physical and verbal abuse by another resident (R30).
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on staff interviews, record review, and review of the facility policy titled Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating, the facility failed to report an allegation of resident-to-resident verbal and physical abuse to the State Survey Agency (SSA) within the required time frame for one of 36 sampled residents. This deficient practice had the potential to place other residents at risk of physical and verbal abuse.
February 20, 2025Standard inspection, Complaint inspection · 7 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 observations, staff interviews, and review of the facility's policy titled Food Receiving and Storage, the facility failed to ensure food items stored in the main kitchen was labeled, dated, and properly stored. The deficient practice had the potential to affect 55 out of 59 residents receiving an oral diet.
- F
Provide and implement an infection prevention and control program.
Inspectors wroteBased on staff interviews, record review, and review of the facility's policy titled, Infection Prevention and Control Program, the facility failed to establish a water management program as part of the overall infection prevention and control program. The deficient practice had the potential to affect all residents in the facility. The facility had a census of 59 residents.
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on staff interviews, record review, and review of the facility's policy Abuse, Neglect, and Exploitation or Misappropriation-Reporting and Investigating, the facility failed to ensure that an allegation of sexual abuse was reported the State Agency (SA) and other officials within the required time frame for one out of 34 sampled residents (R) (R59).
- D
Respond appropriately to all alleged violations.
Inspectors wroteBased on staff interviews, record review, and review of the facility's policy Abuse, Neglect, and Exploitation or Misappropriation-Reporting and Investigating, the facility failed to ensure a thorough investigation was completed for sexual abuse allegations for one out of 34 sampled residents (R) (R59).
- 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 staff interviews, record review, and review of the facility's policy titled Comprehensive Care Plans, the facility failed to develop a comprehensive, person-centered care plan for two of eight residents (R) R10 and R13 receiving respiratory care. Specifically, the facility failed to develop a care plan for nebulizer therapy for R10 and oxygen therapy for R13. The deficient practice had the potential to place the residents at risk for medical complications, unmet needs, and a diminished quality of life.
- 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 the facility's policy titled, Water Temperatures, Safety of, the facility failed to keep the residents free of accident hazards related to water temperatures above 110 degrees Fahrenheit (F) in five out of 38 resident rooms (room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], Room29, and room [ROOM NUMBER]). The sample size was 34 residents.
- 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's policy titled, Oxygen Administration, the facility failed to provide respiratory care consistent with professional standards of practice for one of eight residents (R) (R10) receiving respiratory care. Specifically, the facility failed to properly store the nebulizer mouthpiece, when not in use, for R10. The deficient practices had the potential to cause respiratory infection for R10.
November 22, 2023Complaint inspection · 2 citations
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on staff interviews, record reviews, and review of the facility's policy titled, Resident Incident/Accident Reporting, the facility failed to ensure an injury of unknown origin was reported to the proper authorities immediately, but no later than two hours for one Residents (R) (R12). Specifically, R12 who was bedridden received a closed fracture of the right distal femur, and the facility failed to report this event. The sample size was 21.
- D
Respond appropriately to all alleged violations.
Inspectors wroteBased on staff interview, record reviews, and review of the facility's policy titled Abuse Prohibition Policy and Procedures, the facility failed to investigate an allegation of Injury of unknown origin for one Resident (R) (R12). This failure not to conduct an investigation had the potential to result in other residents not being identified as potential victims of injury of unknown origin. The sample size was 21.
October 15, 2022Standard inspection · 6 citations
- F
Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
Inspectors wroteBased on record review and interview, the facility failed to have a certified Dietary Manager employed 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 observations, interviews, and record review, the facility failed to document temperatures of all foods on the steam table for all meals (breakfast, lunch, and dinner) served to residents; also failed to document dish machine temperatures. This failure increased the potential to negatively impact food quality and cleanliness of the dishes for all 60 residents.
- E
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 observations, record review, interviews, and review of the policy titled Notice of Immediate Transfer or Discharge Policy, the facility failed to ensure four residents (R) (R#6, R#14, R#31, and R#49) of four residents reviewed for discharge, and/or their representatives were provided with a written transfer/discharge notice, and failed to notify the Ombudsman's office of these transfers in a timely manner.
- E
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 record review, and interview, the facility failed to ensure four of four residents (R) (R#6, R#14, R#31, and R#49) reviewed for transfers to the hospital or their representatives, were provided at a written notice of the bed-hold policy at the time of transfer.
- 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, interview, and review of the facility policy titled, Psychotropic Medication Policy and Procedure, the facility failed to ensure a PRN (as needed) antipsychotic was used for an appropriate indication and that PRN psychotropic medications were not prescribed for more than 14 days at a time for one resident (R)(R#45) of five residents reviewed for unnecessary medications.
- D
Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.
Inspectors wroteBased on interview and record review, the facility failed to ensure all direct care staff had training in dementia, abuse, and/or behavioral health prior to caring for residents for two Certified Nursing Assistant (CNA) BB and CNA CC of five sampled personnel records.
Fire safety inspections
25 fire safety citations on file: 3 on March 25, 2026, 16 on February 20, 2025, 6 on October 15, 2022.
Every fire safety citation25 citations
- E
Ensure proper usage of power strips and extension cords.
K 920 · March 25, 2026 · Corrected (the home has a date of correction)
- D
Inspect, test, and maintain automatic sprinkler systems.
K 353 · March 25, 2026 · Corrected (the home has a date of correction)
- D
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · March 25, 2026 · Corrected (the home has a date of correction)
- F
Develop and maintain an Emergency Preparedness Program (EP).
E 4 · February 20, 2025 · Corrected (the home has a date of correction)
- F
Conduct testing and exercise requirements.
E 39 · February 20, 2025 · Corrected (the home has a date of correction)
- F
Meet other general requirements.
K 200 · February 20, 2025 · Corrected (the home has a date of correction)
- F
Have properly located and lighted "Exit" signs.
K 293 · February 20, 2025 · Corrected (the home has a date of correction)
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · February 20, 2025 · Corrected (the home has a date of correction)
- F
Properly provide smoke detection systems in areas open to corridors.
K 347 · February 20, 2025 · Corrected (the home has a date of correction)
- F
Properly install and monitor supervisory attachments on automatic sprinkler systems.
K 352 · February 20, 2025 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · February 20, 2025 · Corrected (the home has a date of correction)
- F
Have properly installed electrical wiring and gas equipment.
K 511 · February 20, 2025 · Corrected (the home has a date of correction)
- F
Have simulated fire drills held at unexpected times.
K 712 · February 20, 2025 · 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 · February 20, 2025 · Corrected (the home has a date of correction)
- D
Properly select, install, inspect, or maintain portable fire extinguishes.
K 355 · February 20, 2025 · Corrected (the home has a date of correction)
- D
Install corridor and hallway doors that block smoke.
K 363 · February 20, 2025 · Corrected (the home has a date of correction)
- D
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
K 521 · February 20, 2025 · Corrected (the home has a date of correction)
- D
Meet requirements for the installation and maintenance of electrical systems.
K 911 · February 20, 2025 · Corrected (the home has a date of correction)
- D
Have proper medical gas storage and administration areas.
K 923 · February 20, 2025 · Corrected (the home has a date of correction)
- D
Establish an Emergency Preparedness Program (EP).
E 1 · October 15, 2022 · Corrected (the home has a date of correction)
- D
Keep aisles, corridors, and exits free of obstruction in case of emergency.
K 211 · October 15, 2022 · Corrected (the home has a date of correction)
- D
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · October 15, 2022 · Corrected (the home has a date of correction)
- D
Inspect, test, and maintain automatic sprinkler systems.
K 353 · October 15, 2022 · Corrected (the home has a date of correction)
- D
Have simulated fire drills held at unexpected times.
K 712 · October 15, 2022 · 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 · October 15, 2022 · Corrected (the home has a date of correction)