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 61 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
3G
0H
0I
Potential for more than minimal harm
49D
6E
2F
Potential for minimal harm
0A
0B
1C
July 24, 2026Complaint inspection · 1 citation
- D
Honor the resident's right to manage his or her financial affairs.
Inspectors wroteBased on medical record review, facility financial account review, and staff interview, the facility failed to ensure remaining fund balances were dispersed to residents at the time of discharge from the facility. This affected two (#1, #7) of three residents reviewed for disbursement of fund account balances in a facility census of 61.
June 29, 2026Complaint inspection · 4 citations
- D
Let each resident or the resident's legal representative access or purchase copies of all the resident's records.
Inspectors wroteBased on record review, staff interview, and policy review, the facility failed to ensure residents received timely copies of their medical records. This affected two (#75 and #77) of three residents reviewed for medical record requests. The facility census was 64.1. Review of the medical record for Resident #75 revealed an admission date of 10/10/25 with diagnoses of heart failure, anxiety, edema, depression, and hypertension. Resident #75 discharged to the community on 04/02/26. Review of the quarterly Minimum Data Set (MDS) assessment, dated 01/30/26, revealed Resident #75 had severely impaired cognition. Review of the comprehensive admission MDS assessment, dated 10/2025, revealed Resident #75 had intact cognition. Interview on 06/24/26 at approximately 4:00 P.M. [...]
- D
Respond appropriately to all alleged violations.
Inspectors wroteBased on review of Self-Reported Incidents (SRIs), staff interviews, record review, and policy review, the facility failed to ensure allegations of abuse and injuries of unknown origin were thoroughly investigated. This affected two (#80 and 81) of nine residents reviewed for self-reported incidents. Additionally, the facility failed to ensure residents were timely assessed after alleging abuse. This affected one (#80) of nine residents reviewed for self-reported incidents. The facility census was 64.
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on observation, staff interview, record review and policy review, the facility failed to ensure fall interventions were in place and fall interventions were reviewed and revised as needed, and failed to accurately document the use of fall interventions. This affected one (#31) of three residents reviewed for falls. Additionally, the facility failed to implement their policy regarding post-fall procedures when a fall was reported by family. This affected one (#77) of three residents reviewed for falls. Finally, the facility failed to show evidence of investigations into a fall with injury. This affected two (#31 and #76) of three residents reviewed for falls. The facility census was 64. 1. [...]
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, staff interview, and facility policy, the facility failed to perform hand hygiene and failed to use proper technique during foley catheter care. This affected one (#51) resident out of one resident observed for foley catheter care. The census was 64.
December 11, 2025Standard inspection · 8 citations
- G
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on medical record review, review of hospital records, review of investigation statements, review of interdisciplinary investigation notes, staff and resident interviews, review of a mechanical lift owner's manual, review of a mechanical lift sling owner's manual, review mechanical lift safety inspections, and review of facility policy, the facility failed to ensure Resident #02 was safely transferred using a mechanical lift resulting in an avoidable fall. This resulted in Actual Harm on 08/07/25 when Resident #02 was not safely transferred resulting in a mechanical lift tipping and the resident suffering an avoidable fall sustaining a right hip fracture requiring surgical repair. This affected one (#02) of four residents reviewed for accidents. [...]
- 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, staff interview, and review of the facility menu with spread sheets, the facility failed to ensure residents on a mechanically altered diet received the same portions as the residents who received a regular diet. This had the potential to affect the 24 residents (#9, #10, #11, #13, #15, #17, #18, #21, #22, #23, #27, #30, #35, #38, #39, #53, #54, #57, #60, #63, #64, #66, #76 and #84) who received mechanically altered diet. The facility census was 77. Findings Include: Observations on 12/09/25 at 11:17 A.M. of the texture modification process for the pureed turkey meat found ten, three ounce (3 oz) #10 scoops of turkey were added to the food processor. Dietary Staff (DS) #235 then added turkey gravy and slices of bread to thin, blend, and thicken the processed meat. Observations on 12/09/25 at 11:22 A.M. [...]
- D
Provide doctor's orders for the resident's immediate care at the time the resident was admitted.
Inspectors wroteBased on medical record review, resident interview, and staff interview, the facility failed to ensure wound care orders were in place for a resident's wounds upon admission. This affected one resident (#83) of four residents reviewed for wound care and treatment. The facility census was 77. Findings Include: Review of Resident #83's medical record revealed an admission date of 12/01/25 and a discharge date of 12/08/25. Diagnoses included rheumatoid arthritis, type II diabetes, chronic pain, nicotine dependence, severe protein calorie malnutrition, and cognitive communication deficit. Review of Resident #83's admission Skin assessment dated [DATE] revealed Resident #83 had a sacrum area crusted measuring 5 centimeters (cm) by 4 cm into the second layer of skin and a right gluteal fold area 1.5 cm by 1 cm into the second layer of skin. [...]
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on medical record review, resident interview, and staff interview, the facility failed to ensure residents who were identified as at risk for constipation had interventions implemented when they went longer than three days without a bowel movement. This affected one Resident (#5) of three residents reviewed of constipation. The facility census was 77. Findings Include: Review of Resident #5's medical record revealed an admission date of 05/14/21. Diagnoses included spinal stenosis, history of stroke, hemiplegia and hemiparesis, bipolar disorder, fibromyalgia, constipation, and anxiety disorder. Review of Resident #5's Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 indicating Resident #5 was cognitively intact. Resident #5 was dependent on staff for toilet use, bathing, dressing, bed mobility and transfers. [...]
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on medical record review, observations, and resident, staff and physician interviews, the facility failed to timely implement physician's orders for Resident #3's pressure ulcer dressing change and failed to ensure the physician/provider was notified regarding the presence of eschar to Resident #7's heel ulcer and the potential need to change the treatment plan. This affected two (#3 and #7) out of three residents reviewed for pressure ulcer care. The current census is 77.
- 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, interview, record review, and policy review, the facility failed to ensure catheter drainage bags were maintained below the level of the bladder to allow proper gravity drainage for one resident (#54) of one resident reviewed for catheter care. The facility census was 77. Findings Include:Record review for Resident #54 revealed the resident was admitted to the facility on [DATE] with multiple diagnoses including dementia, diabetes mellitus (high sugar), and obstructive and reflux uropathy (inability to urinate normally due to blockage). Record review for Resident #54 revealed the resident had impaired cognition and required partial to moderate assistance with indwelling catheter care. Review of physician orders for Resident #54 revealed order dated 07/24/25 for a suprapubic (catheter inserted directly into the bladder with surgery) catheter. [...]
- D
Provide enough food/fluids to maintain a resident's health.
Inspectors wroteBased on medical record review, observation, resident interview, and staff interview, the facility failed to ensure resident's diet orders were followed as written. This affected one (Resident #9) of four residents reviewed for nutrition. The facility census was 77. Findings Include: Review of Resident #9's medical record revealed an admission date of 10/01/25. Diagnoses included abnormal weight loss, anxiety disorder, asthma, heart failure, osteoarthritis, cognitive communication deficit, and dysphagia. Review of Resident #9's Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 14 indicating Resident #9 was cognitively intact. Resident #9 required moderate assistance with toilet use, bathing, parts of dressing, and transfer. Resident #9 displayed no behaviors during the review period. Resident #9 received a mechanically altered diet. [...]
- D
Ensure that residents are free from significant medication errors.
Inspectors wroteBased on medical record review, observation of medication administration, and review of facility policy, the facility failed to ensure a seizure medication was administered as ordered which resulted in a significant medication error. This affected one (Resident #20) of nine residents observed for medication administration. The facility census was 77.
December 9, 2024Complaint inspection · 1 citation
- D
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Inspectors wroteTHE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on review of Self-Report Incidents (SRI), review of open and closed medical records, review of facility incident reports, staff interview and review of facility policy, the facility failed to prevent resident to resident sexual abuse. This affected two (#8 and #12) of three residents reviewed for abuse. The facility census was 79.
August 29, 2024Complaint inspection · 3 citations
- D
Plan the resident's discharge to meet the resident's goals and needs.
Inspectors wroteBased on observation, medical record review, and staff interview, the facility failed to ensure ongoing interventions were implemented to promote discharge from the facility were provided. This affected one (#4) of four sampled residents reviewed for discharge opportunity. The facility census was 82.
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on observation, medical record review, and staff interview, the facility failed to ensure interventions and monitoring were provided to a resident following difficulty consuming meal. This affected one (#3) of three sampled residents reviewed for meal time assistance in a facility census of 82.
- 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 and resident interview, and facility bowel and bladder management policy, the facility failed to provide and implement interventions to address specific resident incontinence needs. This affected one (#1) of three sampled residents reviewed for incontinence maintenance. The facility census was 82.
July 2, 2024Complaint inspection · 3 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 staff interview and review of staffing schedules, the facility failed to ensure staffing included the services of a registered nurse (RN) in-house for at least eight consecutive hours a day, seven days a week. This had the potential to affected all 90 residents residing in the facility. The facility census was 90.
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on observation, medical record review, staff interview, and review of the facility wound care policy, the facility failed to ensure pressure ulcer wound dressings and preventative interventions were implemented as ordered by the physician. This affected one (#1) of three sampled residents reviewed for skin integrity and wound prevention in a facility census of 90.
- D
Ensure that residents are free from significant medication errors.
Inspectors wroteBased on observation, medical record review, staff interview, and review of the facility administration and documentation of medication policy, the facility failed to ensure medications were provided as ordered by the physician. This resulted in a significant medication error when a resident was not administered an antipsychotic medication as prescribed. The affected one (#4) of three residents reviewed for medications in a facility census of 90.
May 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 staff interview, resident interview, record review and review of the facility policy, the facility failed to ensure residents dependent for care received showers as scheduled or per request. This affected one (#14) of four residents reviewed for showers. The facility census was 90.
March 21, 2024Standard inspection · 3 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, staff interview, and review of the facility policy, the facility failed to remove molded foods from the refrigerator, store food off the floor, and discard expired foods. This had the potential to affect all 100 residents who received food from the kitchen. There was one resident (#84) identified by the facility as not receiving food from the kitchen. The facility census was 101.
- D
Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death.
Inspectors wroteBased on review of resident funds records and staff interview, the facility failed to ensure resident's funds were maintained under the Medicaid limit. This affected three residents (#02, #25, and #47) of five residents reviewed for personal funds. The facility census was 101.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on observations, medical record reviews, resident and staff interviews, and review of the facility policy, the facility failed to timely address the resident's skin impairments and failed to implement physician orders routinely to address the resident's skin conditions. This affected two (#21 and #68) of four residents reviewed for skin integrity. The facility census was 101.
February 8, 2024Complaint inspection · 1 citation
- D
Ensure that residents are free from significant medication errors.
Inspectors wroteBased on record review, staff interview, and review of facility policy, the facility failed to administer medications per physician which resulted in a significant medication error for one (#94) of three residents reviewed for medication administration. The facility census was 101.
January 11, 2024Complaint inspection · 7 citations
- G
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 closed medical record review, review of hospital records, staff interview and review of facility policy, the facility failed to ensure physician ordered labs were followed-up on and completed timely to identify a urinary tract infection (UTI) for Resident #110 who had a urinary catheter. Actual harm occurred on 12/07/23 when the facility failed to properly obtain a urine specimen for Resident #110 who was symptomatic of a urinary tract infection. Between 12/07/23 and 12/14/23 no additional testing or interventions to treat a urinary tract infection were provided. On 12/14/23 Resident #110's family transported the resident to the hospital where the resident was admitted and required intravenous (IV) antibiotics for treatment of a urinary tract infection. The resident was hospitalized for four days. This affected one resident (#110) of three residents reviewed for UTIs. [...]
- D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Inspectors wroteBased on observation, medical record review, staff interview and review of facility policy, the facility failed to ensure timely pharmacy response for medication refill requests. This affected one #40) of seven residents reviewed for medication administration. The facility census was 105.
- D
Ensure that residents are free from significant medication errors.
Inspectors wroteBased on observation, medical record review, staff interview, and review of the pharmacy services provider agreement, the facility failed to ensure medication prescribed to assist with lowering blood sugar was available and administered as ordered. This affected one (#40) of seven residents reviewed for medication administration. The facility census was 105.
- 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 observation, resident interview, staff interview, and review of facility policy, the facility failed to ensure medications were kept secure at all times. This affected one (#97) of one residents reviewed for medication storage. The facility census was 105.
- D
Provide timely, quality laboratory services/tests to meet the needs of residents.
Inspectors wroteBased on medical record review, staff interview and review of facility policy the facility failed to ensure physician ordered laboratory services were completed in a timely manner. This affected one (#18) of three residents reviewed for laboratory services. The facility census was 105.
- D
Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.
Inspectors wroteBased on closed medical record review, staff interview and review of facility policy, the facility failed to ensure timely physician notification of laboratory (lab) results. This affected one (#110) of three residents reviewed for physician notification. The facility census was 105.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, medical record review, staff interview and review of facility policy, the facility failed to maintain proper infection control practices during wound care. This affected three (#9, #40 and #85) of three residents reviewed for wound care. The facility census was 105.
November 22, 2023Complaint inspection · 3 citations
- D
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Inspectors wroteTHE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NONCOMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on medical record review, staff interview, review of the facility Self-Reported Incident (SRI), review of facility corrective action documents, and policy review, the facility failed to ensure a resident was not physically restrained. This affected one (#57) of five residents reviewed for abuse. The facility census was 107.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on observation, staff interview, review of the medical record and review of facility policy, the facility failed to ensure wound treatments were completed as ordered. This affected one (#56) of four residents reviewed for wound care. The facility census was 107.
- D
Ensure that residents are free from significant medication errors.
Inspectors wroteBased on observation, staff interview, medical record review, review of facility policy and review of manufacturer's instructions, the facility failed to ensure medications were administered as ordered. This affected one (#90) of six residents reviewed for medication administration. The facility census was 107.
September 27, 2023Complaint inspection · 1 citation
- D
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Inspectors wroteBased on review of the medical record, staff interview, and policy review, the facility failed to ensure resident preferences for showers were honored. This affected one (Resident #6) of three residents reviewed for bathing/showers. The facility census was 105.
September 1, 2023Complaint inspection · 6 citations
- G
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteTHE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NONCOMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on medical record review, staff interview, review of facility corrective action documents, and policy review, the facility failed to ensure a resident identified at risk for pressure ulcer development did not develop an in-house acquired stage III pressure ulcer (full thickness skin loss) and received timely interventions to promote healing. Actual harm occurred when Resident #61 was discovered with a stage III pressure ulcer to the sacrum one day after being assessed with intact skin integrity and no documented intervention was implemented to promote healing or further tissue damage until three days following discovery. This affected one (#61) of three residents reviewed for pressure ulcer care and treatment. The facility census was 109.
- D
Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home.
Inspectors wroteBased on review of resident trust account records, review of receipts, review of a withdrawal record document, and staff interview, the facility failed to ensure funds were withdrawn from the appropriate resident account. This affected two (#12 and #123) of three residents reviewed for resident trust accounts. The facility census was 109.
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on medical record review, review of a facility investigation, staff interview, review of self-reported incidents, and review of a facility policy, the facility failed to report an allegation of sexual abuse to the State Survey Agency. This affected two (#12 and #105) of four residents reviewed for abuse. The facility census was 109.
- D
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Inspectors wroteBased on observation, record review, and staff interview, the facility failed to ensure a cognitively impaired resident received adequate assistance with eating. This affected one (#61) of three residents reviewed for assistance with meals. The facility census was 109.
- 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 facility policy review, the facility failed to ensure a resident at risk for incontinence received timely and adequate incontinence care following an episode of urinary incontinence. This affected one (#61) of three residents reviewed for incontinence. The census was 109.
- D
Provide enough food/fluids to maintain a resident's health.
Inspectors wroteBased on observation, medical record review, staff interview, and review of a facility policy, the facility failed to obtain weights per the plan of care and per the facility policy to assess residents for unplanned weight loss. This affected one (#61) of one residents reviewed for weight loss. The facility census was 109.
April 11, 2022Standard inspection · 19 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, medical record reviews, policy review, resident and staff interviews, the facility failed to promote dignity by ensuring a resident (#27) was provided with grooming and clean clothing and a dignified experience when responding to a resident's (#42) request for incontinence care. In addition, the facility failed to ensure seven (#12, #14, #18, #32, #42, #49, #61) were provided with eating assistance in a dignified manner. This affected eight (#12, #14, #18, #32, #27, #42, #49, #61) of 21 residents observed for the promotion of resident dignity. The facility census was 91.
- E
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 observations record reviews, policy reviews, interviews with resident representative, residents and staff, the facility failed to provide adequate staff to meet the residents needs. This affected twelve (#7, #12, #14, #18, #22, #27, #32, #42, #49, #61, #69) of 91 residents discovered to experience the lack of care and treatment related to insufficient nursing service staffing levels. The census was 91.
- 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, facility census review, meal ticket reviews, food menus and spreadsheet review, resident and staff interviews, the facility failed to provide appropriate food servings sizes to residents who received the regular and pureed main lunch meal. This affected 25 (#4, #7, #9, #19, #25, #30, #31, #39, #40, #44, #47, #51, #53, #55, #58, #59, #63, #67, #68, #78, #79 #80, #83, #88, and #441) residents on the 100, 300, and 500 hall. In addition, the facility failed to honor Resident #10's food choices. The facility census was 91.
- 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, staff interview, and facility policy the facility failed to store food in a safe and sanitary manner in the unused kitchen, main kitchen, and unit refrigerators. The facility identified one resident (#13) that does not receive food from the kitchen. The facility failed to ensure residents were provided with eating assistance in a manner to prevent food borne illness, infection, or cross contamination. This affected five residents (#12, #14, #18, #32, and #61) observed during meals. The facility census was 91.
- E
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Inspectors wroteBased on observations, resident and staff interviews, and review of exterminator invoices, the facility failed to effectively ensure there were no gnats in the facility. This affected 38 of 38 residents residing on the 500, 700, and 800 hall. The facility census was 91.
- D
Reasonably accommodate the needs and preferences of each resident.
Inspectors wroteBased on observation, resident and staff interviews, and policy review, the facility failed to ensure call lights were provided to residents to alert staff to needs. This affected two (#41 and #60) of 91 residents in the facility. The facility census was 91.
- D
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Inspectors wroteBased on medical record review, resident and staff interviews, and policy reviews, the facility failed to ensure a resident's requests to get out of bed were honored. This affected one (#7) of one residents reviewed for choices. The facility census was 91.
- D
Protect each resident from the wrongful use of the resident's belongings or money.
Inspectors wroteBased on medical record review, personal funds account review, policy review, resident and staff interviews, the facility failed to ensure a resident was free from misappropriation. This affected one (#6) of seven residents reviewed for personal funds. The facility census was 91.
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on medical record review, personal funds account review, policy review, resident and staff interviews, the facility failed to timely report the potential misappropriation of property to the appropriate state agency. This affected one resident (#6) of seven residents reviewed for personal funds. The facility census was 91.
- D
Respond appropriately to all alleged violations.
Inspectors wroteBased on medical record review, personal funds account review, policy review, resident and staff interviews, the facility failed to complete an investigation of possible misappropriation of personal funds. This affected one (#6) of seven residents reviewed for personal funds. The facility census was 91.
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on medical record review, resident representative and staff interview, and review of policy, the facility failed to ensure residents were provided with timely and adequate bathing. This affected three (#7, #32, and #69) of seven residents reviewed for activities of daily living (ADLs). The facility identified 66 residents that required assist of one or two staff for bathing and 21 residents who were dependent with bathing activities. The census was 91.
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on medical record review, observations, and staff interviews, the facility failed to accurately assess and treat an existing pressure ulcer, implement care planned and physician ordered pressure relieving interventions, and accurately document wounds. This affected two (#22 and #61) of three residents reviewed for pressure ulcers. The facility identified a total of four residents with pressure ulcers. The facility census was 91.
- 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, facility policy review, and staff interview, the facility failed to ensure timely incontinence care was provided. This affected two (#14 and #42) of six residents reviewed for the provision of incontinence interventions and assistance. The facility census was 91.
- D
Provide enough food/fluids to maintain a resident's health.
Inspectors wroteBased on observation, medical record review, and staff interview, the facility failed to ensure nutritional supplements were provided as ordered by the physician. This affected one (#61) of four residents reviewed for the provision of nutritional interventions. The facility census was 91.
- D
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Inspectors wroteBased on observations, medical record review, policy review, resident and staff interviews, the facility failed to ensure a resident on a fluid restriction had the fluid restriction noted on their meal ticket and properly communicated with staff providing meals. This affected one (#10) of one reviewed for dialysis. The facility identified one resident receiving dialysis. The facility census was 91.
- D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Inspectors wroteBased on medical record review, policy review and staff interview, the facility failed to administer medications as ordered by the physician. This affected one (#23) of five residents reviewed for unnecessary medications. The census was 91.
- D
Provide or obtain dental services for each resident.
Inspectors wroteBased on medical record review, resident and staff interview, and policy review, the facility failed to ensure lost dentures were replaced timely for a resident. This affected one (#86) of one resident reviewed for dental care. The facility census was 91.
- D
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Inspectors wroteBased on observation, medical record review, and staff interview the facility failed to ensure a resident received a meal served at a palatable, safe, and appetizing temperature. This affected two (#33 and #61) of 90 residents identified to received food from the facility kitchen. The facility census was 91.
- C
Observe each nurse aide's job performance and give regular training.
Inspectors wroteBased on personnel record reviews and staff interviews, the facility failed to ensure annual performance evaluations were completed as required for State Tested Nursing Assistants (STNAs). This affected two (#572 and #576) of three STNAs whose personnel files were reviewed and had the potential to affect all 91 residents residing in the facility. The facility census was 91.
Fire safety inspections
25 fire safety citations on file: 11 on December 11, 2025, 9 on March 21, 2024, 5 on April 11, 2022.
Every fire safety citation25 citations
- F
Conduct testing and exercise requirements.
E 39 · December 11, 2025 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · December 11, 2025 · Corrected (the home has a date of correction)
- F
Provide a written emergency evacuation plan.
K 711 · December 11, 2025 · Corrected (the home has a date of correction)
- F
Have simulated fire drills held at unexpected times.
K 712 · December 11, 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 · December 11, 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 · December 11, 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 · December 11, 2025 · 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 · December 11, 2025 · Corrected (the home has a date of correction)
- E
Provide properly protected cooking facilities.
K 324 · December 11, 2025 · Corrected (the home has a date of correction)
- E
Install corridor and hallway doors that block smoke.
K 363 · December 11, 2025 · 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 · December 11, 2025 · Corrected (the home has a date of correction)
- F
Address subsistence needs for staff and patients.
E 15 · March 21, 2024 · 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 · March 21, 2024 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · March 21, 2024 · Corrected (the home has a date of correction)
- F
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · March 21, 2024 · Corrected (the home has a date of correction)
- F
Have properly installed electrical wiring and gas equipment.
K 511 · March 21, 2024 · Corrected (the home has a date of correction)
- F
Have simulated fire drills held at unexpected times.
K 712 · March 21, 2024 · 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 · March 21, 2024 · Corrected (the home has a date of correction)
- E
Have restrictions on the use of highly flammable decorations.
K 753 · March 21, 2024 · Corrected (the home has a date of correction)
- E
Have proper medical gas storage and administration areas.
K 923 · March 21, 2024 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · April 11, 2022 · 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 · April 11, 2022 · Corrected (the home has a date of correction)
- E
Install corridor and hallway doors that block smoke.
K 363 · April 11, 2022 · Corrected (the home has a date of correction)
- E
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · April 11, 2022 · 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 · April 11, 2022 · Corrected (the home has a date of correction)