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 12 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
0E
1F
Potential for minimal harm
0A
0B
0C
June 3, 2026Standard inspection · 4 citations
- D
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Inspectors wroteBased on facility policy review, medical record review, observations, and interviews, the facility failed to perform an assessment for the use of a seatbelt for 2 residents (Resident #34 and #67) of 3 residents reviewed for physical restraints.
- 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 facility policy review, medical record review, observations, and interviews, the facility failed to implement the care plan for the use of a lap belt for 2 residents (Resident #34 and #67) and for falls for 1 resident (Resident #107) of 15 residents reviewed for care plans.
- 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 medical record review, observations, and interviews, the facility failed to revise the care plan for 1 resident (Resident #107) of 15 residents reviewed for care plans.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on facility policy review, medical record review, observations and interviews, the facility failed to ensure proper infection control practices during medication administration for 1 resident (Resident #18) of 5 residents reviewed for medication administration.
September 24, 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 job description review, facility policy review, facility investigation documentation review, and interview, the facility failed to ensure 1 resident (Resident #1) was returned to her room after transportation to a medical appointment for 1 of 3 residents reviewed for accident hazards. The facility failure occurred on 5/8/2024 when Resident #1 was taken to a medical appointment by the Transportation Coordinator and returned to the facility at approximately 4:30 PM. The facility was under a code black at the time for serious weather conditions. The Transportation Coordinator failed to unload Resident #1 from the facility van and Resident #1 was locked inside the facility van for an unknown amount of time, estimated to be 3 to 4 hours. [...]
December 7, 2022Standard inspection · 4 citations
- F
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteFACILITY Kitchen 12/06/22 11:10 AM Steam table set up in dining room, vertical barrier hung between food station and the rest of dining room, as ceiling was being worked on. 12/06/22 09:58 AM Observation of plating station showed dining area back to normal, with no repairs being done and barrier gone. 12/07/22 8:30 AM Observation of kitchen workers showed appropriate hand sanitation and hair nets in place. During an interview on 12/5/22 at 8:42 AM, [NAME] O'Keefe, Dietary Manager the facility has a full-time qualified with ServSafe Certification that expires 5/18/23, with 14 years experience in healthcare foodservice. Menu was reviewed and the mechanical consistency of the meal is followed per orders from Speech therapy, RD and physician. Alternatives are offered for any meal. Copy of menu reviewed with DM. A tour of the kitchen followed. [...]
- D
Respond appropriately to all alleged violations.
Inspectors wroteBased on facility policy review, medical record review, the facility's documentation, and interviews, the facility failed to provide evidence that the allegations of abuse were thoroughly investigated for 2 residents (Residents #40 and #96) of 4 residents reviewed for abuse.
- D
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Inspectors wroteResident #21 was admitted to the facility on [DATE] and had diagnoses including Dementia, Generalized Anxiety Disorder, Schizophrenia, Morbid Obesity, Cognitive Communication Deficit, Bipolar Disorder, Major Depressive Disorder, and Obsessive Compulsive Disorder. The diagnosis of Impulse Disorder was added on 9/19/2019 and the diagnosis of Psychotic Disorder was added 10/12/2021. Review of a PASARR dated 6/11/2012 showed a level 1 PASARR was completed and included the diagnosis of Schizophrenia. Resident #21 was not referred for level 2 services due to the resident not requiring specialized services. Review of the medical record showed a new PASARR had not been submitted to the stated designated authority after the diagnosis of Impulse Disorder was added on 9/19/2019 or the diagnosis of Psychotic Disorder was added on 10/12/2021. [...]
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on facility policy review, medical record review, observation, and interview the facility failed to ensure appropriate infection control practices were maintained for 1 resident (#115) of 5 residents reviewed for transmission-based precautions which had the potential to affect 11 of 116 residents.
August 7, 2019Standard inspection · 3 citations
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on facility policy review, medical record review, grievance report review, and interviews, the facility failed to immediately report an allegation of abuse for 1 resident (#33) of 24 residents reviewed for abuse.
- D
Respond appropriately to all alleged violations.
Inspectors wroteBased on facility policy review, medical record review, grievance report review, and interviews, the facility failed to initiate an immediate investigation of an allegation of abuse for 1 resident (#33) of 24 residents reviewed for abuse.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on facility policy review, observation, and interview, the facility failed to perform proper hand hygiene after providing direct resident care for 1 resident (#32) of 3 residents during resident care of 17 sampled residents.
Fire safety inspections
5 fire safety citations on file: 1 on June 3, 2026, 3 on December 7, 2022, 1 on August 7, 2019.
Every fire safety citation5 citations
- D
Ensure proper usage of power strips and extension cords.
K 920 · June 3, 2026 · 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 · December 7, 2022 · Corrected (the home has a date of correction)
- D
Provide properly protected cooking facilities.
K 324 · December 7, 2022 · Corrected (the home has a date of correction)
- D
Provide properly sized and located linen or trash receptacles.
K 754 · December 7, 2022 · Corrected (the home has a date of correction)
- D
Inspect, test, and maintain automatic sprinkler systems.
K 353 · August 7, 2019 · Corrected (the home has a date of correction)