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 29 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
18D
2E
8F
Potential for minimal harm
0A
0B
1C
July 30, 2026Complaint 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 wroteTHE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NONCOMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY Based on Self-Reported Incident (SRI) review, medical record review, interview, and facility policy review, the facility failed to prevent resident-to-resident sexual abuse. This affected two residents (Residents #2 and #4) of four residents reviewed for abuse. The facility census was 147.
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on medical record review, Self-Reported Incident (SRI) review, interview, and facility policy review, the facility failed to report an allegation of misappropriation in the appropriate time frame to the state agency. This affected one resident (Resident #15) of four residents reviewed for abuse. The census was 147.
May 7, 2026Complaint inspection · 7 citations
- F
Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs.
Inspectors wroteBased on resident interviews, staff interviews, facility documents and policy review, the facility failed to ensure residents were served a variety of meal choices. This had the potential to affect all residents residing in the facility except three Residents (#29, #54 and #125) who were identified by the facility as not receiving food by mouth (NPO) or from the kitchen. The facility census was 136.
- 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, resident interviews, staff interviews, and facility policy review, the facility failed to ensure meals were served in a timely manner to ensure proper temperature and failed to ensure hairnets were worn to ensure proper sanitation. This had the potential to affect all residents residing in the facility except three Residents (#29, #54 and #125) who were identified by the facility as not receiving food by mouth (NPO) or from the kitchen. The facility census was 136.
- D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteBased on observation, resident record reviews, staff interview, and facility policy review, the facility failed to ensure residents were treated with dignity during dining. This affected one resident (#30) of two reviewed for dignity. The facility census was 136.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on record review and interview, the facility failed to ensure Resident #139's new wound was identified and treated before developing a large size, becoming infected, and beginning to heal independent of facility action. This affected one of three residents reviewed for changes in status. The total census was 136.
- 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 resident record review, resident interviews, staff interviews, and facility policy review, the facility failed to ensure restorative programs were implemented. This affected three residents (#24, #31, #130) of three reviewed for restorative services. The facility census was 136.
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on resident record review, resident interview, staff interviews, and facility policy review, the facility failed to provide care and services to prevent a fall during a mechanical lift transfer. This affected one resident (#24) of three reviewed for falls. The facility census was 136.
- D
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Inspectors wroteBased on observations, resident record review, staff interview, and facility policy review, the facility failed to ensure resident meal preferences were honored. This affected one resident (#109) of one reviewed for preferences. The facility census was 136.
July 2, 2025Complaint inspection · 1 citation
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on record review, interview, and facility policy review, the facility failed to ensure blood glucose testing (BGT) was completed per the physician's order. This finding affected one (Resident #150) of three residents reviewed for BGT. The facility census was 140.
December 12, 2024Standard inspection · 2 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, record review and staff interview the facility failed to ensure food was served and stored in a clean and sanitary manner. This had the potential to affect all 142 residents in the facility that consumed food from the kitchen. Findings Include: Observation of the kitchen area with Assistant Dietary Manager (ADM) #522 on 12/09/24 between 8:45 A.M. and 9:15 A.M. revealed the following that was observed and verified the time of discovery: 1. In the dry storage area an open packed of white rice with no date, an open bag of dinner rolls with no date, an open box of stuffing with no date, two containers of granulated sugar that were open with no date, an open box of bread crumbs with no date, and an open box of yellow cake with no date. 2. [...]
- D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on record review and staff interview, the facility failed to ensure a complete and accurate medical record for Resident #9. This affected one of twenty six sampled residents for medical record accuracy. Findings Include: Resident #9 was admitted to the facility on [DATE] with diagnoses that included metabolic encephalopathy, heart failure and Parkinson's disease. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #9 was severely cognitive impaired and required hands on assistance of one staff person for completing activities of daily living such as toileting, transfers and bed mobility. The assessment further noted that Resident #9 required supervision for eating activities. [...]
November 5, 2024Complaint 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 observations, interviews, staff training, and policy review, the facility failed to maintain a sanitary kitchen and failed to ensure food and liquids were stored in accordance with professional standards for food safety. This had the potential to affect all 142 residents residing in the facility and receiving food from the facility's main kitchen.
- 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 observations, interview, review of facility menu and review of staff training, the facility failed to follow menus in regard to portion sizes and recipes in regard to food preparation. This affected 29 (#78, #80, #81, #82, #83, #86, #87, #88, #89, #91, #93, #96, #100, #101, #103, #104 #107, #108, #112, #113, #114, #115, #116, #118, #122, #123, #124, #125, and Resident #126) of 49 residents residing on the east wing of the third floor.
- E
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Inspectors wroteBased on observations, resident interviews, staff interviews, review of facility menus, review of staff trainings, and review of policies and procedures, the facility failed to maintain appropriate and appetizing food temperatures. This had the potential to affect 29 (Resident #78, #80, #81, #82, #83, #86, #87, #88, #89, #91, #93, #96, #100, #101, #103, #104 #107, #108, #112, #113, #114, #115, #116, #118, #122, #123, #124, #125, and Resident #126) of 49 residents residing on the east wing of the third floor.
September 3, 2024Complaint inspection · 1 citation
- 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 record review and interview, the facility failed to ensure physician's orders were followed timely to change the resident's suprapubic catheter (a catheter that drains urine from the bladder through a small incision in the abdomen). This affected one (Resident #64) of three residents reviewed for urinary catheters. The facility census was 144.
February 28, 2024Complaint inspection · 1 citation
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on record review and interview, the facility failed to timely report potential mistreatment or abuse to the State Agency identified for Resident #92. This affected one (Resident #92) of three residents reviewed for abuse. The facility census was 145.
December 14, 2023Complaint inspection · 2 citations
- F
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Inspectors wroteBased on observation, interview, and record review the facility failed to provide palatable meals and failed to ensure food was served at adequate temperatures. This had the potential to affect all residents residing in the facility. The facility census was 151.
- F
Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.
Inspectors wroteBased on observation, record review, and interview the facility failed to ensure timely meal service. This had the potential to affect all residents residing in the facility. The facility census was 151.
June 9, 2022Standard inspection · 2 citations
- F
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observations, staff interview, and review of the Centers for Disease Control and Prevention (CDC) guidelines, the facility failed to ensure staff wore eye protection to prevent the spread of Covid-19. This had the potential to affect 135 residents residing at the facility. The facility also failed to ensure oxygen tubing was changed weekly affecting Resident #33, #67 and #79 out of 38 residents receiving oxygen. The facility also failed to ensure the proper use of gloves during meal pass. This affected 135 residents in the facility. 1. Observation on 06/06/22 at 11:30 A.M. of State Tested Nursing Assistant (STNA) #791 walking out of a resident's room revealed STNA #791 was wearing an N95 mask and no eyewear. Interview at this time, with STNA #791 revealed she was an agency nurse and the facility gave her an N95 mask to wear at the start of her shift. [...]
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on observation, interview and record review the facility failed to ensure medications were not left unattended at the resident bedside. This affected one ( Resident #79) of 135 residents observed for environmental safety. The census was 135. Findings Included: Review of the medical record for Resident #79 revealed an admission date of 08/12/21 and diagnoses including Chronic Obstructive Pulmonary Disease (COPD) and emphysema. Review of orders for June 2022 revealed Ventolin HFA Aerosol solution 90 micromilligram (mcg)/Actuation Breath Activated Powder Inhaler (ACT) (used to treat wheezing and shortness of breath ) two puff inhale orally four times a day for shortness of breath (SOB) and one puff inhale orally every four hours as needed for SOB. [...]
July 18, 2019Standard inspection · 8 citations
- F
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
Inspectors wroteBased on record review and interview, the facility failed to ensure the Medical Director (MD) and the Administrator attended the Quality Assessment and Assurance (QAA) and the Quality Assurance Performance Improvement (QAPI) meetings quarterly. This had the potential to affect all 139 residents residing in the facility.
- D
Allow resident to participate in the development and implementation of his or her person-centered plan of care.
Inspectors wroteBased on record review and interview, the facility failed to notify and involve Resident #35's power of attorney in care conferences and care planning. This affected one of one resident reviewed for participation in care planning. The facility census was 139.
- D
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Inspectors wroteBased on record review and staff interview, the facility failed to implement its abuse policy related to an allegation of verbal abuse by Resident #82's family. This affected one of two residents reviewed for abuse (Resident #82). The facility census was 139. Findings Include: Resident #82 was admitted the facility on 05/23/19 with diagnoses including multiple sclerosis, broken internal left knee prosthesis and chronic heart failure. Interview with the family member of Resident #82 on 07/16/19 at 2:30 P.M. revealed on 06/28/19 Physical Therapy Assistant (PTA) #900, while completing treatment with family present, began to speak to Resident #82 in a way that was not appropriate to Resident #82's family. [...]
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on record review and staff interview, the facility failed to ensure an allegation of verbal abuse was reported to the state agency as required. This affected one of two residents reviewed for abuse (Resident #82). The facility census was 139. Findings Include: Resident #82 was admitted the facility on 05/23/19 with diagnoses including multiple sclerosis, broken internal left knee prosthesis and chronic heart failure. Interview with the family member of Resident #82 on 07/16/19 at 2:30 P.M. revealed on 06/28/19 Physical Therapy Assistant (PTA) #900, while completing treatment with family present, began to speak to Resident #82 in a way that was not appropriate to Resident #82's family. [...]
- D
Respond appropriately to all alleged violations.
Inspectors wroteBased on record review and staff interview, the facility failed to complete an investigation of an allegation of verbal abuse. This affected one of two residents reviewed for abuse (Resident #82). The facility census was 139. Findings Include: Resident #82 was admitted the facility on 05/23/19 with diagnoses including multiple sclerosis, broken internal left knee prosthesis and chronic heart failure. Interview with the family member of Resident #82 on 07/16/19 at 2:30 P.M. revealed on 06/28/19 Physical Therapy Assistant (PTA) #900, while completing treatment with family present, began to speak to Resident #82 in a way that was not appropriate to Resident #82's family. Per Resident #82's family from the moment PTA #900 entered Resident #82's room PTA #900 had an unfriendly tone and was verbally abusive to Resident #82 regarding her home going situation and progress in therapy. [...]
- 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 record review and interview the facility failed to ensure Resident #76 and #7's care plan. This affected two of 31 residents reviewed for care plans. The facility census was 139.
- 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 record review and interview, the facility failed to revise the care plan for Resident #30. This affected one resident of two residents reviewed for non-pressure skin conditions. The facility census was 139.
- C
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 record review and staff interview, the facility failed to ensure the state ombudsman was notified of resident transfers to the hospital. This affected one (Resident #149) of one resident reviewed for hospitalization and had the potential to affect all 139 residents currently residing in the facility.
Fire safety inspections
41 fire safety citations on file: 9 on December 12, 2024, 5 on June 9, 2022, 27 on July 18, 2019.
Every fire safety citation41 citations
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · December 12, 2024 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · December 12, 2024 · 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 · December 12, 2024 · Corrected (the home has a date of correction)
- E
Have an enclosure around a vertical opening shaft.
K 311 · December 12, 2024 · Corrected (the home has a date of correction)
- E
Provide properly protected cooking facilities.
K 324 · December 12, 2024 · Corrected (the home has a date of correction)
- E
Install an approved automatic sprinkler system.
K 351 · December 12, 2024 · Corrected (the home has a date of correction)
- E
Meet other general requirements that are deficient.
K 500 · December 12, 2024 · Corrected (the home has a date of correction)
- E
Have properly installed electrical wiring and gas equipment.
K 511 · December 12, 2024 · Corrected (the home has a date of correction)
- E
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
K 761 · December 12, 2024 · Corrected (the home has a date of correction)
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · June 9, 2022 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · June 9, 2022 · Corrected (the home has a date of correction)
- F
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
K 362 · June 9, 2022 · Corrected (the home has a date of correction)
- F
Install corridor and hallway doors that block smoke.
K 363 · June 9, 2022 · Corrected (the home has a date of correction)
- F
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · June 9, 2022 · Corrected (the home has a date of correction)
- F
Keep aisles, corridors, and exits free of obstruction in case of emergency.
K 211 · July 18, 2019 · 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 · July 18, 2019 · Corrected (the home has a date of correction)
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · July 18, 2019 · Corrected (the home has a date of correction)
- F
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · July 18, 2019 · 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 · July 18, 2019 · Corrected (the home has a date of correction)
- E
Have ramps, exits, fire escape ladders, steps, and areas of refuge that meet safety requirements.
K 227 · July 18, 2019 · 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 · July 18, 2019 · Corrected (the home has a date of correction)
- E
Install an approved automatic sprinkler system.
K 351 · July 18, 2019 · Corrected (the home has a date of correction)
- E
Properly select, install, inspect, or maintain portable fire extinguishes.
K 355 · July 18, 2019 · Corrected (the home has a date of correction)
- E
Install corridor and hallway doors that block smoke.
K 363 · July 18, 2019 · Waiver
- E
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
K 521 · July 18, 2019 · Corrected (the home has a date of correction)
- E
Meet requirements for the installation and maintenance of electrical systems.
K 911 · July 18, 2019 · Corrected (the home has a date of correction)
- C
Develop and maintain an Emergency Preparedness Program (EP).
E 4 · July 18, 2019 · deficient, provider has
- C
Address patient/client population and determine types of services needed.
E 7 · July 18, 2019 · deficient, provider has
- C
Develop Emergency Preparedness policies and procedures.
E 13 · July 18, 2019 · deficient, provider has
- C
Establish procedures for tracking staff and patients during an emergency.
E 18 · July 18, 2019 · deficient, provider has
- C
Establish policies and procedures including evacuation.
E 20 · July 18, 2019 · deficient, provider has
- C
Establish policies and procedures for volunteers.
E 24 · July 18, 2019 · deficient, provider has
- C
Establish roles under a Waiver declared by secretary.
E 26 · July 18, 2019 · deficient, provider has
- C
Develop a communication plan.
E 29 · July 18, 2019 · deficient, provider has
- C
List the names and contact information of those in the facility.
E 30 · July 18, 2019 · deficient, provider has
- C
Provide emergency officials' contact information.
E 31 · July 18, 2019 · deficient, provider has
- C
Provide a means of sharing information on occupancy/needs.
E 34 · July 18, 2019 · deficient, provider has
- C
Establish emergency prep training and testing.
E 36 · July 18, 2019 · deficient, provider has
- C
Establish staff and initial training requirements.
E 37 · July 18, 2019 · deficient, provider has
- C
Meet requirements for sections of health care facilities separated by fire resistive construction.
K 131 · July 18, 2019 · deficient, provider has
- C
Install a fire alarm system that can be heard throughout the facility.
K 341 · July 18, 2019 · deficient, provider has