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 31 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
23D
4E
2F
Potential for minimal harm
0A
1B
1C
July 27, 2026Complaint inspection · 2 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, clinical record review, review of facility documentation, and staff interview, it was determined that the facility failed to report allegations of abuse to the State Survey Agency for two of eight sampled residents. (Residents 1 and 2)Findings Include: Review of the facility policy entitled, Abuse Policy, last reviewed July 8, 2026, revealed that immediately upon receiving information concerning a report of suspected or alleged abuse, the Administrator or designee would report allegations that involved abuse not later than two hours after the allegation was made and report allegations to the appropriate state and local authorities within 24 hours if the event did not result in serious bodily injury. Clinical record review revealed that Resident 2 had diagnoses that included chronic kidney disease, heart disease, type 2 diabetes, and dementia. [...]
- D
Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder.
Inspectors wroteBased on clinical record review, observation, and staff interview, it was determined that the facility failed to implement interventions to monitor and prevent behavioral symptoms for one of eight sampled residents. (Resident 8)
July 15, 2026Standard inspection · 12 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 policy review, observation, and staff interview, it was determined that the facility failed to properly store food and maintain sanitary conditions in the dietary department.
- D
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Inspectors wroteBased observation and staff interview, it was determined that the facility failed to ensure that a safe, clean, and comfortable environment was maintained on one of four nursing units. (Third Floor)
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on clinical record review and staff interview, it was determined that the facility failed to ensure physicians' orders were implemented for two of 20 sampled residents. (Residents 1 and 74)
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on facility policy review, clinical record review, and staff interview, it was determined that the facility failed to provide treatment and assess and document the status of wounds for one of four sampled residents with pressure ulcers. (Resident 7)
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on clinical record review, observation, and staff interview, it was determined the facility failed to implement safety interventions for one of 20 sampled residents. (Resident 34)
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on facility policy review, clinical record review, observation, and resident and staff interview, it was determined that the facility failed to provide adequate respiratory care for two of 20 sampled residents. (Residents 1 and 74)
- D
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Inspectors wroteBased on facility policy review, clinical record review, and staff interview, it was determined that the facility failed to provide ongoing assessment and monitoring for one of one sampled resident receiving dialysis (process of removing excess toxins and water from the blood). (Resident 2)
- D
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
Inspectors wroteBased on clinical record review, facility documentation, observation, and staff interview, it was determined that the facility failed to serve food in a form prescribed to meet the needs of one of 20 sampled residents. (Resident 8)
- 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 clinical record review, observation, resident and staff interview, it was determined that the facility failed to accommodate food preferences for one of 20 sampled residents. (Resident 8)
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on facility policy review, clinical record review, observation, and staff interview, it was determined that the facility failed to follow policies and procedures to prevent the spread of infection for one of 20 sampled residents. (Resident 11)
- C
Post nurse staffing information every day.
Inspectors wroteBased on observation and staff interview, it was determined that the facility failed to post accurate and current nurse staffing information.
- B
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Inspectors wroteBased on clinical record review and staff interview, it was determined the facility failed to notify the resident's representative(s) of transfer(s), including the reasons for the moves in writing upon transfer, for one of five residents who were transferred out of the facility. (Resident 10) Additionally, it was determined that the facility failed to provide copies of written discharge or transfer notices to a representative of the Office of the State Long Term Care Ombudsman for four of five sampled residents who were transferred out of the facility. (Residents 7, 9, 12, and 87)
June 18, 2026Complaint inspection · 3 citations
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on clinical record review and staff interview, it was determined that the facility failed to follow physician orders for one of five sampled residents. (Resident 1)
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on facility policy review, clinical record review, and staff interview, it was determined that the facility failed to provide treatment, and assess and document the status of wounds for one of five sampled residents. (Resident 1)
- D
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Inspectors wroteBased on facility policy review, clinical record review, observation, and resident and staff interview, it was determined that the facility failed to implement appropriate measures for the care and management of a peripherally inserted central catheter (PICC) (thin, flexible tube inserted into a vein that allows healthcare providers to deliver medications, fluids, blood products, or nutrition directly into the bloodstream over an extended period) in accordance with facility policy and physician's orders for one of five sampled residents. (Resident 2)
April 3, 2026Complaint inspection · 2 citations
- D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteBased on clinical record review, resident interview, and observation, it was determined that the facility failed to provide timely assistance with care in a manner that maintained dignity for two of five sampled residents. (Residents 2, 5)
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on clinical record review and resident interview, it was determined that the facility failed to provide services to maintain adequate hygiene for one of five sampled residents. (Resident 2)
March 19, 2026Complaint inspection · 1 citation
- F
Make sure that a working call system is available in each resident's bathroom and bathing area.
Inspectors wroteBased on clinical record review, observation, and resident and staff interviews, it was determined that the facility failed to provide a properly working call bell system on three of three units. (1st floor, 2nd floor, 3rd floor)
February 24, 2026Complaint inspection · 1 citation
- D
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Inspectors wroteBased on clinical record review, and staff interview, it was determined that the facility failed to notify the resident or responsible party of physician ordered changes for two of five sampled residents. (Residents 1, 3)
January 23, 2026Complaint inspection · 1 citation
- E
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Inspectors wroteBased on observation and resident and staff interviews, it was determined that the facility failed to maintain the resident environment in a clean and homelike manner for three of three nursing units (first, second and third floor nursing units) and for one of six sampled residents. (Resident 1)
January 12, 2026Complaint inspection · 1 citation
- D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Inspectors wroteBased on clinical record review and staff interview, it was determined that the facility failed to ensure that a medication was available from the pharmacy for administration as ordered by the physician for one of three sampled residents. (Resident 1)
August 21, 2025Standard inspection · 5 citations
- E
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Inspectors wroteBased on observation, it was determined that the facility failed to provide a safe, clean, and comfortable environment on one of two nursing units. (Healthcare 1)
- E
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 staff interview, it was determined that the facility failed to employ a full-time qualified dietary services manager in the absence of a full-time qualified dietitian.
- E
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on facility policy review, observation, and staff interview, it was determined the facility failed to store food in a sanitary manner on two of two nursing units. (Health Care 1 and Health Care 2)
- D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteBased on clinical record review, observation, staff and resident interview, it was determined that the facility failed to ensure that a resident's call bell was answered in a timely manner for one of 16 sampled residents. (Resident 19)
- 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 clinical record review, observation, resident and staff interview, it was determined that the facility failed to accommodate resident food allergies one of 16 sampled residents. (Resident 28)
June 5, 2025Complaint inspection · 1 citation
- D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Inspectors wroteBased on clinical record review, resident interview, and staff interview, it was determined that the facility failed to ensure that physician's orders were implemented for one of six sampled residents. (Resident 1)
July 25, 2024Standard inspection · 2 citations
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on clinical record review and staff interview, it was determined that the facility failed to implement physician's orders for one of 15 sampled residents. (Resident 52)
- 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 policy, clinical record review, observation, and staff interview, it was determined that the facility failed to ensure that adequate catheter care was provided for one of two sampled residents with an indwelling urinary catheter. (Resident 40)
Fire safety inspections
10 fire safety citations on file: 3 on July 25, 2024, 4 on August 17, 2023, 3 on September 22, 2022.
Every fire safety citation10 citations
- E
Keep aisles, corridors, and exits free of obstruction in case of emergency.
K 211 · July 25, 2024 · Corrected (the home has a date of correction)
- E
Inspect, test, and maintain automatic sprinkler systems.
K 353 · July 25, 2024 · Corrected (the home has a date of correction)
- C
Meet other general requirements.
K 100 · July 25, 2024 · Corrected (the home has a date of correction)
- E
Use approved construction type or materials.
K 161 · August 17, 2023 · Corrected (the home has a date of correction)
- E
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
K 225 · August 17, 2023 · Corrected (the home has a date of correction)
- E
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · August 17, 2023 · Corrected (the home has a date of correction)
- E
Install corridor and hallway doors that block smoke.
K 363 · August 17, 2023 · Corrected (the home has a date of correction)
- F
Install emergency lighting that can last at least 1 1/2 hours.
K 291 · September 22, 2022 · Corrected (the home has a date of correction)
- E
Inspect, test, and maintain automatic sprinkler systems.
K 353 · September 22, 2022 · Corrected (the home has a date of correction)
- E
Meet other general requirements.
K 932 · September 22, 2022 · Corrected (the home has a date of correction)