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 43 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
1G
0H
0I
Potential for more than minimal harm
17D
10E
12F
Potential for minimal harm
0A
0B
3C
March 27, 2026Complaint inspection · 1 citation
- 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 #40 was provided with timely care and services following a fall. This finding affected one (Resident #40) of three residents reviewed for falls.
January 15, 2026Standard inspection, Complaint inspection · 4 citations
- E
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Inspectors wroteBased on observation, interview and facility policy review, the facility failed to maintain a clean and sanitary homelike environment. This had the potential to affect all 92 residents residing in the facility. The facility census was 92.
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on record review, observations, interviews, and facility policy review, the facility did not ensure safe smoking practices within the facility for Residents #67 and #34. This affected two residents (#67 and #34) out of two residents reviewed for smoking. The facility census was 92. Findings Include:1. Review of the medical record revealed Resident #67 was admitted to the facility on [DATE] with diagnoses of muscle weakness, chronic obstructive pulmonary disease (COPD), chronic kidney disease, disorders of bone density and structure, rheumatoid arthritis, pain in left hip, patient's noncompliance with other medical treatment and regimen due to unspecified reason, mental disorder, major depressive disorder, acquired absence of the right leg below the knee, tobacco use, anxiety disorder, and hypertension. [...]
- 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 record review, observation, interview and facility policy review, the facility failed to ensure medications were stored in a safe fashion. This affected one resident (#43) of 92 residents observed for medications at the bedside. The facility census was 92.
- D
Make sure that a working call system is available in each resident's bathroom and bathing area.
Inspectors wroteBased on record review, observation, interview and facility policy review, the facility to ensure call lights were in reach. This affected two residents (#24 and #41) of 92 residents observed for call lights. The facility census was 92.
September 11, 2024Complaint 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 wroteBased on observation, record review and interview, the facility failed to ensure food was stored, prepared and served under sanitary conditions. This had the potential to affect all residents who received meals from the kitchen. The facility identified seven residents (#7, #25, #44, #50, #52, #61, and #85) as receiving nothing by mouth. The census was 92.
- F
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Inspectors wroteBased on observation, interviews, and review of facility policies, facility menu, and job descriptions, the facility administration failed to ensure there was an adequate supply of emergency food and water on hand as required. This had the potential to affect all 92 residents in the facility. The facility census was 92.
- D
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, record review and interview, the facility failed to follow the menu as written. This affected two residents (#5 and #89) of five residents reviewed for nutrition and had the potential to affect all residents who received meals from the kitchen excluding seven residents (#7, #25, #44, #50, #52, #61 and #85) who the facility identified as receiving nothing by mouth. The facility census was 92.
- D
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Inspectors wroteBased on observation, record review and interview, the facility failed to ensure palatable food was served to all residents. This affected three residents (#36, #39 and #45) of five residents reviewed for nutrition and had the potential to affect all residents receiving meals from the kitchen. The facility identified seven residents (#7, #25, #44, #50, #52, #61, and #85) as not receiving anything by mouth. The census was 92.
May 14, 2024Complaint 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, interview and review of facility policy, the facility did not ensure the memory care unit environment was maintained in a clean, comfortable and homelike manner. This had the potential to affect all 22 residents (Residents #2, #3, #4, #7, #8, #12, #13, #16, #23, #32, #40, #55, #58, #62, #64, #67, #71, #72, #75, #85, #86, and # 94) living on the memory care unit out of 94 residents living in the facility. The facility census was 94.
April 12, 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 observation, interview, and review of the Hydrion Test Strip instructions the facility failed to maintain a sanitary kitchen to prepare food in a manner to prevent contamination and food borne illness. This had the potential to affect all residents (#15, #16, #18, #28 and #31) who received nothing by mouth. The facility census was 92.
- F
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Inspectors wroteBased on observation, interview, and facility policy review, the facility failed to provide a clean and sanitary environment. This had the potential to affect all 92 residents in the facility.
- C
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Inspectors wroteBased on observation and interview the facility failed to provide palatable food when gelatine was served in a liquid form. This had the potential to affect all residents who received food from the kitchen. The facility identified five residents (#15, #16, #18, #28 and #31) who received nothing by mouth. The facility census was 92.
March 13, 2024Complaint inspection · 2 citations
- G
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on record review, observation and interview, the facility failed to develop and implement an effective and individualized pressure ulcer prevention program for Resident #101 to prevent the development of a facility acquired pressure ulcer to the back of the resident's neck. Actual Harm occurred on 02/27/24 when Resident #101, who was cognitively impaired, ventilator dependent, at risk for pressure ulcer development and required total dependence on staff for bed mobility and all activities of daily living, was assessed on 02/27/24 by Wound Nurse Practitioner (NP) #703 to have a Stage IV (full thickness skin and tissue loss) facility acquired pressure ulcer with correction of the staging completed on 03/05/24 to an unstageable (full thickness loss of tissue completely covered by dead tissue) pressure ulcer to his rear neck found under his tracheostomy ties. [...]
- C
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteBased on observation, interviews, and review of facility policy, the facility did not ensure all residents were treated with dignity and respect at all times due to multiple staff members not wearing name badges while on duty in the facility. This had the potential to affect all 96 residents living in the facility. The facility census was 96.
June 8, 2023Standard inspection · 11 citations
- F
Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.
Inspectors wroteBased on observations, interviews and record reviews, the facility failed to ensure the kitchen was staffed with sufficient, competent support personnel to safely and effectively carry out the functions of the food and nutrition services for resident food production and service. This had the potential to affect all residents receiving meals from the kitchen except four residents (Resident #22, #73, #79 and Resident #80) who did not receive nutrition by mouth. The census was 94 residents.
- F
Dispose of garbage and refuse properly.
Inspectors wroteBased on observations and interview, the facility failed to dispose of garbage/refuse appropriately. This had the potential to affect all 94 residents residing in the facility at the time of survey.
- E
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteBased on record review, observations, and interviews, the facility failed to ensure Resident #30, #35, #237 and #440 were treated in a dignified and respectful manner including covering their indwelling catheter drainage bags. This affected four residents (Resident #30, #35, 237, and Resident #440) of seven residents reviewed for indwelling catheters. The facility census was 94.
- 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 policy review, observation, and staff interviews, the facility failed to maintain all resident rooms in a clean and comfortable manner. This affected six residents (Resident #12, #21, #187, #27, 50, and Resident #10) of 24 residents reviewed for physical environment. The facility census was 94.
- D
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Inspectors wroteBased on record review and interview, the facility failed to complete resident assessments within the required times frame for Resident #439. This affected one resident (#439) of 24 residents reviewed for comprehensive assessments. The facility census was 94.
- 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, observation and interview, the facility failed to complete in a timely manner a comprehensive, person-centered care plan for Resident #82. This affected one resident (#82) of 24 residents reviewed for comprehensive care plans. The facility census was 94.
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on observation, interview, and record review, the facility failed to provide appropriate and physician ordered care and services to promote wound healing for Resident #57. This affected one resident (Resident #57) of two residents reviewed for wound care. The facility census was 94.
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on record review, observation and interview, the facility failed to ensure oxygen was administered as ordered for Resident #19. This affected one resident (#19) of three residents reviewed for oxygen therapy. The facility census was 94.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to perform hand hygiene during medication administration and wound care for residents #57, #64, and #443, and failed to ensure a urinary catheter drainage bag was off the floor for Resident #440. This affected four residents (#57, #64, #443, and #440) of 24 residents reviewed for infection control. The facility census was 94.
- D
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Inspectors wroteBased on record review, observations, and interview the facility failed to maintain appropriate pest control to prevent infestation. This affected two (Resident #30, #52) of 24 residents reviewed for physical environment. The facility census was 94.
- C
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Inspectors wroteBased on record review, facility policy and procedure review and interview, the facility failed to check all employees against the State Nurse Aide Registry (NAR) prior to or on their first day of work/hire to ensure the employee did not have a finding entered in the NAR concerning abuse, neglect, exploitation, mistreatment of residents or misappropriation of their property as required. This had the potential to affect all 94 residents residing in the facility.
May 14, 2021Standard inspection · 17 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 ensure Dietary Manager #553 met the minimum qualifications to serve as the director of food and nutrition services. This had the potential to affect all 87 residents who received food prepared at facility (Residents #31 and # 58 received nothing by mouth). The facility census was 89 residents.
- F
Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure sufficient kitchen staff were available to prepare resident meals and snacks, serve resident meals, and maintain a clean and sanitary environment in the kitchen. This affected all 87 residents who received meals prepared in the facility kitchen (Residents #31 and # 58 received nothing by mouth). The facility census was 89 residents.
- F
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, resident interview, and staff interview, the facility failed to ensure the menu and food choice alternates were available for residents to review in order to meet the resident's needs and food preferences. This affected one (Resident #194) of one resident reviewed for food choices and meal service, and had the potential to affect all 87 residents (Residents #31 and #58 received nothing by mouth) who received meals prepared at the facility. The facility census was 89 residents.
- 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 interview and record review, the facility failed to act upon resident council's concerns regarding the provision of snacks. This affected 12 (Residents #11, #13, #25, #32, #38, #47, #51, #61, #79, #80, #81, and #83) residents who attended resident council meetings, and had the potential to affect all 87 residents who received food from the facility (Residents #31 and # 58 received nothing by mouth). The facility census was 89 residents.
- 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 and staff interview, the facility failed to store, prepare, and distribute food under sanitary conditions to prevent contamination and potential food borne illness. This had the potential to affect all 87 residents (Residents #31 and # 58 received nothing by mouth).who were provided meals prepared in the facility kitchen. The facility census was 89 residents.
- F
Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.
Inspectors wroteBased on record review and interviews, the facility did not ensure staff competencies necessary to provide the level and types of care needed for the resident population were included in the facility assessment. This had the potential to affect all 89 facility residents.
- E
Honor the resident's right to organize and participate in resident/family groups in the facility.
Inspectors wroteBased on interview and record review, the facility failed to act upon resident council's concern regarding the provision of snacks. This affected 12 (Residents #11, #13, #25, #32, #38, #47, #51, #61, #79, #80, #81, and #83) residents, and had the potential to affect all 87 residents who received food from the facility (Residents #31 and # 58 received nothing by mouth). The facility census was 89 residents.
- 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 record review, observation, and interviews, the facility did not ensure adequate cleaning of the resident rooms or common areas. The facility also failed to ensure laundry was washed and dried in a timely manner. This affected 12 (Residents #11, #13, #25, #32, #38, #47, #51, #61, #79, #80, #82, and #83) of 24 residents reviewed for their living environment. The facility census was 89 residents.
- E
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 develop care plans relative to ventilator care, dialysis care, and psychotropic drug use. This affected four (Residents #54, #59, #65, and #191) of ten residents reviewed for ventilator and dialysis care needs, and unnecessary medications. The facility census was 89 residents.
- E
Provide enough food/fluids to maintain a resident's health.
Inspectors wroteBased on record review and interviews, the facility failed to ensure nutritional assessments were completed in a timely manner for five (Residents #9, #22, #30, #70, and #75 ) of 16 sampled residents. The facility census was 89 residents.
- E
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Inspectors wroteBased on observation, interview, and test tray evaluation, the facility failed to ensure food was prepared by methods to conserve nutritional value and palatablity. This affected 13 residents, including 10 (Residents #4, #7, #16, #21, #22, #41, #71, #75, #76, and #193) of 10 residents who received a pureed diet, as well as Residents #27, #28, and #194. The facility census was 89 residents.
- E
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
Inspectors wroteBased on observation, interview, and pureed food sampling, the facility failed to puree food to the correct consistency. This affected 10 (Residents #4, #7, #16, #21, #22, #41, #71, #75, #76, and #193) of 10 residents who received a pureed diet at the facility. The facilty census was 89 residents.
- D
Assist a resident in gaining access to vision and hearing services.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one resident's hearing aides were replaced timely. This affected one (Resident #73) of one resident reviewed for missing hearing aides. The facility census was 89 residents.
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a nutritional progress note was completed and interventions implemented after one resident had a recurring Stage II pressure ulcer found on the right buttock. This affected one (Resident #4) of two residents reviewed for pressure ulcer care and services. The facility census was 89 residents.
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteThe facility failed to ensure all nurses were trained regarding ventilator care and related documentation. This had the potential to affect one (Residents #59) of three residents reviewed for ventilator care. The facility census was 89 residents.
- D
Dispose of garbage and refuse properly.
Inspectors wroteBased on observation and staff interview, the facility failed to maintain its dumpster area in a clean and sanitary manner. This had the potential to affect all 89 facility residents.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure appropriate incontinence care was provided in a manner to prevent cross contamination and infection. This affected one (Resident #63) of one resident reviewed for incontinence care. The facility census was 89 residents.
Fire safety inspections
28 fire safety citations on file: 11 on January 15, 2026, 7 on June 8, 2023, 10 on May 14, 2021.
Every fire safety citation28 citations
- F
Install emergency lighting that can last at least 1 1/2 hours.
K 291 · January 15, 2026 · Corrected (the home has a date of correction)
- F
Provide properly protected cooking facilities.
K 324 · January 15, 2026 · Corrected (the home has a date of correction)
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · January 15, 2026 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · January 15, 2026 · Corrected (the home has a date of correction)
- F
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · January 15, 2026 · Corrected (the home has a date of correction)
- E
Have exits that are accessible at all times.
K 271 · January 15, 2026 · Corrected (the home has a date of correction)
- E
Have an alternate power supply for its alarm system.
K 344 · January 15, 2026 · Corrected (the home has a date of correction)
- E
Have properly installed electrical wiring and gas equipment.
K 511 · January 15, 2026 · 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 · January 15, 2026 · Corrected (the home has a date of correction)
- E
Have proper power supply for life support equipment.
K 915 · January 15, 2026 · Corrected (the home has a date of correction)
- E
Ensure proper usage of power strips and extension cords.
K 920 · January 15, 2026 · Corrected (the home has a date of correction)
- F
Have simulated fire drills held at unexpected times.
K 712 · June 8, 2023 · 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 · June 8, 2023 · 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 8, 2023 · Corrected (the home has a date of correction)
- E
Have exits that are accessible at all times.
K 271 · June 8, 2023 · Corrected (the home has a date of correction)
- E
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · June 8, 2023 · 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 · June 8, 2023 · Corrected (the home has a date of correction)
- D
Have properly installed electrical wiring and gas equipment.
K 511 · June 8, 2023 · Corrected (the home has a date of correction)
- F
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · May 14, 2021 · 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 · May 14, 2021 · Corrected (the home has a date of correction)
- F
Have simulated fire drills held at unexpected times.
K 712 · May 14, 2021 · 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 · May 14, 2021 · Corrected (the home has a date of correction)
- E
Install an approved automatic sprinkler system.
K 351 · May 14, 2021 · Corrected (the home has a date of correction)
- E
Have properly installed electrical wiring and gas equipment.
K 511 · May 14, 2021 · Corrected (the home has a date of correction)
- E
Have proper power supply for life support equipment.
K 915 · May 14, 2021 · Waiver
- D
Provide properly protected cooking facilities.
K 324 · May 14, 2021 · Corrected (the home has a date of correction)
- D
Inspect, test, and maintain automatic sprinkler systems.
K 353 · May 14, 2021 · Corrected (the home has a date of correction)
- D
Install corridor and hallway doors that block smoke.
K 363 · May 14, 2021 · Corrected (the home has a date of correction)