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
1J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
19D
8E
1F
Potential for minimal harm
0A
0B
0C
March 18, 2026Standard inspection · 11 citations
- F
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation and staff interviews, the facility failed to maintain an infection control program which limits the transmission of pathogens and helps prevent the spread of disease, as evidenced by; Not having the correct enhanced barrier protection (EBP) sign indicators for residents rooms. There were lift pads left out on wheelchairs and on lifts. In the laundry room there were no cleaning logs and the air vent was off during the washing/drying process. Finally, the water control / maintenance program was missing logs, diagrams and service checks for the entire system. These were random opportunities for discoveries during the Long Term Survey Process and have the ability to affect more than a limited number of residents. Facility Census: 62. Findings Include: [...]
- 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 observation, record review and staff interview, the facility failed to implement and develop a comprehensive person-centered care plan which includes the measurable side effects of medications treating psychosocial needs, use of a communication board, and a preference to keep the room door closed. This was found during the Annual Long Term Care Survey Process. This was true for (3) three of 19 records reviewed. Resident identifiers: #12, #26 and #42. Facility census: 62.
- E
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Inspectors wroteBased on record review and staff interview the facility failed to have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. This was true for five (5) out of five (5) employees reviewed during the long term care survey process. Employee identifiers #18, 62,52,46 and 36. Facility census: 62.
- E
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 staff interview the facility assessment failed to state the break down of staffing needed to care for the residents based on their acuity levels. This failed practice had the potential to affect more than a limited number of residents. Facility census: 62.
- E
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
Inspectors wroteBased on staff interview and record review the facility failed to provide the required training for two (2) out of five (5) employees reviewed for training during the long term care survey process. Nursing Aide (NA) identifiers #62 and 18. Facility census: 62.
- 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 interviews and record reviews during a recertification survey, the facility did not ensure timely notification to the physician of Resident's significant weight loss. This is true for one (1) of three (3) Resident's reviewed for weight loss. Resident identifiers: Resident #5. Facility census: 62.
- D
Assess the resident when there is a significant change in condition
Inspectors wroteBased on Interviews and record review, the facility failed to update the Minimum Data Set (MDS) with a Significant Change is status for Resident #9. No significant change in status assessment was completed within 14 days of a significant change in a resident's medical status as per regulations. This was discovered during the the Long Term Care Survey Process and was true for one (1) of 19 sampled residents. Resident Identifier: Resident #9. Facility Census: 62Findings Include: During an interview with Resident #9 and their roommate on 03/16/26 at approximately 12:51 PM, they stated they had a fall in their room on water on 1/20/26. It was unwitnessed by staff, but was seen by the roommate who alerted the staff Resident #9 had fallen and hit her head after slipping on some water Resident #9 had spilled. [...]
- 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 staff interview, Resident #42 care plan was found to not be revised to address Resident #42 dental issues. This was true for one (1) of 19 sampled residents reviewed during the long term care survey process. Resident Identifier #42. Facility Census: 62.
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on observations and interviews, the facility failed to ensure the resident environment remained as free from accident hazards as possible. During a random opportunity for discovery, the following issues were identified: A treatment cart was left unlocked and unattended and oxygen tanks were stored improperly. These failed practices had the potential to effect more than a limited number of resident currently residing in the facility. Facility census: 62. Findings Include: a) Treatment Cart On 03/18/26 at 8:50 AM, an observation of an unlocked, unattended treatment cart was made. The cart was in a place easily accessible allowing access to these treatment supplies by residents, unauthorized persons, or visitors. At 8:56 AM, Licensed Practical Nurse (LPN) #4 confirmed during an interview the treatment cart was left unlocked and unattended. [...]
- D
Provide enough food/fluids to maintain a resident's health.
Inspectors wroteBased on observation, record review and staff interview the facility failed to ensure Resident #42 maintained acceptable parameters of nutritional status. Resident #42 suffered a severe weight loss and the facility failed to ensure the resident was reviewed by the licensed dietician and/or interventions were put into place to prevent further weight loss. This was true for one (1) of six (6) residents reviewed for the care area of nutrition during the long term care survey process. Resident Identifier: #42. Facility Census: 62.a) Resident #42 An observation of Resident #42 in her bed on 03/16/26 at approximately 1:30 PM, found her noon time meal was on her over the bed table and was untouched, The resident indicated she did not want to eat. A review of Resident #42's medical record found the following weights: -- 05/30/25 - 170.2 pounds (Lbs.) -- 07/18/25 - 169.5 Lbs. [...]
- D
Post nurse staffing information every day.
Inspectors wroteBased on record review and staff interview the facility failed to ensure nurse staff postings were correct. There were seven (7) out of 14 days of incorrect nurse staff postings. This failed practice had the potential to effect more than an isolated number of residents. Facility census: 62. The nurse staff posting was requested from the Nursing Home Administrator (NHA) on 03/17/26 for the timeframe of 02/08/26 to 02/22/26. On 03/18/26 the NHA provided the nurse staff posting and the hours per patient day (HPPD) report. This surveyor compared the staff posting to the HPPD report and found on the following days the nurse staff posting was incorrect: [...]
August 28, 2024Standard inspection, Complaint inspection · 11 citations
- J
Ensure that residents are free from significant medication errors.
Inspectors wroteBased on record review, resident interview and staff interview, the facility failed to ensure resident safety for medication administration. Resident Identifiers: #3 and #13. Facility Census: 42. The state agency notified the Nursing Home Administrator of the immediate jeopardy at 4:30 PM on 08/26/24. The facility submitted a plan of correction (POC) at 6:09 PM. At 6:25 PM, the POC was accepted by the state agency. The state agency verified the POC was implemented by conducting staff interviews and the immediate jeopardy was abated at 10:15 AM on 08/27/24. Findings Include: a) On 08/25/24 at approximately 11:25 AM, the resident was interviewed regarding receiving the wrong medication on 07/01/24. Resident #3 responded, I don't even know what medication I take, there is probably eight (8) or nine (9) of them. [...]
- E
Observe each nurse aide's job performance and give regular training.
Inspectors wroteBased on record review and staff interview, the facility failed to ensure annual performance reviews were completed for nursing staff. This was true for four (4) of five (5) staff members reviewed under the care area of sufficient and competent nurse staffing. Facility Census: 42. Findings Include: a) Annual Performance Reviews On 08/27/24 at 3:00 PM, a review of the staff employment files was completed. The review found the annual performance evaluations were not completed for the following nurse aides (NAs): -NA #71 -NA #50 -NA #72 -NA #14 On 08/28/24 at approximately 9:45 AM, the Administrator was notified of the missing evaluations. The Administrator stated, we will be working on this.
- E
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 and staff interview, the facility failed to monitor refrigerator temperatures in the medication room on the 300 hall. This was a random opportunity for discovery and has the potential to affect more than a limited numberof residents. Facility Census: 42. Findings Include: a) Medication Refrigerator On 08/26/24 at 8:10 AM, a tour of the medication room on the 300 hall was completed. The tour found the medication refrigerator temperatures were not monitored and documented on the following dates: --08/02/24 AM --08/02/24 PM --08/03/24 AM --08/04/24 AM --08/04/24 PM --08/05/24 PM --08/07/24 AM --08/08/24 AM --08/10/24 AM --08/11/24 AM --08/12/24 AM --08/13/24 AM --08/13/24 PM --08/15/24 AM --08/16/24 AM --08/17/24 AM --08/17/24 PM --08/18/24 AM --08/18/24 PM --08/19/24 PM --08/21/24 AM --08/22/24 AM On 08/26/24 at 8:18 AM, the Director of Nursing (DON) was notified. [...]
- 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 on observation and staff interview the facility failed to provide a safe, clean, comfortable and homelike environment for Resident #21. This was a random opportunity for discovery. Resident Identifier: #21. Facility Census: 42.
- D
PASARR screening for Mental disorders or Intellectual Disabilities
Inspectors wroteBased on record review and staff interview the facility failed to ensure all admitting diagnosis were reflected on the Preadmission Screening and Resident Review (PASRR). This was true on two (2) of four (4) PASRRs reviewed during the Long-Term Care Survey Process. Resident identifiers: #36 and #21. Facility Census:
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on record review and staff interview the facility failed to comply with the Medical Power of Attorneys' (MPOA) wishes regarding administration of immunizations. This was true for two (2) of six (6) immunizations reviewed during the long term care survey process. Resident identifiers: #35 and #36. Facility Census:
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on observation and staff interview, the facility failed to maintain a safe and accident free environment as possible regarding the disposal of razors. This was a random opportunity for discovery and had the potential to affect no more than an isolated number of residents. Resident Identifier: #43. Facility Census: 42.
- D
Provide enough food/fluids to maintain a resident's health.
Inspectors wroteBased on record review and staff interview the facility failed to ensure Resident #5 maintained acceptable perimeters of nutrition by not implementing recommendations made by the registered dietician. This was true of one (1) of two (2) residents reviewed for the care area of nutrition during the long term care survey process. Resident identifier: #5. Facility Census: 42.
- D
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Inspectors wroteBased on record review and staff interview, the facility failed to monitor behaviors and/or side effects for residents prescribed psychotropic medications. This was true for three (3) of five (5) residents reviewed under the care area of unnecessary medications. Resident Identifiers: #43, #21 and #5. Facility Census: 42. Findings Include: a) Resident #43 On 08/27/24 at 12:35 PM, a record review was completed for Resident #43. The review found the resident had three psychiatric diagnoses; Unspecified Dementia, Bipolar Disorder and Depression. The resident was prescribed Risperdal (antipsychotic medication) 2mg (milligram) daily for bipolar disorder. The review also, found no documentation regarding the monitoring of behaviors for the resident who was receiving an antipsychotic medication. [...]
- D
Make sure that a working call system is available in each resident's bathroom and bathing area.
Inspectors wroteBased on observation and staff interview the facility failed to ensure Resident #18's call light was with in reach. This was true for one (1) of 42 residents currently residing in the facility. Resident identifier: #18. Facility Census: 42.
- D
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
Inspectors wroteBased on record review and staff interview, the facility failed to ensure completion of the required staff education for one (1) of five (5) staff members reviewed under the care area of sufficient and competent nurse staffing. Employee identifier: Nurse Aide (NA) #35. Facility Census: 42.
January 5, 2023Standard inspection · 7 citations
- 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 and record review, the facility failed to employ a qualified Dietary Manager. This has the potential to affect more than a limited number of Residents that receive their nutrition from the kitchen. Facility census:
- 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 and staff interview, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety. Items in the kitchen, service area and coffee bar were opened, without being dated to indicate when to discard. This practice has the ability to affect more than a limited number of Residents that get their nutrition from the kitchen. Facility census: 54 Findings Included: Record review of the facility's policy titled, Food Receiving and Storage, showed that All food stored in the refrigerator or freezer will be covered, labeled, and dated. a) Kitchen tour During the initial kitchen tour on 01/03/22 at 10:30 AM, the following was found: 1) Kitchen --Walk-in refrigerator - One container of pimento spread, one bag of Organic Blend Vegetables, One bag of Naan Bread opened, not labeled, or dated. [...]
- 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 report a serious bodily injury after a fall to the proper State authorities for one (1) of two (2) residents reviewed for the care area of abuse. This was a random opportunity for discovery. Resident Identifier: #12. Facility Census: 54. Findings Included: a) Resident #177 Policy A review of the facility policy entitled Reporting Abuse/The Complaint Procedure was completed on 01/04/23 at 12:15 PM was completed. Section 3 (three) states If the alleged incident is abuse or serious bodily injury (injury involving extreme physical pain, involving substantial risk of death, impairment of a bodily member, organ or mental facility, or requiring medication intervention such as surgery or hospitalization) these allegations must be reported within two hours to the appropriate agencies . [...]
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on medical record review, observation, and staff interview, the facility failed to ensure a Resident received treatment and care in accordance with professional standards of practice. Specifically, a physician's order was not obtained for an ace wrap applied to a resident's left wrist and arm . This was true for one (1) of 16 residents reviewed during the long term care survey process. Resident identifier: #56. Facility census: 54. Findings Included: a) Resident #56 During an Interview and observation on 01/03/23 at 12:15 PM, Resident #56 stated that he has a lot of pain in his left wrist from a contracture. Observations found an ace wrap was in place on his left wrist and arm. A medical record review for Resident #56 revealed, there was no physician order for an ace wrap to be in place on his left wrist or arm. [...]
- 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 wroteased on record review and staff interview, the facility failed to ensure one (1) of 16 residents reviewed received services to prevent a decrease in range of motion. Resident identifier: #28. Facility census: 54.
- D
Provide safe, appropriate pain management for a resident who requires such services.
Inspectors wroteBased on resident interview, staff interview, and record review, the facility failed to ensure a resident received the treatment and care in accordance with professional standards of practice in regards to monitoring pain levels. This was true for one (1) of 16 residents reviewed during the recertification process. Resident Identifier: #56. Facility census: 54.
- D
Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care.
Inspectors wroteBased on staff interview and record review, the facility failed to ensure timely notification to the physician of a Resident's significant weight loss. This is true for one (1) of two (2) Residents reviewed for nutrition. Resident identifiers: R #54. Facility census: 54.
Fire safety inspections
19 fire safety citations on file: 10 on March 18, 2026, 5 on August 28, 2024, 4 on January 5, 2023.
Every fire safety citation19 citations
- F
Install emergency lighting that can last at least 1 1/2 hours.
K 291 · March 18, 2026 · Corrected (the home has a date of correction)
- F
Provide properly protected cooking facilities.
K 324 · March 18, 2026 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · March 18, 2026 · Corrected (the home has a date of correction)
- F
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · March 18, 2026 · Corrected (the home has a date of correction)
- F
Have properly installed electrical wiring and gas equipment.
K 511 · March 18, 2026 · 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 · March 18, 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 · March 18, 2026 · Corrected (the home has a date of correction)
- F
Ensure that testing and maintenance of electrical equipment is performed.
K 921 · March 18, 2026 · Corrected (the home has a date of correction)
- D
Develop and maintain an Emergency Preparedness Program (EP).
E 4 · March 18, 2026 · Corrected (the home has a date of correction)
- D
Ensure proper usage of power strips and extension cords.
K 920 · March 18, 2026 · Corrected (the home has a date of correction)
- F
Provide properly protected cooking facilities.
K 324 · August 28, 2024 · Corrected (the home has a date of correction)
- F
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
K 761 · August 28, 2024 · Corrected (the home has a date of correction)
- C
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · August 28, 2024 · Corrected (the home has a date of correction)
- C
Ensure proper usage of power strips and extension cords.
K 920 · August 28, 2024 · Corrected (the home has a date of correction)
- C
Ensure that testing and maintenance of electrical equipment is performed.
K 921 · August 28, 2024 · Corrected (the home has a date of correction)
- F
Install corridor and hallway doors that block smoke.
K 363 · January 5, 2023 · Corrected (the home has a date of correction)
- F
Ensure that testing and maintenance of electrical equipment is performed.
K 921 · January 5, 2023 · Corrected (the home has a date of correction)
- C
Have simulated fire drills held at unexpected times.
K 712 · January 5, 2023 · Corrected (the home has a date of correction)
- C
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · January 5, 2023 · Corrected (the home has a date of correction)