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 17 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
13D
3E
1F
Potential for minimal harm
0A
0B
0C
March 5, 2026Standard inspection · 4 citations
- F
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 observation, staff interviews, and review of facility policies, the facility failed to ensure stocked medications were not expired. This had the potential to affect all residents in the facility. The facility census was 63.
- D
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Inspectors wroteBased on record review, resident interview, staff interview, and policy review, the facility failed to provide bathing per resident choice. This affected one (Resident #27) of one reviewed for activities of daily living (ADL). The facility census was 63 residents. Review of the medical record revealed Resident #27 was admitted to the facility on [DATE]. Diagnoses included unspecified convulsions, dysphagia, epilepsy, hyperlipidemia, hypothyroidism, gastric esophageal reflux disease, anxiety, and asthma. Review of the annual Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed no cognitive impairment, and the resident required substantial/maximal assistance for activities of daily living. [...]
- 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 resident interview, observation, staff interviews, and review of facility policy, the facility failed to ensure a clean and homelike environment. This affected one (Resident #56) of 20 residents residing on B hall. The facility census was 63.
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on medical record review, observation, and staff interview, the facility failed to ensure care planned interventions to reduce injury from falls were implemented. This affected one (Resident #16) of three residents reviewed for accident hazards. The facility census was 63.
December 24, 2025Complaint inspection · 2 citations
- E
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, staff interview, review of Resident Council meeting minutes, review of Centers for Disease Control and Prevention (CDC) guidance, and policy review, the facility failed to ensure staff wore appropriate personal protective equipment (PPE) during a COVID-19 outbreak. This had the potential to affect all residents in the facility except 10 residents (#11, #13, #21, #25, #31, #58, #65, #68, #71, and #72) who were identified with a current COVID-19 infection. The facility census was 62.
- 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 observations, resident and staff interviews, record review, review of cleaning procedures, and review of Resident Council meeting minutes, the facility failed to ensure resident rooms were routinely cleaned and maintained. This affected three (#29, #54, and #56) of nine residents reviewed for room cleanliness. The facility census was 62.
July 30, 2024Complaint inspection · 2 citations
- E
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Inspectors wroteBased on observation, resident interviews, staff interviews, and facility policy, the failed to maintain an effective pest control program. This affected all 17 (#14, #17, #21, #23, #25, #27, #29, #32, #33, #36, #38, #45, #47, #53, #57, #58, and #60) residents on the Pathways locked unit. The facility census was 53.
- D
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Inspectors wroteBased on medical record review, observation, staff interview, and facility policy, the facility failed to ensure a resident's bathroom was adequately maintained and in a sanitary condition. This affected one (#29) of four residents reviewed. The facility census was 53.
May 4, 2023Standard inspection · 7 citations
- E
Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death.
Inspectors wroteBased on staff interview, record review, review of personnal fund accounts, and review of the facility policy, the facility failed to ensure residents were notified when their personal funds account balance was within $200.00 of the Medicaid resource limit. This affected three (#1, #3 and #25) of six residents reviewed for personal funds. Further, the facility failed to ensure resident funds were disbursed in a timely manner after discharge from the facility. This affected two (#161 and #162) of six residents reviewed for resident trust accounts. The facility census was 58.
- D
Reasonably accommodate the needs and preferences of each resident.
Inspectors wroteBased on observation, resident interview, staff interview and review of facility policy the facility failed to ensure the call light and bed controllers were within reach for one resident (Resident #10) dependent for incontinence care. The facility census was 58.
- D
Honor the resident's right to manage his or her financial affairs.
Inspectors wroteBased on staff interview, record review, review of personnal fund accounts, and review of the facility policy, the facility failed to ensure authorizations to open a Resident Trust account were signed by the resident. This affected two (Resident #3 and Resident #25) of six residents reviewed for Resident Trust accounts. The facility census was 58.
- 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 observation, resident interview, staff interview and review of facility policy, the facility failed to provide timely incontinence care to one resident (Resident #10) dependent for incontinence care. The facility identified 33 residents incontinent of bladder and 19 residents incontinent of bowel. The facility census was 58.
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on medical record review, observation, resident interview, staff interview and review of facility policy, the facility failed to ensure oxygen supplies were dated when initiated. This affected one resident (#20) of two residents reviewed for oxygen therapy. The facility census was 58. Findings Include: Review of Resident #20's medical record revealed an admission date of 10/23/20. Diagnoses included cognitive communication deficit, personal history of COVID-19, peripheral vascular disease, heart disease, anxiety disorder, psychosis, major depressive disorder, and paranoid schizophrenia. Review of Resident #20's Minimum Data Set (MDS) 04/09/23 revealed Resident #20's cognitive skills were moderately impaired. Resident #20 was receiving oxygen therapy at the time of the review. [...]
- D
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Inspectors wroteBased on resident interview, observation, staff interview and completion of the a lunch meal test tray revealed the facility failed to ensure residents received palatable food that was properly cooked. This affected three residents (#28, #38, and #22) of four residents reviewed for food palatability. The facility census was 58.
- D
Implement a program that monitors antibiotic use.
Inspectors wroteBased on medical record review, staff interview, review of the infection surveillance log, and review of facility policy, the facility failed to ensure residents receiving an ongoing prophylactic antibiotic had a reason for continued use. This affected one (Resident #2) of six residents reviewed for unnecessary medications. The facility census was 58.
December 5, 2019Standard inspection · 2 citations
- D
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 medical record review, staff interview and review of facility policy the facility failed to ensure residents and responsible parties were provided with a written notice of transfer upon transfer/discharge from the facility. This affected one (Resident #38) of one resident reviewed for hospitalizations. The facility identified four residents transferred to the hospital in the last 60 days. The facility census was 57.
- D
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Inspectors wroteBased on medical record review, staff interview, and review of a facility policy, the facility failed to ensure pharmacy recommendations were responded to in a timely manner. This affected two (Resident's #36 and #41) of five residents reviewed for unnecessary medications. he facility census was 57.
Fire safety inspections
15 fire safety citations on file: 3 on March 5, 2026, 8 on May 4, 2023, 4 on December 5, 2019.
Every fire safety citation15 citations
- F
Meet requirements for sections of health care facilities separated by fire resistive construction.
K 131 · March 5, 2026 · Corrected (the home has a date of correction)
- F
Have restrictions on the use of highly flammable decorations.
K 753 · March 5, 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 5, 2026 · Corrected (the home has a date of correction)
- F
Use approved construction type or materials.
K 161 · May 4, 2023 · 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 · May 4, 2023 · Corrected (the home has a date of correction)
- F
Provide properly protected cooking facilities.
K 324 · May 4, 2023 · Corrected (the home has a date of correction)
- F
Provide a written emergency evacuation plan.
K 711 · May 4, 2023 · Corrected (the home has a date of correction)
- F
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
K 741 · May 4, 2023 · Corrected (the home has a date of correction)
- F
Ensure proper usage of power strips and extension cords.
K 920 · May 4, 2023 · Corrected (the home has a date of correction)
- F
Ensure that testing and maintenance of electrical equipment is performed.
K 921 · May 4, 2023 · Corrected (the home has a date of correction)
- E
Install corridor and hallway doors that block smoke.
K 363 · May 4, 2023 · 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 · December 5, 2019 · Corrected (the home has a date of correction)
- E
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
K 223 · December 5, 2019 · Corrected (the home has a date of correction)
- E
Install an approved automatic sprinkler system.
K 351 · December 5, 2019 · Corrected (the home has a date of correction)
- E
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
K 761 · December 5, 2019 · Corrected (the home has a date of correction)