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 26 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
14D
7E
4F
Potential for minimal harm
0A
0B
1C
January 15, 2026Standard inspection · 0 citations
September 10, 2025Complaint inspection · 2 citations
- E
Respond appropriately to all alleged violations.
Inspectors wroteBased on record review, interviews, and review of the facility's policy titled, Freedom of Abuse, Neglect and Exploitation, Abuse Prevention: Fast Alerts, the facility failed to ensure a complete and thorough abuse investigation was conducted for six of nine Residents (R) (R2, R3, R4, R6, R5, and R9) reviewed for abuse investigations out of a total sample of 22 residents. This failure had the potential to result in additional residents to be abused by the same perpetrator.
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on record review, interview, and review of the facility's policy titled, Freedom of Abuse, Neglect and Exploitation; Abuse Prevention: Fast Alerts, the facility failed to notify the State Survey Agency (SSA) of an allegation of physical abuse for one of seven Residents (R) (R9) reviewed for abuse out of 22 sampled residents. Specifically, there was no documentation that the SSA was notified of an allegation of physical abuse when the Director of Nursing (DON) was notified of bruising to R9's body by the hospital's Social Worker. This failure had the potential to contribute to further abuse or injury, which could result in mental anguish, physical harm, or fear.
August 21, 2024Standard inspection, Complaint inspection · 11 citations
- F
Dispose of garbage and refuse properly.
Inspectors wroteBased on observations and staff interviews, the facility failed to ensure three of three garbage dumpsters were maintained in sanitary conditions, free from trash and debris on the ground, and with secure fitting lids. The deficient practice had the potential to promote the harboring of pests, rodents, insects, and other organisms. The facility census was 101 residents.
- E
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on observations, staff interviews, record review, and review of the facility policy titled, F-689 Accidents -Water Temperatures, the facility failed to maintain safe water temperatures at the hand washing sink in 12 of 28 resident bathrooms and two of three resident shower rooms. In addition, the facility failed to ensure an environment free from chemical and environmental hazards in one of three shower rooms. This deficient practice placed the residents residing in the affected rooms and using the affected shower rooms at risk of avoidable injuries and a diminished quality of life. The census was 101 residents.
- 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 observations, interviews, and a review of the facility's policy titled, Medication Administration Guidelines, the facility failed to ensure that one of two medication carts was locked and secured when unattended by the nurse. The deficient practice had the potential to allow unauthorized persons, including residents and visitors, to access medications. The census was 101 residents.
- E
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observations, staff interviews, and review of the facility's policies titled, Laundry Linen: Handling of, and Biohazardous/Infectious Waste, the facility failed to follow acceptable infection control practices to prevent cross-contamination during a glucometer check for one resident, during the storage of linen in one linen storage room, during the storage of soiled linen in two shower rooms, and during the storage of washbasins and urinals in three resident restrooms. These deficient practices had the potential to increase the risk of cross-contamination and spread infections.
- D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteBased on observations, staff interviews, and record review, the facility failed to place a privacy bag over the indwelling urinary catheter drainage bag of one of two residents (R) (R251) reviewed with a urinary catheter. This failure had the potential to diminish R251's quality of life in an environment that promotes the maintenance or enhancement of each resident's quality of life.
- D
Allow residents to self-administer drugs if determined clinically appropriate.
Inspectors wroteBased on observations, resident and staff interviews, and record review, the facility failed to ensure two of 54 residents (R) (R49 and R1) reviewed did not have unsecured, unauthorized medications and over-the-counter medication products stored at the bedside. This failure placed R49 and R1 at risk for inappropriate and unsafe medication use and had the potential to allow unauthorized access to medications to other residents and visitors in the facility.
- D
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Inspectors wroteBased on staff interviews, record review, and review of the facility policy titled, New Hire Checklist, the facility failed to ensure pre-employment screenings, specifically reference checks and fingerprinting, were conducted prior to employment for four of 10 employees reviewed. This deficient practice had the potential to place residents residing in the facility at risk of abuse, neglect, and exploitation from staff. The census was 101 residents.
- 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 observations, staff interviews, record review, and review of the facility policy titled RAI (Resident Assessment Instrument)/Care Planning Management, the facility failed to implement the person-centered comprehensive care plan for one of 12 residents (R) (R78) with a care plan for fall mats and two of two R (R49 and R68) with a care plan for oxygen (O2). This failure had the potential for R78, R49, and R68 to not receive treatment and/or care according to their needs.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on observations, staff interviews, and record review, the facility failed to follow the physician's orders for two residents (R) (R43 and R78). Specifically for an evaluation for Physical Therapy (PT), Occupational Therapy (OT), and Speech Therapy (ST) for R43 and for gastrostomy tube (G-tube) water flushes for R78. This failure had the potential for R43 and R78 to not receive medical treatment according to their needs and placed them at risk for adverse consequences.
- 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 observations, staff interviews, and record review, the facility failed to provide services to increase or prevent a decrease in range of motion (ROM) for one of 52 sampled residents (R) (R43). The deficient practice had the potential to place R43 at risk for medical complications, unmet needs, and a diminished quality of life.
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observations, staff interviews, record review, and review of the facility policy titled, Respiratory System Management Standard, the facility failed to ensure two residents (R) (R49 and R68) receiving oxygen (O2) therapy were administered O2 in accordance with the physician order. The deficient practice had the potential to increase the risk of respiratory complications for R49 and R68. The sample size was 52 residents.
February 23, 2023Standard inspection · 13 citations
- F
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Inspectors wroteBased on observations, staff and resident interviews, and record review the facility failed to serve food that was hot and/or well-seasoned to four of five sampled residents (R) (#48, #82, #57, and #75) reviewed for food palatability. This failure had the potential to affect all 99 residents who consumed food from the kitchen.
- 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, staff interviews, and a review of the facility's policy titled, Food storage, the facility failed to cover stored food, keep scoops and cups out of stored dried foods, store meat, vegetables, nutritional supplements, and bread products in a kitchen reach-in freezer at zero degrees Fahrenheit (F) or lower, and date nutritional supplements when removed from freezer storage. This failure had the potential to affect all 99 residents who consumed food from the kitchen.
- F
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Inspectors wroteBased on observation, staff and resident interviews, record review, and a review of the facility's policy titled, Pest Control, the facility failed to maintain an effective pest control program so that the facility was free of rodents. This failure had the potential for all the residents of the facility to be at risk for diseases caused by rodent infestations.
- 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 observations, staff interviews, and a review of the facility's policy titled, Homelike Environment, the facility failed to ensure the secure unit was in good repair, and free from odors. Additionally, the facility failed to ensure that dressers were kept in good repair in the secure unit for four residents (R) (#2, #15, #48, and #82). This failure had the potential to affect all 51 residents who resided in the secure unit.
- E
Ensure that the facility has sufficient staff members who possess the competencies and skills to meet the behavioral health needs of residents.
Inspectors wroteBased on observations and staff interviews, the facility failed to ensure adequate staffing to provide routine care and adequate supervision for the 51 residents on the secure unit out of a total of 99 residents in the facility.
- 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 observations, staff interviews, and a review of the facility's policy titled, Mobility Aids: Conduct wheelchair Inspection, the facility failed to provide wheelchairs and geri-chairs that were functional, clean, and in good repair for 10 of 49 sampled Residents (R) (#3, #22, #42, #61, #63, #9, #27, #87, #5, and #11) who used wheelchairs or geri-chairs. This failure had the potential to affect residents' mobility and have a negative impact on their quality of life.
- D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteBased on observations, staff and resident interviews, the facility failed to promote a dignified dining experience at meals by serving residents food and beverages on disposable Styrofoam plates, disposable Styrofoam cups, small disposable plastic cups, and disposable plastic eating utensils for three of four sampled residents (R) (#48, #76, and #82) reviewed for dignity while dining. This failure had the potential to affect all 51 residents who resided in the facility on hallways A, B, and C.
- D
PASARR screening for Mental disorders or Intellectual Disabilities
Inspectors wroteBased on staff interviews, record review, and review of the facility's policy titled, Pre-admission Screening and Resident Review (PASRR), the facility failed to ensure one of three residents (R) (#22) reviewed for the Pre-admission Screening and Resident Review (PASRR) process, who was admitted with a mental health diagnosis, was referred for a Level II screening. This failure had the potential to increase the risk for a resident with a mental illness diagnosis from not receiving specialized services.
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on observations, staff interviews, record review, and a review of the facility's policy titled, Resident Hygiene-Bath and Shower Standards, the facility failed to ensure baths/showers and consistent Activities of Daily Living (ADLs) were provided to a resident who was dependent on staff for personal hygiene needs. This affected one of six residents (R) (#83) reviewed for ADLs on the secure unit. This failure had the potential to affect the quality of care by residents not receiving bathes/showers according to the facility policy.
- D
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Inspectors wroteBased on observation, interview, record review, and a review of the facility policy titled, Behavior Monitoring, the facility failed to identify target behaviors for monitoring of effectiveness of antipsychotic medication for three of five residents (R) (#22, #42 and #72) reviewed for unnecessary medications. This failure had the potential to contribute to unnecessary antipsychotic medication use for residents who used the medication to treat the behavioral symptoms of dementia.
- D
Provide special eating equipment and utensils for residents who need them and appropriate assistance.
Inspectors wroteBased on observations, staff interviews, and record review, the facility failed to provide an angled rocker knife and evaluate a resident's need for other special eating utensils for one of one sampled residents (R) (#2) reviewed for assistive eating devices.
- D
Provide at least one room set aside to use as a resident dining room and for activities, that is a good size, with good lighting, air flow and furniture.
Inspectors wroteBased on observations and staff interviews, the facility failed to provide an adequately furnished dining room for resident dining by utilizing two overbed tables and two folding tables in the dining room. This affected two of 28 residents (R) (#2 and #48) who ate their meals in the facility's main dining room.
- C
Post nurse staffing information every day.
Inspectors wroteBased on observation, staff interviews, record review, and review of the facility's policy titled, Clinical Staffing Standard dated August 2021 revealed, the facility failed to ensure the nurse staffing information was posted in a prominent place readily accessible to residents and visitors. This failure had the potential to affect all residents and visitors to the facility.
Fire safety inspections
13 fire safety citations on file: 4 on January 15, 2026, 6 on August 21, 2024, 3 on February 23, 2023.
Every fire safety citation13 citations
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · January 15, 2026 · Corrected (the home has a date of correction)
- D
Keep aisles, corridors, and exits free of obstruction in case of emergency.
K 211 · January 15, 2026 · Corrected (the home has a date of correction)
- D
Have an enclosure around a vertical opening shaft.
K 311 · January 15, 2026 · Corrected (the home has a date of correction)
- D
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
K 321 · January 15, 2026 · 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 · August 21, 2024 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · August 21, 2024 · Corrected (the home has a date of correction)
- D
List the names and contact information of those in the facility.
E 30 · August 21, 2024 · Corrected (the home has a date of correction)
- D
Implement emergency and standby power systems.
E 41 · August 21, 2024 · Corrected (the home has a date of correction)
- D
Have properly sized and located compartments to protect residents from smoke.
K 371 · August 21, 2024 · Corrected (the home has a date of correction)
- D
Have properly installed electrical wiring and gas equipment.
K 511 · August 21, 2024 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · February 23, 2023 · Corrected (the home has a date of correction)
- D
Properly select, install, inspect, or maintain portable fire extinguishes.
K 355 · February 23, 2023 · Corrected (the home has a date of correction)
- D
Install corridor and hallway doors that block smoke.
K 363 · February 23, 2023 · Corrected (the home has a date of correction)