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 16 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
5G
0H
0I
Potential for more than minimal harm
7D
2E
2F
Potential for minimal harm
0A
0B
0C
January 29, 2026Standard inspection · 7 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 record review the facility failed to ensure food was labeled, the sanitation level on the dishwasher was at 50 ppm, dishware and flatware was not used until it was sanitized, and pureed food was at least 135 degrees Fahrenheit on the steam table. This applies to all 52 residents in the facility. The facility's Long Term Care Facility Application for Medicare and Medicaid form dated 1/27/26 showed a census of 52 residents. 1. On 1/27/26 at 9:35 AM, A sign on the refrigerator door stated, refrigerate for safety! cover, label, and date all items. The French toast sticks in the refrigerator were in a bag that was not sealed or labeled. There were 3 resealable storage bags with sliced yellow cheese and sliced ham wrapped in a clear wrap with no labels. [...]
- E
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, interview, and record review the facility failed to provide pureed bread and margarine for the noon meal on 1/27/26 for 8 of 8 residents reviewed (R7, R33, R54, R4, R48, R37, R23, & R43) for dining in the sample of 35 residents.
- E
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview and record review the facility failed to ensure Enhanced Barrier Precautions were followed (R4), failed to ensure hand hygiene was performed during medication pass (R7, R22, R36, R37), and failed to ensure staff did not touch a resident's food with bare hands (R5) for 6 of 6 residents reviewed for infection control in the sample of 35.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on interview and record review, the facility failed to consistently obtain daily weights for residents with congestive heart failure (R42, R3) and/or a blood pressure every shift as ordered by the physician following a fall incident (R42). This failure affected 2 of 2 residents (R42, R3) who were reviewed for quality of care in the sample of 35.
- 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, interview and record review the facility failed to ensure catheter tubing was cleansed prior to use (R4) and failed to ensure catheter tubing remained off the floor for 2 of 4 residents (R4, R26) reviewed for catheters in the sample of 35.
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observation, interview, and record review the facility failed to ensure oxygen tubing was changed weekly for 1 of 2 resident (R18) reviewed for oxygen in the sample of 35.
- D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Inspectors wroteBased on observation, interviews and record review, the facility failed to ensure that prescribed medications were safely administered to a resident as ordered by the physician. This failure affected 1 of 1 resident (R42) reviewed for medication administration in the sample of 35.
October 3, 2024Standard inspection · 2 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 record review the facility failed to cool a pork roast before freezing and failed to use serving utensils while serving food. This applies to all residents in the facility.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on interview and record review, the facility failed to ensure daily weights were obtained for a resident with a diagnosis of heart failure, and failed to notify the resident's doctor when weight gain was outside of the set parameters for 1 of 1 resident (R19) reviewed for congestive heart failure (CHF) in the sample of 15.
July 31, 2024Complaint inspection · 1 citation
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a dependent residents was provided showers for 1 of 3 residents (R1) reviewed for activities of daily living in the sample of 7.
April 3, 2024Complaint inspection · 1 citation
- G
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Inspectors wroteBased on observation, interview, and record review the facility failed to have interventions in place to prevent resident to resident abuse. This applies to 3 of 3 residents (R1, R2, R3) reviewed for abuse in the sample of 3. This failure resulted in R1 being sent to the hospital, receiving a hematoma, and experiencing pain with activities of daily living.
December 6, 2023Complaint inspection · 1 citation
- G
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a resident was transferred and ambulated in a safe manner for 1 of 3 residents (R1) reviewed for safety in the sample of 3. These failures resulted in R1 sustaining a fractured nasal bone, sutures to the forehead, and bruising.
September 15, 2023Standard inspection · 4 citations
- G
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on observation, interview, and record review the facility failed to cleanse a stage four pressure ulcer in a manner to prevent cross contamination and failed to ensure staff were knowledgeable in the use of a pressure reduction device for 1 of 2 residents (R42) reviewed for pressure in the sample of 14. These failures resulted in R42 being at an increased risk of infection and delayed wound healing.
- G
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on observation, interview and record review, the facility failed to supervise a resident at high risk for falls, with previous falls in the facility, and failed to supervise a resident with wandering behaviors for 2 of 8 residents (R41, R26) reviewed for safety and supervision in the sample of 14. This failure resulted in R41 falling, sustaining a hip fracture, and being sent out to a local hospital for evaluation and surgical treatment.
- G
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, interview, and record review the facility failed to ensure catheter changes were performed as ordered and failed to ensure catheter care orders were in place for 2 of 3 residents (R6, R20) reviewed for catheters in the sample of 14. This failure resulted in catheters having a gray discoloration for residents with recurrent urinary tract infections (R6, R20), R6's urine was cloudy yellow with sediment, and R20's urine was thick, foul-smelling, and amber in color.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview and record review the facility failed to sanitize resident equipment and failed to provide peri care in a manner to prevent cross contamination for 3 of 3 residents (R31, R39, R41) reviewed for infection control in the sample of 14.
Fire safety inspections
14 fire safety citations on file: 3 on January 29, 2026, 5 on October 3, 2024, 6 on September 15, 2023.
Every fire safety citation14 citations
- E
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 29, 2026 · Corrected (the home has a date of correction)
- E
Provide properly protected cooking facilities.
K 324 · January 29, 2026 · Corrected (the home has a date of correction)
- E
Install corridor and hallway doors that block smoke.
K 363 · January 29, 2026 · Corrected (the home has a date of correction)
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · October 3, 2024 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · October 3, 2024 · Corrected (the home has a date of correction)
- F
Have simulated fire drills held at unexpected times.
K 712 · October 3, 2024 · Corrected (the home has a date of correction)
- E
Install smoke barrier doors that can resist smoke for at least 20 minutes.
K 374 · October 3, 2024 · Corrected (the home has a date of correction)
- E
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
K 761 · October 3, 2024 · Corrected (the home has a date of correction)
- F
Establish roles under a Waiver declared by secretary.
E 26 · September 15, 2023 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · September 15, 2023 · Corrected (the home has a date of correction)
- E
Have exits that are accessible at all times.
K 271 · September 15, 2023 · Corrected (the home has a date of correction)
- E
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
K 321 · September 15, 2023 · Corrected (the home has a date of correction)
- E
Have properly installed electrical wiring and gas equipment.
K 511 · September 15, 2023 · Corrected (the home has a date of correction)
- E
Ensure proper usage of power strips and extension cords.
K 920 · September 15, 2023 · Corrected (the home has a date of correction)