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 22 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
4E
4F
Potential for minimal harm
0A
0B
0C
June 25, 2026Standard inspection · 4 citations
- D
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Inspectors wroteNumber of residents sampled: Number of residents cited: Based on record review, interview, and facility policy review, the facility failed to develop and implement dementia care needs on a person-centered comprehensive care plan for one (Resident #7) of one resident reviewed.
- D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Inspectors wroteBased on record review, observations, interviews, and facility policy review, the facility failed to remove expired medications from active rotation to avoid administration for one (Resident #21) of one resident reviewed. Specifically, the facility failed to remove expired medication from active rotation for which Resident #21 had an active order and was receiving as needed.
- D
Provide timely, quality laboratory services/tests to meet the needs of residents.
Inspectors wroteBased on record review observations, and interviews, it was determined that the facility failed to ensure lab specimen supplies were not expired and lab specimens were stored in a refrigerator 36 degrees Fahrenheit (F) to 46 degrees F and away from food items.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observations, record reviews, interviews, and facility policy reviews, it was determined that the facility failed to ensure infection control practices were followed during laundry activities to prevent the spread of infection for the facility residents and failed to ensure contact precautions were consistently implemented for one (Resident #5) of one resident reviewed.
April 4, 2025Standard inspection, Complaint inspection · 4 citations
- 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 interview, the facility failed to ensure the minimum requirements were addressed in the facility assessment, as evidenced by, the medical director was not actively involved in the organization of the facility assessment for 1 of 1 facility. This failed practice had the potential to affect all residents in the facility (total census: 69).
- 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, interviews, and facility digital thermometer readings, the facility failed to maintain rehab resident rooms and the rehab hallway at a comfortable temperature level for residents in 1 of 5 hallways in the facility.
- E
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 record review and interview, the facility failed to ensure the Ombudsman was notified of residents transferred from the facility and send a copy of the transfer of notification for 2 (Residents #15 and #63) of 2 sampled residents reviewed for hospitalization.
- D
Protect each resident from the wrongful use of the resident's belongings or money.
Inspectors wroteBased on record review, interview, and facility policy review, the facility failed to protect a resident's right to be free from misappropriation of resident ' s property, as evidenced by a medication card of [Compound Narcotic Pain Medication], 5 milligrams (mg)/325 mg which contained 43 pills, was taken from a medication cart and the empty card was located in a dumpster behind the facility, for 1 (Resident #8) of 1 sampled resident reviewed for misappropriation of property.
January 26, 2024Standard inspection · 14 citations
- F
Ensure residents have reasonable access to and privacy in their use of communication methods.
Inspectors wroteBased on interview, and record review, the facility failed to ensure residents received personal mail on Saturdays. This failed practice had the potential to affect all 60 residents who resided in the facility, as documented on the Midnight Census provided by the Administrator on 1/22/2024 at 1:52 PM.
- 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 interview, the facility failed to ensure potential frozen meat items were not stored above frozen packages of food items; cartons of pasteurized eggs were not stored above butter logs; foods stored in the refrigerator, and dry storage area were covered and sealed to minimize the potential for food borne illness for residents who received meals from 1 of 1 kitchen, foods were dated the day received or opened to assure first in, first out usage to prevent potential for food bone illness, the dining floor was free of stains; door frames were free of rotten wood; the kitchen vent over the dish washing machine was free of rust stains, the clean dish machine counter was replaced, the dish washer and kitchen walls were free of paint peeling; [...]
- F
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff used proper hand hygiene when assisting resident during meal service; laundry staff were properly trained to process contaminated linen; the folding table was free from contamination and to establish/implement a plan for Legionella to prevent the spread waterborne pathogens to reduce the potential for infections. This failed practice had the potential to affect 60 residents residing in the facility based on a list provided by the Administrator on 01/22/24 at 1:52 PM.
- E
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 interview, the facility failed to ensure care plans were reviewed and revised at least quarterly and/or when residents' care needs changed, as evidence by failure to revise the plan of care to address the use of an antidepressant, an anticoagulant and insulin injections to ensure staff were aware of the necessary care, assessments and services required for 1 (Resident #43) of 17 (Residents #6, #8, #11, #17, #18, #19, #23, #26, #27, #29, #31, #32, #43, #52, #53, #54 and #58) sampled residents who had orders for an antidepressant, 1 (Resident #43) of 6 (Residents #25, #27, #32, #43, #270 and #271) sampled residents who had orders for an anticoagulant and 1 (Residents #17) of 6 (Residents #8, #9, #17, #19, #29 and #32) sampled residents who had orders for insulin, as documented on lists provided by the Director of Nursing on 01/26/24 at 11:56 AM, and 1 (Resident [...]
- E
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
Inspectors wroteBased on observation and interview, the facility failed to ensure pureed food items were blended to a smooth, lump free consistency to minimize the risk of choking or other complications for those residents who required pureed diets for 2 of 2 meals observed. The failed practice had the potential to affect 5 residents who received pureed diets, as documented on the list provided by the Food Service Supervisor on 01/25/2024
- D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteBased on observation, record review and interview, the facility failed to ensure staff complied with a resident's request to use the bathroom to promote dignity for 1 (Resident #6) of 13 (Residents #6, #8, #11, #17, #23, #25, #26, #29, #31, #43, #53, #54, and #270) sampled residents who required staff assistance for toileting, as documented on a list provided by the Director of Nursing on 1/26/24 at 11:56 am.
- D
Allow resident to participate in the development and implementation of his or her person-centered plan of care.
Inspectors wroteBased on record review and interview, the facility failed to ensure residents were invited and/or assisted to exercise their right to participate in development of their person-centered plans of care, to facilitate development of plans that would incorporate residents' goals, choices and preferences for 1 (Resident #25) of 6 (Residents #8, #17, #25, #29, #31 and #52) sampled residents whose Brief Interview for Mental Status (BIMS) scores were between 13 to 15 (13-15) which indicates the residents were cognitively intact, as documented on a list provided by the Director of Nursing (DON) on 1/26/24 at 11:56 AM.
- 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 accurately code the Minimum Data Set (MDS) for 1 (Resident #19) of 1 sampled resident who had a diagnosis of a mental disorder.
- D
Assess the resident when there is a significant change in condition
Inspectors wroteBased on record review and interview, the facility failed to ensure a Significant Change Minimum Data Set (MDS) assessment was completed within 14 days after a decline in activities of daily living (ADL) was noted, in order to address any potential changes in care needs for 1 (Resident #43) of 1 sampled resident who experienced an ADL decline.
- 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 and interview, the facility failed to ensure comprehensive care plans were developed to address the resident's insulin injection order to ensure staff were aware of the required medication to promote continuity of care for 1 (Resident #32) of 6 (Residents #29, #8, #32, #9, #17, and #19) who had physician orders for insulin.
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on observation, record review and interview, the facility failed to ensure nail care services were regularly provided to promote good personal hygiene and grooming for 1 (Resident #6) of 16 (Residents #6, #8, #11, #17, #23, #25, #26, #29, #31, #40, #43, #52, #53, #54, #58, #270 ) sampled residents who required assistance for nail care, as documented on a list provided by the Director of Nursing on 1/26/24 at 11:56 am.
- 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 Resident #19 received proper incontinence care to prevent the potential for skin breakdown, poor hygiene, and/or infection.
- D
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure bed rails were utilized only after an assessment for entrapment risk was conducted and documented for 1 (Resident #60) of 5 (Residents #27, #8, #54, #60, and #23) sampled residents who used bed rails.
- D
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Inspectors wroteBased on observation, interview and record review, the facility failed to ensure call lights were answered in a timely manner to ensure resident safety and care needs were met.
Fire safety inspections
4 fire safety citations on file: 1 on June 25, 2026, 1 on April 4, 2025, 2 on January 26, 2024.
Every fire safety citation4 citations
- B
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
K 521 · June 25, 2026 · Not yet corrected
- B
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
K 521 · April 4, 2025 · deficient, provider has
- F
Install a fire alarm system that can be heard throughout the facility.
K 341 · January 26, 2024 · 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 · January 26, 2024 · Waiver