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 20 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
5E
1F
Potential for minimal harm
0A
0B
1C
June 5, 2026Standard inspection · 8 citations
- 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, interview, and facility policy review, the facility failed to ensure food was stored properly; failed to ensure staff utilized facial hair restraint/covers when preparing, distributing, and serving food during 2 of 2 meal preparation observations; and failed to ensure staff washed/sanitized their hands when serving meals to residents during 1 of 1 meal service observations. These deficiencies had the potential to affect all residents who received food from the facility kitchen, and all residents who received staff assistance with meals in the dining room.
- D
Allow residents to self-administer drugs if determined clinically appropriate.
Inspectors wroteBased on observation, interview, and record review, and facility policy review, the facility failed to assess a resident for self-administration of medication, failed to obtain a physician's order for self-administration of medication, and failed to obtain a physician's order to keep medication at the bedside for 1 resident (Resident # 34) of 5 residents observed during medication pass.
- 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 observation, interview, and record review, the facility failed to ensure the physician was notified when medication was not available for administration for 1 (Resident #34) of 5 residents observed for medication administration.
- D
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Inspectors wroteBased on interview and record review the facility failed to submit a Preadmission Screening and Resident Review (PASRR) form to the state-designated authority after the addition of a new psychiatric diagnosis for 1 (Resident #10) of 2 residents reviewed for the accuracy of the PASRR.
- 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, record review, and facility document review, the facility failed to ensure an indwelling urinary catheter tubing was secured and a urine collection bag was stored in a manner to prevent infection for 1 (Resident #60) of 2 residents with a urinary catheter.
- D
Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.
Inspectors wroteBased on observation, interview, and facility policy review, the facility failed to ensure dietary staff were trained on the Personal Protective Equipment (PPE) required for contact isolation for 1 (Dietary Aide [DA] #15) of 1 dietary staff reviewed for infection control competencies.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure dietary staff donned Personal Protective Equipment (PPE) on entering a resident's room with contact isolation precautions for 1 (Resident #45) of 4 residents reviewed for transmission based precautions. Specifically, Dietary Aide (DA) #15 entered and exited Resident #45's room without donning PPE, when the resident was on contact isolation precautions.
- C
Post nurse staffing information every day.
Inspectors wroteBased on observation and interview, the facility failed to ensure nurse staffing data was posted in a prominent place accessible to residents, staff, and visitors on 1 (06/02/2026) of 5 days of the survey.
October 31, 2024Standard inspection, Complaint inspection · 3 citations
- F
Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
Inspectors wroteBased on record review and interview, the facility failed to submit payroll based staffing information to CMS as required for the 3rd quarter of 2024. The administrator identified 95 residents resided in the facility.
- E
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 provide ADL care to dependent residents for two (#21 and #64) of three sampled residents reviewed for ADLs. The administrator identified 95 residents resided in the facility.
- 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 observation, record review, and interview, the facility failed to ensure medications were not left at a resident's bedside for one (#55) of 24 sampled residents observed for bedside medications. The administrator identified 95 residents resided in the facility.
September 15, 2023Standard inspection, Complaint inspection · 9 citations
- E
PASARR screening for Mental disorders or Intellectual Disabilities
Inspectors wroteBased on record review and interview, the facility failed to complete a level I PASARR upon admission for two (#19 and #66) of eight residents sampled for level I PASARR completed upon admission. The Resident Census and Conditions of Residents report, dated 09/12/23, documented 57 residents had psych diagnosis.
- 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, record review, and interview, the facility failed to ensure the menu was followed for four (#78, 45, 70, and #24) of 10 sampled residents observed for dining services. The Resident Census and Conditions of Residents report, dated 09/12/23, documented 92 residents resided in the facility. The DON identified two residents received nutrition and hydration solely through a peg tube.
- D
Keep residents' personal and medical records private and confidential.
Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure privacy was provided while administering peg tube medication to one (#8) of one sampled resident observed for peg tube medication administration. The DON identified two residents who received nutrition and hydration solely through a peg tube.
- 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 ensure a resident's comprehensive assessment was completed timely for one (#138) of 22 sampled residents reviewed for MDS assessments. The Resident Census and Conditions of Residents report, dated 09/12/23, documented 92 residents resided in the facility.
- 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, record review, and interview, the facility failed to ensure staff cleaned an insulin vial prior to administration for one (#38) of one sampled resident observed for insulin administration. The DON identified 15 residents received injectable insulin.
- D
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, record review, and interview, the facility failed to ensure a treatment cart was secured for one of three sampled carts observed. A Number of Medication Carts document, undated, documented seven carts were in the facility.
- D
Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.
Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure a resident received a therapeutic diet as ordered for one (#68) of 10 sampled residents observed for dining services. The RD identified 10 residents received ground meat diets.
- D
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure kitchen equipment, storage shelf, and the ceiling above the food preparation area was maintained to promote sanitation. The DON identified 89 Residents received nutrition from the kitchen.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure staff wore a faceshield/goggles while in a COVID-19 positive resident's room for two (#57 and #43) of four sampled residents observed for infection control. The Resident Census and Conditions of Residents report, dated 09/12/23, documented 92 residents resided in the facility. The DON identified four residents were COVID-19 positive.
Fire safety inspections
10 fire safety citations on file: 5 on June 5, 2026, 3 on October 31, 2024, 2 on September 15, 2023.
Every fire safety citation10 citations
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · June 5, 2026 · Corrected (the home has a date of correction)
- F
Install smoke barrier doors that can resist smoke for at least 20 minutes.
K 374 · June 5, 2026 · Corrected (the home has a date of correction)
- F
Have simulated fire drills held at unexpected times.
K 712 · June 5, 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 · June 5, 2026 · 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 · June 5, 2026 · 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 · October 31, 2024 · Corrected (the home has a date of correction)
- E
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · October 31, 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 31, 2024 · 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)
- F
Have simulated fire drills held at unexpected times.
K 712 · September 15, 2023 · Corrected (the home has a date of correction)