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 14 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
5D
8E
1F
Potential for minimal harm
0A
0B
0C
May 21, 2026Standard inspection · 1 citation
- 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 a person-centered comprehensive care plan that included dementia care needs for one (Resident #37) of one resident reviewed.
September 19, 2024Standard inspection, Complaint inspection · 3 citations
- D
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 observation, interview, and record review, the facility failed to ensure the care plan was followed related to fall interventions for 1 (Resident #32) of 1 sampled resident with a history of falls.
- D
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Inspectors wroteBased on observation, interview, and record review, the facility failed to provide alternative communication methods for 1 (Resident #15) of 1 sampled resident who required alternative formats for communication.
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on interviews, record review, and facility policy review, it was determined the facility failed to ensure 1 (Resident #4) of 7 residents reviewed for accidents and hazards received adequate supervision to prevent the potential for accidents. Specifically, the facility failed to ensure Resident #4 was supervised to prevent the access and potential for ingestion of hand sanitizer, on the overbed table next to a cup of water in Resident #4's room.
July 14, 2023Standard inspection · 10 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 and interview, the facility failed to ensure food items stored in the refrigerator/freezer were covered, sealed and dated; expired food items were promptly removed/discarded by the expiration or use by dates to prevent potential food borne illness for residents who received meal trays from 1 of 1 kitchen; and dietary staff washed their hands before handling clean equipment or food items to prevent potential food borne illness for residents who received meals from 1 of 1 kitchen. The failed practices had the potential to affect 97 residents who received meals from the kitchen (total census: 98), as documented on a list provided by the Dietary Supervisor on 07/11/23 at 2:22 AM.
- E
Keep residents' personal and medical records private and confidential.
Inspectors wroteBased on observation and interview, the facility failed to ensure privacy and confidentiality of personal and medical information was maintained during medication administration by not locking the computer screens when not in use for 2 (Residents #29 and #59) of 2 sampled residents.
- E
Ensure each resident receives an accurate assessment.
Inspectors wroteBased on interview and record review, the facility failed to accurately record the resident assessment for 4 (Resident #6, #48, #86, #89) of 4 sampled residents.
- E
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 develop and implement a comprehensive person-centered plan of care for 2 (Residents #27 and #86) of 13 (Residents #6, #27, #29, #48, #55, #59, #63, #71, #84, #86, #89, #91 and #96) sampled residents whose Care Plans were reviewed.
- 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 ensure Activities of Daily Living (ADL) care was provided to promote cleanliness and good personal hygiene for 1 (Resident # 71) of 10 (Residents #15, #20, #30, #63, #65, #68, #71, #86, #89 and #91) sampled residents who required staff assistance with shaving on the South Hall (Secure Unit). This failed practice had the potential to affect 24 residents who required assistance on the South Secured Unit with ADL care as documented on a list provided by the Director of Nursing (DON) on 07/14/23 at 9:06 AM.
- E
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, record review and interview, the facility failed to ensure an indwelling catheter bag was covered to maintain privacy for 1 (Resident #63) of 6 (Residents #12, #22, #29, #51, #63 and #78) sampled residents who had an indwelling catheter.
- 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 meals were prepared and served according to the planned written menu to meet the nutritional needs of the residents for 1 of 1 meal observed. This failed practice had the potential to affect 71 residents who received regular diets, 18 residents who received mechanical soft diets, and 6 residents who received pureed diets from the kitchen according to a list provided by the Dietary Supervisor on 07/11/23.
- E
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 observation, interview, and record review, the facility failed to ensure a comfortable, homelike, social dining experience was provided for residents who resided on the facility's Secure Unit. This failed practice had the potential to affect 31 residents as documented on the Census for the Secure Unit South Hall provided by the Registered Nurse (RN) Consultant on 07/10/23 at 1:39 PM.
- E
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Inspectors wroteBased on observation, record review and interview, the facility failed to ensure food preparation, service areas, and resident areas were free from visible signs of rodents and pests. This failed practice had the potential to affect 98 residents who received a meal tray from the kitchen as documented on a list provided by the Dietary Supervisor on 07/11/23 at 2:22 PM.
- D
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Inspectors wroteBased on observation, record review and interview, the facility failed to ensure meals were served at temperatures that were acceptable to the residents to improve palatability and encourage good nutritional intake during 2 of 2 meals observed. The failed practice had the potential to affect 8 residents who received meal trays in their room on the 100 Hall; 31 residents who received meal trays in their room on the South Hall (Secure Unit); 16 residents who received meal trays in their room on the [NAME] Hall; 17 residents who received meal trays in their room on the North Hall and 26 residents who received meal trays in their room on the East Hall, as documented on a list provided by the Dietary Supervisor on 07/11/23 at 6:30 PM.
Fire safety inspections
7 fire safety citations on file: 2 on May 21, 2026, 2 on September 19, 2024, 3 on July 14, 2023.
Every fire safety citation7 citations
- F
Have an alternate power supply for its alarm system.
K 344 · May 21, 2026 · Corrected (the home has a date of correction)
- F
Properly select, install, inspect, or maintain portable fire extinguishes.
K 355 · May 21, 2026 · Corrected (the home has a date of correction)
- F
Install a fire alarm system that can be heard throughout the facility.
K 341 · September 19, 2024 · Corrected (the home has a date of correction)
- F
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · September 19, 2024 · Corrected (the home has a date of correction)
- F
Properly provide smoke detection systems in areas open to corridors.
K 347 · July 14, 2023 · Corrected (the home has a date of correction)
- F
Install an approved automatic sprinkler system.
K 351 · July 14, 2023 · Corrected (the home has a date of correction)
- F
Have simulated fire drills held at unexpected times.
K 712 · July 14, 2023 · Corrected (the home has a date of correction)