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 24 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
16D
7E
1F
Potential for minimal harm
0A
0B
0C
February 5, 2026Standard inspection · 4 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 staff interview, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food safety. The staff failed to don a hairnet while in the kitchen. Lastly, the facility failed to follow the proper sanitation practices for the kitchen and the food preparation equipment This practice had the potential to affect all of the residents. Facility census: 27. Initial walkthrough of the kitchen upon entry into the facility on 2/2/26 at 11:45 AM.
- E
Provide activities to meet all resident's needs.
Inspectors wroteBased on observation and staff and resident interviews the facility failed to have an ongoing activities program that meets the needs of the residents. Census 28. PS and findings JS The facility failed to provide activities for the residents based on observation and interviews with residents and staff.02/02/2026 3:14 PM complaints that there are never any activities, stated that the girl never shows up Interview with activity director 2:40 pm on 2/4/26 when questioned about why there are only four days a week scheduled for activities, she replied that they are short on staffing. Based on observation there was only one group activity done out of four days Monday through Thursday. The only activity completed was bingo which was held 2/4/26 at 1:30 PM.The activity calendar was only completed for 4 days a week with no activities being held on the other 3 days.
- E
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on observation and interviews, the facility failed to ensure the resident environment over which they had control was as free from accident hazards as possible in regards to bed safety. This was a random opportunity for discovery. Room Identifiers: #1, #10, #15. Facility census: 27. Findings Include: a) Resident #10 During an initial tour of the facility an observation, completed on 02/09/26 at 3:16 PM, revealed Resident #10 was lying in bed with an approximate 12-inch gap between the mattress and foot board. b) Resident # 1During an initial tour of the facility an observation, completed on 02/09/26 at 3:30 PM, revealed Resident #1 was lying in bed with an approximate 12-inch gap between the mattress and foot board. c) Resident #15An observation on 02/09/26 at 3:45 PM was made of Resident # 15 sitting up in a chair by his bed. [...]
- D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on records review and staff interviews, the facility failed to ensure a complete and accurate medical records. This failed practice was found true for one (1) of four (4) residents reviewed during the survey. Resident identifier: #5 Facility Census: 27 Findings Included:During an electronic medical record review of Resident #5's Physician designated code status on 02/05/26 at 8:20 AM, Resident #5 was listed as a full code, attempt to resuscitate. On 02/05/26 at 8:25AM, during a record review of Resident #5's Chart, an Advance Directive form was not in the chart. Registered Nurse Employee # 66 provided Resident #5's Kardex. The Kardex, it was marked comfort at which time, She acknowledged the Kardex did not match the electronic medical record. When asked what staff would go by for guidance of resident wishes, she stated the Kardex. [...]
June 26, 2024Standard inspection · 12 citations
- E
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Inspectors wroteBased on record review and staff interview, the facility failed to develop accurate written abuse and neglect policies and failed to implement procedures for reporting to prevent all types of abuse. The facility failed to report an incident of neglect/mistreatment with Resident #2. This practice affected one (1) of two residents reviewed using the abuse pathway in the survey process. This failed practice had the potential to affect more than a limited number of residents who reside at the facility. Resident identifier: #2. Facility census: 24.
- E
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteThe facility failed to provide an environment that was free from accident hazards over which the facility had control. Water temperatures were found to be above 120 degrees Fahrenheit (F). This deficient practice had the potential to affect more than a limited number of residents. Facility census: 24.
- 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, and staff interview, the facility failed to ensure the safe storage of medications in the medication room. The facility had made no provision to install the appropriate environmental controls, and monitoring devices, to preserve the integrity of the medications stored in the medication room. This was a random opportunity for discovery. This failed practice had the potential for more than minimal harm. Facility census: 24.
- D
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Inspectors wroteBased on interview and investigation, the facility failed to ensure Resident #2's preferred sleeping and waking times were honored. This failed practice had the potential to affect more than a limited number of residents who reside at the facility. This was a random opportunity for discovery. Resident Identifier #2. Facility Census:
- D
Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.
Inspectors wroteBased on observation and staff interview, the facility failed to post in a place readily accessible to residents, and family members and legal representatives of residents, the results of the most recent survey of the facility. This deficient practice had the ability to affect more than a limited number of residents and/or family members. This was a random opportunity for discovery. Facility census: 24.
- D
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Inspectors wroteBased on medical record review and staff interview, the facility failed to ensure Advance Directive paperwork was part of the resident's medical record. This was true for one (1) of 13 residents reviewed in the Long-Term Care Survey Process. Resident identifier: #139. Facility census: 24.
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on record review, resident interview, and staff interviews, the facility failed to report allegations of neglect and verbal abuse for Resident #2. This was a random opportunity for discovery. This failed practice has the potential to affect more than a limited number of residents at the facility. Resident Identifier #2.
- D
Respond appropriately to all alleged violations.
Inspectors wroteThis was a random opportunity for discovery. Based on record review and resident and staff interview, the facility failed to initiate an investigation of an alleged violation of neglect and verbal abuse for Resident #2. This failed practice had the potential to affect more than a limited number of residents at the facility. Resident Identifier #2. Facility Census:24. a) Resident #2 Based on an interview of Resident #2 on 06/24/24 at 1:05 PM, resident stated that she had needed to use her bedside commode on 06/23/24 at around 6:00 AM. Resident stated that no one had responded to her call light for over two (2) hours. She further stated that she was sitting on the edge of her bed and could feel herself sliding off, so she had begun to shout out loudly. Her calls were responded to by a Nursing Assistant (NA) #15, who told her to stop shouting so loudly. [...]
- D
Provide enough food/fluids to maintain a resident's health.
Inspectors wroteBased on staff interview and medical record review the facility failed to ensure resident #92 received an adequate amount of nutrition. This was true for one (1) of (1) residents reviewed for nutrition. Resident identifier #92. Facility census 24.
- D
Provide safe, appropriate pain management for a resident who requires such services.
Inspectors wroteBased on record review and staff interview, the facility failed to ensure that pain management was provided to residents who required such services, consistent with professional standards of practice. Pain medication was not administered appropriately per the physician's order. This was true for one (1) of two (2) residents who were reviewed under the pain pathway in the Long-Term Care Survey Process. Resident #139. Facility census:
- D
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Inspectors wroteBased on record review and staff interview, the facility failed to ensure the attending physician documented in the resident's medical record, that the pharmacist's monthly medication review with recommendations had been reviewed and what, if any, action has been taken to address it. This was true for one (1) of five (5) unnecessary medication reviews throughout the long-term care survey process. Resident identifier: #2. Facility census: 24.
- D
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
Inspectors wroteBased on facility documentation and staff interview the facility failed to have required members sign in at the Quality Assessment and Assurance (QAA) meetings. This failed practice had the potential to affect all residents residing at the facility. Facility Census: 24.
August 31, 2022Standard 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 and staff interview, the facility failed to store food in accordance with professional standards for food service safety. The facility failed to label and date food items that were opened. This failed practice had the potential to affect a limited number of residents who are served food from the kitchen. Facility census: 20.
- E
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Inspectors wroteBased on medical record review, and staff interview, the facility failed to ensure residents are offered the pneumococcal vaccines currently recommended by the Center for Disease Control (CDC), educated on the risks and benefits and receive the vaccine unless medically contraindicated or refused. This is true for four (4) of five (5) residents reviewed for immunizations. Resident identifiers: #75, #66, #76, #73. Facility census: 20.
- D
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 medical record review and staff interview, the facility failed to provide evidence a resident/resident's representative was provided a written Notice of Transfer for an acute hospital transfer. This was true for one (1) of two (2) residents reviewed for hospitalizations/discharges during the long-term care survey process. Resident identifier: #11. Facility census: 20.
- 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 staff interview, the facility failed to submit the initial comprehensive assessment within the 14 day time limit. This is true for one (1) of two (2) reviewed for admission Minimum Data Set (MDS) assessments. Resident identifier: 73. Facility census: 20.
- D
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Inspectors wroteBased on medical record review and staff interview, the pharmacist failed to identify an incomplete medication order during the initial drug regimen review. This is true for one (1) of five (5) residents reviewed for unnecessary medications. Resident identifier: #71. Facility census: 20.
- D
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Inspectors wroteBased on medical record review and staff interview, the facility failed to ensure a medication order included an adequate indication for its use. This is true for one (1) of five (5) residents reviewed for unnecessary medications. Resident identifier: #71. Facility census: 20.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, policy review and staff interview, the facility failed to ensure staff followed hand hygiene practices consistent with accepted standards of practice. This practice has the potential to affect a limited number of residents. Resident identifier: #36. Facility census: 20.
- D
Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
Inspectors wroteBased on medical record review and staff interview the facility failed to ensure the resident and/or resident representative is provided with current information regarding additional doses of the COVID vaccine, including any changes in the benefits or risks and potential side effects associated with the COVID-19 vaccine, before requesting consent for administration of any additional doses. This was true for one (1) of five (5) residents reviewed for the COVID vaccine. Resident identifier: #76. Facility census: 20.
Fire safety inspections
6 fire safety citations on file: 3 on June 26, 2024, 3 on August 31, 2022.
Every fire safety citation6 citations
- F
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
K 321 · June 26, 2024 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · June 26, 2024 · Corrected (the home has a date of correction)
- C
Have simulated fire drills held at unexpected times.
K 712 · June 26, 2024 · Corrected (the home has a date of correction)
- F
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
K 321 · August 31, 2022 · Corrected (the home has a date of correction)
- C
Have simulated fire drills held at unexpected times.
K 712 · August 31, 2022 · Corrected (the home has a date of correction)
- C
Ensure proper storage of liquid oxygen.
K 930 · August 31, 2022 · Corrected (the home has a date of correction)